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Form 5310 Application For Determination Upon Termination 5310 - Official Federal Forms
| Form 5310 Application For Determination Upon Termination Form. This is a national form and can be used in Department Of Treasury . |
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Form 5310 (Rev. April 2006) Department of the Treasury Internal Revenue Service Application for Determination for Terminating Plan (Under section 401(a) of the Internal Revenue Code) (See separate instructions.) OMB No. 1545-0202 For IRS Use Only See the Procedural Requirements Checklist on page 7 before submitting this application. 1a Name of plan sponsor (employer if single-employer plan) 1b Employer identification number Number, street, and room or suite no. (If a P.O. box, see page 2 of the instructions.) 1c Employer's tax year ends--Enter (MM) City State ZIP code 1d Telephone number ( 2a Person to contact if more information is needed. (See page 2 of the instructions.) (If Form 2848 or Form 8821 is attached, check box and do not complete this line.) Name 1e ) ) Fax number ( Number, street, and room or suite no. (If a P.O. box, see page 2 of the instructions.) 2b Telephone number ( City State ZIP code 2c ) Fax number ( ) If more space is needed for any item, attach additional sheets the same size as this form. Identify each sheet with the plan sponsor's name and EIN and identify each item. 3a Have interested parties (as defined in Treasury Regulations section 1.7476-1(b)(5)) been given the required notification of this application? / / b If line 3a is "Yes," enter date of notification (MMDDYYYY) Date / / Date of letter c Has the plan received a determination letter? (1) If "Yes," submit a copy of the latest letter and subsequent amendments. Number of amendments (2) If "No," submit all prior plan(s) and/or adoption agreement(s). (See page 3 of the instructions.) d Does the plan have a cash or deferred arrangement (section 401(k))? e Does the plan have matching contributions (section 401(m))? f Does the plan have after-tax employee voluntary contributions (section 401(m))? 4a Name of Plan (Plan name may not exceed 66 characters, including spaces.): b c 5 Enter 3-digit plan number Enter date plan year ends (MMDD) d e Yes Yes No No Yes Yes Yes No No No / Enter plan's original effective date (MMDDYYYY) Enter number of participants (See page 3 of the instructions.) 6a b 7 a b c Indicate type of plan by entering the number from the list below. (1)--profit sharing and/or section 401(k) (4)--defined benefit but not cash balance (7)--non-leveraged ESOP (2)--money purchase (5)--cash balance (8)--stock bonus (3)--target benefit (6)--leveraged ESOP (9)--safe harbor section 401(k) Yes No Is the employer a member of an affiliated service group? Yes No Is the employer a member of a controlled group of corporations or a group of trades or businesses under common control? If line(s) 6a and/or 6b is "Yes," see page 3 of the instructions for the required statement. Attach copies of records of all actions taken to terminate the plan (see page 3 of the instructions). / / Proposed date of plan termination (MMDDYYYY) Yes No Will funds be distributed as soon as administratively feasible? Yes No Will any funds be, or have any funds been, returned to the employer? (See page 3 of the instructions.) $ (1) If "Yes," enter the estimated amount Yes No (2) If "Yes," has the employer established or intend to establish a Qualified Replacement Plan? Yes No governmental plan? is the plan a state level plan? nonelecting church plan? collectively bargained plan? (See Regulations section 1.410(b)-9.) section 412(i) plan? multiple employer plan? enter number of participating employers 8a Is this a If "Yes," b Is this a c Is this a d Is this a e Is this a If "Yes," Under penalties of perjury, I declare that I have examined this application, including accompanying statements, and to the best of my knowledge and belief, it is true, correct, and complete. Signature Title Cat. No. 11840Y Date Form For Paperwork Reduction Act Notice, see separate instructions. 5310 (Rev. 4-2006) Form 5310 (Rev. 4-2006) Page 2 Yes No 9a Have any of the amendments altered the plan's vesting provisions? b Have any of the amendments (including the termination) decreased plan benefits for any participant? 10 Reason for termination. Check only one box to indicate primary reason for termination. a Change in ownership by merger b Liquidation or dissolution of employer c Change in ownership by sale or transfer d Adverse business conditions (See page 3 of the instructions and attach explanation.) e Adoption of new plan. Enter type of new plan f Other (specify) 11 Last employer/sponsor contribution to the plan: (a) Date (MMDDYYYY) (b) Amount $ (c) For plan year ending (MMDDYYYY) 12a Name(s) of trustee(s) or custodian(s) 12b Telephone number ( ) Address (number and street) City or town, state, and ZIP code 13 Coverage Complete only lines 13a through 13n if the plan satisfied the ratio percentage test for the year of termination. Complete only line 13o if the plan satisfied the average benefit test for the year of termination. Complete only line 13p if the plan satisfied coverage using one of the special requirements of Regulations section 1.410(b)-2(b)(5), (6), or (7). Plans that use the qualified separate line of business rules of section 414(r) must attach Demo 1. See Guidelines for Demonstrations on page 6 of the instructions. Yes No a Is this plan disaggregated into two or more separate plans that are not section 401(k), 401(m), or profit sharing plans? If "Yes," see page 3 of the instructions and attach separate schedules for each disaggregated portion. b Does the employer receive services from any leased employees as defined in section 414(n)? / / c Coverage date (MMDDYYYY) (See page 3 of the instructions.) d Total number of employees (employer-wide) (include self-employed individuals) e Statutory and regulatory exclusions under this plan (do not count an employee more than once): (1) Number of employees excluded because of the minimum age or years of service required (2) Number of employees excluded because of their inclusion in a collective bargaining unit (3) Number of employees excluded because they terminated employment with less than 501 hours of service and were not employed on the last day of the plan year (4) Number of employees excluded because they were employed by other qualified separate lines of business (QSLOBs) (5) Number of employees excluded because they were nonresident aliens with no earned income from sources within the United States f Total statutory and regulatory exclusions. Add lines 13e(1) through 13e(5) g Nonexcludable employees. Subtract line 13f from line 13d h Number of nonexcludable employees on line 13g who ar
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