1790 005 401_k_ PDQ V1 USB 401P 401k Restatement
User Manual: USB-401P
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ab UBS Financial Services Inc.
Account Number ______________________________
401(k) PDQ – 2010 Restatement 1/10
401(k) Plan Document Restatement Questionnaire
(Use To Restate an Existing UBS Financial Services Inc. Prototype 401(k) Plan Document for IRS Mandated Changes)
Overview
All employers who sponsor qualified retirement plans (“Plan
Sponsors”) are required by the IRS to replace their current
plan documents with new plan documents that incorporate
the changes brought about by legislative and regulatory
changes, primarily the Economic Growth and Tax Relief
Reconciliation Act of 2001 (EGTRRA). Plan Sponsors who fail
to properly restate their qualified plan by the IRS mandated
deadline risk the tax-qualified status of the plan. This
questionnaire will help to guide Plan Sponsors and their
tax/legal advisors through this essential process.
This 401(k) Plan Document Restatement Questionnaire
gathers information that will be used to restate an existing
UBS prototype 401(k) plan document. Plan Sponsors who
do not follow this process to restate their plan will be
removed from the UBS prototype plan document program.
UBS Financial Services Inc. (UBS) now offers its retirement
plan clients a qualified plan prototype document service
through Ascensus, a retirement services company. The
annual fee for the service is $150, charged automatically
to the UBS master account for the plan.
To restate a UBS prototype plan document, the Plan
Sponsor must refer to a copy of its current UBS
prototype plan adoption agreement (including any
amendments adopted) to first complete this 401(k) Plan
Document Restatement Questionnaire. Upon receipt of this
Questionnaire, Ascensus will prepare the prototype plan
document for the Plan Sponsor’s review based upon the
information provided by the Plan Sponsor in this document.
All communication with the Plan Sponsor in connection
with the UBS prototype document service is conducted
electronically. Ascensus will create a secure file transfer
protocol (FTP) website for the Plan Sponsor and will provide
the Plan Sponsor with an e-mail detailing how to access the
site and retrieve its plan documents. Upon downloading
the documents, the Plan Sponsor will need to confirm that
the elections in the adoption agreement are correct. This
includes any options defaulted to those frequently selected
by Plan Sponsors. The Plan Sponsor will then need to sign
the adoption agreement and return a copy of it to
Ascensus with a Certification of Adoption (the new
adoption agreement, along with a copy of the basic plan
document which supports it, should be maintained in the
Plan Sponsor’s permanent records for the plan). Future
amendments to the prototype document, whether required
by the IRS or requested by the Plan Sponsor, will be
provided by Ascensus through the FTP website.
No Longer Using UBS Prototype Documents
UBS realizes that some Plan Sponsors may no longer need a UBS prototype plan document because they are obtaining plan
document services from their legal counsel, plan administration firm or other document provider. Please indicate below
whether you have discontinued using the UBS prototype plan document.
If you are no longer using a UBS prototype document, check this box, fill in your plan name, sign below and
do not complete the rest of this questionnaire.
I am no longer using a UBS prototype document. Please reclassify my qualified plan on your records as
using a non-UBS plan document.
Please sign below and return this page in the enclosed envelope to Ascensus DCS Unit:
By Regular Mail: P.O. Box 726, Brainerd, MN 56401
By Express or Overnight Mail: 415 8th Avenue NE, Brainerd, MN 56401
Plan Name
Legal Name of Plan Sponsor
Name _______________________________________________________ Title
Print Authorized Individual’s Name (Print Clearly)
Signed _______________________________________________________ Date
Authorized Individual for the Plan Sponsor
ab UBS Financial Services Inc.
Account Number ______________________________
401(k) PDQ – 2010 Restatement 2/10
Continued Use of UBS Prototype Documents
I want to continue to use a UBS prototype document. Please amend and restate my qualified plan based on
the information provided below.
