EQUITY QUESTIONNAIRE YEAR ENDING DECEMBER 31, 2012 AMBROSE MULTIPLE EMPLOYER RETIREMENT SAVINGS PLAN

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1 EQUITY QUESTIONNAIRE YEAR ENDING DECEMBER 31, 2012 AMBROSE MULTIPLE EMPLOYER RETIREMENT SAVINGS PLAN IMPORTANT NOTICE (PLEASE READ) IN ORDER FOR AMBROSE TO COMPLETE THE RETIREMENT PLAN TESTING 1 AS REQUIRED BY THE INTERNAL REVENUE CODE IN A TIMELY FASHION, THIS FORM MUST BE RETURNED TO AMBROSE NO LATER THAN MONDAY, DECEMBER 31, KINDLY HAVE THE COMPLETED FORM SIGNED BY AN EXECUTIVE OFFICER, PARTNER OR MANAGING MEMBER AND RETURN TO AMBROSE AS A PDF DOCUMENT VIA TO 401K@AMBROSEGROUP.COM. ALTERNATIVELY, YOU MAY MAIL THIS FORM TO AMBROSE EMPLOYER GROUP, LLC, 301 TRESSER BLVD, 13 TH, FL STAMFORD, CT OR FAX IT TO IF THIS FORM IS RECEIVED AFTER MONDAY, DECEMBER 31, 2012, YOU MAY BE SUBJECT TO A TEN PERCENT (10) EXCISE TAX IMPOSED BY INTERNAL REVENUE CODE SECTION 4979 ON EXCESS CONTRIBUTIONS TO THE PLAN FOR YOUR GROUP AND/OR A $500 CHARGE FOR TESTING REVISIONS. IF YOU HAVE ANY QUESTIONS REGARDING THIS FORM OR THE INFORMATION THAT IS REQUIRED, PLEASE CONTACT AMBROSE AT (646) PLEASE REFER TO THE AMBROSE MEMORANDUM ENTITLED, RETIREMENT PLAN OVERVIEW, LOCATED AT FOR AN OVERVIEW OF THE AMBROSE MULTIPLE EMPLOYER RETIREMENT SAVINGS PLAN AND THE INTERNAL REVENUE CODE PROVISIONS REGULATING THE ADMINISTRATION OF THE PLAN. 1 Code Section 401(k) nondiscrimination testing for salary deferrals from employees (the ADP Test ); Code Section 401(m) nondiscrimination testing for employer matching employer (if applicable)(the ACP Test ); Code Section 404 deduction limits; Code Section 415(c)(1) annual addition limitation for contributions to participants accounts; and Code Section 416(g)(1)(A)(ii) top heavy testing to determine percentage of plan assets held in key employees accounts.

2 Retirement Plan Equity Questionnaire FAQ s 1. Q: I logged on to but cannot find the questionnaire. How can I get it? A: Unfortunately, third-party HR Managers do not have the same online access as internal HR Managers. If you are an external HR Manager (not an employee of the client company, even if you do have an address at the client company), please 401k@ambrosegroup.com and we will the questionnaire to you. 2. Q: Why does Ambrose need information related to ownership and compensation? Don t you already have our compensation? A: Ambrose requests the questionnaire be completed on an annual basis in order to have the most accurate information for 401(k) plan compliance testing. The IRS requires retirement plans to conduct annual compliance tests on the plan to ensure it meets the rules set forth. This ownership information is crucial to having the most accurate information to include on these tests. In addition, since K-1 income is not paid through Ambrose, it needs to be reported on this form to be included for total compensation on the tests. 3. Q: We don t have final K-1 figures yet. Can I wait to provide them? A: We ask for you to provide the best estimate for year-end numbers as possible. If you will have the final figures prior to 1/14/13, please provide estimates now and an update before that date. Also, if you are unsure about the final exact numbers but you know that it will certainly be over $250,000, you can provide the $250,000 to us since that is the maximum compensation taken into account for compliance purposes. 4. Q: Does each member of our organization need to fill this form out, or can one representative from the Company complete it? A: Even though this questionnaire was sent to all listed HR Manager contacts, we only need one completed form per company. 5. Q: We are a safe harbor plan; do we still need to complete it? A: Ambrose requests this information from all clients, including safe harbor plans. In 2010, we began conducting interim (mid-year) compliance testing for all clients in order to monitor their status throughout the year. Since the safe harbor contribution is an annual election, if a company decides to remove the safe harbor one year, we will need this information to conduct testing in the subsequent years. In addition, even safe harbor plans can potentially be part of a controlled group (common ownership) and we need the information on the form to make that determination. 2

3 PLEASE COMPLETE THE BELOW INFORMATION Federal EIN: Legal Name: Main Address: Main Telephone: Ambrose HR Associate: Finance Contact & Title: Type of Business Entity: How are you Taxed? : YES NO 1. Does Client Company own any subsidiary companies with employees earning wages in the United States? (If yes, please attach a sheet listing each subsidiary and percentage ownership interest therein) 2. Do any of the corporate or individual equity owners (or the spouse or child of an individual equity owner) currently own 80 percent or more of another non-publicly traded company or business? (If yes, you MUST complete the attached Controlled Group Worksheet) 3. Did Client Company maintain another retirement plan in 2012? 4. Did Client Company maintain another retirement plan in 2011? IMPORTANT: If you maintained another plan in 2011, we also need a copy of your 2011 Testing Analysis and Results in order to properly test This analysis will indicate 2011 compensation levels, deferral amounts, HCE and NHCE designations etc., which is critical to properly completing your 2012 testing. 3

