Year-End Summary Questionnaire

REQUIRED GOVERNMENT REPORTING: This entire questionnaire must be completed. The year‐end documents provide us data needed to perform the annual plan testing and Form 5500 tax reporting for the plan. Please be aware that we may request additional information based on your responses in order to be able to complete your annual testing and reporting. Questions? email us at:

I. Information About You

Information about the C-corporation that you funded with your retirement funds

1. Enter the name of the C-corporation that you funded with your retirement funds

2. Enter Business Address & Business Telephone Number

3. Enter the six-digit business activity code that best describes the nature of the C-corporation’s business. You can find the list of business activity codes on pages 9-11 of the instructions for Form 5500-EZ here.

4. If the name and/or EIN of the Company has changed, please enter new name and/or EIN. If not, please enter “N/A”.

5. Did you or any other investors invest additional retirement or non-retirement funds in the business in 2015 or 2016? Has there been any change in the owners or ownership percentages during the last plan year? For example, did the corporation issue new shares of stock, did any of the owners sell any of their stock, etc. YesNo

If yes, please explain:


6. Does the C-corporation have any leased employees? If yes, please include their information on the Employee Survey. YesNo

7. Did any employees who were participating in the 401k plan separate from employment or retire from the C-corporation?YesNo

8. Did any participants in the 401k plan decease? YesNo

9. Does the Plan benefit any collectively bargained employees? YesNo


II. Investment of Retirement Funds from the ROBS 401k Business Financing Plan into the C-corporation Bank Account

For each former employer retirement account and IRA that you transferred to the Fidelity/Schwab/TD brokerage account for the ROBS 401k Business Financing plan, list the EXACT amount (no rounding) of funds transferred from each former employer retirement account or IRA. For EACH former employer plan or IRA, please also provide copies of each 1099R that you received in connection with the transfer or directed rollover to the ROBS 401k Business Financing Plan.

Example: John Smith used our 401k Business Financing plan to start a franchise. John transferred $165,000 from a Traditional IRA and $45,000 from his former employer 401k into the Fidelity brokerage account for the new 401k (total transferred: $210,000). John then invested $150,000 into the company stock of his new business. John should enter $210,000 below, the date of the rollover and provide two (2) 1099r forms (i.e., one for each transfer from each retirement account).



State the EXACT amount (no rounding) of funds invested from the 401(k) Business Financing Plan account to the C-corporation bank account for the purchase of company stock. If there was no purchase of corporate stock with rollover funds, enter “N/A”.


III. Plan Assets and Liabilities

10. Enter the name of the 401k plan (i.e. 401k Business Financing plan):

11. Excluding the C-corporation stock purchased with retirement funds, were the other amounts in the 401k plan (i.e., typically the Fidelity brokerage account) invested in traditional investments such as stocks, bonds, mutual funds, etc.? YesNo

If some amounts in the 401k plan were invested in other alternative investments such as real estate, precious metals, etc., please explain below:

Note: Please separately email us the year-end account statement for all participants in the 401k (e.g., Fidelity brokerage account statement).

12. Does the 401k plan have any liabilities? YesNo

Note: this question does not refer to liabilities of the C-corporation. If yes, please explain below:


IV. Income, Expenses, and Transfers

13. Were any employee contributions made to the 401k? For example, an employee contribution would include any portion of your w-2 income from the C-corporation that you contributed to the 401k. YesNo

14. Did the C-corporation make any contributions (e.g., profit-sharing or matching) to the 401k? Please note that this does not include dividends that may have been deposited in the 401k on account of the company stock that you hold in the 401k account. YesNo

15. Were any non-cash contributions made to the 401k plan? For example, if you transferred shares of stock to the 401k plan from a previous employer plan, you would enter the value of the stock on the date it was transferred to the 401k plan. YesNo

If yes, please explain below:


16. Were there any distributions of cash or other assets from the 401k plan? For example, if you took a cash distribution from the Fidelity brokerage account.YesNo

If yes, please explain below:


17. Did the 401k plan have any expenses? Note: this question does not refer to expenses of the C-corporation. YesNo

If yes, please explain below:


V. Participant Loans

18. Were there any outstanding participant loans? For example, a participant loan would include a loan that you personally took from the 401k. YesNo
If yes, please enter the balance as of June 30, 2016


VI. Fidelity Bond Coverage Information

19. Was the plan covered by a fidelity bond ? A Fidelity bond is required if any employees besides the business owner(s) are eligible to participate in the 401k plan. The bond is meant to protect the plan funds from bad acts (fraud, theft, etc.) by the plan’s trustee(s).YesNo


VII. Compliance Questions

20. Were there any nonexempt transactions with any party-in-interest? For example, did the 401K plan engage in any transactions with any owner or officer of the C-corporation, a family member of any owner or officer of the C-corporation, or any entity in which any owner or officer of the C-corporation has any ownership interest? YesNo

If yes, please explain below:


21. Has the plan failed to provide any benefit when due under the plan? For example, has the 401k plan failed to pay 401k benefits to any participating employees who no longer work for the company?YesNo

22. At any time during the plan year, was there a period of three or more consecutive business days during which participants or beneficiaries of the plan were unable to, or were limited or restricted in their ability to, direct or diversify assets credited to their accounts, obtain loans from the plan, or obtain distributions from the plan?YesNo

23. Has a resolution to terminate the plan been adopted during the plan year or any prior plan year?YesNo

24. Were any assets or liabilities transferred from this plan to another plan?YesNo



  I understand that ANY interaction or co-commerce between any entity/business I have an ownership interest in and the new corporation that was set up as part of my 401k Business Financing Plan may constitute a prohibited transaction. If I decide that the entity or entities in which I have a personal ownership interest will interact with the C-Corporation in any way, I agree to consult with my outside legal counsel prior to such interaction. I agree to inform my outside legal counsel of all facts relating to any such possible interaction. By checking this box, I indicate that all individuals involved in the C- Corporation structure understand and agree to the above statements.

  I understand and agree (1) that Selfstarter LLC has been authorized in writing by the company named above in its capacity as the plan administrator/plan sponsor (“Company”) to electronically submit the annual Form 5500; (2) that a copy of this specific written authorization will be kept in the records of Selfstarter LLC; (3) that, in addition to any other required schedules or attachments, the electronic filing includes a true and correct PDF copy of the completed Form 5500 (without schedules or attachments) bearing the manual signature of the Company under penalty of perjury; (4) that Selfstarter LLC advised the Company named above that the image of the company’s manual signature will be included with the rest of the return/report posted by the Department of Labor on the Internet for public disclosure; and (5) that Selfstarter LLC will communicate to the Company any inquiries and information received from EFAST2, DOL, IRS or PBGC regarding the return/report.

  Please check this box when this entire form is complete.

By checking the box above, this will represent your signature whereby you understand that you must provide complete and accurate responses to all of the questions within this Year‐End Summary Questionnaire. Testing and reporting will be completed based on my responses. You hold Selfstarter LLC harmless for inaccurate recordkeeping services arising from your failure to provide the Year‐End Summary Questionnaire and any required supporting documents and information on a timely basis. Further you agree to hold Selfstarter LLC harmless for any excise taxes or penalties resulting from your late filing of the Form 5500. You declare that you have completed this summary to the best of your knowledge and ability.