» Emparion

Funding Request Form - 2022

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1Introduction

2General Information

3Plan Information

4Compensation Information

5Defined Benefit / Cash Balance Plan Information

6401(K) Information

7Confirmation

This form is ONLY to be used to submit your 2022 defined benefit plan & 401(k) funding request.

Please note the following:

- Please carefully review your entries for accuracy as they will be used to finalize your funding range.
- At the end of each form section, you will have a space to make any comments or ask questions.
- A copy of your submission will be emailed to you for your records.
- Once submitted, you will be contacted with a funding range within 10 business days.

General Information

Enter your name:*

First Last

Enter your business name:*

If you have multiple businesses, enter your primary business name or the name tied to this plan.

Enter your email:*

Enter Email Confirm Email

Please use the same email that we have on file, which should be the email that you received this form link.

Enter your phone number:*

Please use the same phone number that you used when you set up your account.

If you have any changes or comments, please note below:

Plan Information

How is your business entity taxed?*

Sole Proprietor (Including Single Member LLC)

S-Corp (Including LLC Taxed as S-Corp)

C-Corp

Partnership

What type of plan(s) do you have (check all that apply)?*

Defined Benefit Plan or Cash Balance Plan

401(k) with Profit Sharing

Mega Backdoor Roth (only select if Emparion administers this plan)

*Please select ONLY plans administered my Emparion*

Which option below best describes your employee eligibility?*

Myself*

Myself and My Spouse*

Myself and other Partners/Shareholders*

Owners + other Eligible Employees**

*You are a solo plan and will not be subject to discrimination testing.

**If you have other eligible employees, you are considered a group plan. Click here for more information.

Please provide any additional questions/comments regarding the questions above:

Compensation Information

How many shareholders received compensation?*

Shareholder #1 Name:*

Shareholder #1 Compensation:*

Shareholder #2 Name:*

Shareholder #2 Compensation:*

Shareholder #3 Name:*

Shareholder #3 Compensation:*

How many Sole Proprietors (Schedule Cs) do you have that are tied to this plan?*

Who owns the 1st Sole Proprietor?*

Myself

Spouse

What is the profit for the 1st Sole Proprietor?*

For add'l information regarding how to calculate your business profit please click here.

Who owns the 2nd Sole Proprietor?*

Myself

Spouse

What is the profit for the 2nd Sole Proprietor?*

For add'l information regarding how to calculate your business profit please click here.

Please upload a list of the net profit for each sole proprietor and the owner:*

Max. file size: 256 MB.

Please enter your business profit as reported:*

For add'l information regarding how to calculate your business profit please click here.

Please enter your compensation as reported on your W2:*

To determine the proper W2 amount to report to us, please click here.

Please enter your spouse's compensation as reported on their W2:*

To determine the proper W2 amount to report to us, please click here.

Please upload your employee census (if you need the template, click here to download):

Upload Census*

Max. file size: 256 MB.

If you would like to upload your W2(s), please do so below:

Max. file size: 256 MB.

How many partners do you have in the business?*

For each partner, enter their full name and profit as reported on Form K1:

Partner #1 Name:*

Partner #1 Profit:*

For information on how profit is calculated, click here.

Partner #2 Name:*

Partner #2 Profit:*

Partner #3 Name:*

Partner #3 Profit:*

Partner #4 Name:*

Partner #4 Profit:*

Partner #5 Name:*

Partner #5 Profit:*

Partner #6 Name:*

Partner #6 Profit:*

Partner #7 Name:*

Partner #7 Profit:*

Partner #8 Name:*

Partner #8 Profit:*

Partner #9 Name:*

Partner #9 Profit:*

Partner #10 Name:*

Partner #10 Profit:*

Please provide any additional questions/comments regarding the questions above:

Defined Benefit / Cash Balance Plan Information

What was your Defined Benefit / Cash Balance Plan account balance as of December 31, 2022?*

If you have multiple investment accounts, please include the sum of those account balances above. If you have a self-directed plan, please include the total valuation of all plan assets. Please click here for more information..

Have you already funded a portion of your 2022 Defined Benefit / Cash Balance Plan?*

Yes

Please enter the total 2022 contribution made for the Defined Benefit Plan or Cash Balance Plan ONLY (exclude contributions made to your 401K plan):*

Note: Please DO NOT include contributions made in 2022 for plan year 2021. If you have any questions, reach out to us.

How many contributions did you make?*

List each contribution amount and the date it was made:

1) Contribution Amount:*

1) Date Funded*

MM slash DD slash YYYY

2) Contribution Amount:*

2) Date Funded*

MM slash DD slash YYYY

3) Contribution Amount:*

3) Date Funded*

MM slash DD slash YYYY

4) Contribution Amount:*

4) Date Funded*

MM slash DD slash YYYY

Please upload a list of your contributions and dates:*

Max. file size: 256 MB.

Please provide any questions/comments regarding your account balance or funding:

401(k) Information

Please tell us which eligible employees contribute to this 401(k) Plan?*

Myself only

Myself and my Spouse

My Spouse only

Have you already funded a portion of your 2022 401(k) plan?*

Yes

Please enter your 401(k) deferral amount funded for 2022:*

The 401(k) deferral for 2022 is limited to $20,500 if under 50 years of age and $27,000 if age 50 or older.

Did you make the full deferral deposit during the 2022 calendar year?*

Yes

Enter the amount deposited during 2022 for your deferral:*

Enter the amount deposited during 2023 for your deferral:*

Please enter your spouse's 401(k) deferral amount funded for 2022:

Did they make the full deferral deposit during the 2022 calendar year?*

Yes

Enter the amount deposited during 2022 for your spouses's deferral:*

Enter the amount deposited during 2023 for your spouses's deferral:*

Please enter your 401(k) profit sharing amount funded for 2022:*

Remember the 401(k) profit sharing is limited to 6% of your W2 or deemed wage (if sole proprietor).

Did you make the full profit sharing deposit during the 2022 calendar year?*

Yes

Enter the amount deposited during 2022 for your profit sharing:*

Enter the amount deposited during 2023 for your profit sharing:*

Please enter your spouse's 401(k) profit sharing amount funded for 2022:

Did they make the full profit sharing deposit during the 2022 calendar year?*

Yes

Enter the amount deposited during 2022 for your spouse's profit sharing:*

Enter the amount deposited during 2023 for your spouse's profit sharing:*

Please tell us your 401(k) account balance as of December 31, 2022:*

Please only include 401(k) balance tied to this company and control groups. If you have multiple investment accounts, please include the sum of those account balances above. If you have a self-directed plan, please include the total valuation of all plan assets. Please click here for more information.

If we administer your Mega Backdoor Roth, please enter your contribution details below:*

Please provide any questions/comments regarding your 401(k):

Confirmation

{all_fields}

Consent*

I certify that this form has been completed accurately and to the best of my knowledge.*

Please note any questions/comments regarding your funding:

Funding Request Form - 2022

General Information

Plan Information

Compensation Information

Defined Benefit / Cash Balance Plan Information

401(k) Information

Confirmation

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