*Required Fields

Section I - Company Information

* Name of Company:

* Address:

Web Address:

* City, State ZIP:

* Primary Contact:

* Email:

* Phone:

Fiscal Year End (month/day)

Date Business Established (month/year)

Business Structure

C Corporation

S Corporation

Partnership

LLP

Sole Proprietor

LLC

(is taxed as a

Corporation or a

Partnership? Please check one)

Does the employer currently have or ever had a non-qualified deferred compensation plan?

Yes

No

If yes - please complete Section II.

Section II - For Existing Plan (Complete for existing plan only)

Number of nonqualified plans?

Effective Date(s) of Existing Plan(s):

Has existing plan been filed with Department of Labor?

Yes

No

Unknown

Plan Type(s) :

Non Account Balance (define benefits)

Account Balance (define benefits)

Other (describe briefly)

Existing Plan Administrator

Issues (if any)?

Has the plan been amended to comply with Section 409A of the Code?

Yes

No

if yes, briefly describe action taken with regard to 409A compliance

Section III - Financial Information

Please provide previous two years financial statements.

Section IV - Participant Eligibility Requirements (complete for all plans)

DEFINITION OF ELIGIBILITY

Those Executives designated by Board of Directors

All Executives with a position ranking above

All Executives earning a minimum of $

per year.

By class of management title:

Other :

Please complete attached census.

It is important that eligibility be limited to a “select group of management or highly compensated employees.” Known as the top-hat exemption, this design is used to avoid unwanted income tax and ERISA consequences. The following are guidelines when determining the eligible group: (1) less than 10% of total employees, (2) $95,000 + of total wages, (3) the plan participant, by virtue of their position or compensation level, has the ability to influence the design and operation of the plan, (4) average compensation of Top-Hat group is 3 times greater than the average compensation of the non Top-Hat group.

Section V - Defined Contribution Plans (complete for defined contribution plans only)

ELIGIBLE COMPENSATION

(Please select all that apply)

Base Salary/Wages

Discretionary Bonuses

Non-Performance Based Compensation

Performance Based Compensation

Commissions

Long-Term Incentive Plan Income

1099 Independent Contractor Fees

Other:

EMPLOYER CONTRIBUTIONS:

Discretionary

%, with a cap of $

Matching (indicate percent)

% of compensation, with a cap of $

Uniform dollar amount: $

Other :

VESTING SCHEDULE FOR EMPLOYER'S CONTRIBUTIONS:

Based on:

OR

Years of Participation?

Years of Service?

Vesting :

None (0% pre-retirement - 100% at retirement)

Cliff vesting in year

(e.g. 0% for 5 years, 100% thereafter - favors employer)

Graded vesting in year

years (e.g. 10% per year for 10 years - favors executive)

Other :

Section VI - Defined Benefit Plans (complete for defined benefit plans only)

DATE OF RETIREMENT:

The date Participant attains age

The earlier of: (a) the date the Participant attains age

OR (b) the date the Participant

completes

years of Service ( or

years of Plan Participation)

The later of: (a) the date the Participant attains age

OR (b) the date the Participant

completes

years of Service ( or

years of Plan Participation)

RETIREMENT BENEFITS:

Stated dollar amount: $

per year for

years.

OR

Formula based on compensation

OR

Formula based on service or participation

Other:

Define exact benefit formula:

BENEFIT FORMULA COMPONENTS:

Current Salary

Future Salary

Final Average Salary ( years to average)

Scale %

Current Bonus

Future Bonus

Final Average Bonus ( years to average)

Scale %

Current Comp

Future Comp

Final Average Comp ( years to average)

Scale %

OTHER PLAN DESIGN FEATURES: ( Please check all that apply)

First Payment Date

First day of the first month following the date of retirement

January 1st following the date of retirement

days following retirement

Other:

Date of Full Eligibility (the date a Participant becomes eligible to receive full benefits)

Entry into the plan

Retirement Age

Yrs of Plan Participation

Yrs of service

The earlier of: (a) the date the Participant attains age

OR (b) the date the Participant

completes

years of Service ( or

years of Plan Participation)

The later of: (a) the date the Participant attains age

OR (b) the date the Participant

completes

years of Service ( or

years of Plan Participation)

Vesting of Accrued Benefits (define what and when Participant is eligible to receive a benefit if separation of service occurs prior to the scheduled retirement date)

No benefit payable prior to Retirement

Participant will receive a percentage of accrued benefit at the otherwise scheduled retirement date

Participant will receive a percentage of accrued benefit following separation of service

Accrued benefits based on :

Years of Plan Participation

Years of service

Calculation of Accrued Benefits

Pro-rata amount based on actual participation or service

Based on vesting table :

Cliff vesting in year

Graded vesting over

years

Other:

Section VII - General Provisions (complete for all plans)

ADDITIONAL BENEFITS TO BE PROVIDED:

Pre-Retirement Death Benefit: (other than Split Dollar arrangements)

Stated dollar amount ($

) (attach list if it varies in amount by individual participant)

Vested accrued benefit

Other:

Pre-Retirement Death Benefit - Split Dollar ONLY: (define either EMPLOYER or EMPLOYEE share)

Employer share of death benefit :

Employee share of death benefit :

Split Dollar death benefit applies:

PRE-RETIREMENT ONLY

POST-RETIREMENT ONLY

BOTH PRE & POST-RETIREMENT

Disability Benefit:

Yes

No

if YES, Accelerate Vesting (if applicable)

Yes

No

Other:

Change of Control Benefit:

Yes

No

if YES:

Accelerate Vesting

Accelerate Payment

Both

Other:

Financial Hardship Withdrawls:

Yes

No

OTHER BENEFITS?

A plan sponsor should carefully consider the vesting provisions of the plan agreement as an increase in the vested benefit may trigger FICA/FUTA taxes in the year in which they vest. See IRC code section 3121(v)(2)

Section VIII - Benefit Distributions (complete for all plans)

BENEFIT DISTRIBUTION OPTIONS

(Check the distribution choices and benefit payment options that the Plan Sponsor wants to offer the Participant (if any) as part of the Plan Agreement)

1. Benefit Distribution Choices:

2. Benefit Payment Choices

Section IX - Informal Plan Funding (complete for all plans)

With key person life insurance (COLI) (name of carrier

With life insurance using endorsement split dollar (name of carrier

With mutual funds (name of fund family

NO INFORMAL FUNDING

If Life Insurance Funding:

Participant's benefits based on policy cash value (a.k.a "fully informally funded")

OR

Participant's benefits based on policy unit value performance (a.k.a "deemed investments")

OR

Participant's benefits based on policy death benefits (a.k.a "cost recovery/mortality funded")

Section X - Additional Comments

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