401(k) PLAN FEE DISCLOSURE FORM
For Services Provided by XYZ Company1
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 X/XX/XX through X/XX/XX or _____ estimated 401(k) plan expenses2 for the period
X/XX/XX through X/XX/XX. 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