OMB No. 1545-0200

Application for Determination for Adopters of Expires: 4-30-96

Master or Prototype, Regional Prototype or Volume

Submitter Plans

5307

Rev 5/93 For IRS Use Only File folder

number ©

Department of the Treasury

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

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

File page 1 of Form 5307 in duplicate.

The information provided on this form will be read by a 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

Number, street, and room or suite no. (If a P.O. box, see instructions.) 1c Employer’s tax year ends—Enter (MM)

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

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

3a Determination requested for (enter applicable number(s) at left and fill in required information.) (See 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 (See instructions)

Has the plan received a determination letter dated after 1/1/84? (Submit a copy of

the latest letter if one was ever received.)

b

Yes No

If 3b is no, were required amendments made retroactively effective? Yes No

c Have interested parties (defined in Treasury Regulations section 1.7476-1) been 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))? Yes No

4a Name of plan:

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?

Enter 1 if “Yes” and see the instructions Enter 2 if “No”

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” and see the instructions 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

Enter 2 if church plan not subject to ERISA

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 5307 (Rev. 5-93)

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Enter 3 if plan is collectively bargained Enter 5 if other

Enter 4 if section 412(i) plan

Cat. No. 11832Y

OMB No. 1545-0200

Application for Determination for Adopters of Expires: 4-30-96

Master or Prototype, Regional Prototype or Volume

Submitter Plans

5307

Rev 5/93 For IRS Use Only File folder

number ©

Department of the Treasury

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

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

File page 1 of Form 5307 in duplicate.

The information provided on this form will be read by a 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

Number, street, and room or suite no. (If a P.O. box, see instructions.) 1c Employer’s tax year ends—Enter (MM)

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

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

3a Determination requested for (enter applicable number(s) at left and fill in required information.) (See 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 (See instructions)

Has the plan received a determination letter dated after 1/1/84? (Submit a copy of

the latest letter if one was ever received.)

b

Yes No

If 3b is no, were required amendments made retroactively effective? Yes No

c Have interested parties (defined in Treasury Regulations section 1.7476-1) been 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))? Yes No

4a Name of plan:

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?

Enter 1 if “Yes” and see the instructions Enter 2 if “No”

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” and see the instructions 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

Enter 2 if church plan not subject to ERISA

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 5307 (Rev. 5-93)

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Enter 3 if plan is collectively bargained Enter 5 if other

Enter 4 if section 412(i) plan
Form 5307 (Rev. 5-93) Page 2

9a Do you maintain any other qualified plan(s)? (See instructions.)

If “No,” skip to line 9c.

b 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:

the top-heavy minimum benefit under the defined benefit plan?

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

the minimum benefit offset by benefits provided by the defined contribution plan?

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? (See Regulations

section 1.415-7 and 1.415-8.)

COVERAGE (See instructions.)

10a 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 to 10f.)

d

%

Divide the percentage of nonhighly compensated employees who benefit under the plan (line 10d) 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

f If the plan contains a CODA, compute the ratio in line 10e above on the basis of employees eligible to

make elective deferrals under the CODA portion of the plan and enter the result here

If the plan provides for employee or matching contributions, compute the ratio in line 10e above on the

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

plan and enter the result here

g

h Are the results in line 10e, 10f, or 10g based on the aggregated coverage of more than one plan?

(If “Yes,” see instructions.)

i If line 10e, 10f, or 10g is less than .7, does the plan pass the average benefit test?

(1) Enter the safe harbor percentage

(2) Enter the average benefit percentage

(1)

(2)

(3)

(4)

j Enter total number of employees 

Yes No

%

%

N/A No Yes
Form 5307 (Rev. 5-93) Page 3

N/A No Yes

Miscellaneous Provisions

11a Does any amendment to the plan reduce or eliminate any section 411(d)(6) protected benefit? (See

instructions.)

Are contributions allocated or benefits accrued 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,” attach an explanation of how forfeitures are allocated under

the plan

c

d

e

f Does the plan provide for permitted disparity?

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 detailing the specific nature of the matter and the details of

who is considering the matter

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

If “No,” attach an explanation of how trust earnings and losses are allocated
Form 5307 (Rev. 5-93) Page 4

Procedural Requirements

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

application.

Is Form 5302, Employee Census attached?

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

Master or Prototype, Regional Prototype or Volume Submitters Plans—Is a copy of the adoption agreement attached or

in the case of a volume submitter plan, a copy of modifications? (See What to File, item 6 and 7 in the instructions)

Have you attached a copy of the master or prototype, regional prototype or volume submitter letter? (See What to File, item

8 in the instructions)

Is a copy of the plan’s latest determination letter attached? (Previously approved plans only, see What to File, item 9)

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

Are both copies of page one of the application signed?

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

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

Taxpayer on page 1 of the instructions.)

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

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

“What To File” and the line 6 instructions attached?

Volume Submitter Plans—Is a copy of the plan or trust instrument attached? (See What to File, item 7, in the instructions)

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

IN THE RETURN OF THIS APPLICATION TO YOU.

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Are the appropriate certifications, designations, and demonstrations attached?

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