Short Form Application for OMB No. 1545-0200
fom 9307 Determination for Employee Benefit Plan | Brones 8/21/87

(Rev. March 1986) . . ‘il For IRS Use Only
(Other than Collectively Bargained Plans) File folder.
Treen she ita (Under sections 401(a) and 501(a) of the Internal Revenue Code) Case number >

Church and governmental plans not subject to ERISA need not complete items 16, 17, 18, and 19.

All other plans must complete all items except as indicated on the specific lines. For example, if you answer “No” to line 16a(i), you need not complete lines
16a(ii) and (ii) since they require responses only if you answer “Yes”, to line 16a(i). "N/A" is only an acceptable answer if an N/A block is provided. All
applications are now computer screened; therefore, it is important that you provide all the information requested and have the application signed by the
employer, plan administrator, or authorized representative. Otherwise, we may need to correspond with you or return your application for completion,
which will delay its processing.

la Name, address and ZIP code of sponsor (employer if single employer plan) 2a Employer identification number
b Employer's tax year ends
[Telephone number ® (+) Month ON/A
3 Name, address, ZIP code, and phone number of person to be contacted if more information is needed.
(See Specific Instructions.) (If same as la, enter “same as 1a”.)
Name > _
Address >
4 Determination requested for—(Check applicable box):
a (i) O Initial qualification—date plan adopted >
(i) C2 Amendment—date adopted >
(iii) \f (ii) is checked, enter file folder number > __
b Were employees who are interested parties given the required notification o1
5 Check appropriate box to indicate the type of plan entity:

e filing o

a Single employer plan dO Church plan
b C Plan of controlled group of corporations, common e ( Governmental plan
control employers, or affiliated service group f (1 Other (specify) >
c¢ Multipleemployerplan i sssnrsrssreee
6a Name of plan b Plannumber >»
c Planyearends >
7a Thisisa: b Letter serial number or notification letter number
(i) 0 Master or prototype plan
(i) Field prototype plan
(ii) (Uniform plan (see instructions)
8a Is this a defined benefit plan? O Yes (1 No—If “Yes,” indicate whether:
(i) 0 Unit benefit (ii) OO Flat benefit
(di) O Fixed benefit (iv) 0 Other(specify) >
b Is this a defined contribution plan? O) Yes C1 No—If “Yes,” indicate whether:
(i) O Profit-sharing (ii) [1 Stock bonus
Gi) [C1 Money purchase (iv) 0 Target benefit
© (i) {f8a(i), (i), (ii), or (iv) is checked, is this a defined benefit plan covered under (i) If 4a (ii) and 8b (i), (i), (iil), or (iv) are checked and the plan was a defined
‘the Pension Benefit Guaranty Corporation termination insurance program? benefit plan before the amendment, was the plan covered by the termination
insurance program before the amendment?
O Yes O No ( Notdetermined O Yes (] No [] N/A
9 Effective date of plan 10 Effective date of amendment
O N/A
11 Date plan was communicated to employees ® ooo... ee eee eee
How communicated >
12 __ Integration: Is this plan integrated with social security or railroad retirement (see instructions)?. . . . . . . 0 Yes () No
13 Type of funding entity:
aQ Trust c O Non-trusteed
b 1 Custodial account dO) Trust with insurance contracts
14a Does plan provide for maximum limitation under section 415 (see instructions)? . . . . . . . . .. .O Yes () No
b Do you maintain any other qualified plan(s) (see instructions)? . . . .. . . O Yes 0 No

Under penalties of perjury I deciare that | have examined this application, including accompanying Statements, and tothe best of my knowledge and belief Ris true, correct
and complete.

Signature > Title > Date >

Signature > Title > Date >

For Paperwork Reduction Act Notice, see page 1 of the instructions. Form 5307 (Rev. 3-86)


Form 5307 (Rev. 3-86)

Page 2

15 Is any issue relating to this plan or trust currently pending before the Internal Revenue Service, the Department

of Labor, the Pension Benefit Guaranty Corporation or any Court? . . O Yes O No
If “Yes,” attach explanation.
Yes | No Not Certain
16a (i) \sthe employer a member of an affiliated service group? . .
If there is uncertainty whether the employer is a member of an affiliated service e group,
check the “Not Certain’ column.
(ii) If 16a(i) is “Yes” or ‘Not Certain,” did a prior ruling or determination letter rule on
what organizations were members of the employer's affiliated service group?
(see instructions) .
(iii) \f 16a(ii) is Yes," have the facts on n which that letter was based materially changed?
(see instructions) woe .
b Is the employer a member of a controlled group of corporations or a group of trades 0 or
businesses under common control? :
Number

17 Coverage of plan at (give date) >
a Total employed

Enter “0” if N/A

b Exclusions under plan because ‘of (do! not count an employeen more ethan once): Us
(i) Minimum age (specify) Ps. 0 N/A Years of service (specify) > __
(ii) Employees included in collective bargaining
(iii) Nonresident aliens who receive no earned income from United States sources
c Total exclusions (add b(i) through (iii). .
d_ Employees not excluded under the statute (subtract c c from a),
e Ineligible under plan because of (do not count an employee included in b): Ue
() Minimum pay (specify) ® OC N/A
(ii) Hourly-paid .
(iii), Maximum age (specify) Pence eee eee ee eee eee eee eee eee O N/A
(iv) Other (specify) >
f Total employees ineligible (add e(i) through (iv)) .
g Employees eligible to participate (subtract f from d) ,
h_ Number of employees participating in plan . ns
i Percent of nonexcluded employees who are participating (divide h by d) Coe ee %
If line iis 70% or more, go to line |.
j Percent of nonexcluded employees who are eligible to participate (aides byd)) - %
k Percent of eligible employees who are participating (dividehbyg) . . oe ee % Uf,
If iand j are less than 70%, ork is less than 80%, see instructions.
|__ Total number of participants, including certain retired and terminated employees (see instructions)
18 Vesting—Check only one of the boxes for the vesting provisions of the plan:
a CO Fullandimmediate
b (O Fullvesting after 10 years of service (see instructions)
c ( 5-to 15-year vesting, i.e., 25% after 5 years of service, 5% additional for each of the next 5 years,
then 10% additional for each of the next 5 years (see instructions)
d ( Rule of 45 (section 411(a)(2)(C)) (see instructions)
e (J Foreach year of employment, beginning with the 4th year, vesting not less than 40% after 4 years of
service, 5% additional for each of the next 2 years, and 10% additional for each of the next 5 years
f (1 Other (specify and see instructions) ® ___....... eee
19 Complete only for a plan of more than one employer: Uf,

a Total number of participants (including certain retired and terminated employees) an
b Participants whose benefits or accounts arefullyvested . 2 2. 1. ww ee ee
c Number of contributing employers ee
20 Is the plan sponsoranSCorporation?. . . . .. .........~. ~~. ~-O1 Yes 0) No