Order Form

INSTRUCTIONS: Print this document on your computer's printer, then complete the form and fax it to GSL Galactic Consulting at (317) 254-0386. I will contact you prior to preparation of illustrations. Other formats that contain the needed information may also be acceptable. Computer file transfers can be arranged.

Or, if you prefer, mail the completed form to:

Gary S. Lesser, J.D.
GSL Galactic Consulting
944 Stockton Street
Indianapolis, IN 46260-4925

Telephone (317) 317-254-0385
Facsimile (317) 317-254-0386
E-mail: qpsep@aol.com

___ PS Profit Sharing

___ MP Money Purchase Pension

___ Simple IRA or 401(k) Simple

___ PS and MP (MP contribution percentage is: _______)

___ SEP and/or SARSEP

___ SEP/SARSEP and MP (MP contribution percentage is: _______)

___ Maximize effective contribution to favored employees.

___ Spend $_____________ (if possible).

___ Spend ______ (max. 25%) percent of deduction compensation.

Contribution formula should primarily benefit:

___ All employees equally (not integrated with social security benefits)

___ Owners

___ Employees earning above $________________

Your organization: _______________________________________________

Your designation (circle one or more): JD CPA FLMI CLU CEBS ChFC CPC EA QPA QPC QPA

I have read, understand, and accept the terms of the Service Warranty and Limitation of Liability contained in the Agreement at the end hereof.

Name: __________________________________________________________

Address: _______________________________________________________

City, State, Zip: ______________________________________________

Telephone: (__________) ______________________________ (IMPORTANT)

Fax: (______) _______________

Charge my:

___ American Express

___ Master Card

___ VISA

Expires: _______

Card No: ___________________________________________

Signature: ___________________________________________

Employer's name: ______________________________________________

Employer is:

___ a corporation

___ a partnership

___ a sole-proprietorship

Employer's business's taxable year ends (month): _____________

Plan Year ends (must be same month as above or December): ____________

(1) Should plan allow for employee salary reduction (SARSEP) contributions?

___ Yes

___ No

If "yes," indicate amount that the non-highly compensated employees will (have) elect(ed) to defer and/or indicate desired amount (or state "max") for each employee on census.

Owner deferral amounts will be maximized unless otherwise indicated on the census.

(2) The employer

___ maintains

___ does not maintain

an existing SEP or defined contribution plan. (If "yes," this plan will replace the existing plan for the current year unless indicated otherwise.)

(3) The employer

___ currently maintains

___ once maintained but has since terminated

___ has never sponsored

a defined benefit plan.

(4) If the plan is an individually designed SEP and it has obtained a favorable IRS private letter ruling, specify the PLR number: _______________.

(5) Has the employer maintained a qualified plan or SEP within the last 5 years?

___ Yes

___ No

___ Not sure

(6) Employer contributions will be based on allowable compensation that

___ includes

___ excludes

elective deferrals.

Number of employees submitted with this request is: ______

Complete the items below for each eligible employee. Other formats that contain the needed information may also be acceptable. Computer file transfers can be arranged.

If the employer is related to, controlled by or affiliated with another employer, indicate and list each employer separately. Attach additional sheets if necessary. Indicate all ownership interests. Enter full amount of pre-plan earned income or compensation (do not cap compensation at $245,000 for 2009).

Indicate all family relationships (e.g., spouses, lineal ancestors and descendants).

Use these "codes" where requested by the form:

O = OWNER (indicate ownership percentage if less than 5%).

F = OFFICER

H = HIGHLY COMPENSATED EMPLOYEE. Generally includes employees who, during the contribution year or preceding year, owned at least 5% of the employer or received more than $110,000 (for 2009) in compensation, for the preceding year. Use definition of highly compensated employee found in the plan documents.

K = KEY EMPLOYEE. Generally includes employees who at any time during the plan year are or were: officers earning over $160,000, 5 percent owners, 1 percent owners earning more than $150,000. Use definition of key employee found in the plan documents.

N = NONRESIDENT ALIEN EMPLOYEE who receives no U.S.-source income (may be excluded and omitted from census if excluded under plan provisions).

U = UNIONIZED EMPLOYEE covered by a collective bargaining agreement and for whom retirement benefits were the subject of good faith bargaining with the employer (may be excluded and omitted from census if excluded under plan provisions).

