Name Request for Proposal Name of Employer Physical Address P.O. Box City/State/Zip Telephone Fax Contact Person Form of Business Sole Proprietor Partnership Church Governmental For Profit Corporation S Corporation Limited Liability Corporation Limited Liability Partnership Tax-Exempt under 501(c) Non-Profit not tax exempt under 501(c) Professional Corporation Other Date Business Began Fiscal Year Ownership* Largest Next Next Next Next Percent Percent Percent Percent Percent Anticipated Effective Date Report Frequency Annual Semi-Annual Quarterly Number of Employees Estimated Annual Contribution** Targeted Individuals or Groups 1 2 3 4 5 Maximum Contribution Desired Minimum Contribution Needed Employee participation desired? Yes No Do you have leased employees? Yes No What do you expect to accomplish by setting up this plan? Maximize benefit for owners/highly compensated? Yes No Attract and retain key employees? Yes No Provide a benefit for all employees? Yes No Other goals (specify) Affiliated Companies Company Name 1 2 3 4 5 6 7 Owner 1 / % Own Owner 2 / % Own Owner 3 / % Own Owner 4 / % Own Owner 5 / % Own Referred by Name Address City/State/Zip Phone Number Fax Fund Family Asset Manager Name Address Cite/State/Zip Phone Number Fax C.P.A. Name Address City/State/Zip Phone Number Fax *List the 5 largest owners of the employer and the percentages of ownership for each owner. **The amount of money that will be contributed by the employer exclusive of employee contributions. If a range of contributions is needed, enter the range. Notes: Complete the attached census form so that we may analyze the employer and provide options tailored to this employer.
