Page 1 of 2 TDA 675 F 10/21
Plan Contact Information (Required Fields)
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 10th Avenue
Omaha, NE 1-1
Fax: --
Qualied Retirement
Plan (QRP) Plan Status
Information Form
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 Prot 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).
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:
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:
Reset Form
Page 2 of 2 TDA 675 F 10/21
Employee Information
Please list all TD Ameritrade accounts within your qualied plan. This section is used to identify all employees covered by specic
employers to remove them from the administrator mailing lists.
Employee Name TD Ameritrade Account Number
Relationship for Owner Only Plan
(Self, Spouse, Minor Child, Partner)
Employer's Signature:
Sign Here
are required;
fonts are not
Title:Print Name:
TD Ameritrade, Inc., member FINRA/SIPC, a subsidiary of The Charles Schwab Corporation.
TD Ameritrade is a trademark jointly owned by TD Ameritrade IP Company, Inc. and The Toronto-Dominion Bank.
©01 Charles Schwab & Co. Inc. All rights reserved.
Investment Products: Not FDIC Insured * No Bank Guarantee * May Lose Value