room 9007 Short Form Application for For IRS Use Only

(Rev, August 1979) Determination for Employee Benefit Plan File
Department of the Treasuy | (Other than Plans that Include Self-employed Individuals) folder
Internal Revenue Service (Under sections 401(a), and 501(a) of the Internal Revenue Code) number D>
> Please complete every item on this form. If an item does not apply, enter N/A.
1 (a) Name, address and ZIP code of employer 2 (a) Employer's identification number

(b) Employer's tax year ends

| Telephone number D> ( )
(b) Name, address and ZIP code of plan administrator, if other than employer 3 Administrator's identification number

“| Telephone number b> ( )
(c) Name, address and phone number of person to be contacted if more information is needed:

Name >
Address b>
4 Determination requested for:
(a) (i) [J Initial qualification—date plan adopted >
(i) [ Amendment—date adopted p>
(iii) If (ii) is checked, enter file folder number p> -
(b) Were employees who are interested parties given the required notification of the filing of this application? ._[] Yes [] No

5 Check appropriate box to indicate the type of plan entity:

Telephone number D> ( )

(a) [J Single-employer pian (4) [ Church
(b) [[) Plan of controlled group of corporations (e) [] Governmental organization
or of common control employers (f) [J Other (specify) p.
(c) () Multiple-employer plan
6 (a) Name of plan (b) Plan number >.
(c) Plan year ends &
7 (a) This is a: (b) Letter seria! number or notification letter number
(i) [1) Master or prototype plan
(ii) ([] Field prototype plan
Gi) [ Other (see instructions)
8 (a) Defined benefit plan—tIndicate whether: (iii) (1) Flat benefit
(i) [) Unit benefit (iv) [J Other (specify) P.....

(ii) [1] Fixed benefit
(b) Defined contribution plan—indicate whether:

(i) ( Profit-sharing (ii) [J Stock bonus
(ii) [) Money purchase (iv) [] Target benefit
(c) (i) If 8(a) (i), (ii), (iii), or (iv) is checked, is this a defined (ii) If 4(a) (ii) and 8(b) (i), (ii), (iii), or (iv) are checked,
benefit plan covered under the Pension Benefit Guar- was the plan covered by the termination insurance
anty Corporation termination insurance program? program prior to the amendment? [] Yes [] No
( Yes [No [LJ Not determined
9 Effective date of plan 10 Effective date of amendment

11 Date plan was communicated to employees D.
How communicated D>

12 Integration:

Is this plan integrated with Social Security or Railroad Retirement?. . . . . . . . . + + +. + + ([] Yes [] No
13 Type of funding entity:
(a) [J Trust (c) [1] Non-trusteed
(b) [J Custodial account (4) [J Trust with insurance contracts
14 (a) Does plan provide for maximum limitation under section 4157. . . . . . . . . . «+ +f] Yes [] No
(b) Do you maintain any other qualified plan(s)?. . . . - se ee eee ee ee ee ee EP Yes FF] NO

Under penaities of perjury, | declare that | have examined this application, including accompanying statements, and to the best of my knowledge
and belief it is true, correct and complete.

Signature > Title > Date >

Signature > Title > Date >
Form 5307 (Rev. 8-79)



Form 5307 (Rev. 8-79)

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?. 2. 2. 2 6 1 1 ee ee
If “Yes,” attach explanation.

+ + {] Yes [] No

16

Coverage of plan at (give date) >---.

(a) Total employed. © 6 ww we ee
(b) Exclusions under plan (do not count an employee more than once):

(i) Minimum age (specify) D>. .. 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, sum of (b)¢i) through (ili) .

(a) Employees not excluded under the statute, (a) minus (c) . . 2...
(e) Ineligible under plan because of (do not count an employee included in (b)):

(i) Minimum pay (specify) > ---

(i) Hourly-paid. 2 2 ee

(iii) Maximum age (specify) p>-

(iv) Other (specify) D>.

(f) Employees ineligible, sum of (e)(i) through (iv) .

(g) Employees eligible to participate, line (d) minus line (f) .
(h) Number of employees participating in plan .

(Percent of nonexcluded employees who are participating, (h) divided by (d) .

Complete (j) only if (i) is less than 70% and complete (k) only if (j) is 70% or more. _|YWWWYW4

(i) Percent of nonexcluded employees who are eligible to participate, (g) divided by (4). . |__%_|

(k) Percent of eligible employees who are participating, (h) divided by(g). . . . . - %

If (i) and (j) are less than 70% or (k) is less than 80%, see instructions.
(1) Total number of participants, include certain retired and terminated employees (see instructions) .

17

Vesting—Check the appropriate box to indicate the vesting provisions of the plan:

(a) (|) Full and immediate

(b) [7] Full vesting after 10 years of service (see instructions)

(c) [7] 5- to 15-year vesting, ie. 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) [7] Rule of 45 (see section 411(a)(2)(C)) (see instructions)

(e) [J For each year of employment, commencing with the 4th such 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) ([] Other (specify and see instructions) > _

Number

MMM

#7

18

Complete only for a plan of more than one employer:
(a) Total number of participants (include certain retired and terminated employees). . . .

(b) Participants whose benefits or accounts are fully vested . 2. 6 ee ee ee

Yd

(c)_Number of contributing employers... - - +) + 7 7 +) ee

8.US. GOVERNMENT PRINTING OFFICE : 1579—-0-283-484 39-1178745