Trustee/Custodian: Self-Trusteed (must complete Trustee information below)
UBS Financial Services Inc. as Custodian Wilmington Trust as Trustee
(Refer to the Signature Page, Appointment of Trustee, in the UBS Financial Services Inc. 401(k) Profit Sharing Plan Adoption
Agreement (No. 005 or 006))
Trustee:
Enter below the individual who is the trustee of the plan (may not be UBS or any of its employees or representatives).
Name of Trustee
Address
City State Zip Code
Title Phone
The trustee named here must match the trustee listed on the UBS Account Application and Agreement for ERISA Plans. If
you have more than one trustee for the plan, list additional trustees in the Comments/Notes section of this form.
Plan Sponsor Information
(Refer to Section I., Employer Information, in the UBS Financial Services Inc. 401(k) Profit Sharing Plan Adoption Agreement
(No. 005 or 006))
Plan Name
Legal Name of Plan Sponsor
Legal Address of Plan Sponsor
City State Zip Code
Employer Identification Number (i.e. Tax ID Number of Plan Sponsor) ___ ___ - ___ ___ ___ ___ ___ ___ ___
Trust Identification Number, if any (i.e. separate Tax ID Number for the Plan’s Trust) ___ ___ - ___ ___ ___ ___ ___ ___ ___
Plan Sponsor’s Tax Year End (Month/Day):
The plan year end will coincide with the employer’s tax year end unless a different plan year end is indicated here:
_________________________________________________________________
Type of Business Organization:
Sole Proprietorship Partnership C Corp
S Corp Limited Liability Company Other
3 digit Plan Number: ___ ___ ___
(Use the plan number on the most recent Form 5500.)
Number of Current UBS Prototype Adoption Agreement 005 006
Name of Plan Sponsor Contact Person
Title of Plan Sponsor Contact Person
Phone Number
E-mail (required)
Note: Plans will not continue to be maintained in the UBS qualified plan prototype document service without a
valid e-mail address.
Estimated Number of Participants in the Plan:
ab UBS Financial Services Inc.
Account Number ______________________________
401(k) PDQ – 2010 Restatement 3/10
Plan Effective Date
(Refer to Section II, Effective Dates, in the UBS Financial Services Inc. 401(k) Profit Sharing Plan Adoption Agreement
(No. 005 or 006))
1. The original plan effective date was
2. The plan will be restated effective January 1, 2010 for calendar year plans. For plans with a fiscal plan
year, the effective date will be the first day of the plan year ending in 2010. If you would like a different
restatement effective date, please indicate here:
Owner-Only Plans
If you are an Owner-Only plan, please check the box below and a plan document will be prepared for your plan
based on the previous UBS Prototype Owner-Only plan defaults.
I am on Owner-Only plan. Please prepare my new documents using the previous owner-only plan defaults.
(If checked, please proceed to the “Authorized Individual” section of this questionnaire.)
Employee Eligibility
(Refer to Section III, Eligibility Requirements and Service Crediting Rules, in the UBS Financial Services Inc. 401(k) Profit
Sharing Plan Adoption Agreement (No. 005 or 006))
3. Age: An employee must be 21 years old to participate in the plan, unless the employer chooses a lower age:
_____ (may not be higher than age 21)
4. Service: An employee must be employed for at least 1 year before being allowed to participate in the plan,
unless the employer chooses a different number of months:
_____ Months for Elective Deferrals (may not be higher than 12 months)
_____ Months for Matching and Profit Sharing Contributions (may not be higher than 24 months)
5. Union employees will be excluded from the Plan, unless otherwise indicated below:
Union employees will be included.
6. Non-resident aliens will be excluded from the Plan, unless otherwise indicated below:
Non-resident aliens will be included.
7. Employees who become employees as a result of a merger or acquisition transaction will be excluded from
the Plan until after the expiration of the “transition period”, unless otherwise indicated below:
Employees as a result of a merger or acquisition transaction will be included prior to the expiration of the
transition period.
8. All other employees will be included in the plan once they satisfy the eligibility requirements unless otherwise
indicated: __________________________________
___________________________________________
9. Entry dates will be the first day of the plan year and the first day of the seventh month of the plan year
(semi-annual entry dates), unless otherwise indicated below.
