For Paperwork Reduction Act Notice, see page 1 of the instructions.

OMB No. 1545-1225 Notice of Plan Merger or Consolidation, Spinoff, or Transfer of Plan

Assets or Liabilities; Notice of Qualified Separate Lines of Business

For IRS Use Only

Department of the Treasury

Internal Revenue Service

Under sections 6058(b) and 414(r) of the Internal Revenue Code.

Address (number, street, room, or suite no. (If a P.O. box, see page 3 of the instructions.)

Person to contact if more information is needed. (If same as line 1a, leave blank.) (Complete even if Power of Attorney is attached):

If this is a defined contribution plan, enter the appropriate code (see instructions) in the box AND attach an actuarial statement of

valuation showing compliance with the requirements of sections 401(a)(12) and 414(l).

Form 5310-A (Rev. 6-97)

File page 1 of Form 5310-A in duplicate.

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 shaded areas.

Cat. No. 12783Y

Address (number, street, room, or suite no. (If a P.O. box, see page 3 of the instructions.)

1a Name of plan sponsor (employer if single-employer plan or if reason for filing 1 was entered above) 1b Employer identification number

1c Employer’s tax year ends—N/A or (MM)

City State ZIP code 1d Telephone number

2

Name

3a Name of plan (plan name may not exceed 66 characters):

Under penalties of perjury, I declare that I have examined this notice, 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 ©

Telephone number

( )

City

( )

State ZIP code

4b

See Who Must File instructions before filing this form.

5310-A

Rev. 6/97

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Reason for filing (see specific instructions for code to enter): v

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All filers must complete lines 1 and 2.

Complete lines 3 through 5 if this is a notice of a plan merger or consolidation, spinoff, or transfer of plan

assets or liabilities to another plan.

5 Other plan(s) involved in the transaction (see instructions).

Plan name:

Name of employer:

Employer identification number: Plan number (3 digits):

Date of merger or consolidation, spinoff, or transfer of plan assets or liabilities (MMDDYY):

Type of plan (see instructions for code to enter):

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a Enter the total number of plans involved in the transaction other than the plan listed on line 3a: v

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Complete the following information for the other plan. If more than one other plan, see instructions for the required attachment(s).

b If more than one other plan is involved in the transaction, enter the number of this statement (1 of 3, etc.): v

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4a Is this a defined benefit plan? If “Yes,” enter 1.

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If you enter 1, attach an actuarial statement of valuation showing compliance with the requirements of section 401(a)(12) and the

regulations under section 414(l).

If “No,” enter 2.

Complete lines 6 through 11 if you are filing a notice of qualified separate lines of business (QSLOB).

6a

Part III

Part I

Part II

(continued on page 2)

If “Yes,” enter “1” and complete lines 6b and 6c. v

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7 First testing year for which this notice applies (MMDDYY):

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Has the employer previously filed a notice of QSLOB?

Enter the first day of the first testing year for which such notice applied (MMDDYY):

Enter the filing date (MMDDYY) and filing location:

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Enter plan number (3 digits) v

Are you filing this form to give notice that you are revoking a previously filed notice and that you are no longer testing on a QSLOB

basis? v

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If “No,” enter “2” and skip lines 6b and 6c.

If “Yes,” enter “1,” complete line 9 and skip lines 10 and 11.

If “No,” enter “2” and complete lines 9, 10, and 11.
Form 5310-A (Rev. 6-97) Page 2

Enter the following information relating to each plan maintained by the employer. If more than 1 plan, attach a schedule for

each plan showing the information requested on lines 11a through 11e. See the instructions.

11

a Name of plan:

b Date (MMDDYY) of determination letter, if any:

c Date (MMDDYY) of letter and serial number of opinion/notification letter:

d Date (MMDDYY) and location of pending determination letter request, if any:

e List each QSLOB that has employees benefiting under the plan:

On an attached list, identify each QSLOB operated by the employer. See the line 10 instructions for more details.

(continued from page 1)

9 Check the box(es) for the appropriate code section(s) for which the employer is testing on a QSLOB basis (or for which the

employer tested, if the answer to line 8 is “Yes”).

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Section 410(b) Section 401(a)(26) Section 129(d)(8)