Authorization Form Page 4

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Are there any controlled/affiliated service group businesses including spouses?
No
Yes
(If yes include: Employer, entity type, % ownership, authorized signer and title):
Does employer have/had any other qualified plans in past 5 years?
No
Yes: IRS#
Plan Name
Plan Type
Active or Terminated?
CLIENT RESPONSIBILITY CHECKLIST
Promptly provide NPC: annual census, ERISA bond, terminations and investment statements.
Additional documents (including amendments) may be requested for takeover plans under audit.
Provide participants: beneficiary/enrollment forms, SPDs, blackout notice, PPA quarterly benefit
statement and 404(a)(5) Participant Fee Disclosure. These may come from NPC or other sources.
Timely 401k and participant loan deposits required.
Review 401k General Overview (ADP, Top-Heavy, 100% vest Safe Harbor w/ no last day).
Review DB General Overview (required contribution, permanency, possibly PBGC reporting).
Notify NPC of Financial Institution choice or change, so NPC can disclose revenue sharing.
NPC requires all information within 8 months after the Plan year end or a rush fee applies.
Install / Restate:
Base $
Plus $
/ Participants
= $
Administration:
Base $
Plus $
/ Participants
= $
Please see Fee Schedule for a complete list of all fees.
Notes:
X
(Signature)
(Date)
I AUTHORIZE NICHOLAS PENSION CONSULTANTS TO PERFORM THE WORK FOR THE FEES LISTED
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