Plan Administrative Contact Name *

Who is responsible for the day-to-day operation of the 401k plan at your company?

First Name

Last Name

Name of Authorized Plan Representative *

Your Name

First Name

Last Name

Affirmation that the individual listed above is an authorized plan representative with the authority to engage these services. *

I affirm the information provided in this form is true to the best of my knowledge and that I am authorized by the plan to engage these services.

Authorization to Release Plan Information & Data *

I authorize the release of any and all plan data to The Dayton Co. Inc. and to speak with The Dayton Co. Inc. regarding the plan identified above.

Acknowledgement of Engagement *

I acknowledge that I am engaging The Dayton Co. Inc. to collect information on the plan listed above for the sole purpose of performing a comprehensive review of the plan. I also acknowledge that The Dayton Co. Inc. will share this data with PLANALYTiQ LLC. I understand some service providers may require additional authorization documentation and agree to execute any necessary documents and to utilize electronic signature when provided.