Census Questionnaire

Plan Sponsor Name

Plan Year End

If this Plan covers employees of more than one company, please give the data for each company.

Names of Officers or Partners Who are Employees

Titles

Names of Stockholders/Partners Who are Employees

% of Stock/Partnership interest owned

Are there other businesses, incorporated or not, owned by this business or the owners of this business? Is this an affiliated service group?
Yes No

Please list the names of any employees who are related to stockholders.
Name	Relationship	Related to Whom

Fiduciary Surety Bonding Information

Name of Insurance Company

Amount of Bond

Did you, or a business you control, maintain any other qualified plan (including frozen plans) for which Pension Investors Corp. does not provide services?
Yes No
If Yes, explain:

Are there shared or leased employees?
Yes No

Completed By

Title

Date Completed

Forms