+-----------------------------------------------------------------------+
| ### ABC Plan                                                          |
+-----------------------------------------------------------------------+
| **401(k) Plan Fee Disclosure Form**                                   |
+-----------------------------------------------------------------------+
| **For Services Provided by \[Company Name\]^(1)^**                    |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| #### Overview                                                         |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| The Employee Retirement Income Security Act of 1974, as amended       |
| (ERISA) requires employee benefit plan fiduciaries to act solely in   |
| the interests of, and for the exclusive benefit of, plan participants |
| and beneficiaries. As part of that obligation, plan fiduciaries       |
| should consider cost, among other things, when choosing investment    |
| options for the plan and selecting plan service providers.            |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| This 401(k) plan fee disclosure form may assist you in making         |
| informed cost-benefit decisions with respect to your plan. The        |
| purpose of this form is to help you determine the total cost of the   |
| plan. It is also intended to provide you with a means to compare      |
| investment product fees and plan administration expenses charged by   |
| competing service providers, regardless of how a particular service   |
| provider structures its fees.                                         |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| The 401(k) plan fees included in this disclosure form represent the   |
| following: \_\_\_\_\_ actual 401(k) plan expenses for the period      |
| \[date\] through \[date\] or \_\_\_\_\_ estimated 401(k) plan         |
| expenses^(2)^ for the period \[date\] through \[date\]. Additional    |
| investment product information regarding fees may be obtained from    |
| the product prospectus, annuity contract or other similar documents.  |
| Additional information relating to plan administration services and   |
| expenses is contained in documentation provided by the service        |
| provider, including the contract for plan services. Other plan        |
| expenses may include legal fees for initial plan design and ongoing   |
| amendments resulting from changes in pension law or plan design and   |
| the cost of a mandatory annual audit. You need to contact your legal  |
| advisor or accountant to determine these charges.                     |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| Selecting a service provider requires that you evaluate and           |
| differentiate services offered by competing companies. Cost is one of |
| the criteria, but not the only criterion, for making this evaluation. |
| Other factors of equal or greater importance to consider include the  |
| quality and type of services provided, the anticipated performance of |
| competing providers and their investment products and other factors   |
| specific to your plan\'s needs. The service provider offering the     |
| lowest cost services is not necessarily the best choice for your      |
| plan.                                                                 |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| #### Calculation Of Fees                                              |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| In general, fees are calculated in four ways:                         |
+-----------------------------------------------------------------------+
| -   **Asset-Based:** expenses are based on the amount of assets in    |
|     the plan and generally are expressed as percentages or basis      |
|     points.                                                           |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   **Per-Person:** expenses are based upon the number of eligible    |
|     employees or actual participants in the plan.                     |
|                                                                       |
| -   **Transaction-Based:** expenses are based on the execution of a   |
|     particular plan service or transaction.                           |
|                                                                       |
| -   **Flat Rate:** fixed charge that does not vary, regardless of     |
|     plan size.                                                        |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| Fees may be calculated using one or any combination of these methods. |
| Plan administration-related expenses can also be charged as one-time  |
| fees or ongoing expenses. One-time fees are typically related to      |
| start-ups, conversions (moving from one provider to another) and      |
| terminations of service. Ongoing fees are recurring expenses relating |
| to continuing plan operation.                                         |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| ### ABC Plan                                                          |
+-----------------------------------------------------------------------+
| **401(k) Plan Fee Disclosure Form**                                   |
+-----------------------------------------------------------------------+
| **For Services Provided By \[Company Name\]**                         |
+-----------------------------------------------------------------------+
| **Total Plan Expenses**                                               |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|   --------------------- ---------------------- ---------------------- |
|   Contact Name          Institution            Telephone              |
|                                                                       |
|   --------------------- ---------------------- ---------------------- |
+-----------------------------------------------------------------------+
| +---+------------------------------------------+------------------+   |
| | * | **Investment Product Fees (See Schedule  | **Amount         |   |
| | * | A)**                                     | /Estimate^(3)^** |   |
| | I |                                          |                  |   |
| | . |                                          |                  |   |
| | * |                                          |                  |   |
| | * |                                          |                  |   |
| +---+------------------------------------------+------------------+   |
| |   | A. Collective Investment Fund(s)         | \$               |   |
| +---+------------------------------------------+------------------+   |
| |   | B. Insurance/Annuity Product(s)          | \$               |   |
| +---+------------------------------------------+------------------+   |
| |   | C. Mutual Fund(s)                        | \$               |   |
| +---+------------------------------------------+------------------+   |
| |   | D. Individually Managed Account(s)       | \$               |   |
| +---+------------------------------------------+------------------+   |
| |   | E. Brokerage Window                      | \$               |   |
| +---+------------------------------------------+------------------+   |
| |   | F. Other Product(s) (Specify)            | \$               |   |
| +---+------------------------------------------+------------------+   |
| |   | Total Investment Product Fees            | \$               |   |
| +---+------------------------------------------+------------------+   |
| | * | **Plan Administration Expenses (See      |                  |   |
| | * | Schedule B)**                            |                  |   |
| | I |                                          |                  |   |
| | I |                                          |                  |   |
| | . |                                          |                  |   |
| | * |                                          |                  |   |
| | * |                                          |                  |   |
| +---+------------------------------------------+------------------+   |
| |   | Total Plan Administration Expenses       | \$               |   |
| +---+------------------------------------------+------------------+   |
| | * | **Plan Start-Up or Conversion Related    |                  |   |
| | * | Charges (See Schedule C)**               |                  |   |
| | I |                                          |                  |   |
| | I |                                          |                  |   |
| | I |                                          |                  |   |
| | . |                                          |                  |   |
| | * |                                          |                  |   |
| | * |                                          |                  |   |
| +---+------------------------------------------+------------------+   |
| |   | One Time Start-Up/Conversion expenses    | \$               |   |
| +---+------------------------------------------+------------------+   |
| | * | **Service Provider Termination Related   |                  |   |
| | * | Charges (See Schedule D)**               |                  |   |
| | I |                                          |                  |   |
| | V |                                          |                  |   |
| | . |                                          |                  |   |
| | * |                                          |                  |   |
| | * |                                          |                  |   |
| +---+------------------------------------------+------------------+   |
| |   | Service Provider Termination expenses    | \$               |   |
| +---+------------------------------------------+------------------+   |
| |   | #### Total Plan Expenses                 | \$               |   |
| +---+------------------------------------------+------------------+   |
| |   |                                          |                  |   |
| +---+------------------------------------------+------------------+   |
| | F |                                          |                  |   |
| | o |                                          |                  |   |
| | r |                                          |                  |   |
| | d |                                          |                  |   |
| | e |                                          |                  |   |
| | f |                                          |                  |   |
| | i |                                          |                  |   |
| | n |                                          |                  |   |
| | i |                                          |                  |   |
| | t |                                          |                  |   |
| | i |                                          |                  |   |
| | o |                                          |                  |   |
| | n |                                          |                  |   |
| | s |                                          |                  |   |
| | o |                                          |                  |   |
| | f |                                          |                  |   |
| | t |                                          |                  |   |
| | e |                                          |                  |   |
| | r |                                          |                  |   |
| | m |                                          |                  |   |
| | s |                                          |                  |   |
| | u |                                          |                  |   |
| | s |                                          |                  |   |
| | e |                                          |                  |   |
| | d |                                          |                  |   |
| | t |                                          |                  |   |
| | h |                                          |                  |   |
| | r |                                          |                  |   |
| | o |                                          |                  |   |
| | u |                                          |                  |   |
| | g |                                          |                  |   |
| | h |                                          |                  |   |
| | o |                                          |                  |   |
| | u |                                          |                  |   |
| | t |                                          |                  |   |
| | t |                                          |                  |   |
| | h |                                          |                  |   |
| | i |                                          |                  |   |
| | s |                                          |                  |   |
| | d |                                          |                  |   |
| | i |                                          |                  |   |
| | s |                                          |                  |   |
| | c |                                          |                  |   |
| | l |                                          |                  |   |
| | o |                                          |                  |   |
| | s |                                          |                  |   |
| | u |                                          |                  |   |
| | r |                                          |                  |   |
| | e |                                          |                  |   |
| | f |                                          |                  |   |
| | o |                                          |                  |   |
| | r |                                          |                  |   |
| | m |                                          |                  |   |
| | , |                                          |                  |   |
| | s |                                          |                  |   |
| | e |                                          |                  |   |
| | e |                                          |                  |   |
| | S |                                          |                  |   |
| | c |                                          |                  |   |
| | h |                                          |                  |   |
| | e |                                          |                  |   |
| | d |                                          |                  |   |
| | u |                                          |                  |   |
| | l |                                          |                  |   |
| | e |                                          |                  |   |
| | E |                                          |                  |   |
| | . |                                          |                  |   |
| +---+------------------------------------------+------------------+   |
+-----------------------------------------------------------------------+

+-----------------------------------------------+-----------------------+
| ### ABC Plan                                  |                       |
+-----------------------------------------------+-----------------------+
| **401(k) Plan Fee Disclosure Form**           |                       |
+-----------------------------------------------+-----------------------+
| ### For Services Provided by \[Company Name\] |                       |
+-----------------------------------------------+-----------------------+
| Schedule A                                    |                       |
+-----------------------------------------------+-----------------------+
| <table>                                       |                       |
| <colgroup>                                    |                       |
| <col style="width: 23%" />                    |                       |
| <col style="width: 13%" />                    |                       |
| <col style="width: 16%" />                    |                       |
| <col style="width: 18%" />                    |                       |
| <col style="width: 14%" />                    |                       |
| <col style="width: 12%" />                    |                       |
| </colgroup>                                   |                       |
| <tbody>                                       |                       |
| <tr class="odd">                              |                       |
| <td colspan="6"><h3                           |                       |
| id=                                           |                       |
| "investment-product-feesestimates">Investment |                       |
| Product Fees/Estimates</h3></td>              |                       |
| </tr>                                         |                       |
| <tr class="even">                             |                       |
| <td><strong>Collective Investment             |                       |
| Fund</strong></td>                            |                       |
| <td><strong>Assets<br />                      |                       |
| [Date]</strong></td>                          |                       |
| <td><strong>Management Fee</strong></td>      |                       |
| <td><strong>Other<sup>(4)</sup><br />         |                       |
| (Specify)</strong></td>                       |                       |
| <td colspan="2"><strong>Total<br />           |                       |
| Cost</strong></td>                            |                       |
| </tr>                                         |                       |
| <tr class="odd">                              |                       |
| <td>Fund 1</td>                               |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td colspan="2"></td>                         |                       |
| </tr>                                         |                       |
| <tr class="even">                             |                       |
| <td>Fund 2</td>                               |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td colspan="2"></td>                         |                       |
| </tr>                                         |                       |
| <tr class="odd">                              |                       |
| <td>Fund 3</td>                               |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td colspan="2"></td>                         |                       |
| </tr>                                         |                       |
| <tr class="even">                             |                       |
| <td>Fund 4</td>                               |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td colspan="2"></td>                         |                       |
| </tr>                                         |                       |
| <tr class="odd">                              |                       |
| <td><h4 id="total">Total</h4></td>            |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td colspan="2"></td>                         |                       |
| </tr>                                         |                       |
| <tr class="even">                             |                       |
| <td><strong>Insurance/Annuity                 |                       |
| Product</strong></td>                         |                       |
| <td><strong>Assets<br />                      |                       |
| [Date]</strong></td>                          |                       |
| <td><strong>Management Fee</strong></td>      |                       |
| <td><strong>Mortality Risk and                |                       |
| Administrative Expense</strong></td>          |                       |
| <td><strong>Other<sup>(4)</sup><br />         |                       |
| (Specify)</strong></td>                       |                       |
| <td><strong>Total Cost</strong></td>          |                       |
| </tr>                                         |                       |
| <tr class="odd">                              |                       |
| <td>Fund 1</td>                               |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| </tr>                                         |                       |
| <tr class="even">                             |                       |
| <td>Fund 2</td>                               |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| </tr>                                         |                       |
| <tr class="odd">                              |                       |
| <td>Separate Account 1</td>                   |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| </tr>                                         |                       |
| <tr class="even">                             |                       |
| <td>Separate Account 2</td>                   |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| </tr>                                         |                       |
| <tr class="odd">                              |                       |
| <td><h4 id="total-1">Total</h4></td>          |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| </tr>                                         |                       |
| <tr class="even">                             |                       |
| <td><strong>Mutual Fund</strong></td>         |                       |
| <td><strong>Assets<br />                      |                       |
| [Date]</strong></td>                          |                       |
| <td><strong>Expense                           |                       |
| Ratio<sup>(5)</sup></strong></td>             |                       |
| <td><strong>Front-end Load</strong></td>      |                       |
| <td><strong>Other<sup>(4)</sup><br />         |                       |
| (Specify)</strong></td>                       |                       |
| <td><strong>Total Cost</strong></td>          |                       |
| </tr>                                         |                       |
| <tr class="odd">                              |                       |
| <td>Fund 1</td>                               |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| </tr>                                         |                       |
| <tr class="even">                             |                       |
| <td>Fund 2</td>                               |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| </tr>                                         |                       |
| <tr class="odd">                              |                       |
| <td>Fund 3</td>                               |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| </tr>                                         |                       |
| <tr class="even">                             |                       |
| <td>Fund 4</td>                               |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| </tr>                                         |                       |
| <tr class="odd">                              |                       |
| <td><h4 id="total-2">Total</h4></td>          |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| </tr>                                         |                       |
| <tr class="even">                             |                       |
| <td><strong>Individually-Managed              |                       |
| Account</strong></td>                         |                       |
| <td><strong>Assets<br />                      |                       |
| [Date]</strong></td>                          |                       |
| <td><strong>Management Fee</strong></td>      |                       |
| <td><strong>Other<sup>(4)</sup><br />         |                       |
| (Specify)</strong></td>                       |                       |
| <td colspan="2"><strong>Total                 |                       |
| Cost</strong></td>                            |                       |
| </tr>                                         |                       |
| <tr class="odd">                              |                       |
| <td>Product 1</td>                            |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td colspan="2"></td>                         |                       |
| </tr>                                         |                       |
| <tr class="even">                             |                       |
| <td>Product 2</td>                            |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td colspan="2"></td>                         |                       |
| </tr>                                         |                       |
