State of Washington
|State of Washington |WASHINGTON SMALL BUSINESS RETIREMENT MARKETPLACE |[pic] |
|Dept. of Financial Institutions |APPLICATION FOR VERIFICATION | |
|Securities Division | | |
|P.O. Box 9033 |Pursuant to RCW 43.330.730 – RCW 43.330.750, RCW 43.320.180, and Chapter 208-710 WAC | |
|Olympia, WA 98507-9033 | | |
|(360) 902-8760 | | |
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|Item 1. Financial Services Firm |
| |
| | | |Type of Application: |
|Name of Financial Services Firm: | | |[pic] |
|[pic] | | |[pic][pic] |
|Prior Name (if any): | | | |
|[pic] | | | |
|Name of the Retirement Plan to be offered on the Marketplace: | | | |
|[pic] | | | |
| | | |DFI File Number (if previously |
| | | |assigned): |
| | | |[pic] |
| |
| | |
|Is the Financial Services Firm regulated by a Banking, |[pic][pic] |
|Credit Union, Securities, or | |
|Broker-Dealer Regulator? | |
|Name of Banking, Securities, Credit Union, or |[pic] |
|Broker-Dealer Regulator(s): | |
|Is the Financial Services Firm currently licensed and in |[pic][pic] |
|good standing with its Regulator(s)? | |
|File/License Number (if any): |[pic] |
|License Expiration Date (if any): |[pic] |
| |
|Item 2. Principal Place of Business |
| |
|Street Address Line 1 | |Street Address Line 2 |
|[pic] | |[pic] |
|City |
|Item 3. Contact Person |
| |
|Directions: Provide the name and contact information for the person to contact with questions about the filing of this application. |
| |
|Last Name |First Name |Firm Name |
|[pic] |[pic] |[pic] |
|Street Address Line 1 |Street Address Line 2 |
|[pic] |[pic] |
|City |State/Province/Country |ZIP/Postal Code |
|[pic] |[pic] |[pic] |
|Phone |Fax |E-mail |
|[pic] |[pic] |[pic] |
|Item 4. Information about the Retirement Plan |
| |
|Please attach the following Exhibits to this application: |
| |
|A copy of the Retirement Plan Agreement; |
|A copy of the materials routinely used to market the Retirement Plan to eligible employers and/or individuals; |
|The Prospectus for each balanced fund, target date fund, or other fund offered under the Retirement Plan; |
|A summary of the Retirement Plan’s investment options, fees, and other features. The summary should include, but not necessarily be limited to, the following |
|information: |
|The type of retirement plan (e.g. SIMPLE IRA); |
|The investment options available in the Retirement Plan; |
|The fee structure applicable to the different investment options in the Retirement Plan (including fees payable to the financial services firm offering the |
|retirement plan and any other service providers); |
|The identity of the custodian of enrollee accounts; |
|The roll-over options for enrollees in the Retirement Plan; |
|Whether the financial services firm offering the Retirement Plan will recommend investments to enrollees, and if so, how the firm will communicate to enrollees |
|the option to select investments other than the recommended investments; |
|A list of documents an employer must complete to establish the Retirement Plan and its business relationship with the financial services firm offering the Plan; |
|A list of the documents enrollees must complete to establish their retirement account and their relationship with the financial services firm offering the Plan; |
|and |
|Disclosure of any other fees associated with the Retirement Plan; and |
|If the above-listed documents do not (1) identify the funds and other investment products to be offered under the Plan; (2) specify the Plan’s fees and roll-over |
|options; or (3) disclose historical investment performance for the investment products in the Plan, please submit additional documentation in order to provide |
|this information. |
| |
|Item 5. Signature and Submission |
| |
|The Department of Financial Institutions will review the Financial Services Firm’s application materials to verify whether the Retirement Plan and the Firm meet |
|the requirements set forth in RCW 43.330.732(7) and RCW 43.330.735. The Financial Services Firm understands that it must separately apply to the Department of |
|Commerce for listing on the Washington Small Business Retirement Marketplace. The Financial Services Firm further understands that the Department of Commerce |
|will not approve the Retirement Plan for listing unless the Department of Financial Institutions has issued a currently effective Verification Letter. |
| |
|A Verification Letter will be effective for one year. Pursuant to WAC 208-710-060, the Financial Services Firm may apply for renewal for additional one-year |
|periods. Pursuant to WAC 208-710-070, the Financial Services Firm must file an amended application at least 30 days prior to implementation if material |
|amendments to the Retirement Plan or its underlying investment options are proposed. |
| |
|The Financial Services Firm has read this application, knows the contents to be true, and has duly caused this application to be signed on its behalf by the |
|undersigned duly authorized person. |
| | |
|Signature |Name of Signer (Print) |
|[pic] |[pic] |
|Title |Date |
|[pic] |[pic] |
Please mail your completed application form to the following address:
Washington Dept. of Financial Institutions
Securities Division
P.O. Box 9033
Olympia, WA 98507-9033
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