SCHEDULE Q

OMB No. 1545-0197

Elective Determination Requests (Form 5300)

Department of the Treasury

Internal Revenue Service

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For Paperwork Reduction Act Notice, see the Instructions for Form 5300. Cat. No. 21811R Schedule Q (Form 5300) (Rev. 8-2001)

 File as an attachment to Form 5300, 5307, or 5310 to request specific determinations.

See the instructions before completing this schedule.

Name of plan sponsor (employer, if single-employer plan) as shown on Form 5300, 5307, or 5310 Employer identification number

Name of plan

Yes No

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(Rev. August 2001)

If “Yes,” see instructions and attach Demo 1.

Sections 401(a)(26) and 410(b). See instructions.

Is this a request for a determination that specified benefits, rights, or features meet the nondiscriminatory current

availability requirement?

If “Yes,” see instructions and attach Demo 3.

Is this a request for a determination regarding the plan being restructured, mandatorily disaggregated, or

permissively aggregated? (See instructions.)

If “Yes”, see the instructions and attach Demo 4.

If Form 5300 line 13 or Form 5307 line 11 is answered “No,” is this a request for a determination regarding

Regulations section 1.410(b)-2(b)(5) average benefit test? If “Yes,” see instructions and attach Demo 5

If Form 5300 line 14 or Form 5307 line 12 is answered “No,” is this a request for a determination regarding a

nondesign-based safe harbor or a general test under 401(a)(4)?

If “Yes,” see instructions and attach Demo 6. Also, enter the letter (A, B, or C) corresponding to the

type of determination requested 

A = General test, involving “safety valve” rule in Regulations section 1.401(a)(4)-3(c)(3) (defined benefit plans only)

B = General test, not involving “safety valve” rule

C = Nondesign-based safe harbor

(i) Is this a request for a determination regarding a plan provision that provides for pre-participation or imputed

service?

(ii) Is this a request for a determination regarding a plan amendment (or, for an initial determination, a plan

provision) providing a period of past service in excess of the safe harbor?

If (i) or (ii) is “Yes,” see instructions and attach Demo 7.

Is this a request for a determination regarding a floor offset arrangement intended to satisfy the safe harbor in

Regulations section 1.401(a)(4)-8(d)?

If “Yes,” see instructions and attach Demo 8.

Is this a request for a determination that a definition of compensation is nondiscriminatory? (See instructions.)

If “Yes,” see instructions and attach Demo 9.

Is this a request for a determination for a defined benefit plan with employee contributions not allocated to

separate accounts?

If “Yes,” complete lines 11 and 12.

Enter the letter (A, B, C, D, or E) corresponding to the method used to determine the employer-provided

benefit: 

Method

A = Composition-of-workforce method

B = Minimum benefit method (also enter the plan factor, if applicable (.4 or .6))

C = Grandfather rule

D = Government plan method

E = Cessation of employee contributions method

If “A,” see instructions and attach Demo 10. If applicable, list the plan provisions and indicate the plan factor

here:

Enter the letter (A, B, or C) corresponding to the method used to show that the employee-provided

benefit is nondiscriminatory in amount: 

Method

A = Same rate of contributions

B = Total benefits method

C = Grandfather rule

If “C,” see instructions and attach Demo 11.

Is this a request for a determination on whether a plan that uses the qualified separate lines of business rules

of section 414(r) satisfies the gateway test of section 410(b)(5)(B) or satisfies the special requirements for

employer-wide plans?

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Type