Retirement Plan Employee Census

Name of Employer: *

Data as of: *

Controlled Group:Yes No *


Employee name:	M/F:	DoB:	Date of Employment:	Officer/ Director:	% Stock/ Business Owned:	Annual Compensation:	# of Hours	Job Title	Smoker:	Relationship to Owner:

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.