| <tr class="odd">                              |                       |
| <td>Product 3</td>                            |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td colspan="2"></td>                         |                       |
| </tr>                                         |                       |
| <tr class="even">                             |                       |
| <td>Product 4</td>                            |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td colspan="2"></td>                         |                       |
| </tr>                                         |                       |
| <tr class="odd">                              |                       |
| <td><h4 id="total-3">Total</h4></td>          |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td colspan="2"></td>                         |                       |
| </tr>                                         |                       |
| <tr class="even">                             |                       |
| <td><strong>Brokerage                         |                       |
| Window<sup>(6)</sup></strong></td>            |                       |
| <td><strong>Assets<br />                      |                       |
| [Date]</strong></td>                          |                       |
| <td><strong>Commission<br />                  |                       |
| (Range)</strong></td>                         |                       |
| <td><strong>Transaction Fee<br />             |                       |
| (Range)</strong></td>                         |                       |
| <td><strong>Other<sup>(7)</sup><br />         |                       |
| (Specify)</strong></td>                       |                       |
| <td><strong>Total Cost</strong></td>          |                       |
| </tr>                                         |                       |
| <tr class="odd">                              |                       |
| <td>Total Transactions</td>                   |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| </tr>                                         |                       |
| <tr class="even">                             |                       |
| <td><strong>Other                             |                       |
| Product<sup>(8)</sup></strong></td>           |                       |
| <td><strong>Assets<br />                      |                       |
| [Date]</strong></td>                          |                       |
| <td><strong>Management Fee</strong></td>      |                       |
| <td><strong>Other<sup>(7)</sup><br />         |                       |
| (Specify)</strong></td>                       |                       |
| <td colspan="2"><strong>Total<br />           |                       |
| Cost</strong></td>                            |                       |
| </tr>                                         |                       |
| <tr class="odd">                              |                       |
| <td>Product 1</td>                            |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td colspan="2"></td>                         |                       |
| </tr>                                         |                       |
| <tr class="even">                             |                       |
| <td>Product 2</td>                            |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td colspan="2"></td>                         |                       |
| </tr>                                         |                       |
| <tr class="odd">                              |                       |
| <td>Product 3</td>                            |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td colspan="2"></td>                         |                       |
| </tr>                                         |                       |
| <tr class="even">                             |                       |
| <td>Product 4</td>                            |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td></td>                                     |                       |
| <td colspan="2"></td>                         |                       |
| </tr>                                         |                       |
| </tbody>                                      |                       |
| </table>                                      |                       |
+-----------------------------------------------+-----------------------+
| #### Total Investment Product Fees            | \$                    |
+-----------------------------------------------+-----------------------+

+-----------------------------------------------------------------------+
| +--------------+--------------+--------------+-------------------+    |
| | #            |              |              |                   |    |
| | ### ABC Plan |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | **401(k)     |              |              |                   |    |
| | Plan Fee     |              |              |                   |    |
| | Disclosure   |              |              |                   |    |
| | Form**       |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | **For        |              |              |                   |    |
| | Services     |              |              |                   |    |
| | Provided by  |              |              |                   |    |
| | \[Company    |              |              |                   |    |
| | Name\]**     |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | **Schedule   |              |              |                   |    |
| | B**          |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | ### Plan     |              |              |                   |    |
| |  Administrat |              |              |                   |    |
| | ion Expenses |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | **Expense    | **Rate/Est   | **Bundled    | **Total           |    |
| | Type**       | imate^(9)^** | Service      | Cost^(11)^**      |    |
| |              |              | Arrange      |                   |    |
| |              |              | ment^(10)^** |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | ##           |              |              |                   |    |
| | ## Administr |              |              |                   |    |
| | ation/Record |              |              |                   |    |
| | keeping Fees |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Daily        | \$           |              | \$                |    |
| | valuation    |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Payroll      | \$           |              | \$                |    |
| | processing   |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Balance      | \$           |              | \$                |    |
| | inquiry      |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Investment   | \$           |              | \$                |    |
| | transfer     |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Contract     | \$           |              | \$                |    |
| | ad           |              |              |                   |    |
| | ministration |              |              |                   |    |
| | charge       |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Distribution | \$           |              | \$                |    |
| | processing   |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | QDRO         | \$           |              | \$                |    |
| | processing   |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Participant  | \$           |              | \$                |    |
| | statements   |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Plan sponsor | \$           |              | \$                |    |
| | reports      |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | VRU/Internet | \$           |              | \$                |    |
| | services     |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Other        | \$           |              | \$                |    |
| | (Specify)    |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | #            |              |              | \$                |    |
