< 5307 > Application for Determination for Adopters of | ‘OMB No. 1545-0200
Master or Prototype, Regional Prototype or Volume

For IRS Use Only

< Reve/I0 > Submitter Plans File folder
Department ofthe Tressury (Other than Collectively Bargained Plans) number P
Internal Revenue Service (Under sections 401 (a) and 501(a) of the Internal Revenue Code) Case number >

Note: User fee must be attached to this application. (See Instruction B, “What To File.”)

File page 1 of Form 5307 in duplicate.

The information provided herein will be read by computer. Therefore page 1 must be typed (except the signature). Please enter information exactly as
requested and only in the space provided. Do not type in areas that are shaded.

Review the Procedural Requirements Checklist before submitting this application.

a_Name of plan sponsor (employer if single employer plan) 1b Employer identification number
< > < >
‘Address (number and street) 1c Employer's tax year ends—
> Enter (MM)
City State ZIP code 1d Telephone number
< >_< >_< > ie )
2 Person to be contacted if more information is needed. (See Specific Instructions.)

(If same as 1a, leave blank.) (Complete even if Power of Attorney is attached.)

Name
< >
‘Address (number and street)
<
City State 2IP code Telephone number
< >_< > < > C )
3a Determination requested for (enter applicable number(s) at left and fill in required information.) (See Specific Instructions.)
< > Enter 1 for initial Qualification—Date plan signed .
< > Enter 2 for Amendment after Initial Qualification
Date amendment signed Date amendment effective . .
< > Enter 3 for Standardized Plans (section 401(a)(26) plans and nonpaired plans)
b Has the plan received a determination letter dated after 1/1/84? (Submit a copy of the latest
letter if one was ever received.) . . . . 2. Yes < > No < >
If 3b is no, were required amendments made retroactively effective? . woe . Yes No ___
¢ Have interested parties (as defined in Treasury Regulation section 1.7476- pt been given the
required notification of this application? . . . 2. Yes < > No <
d Does the plan have a cash or deferred arrangement, or employee or ‘matching contributions
(section 401(kK)or(m))? 2 6 6 ee re (20 > No <
4a Name of pian:
<
< > b Enter plan number (3 digits) — d Enter date plan effective (MMDDYY)
< > c¢ Enter date plan-year ends (MMDD) < __ > e Enter number of participants in plan

5a If this is a defined benefit plan, enter the appropriate number in box at left.
> Enter 1 for unit benefit Enter 3 for flat benefit
Enter 2 for fixed benefit Enter 4 for other (Specify)
b If this is a defined contribution plan, enter the appropriate number in box at left.
< > Enter 1 for profit sharing _Enter 4 for target benefit
Enter 2 for stock bonus Enter 5 for other (Specify)
Enter 3 for money purchase
6a Is the employer a member of an affiliated service group?

N

> Enter 1 if "Yes" Enter 2 if "No”
b isthe employer a member of a controtled group of corporations or a group of trades or businesses under common control?
< > Enter 1 if "Yes" Enter 2 if “No”
7 Enter type of adopter.
< > Enter 1 if a master or prototype plan Enter 3 if a District approved volume submitter plan

Enter 2 if a regional prototype plan
8 Enter type of plan.
> Enter 1 if governmental plan or church plan not subject to ERISA
Enter 2 if other

Under penalties 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. Both copies of this page must be signed.

Signature > Title > Date >

Instructions are separate. See page 1 for Paperwork Reduction Act Notice. Form 5307 (Rev. 2-90)


Form 5307 (Rev. 2:90)

Page 3

13

Miscellaneous provisions:

Does any amendment to the plan reduce or eliminate any section 411(d)(6) protected benefit? (See Specific
Instructions.) : . Se

Are contributions or benefits allocated on the basis of total compensation within the meaning of section 414(s)? If
“No,” explain. (See Specific Instructions.) . wee eo ee

4s this plan or trust currently under examination or is any issue related to this plan or trust currently pending
before the Internal Revenue Service, the Department of Labor, the Pension Benefit Guaranty Corporation, or any
court? If “Yes,” attach explanation

N/A Yes No



Form 5307 (Rev. 2-90)

Page 4

Procedural Requirements Checklist

This checklist identifies certain basic data required to process your application. The checklist identifies items that MUST be included with

your application. Completion of this checklist is optional and is for the benefit of the plan sponsor.

e

Have you attached Form 5302, EmployeeCensus? . . . . . 2... ee

b. Have you attached the appropriate user fee and Form 8717, User Fee for Employee Determination Letter Request?

c. Master or Prototype or Regional Prototype Plans—Have you attached a copy of the adoption agreement? (See General
Instruction B.5.) .

d. Have you attached a copy of the ‘master or ar prototype, ronal prototype ¢ or volume submitter letter? (See General
Instruction B.7.) . oa . soe

e. Have you attached a copy of the plan's latest determination letter? (Previously approved plans only)

f. Have you submitted page one in duplicate (at least one copy must be an original)? .

g- Have you signed both copies of page one of the application? .

h. Have you entered the pian sponsor's 9-digit employer identification number online 1b? .

1. H appropriate, have you attached Form 2848, Power of Attorney and Declaration of Representative, or Form 2848-D,
Tax Information Authorization and Declaration of Representative? (See General Information.) . .

J. Have you entered the effective date of the plan on line 4d?

k. Affiliated Service Groups, Controlied Groups or Entities Under Common Control—Have you attached the information
requested in General Instructions B.|I “What To File” and item 6 of the Specific Instructions?

|, Volume Submitter Plans—Have you attached a copy of the plan or trust instrument? (See General Instruction B.1.6.) .

Yes

No

ALL APPLICATIONS ARE SCREENED BY COMPUTER. FAILURE TO INCLUDE A REQUIRED ITEM WILL RESULT IN

THE RETURN OF THIS APPLICATION TO YOU.

“U.S. Government Printing Office: 1900 —~ 278-302


< 5307 > Application for Determination for Adopters of | OMB No. 1545-0200
Master or Prototype, Regional Prototype or Volume

< Reve/0 > Submitter Plans

Department of the Treasury (Other than Collectively Bargained Plans)

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

Note: User fee must be attached to this application. (See Instruction B, “What To File.")

File page 1 of Form 5307 in duplicate.

The information provided herein will be read by computer. Therefore page 1 must be typed (except the signature). Please enter information exactly as
requested and only in the space provided. Do not type in areas that are shaded.

Review the Procedural Requirements Checklist before submitting this application

For IRS Use Only
File folder
number >

Case number >

la_Name of pian sponsor (employer if single employer plan) 1b Employer identification number
> < >
Address (number and street) Le Employer's tax year ends—
_ > Enter (MM)
City State ZIP code 1d Telephone number
< >_< >_< > ¢ )
2 Person to be contacted if more information is needed. (See Specific Instructions.)

(If same as 1a, leave blank.) (Complete even if Power of Attorney is attached.)

Name
< >
‘Address (number and street)
< >
City State 21P code Telephone number
< > < >< > Cc)
3a_ Determination requested for (enter applicable number(s) at left and fill in required information.) (See Specific Instructions.)
< > Enter 1 for initial Qualification—Date plansigned. © 2 2 2... ee
< > Enter 2 for Amendment after Initial Qualification
Date amendment signed == (Date amendment effective .
< > Enter 3 for Standardized Plans (section 401(a)(26) plans and nonpaired plans)
b Has the plan received a determination letter dated after 1/1/84? Submit @ copy of the latest
letter if one was ever received.) . 2... coe ee Ys < > No < >
{f 3b Is no, were required amendments made retroactively effective? ton . Yes _ No ___
c Have interested parties (as defined in Treasury Regulation section 1.7476- Dt heen g given the
required notification of this application? . . . Yes < > No <
d Does the plan have a cash or deferred arrangement, or employee or ‘matching contributions
(section 401(k)or(m))?. . 2. 2 we to ho coe Yes < > No < >
4a Name of plan:
< >
< sD ib Entterr pian number (3 digits) —— d Enter date plan effective (MMDDYY)
<_sCéD sc Enter date plan-yearends(MMDD) << > Enter number of participants in plan
5a If this is a defined benefit plan, enter the appropriate number in box at left.
< > Enter 1 for unit benefit Enter 3 for flat benefit

Enter 2 for fixed benefit Enter 4 for other (Specify)
b !fthis is a defined contribution plan, enter the appropriate number in box at left.
< > Enter ] for profit sharing Enter 4 for target benefit
Enter 2 for stock bonus Enter 5 for other (Specify)
Enter 3 for money purchase
6a Is the employer a member of an affiliated service group?