4 6. Please list all employees (or spouses, children, siblings, grandchildren or parents thereof) owning one percent (1) 2 or more, directly or indirectly, of Client Company at any time in calendar year 2011 or calendar year 2012: (This includes any partners, members, or other owners, that are on Ambrose s platform with ownership interests) NAME PERCENTAGE 7. Please list non-employee individuals, partnerships, estates, trusts, corporations and other entities owning, directly or indirectly, 3 fifty percent (50) or more of your company at any time during calendar year 2012: (This includes any partner, member, or other owner that is not on Ambrose s platform for payroll or other benefits) NAME PERCENTAGE 2 Vested stock options are considered in this determination. Thus, vested stock options are to be included in the numerator and in the denominator of the percentage ownership calculation. Non-vested stock options are to be excluded from this calculation. Code Sections 416 and 318(a)(4). 3 A partnership is considered to own stock owned by its partners. An estate is considered to own stock of its beneficiaries. A trust is considered to own stock owned by its beneficiaries unless the beneficiary s interest in the trust is a remote contingent interest. A corporation is considered to own the stock owned by a shareholder owning fifty percent (50) or more of the value of the stock. 4

5 8. Please list all employees related to any owners of the Client Company with the following familial relationships during calendar year 2012: spouse, children, parents, or grandchildren: 9. Please list all partners/members providing services to your company and each individual s estimated K-1 income for Please note that you only need to indicate K-1 income up to $250,000 per partner. Also, if you provide an estimate for testing purposes, you will need to provide us actuals by January 14, *If no K-1 Income is paid, PLEASE INDICATE N/A below **Failure to provide this information could negatively impact your test results 10. Please list all corporate officers. (Please note this is based on officer by function and according to the IRS definition anyone who holds executive administrative duties, such as (but not limited to): hiring/firing employees, signing tax returns, enter into contractual arrangements on behalf of the company). 11. If your company currently has an active Profit Sharing election, please check the box if you intend on making a profit sharing contribution for the 2012 Plan Year (to be paid in early 2013): If you check yes, please reach out to your Ambrose Retirement Plan Specialist ( or 401k@ambrosegroup.com) to discuss the Profit Share Modeling and Allocation: Yes: All Profit Share Allocation requests MUST be submitted by 2/15/13 or there is a $500 fee for any requests after that date. 5

6 THIS FORM IS REQUIRED ONLY IF CLIENT COMPANY PAID WAGES IN CALENDAR YEAR 2011 OR 2012 AND DID NOT PAY THOSE WAGES THROUGH AMBROSE EMPLOYER GROUP, LLC (If your company joined Ambrose after the start of 2012 and paid wages prior to coming onboard (in 2011 or 2012), please list below) Non-Ambrose Employee Census Request for Calendar Year 2011 & 2012 Social Security Number First and Last Name Year (2011 or 2012) Gross Wages (excluding wages paid through Ambrose) *Elective Deferrals *Match or Safe Harbor Match *Profit Sharing or Safe Harbor Profit Sharing * These columns are only applicable if Client Company participated in a 401(k) plan, other than the Ambrose Plan, in calendar year 2011, and are exclusive of contributions to the Ambrose Plan. 6

7 Signature and Acknowledgment I, the undersigned, do attest that the information contained herein is true, complete and correct. I accordingly indemnify all parties who may rely on such information. I further acknowledge that I cannot operate a separate qualified retirement plan without the written consent of the Trustees of the Ambrose Multiple Employer Retirement Savings Plan. Signature of Chief Financial Officer, Chief Executive Officer, General Partner, Managing Member Date Print Name & Title Address 7

8 Control Group Worksheet A separate table must be completed for EVERY company in which an owner of the Client Employer has a GREATER THAN 80 COMMON OWNERSHIP interest. Use additional sheets as necessary. All ownership interests must be identified for each company (including companies which have an ownership interest in other companies). The ownership total must equal 100. Failure to properly complete all information in this form could cause disqualification of the plan with resulting IRS fees and penalties. Business Name & Address: Tax ID#: Does this company have any employees? (Y or N): Is this company also a Client of AEG? (Y or N): Owner s Name Owned: Owner s Name Owned: TOTAL MUST EQUAL 100 Business Name & Address: Tax ID#: Does this company have any employees? (Y or N): Is this company also a Client of AEG? (Y or N): Owner s Name Owned: Owner s Name Owned: TOTAL MUST EQUAL 100 Business Name & Address: Tax ID#: Does this company have any employees? (Y or N): Is this company also a Client of AEG? (Y or N): Owner s Name Owned: Owner s Name Owned: TOTAL MUST EQUAL 100 8