| | ### Subtotal |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | #### Part    |              |              |                   |    |
| | icipant Educ |              |              |                   |    |
| | ation/Advice |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Participant  | \$           |              | \$                |    |
| | education    |              |              |                   |    |
| | materials/   |              |              |                   |    |
| | distribution |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Education    | \$           |              | \$                |    |
| | meetings     |              |              |                   |    |
| | \            |              |              |                   |    |
| | [frequency\] |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Investment   | \$           |              | \$                |    |
| | advice       |              |              |                   |    |
| | programs     |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Other        | \$           |              | \$                |    |
| | (Specify)    |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | #            |              |              | \$                |    |
| | ### Subtotal |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | #### Tr      |              |              |                   |    |
| | ustee/Custod |              |              |                   |    |
| | ial Services |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Certified    | \$           |              | \$                |    |
| | annual trust |              |              |                   |    |
| | statement    |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Safekeeping  | \$           |              | \$                |    |
| | of plan      |              |              |                   |    |
| | assets       |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Other        | \$           |              | \$                |    |
| | (Specify)    |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | #            |              |              | \$                |    |
| | ### Subtotal |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | #            |              |              |                   |    |
| | #### Complia |              |              |                   |    |
| | nce Services |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Nondi        | \$           |              | \$                |    |
| | scrimination |              |              |                   |    |
| | testing      |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Signature    | \$           |              | \$                |    |
| | ready form   |              |              |                   |    |
| | 5500         |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Annual audit | \$           |              | \$                |    |
| +--------------+--------------+--------------+-------------------+    |
| | Other        | \$           |              | \$                |    |
| | (Specify)    |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | #            |              |              | \$                |    |
| | ### Subtotal |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | #### Plan A  |              |              |                   |    |
| | mendment Fee |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Plan         | \$           |              | \$                |    |
| | amendment    |              |              |                   |    |
| | fee          |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Plan         | \$           |              | \$                |    |
| | document\    |              |              |                   |    |
| | d            |              |              |                   |    |
| | etermination |              |              |                   |    |
| | letter fee   |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Other        | \$           |              | \$                |    |
| | (Specify)    |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | #            |              |              | \$                |    |
| | ### Subtotal |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | #### Loan Ad |              |              |                   |    |
| | ministration |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Loan         | \$           |              | \$                |    |
| | origination  |              |              |                   |    |
| | fee          |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Loan         | \$           |              | \$                |    |
| | processing   |              |              |                   |    |
| | fee          |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Loan         | \$           |              | \$                |    |
| | maintenance  |              |              |                   |    |
| | and          |              |              |                   |    |
| | repayment    |              |              |                   |    |
| | tracking fee |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | Other        | \$           |              | \$                |    |
| | (Specify)    |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | #            |              |              | \$                |    |
| | ### Subtotal |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | **Total      |              |              | \$                |    |
| | Separate     |              |              |                   |    |
| | Charges**    |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | **Total      |              |              | \$                |    |
| | Bundled      |              |              |                   |    |
| | Services**   |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | **Less       |              |              | \$                |    |
| | Off          |              |              |                   |    |
| | sets/Credits |              |              |                   |    |
| | Paid To      |              |              |                   |    |
| | Plan**       |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
| | **Total Plan |              |              | \$                |    |
| | Ad           |              |              |                   |    |
| | ministration |              |              |                   |    |
| | Expenses**   |              |              |                   |    |
| +--------------+--------------+--------------+-------------------+    |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| ### ABC Plan                                                          |
+-----------------------------------------------------------------------+
| **401(k) Plan Fee Disclosure Form**                                   |
+-----------------------------------------------------------------------+
| **For Services Provided by \[Company Name\]**                         |
+-----------------------------------------------------------------------+
| ### Schedule C                                                        |
+-----------------------------------------------------------------------+
| +---------------------------------------+------------+------------+   |
| | **One Time Start-Up/Conversion        |            |            |   |
| | Expenses**                            |            |            |   |
| +---------------------------------------+------------+------------+   |
| | ##### Expense Type                    | **R        | **Total    |   |
| |                                       | ate/Estima | Co         |   |
| |                                       | te^(12)^** | st^(13)^** |   |
| +---------------------------------------+------------+------------+   |
| | Start-up/conversion education program | \$         | \$         |   |
| +---------------------------------------+------------+------------+   |
| | Start-up/conversion enrollment        | \$         | \$         |   |
| | expense                               |            |            |   |
| +---------------------------------------+------------+------------+   |
| | Installation fee                      | \$         | \$         |   |
| +---------------------------------------+------------+------------+   |