Immediately
Monthly
Quarterly
Annually
ab UBS Financial Services Inc.
Account Number ______________________________
401(k) PDQ – 2010 Restatement 4/10
401(k) Contributions and Employer Match
(Refer to Section VIII, 401(k) Features, and Section IX, Safe Harbor Rules for 401(k) Plans, in the UBS Financial Services Inc.
401(k) Profit Sharing Plan Adoption Agreement (No. 005 or 006))
10. Roth deferrals will not be permitted under this plan, unless otherwise indicated below:
Roth elective deferrals, in addition to pre-tax elective deferrals, will be permitted under this plan.
Are Roth deferrals being allowed for the first time? Yes No
11. Each participant may make Elective Deferrals in an amount up to ____ % of compensation each year,
in increments of ____ %.
12. Will a participant’s elective deferrals be made from the participant’s cash bonuses? Yes No
13. The plan will not have automatic elections for Elective Deferrals, unless otherwise indicated below:
The plan will have automatic enrollment for Elective Deferrals and the following percentage will be
automatically withheld ______ %.
The plan was amended in 2008 to incorporate the new safe harbor automatic enrollment provisions.
(If selected, please attach a copy of page 6, New Plan Provisions for Automatic Enrollment, from the
UBS Prototype Automatic Enrollment Amendment.)
14. Will the employer make matching contributions to the plan? Yes No
If Yes, matching contributions will be made with respect to which of the following types of contributions:
Elective deferrals
After-tax employee contributions
15. Matching contributions will be based on the following:
A discretionary amount that you determine annually
A mandatory fixed amount according to the following schedule
Elective Deferral Percentage Matching Percentage
Less than or equal to ______ % ______ %
Greater than _____, but less than or equal to ______ % ______ %
Greater than ______% ______%
(If you select this option, you are only required to complete one tier of the schedule above.
If you elect to complete additional tiers, the matching percentage on each subsequent tier must be less
than the prior tier)
If the mandatory fixed amount matching contribution is selected above, the match will not be made in
excess of $ ____________ or ______ % of the employee’s compensation for any plan year.
16. A participant who is employed on at least one day during the plan year will be eligible to receive a matching
contribution, unless any of the following conditions are selected below:
Last Day Requirement/Under 501 Hours – if an employee works less than 501 hours, the employee must
be employed on the last day of the plan year to receive a contribution.
Last Day Requirement - the employee must be employed on the last day of the plan year to receive a
contribution regardless of hours worked.
Last Day Requirement - the employee must be employed on the last day of the plan year to receive a
contribution regardless of hours worked, unless the participant terminated employment after attaining
normal retirement age or because of his or her death or disability.
Hours of Service Requirement - the employee will be required to work at least _______ hours
(cannot exceed 1,000) of service during the year in order to receive a contribution
ab UBS Financial Services Inc.
Account Number ______________________________
401(k) PDQ – 2010 Restatement 5/10
17. The 401(k) safe harbor provisions will not apply to this plan, unless indicated otherwise below:
The 401(k) safe harbor provisions will apply to this plan and the employer will make the following
ADP test safe harbor contribution each plan year.
Basic Safe Harbor Matching Contribution - the employer will make the basic matching contribution
equal to 100% of the employee’s elective deferrals that do not exceed 3% of the employee’s
compensation plus 50% of the employee’s elective deferrals between 3% and 5% of the
employee’s compensation.
Enhanced Safe Harbor Matching Contribution – the employer will make a matching contribution
equal to 100% of the employee’s elective deferrals not greater than _____ % (not less than 3%)
of the employee’s compensation plus ____ % of the employee’s elective deferrals between ____ %
and ____ % (not greater than 6%) of the employee’s compensation.
Safe Harbor Nonelective Contribution – the employer will make a nonelective contribution to
each eligible employee, whether or not they defer into the plan, in an amount equal to ____ %
(not less than 3%).
