Short Form Application for Determination for 6406 Minor Amendment of Employee Benefit Plan

(Under sections 401(a) and 501(a) of the Internal Revenue Code)

3a Determination requested for amendment (fill in appropriate dates):

b Has the plan received a determination letter?

If “Yes,” submit a copy of the latest letter.

c Have interested parties been given the required notification of this application? (See Instructions.)

d Does the plan have a cash or deferred arrangement (section 401(k))? 

4a Name of plan (Plan name may not exceed 66 characters, including spaces):

Does the plan have matching contributions (section 401(m))?

Does the plan have after-tax employee voluntary contributions (section 401(m))?

e

f

If “No,” this form cannot be used. See instructions under Who May File.

Does the plan provide for disparity in contributions or benefits that is intended to meet the permitted

disparity requirements of section 401(l)?

g

5—cash balance

OMB No. 1545-0229

For IRS Use Only

Department of the Treasury

Internal Revenue Service

Date amendment signed 

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.

Signature  Date 

For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 24500L Form 6406 (Rev. 9-2001)

Print Name  Title 

Form

(Rev. September 2001)

1a Name of plan sponsor (employer if single-employer plan) 1b Employer identification number

1c Employer’s tax year ends—Enter (MM)

City State ZIP code 1d Telephone number

Person to contact if more information is needed. (See instructions.) (If Form 2848, Power of Attorney

and Declaration of Representative, or other written designation is attached, check box and do not

complete the rest of this line.) 

2a

Name

Number, street, and room or suite no. (If a P.O. box, see instructions.)

Fax number

( )

Review the Procedural Requirements Checklist on page 3 before submitting this application.

City

( )

State ZIP code

1e Fax number

( )

Telephone number

( )

Number, street, and room or suite no. (If a P.O. box, see instructions.)

Yes No

b Enter 3-digit plan number d Enter plan’s original effective date (MMDDYYYY)

c Enter date plan year ends (MMDD) e Enter number of participants (See instructions.)

Date of letter 

/ /

/

1—profit-sharing and/or 401(k)

2—money purchase

3—target benefit

5 Indicate type of plan by entering the number from the list below.

4—defined benefit but not cash balance

Date amendment effective 

/ /

/ /

/ /

6—leveraged ESOP

7—non-leveraged ESOP

8—stock bonus

Yes No

Yes No

Yes No

Yes No

Yes No

2b

2c
Form 6406 (Rev. 9-2001) Page 2

Yes No

MISCELLANEOUS

9a Does any amendment to the plan reduce or eliminate any section 411(d)(6) protected benefit including an

amendment adopted after September 6, 2000, to eliminate the joint and survivor annuity form of benefit?

(See instructions.)

b Is this plan or trust currently under examination or is any issue related to this plan or trust currently pending

before:

If “Yes,” attach a statement explaining the issues involved, the contact person’s name (IRS Agent, DOL

Investigator, etc.) and their telephone number. Do not answer “Yes” if the plan has been submitted under

the Voluntary Compliance Program of the Employee Plans Compliance Resolution System (EPCRS).

Is this a master or prototype plan?

Is this plan an approved volume submitter plan?

Is this plan an individually designed plan?

Is this plan a governmental plan?

Is this plan a nonelecting church plan?

7a

b

c

8a

b

● The Internal Revenue Service

● The Department of Labor

● The Pension Benefit Guaranty Corporation

● Any court?

NA Yes No

Is the employer a member of an affiliated service group?

Is the employer a member of a controlled group of corporations or a group of trades or businesses under common

control? 

If a and/or b above is “Yes,” complete the required statement (see the instructions).

Is this plan a collectively bargained plan? (See Regulations section 1.410(b)-9.)? 

Is this plan a section 412(i) plan?

6a

b

c

d

If “Yes,” is the plan below the state level? 

Form 6406 (Rev. 9-2001)
Form 6406 (Rev. 9-2001) Page 3

Procedural Requirements Checklist

1

2

3

4

5

6

7

8

9

10

11

Use this list to assure that your submitted package is complete. Failure to supply the appropriate information may result

in a delay in the processing of the application.

Are the amendments MINOR in nature? (i.e., Form 6406 may not be used to amend for law changes or for significant

changes to plan benefits or coverage.) For more information, please see Who May File in the instructions?

Is Form 8717, User Fee for Employee Plan Determination Letter Request, attached to your submission?

Is the appropriate user fee for your submission attached to Form 8717?

If appropriate, is the Form 2848, Power of Attorney and Declaration of Representative, or a privately designated

authorization attached? (For more information, see the Disclosure Request by Taxpayer in the instructions.)

Is a copy of your plan’s latest determination letter, if any, attached?

Is the Employer Identification Number (EIN) of the plan sponsor/employer (NOT the trust’s EIN) entered on line 1b?

Does line 4d list the plan’s original effective date?

Is page 1 of the application signed and dated?

Have interested parties been given the required notification of this application? (See instructions.)

Have you included the following information:

A copy of the new amendment(s) or adoption agreement;

A statement as to how the amendment(s) or new adoption agreement elections affect or change the plan or any other

plan maintained by the employer;

A copy of the latest determination letter, and

A copy of the approval letter if your plan is either a volume submitter or M&P document?

If you answered “Yes” to line(s) 6a and/or 6b, have you included the information requested in the instructions?

12 Have you completed the information on page 2?

**********Form 6406**********