| | Start-up/conversion plan document     | \$         | \$         |   |
| | fee/filing fee                        |            |            |   |
| +---------------------------------------+------------+------------+   |
| | Other (Specify)                       | \$         | \$         |   |
| +---------------------------------------+------------+------------+   |
| | ##                                    | \$         | \$         |   |
| | ## Total Start-Up/Conversion Expenses |            |            |   |
| +---------------------------------------+------------+------------+   |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| ### ABC Plan                                                          |
+-----------------------------------------------------------------------+
| **401(k) Plan Fee Disclosure Form**                                   |
+-----------------------------------------------------------------------+
| **For Services Provided by \[Company Name\]**                         |
+-----------------------------------------------------------------------+
| Schedule D                                                            |
+-----------------------------------------------------------------------+
| +---------------------------------------+------------+------------+   |
| | ######                                |            |            |   |
| | Service Provider Termination Expenses |            |            |   |
| +---------------------------------------+------------+------------+   |
| | **Expense Type**                      | **R        | **Total    |   |
| |                                       | ate/Estima | Co         |   |
| |                                       | te^(14)^** | st^(15)^** |   |
| +---------------------------------------+------------+------------+   |
| | Investment Product Expenses           |            |            |   |
| +---------------------------------------+------------+------------+   |
| | Contract termination charges          | \$         | \$         |   |
| +---------------------------------------+------------+------------+   |
| | Back-end load                         | \$         | \$         |   |
| +---------------------------------------+------------+------------+   |
| | Product termination fee               | \$         | \$         |   |
| +---------------------------------------+------------+------------+   |
| | Other (Specify)                       | \$         | \$         |   |
| +---------------------------------------+------------+------------+   |
| | #### Total {#total-4}                 |            | \$         |   |
| +---------------------------------------+------------+------------+   |
| | Plan Administration Expenses          |            |            |   |
| +---------------------------------------+------------+------------+   |
| | Service provider termination charge   | \$         | \$         |   |
| +---------------------------------------+------------+------------+   |
| | Service contract termination charge   | \$         | \$         |   |
| +---------------------------------------+------------+------------+   |
| | Other (Specify)                       | \$         | \$         |   |
| +---------------------------------------+------------+------------+   |
| | #### Total Termination Expenses       |            | \$         |   |
| +---------------------------------------+------------+------------+   |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| ### ABC Plan                                                          |
+-----------------------------------------------------------------------+
| **401(k) Plan Fee Disclosure Form**                                   |
+-----------------------------------------------------------------------+
| **For Services Provided by \[Company Name\]**                         |
+-----------------------------------------------------------------------+
| **Schedule E**                                                        |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| **Definition Of Terms**                                               |
+-----------------------------------------------------------------------+
| **Administration/Recordkeeping Fee:** Fee for providing recordkeeping |
| and other plan participant administrative type services. For start-up |
| or takeover plans, these fees typically include charges for           |
| contacting and processing information from the prior service provider |
| and \"matching up\" or mapping participant information. Use of this   |
| term is not meant to identify any ERISA Section 3(16)(A) obligations. |
|                                                                       |
| **Annual Audit:** Federal law requires that all ERISA-covered plans   |
| with more than 100 participants be audited by an independent auditor. |
| It is also common to refer to a DOL or IRS examination of a plan as a |
| plan audit. Any charge imposed by a service provider in connection    |
| with this audit is reflected on Schedule B.                           |
|                                                                       |
| **Back-End Load:** Sales charges due upon the sale or transfer of     |
| mutual funds, insurance/annuity products or other investments, which  |
| may be reduced and/or eliminated over time.                           |
|                                                                       |
| **Balance Inquiry:** Fee that may be charged each time a participant  |
| inquires about his or her balance.                                    |
|                                                                       |
| **Brokerage Commission:** A fee paid to a broker or other             |
| intermediary for executing a trade.                                   |
|                                                                       |
| **Brokerage Window:** A plan investment option allowing a participant |
| to establish a self-directed brokerage account.                       |
|                                                                       |
| **Bundled Services:** Arrangements whereby plan service providers     |
| offer 401(k) plan establishment, investment services and              |
| administration for an all-inclusive fee. Bundled services by their    |
| nature are priced as a package and cannot be priced on a per service  |
| basis.                                                                |
|                                                                       |
| **Collective Investment Fund:** A tax-exempt pooled fund operated by  |
| a bank or trust company that commingles the assets of trust accounts  |
| for which the bank provides fiduciary services.                       |
|                                                                       |
| **Contract Administration Charge:** An omnibus charge for costs of    |
| administering the insurance/annuity contract, including costs         |
| associated with the maintenance of participant accounts and all       |
| investment-related transactions initiated by participants.            |
|                                                                       |
| **Contract Termination Charge:** A charge to the plan for             |
| \"surrendering\" or \"terminating\" its insurance/annuity contract    |
| prior to the end of a stated time period. The charge typically        |
| decreases over time.                                                  |
|                                                                       |
| **Conversion:** The process of changing from one service provider to  |
| another.                                                              |
|                                                                       |
| **Distribution Expense:** The costs typically associated with         |
| processing paperwork and issuing a check for a distribution of plan   |
| assets to a participant. May include the generation of IRS Form       |
| 1099R. This fee may apply to hardship and other in-service            |
| withdrawals as well as to separation-from-service or retirement       |
| distributions.                                                        |
|                                                                       |
| **Eligible Employee:** Any employee who is eligible to participate in |
