If you are interested in possibly establishing a plan and would like to see a plan design
please fill out the following information and email to jheller@hellerpension.com or fax to
(845)229-2302
please fill out the following information and email to jheller@hellerpension.com or fax to
(845)229-2302
Business Name
Business Address
Tel/Fax Number
Business EIN
Business Fiscal Year
Date Business began
Type of Business Entity
Current Plan, if any
Union Employees?
If so, how many?
Is there a Union Plan?
Ownership Detail
please list name, % of
ownership & officers
Other Business Presently
owned. Please list owners
and officers.
Was there a prior
business? If so, what type
and when did start & end?
Did the prior business
have a plan?
If yes, What type?
CENSUS INFORMATION
Employee Name
Date of Birth
Date of Hire
Hours Worked
Annual Salary
Termination Date
Employee Name
Date of Birth
Date of Hire
Hours Worked
Annual Salary
Termination Date
Employee Name
Date of Birth
Date of Hire
Hours Worked
Annual Salary
Termination Date
Employee Name
Date of Birth
Date of Hire
Hours Worked
Annual Salary
Termination Date
Employee Name
Date of Birth
Date of Hire
Hours Worked
Annual Salary
Termination Date
Employee Name
Date of Birth
Date of Hire
Hours Worked
Annual Salary
Termination Date
Employee Name
Date of Birth
Date of Hire
Hours Worked
Annual Salary
Termination Date
Business Address
Tel/Fax Number
Business EIN
Business Fiscal Year
Date Business began
Type of Business Entity
Current Plan, if any
Union Employees?
If so, how many?
Is there a Union Plan?
Ownership Detail
please list name, % of
ownership & officers
Other Business Presently
owned. Please list owners
and officers.
Was there a prior
business? If so, what type
and when did start & end?
Did the prior business
have a plan?
If yes, What type?
CENSUS INFORMATION
Employee Name
Date of Birth
Date of Hire
Hours Worked
Annual Salary
Termination Date
Employee Name
Date of Birth
Date of Hire
Hours Worked
Annual Salary
Termination Date
Employee Name
Date of Birth
Date of Hire
Hours Worked
Annual Salary
Termination Date
Employee Name
Date of Birth
Date of Hire
Hours Worked
Annual Salary
Termination Date
Employee Name
Date of Birth
Date of Hire
Hours Worked
Annual Salary
Termination Date
Employee Name
Date of Birth
Date of Hire
Hours Worked
Annual Salary
Termination Date
Employee Name
Date of Birth
Date of Hire
Hours Worked
Annual Salary
Termination Date
Heller Pension Associates, Inc
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