OMB No. 1545-0197 Application for Expires 11-30-95

Determination for Employee Benefit Plan

5300

Rev 11/92 For IRS Use Only

File folder number © Department of the Treasury

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

File page 1 of Form 5300 in duplicate.

Note: User fee must be attached to this application. (See What To File.) Enter amount of user fee submitted .

The information provided on this form 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 on page 4 before submitting this application.

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

Employer’s tax year ends-Enter N/A

or (MM)

Number, street, and room or suite no. (If a P.O. box, see instructions.) 1c

City State ZIP code 1d Telephone number

( )

Person to be contacted if more information is needed. (See instructions.) (If the same

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

2

Name

City State ZIP code Telephone number

( )

Determination requested for (enter applicable number(s) at left and fill in required information).

(See instructions.)

3a

Enter 1 for Initial Qualification—Date plan signed 

Enter 2 for Amendment after initial qualification—Is plan restated? Yes No

Date amendment signed Date amendment effective

Enter 3 for Affiliated Service Group status (section 414(m))—Date effective

Enter 4 for Leased Employee Status

Enter 5 for Partial termination—Date effective

b Has the plan received a determination letter? If “Yes,” submit a copy of the latest letter Yes No

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

required notification of this application?

c

Yes No

Does the plan have a cash or deferred arrangement, or employee or matching contributions

(section 401(k) or (m))?

d

Yes No

Name of Plan:

4a

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 ESOP

Enter 3 for money purchase

6a Is the employer a member of an affiliated service group?

Enter 1 if “Yes” Enter 2 if “No” Enter 3 if “Not Certain”

b Is the employer a member of a controlled 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 plan:

Enter 1 if governmental plan

Enter 3 if multiple employer plan (described in section 413(c)). Enter number of participating employers

Enter 4 if section 412(i) plan

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. Both copies of this page must be signed.

Signature © Title © Date ©

Instructions are separate. See page 1 for Paperwork Reduction Act Notice. Form 5300 (Rev. 11-92)

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

Enter 6 for other (Specify)

Enter 2 if church plan not subject to ERISA (see instructions)

Enter 5 if other

Cat. No. 11740X

OMB No. 1545-0197 Application for Expires 11-30-95

Determination for Employee Benefit Plan

5300

Rev 11/92 For IRS Use Only

File folder number © Department of the Treasury

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

File page 1 of Form 5300 in duplicate.

Note: User fee must be attached to this application. (See What To File.) Enter amount of user fee submitted .

The information provided on this form 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 on page 4 before submitting this application.

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

Employer’s tax year ends-Enter N/A

or (MM)

Number, street, and room or suite no. (If a P.O. box, see instructions.) 1c

City State ZIP code 1d Telephone number

( )

Person to be contacted if more information is needed. (See instructions.) (If the same

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

2

Name

City State ZIP code Telephone number

( )

Determination requested for (enter applicable number(s) at left and fill in required information).

(See instructions.)

3a

Enter 1 for Initial Qualification—Date plan signed 

Enter 2 for Amendment after initial qualification—Is plan restated? Yes No

Date amendment signed Date amendment effective

Enter 3 for Affiliated Service Group status (section 414(m))—Date effective

Enter 4 for Leased Employee Status

Enter 5 for Partial termination—Date effective

b Has the plan received a determination letter? If “Yes,” submit a copy of the latest letter Yes No

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

required notification of this application?

c

Yes No

Does the plan have a cash or deferred arrangement, or employee or matching contributions

(section 401(k) or (m))?

d

Yes No

Name of Plan:

4a

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 ESOP

Enter 3 for money purchase

6a Is the employer a member of an affiliated service group?

Enter 1 if “Yes” Enter 2 if “No” Enter 3 if “Not Certain”

b Is the employer a member of a controlled 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 plan:

Enter 1 if governmental plan

Enter 3 if multiple employer plan (described in section 413(c)). Enter number of participating employers

Enter 4 if section 412(i) plan

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. Both copies of this page must be signed.

Signature © Title © Date ©

Instructions are separate. See page 1 for Paperwork Reduction Act Notice. Form 5300 (Rev. 11-92)

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

Enter 6 for other (Specify)

Enter 2 if church plan not subject to ERISA (see instructions)

Enter 5 if other
Form 5300 (Rev. 11-92) Page 2

8a Do you maintain any other qualified plan(s)? (See instructions.) Yes No

If “No,” skip to line 8c.

If 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:

b

(1) the top-heavy minimum benefit under the defined benefit plan? 

(2) at least a 5% minimum contribution under the defined contribution plan? 

(3) the minimum benefit offset by benefits provided by the defined contribution plan? 

(4) benefits under both plans that, using a comparability analysis, are at least equal to the minimum benefit?

(See instructions.) 

c Do the provisions of the plan preclude the possibility that the section 415 limitations will be exceeded for

any employee who is (or has been) a participant in this plan and any other plan of the employer?

9 COVERAGE (See instructions.):

a Is the employer applying the separate line of business rules of section 414(r)? 

