Form 5309 Application For Determination Of Employee Stock Ownership Plan {5309}

Form 5309 Application for Determination of Employee Stock Ownership Plan (Under section 4975(e)(7) of the Internal Revenue Code) Attach to Form 5300. OMB No. 1545-0284 (Rev. January 2012) Department of the Treasury Internal Revenue Service For IRS Use Only 1 Name of plan sponsor (employer if single-employer plan) 2 Employer identification number (EIN) 3 Plan number All Plans (Complete lines 4a through 4k.) Yes No 4a b c d Is the plan designated as an employee stock ownership plan (ESOP) within the meaning of section 4975(e)(7)? Is the plan designed to invest primarily in employer securities as defined in section 409(l)? Is each participant or beneficiary entitled to direct the plan to vote the allocated securities as required by section 409(e)? Does the plan provide that each participant who is entitled to a distribution from the plan has a right to demand that the benefit be distributed in the form of employer securities? If the answer to d is "No," please answer the following questions: (i) If the charter or bylaws of the corporation restrict substantially all outstanding stock ownership to employees or to a 401(a) trust, does the plan provide that participants are entitled to receive distributions in cash, except that such plan may distribute employer securities subject to a requirement that such securities may be resold to the employer under a fair valuation formula? (See section 409(h)(2)) If the plan is maintained by an S corporation, does the plan provide that participants are entitled to receive distributions in cash, except that such plan may distribute employer securities subject to a requirement that such securities may be resold to the employer under a fair valuation formula? (See section 409(h)(2)) If the plan is established and maintained by a bank which is legally prohibited from redeeming or purchasing its stock, does the plan provide that participants are entitled to receive distributions in cash? (See section 409(h)(3)) If the trust makes a distribution in stock and the securities are not readily tradable on an established market, can the participant require the employer to repurchase the securities under a fair valuation formula within the time frames prescribed by law? (See section 409(h)(1)(B)) If the plan holds employer securities consisting of stock in an S corporation, does the plan provide that no portion of the assets of the plan attributable to (or allocable in lieu of) such employer securities may, during a nonallocation year, accrue (or be allocated directly or indirectly under any section 401(a) plan of the employer) for the benefit of any disqualified person? (See section 409(p)) Does the plan provide that a qualified participant may elect to diversify a portion of his or her account investment in employer securities, as described in section 401(a)(28)(B)? If the answer to h is "No," please answer the following question: (i) i Does the plan provide that an applicable individual may elect to diversify a portion of his or her account investment in employer securities as described in section 401(a)(35)? With respect to activities that are carried on by the plan, are all valuations of employer securities acquired after December 31, 1986, which are not readily tradable on an established securities market, made by an independent appraiser? (See section 401(a)(28)(C)) Cat. No. 11835F Form 5309 (Rev. 1-2012) (ii) e f g h For Paperwork Reduction Act Notice, see instructions. American LegalNet, Inc. www.FormsWorkFlow.com Form 5309 (Rev. 1-2012) Page 2 Yes No j Does the plan provide that a participant may begin receiving a distribution of his or her account that is attributable to employer securities after the participant has separated from service upon reaching normal retirement age, or after death, disability, or other separation from service, within the time frames specified in section 409(o)? k If the plan is maintained by a C corporation, does the plan provide that the assets of the plan attributable to (or allocable in lieu of) employer securities acquired by the plan in a sale to which section 1042 applies cannot accrue (or be allocated directly or indirectly under any section 401(a) plan of the employer) for the benefit of persons specified in section 409(n) during the nonallocation period? Plans Applying Under Section 4975(d)(3) and Regulations Section 54.4975-7 (Leveraged ESOPs) (Complete lines 5a through 5g.) 5a b c Does the plan provide that the exempt loan proceeds must be used within a reasonable time to acquire qualifying employer securities, repay such loan, or repay a prior loan as required under Regulations section 54.4975-7(b)(4)? Does the plan provide for the establishment and maintenance of a suspense account as required under Regulations section 54.4975-11(c)? Does the plan provide that the collateral must be limited to qualifying employer securities purchased with such exempt loan or qualifying employer securities used as collateral on a prior exempt loan repaid with the proceeds of the current exempt loan as required under Regulations section 54.4975-7(b)(5)? Does the plan provide that no person entitled to payment under an exempt loan shall have any right to assets of the ESOP other than collateral given for such loan, contributions (other than contributions of employer securities) made to repay such exempt loan, and earnings attributable to such collateral and the investment of such contributions as required under Regulations section 54.4975-7(b)(5)? Does the plan provide that payments made with respect to an exempt loan by the ESOP during the year must not exceed an amount equal to the sum of contributions and earnings received during or prior to such year less such payments in prior years as required under Regulations section 54.4975-7(b)(5)? Do plan terms provide that qualifying employer securities will be forfeited only after other assets as required under Regulations section 54.4975-11(d)(4)? Does the plan provide that the protections and rights provided to participants and beneficiaries with respect to employer securities are nonterminable as required in Regulations section 54.4975-11(a)(3)(i) and (ii)? d e f g 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 Type or print name Type or print title Date Form 5309 (Rev. 1-2012) American LegalNet, Inc. www.FormsWork