The safe harbor contribution indicated above will be made to:
All eligible employees (who, in the case of safe harbor matching contributions, make elective deferrals
to the plan)
Each eligible employee who is a nonhighly compensated employee (and, in the case of safe harbor
matching contributions, makes elective deferrals to the plan)
Profit Sharing Contributions
(Refer to Section VII, Profit Sharing Contributions, in the UBS Financial Services Inc. 401(k) Profit Sharing Plan Adoption
Agreement (No. 005 or 006))
18. Will profit sharing contributions be made to the plan? Yes No
If Yes, profit sharing contributions are allocated as follows:
Pro rata (nonintegrated)
Integrated with Social Security. The integration level will be the Social Security taxable wage base
in effect at the beginning of the plan year, unless a different integration level is indicated in the
Comments/Notes section of this questionnaire.
19. A participant who is employed on at least one day during the plan year will be eligible to receive a
contribution, unless any of the following conditions are selected below:
Last Day Requirement/Under 501 Hours – if an employee works less than 501 hours, the employee must
be employed on the last day of the plan year to receive a contribution.
Last Day Requirement – the employee must be employed on the last day of the plan year to receive a
contribution regardless of the hours worked.
Last Day Requirement - the employee must be employed on the last day of the plan year to receive a
contribution regardless of the hours worked, unless the participant terminated employment after
attaining normal retirement age or because of his or her death or disability.
Hours of Service Requirement - the employee will be required to work at least _______ hours
(cannot exceed 1,000) of service during the year in order to receive a contribution
Other Employee Contributions
(Refer to Section VII, Profit Sharing Contributions, in the UBS Financial Services Inc. 401(k) Profit Sharing Plan Adoption
Agreement (No. 005 or 006))
20. Rollover contributions will be permitted into the plan, unless otherwise indicated below:
The plan will not permit rollover contributions into the plan.
21. Transfer contributions will be permitted into the plan, unless otherwise indicated below:
The plan will not permit transfer contributions into the plan.
22. After-Tax employee contributions will not be permitted into the plan, unless otherwise indicated below:
The plan will permit after-tax employee contributions into the plan.
ab UBS Financial Services Inc.
Account Number ______________________________
401(k) PDQ – 2010 Restatement 6/10
Vesting and Forfeitures
(Refer to Section IV, Vesting, in the UBS Financial Services Inc. 401(k) Profit Sharing Plan Adoption Agreement
(No. 005 or 006))
23. Matching and profit sharing contributions will vest according to the following schedule (with the exception of
Safe Harbor Matching Contributions which are 100% vested at all times) (select one):
Years of
Service
Option 1 Option 2 Option 3 Option 4 (Complete if chosen)
0 100% 0% 0% ______ %
1 100% 0% 0% ______ %
2 100% 0% 20% ______ % (not less than 20%)
3 100% 100% 40% ______ % (not less than 40%)
4 100% 100% 60% ______ % (not less than 60%)
5 100% 100% 80% ______ % (not less than 80%)
6 100% 100% 100% 100%
Note: If no vesting option is selected, Option 1 will apply.
Distributions
(Refer to Section X, Other Options, in the UBS Financial Services Inc. 401(k) Profit Sharing Plan Adoption Agreement
(No. 005 or 006))
24. Will in-service distributions of elective deferrals (including Roth, if applicable) be permitted? Yes No
If Yes, in-service distributions will be available at all times permitted under law or regulations unless additional
requirements are selected below:
Upon attainment of age_____ (must be at least age 59½)
Upon hardship
25. Will in-service distributions of matching and profit sharing contributions be permitted? Yes No
If Yes, in-service distributions will be available at all times permitted under law or regulations unless additional
requirements are selected below:
Upon attainment of age 59½
Upon attainment of normal retirement age
Upon reaching a vested percentage equal to 100%
After participating in the plan for a period of five years
Upon hardship
26. Will distributions of rollover and transfer contributions be permitted at any time? Yes No
Loans and Plan Investments
(Refer to Section X, Other Options, in the UBS Financial Services Inc. 401(k) Profit Sharing Plan Adoption Agreement (No.
005 or 006))
27. Loans are not permitted from the plan, unless indicated here:
Yes, loans are permitted from the plan.
