Integrated Wealth Strategies, LLC

Section I: Employer Information

*Employer name (or DBA)

*Plan Name:
Most likely: Bob Smith 401(k) plan; Evergreen Services, LLC 401(k) plan

*Contact person:

*Mailing Address:

Mailing Address (continued):

*City

*State
(2 letter abreviation)

*Telephone
(Please enter as: xxx-xxx-xxxx)

*Email Address:

*Business Entity Type: Select Sole Proprietor LLC

Date Desired
Mon - Thursday

Section II: Plan Information

*Enter Security Code

*Required