National Retirement Services, Inc.

Service is an ART - Accuracy - Responsiveness - Timeliness

Census Request

Complete this form (in addition to the Proposal Request Form) only if you are requesting a Profit Sharing or Defined Benefit Plan Proposal and would like a customized illustration for your client.

Requestor Information:

Name

Company

Address

City

State

Zip

Phone

Fax

E-mail

Company Name

	Employee Name	1	2	3	4	Date of Birth	Date of Hire	Annual Pay	Hours Worked
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1. Indicate family members of preferred employees with an S for Spouse, C for Child, M for mother, F for Father.
2. Indicate owners or officers of the company with a check mark.
3. Indicate the preferred employees with a check mark.
4. Indicate percentage of ownership in the business.

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