USPTA Retirement Gold + Attestation Form

Your Information

Contact Preference

Pro Shop Information

Contributions Accepted From:

(Must own a club or resort pro shop and/or have fiscal responsibility for the shop. Contribution will be made once $750 has been spent on NIKE shoes and apparel in a calendar year)

AFFIRMATION / ATTESTATION

Please accept this as my interest in participating in the USPTA Retirement Gold+ program. I understand I must be a USPTA member in good standing to participate, and I understand my participation is voluntary. My eligibility must be validated by the USPTA for me to participate in the Vendor-Sponsored program. I further understand in order to receive contributions from Fromuth, I must also be either a pro shop owner and/or pro shop manager who is directly responsible for making the purchasing decision for a qualifying pro shop.

If I am approved for the Vendor-Sponsored version of the plan, I further understand that only specific vendors will be tendering a contribution to my retirement  program, based on the value of qualifying goods and/or services purchased through their distribution channel. I also understand that not all products purchased through a participating vendor may be a contribution-eligible product and that I am not obligated in any way to direct my purchases to any specified vendor. I acknowledge my vendor account must remain in good standing, and should my account become delinquent the vendor reserves the right to withhold any vendor-sponsored matching contribution until such time as my vendor account is current and in good standing. If I fail to bring my account current within a reasonable period, the

USPTA may cancel my enrollment.

Even if I am ineligible for participation in the vendor-sponsorship retirement program, I am still eligible to open a personal retirement account and select among the individual USPTA Retirement Gold+ plan options available to me. I acknowledge if I work for a municipality, school, university or other employer who may restrict any vendor-sponsored contributions that I am still eligible to open and participate in a personal retirement plan; however, I would not be eligible for any qualifying vendor-sponsored contributions to my retirement plan. All applicants for vendor-sponsorship participation in Retirement Gold+ will be vetted by the USPTA to assure eligibility.

I acknowledge at the end of each qualifying period, the participating vendors will submit an accounting report to the USPTA along with the qualifying funds, based on the purchase of qualifying products. These funds will be disbursed to your account from all participating vendors no later than 30 days of the close of the quarter, based on the sales of product(s) from all participating vendors.

Please note: You must have a retirement account set up with Paloma Financial/Institutional Securities Corporation to receive vendor contributions. For more information, please visit http://uspta.com/default.aspx?menuitemid=2292

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Retirement

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