Form 5 3 0 7 Short Form Application for OMB No. 1545-0200

tres Juy 1967) Determination for Employee Benefit Plan [&* ee ee
(Other than Collectively Bargained Plans) Filefolder For IRS Use Only

Department of the Treasury

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

Church and governmental plans not subject to ERISA need not complete items 16, 17, 18, 19, and 20.

Allother plans must complete all items except as indicated on the specific lines. For example, if you answer “No” to line 16a(i), you need not complete lines
16a(ii) and (iii) since they require responses only if you answer “Yes” to line 16a(i). “N/A” is only an acceptable answer if an N/A block is provided. All
applications are now computer screened; therefore, it is important that you provide all the information requested and have the application signed by the

employer, plan administrator, or authorized representative. Otherwise, we may need to correspond with you or return your application for completion,
which will delay its processing.

la Name, address, and ZIP code of sponsor (employer if single employer plan) 2a Employer identification number

b Employer's tax year ends
[Telephonenumber > (_) Month ON/A
3 Name, address, ZIP code, and phone number of person to be contacted if more information is needed.
(See Specific Instructions.) (If same as 1a, enter “same as 1a.")
Name ® ooo eee eee een eee eee eee Telephone number > 4
Address >
4 Determination requested for—(Check applicable box):
a (i) (. Initial qualification—date plan adopted >
(ii) (1 Amendment—date adopted >
(iii) _\f (ii) is checked, enter file folder number >

b Were employees who are interested parties given the required notification of the filing of this application? O Yes 0) No
5 Check appropriate box to indicate the type of plan entity:
a Single employer plan dO Church plan
b O Plan of controlled group of corporations, common e O) Governmental plan
control employers, or affiliated service group f (1 Other (specify) m2... eee eee e eee eee eee e eee eee
c C1 Multiple-employer plan
6a Name of plan b Plannumber >
' ¢ Planyearends® SC
7a Thisisa: b Letter serial number or notification letter number
(i) 0 Master or prototype plan
(ii) CO Field prototype plan
(iii) (Uniform plan (see instructions)
8a Is this a defined benefit plan? 1 Yes 1) No—If “Yes,” indicate whether:
(i) 0 Unit benefit (ii) (1 Flat benefit
(i) O_ Fixed benefit (iv) 1 Other (specify) >
b Is this a defined contribution plan? L1 Yes L) No—'If “Yes,” indicate whether:
(i) C2 Profit-sharing (ii) (C1 Stock bonus
(ii) (1 Money purchase (iv) Target benefit
© (i) \8a(i), Gi, (il), oF (iv)is checked, is this a defined benefit plan covered under (ii) If 4a (ji) and 8b (i), (ji), (ii), or (iv) are checked and the plan was a defined
the Pension Benefit Guaranty Corporation termination insurance program? benefit plan before the amendment, was the plan covered by the termination
insurance program before the amendment?
O Yes C1 No [] Notdetermined O Yes C(] No (1 N/A
9 Effective date of plan 10 Effective date of amendment
O N/A
11 Date plan was communicated to employees  _ o_o... enn eee cee eee nee ne nee eee cee eee
How communicated >
12 Integration: Is this plan integrated with social security or railroad retirement (see instructions)?. . . . . . . C1 Yes (] No
13 Type of funding entity:
a Trust ¢ 0) Nontrusteed
b 1) Custodial account. ¢@ C1) Trust with insurance contracts
14a Does plan provide for maximum limitation under section 415 (see instructions)? . . ..... =... =. 0) Yes LJ No
b Do you maintain any other qualified plan(s) (see instructions)? _..... 0 Yes 1) No

‘Under penalties of perjury, | declare that | have examined this application, including accompanying statements, and to the best of my Knowledge and belie itis true, corect,
and complete.

Signature > Title > Date >

Signature > Title > Date >

For Paperwork Reduction Act Notice, see page 1 of the instructions. Form 5307 (Rev. 7-87)



Form 5307 (Rev. 7-87) 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, oranycourt?. . . 1. 6. ee ee ee es 0 Yes 1 No
lf Yes," attach explanation.

Yes | No Not Certain

16a (i) \sthe employera member of an affiliated service group?. . . . .
If there is uncertainty whether the employer Is a member of an atfillated ‘service group,
check the ‘Not Certain’ column.

(i) \f 16a(i) ls “Yes” or ‘Not Certain," did a prior ruling or determination letter rule on
what organizations were members of the employer's affiliated service group?
(See instructions.) . . . soe
(ii) \f 16a(ii) is Yes," have the facts on nwhich that letter was based materially changed
(See instructions.) . .
b  Isthe employer a member of a controlled group sof corporations ora ‘agroup of trades 0 or
businesses undercommoncontrol? . . . . soe see ee ee

Number
17 Coverage of plan at (give date) > : Enter “O" if N/A
a Total employed rary
b Exclusions under plan because of (do not count an n employee m more rethan once): Ui
(i) Minimum age (specify) > 8. O N/A Years of service (specify) >
(ji) Employees included in collective bargaining
(ii) Nonresident aliens who receive no earned income from United States sources

¢ Total exclusions (add b(i) through (iii),
Employees not excluded under the statute (subtract c from a). Coe ee ke ek ke
e Ineligible under plan because of (do not count an employee included in by: Mh

a

(i) Minimum pay (specify) > O N/A

(ii) Hourly-paid .

(iii) Maximum age (specify) >. O N/A

(iv) Other (specify) >
Total employees ineligible (add e(i) through (iv) .
Employees eligible to participate (subtract f from d) ,
Number of employees participating in plan . see ee et
Percent of nonexcluded employees who are participating (divide h by d) Lok ee ee %
If line iis 70% or more, go to line |.
J Percent of nonexcluded employees who are eligible to participate (divide g by d)-
k Percent of eligible employees who are participating (divideh byg) .
If i and j are less than 70%, or k is less than 80%, see instructions.
Total number of participants, including certain retired and terminated employees (see instructions)
18 Vesting—Check only one of the boxes for the vesting provisions of the plan:

O N/A

— Tm

.

Ik fk

a ( Fullandimmediate

b (1 Fullvesting after 10 years of service (see instructions)

c (© 5-to 15-year vesting, i.e., 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 C1 Rule of 45 (section 411(a)(2)(C)) (see instructions)

e (1 Foreachyear of employment, beginning with the 4th 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
t_1_Other (specify and see instructions) >
19 Complete only for a plan of more than one employer: YP
a Total number of participants (including certain retired and terminated employees) ,
b Participants whose benefits or accounts are fully vested
c¢ Number of contributing employers Cn ek
20 Isthe plan sponsor an$Corporation?, 6. O Yes O_No

FUL. Government Printing Office: 1987—201-993/60086