If Yes: What will be the maximum number of outstanding loans at one time, per participant? _________
What is the minimum loan amount? $____________________ (not to exceed $1,000)
What is the loan interest rate? Prime Prime + 1% Other
28. Will participants direct their own investments? Yes No
If Yes, is it intended that the plan meet the requirements of ERISA Section 404(c)? Yes No
Note: If this is a one participant plan, the plan is deemed to be participant directed.
ab UBS Financial Services Inc.
Account Number ______________________________
401(k) PDQ – 2010 Restatement 7/10
Service Crediting Rules
(Refer to Section III, Eligibility Requirements and Service Crediting Rules, in the UBS Financial Services Inc. 401(k) Profit
Sharing Plan Adoption Agreement (No. 005 or 006))
29. An employee will earn a year of eligibility and/or vesting service by working at least 1,000 hours in a 12-
month period. Hours will be measured by counting actual hours unless an elapsed time method is indicated
here. If an equivalencies method is preferred, please indicate in the Comments/Notes section of the
questionnaire.
The elapsed time method will be used for determining years of service
30. An employee will not be given credit for eligibility, vesting or contribution allocation purposes for service with
a predecessor employer unless a predecessor employer is indicated here:
Service with the following predecessor employer(s) or the following type(s) of business(es):
____________________________________________________________________________________
is counted for purposes of:
Eligibility
Vesting
Authorized Individual
31. Authorized individual of the employer who should receive legal paper work if claim is to be made against the plan
(to be reflected in summary plan description):
Name
Business Address
City State Zip Code
Comments/Notes
Use this section to provide any additional information or changes to the plan design assumptions in the next
section of this Questionnaire that will assist us in preparing the plan document (attach additional page(s) if
necessary).
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
ab UBS Financial Services Inc.
Account Number ______________________________
401(k) PDQ – 2010 Restatement 8/10
Plan Design Assumptions
In addition to the choices made on the prior pages, the following assumptions will be incorporated into your plan
document as additional plan provisions. You need to review each of these assumptions carefully with your legal/tax
advisor to ensure that these provisions are appropriate for your plan. If they are not, please indicate the changes
needed in the Comments/Notes section on page 7.
ADP and ACP Testing Method. For purposes of ADP and ACP testing, the prior year testing method will be used, unless the
employer has elected the 401(k) safe harbor provisions in item number 17, in which case the current year testing method will
apply. If this is not a successor plan, for the first plan year that the plan allows elective deferrals, nondeductible employee
contributions, or matching contributions, the ADP and ACP for non-highly compensated employees shall be 3%.
Age 50 Catch-up Contribution. All employees who are eligible to make elective deferrals under the plan and who reach age 50
before the close of the plan year will be eligible to make age 50 catch-up contributions. The matching contribution formula
selected in item number 15 will apply to catch-up contributions.
Allocation Requirements. If the Hours of Service Requirement was selected in item number 16 and/or 19, this requirement is not
waived for normal retirement age, disability, death or any other event.
Automatic Enrollment of Elective Deferrals. If automatic enrollment of elective deferrals is a feature in this plan, and if the
safe harbor automatic enrollment is not elected, the automatic enrollment will only apply to new employees and elective deferrals
automatically withheld will be designated as pre-tax elective deferrals (as opposed to Roth elective deferrals). Also, the deferral
percentage for employees who are automatically enrolled will not increase without the participant’s direction. If the safe harbor
automatic enrollment is elected, the elective deferral levels will be at the minimum amounts required by the Internal Revenue
Code. The employer will make the matching contributions, which will always be 100% vested.
Compensation. Compensation, for purposes of contributions, will be W-2 compensation. Other available definitions of
compensation include IRC Section 3401(a) wages or IRC Section 415 compensation. The compensation measuring period will be
the plan year and will include only compensation from the time the employee became a participant in the plan. Compensation
includes employer contributions made on behalf of a participant under a salary reduction agreement (i.e., Sections 125, 132(f)(4),
402(e)(3), 408(k), 403(b), and 457). Any exclusions from compensation (e.g., commissions, fringe benefits, moving expenses,
bonuses, overtime) must be listed in the Comments/Notes section of this questionnaire. Post-severance compensation consisting of
regular compensation and leave payments that are paid within 2½ months of severance will be included in compensation.