(If “Yes,” see instructions.)

b Does the employer receive services from any leased employees within the meaning of section 414(n)? 

c Coverage of plan at (give date) 

Enter the percentage of nonhighly compensated employees who benefit under the plan, excluding

employees who benefit only under a part of the plan containing a CODA or employee or matching

contributions. (If 70% or more, skip line 9e and go to line 9f.)

d

%

Divide the percentage of nonhighly compensated employees who benefit under the plan (line

9d) by the percentage of highly compensated employees who benefit under the plan, excluding

employees who only benefit under a part of the plan containing a CODA or employee or matching

contributions

e

If the plan contains a CODA, compute the ratio in line 9e above on the basis of employees

eligible to make elective deferrals under the CODA portion of the plan 

f

If the plan provides for employee or matching contributions, compute the ratio in line 9e above

on the basis of employees eligible to make employee contributions or to receive matching

contributions under the plan 

g

h Are the results in line 9e, 9f, or 9g based on the aggregated coverage of more than one plan? 

(If “Yes,” see instructions.)

i If line 9e, 9f, or 9g is less than 70%, does the plan pass the average benefit test? 

Enter the safe harbor percentage 

Enter the average benefit percentage. (See instructions.) 

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

N/A Yes No

Yes No

N/A

N/A

N/A

N/A

(1)

(2)

j Enter total number of employees
Form 5300 (Rev. 11-92) Page 3

N/A Yes No 10 PERMITTED DISPARITY:

If the plan provides for disparity in contributions or benefits, is the plan intended to meet the requirements of

section 401(l)? 

a

If N/A, do not complete lines 10b through 10f. If “Yes” or “No,” complete lines 10b through 10f. (See instructions.)

In the case of a defined contribution plan, does the excess contribution percentage exceed the base contribution

percentage by a uniform amount that does not exceed the maximum excess allowance? 

b

Base Contribution Percentage Excess Contribution Percentage

c In the case of a defined benefit excess plan, does the excess benefit percentage exceed the base benefit

percentage by a uniform amount no greater than the maximum excess allowance? 

Base Benefit Percentage Excess Benefit Percentage

In the case of a defined benefit offset plan, are the gross benefit percentage and the offset uniform and is the

offset less than the maximum offset allowance?

d

Gross Benefit Percentage Offset

e What is the plan’s integration/offset level?

In the case of a defined benefit plan, does the plan adjust the 75% factor for benefits commencing at ages other

than social security retirement age in accordance with Treasury Regulations section 1.401(l)–3(e)?

f

11 General eligibility requirements—Complete lines 11a, 11b, and 11c below.

a Check one box:

(1) All employees

(2) Hourly rate employees only

(3) Salaried employees only

(4) Other (Specify)

b Length of service (number of years) N/A

c Minimum age (Specify) N/A

12 Vesting:

Check one box to indicate the vesting provisions of the plan:

a Full and immediate.

b Full vesting after 2 years of service.

c Full vesting after 3 years of service.

d Full vesting after 5 years of service.

e 6 year graded vesting.

f 3 to 7 year graded vesting.

g Other (Specify) (See instructions and attach schedule.)

13 Benefits and requirements for benefits:

a For defined benefit plans—Method for determining accrued benefit:

(1) Benefit formula at normal retirement age is

(2) Benefit formula at early retirement age is

(3) Normal form of retirement benefit is

b For defined contribution plans—Employer contributions:

(1) Profit-sharing or stock bonus plan contributions are determined under:

A definite formula An indefinite formula Both

(2) Money purchase—Enter rate of contribution

(3) State target benefit formula

Miscellaneous Provisions: N/A Yes No 14

a Does any amendment to the plan reduce or eliminate any section 411(d)(6) protected benefit? (See instructions.)

Are contributions or benefits allocated on the basis of total compensation within the meaning of section 414(s)?

If “No,” explain. (See instructions.)

b

Are forfeitures allocated, in the case of a defined contribution plan, on the basis of total compensation within the

meaning of section 414(s)? If “No,” explain 

c

d Are trust earnings and losses allocated on the basis of account balances in a defined contribution plan? 

Is 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 an explanation 

e

f Does the plan comply with the annual compensation limit of section 401(a)(17)? (See instructions.)

If this is a defined benefit plan, does the plan contain the pre-termination restrictions of Treasury Regulations

section 1.401(a)(4)-(5)(b)?

g
Form 5300 (Rev. 11-92) Page 4

Procedural Requirements Checklist

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

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

Yes No

a Is Form 5302, Employee Census, attached?

b Is Form 8717, User Fee for Employee Plan Determination Letter Request, and the appropriate user fee attached?

c Is a copy of the plan attached? (Initial applications and Restated plans only) 

d Is a copy of the plan’s latest determination letter attached? (Previously approved plans only) 

Has page one been submitted in duplicate (at least one must be an original)? 

e

Are both copies of page one of the application signed? 

f

Is the plan sponsor’s 9-digit employer identification number entered on line 1b? 

g

If appropriate, is Form 2848, Power of Attorney and Declaration of Representative, attached? See Disclosure Requested

by Taxpayer

h

Is the effective date of the plan entered on line 4d? 

i

Affiliated Service Groups, Controlled Groups or Entities Under Common Control—Is the information requested

under What To File and the line 6 instructions attached?

j

Multiple-Employer Plans—Is the information required under What To File, Specific Plans, item 7, attached? 

k

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

IN THE RETURN OF THIS APPLICATION TO YOU.

Are the appropriate certifications, designations, and demonstrations attached?

l

m ESOPs—Is Form 5309, Application for Determination of Employee Stock Ownership Plan, attached?