Retirement Plan Employee Census
Exact legal company name or individual's name: *
Data as of Prior Fiscal Year: * Controlled Group: *
Employee name: M/F: DoB: Date of
Employment: 		Officer/
Director: 		% Stock/
Business
Owned: 		Current Annual
Compensation: 		# of
Hours 		Job Title Smoker: Relationship
to Owner:

Must have Compensation History on ALL Employees for the Past Three (3) Years

Compensation is W-2 wages increased by elective contributions (Section 125-Cafeteria Plans and 401(k) deferrals). For Sole Proprietors and Partnerships compensation is earned income subject to self employment tax. The Senex Group assumes responsibility solely for the accuracy of calculations without regard to the validity or accuracy of the information provided.
Desired contribution/deduction: $ *
** If hours are currently less than 1,000 please indicate whether the employee ever worked 1,000 hours or more in any prior year.
Submitted by:
Broker/Agent name: * Date: *
Address 1: *
Address 2:
City: * State: * Zip: *
Phone: * Email Address: *
Wholesaler/Referral source:
All information contained herein is for the sole purpose of preparing a qualified plan proposal. All information will remain strictly confidential and will not be shared.
* denotes required fields
 
Arlene Williams Phone: 818.593.3535
The Senex Group Fax: 818.593.3550
Woodland Hills Financial Center arlene@senexgroup.com
21021 Ventura Boulevard, Suite 310
Woodland Hills, CA 91364