<p> 111A1m1e1r1i1c1a1n1 1P1e1n1s1i1o1n1 1C1o1r1p1o1r1a1t1i1o1n1 111317151 1P1L1A1I1N1F1I1E1L1D1 1A1V1E1N1U1E1 1 W1A1T1C1H1U1N1G1,1 1N1E1W1 1J1E1R1S1E1Y1 10171016191 1(1910181)1 1715171-151115111 1 1F1a1c1s1i1m1I1l1e1 1(1910181)1 1715171- 191614141 1 1 1P1L1A1N1 1S1P1O1N1S1O1R1 1Q1U1E1S1T1I1O1N1N1A1I1R1E1 1 1N1A1M1E1 1O1F1 1B1U1S1I1N1E1S1S1: 1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_ 1_1_1_1_1_1_1_1_1_1_1 1B1U1I1S1N1E1S1S1 1A1D1D1R1E1S1S1:1_1_1_1_1_1_1_1_1_1_1_1______EXPRESS SERVICE ADDRESS:______(real location, if different) ______TELEPHONE: (_____) ______-______FAX: (_____) ______-______E.I.N.: ______- ______(tax number) STATE of INC. (business):______DATE BUSINESS BEGAN (or D.O. Inc.):______FISCAL Year-end:____/____ (month/day) TYPE OF BUSINESS ENTITY: Reg. Corp. P.A. LLC Sole Prop. Exempt Sub-S P.C. LLP Partnership Govnmt [ ]Single-Employer Plan [ ]Controlled Group [ ]Church Group [ ]Affiliated Service Org. [ ]Government Org.</p><p>NATURE of BUSINESS: ______COUNTY: ______Numeric Business Code: ______if known COMPANY OFFICERS: President: ______Secretary: ______Vice Pres: ______Other: ______</p><p>COMPANY OWNERS: ______% (and percent owned) ______% ______% ______%</p><p>If this is a Controlled Group, or an Affiliated Service Organization, please provide information on those other companies (Relationship, Ownership, Number of employees, Business, Plans in effect).</p><p>American Pension Corporation</p><p>NAME of ATTORNEY or ACCOUNTANT: ______Telephone: ______Fax: ______Address: ______</p><p>Plan Information, if determined NAME OF PLAN: ______</p><p>03bf83310424cfe71258648687df6690.doc Page 1 of 2 TYPE OF PLAN: ______401(a) 401(k) Safe-Harbor Simple-I.R.A. 403(a) 403(b) Who will sign 5500 for the Employer: ______Title: ______Who will sign 5500 as Plan Administrator: ______Title: ______Employer Contact for Year-end Information: ______Title: ______Email addr: ______Tel Ext: ______PLAN'S EFFECTIVE DATE: ____/____/______PLAN'S YEAR-END:______/______(month/day) PLAN NUMBER: ______Plan's T.I.N. ______-______(tax number) ELIGIBILITY: Age______Service______Exclusions: ______Vesting Entry Dates: ______Other: _____% 1 _____% 2 _____% Hours or other Requirement for a Contribution: ______3 _____% 4 _____% Ret. Age: ______Years part: ______Other Option: ______5 _____% 6 _____% Loans: Rate ______% Number Allowed: ______Other: ______7 _____% In-service Distributions: ______MATCH: Matching Percent: ______% Maximum Percent of Salary Matched: ______% $______ALLOCATION FORMULA: ______Investment Program: ______Primary Investment Representative: ______Tel: ______Fax: ______TRUSTEES:______S.S. # ______S.S. # ______S.S. # ______</p><p>Last Plan Document Sponsor (by): ______Approval Letter Date: ______Other Plans in effect: ______OTHER INFO: ______</p><p>2 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222</p><p>03bf83310424cfe71258648687df6690.doc Page 2 of 2</p>