Contact Information Employee Census Telephone Consultation Request Please enter your Contact Information. (All information is required unless otherwise noted) First Name: Last Name: Employer: Association: Please Select ... ────────── American Academy of Family Physicians American Animal Hospital Association American Institute of Architects American Optometric Association ────────── Unaffiliated ────────── Other (please specify) Assoc. Other: : E-mail Regular Mail Fax Address: City: Zip Code: State: Please Select ... ────────── Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Phone: Ext. Fax: E-mail: Preferred Contact Method: Phone E-mail Best Day to Call: Please Select ... ────────── - Any Day - Monday Tuesday Wednesday Thursday Friday Best Time to Call: Please Select ... ────────── - Any Time - 9AM - 10AM 10AM - 12PM 12PM - 1PM 1PM - 3PM 3PM - 5PM Time Zone: EST CST MST PST Relationship to the Program: Please Select ... ────────── Potential Client ────────── Other (please specify) Relationship - Other: Questions or Comments: (optional) I operate as: Please Select ... ────────── Sole Proprietor (with employees) Sole Proprietor (with no employees) Professional Corporation (with employees) Professional Corporation (with no employees) Professional Corporation (more than one shareholder) Partnership (with or without incorporated partners) ────────── Other (please specify) I operate as - Other: Is it your objective to maximize your contributions up to the IRS contribution limit? Yes No Do you have an existing tax-qualified retirement plan? Yes No Plan Name (optional): Plan Assets ($): Annual Contributions ($): Number of Participants with an Acct. Balance: Number of Eligible Employees: Type of Plan: Please Select ... ────────── Profit Sharing Plan 401(k) Simple 401(k) Safe Harbor 401(k) Simple-IRA SEP-IRA Pension Plan ────────── Other (please specify) Type of Plan - Other: Telephone Consultation Request Please complete the following Employee Census. [ Include Owners, Partners, or Shareholders (if incorporated) ] Name Age Owner-ship % Date of Hire Part-Time* Employee Total** Compensation Salary Deferral Amount * Considered a part-time employee, if employee works under 1,000 hours a year. ** Estimate compensation if necessary for current business year. Questions? Call a Retirement Program Specialist at 1-800-523-1125
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