Client Information

Your Name*:

Physical Address (cannot be a PO Box)*:

Telephone 1*:

Telephone 2:

Telephone 3:

Email*:

Note: The person listed above will serve as the Incorporator of the new corporation. The e-mail address provided above may be used by the Secretary of State to send annual renewal reminders and other important notices that may require action or response regarding your corporation.

Corporation Board of Directors and Officers

Corporate Director(s):

Corporate President:

Corporate Secretary:

Corporate Treasurer:

Note: In most states, you can serve in all capacities (we will let you know if you can't). If you list someone other than yourself as the director, please include such person's address.

Provide desired corporation name and alternative name if the first preference is not available.

First Corporation Name Preference:

Second Corporation Name Preference:

Note: The corporation name must include one of the following words or abbreviations: Corporation, Incorporated, Limited Corp., Inc. or Ltd. The word “Company” may not be preceded by the word “and” or a symbol denoting it, such as “&.”

Corporation's Primary Address:

Physical Address (cannot be a PO Box):

Note: It must be a specific address in the state where the Corporation being registered and cannot be a post office box. Please include the County.

Please provide the name of the corporation’s registered agent and the corporation’s registered office:

Registered Agent Name:

Physical Address (cannot be a PO Box):

Note: You can serve as the resident agent if you have an address in the state where the business will be located. If you list someone other than yourself as the resident agent, you confirm that such person has consented to act as the resident agent of the corporation.

Retirement Account Information

Have there been any rollovers within any of the below referenced accounts within the last 12 months?YesNo

If yes, please explain:

Please list the information of all individuals that will be using retirement funds to finance the corporation:

I have confirmed with my retirement account custodian that my funds can be transferred.I have also confirmed the retirement plan I am transferring is a former employer plan not a current employer or a Roth IRA. I acknowledge that I am ultimately responsible for ensuring that my funds are eligible for transfer/rollover into this new 401k plan.

Non-Retirement Funds: Please list all parties investing personal funds in your Corporation

401(k) Plan Mailing Address

Client AddressCorporate AddressCorporate Mailing AddressOther

If other, please indicate the address below:

Proposed Transaction

Are you purchasing an existing business?YesNo

If you are purchasing an existing business, are you purchasing the business from an unrelated person?YesNo

If no, please explain:

If you are purchasing an existing business, does the business have an existing retirement plan of any type?YesNo

Please explain what type of business will be conducted:

Do you contemplate the ROBS 401k Plan funded corporation will purchase, lease or otherwise occupy real estate that is owned by you, a family member or any entity in which you or any family member have any ownership?YesNo

If yes, please explain:

Do you anticipate the ROBS 401k Plan funded corporation entering into any type of commercial transaction or dealings with you, a family member or any entity in which you or any family member have ownership?YesNo

If yes, please explain:

Related Businesses

Do you, your spouse, your children, or other investor(s) currently have an ownership interest in any other business entities (including sole proprietorships, inactive and shell entities)?YesNo

If yes, please provide information on each business or entity below. Please let us know if you have more than three businesses to identify.

#1 Currently Owned Business

#2 Currently Owned Business

#3 Currently Owned Business