For purposes of IRC Section 415, the general definition of 415 compensation will apply. Only payments made during a year are
included in compensation for that year. Taxable payments from a nonqualified plan, and post-severance compensation consisting
of regular compensation, deferred compensation or leave payments that are paid within 2½ months of severance, will be included
in compensation. Imputed compensation for a disabled participant is not included.
Disability. A non-highly compensated participant who has incurred a disability and no longer receives earned income from the
employer, will not be entitled to an employer contribution. A participant who has incurred a disability will be entitled to request a
distribution from the plan.
Distributions. Participants may take distributions in a total lump sum payment, partial payments, installment payments or
purchase an annuity contract once they are eligible to receive payment from the plan. Cash-outs are made only if the participant’s
benefit does not exceed $1,000.
Early Retirement Age. No early retirement age.
Effective Dates for Elective Deferrals. If an elective deferral option (either pre-tax or Roth) is added by this amendment, the
effective date for elective deferrals is the next payroll date coinciding with or following the later of the date the adoption
agreement is signed or the effective date in item number 2.
Elective Deferral Elections. The employer will define an administrative policy regarding the frequency and timing for employees
to change their deferral elections (e.g., cease deferrals, modify the rate of deferrals, or resume deferrals) and apply this policy in a
uniform and nondiscriminatory manner.
Eligibility Computation Period. The initial eligibility period is from date of hire to the first anniversary of that date. Once that
initial period is completed, if an employee has not met the plan’s eligibility requirements, the eligibility period will switch to the
plan year.
Excess Elective Deferrals. A participant who claims excess elective deferrals for the preceding calendar year must submit their
claim in writing to the plan administrator by March 1.
Forfeitures. Forfeitures of matching and profit sharing contributions may always be used to pay plan expenses. Any forfeitures
remaining after plan expenses will be applied to reduce employer contributions.
ab UBS Financial Services Inc.
Account Number ______________________________
401(k) PDQ – 2010 Restatement 9/10
Highly Compensated Employees. The determination of whether an individual is a highly compensated employee (other than by
reason of being a 5% owner) for any plan year will be made by taking into account whether the individual is in the “top paid
group” for the preceding plan year. This determination will be made based on the individual’s compensation from the previous
plan year.
Involuntary Cashouts. If a terminated participant does not elect a distribution option and their vested account balance is $1,000
or less, their vested balance will be paid out of the plan in a single lump sum. If their vested account balance is greater than
$1,000, the participant must provide consent before the balance is distributed.
KETRA. The plan does not incorporate the amendment language necessary for any plans that took advantage of the Katrina
Emergency Tax Relief Act of 2005, the Gulf Opportunity Zone Act of 2005 and other related legislation and pronouncements.
Limitation Year. The limitation year (for purposes of annual additions testing under section 415 of the Internal Revenue Code)
will be the plan year.
Normal Retirement Age. The normal retirement age for the plan will be age 65.
Profit Sharing Allocation Formula: The profit sharing contribution will be allocated using either a pro rata formula or an
integrated formula. A points or cross-testing formula will not be used.
QNECs and QMACs. Qualified matching contributions (QMACs) and qualified nonelective contributions (QNECs) will be available, at your
discretion. If you make QNECs to the plan, you will contribute them only for nonhighly compensated employees and only in the amount
needed to satisfy the ADP or ACP test. QNECs are allocated on the basis of compensation. If you contribute QMACs, you will contribute
them only with respect to elective deferrals made by non-highly compensated employees and only in the amount needed to satisfy the
ADP or ACP test. Other than meeting the plan’s eligibility criteria, a participant will not have to satisfy any additional conditions to receive a
QNEC or QMAC.
Required Beginning Date for Distributions. The required beginning date for distributions is the April 1 of the calendar year
following the later of the calendar year in which a participant attains age 70½ or (except for 5% owners) the calendar year in
which the participant has a termination of employment.
