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 “&.”
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.
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?YesNo
If yes, please explain:
Account Owners Name*:
Type of Account*: 401(a)401(k)403(b)457DBPESOPKEOGHAnnuityQRPREITIRRAFERS/CRSIRARoth IRASEP IRARoth AnnuitySIMPLE IRAVariable AnnuityThrift Savings Plan
Name of Custodian*:
Inherited Account*: YesNo
Account Owners Name:
Type of Account: 401(a)401(k)403(b)457DBPESOPKEOGHAnnuityQRPREITIRRAFERS/CRSIRARoth IRASEP IRARoth AnnuitySIMPLE IRAVariable AnnuityThrift Savings Plan
Name of Custodian:
Inherited Account: YesNo
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 AddressCorporate AddressCorporate Mailing AddressOther
If other, please indicate the address below:
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 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 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?YesNo
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?YesNo
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.
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? YesNo
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