| and receive benefits from a plan.                                     |
|                                                                       |
| **Expense Ratio:** The cost of investing and administering assets,    |
| including management fees, in a mutual fund or other collective fund  |
| expressed as a percentage of total assets.                            |
|                                                                       |
| **Front-End Load:** Sales charges incurred when an investment in a    |
| mutual fund is made.                                                  |
|                                                                       |
| **Individually Managed Account:** An investment account managed for a |
| single plan.                                                          |
|                                                                       |
| **Installation Fee:** One-time fee for initiating a new plan or       |
| initiating new services.                                              |
|                                                                       |
| **Investment Transfer Expense:** Fee associated with a participant    |
| changing his or her investment allocation, or making transfers among  |
| funding accounts under the plan.                                      |
|                                                                       |
| **Loan Maintenance and Repayment Tracking Fee:** Fee charged to       |
| monitor outstanding loans and repayment schedule.                     |
|                                                                       |
| **Loan Origination Fee:** Fee charged when a plan loan is originally  |
| taken.                                                                |
|                                                                       |
| **Loan Processing Fee:** Fee charged to process a plan loan           |
| application.                                                          |
|                                                                       |
| **Management Fee:** Fee charged for the management of pooled          |
| investments such as collective investment funds, insurance/annuity    |
| products, mutual funds and individually managed accounts.             |
|                                                                       |
| **Mortality Risk and Administrative Expense (M&E Fee):** Fee charged  |
| by an insurance company to cover the cost of the insurance features   |
| of an annuity contract, including the guarantee of a lifetime income  |
| payment, interest and expense guarantees, and any death benefit       |
| provided during the accumulation period.                              |
|                                                                       |
| **Nondiscrimination Testing Expense:** Tax qualified retirement plans |
| must be administered in compliance with several regulations requiring |
| numerical measurements. The fee charged for the process of            |
| determining whether the plan is in compliance is collectively called  |
| nondiscrimination testing expense.                                    |
|                                                                       |
| **Participant:** Person who has an account in the plan.               |
|                                                                       |
| **Participant Education Materials/Distribution Expenses:** All costs  |
| (including travel expenses) associated with providing print, video,   |
| software and/or live instruction to educate employees about how the   |
| plan works, the plan investment funds, and asset allocation           |
| strategies. There may be a one-time cost associated with implementing |
| a new plan, as well as ongoing costs for an existing program.         |
|                                                                       |
| **Plan Document/Determination Letter Fee (Filing Fee):** Fee charged  |
| for a written plan document. Fee can also include the costs           |
| associated with preparing and filing IRS required documentation,      |
| including the request for a determination letter (document issued by  |
| the IRS stating whether the plan meets the qualifications for         |
| tax-advantaged treatment).                                            |
|                                                                       |
| **Plan Loan:** The law allows participants to borrow from their       |
| accounts up to prescribed limits. This is an optional plan feature.   |
|                                                                       |
| **Product Termination Fee:** Investment-product charges associated    |
| with terminating one or all of a service provider\'s investment       |
| products.                                                             |
|                                                                       |
| **QDRO (Qualified Domestic Relations Order):** A judgment, decree or  |
| order that creates or recognizes an alternate payee\'s (such as       |
| former spouse, child, etc.) right to receive all or a portion of a    |
| participant\'s retirement plan benefits.                              |
|                                                                       |
| **Separate Account:** An asset account established by a life          |
| insurance company, separate from other funds of the life insurance    |
| company, offering investment funding options for pension plans.       |
|                                                                       |
| **Service Provider Termination Charge:** Plan administrative costs    |
| associated with terminating a relationship with a service provider,   |
| with the permanent termination of a plan, or with the termination of  |
| specific plan services. These may be termed \"surrender\" or          |
| \"transfer\" charges.                                                 |
|                                                                       |
| **Signature Ready Form 5500:** Fee to prepare Form 5500, a form which |
| all qualified retirement plans (excluding SEPs and SIMPLE IRAs) must  |
| file annually with the IRS.                                           |
|                                                                       |
| **Start-up/Enrollment Expense:** Costs associated with providing      |
| materials to educate employees about the plan, and enrolling          |
| employees in the plan. This may be part of, or included in, the       |
| education programs. There may be a one-time cost associated with      |
| implementing a new plan, as well as ongoing enrollment costs.         |
|                                                                       |
| **Trustee Services:** Fees charged by the individual, bank or trust   |
| company with fiduciary responsibility for holding plan assets.        |
|                                                                       |
| **VRU:** Voice Response Unit.                                         |
|                                                                       |
| **Wrap Fee:** An inclusive fee generally based on the percentage of   |
| assets in an investment program, which typically provides asset       |
| allocation, execution of transactions and other administrative        |
| services.                                                             |
|                                                                       |
| **12b-1 Fee:** A charge to shareholders to cover a mutual fund\'s     |
| shareholder servicing, distribution and marketing costs.              |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| #### Footnotes                                                        |
+-----------------------------------------------------------------------+
| 1.  There may be plan expenses incurred by other providers, other     |
|     than the company completing this form. For a complete list of     |
|     expenses charged to your plan, please contact all plan service    |
|     providers with whom you contract or may contract and request fee  |
|     information with respect to their services.                       |
|                                                                       |
| 2.  If you are considering a conversion from an existing plan service |
|     provider to a new service provider, you will need to provide the  |
|     service provider(s) with certain information about the plan,      |
|     including the number of plan participants, the number of eligible |
|     participants and the amount of plan assets in order for the       |
|     service provider(s) to be able to complete this form. Similarly,  |
|     if you are considering starting a plan, you will need to provide  |
|     the service provider(s) with estimates of plan participants and   |
|     plan assets. When providing potential service providers with      |
|     information regarding your plan, it is critical that you provide  |
|     identical information to all of the competing companies in order  |
|     to ensure equivalent comparisons.                                 |
|                                                                       |
| 3.  Amounts are calculated based on rates charged, which are          |
|     identified in attached schedules as applied to relevant           |
|     information (for example amount of assets or number of            |
|     participants). Certain calculations may be estimates based on     |
|     information provided by you, the plan sponsor, and may vary as    |
|     circumstances change.                                             |
|                                                                       |
| 4.  Fees represent product-related charges paid by the plan. Fees     |
|     associated with participants\' transfer of account balances       |
|     between investment options, including investment transfer         |
|     expenses and any contingent back-end loads, redemption fees and   |
|     surrender charges should be included in \"other\" expenses. In    |
|     addition, any wrap fees or pricing charges for non-publicly       |
|     traded assets should be included in the \"other\" expenses        |
|     column. For investment product termination fees associated with   |
|     plan termination or conversion, see Schedule D. Insurance         |
|     companies incur marketing and distribution costs, which are       |
|     recouped through charges assessed against the plan.               |
|                                                                       |
| 5.  Includes 12b-1 fee and management fee. (See the fee table in the  |
|     fund prospectus).                                                 |
|                                                                       |
| 6.  When providing potential service providers with                   |
|     information/assumptions regarding the brokerage window plan       |
|     feature, it is critical that you provide identical information to |
|     all of the competing companies in order to ensure equivalent      |
|     comparisons.                                                      |
|                                                                       |
| 7.  Fees associated with participants\' transfer of account balances  |
|     between investment options, including investment transfer         |
|     expenses and any contingent back-end loads, redemption fees and   |
|     surrender charges should be included in \"other\" expenses. In    |
|     addition, any wrap fees or pricing charges for non-publicly       |
|     traded assets should be included in the \"other\" expenses        |
|     column. For investment product termination fees associated with   |
|     plan termination or conversion, see Schedule D. Insurance         |
|     companies incur marketing and distribution costs, which are       |
|     recouped through charges assessed against the plan.               |
|                                                                       |
| 8.  Other products could include investment vehicles such as REITs    |
|     and limited partnerships.                                         |
|                                                                       |
| 9.  Amounts represent the method by which the fee is calculated, for  |
|     example as a percentage of plan assets under management, based    |
|     upon number of participants or based upon number of transactions. |
|     For start-up or take-over situations, fees are based upon         |
|     estimates and/or certain assumptions, i.e., regarding assets      |
|     under management and number of participants. When providing       |
|     potential service providers with information/assumptions          |
|     regarding your plan, it is critical that you provide identical    |
|     information to all of the competing companies in order to ensure  |
|     equivalent comparisons. Without a standardized set of             |
|     assumptions, service providers will certainly use differing       |
|     assumptions, defeating the intended purpose of clarifying fee     |
|     comparisons among service providers.                              |
|                                                                       |
| 10. Services provided under a bundled services arrangement are        |
|     indicated by a check mark next to the specific service.           |
|                                                                       |
| 11. Amounts represent flat dollar amount charges or total charges     |
|     based upon the particular method of calculation. In some          |
|     instances, these amounts represent estimates based on assumptions |
|     provided by you, the plan sponsor.                                |
|                                                                       |
| 12. Amounts represent the method by which the fee is calculated, for  |
|     example as a percentage of plan assets under management, based    |
|     upon number of participants or based upon number of transactions. |
|     For start-up or take-over situations, fees are based upon         |
|     estimates and/or certain assumptions, i.e., regarding assets      |
|     under management and number of participants. When providing       |
|     potential service providers with information/assumptions          |
|     regarding your plan, it is critical that you provide identical    |
|     information to all of the competing companies in order to ensure  |
|     equivalent comparisons. Without a standardized set of             |
|     assumptions, service providers will certainly use differing       |
|     assumptions, defeating the intended purpose of clarifying fee     |
|     comparisons among service providers.                              |
|                                                                       |
| 13. Amounts represent flat dollar amount charges or total charges     |
|     based upon the particular method of calculation. In some          |
|     instances, these amounts represent estimates based on assumptions |
|     provided by you, the plan sponsor.                                |
|                                                                       |
| 14. Amounts represent the method by which the fee is calculated, for  |
|     example as a percentage of plan assets under management, based    |
|     upon number of participants or based upon number of transactions. |
|     For start-up or take-over situations, fees are based upon         |
|     estimates and/or certain assumptions, i.e., regarding assets      |
|     under management and number of participants. When providing       |
|     potential service providers with information/assumptions          |
|     regarding your plan, it is critical that you provide identical    |
|     information to all of the competing companies in order to ensure  |
|     equivalent comparisons. Without a standardized set of             |
|     assumptions, service providers will certainly use differing       |
|     assumptions, defeating the intended purpose of clarifying fee     |
|     comparisons among service providers.                              |
|                                                                       |
| 15. Amounts represent flat dollar amount charges or total charges     |
|     based upon the particular method of calculation. In some          |
|     instances, these amounts represent estimates based on assumptions |
|     provided by you, the plan sponsor.                                |
+-----------------------------------------------------------------------+