Rollovers. If rollover contributions are permitted into the plan, the plan will accept direct or indirect employee rollover
contributions of pre-tax amounts from a qualified plan, a 403(b) plan, an eligible 457(b) plan and a traditional IRA. Rollover
contributions will be included in determining the value of a participant’s balance for involuntary cash-out purposes. Direct and
indirect rollovers of nondeductible employee contributions and Roth elective deferrals will not be accepted.
Safe Harbor Match. Matching contributions in addition to the safe harbor match selected in item number 16 will not be
provided.
Top Heavy Contributions. If the plan is top-heavy, the Plan Sponsor will make any mandatory top-heavy contribution to this plan
and will allocate it only to non-key employees. If the Plan Sponsor makes profit sharing contributions during a year in which the
plan is top heavy and the allocation of the profit sharing contribution does not satisfy the top heavy minimum requirement, the
Plan Sponsor will allocate an additional contribution to non-key employees in an amount necessary to satisfy the top heavy
minimum contribution. It is assumed that the Plan Sponsor has not maintained a defined benefit plan unless noted otherwise in
the Comments/Notes Section.
Vesting. The vesting computation period will be the plan year. All of an employee’s years of vesting service, including years prior
to age 18 and years before the employer maintained this plan or a predecessor plan, with the employer will be counted to
determine an employee’s vested percentage. An employee will be fully vested upon attainment of normal retirement age, plan
termination, discontinuance of employer contributions, death, disability, or early retirement age, if applicable. If the plan is electing
a new vesting schedule, the new vesting schedule will apply to all participants.
Plan Sponsor Agreements and Signature
1. I have read and understand the choices elected within this 401(k) Plan Document Restatement Questionnaire. The
information provided in this Questionnaire and any ancillary information provided for the purposes of completing the
plan documents are, to the best of my knowledge, correct and complete.
2. I represent that there are no related employers (e.g. controlled, common control or affiliated service group members)
which participate in this plan. If there are related employers which participate, I have provided the name and address
of such related employers in the Comments/Notes section or as an attachment to this 401(k) Plan Document
Restatement Questionnaire.
3. I represent that I am authorized to sign on behalf of the Plan Sponsor (e.g. President, Officer or other person legally
authorized to act on behalf of the entity which established or is establishing the plan).
ab UBS Financial Services Inc.
Account Number ______________________________
Neither UBS Financial Services Inc. nor any of its employees provide legal or tax advice. You must consult with your legal or tax advisor
when making decisions about a retirement plan.
©2010 UBS Financial Services Inc. All rights reserved. Member SIPC.
www.ubs.com/financialservicesinc
100115-1790-005
UBS Financial Services Inc. is a subsidiary of UBS AG. 10/10
4. I understand that neither Ascensus nor UBS, nor their employees or representatives, provide legal or tax advice and I
have consulted with my legal and tax advisors regarding the plan and the 401(k) Plan Document Restatement
Questionnaire. I understand that I am responsible for ensuring that appropriate optional forms of benefit under the
prior document are preserved as required by the Internal Revenue Code and I understand that neither Ascensus nor
UBS has reviewed the prior document.
5. I agree to receive all prototype plan document communication by e-mail and to notify Ascensus of any change in e-mail
address. I understand that failure to notify Ascensus of any e-mail address change may result in the plan not receiving
required amendments and can result in the disqualification of the plan by the IRS.
6. I understand that after the adoption agreement has been signed, future changes to plan provisions can only be made
by a formal plan amendment.
Name _______________________________________________________ Title
Print Authorized Individual’s Name (Print Clearly)
Signed _______________________________________________________ Date
Authorized Individual for the Plan Sponsor
Send only this completed and executed Questionnaire to Ascensus DCS Unit:
By Regular Mail: P.O. Box 726, Brainerd, MN 56401
By Express or Overnight Mail: 415 8th Avenue NE, Brainerd, MN 56401
Do not include other documents, letters or checks when you return this
Questionnaire. Instead, send those directly to your Financial Advisor.
