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Form 5300 Application For Determination For Employee Benefit Plan 5300 - Official Federal Forms
| Form 5300 Application For Determination For Employee Benefit Plan Form. This is a national form and can be used in Department Of Treasury . |
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Form 5300 (Rev. April 2011) Department of the Treasury Internal Revenue Service Application for Determination for Employee Benefit Plan See separate instructions. For Internal Use Only OMB No. 1545-0197 Review the Procedural Requirements Checklist before submitting this application. 1a Number Assigned under Section 6.19 of Revenue Procedure 2008-6 -- 1b Name of plan sponsor (employer if single-employer plan) 1c Address of plan sponsor (if a P.O. Box, see instructions) 1d City 1e State 1f Zip Code 1g Country 1h Employer identification number (EIN) 1i Telephone number 1j Fax number 1k Employer's tax year ends 2a Person to contact if more information is needed. (See instructions.) (If a Power of Attorney is attached, check box, and do not complete this line.) Contact person's name 2b Contact person's address 2c City 2d State 2e Zip Code 2f Telephone number 2g Fax number If more space is needed for any item, attach additional sheets the same size as this form. Identify each additional sheet with the plan sponsor's name and EIN and identify each item. Under penalties of perjury, I declare that I have examined this application, including accompanying statements and schedules, and to the best of my knowledge and belief, it is true, correct, and complete. SIGN HERE Date Type or print name Type or print title For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions. Cat. No. 11740X Form 5300 (Rev. 4-2011) American LegalNet, Inc. www.FormsWorkFlow.com Form 5300 (Rev. 4-2011) Page 2 3a Determination requested for (enter applicable number in box) (See instructions.) 1 - Initial qualification 2 - Request after initial qualification 3 - Affiliated Service Group (ASG) status (IRC section 414(m)) 4 - Leased employee status (IRC section 414(n)) 5 - Partial termination 6 - Termination of collectively bargained multi-employer or multiple-employer plan covered by PBGC insurance b (i) If line 3a is 1, enter the effective date of the plan (ii) If line 3a is 1, enter the date the plan was signed (iii) If line 3a is 2, enter the effective date of the restatement c d e f If line 3a is 5, enter the effective date of the partial termination If line 3a is 6, enter the effective date of termination Enter number of amendments included Enter the date the amendment(s) were signed (If more than 4, see instructions) (i) g (ii) (iii) (iv) Enter the date the amendment(s) were effective (If more than 4, see instructions) (i) Yes No Has the plan received a determination letter? (ii) (iii) (iv) h If "No," submit copies of all prior plan(s) and/or adoption agreement(s) and/or amendments. (See instructions.) i j k l m n o p If 3h is "Yes," enter the date of the latest letter Enter the number of amendments since the last determination letter. Was this plan a prior adopter of a pre-approved plan? (See instructions.) If line 3k is "Yes," enter the Serial Number. If line 3k is "Yes," was the sponsor authorized to adopt amendments? Have interested parties been given the required notification of this application? (See instructions.) Does the plan have a cash or deferred arrangement (section 401(k) or 414(x))? Does the plan have matching contributions (section 401(m))? Form 5300 (Rev. 4-2011) American LegalNet, Inc. www.FormsWorkFlow.com Form 5300 (Rev. 4-2011) Page 3 3 (continued) Yes q r s t No Does the plan have after-tax employee voluntary contributions (section 401(m))? Does the plan benefit noncollectively bargained employees or are more than 2% of the employees who are covered under a collectively bargaining agreement professional employees? See Regulations section 1.410(b)-6(d). Does the plan utilize the permitted disparity rules of section 401(l) when allocating contributions or benefits? Is the plan being filed "on-cycle" pursuant to Section 13 of Revenue Procedure 2007-44? If "Yes," indicate the cycle the plan is being submitted in If "No," skip to question v. Enter the applicable number in the box to indicate the reason the plan was submitted in the cycle listed above. 1 - Last digit of the EIN. 2 - Multiple employer plan. 3 - Governmental plan including governmental multiple employer plan. 4 - Multi-employer plan. 5 - Pre-approved plan filing in the 2-year Remedial Amendment Cycle window (including special ASG leased employee or partial termination) rulings. 6 - Cycle changing event (enter date and attach explanation of cycle changing event). Is the EIN of the parent company, jointly trusted single employer collective bargained plan (if the plan sponsor is the Joint Board of Trustees include the EIN of the Form 5500), or centralized organization (include the EIN of the centralized organization if that organization handles the administration and operations of the plan) being used? (See instructions.) (1) If line 3u is "Yes," enter the EIN of parent, Joint Board of Trustees, or centralized organization. u v If 3t is "No," are you requesting priority considerations as specified in Section 14.02 of Revenue Procedure 2007-44? If "Yes," indicate the cycle the plan is being submitted in Enter the applicable number in the box for the reason the plan was submitted in the cycle listed above. 1 - New plan exception. 2 - Urgent business need. 3 - Cycle changing event (date and explanation of cycle changing event). w Is this plan an offset arrangement with any other plan? (If "Yes," attach a separate statement providing the name, EIN, the plan provision, and type of the other plan including plan sections that is part of the arrangement.) (See instructions.) Form 5300 (Rev. 4-2011) American LegalNet, Inc. www.FormsWorkFlow.com Form 5300 (Rev. 4-2011) Page 4 4a Name of plan (If plan name exceeds 70 characters, including spaces, see instructions): b c d e 5 Enter 3-digit plan number (See instructions.) Enter the month on which the plan year ends Enter plan's original effective date Enter number of participants (See instructions.) Indicate type of plan by entering the number from the list below: 1 -- profit sharing and/or 401(k) 2 -- money purchase 3 -- target benefit 4 -- defined benefit but not cash balance 7 -- non-leveraged ESOP (See instructions.) 5 -- cash balance (See instructions.) 8 -- stock bonus 6 -- leveraged ESOP 9 -- safe harbor 401(k) If this plan contains any ESOP provisions, do not use 1 or 2, use 6 or 7, as applicable. Yes 6a b No Is the employer a member of an affiliated service group (ASG)? Is the employer a member of a controlled group of corporations or a group of trades or busin
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