Client Data

Exact legal company name/person:

*

Address 1:

*

Address 2:

City:

*

State:

*

Zip:

*

Contact person:

*

Title:

*

E-Mail:

*

Phone:

*

Fax:

*

Payroll Provider(s):

*

Type of business:

LLC

Sole Proprietor

Partnership

Regular Corp.

S-Corp.

Prof. Corp.

If an LLC, how is the LLC taxed?

Corporation

Partnership

Business Inception Date:

*

State of Incorporation:

*

Fiscal Year End:

*

Business Code/Type:

Tax ID #/ Soc. Sec.#:

*

Union EE's?

Yes

No

Other Affiliated/Related Business:

Yes

No

Name(s):

Have you ever had another qualified retirement plan?

Yes

No

(If yes, additional information is required)

* Corporate Officers	Title	% of Stock Owned	Director on Board?

Attorney:

Broker:

Accountant:

Firm:

Firm:

Firm:

Address 1:

Address 1:

Address 1:

Address 2:

Address 2:

Address 2:

City:

City:

City:

State:

Zip:

State:

Zip:

State:

Zip:

Remarks: