Application for Determination for Employee Benefit Plan

Transcription

1 Department of the Treasury Internal Reenue Serie Appliation for Determination for Employee Benefit Plan (Under setions 401(a) and 501(a) of the Internal Reenue Code) OMB Expires For IRS Use Only File folder numer Case numer File page 1 of Form 5300 in dupliate. te: User fee must e attahed to this appliation. (See What To File.) Enter amount of user fee sumitted. The information proided on this form will e read y omputer. Therefore page 1 must e typed (exept the signature). Please enter information exatly as requested and only in the spae proided. Do not type in areas that are shaded. Reiew the Proedural Requirements Cheklist on page 4 efore sumitting this appliation. 1a Name of plan sponsor (employer if single-employer plan) 1 Employer identifiation numer Numer, street, and room or suite no. (If a P.O. ox, see instrutions.) 1 Employer s tax year ends-enter or (MM) ZIP ode 1d Telephone numer 2 Person to e ontated if more information is needed. (See instrutions.) (If the same as line 1a, leae lank.) (Complete een if a Power of Attorney is attahed): Name Numer, street, and room or suite no. (If a P.O. ox, see instrutions.) 3a ZIP ode Determination requested for (enter appliale numer(s) at left and fill in required information). (See instrutions.) Enter 1 for Initial Qualifiation Date plan signed Enter 2 for Amendment after initial qualifiation Is plan restated? Date amendment signed Date amendment effetie Enter 3 for Affiliated Serie Group status (setion 414(m)) Date effetie Enter 4 for Leased Employee Status Enter 5 for Partial termination Date effetie Has the plan reeied a determination letter? If, sumit a opy of the latest letter Hae interested parties (as defined in Treasury Regulations setion ) een gien the required notifiation of this appliation? Telephone numer d Does the plan hae a ash or deferred arrangement, or employee or mathing ontriutions (setion 401(k) or (m))? Name of Plan: 4a Enter plan numer (3 digits) d Enter date plan effetie (MMDDYY) Enter date plan year ends (MMDD) e Enter numer of partiipants in plan 5a If this is a defined enefit plan, enter the appropriate numer in ox at left. Enter 1 for unit enefit Enter 3 for flat enefit Enter 2 for fixed enefit Enter 4 for other (Speify) If this is a defined ontriution plan, enter the appropriate numer in ox at left. Enter 1 for profit sharing Enter 4 for target enefit Enter 2 for stok onus Enter 3 for money purhase Enter 5 for ESOP Enter 6 for other (Speify) 6a Is the employer a memer of an affiliated serie group? Enter 1 if Enter 2 if Enter 3 if t Certain Is the employer a memer of a ontrolled group of orporations or a group of trades or usinesses under ommon ontrol? Enter 1 if Enter 2 if 7 Enter type of plan: Enter 1 if goernmental plan Enter 2 if hurh plan not sujet to ERISA (see instrutions) Enter 3 if multiple employer plan (desried in setion 413()). Enter numer of partiipating employers Enter 4 if setion 412(i) plan Enter 5 if other Under penalties of perjury, I delare that I hae examined this appliation, inluding aompanying statements, and to the est of my knowledge and elief, it is true, orret, and omplete. Both opies of this page must e signed. Signature Title Date Instrutions are separate. See page 1 for Paperwork Redution At tie. Cat X Form 5300 (Re )

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3 5300 Re 11/92

4 5300 Re 11/92 Department of the Treasury Internal Reenue Serie Appliation for Determination for Employee Benefit Plan (Under setions 401(a) and 501(a) of the Internal Reenue Code) OMB Expires For IRS Use Only File folder numer Case numer File page 1 of Form 5300 in dupliate. te: User fee must e attahed to this appliation. (See What To File.) Enter amount of user fee sumitted. The information proided on this form will e read y omputer. Therefore page 1 must e typed (exept the signature). Please enter information exatly as requested and only in the spae proided. Do not type in areas that are shaded. Reiew the Proedural Requirements Cheklist on page 4 efore sumitting this appliation. 1a 2 3a Name of plan sponsor (employer if single-employer plan) Numer, street, and room or suite no. (If a P.O. ox, see instrutions.) ZIP ode Person to e ontated if more information is needed. (See instrutions.) (If the same as line 1a, leae lank.) (Complete een if a Power of Attorney is attahed): Name ZIP ode Determination requested for (enter appliale numer(s) at left and fill in required information). (See instrutions.) Enter 1 for Initial Qualifiation Date plan signed Enter 2 for Amendment after initial qualifiation Is plan restated? Date amendment signed Date amendment effetie Enter 3 for Affiliated Serie Group status (setion 414(m)) Date effetie Enter 4 for Leased Employee Status Enter 5 for Partial termination Date effetie Has the plan reeied a determination letter? If, sumit a opy of the latest letter Hae interested parties (as defined in Treasury Regulations setion ) een gien the required notifiation of this appliation? 1 1 1d Employer identifiation numer Employer s tax year ends-enter or (MM) Telephone numer Telephone numer d Does the plan hae a ash or deferred arrangement, or employee or mathing ontriutions (setion 401(k) or (m))? Name of Plan: 4a Enter plan numer (3 digits) d Enter date plan effetie (MMDDYY) Enter date plan year ends (MMDD) e Enter numer of partiipants in plan 5a If this is a defined enefit plan, enter the appropriate numer in ox at left. Enter 1 for unit enefit Enter 3 for flat enefit Enter 2 for fixed enefit Enter 4 for other (Speify) If this is a defined ontriution plan, enter the appropriate numer in ox at left. Enter 1 for profit sharing Enter 4 for target enefit Enter 2 for stok onus Enter 3 for money purhase Enter 5 for ESOP Enter 6 for other (Speify) 6a Is the employer a memer of an affiliated serie group? Enter 1 if Enter 2 if Enter 3 if t Certain Is the employer a memer of a ontrolled group of orporations or a group of trades or usinesses under ommon ontrol? Enter 1 if Enter 2 if 7 Enter type of plan: Enter 1 if goernmental plan Enter 2 if hurh plan not sujet to ERISA (see instrutions) Enter 3 if multiple employer plan (desried in setion 413()). Enter numer of partiipating employers Enter 4 if setion 412(i) plan Enter 5 if other Numer, street, and room or suite no. (If a P.O. ox, see instrutions.) Under penalties of perjury, I delare that I hae examined this appliation, inluding aompanying statements, and to the est of my knowledge and elief, it is true, orret, and omplete. Both opies of this page must e signed. Signature Title Date Instrutions are separate. See page 1 for Paperwork Redution At tie. Form 5300 (Re )

5 Form 5300 (Re ) Page 2 8a Do you maintain any other qualified plan(s)? (See instrutions.) If, skip to line 8. If this is a defined ontriution plan and you also maintain a defined enefit plan, or if this is a defined enefit plan and you also maintain a defined ontriution plan, when the plan is top-heay, do non-key employees oered under oth plans reeie: (1) the top-heay minimum enefit under the defined enefit plan? (2) at least a 5% minimum ontriution under the defined ontriution plan? (3) the minimum enefit offset y enefits proided y the defined ontriution plan? (4) enefits under oth plans that, using a omparaility analysis, are at least equal to the minimum enefit? (See instrutions.) Do the proisions of the plan prelude the possiility that the setion 415 limitations will e exeeded for any employee who is (or has een) a partiipant in this plan and any other plan of the employer? 9 COVERAGE (See instrutions.): a Is the employer applying the separate line of usiness rules of setion 414(r)? (If, see instrutions.) Does the employer reeie series from any leased employees within the meaning of setion 414(n)? Coerage of plan at (gie date) d e f g h i j Enter the perentage of nonhighly ompensated employees who enefit under the plan, exluding employees who enefit only under a part of the plan ontaining a CODA or employee or mathing ontriutions. (If 70% or more, skip line 9e and go to line 9f.) Diide the perentage of nonhighly ompensated employees who enefit under the plan (line 9d) y the perentage of highly ompensated employees who enefit under the plan, exluding employees who only enefit under a part of the plan ontaining a CODA or employee or mathing ontriutions If the plan ontains a CODA, ompute the ratio in line 9e aoe on the asis of employees eligile to make eletie deferrals under the CODA portion of the plan If the plan proides for employee or mathing ontriutions, ompute the ratio in line 9e aoe on the asis of employees eligile to make employee ontriutions or to reeie mathing ontriutions under the plan Are the results in line 9e, 9f, or 9g ased on the aggregated oerage of more than one plan? (If, see instrutions.) If line 9e, 9f, or 9g is less than 70%, does the plan pass the aerage enefit test? (1) Enter the safe haror perentage (2) Enter the aerage enefit perentage. (See instrutions.) Enter total numer of employees %

6 Form 5300 (Re ) 10 a PERMITTED DISPARITY: If the plan proides for disparity in ontriutions or enefits, is the plan intended to meet the requirements of setion 401(l)? If, do not omplete lines 10 through 10f. If or, omplete lines 10 through 10f. (See instrutions.) In the ase of a defined ontriution plan, does the exess ontriution perentage exeed the ase ontriution perentage y a uniform amount that does not exeed the maximum exess allowane? Base Contriution Perentage Exess Contriution Perentage In the ase of a defined enefit exess plan, does the exess enefit perentage exeed the ase enefit perentage y a uniform amount no greater than the maximum exess allowane? Base Benefit Perentage Exess Benefit Perentage d In the ase of a defined enefit offset plan, are the gross enefit perentage and the offset uniform and is the offset less than the maximum offset allowane? Gross Benefit Perentage Offset e What is the plan s integration/offset leel? f In the ase of a defined enefit plan, does the plan adjust the 75% fator for enefits ommening at ages other than soial seurity retirement age in aordane with Treasury Regulations setion 1.401(l) 3(e)? 11 General eligiility requirements Complete lines 11a, 11, and 11 elow. a Chek one ox: (1) All employees (2) Hourly rate employees only (3) Salaried employees only (4) Other (Speify) Length of serie (numer of years) Minimum age (Speify) 12 Vesting: Chek one ox to indiate the esting proisions of the plan: a Full and immediate. Full esting after 2 years of serie. Full esting after 3 years of serie. d Full esting after 5 years of serie. e 6 year graded esting. f 3 to 7 year graded esting. g Other (Speify) (See instrutions and attah shedule.) 13 Benefits and requirements for enefits: a For defined enefit plans Method for determining arued enefit: (1) Benefit formula at normal retirement age is (2) Benefit formula at early retirement age is (3) rmal form of retirement enefit is For defined ontriution plans Employer ontriutions: (1) Profit-sharing or stok onus plan ontriutions are determined under: A definite formula An indefinite formula Both (2) Money purhase Enter rate of ontriution (3) target enefit formula 14 Misellaneous Proisions: a Does any amendment to the plan redue or eliminate any setion 411(d)(6) proteted enefit? (See instrutions.) Are ontriutions or enefits alloated on the asis of total ompensation within the meaning of setion 414(s)? If, explain. (See instrutions.) d e Are forfeitures alloated, in the ase of a defined ontriution plan, on the asis of total ompensation within the meaning of setion 414(s)? If, explain Are trust earnings and losses alloated on the asis of aount alanes in a defined ontriution plan? Is this plan or trust urrently under examination or is any issue related to this plan or trust urrently pending efore the Internal Reenue Serie, the Department of Laor, the Pension Benefit Guaranty Corporation, or any ourt? If, attah an explanation f Does the plan omply with the annual ompensation limit of setion 401(a)(17)? (See instrutions.) g If this is a defined enefit plan, does the plan ontain the pre-termination restritions of Treasury Regulations setion 1.401(a)(4)-(5)()? Page 3

7 Form 5300 (Re ) Page 4 Proedural Requirements Cheklist This heklist identifies ertain asi data required to proess this appliation. The heklist identifies items that MUST e inluded with the appliation. Completion of this heklist is optional and is for the enefit of the plan sponsor. a d e f g h Is Form 5302, Employee Census, attahed? Is Form 8717, User Fee for Employee Plan Determination Letter Request, and the appropriate user fee attahed? Is a opy of the plan attahed? (Initial appliations and Restated plans only) Is a opy of the plan s latest determination letter attahed? (Preiously approed plans only) Are the appropriate ertifiations, designations, and demonstrations attahed? Has page one een sumitted in dupliate (at least one must e an original)? Are oth opies of page one of the appliation signed? Is the plan sponsor s 9-digit employer identifiation numer entered on line 1? i j If appropriate, is Form 2848, Power of Attorney and Delaration of Representatie, attahed? See Dislosure Requested y Taxpayer Is the effetie date of the plan entered on line 4d? k l Affiliated Serie Groups, Controlled Groups or Entities Under Common Control Is the information requested under What To File and the line 6 instrutions attahed? Multiple-Employer Plans Is the information required under What To File, Speifi Plans, item 7, attahed? m ESOPs Is Form 5309, Appliation for Determination of Employee Stok Ownership Plan, attahed? ALL APPLICATIONS ARE SCREENED BY COMPUTER. FAILURE TO INCLUDE A REQUIRED ITEM WILL RESULT IN THE RETURN OF THIS APPLICATION TO YOU.