$ = FAVORED EMPLOYEE (may be helpful in selecting the compensation level, above which employees are to be favored).

EMPLOYEE NAME: _________________________________________________

(a) Circle ALL codes that apply to this employee:

U=Union
F=Officer
$=Favored
H=HCE
K=KEY
N=Nonresident

(b) If corporation, enter stock percentage owned: ______

(c) Pre-plan earned income or compensation: $_____________

(d) Estimated salary reduction amount or percentage:

$____________ or ______ percent

(e) If self-employed, indicate partner's expense sharing percentage if share percentage is not in proportion to total pre-plan earned income or if any owner is a guaranteed payment partner: _________ percent.

(f) If self-employed, enter outside "W-2" income subject to social security taxes: $_____________.

(g) If self-employed, enter W-2 income that is also plan compensation (employee became a partner during the plan year): $___________.

(h) If self-employed, enter outside net gain or loss from self employment activities: $_________.

(i) Indicate if employee is age 50 or older by end of plan year. (SARSEP only)

(j) Additional information: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

EXCEPT AS EXPRESSLY WARRANTED HEREIN, THE ILLUSTRATION, RELATED SERVICE AND INFORMATION IS PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND, EITHER EXPRESSED OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. THE ENTIRE RISK AS TO THE QUALITY AND ACCURACY OF THE ILLUSTRATION OR SERVICE IS WITH YOU. LESSER DOES NOT WARRANT THAT THE ILLUSTRATION MATCHES PLAN PROVISIONS OR WILL MEET YOUR REQUIREMENTS. IN NO EVENT SHALL LESSER OR ANY OTHER PERSON, OR ENTITY BE LIABLE FOR ANY DAMAGES WHATSOEVER (INCLUDING, WITHOUT LIMITATION, SPECIAL, INCIDENTAL OR CONSEQUENTIAL DAMAGES FOR LOSS OF BUSINESS PROFITS, BUSINESS INTERRUPTION, LOSS OF BUSINESS INFORMATION OR DATA OR OTHER PECUNIARY LOSS) ARISING OUT OF THE USE OF OR INABILITY TO USE THIS ILLUSTRATION OR SERVICE. THIS WARRANTY GIVES THE USER SPECIFIC AND LIMITED RIGHTS; HOWEVER, OTHER RIGHTS MAY VARY FROM STATE TO STATE, AND SOME OF THE ABOVE EXCLUSIONS MAY NOT APPLY TO YOU.

WARRANTY and LIMITATIONS OF LIABILITY. As its only warranty under this Agreement, Gary S. Lesser/GSL Galactic Consulting (Lesser) warrants that name and compensation information is entered correctly on the illustration. Lesser's entire liability and your sole remedy under this service arrangement, is at Lesser's option, either (a) return of payment as evidence by a copy of your charge record or receipt, or (b) replacement of the illustration with the corrected name and compensation information. IN NO EVENT WILL LESSER, OR ITS VENDORS BE LIABLE FOR ANY DIRECT, CONSEQUENTIAL OR INCIDENTAL DAMAGE (INCLUDING DAMAGES FOR LOSS OF BUSINESS PROFITS, INFORMATION, OR USE) EVEN IF LESSER HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. SOME STATES DO NOT ALLOW THE EXCLUSION OR LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, SO THE ABOVE LIMITATIONS OR EXCLUSIONS MAY NOT APPLY TO YOU.

GOVERNING LAW. This Agreement is governed by the laws of the State of Indiana. Notwithstanding where any liability or breach originates or arises, any suit, action or proceeding arising out of or relating to this Agreement will be instituted in, or if instituted elsewhere may be removed to, any Court of the United States of America or of the State of Indiana, sitting in the County of Marion, State of Indiana, and each of the parties hereby irrevocably waives any objection the parties may now have or hereafter have to the laying of venue of any such suit, action or proceeding in the above described courts and any claim that any suit, action or proceeding has been brought in an inconvenient forum, and each party irrevocably submits its person and property to the jurisdiction of any such court in any such suit, action or proceeding. Any suit, action or proceeding arising out of or relating to this Agreement including derivative actions including but not limited to any cross-claims and counter-claims, shall be governed entirely by and construed and enforced solely in accordance with the laws of the State of Indiana applicable to agreements made and performed within such State and without giving effect to choice of law principles of such State. (END)

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