Physical Address (cannot be a PO Box):
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.
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.
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 “&.”
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.
Registered Agent Name:
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.
Have there been any rollovers within any of the below referenced accounts within the last 12 months? Yes No
If yes, please explain:
Account Owners Name:
Type of Account: 401(a) 401(k) 403(b) 457 DBP ESOP KEOGH Annuity QRP REIT IRRA FERS/CRS IRA Roth IRA SEP IRA Roth Annuity SIMPLE IRA Variable Annuity Thrift Savings Plan
Name of Custodian:
Rollover Full Partial
Inherited Account: Yes No
I have confirmed with my custodian that my funds can be transferred and I acknowledge that I am ultimately responsible for ensuring that my funds are eligible for transfer/rollover into this new 401k plan.
Account Owner Name:
Client Address Corporate Address Corporate Mailing Address Other
If other, please indicate the address below:
Are you purchasing an existing business? Yes No
If you are purchasing an existing business, are you purchasing the business from an unrelated person? Yes No
If you are purchasing an existing business, does the business have an existing retirement plan of any type? Yes No
Please explain what type of business will be conducted:
Do you contemplate the 401k SelfStarter Plan 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? Yes No
Do you anticipate the 401k SelfStarter Plan 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? Yes No
Do you, your spouse, your children, or other investor(s) currently have ownership interest in any other business entities (including sole proprietorships, inactive and shell entities)? Yes No
If yes, please provide information on each business or entity below. Please let us know if you have more than three businesses to identify.
Active: Yes No
What does it do?
Your Spouse's Ownership:
List other owners, their relationship to you, and percentage of their ownership:
# of Employees:
# of 1099 Contractors:
Type of Existing Retirement Plan:
Will this business interact with the 401k SelfStarter Plan corporation in any way? Yes No
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