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Plan Contact Information (Required Fields)
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*TDA675*
Return Options:
Electronically via Message Center:
Log in and go to Client Services >
Message Center to attach the le
Regular Mail:
PO Box 0, Omaha, NE 10-0
Overnight Mail:
00 South 10th Avenue
Omaha, NE 1-1
Fax: --
Qualied Retirement
Plan (QRP) Plan Status
Information Form
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Single Participant/Business Partners (can include Spouse)
Note: Owner-Only plans (plans with no participants other than business owner(s) and spouses of owners who work for the business) should check here.
If the plan is a Prot Sharing or Money Purchase Pension Plan, also check "No" for "ERISA 0(c) Compliance" in Section of the Adoption Agreement
(not applicable to the Individual 01(k) Adoption Agreement).
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ERISA Plan - Plan with eligible employees
Questions? Call a Client Services representative at 800-669-3900.
Account #:
Company Name:
Plan Fiduciary/Employer Name:
Name of Plan: Plan/Employer TIN (if applicable):
Middle Name: Last Name:
City: State: Zip Code: Country:
Fidicuiary's Address (No PO Boxes):
Fiduciary/Employer's Email:Fiduciary/Employer Phone Number:
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Check here if this is not a U.S. phone number
If you have a Third Party Administrator (TPA) or a Recordkeeper associated with your plan, please provide the following information:
TPA/Recordkeeper Name: Contact Name:
Mailing Address (No PO Boxes):
Phone number: Email:
City: State: Zip Code: Country:
