OMB No. 1545-0202 Application for Determination

for Terminating Plan For IRS Use Only

Department of the Treasury

Internal Revenue Service (See separate instructions.)

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 page 2 of the instructions.) (If Power of Attorney is attached, check box and do not complete this line.) 

2a

Name

Number, street, and room or suite no. (If a P.O. box, see page 2 of the instructions.)

Have interested parties (as defined in Treasury Regulations section 1.7476-1) been given the required

notification of this application?

3a

Yes No

b If line 3a is “Yes,” enter date of notification (MMDDYYYY)

c Has the plan received a determination letter?

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

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

Enter number of participants (See page 3 of

the instructions.)

c Enter date plan year ends (MMDD) e

5

Proposed date of plan termination (MMDDYYYY)

7

a

Attach copies of records of all actions taken to terminate the plan (see page 3 of the instructions).

b

Under penalties of perjury, I declare that I 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 

For Paperwork Reduction Act Notice, see separate instructions. Form 5310 (Rev. 11-2002)

Fax number

( )

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

Cat. No. 11840Y

c Will any funds be, or have any funds been, returned to the employer? (See page 3 of the instructions.)

(1) If “Yes,” enter the estimated amount  $

d

e

Will funds be distributed as soon as administratively feasible?

See the Procedural Requirements Checklist on page 7 before submitting this application.

City

( )

State ZIP code

Form 5310

Rev. November 2002

1e Fax number

( )

Telephone number

( )

Number, street, and room or suite no. (If a P.O. box, see page 2 of the instructions.)

Date 

Date of letter 

f

(1) If “Yes,” submit a copy of the latest letter and subsequent amendments. Number of amendments 

(2) If “No,” submit all prior plan(s) and/or adoption agreement(s). (See page 3 of the instructions.)

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

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

/ /

/ / Yes No

Yes No

Yes No

Yes No

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

(1)—profit sharing and/or section 401(k)

(2)—money purchase

(3)—target benefit

(4)—defined benefit but not cash balance

(5)—cash balance

(6)—leveraged ESOP

(7)—non-leveraged ESOP

(8)—stock bonus

(9)—safe harbor section 401(k)

(2) If “Yes,” has the employer established or intend to establish a Qualified Replacement Plan?

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 line(s) 6a and/or 6b is “Yes,” see page 3 of the instructions for the required statement.

6a

b

Yes No

Yes No

Yes No

Yes No

Yes No

/ /

/

(Under section 401(a) of the Internal Revenue Code)

2b

2c

If more space is needed for any item, attach additional sheets the same size as this form. Identify each

sheet with the plan sponsor’s name and EIN and identify each item.
Form 5310 (Rev. 11-2002) Page 2

No

10

11

Reason for termination. Check only one box to indicate primary reason for termination.

a Change in ownership by merger

b Liquidation or dissolution of employer

c Change in ownership by sale or transfer

d Adverse business conditions (see page 3 of the instructions and attach explanation)

e Adoption of new plan. Enter type of new plan 

f Other (specify) 

12a Name(s) of trustee(s) or custodian(s) 12b Telephone number

Address (number and street)

City or town, state, and ZIP code

8a

( )

Yes

Last employer/sponsor contribution to the plan:

(a) Date (MMDDYYYY) (b) Amount $ (c) For plan year ending (MMDDYYYY) 

Is this a governmental plan?

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

Is this a nonelecting church plan?

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

Is this a section 412(i) plan?

Is this a multiple employer?

Have any of the amendments altered the plan’s vesting provisions?

Have any of the amendments (including the termination) decreased plan benefits for any participant?

b

c

d

e

No

9a

Yes

b

Coverage

● Complete only lines 13a through 13n if the plan satisfied the ratio percentage test for the year of termination.

● Complete only line 13o if the plan satisfied the average benefit test for the year of termination.

● Complete only line 13p if the plan satisfied coverage using one of the special requirements of Regulations section

1.410(b)-2(b)(5), (6), or (7). Plans that use the qualified separate line of business rules of section 414(r) must attach Demo 1.

See Guidelines for Demonstrations on page 6 of the instructions.

Is this plan disaggregated into two or more separate plans that are not section 401(k), 401(m), or profit sharing

plans?

If “Yes,” see page 3 of the instructions and attach separate schedules for each disaggregated portion.

Does the employer receive services from any leased employees as defined in section 414(n)?

Coverage date (MMDDYYYY). See page 3 of the instructions

Total number of employees (employer-wide) (include self-employed individuals)

Statutory and regulatory exclusions under this plan (do not count an employee more than once):

(1) Number of employees excluded because of the minimum age or years of service required

(2) Number of employees excluded because of their inclusion in a collective bargaining unit

(3) Number of employees excluded because they terminated employment with less than 501 hours

of service and were not employed on the last day of the plan year

(4) Number of employees excluded because they were employed by other qualified separate lines

of business (QSLOBs)

(5) Number of employees excluded because they were nonresident aliens with no earned income

from sources within the United States

Total statutory and regulatory exclusions. Add lines 13e(1) through 13e(5).

Nonexcludable employees. Subtract line 13f from line 13d

Number of nonexcludable employees on line 13g who are highly compensated employees (HCEs)

Number of nonexcludable HCEs on line 13h benefiting under the plan

Number of nonexcludable employees who are nonhighly compensated employees (NHCEs). Subtract

line 13h from line 13g

Number of nonexcludable NHCEs on line 13j benefiting under the plan

Ratio percentage (See page 4 of the instructions.)

Enter the ratio percentage for the following, if applicable:

(1) Section 401(k) part of the plan

(2) Section 401(m) part of the plan

13

Yes No a

b

c

d

e

f

g

h

j

k

l

m

i

Form 5310 (Rev. 11-2002)

If “Yes,” enter number of participating employers 

/ /
15a Enter the total number of participants employed at any time during the current plan year and each of the 5 prior plan years

on the schedule below. If all such participants were fully vested at all times during such period, do not complete lines

15a(1) through 15a(5). Instead, enter -0- in each column next to line 15a(6).

Plan Year

End

Number at end of prior plan year

Number added during the plan year

Total. Add lines (1) and (2)

Number dropped during the plan year

Number at end of plan year. Subtract

line (4) from line (3)

Total number of participants in this plan

separated from vesting service during

the plan year without full vesting

(1)

(2)

(3)

(4)

(5)

(6)

Are the results on line 13l or 13m based on the aggregate coverage of more than one plan?

If “Yes,” see Guidelines for Demonstrations on page 6 of the instructions and submit a Demo 4.

Did the plan use the average benefit test to satisfy section 410(b) for the year of termination?

If “Yes,” did the plan receive a favorable determination letter in the three plan years immediately preceding

the date of termination that contained a determination regarding the average benefit test?

If line 13o(2) is “Yes,” are the facts (including benefits provided and employee demographics) upon which

the determination was based materially unchanged?

If line 13o(2) or 13o(3) is “No,” see Guidelines for Demonstrations on page 6 of the instructions and submit Demo 5.

If the plan satisfied coverage using one of the special requirements of Regulations section 1.410(b)-2(b)(5), (6) or (7), enter

the number from the list below for the Regulations section that identifies the special rule:

Form 5310 (Rev. 11-2002) Page 3

Form 5310 (Rev. 11-2002)

Yes No

n

o

(2)

(3)

p

(1)

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

requirements of section 401(l)?

If “Yes,” answer line 14b. Otherwise, skip to line 14c.

Do the provisions of the plan ensure that the overall permitted disparity limits will not be exceeded?

Enter the number from the list below for the Regulations section that identifies the safe harbor intended to be satisfied. 

14

a

b

c

Yes No

(2)—1.410(b)-2(b)(6)—No HCEs benefit

(1)—1.410(b)-2(b)(5)—No NHCEs employed (3)—1.410(b)-2(b)(7)—Collectively bargained only

(1)—1.401(a)(4)-2(b)(2) defined contribution plan with 

uniform allocation formula

(6)—1.401(a)(4)-8(b)(3) target benefit plan (2)—1.401(a)(4)-3(b)(3) unit credit defined benefit plan

(3)—1.401(a)(4)-3(b)(4)(i)(C)(1) unit credit DB fractional rule plan

(4)—1.401(a)(4)-3(b)(4)(i)(C)(2) flat benefit DB plan

(5)—1.401(a)(4)-3(b)(5) insurance account

(7)—1.401(a)(4)-8(c)(3)(iii)(B) cash balance plan

Did the plan use a non-design based safe harbor or a general test to satisfy section 401(a)(4) for the year

of termination?

If “Yes,” did the plan receive a favorable determination letter in the three plan years immediately preceding the

date of termination that contained a determination regarding the non-design based safe harbor or general test?

If “Yes,” are the facts (including benefits provided and employee demographics) upon which the

determination was based materially unchanged?

If line 14e(2) or 14e(3) is “No,” see Guidelines for Demonstrations on page 6 of the instructions and submit Demo 6.

e

(2)

(3)

(1)

(Enter plan year end in MMDDYYYY format).

Current

Plan Year

Plan Year

End

Plan Year

End

Plan Year

End

Plan Year

End

If line 15a(6) shows that a participant(s) separated without full vesting in the current year or any of the past 5 years, attach

the following information.

Name of participant

Date of hire

Date of termination

Years of participation

Vesting percentage

Account balance or accrued benefit

at the time of separation from service

Amount of distribution

Date of distribution

Reason for termination

15b

List the plan section(s) that satisfy the safe harbor (including, if applicable, the permitted disparity requirements)

here 

Note: If you completed line 13p, skip line 14.

Nondiscrimination—Section(s) 401(k) and/or 401(m) plans that do not contain a provision for discretionary contributions, skip line 14. Complete lines 14a

through 14d if the plan satisfied a nondiscrimination safe harbor for the year of termination. Complete line 14e if the plan satisfied a general test for the

year of termination. If this plan has been disaggregated or restructured, see Guidelines for Demonstrations on page 6 of the instructions and submit

Demo 4.

d

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)
16 Summary of participants or claimants by category:

a Retirees and beneficiaries (including disability retirees) receiving benefits

b Active participants

c Participants separated from service with deferred vested benefits

d Total (Add lines 16a through 16c)

17 Miscellaneous:

As a result of the termination, are accrued benefits or account balances nonforfeitable as required under

section 411(d)(3)?

a

b If annuity contracts are distributed on plan termination, are the applicable consent, present value, waiver

and other rights and benefits protected by sections 401(a)(11) and 417 included in the annuity contracts?

Do the accrued benefits for each participant upon termination include the subsidized benefits that the

participant may become entitled to receive subsequent to the termination? (See page 5 of the instructions.)

c

Were any funds contributed in the form of, or invested in, obligations or property of the employer or any

controlled group of corporations or group of trades or businesses under common control?

d

e Will distributions include property other than cash and/or readily tradable marketable securities?

If a defined benefit or money purchase plan, do you estimate there will be an accumulated funding deficiency

as of the end of the plan year during which the proposed termination date occurs if no additional plan

contributions are made and no additional funding waiver is granted? (See page 5 of the instructions.)

f

If ‘‘Yes,’’ complete the following:

(1) Estimated accumulated funding deficiency  $

(2) Was a Form 5330 filed?

(3) Was a funding waiver granted?

(4) Have you attached a copy of Form 5330 or a waiver ruling?

g (1) If there are unallocated funds which can be reallocated to participants without exceeding the

limitations of section 415, have these funds been reallocated to participants?

(2) If line 17g(1) is “Yes,” did the plan originally contain a provision allowing this reallocation?

(3) If line 17g(2) is “No,” was the plan amended to provide for this reallocation?

h

Has the terminating plan been involved in a spinoff or other transfer of assets or liabilities, subject to

section 414(l), within 60 months preceding the proposed date of termination?

If line 17h(1) is “Yes,” answer (A) and (B):

(1)

(A) Are the accrued benefits of all participants, in the other plan(s) included in line 17h(1), fully vested

and nonforfeitable as of the date of this plan termination? (See page 5 of the instructions.)

If any funds will be or have been returned to the employer, complete lines 17h(1) through 17h(10) below

(2)

(4)

Was proper notice filed with the IRS on Form 5310-A?

(3) Was the only transaction in line 17h(1) above, a transfer of assets before any employer reversions?

Form 5310 (Rev. 11-2002) Page 4

Form 5310 (Rev. 11-2002)

Yes No N/A

Total number

(1) were all participants given the option of taking this type of distribution?

(2) what is the section number of the plan which allows for this type of distribution? 

(3) attach a statement explaining how assets were valued and how assets will be allocated.

If “Yes,”

If “Yes,” attach a list and an explanation of the transaction(s) involved.

Have cash distributions or guaranteed annuity contracts been provided for all accrued benefits,

as of the date of this plan termination, of all participants in the other plan(s) included in line 17h(1)?

(See instructions.)

(B)

Note: Distributions generally may not be made to employed participants in nonterminating plans.

Have cash distributions or guaranteed annuity contracts been provided for all accrued benefits of all

participants in this plan?

Attach a statement providing the dates and amounts of these cash distributions or purchases of annuity

contracts.

If this is a defined benefit plan, is it intended, or is it a fact, that any or all of the participants in the

terminating plan will be covered by a new or existing defined benefit plan of the employer?

(5)

If “Yes,” does the new plan give full prior service credit for vesting and entitlement purposes?

If line 17h(1) or 17h(7) is “Yes,” then —

(6)

(A) Has a Form 5300 been submitted for a determination letter for the other plan(s) involved?

Has the IRS granted approval for a change in funding method in connection with this termination

for the other plan(s) involved? If “Yes,” attach a copy of the approval letter(s)

(B)

Did the employer previously receive a reversion of assets upon termination of a defined benefit plan

in the past 15 years? If “Yes,” attach explanation

(7)

(8)

(9)

(10)

If “Yes,” attach plan numbers.
17

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

before:

Did any plan participant during the current plan year or in the 5 prior plan years, receive a single-sum

distribution (see page 5 of the instructions) or have an annuity contract purchased by the plan from an

insurance company on his or her behalf?

Does the value of plan assets at termination exceed the present value of a plan’s liabilities within the

meaning of section 401(a)(2)?

If the answer to line 17k(1) is “Yes,” is the excess value the result of a change in the plan provisions

other than the mere termination of the plan?

If the plan has been top-heavy, have top-heavy minimum benefits accrued or minimum contributions been

made for non-key employees?

18 For defined contribution plans enter the information for the current plan year and the 5 prior plan years on the following

schedule:

Employer contributions

Forfeitures

19a Indicate how distributions will be made on termination (check applicable box(es)):

Single-sum distribution, including direct rollovers

Transfer of assets and liabilities to another plan

Other (specify) 

(continued)

i

j

k

l

(1)

(2)

Participating annuity contract(s)

Non-participating annuity contract(s)

a

b

(1) (2)

(3) (4)

(5)

If “Yes,” state the largest amount so distributed or applied to purchase an

annuity contract  $

Form 5310 (Rev. 11-2002) Page 5

Form 5310 (Rev. 11-2002)

Yes No N/A

● the Internal Revenue Service

● the Department of Labor

● the Pension Benefit Guaranty Corporation; or

● any court?

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

Investigator, etc.) and their telephone number.

Note: Do not answer “ Yes” if the plan has been considered under the Employee Plans Compliance

Resolution System (EPCRS).

Do you maintain any other qualified plan under section 401(a)?

If “Yes,” provide a description as to the type of plan. (See page 5 of the instructions.)

m

Plan Year

End

(Enter Plan Year end in MMDDYYYY format.)

Current

Plan Year

Plan Year

End

Plan Year

End

Plan Year

End

Plan Year

End

c Qualified Transfer/Rollover amount(s)

received 

Will all distributions be made according to plan provisions and have proper consents been obtained, when

applicable?

Yes No b
20 Statement of net assets available to pay benefits as of the proposed date of plan termination or latest valuation date.

Assets

a Total noninterest-bearing cash. (Attach explanation.) 20a

20b(1)

Receivables:

Participant contributions

(3) Income

(4) Other (Attach explanation.)

(5) Allowance for doubtful accounts

(6) Total. Combine lines 20b(1) through 20b(5) 

20c(1)

General Investments:

(2) Certificates of deposit

(3) U.S. Government securities

(4) Corporate debt instruments

(5) Corporate stocks

(6) Partnership/joint venture interests

20c(7)(A)

(7) Real estate:

20c(7)(B) (B)

(8) Loans (other than to participants) secured by mortgages

(9) Loans to participants. (See page 5 of the instructions.)

Other loans (See page 5 of the instructions.) 20c(10) (10)

20c(11) (11)

20c(12) (12)

20c(13) (13)

20c(14) (14)

Value of funds held in insurance company general account

Other (Attach explanation.)

Total. Add lines 20c(1) through 20c(13) 

20d(1)

Employer-related investments: 

Employer real property 20d(2)

e Buildings and other property used in plan operation 20e

Total assets. Add lines 20a, 20b(6), 20c(14), 20d(1), 20d(2), and 20e  20f f

Liabilities

g Benefit claims payable 20g

h Operating payables 20h

Acquisition indebtedness 20i i

Other liabilities (Attach explanation.) 20j j

k Total liabilities. Add lines 20g through 20j  20k

Net Assets

l Net assets. Subtract line 20k from line 20f  20l

(2)

d

b

c

(2)

(1) Employer securities

(1) Interest-bearing cash (including money market funds)

(1) Employer contributions

(A)

Value of interest in registered investment companies

( )

Form 5310 (Rev. 11-2002) Page 6

Form 5310 (Rev. 11-2002)

20c(8)

20c(9)

Income-producing

Nonincome-producing

Date 

20b(2)

20b(3)

20b(4)

20b(5)

20b(6)

20c(2)

20c(3)

20c(4)

20c(5)

20c(6)
Form 5310 (Rev. 11-2002) Page 7

Procedural Requirements Checklist

Use this list to assure that your application package is complete before you submit it. Failure to supply the appropriate information

may result in a delay in processing the application.

1

10

Form 5310 (Rev. 11-2002)

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

Is the appropriate user fee for your application attached to Form 8717, if applicable?

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

authorization attached? (For more information, see Disclosure Request by Taxpayers on page 1 of 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 one of the application signed and dated?

Have interested parties been given the required notification of this application?

Have you included a copy of the Board of Director’s Resolution or other documentation formally terminating the plan?

If you answered “Yes” to line(s) 6a and/or 6b, have you included the information requested on page 3 of the

instructions?

Have you included a copy of the plan, trust, and all amendments since your last determination letter?

If the plan uses the QSLOB rules of section 414(r), has Demo 1 been attached?

If line 13n is answered “Yes,” has Demo 4 been attached?

If line 13o(2) or (3) is answered “No,” has Demo 5 been attached?

If line 14e(2) or (3) is answered “No,” has Demo 6 been attached?

If line 15a(6) shows that a participant(s) separated without full vesting in the current year or any of the past 5 years,

have you attached the required information?

If line 17e is answered “Yes,” have you included the required statement?

If you are requesting additional determinations, is the Schedule Q (Form 5300), Elective Determination Requests,

attached?

If filing a Schedule Q (Form 5300), are all appropriate demonstrations attached?

(See the Instructions for Schedule Q (Form 5300).)

Demo 3

Demo 7

Demo 8

Demo 9

Demo 10

Demo 11

2

3

4

5

6

7

8

9

11

12

13

14

15

16

17

18

19

Form 5310