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 |

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| | | |Type of Application: |

|Name of Financial Services Firm: | | |[pic] |

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|Prior Name (if any): | | | |

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|Name of the Retirement Plan to be offered on the Marketplace: | | | |

|[pic] | | | |

| | | |DFI File Number (if previously |

| | | |assigned): |

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|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] |

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|Item 2. Principal Place of Business |

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|Street Address Line 1 | |Street Address Line 2 |

|[pic] | |[pic] |

|City |

|Item 3. Contact Person |

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|Directions: Provide the name and contact information for the person to contact with questions about the filing of this application. |

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|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 |

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|Please attach the following Exhibits to this application: |

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|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. |

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|Item 5. Signature and Submission |

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|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. |

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|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. |

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|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. |

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|Signature |Name of Signer (Print) |

|[pic] |[pic] |

|Title |Date |

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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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