> Enter 1 if “Yes” Enter 2 if “No”
b Is the employer a member of a controtled group of corporations or a group of trades or businesses under common control?
< > Enter 1 if “Yes” Enter 2 if “No”
7 Enter type of adopter.
< > Enter 1 ifa master or prototype plan Enter 3 if a District approved volume submitter plan

Enter 2 if a regional prototype plan
8 Enter type of plan.
> Enter 1 if governmental plan or church plan not subject to ERISA
Enter 2 if other

Under penalties of penury, | declare that | have examined this application, including accompanying statements, and to the best of my knowledge and belief it 1s true, correct, and
complete. Both copies of this page must be signed.

Signature > Title > Date >

Instructions are separate. See page 1 for Paperwork Reduction Act Notice. Form 5307 (Rev. 2:90)




Form 5307 (Rev. 2-90)

Page 2

9a Do you maintain any other qualified plan(s)? (See Specific Instructions.) . . Ores ONo
If “Yes,” complete 9b and 9c.
b Hi this is a defined contribution plan and you also maintain a defined benefit plan, or if this is a
defined benefit plan and you also maintain a defined contribution plan, when the plan is top-
heavy, do non-key employees covered under both plans receive:
(i) the top-heavy minimum benetit under the defined benefitplan?. . . . . . . . . OON/A Des ONo
(ii) at least a 5% minimum contribution under the defined contribution plan?. . 2. . . . Oo N/A Oyes DONo
(ii) the minimum benefit offset by benefits provided by the defined contribution plan? . . . . ONsa Dyes DNo
(iv) benefits under both plans that, using a comparability analysis, are at least equal to the
minimum benefit? (See Specific Instructions.) . .... Ona Oves Ono
¢ Do the provisions of the pian preclude the possibility that the section 415 ‘imitations will be exceeded with
respect to any employee w who is or has been a Participant | in this * plan and any other qualified Pan of the
employer? . tee . 8 . OYes (No
10 COVERAGE (See Specific Instructions.):
‘a ls the employer applying the separate line of business rules of section 414(r)? . OYes DNo
(If “Yes,” see Specific Instructions.)
b Does the employer receive services from any leased employees within the mening of section 414(n)? . Dyes DNo
c Coverage of planat(givedate) . . . . . . woe ee . sone eee
d Enter the percentage of nonhighly compensated employees who benefit under the plan, excluding employees
who benefit only under a part of the pian containing a CODA or employee or matching contributions. (If 70
Percent or more, proceedtof). . . . . . woe . .. .ONsA %
e Divide the percentage of nonhighly compensated employees who benefit under the plan (10d) by the
percentage of highly compensated employees who benefit under the pian, excluding employees who only’
benefit under a part of the plan containing a CODA or employee or matching contributions . . .CIN/A
1 Ifthe plan contains a CODA, compute the ratio in line e above on the basis of employees eligible
to make elective deferrals under the CODA portion oftheplan. . . . ...... . .DN/A
g Ifthe plan provides for employee or matching contributions, compute ratio in line e above on the
basis of employees eligible t to make employee contributions or to receive matching contributions
underthe plan... . . ee. . /DNZA
h Are the results in lines e, f, or g s based on the aggregated co coverage e of more than one plan? . OyYes ONo
(if "Yes,” see Specific Instructions.)
1 Ifline e, f, or g is less than .7, does the plan pass the average benefittest? . . . . . . . o N/A Ores O No
(i) Enter the sate harbor percentage woe ee .
(ii) Enter the average benefit percentage .
11 PARTICIPATION (See Specific Instructions.):
@ Isa determination requested as to whether the plan satisfies the Participation test under section + 401(2X28)
with respect to each of the plan's current benefit structures? . Yes OONo
b (For defined benefit plans only) Do at least the lesser of 50 employer's employees. or 40, percent
of the employer's employees accrue the minimum current accrual under the plan?. . . . . .CIN/A Oves Dono
c (For detined benefit plans only) If the answer to b is “No,” does the plan satisfy section
401(a)(26) with respect to its prior benefit structure under one of the other tests in the Proposed
Regulations under section 401(aX26). (See Specific Instructions). . . . ... .. . N/A DlYes ONo
12 Isa determination requested as to whether the plan satisfies the coverage or participation tests with respect to
former employees benefiting underthe plan?. . . . . . Dyes COONo
If “Yes,” has a demonstration been attached showing h how the an satisfies sections 4100) and
401(aX26) with respect to former employees? . Oi Yes Dwe