Form 5300 (Rev. 2-90)

Page 4

Procedural Requirements Checklist

This checklist identifies certain basic data required to process your application. The checklist identifies items that MUST be included with
your application. Completion of this checklist is optional and is for the benefit of the plan sponsor.

k

Have you attached Form 5302, Employee Census?

Have you attached the appropriate user fee and Form 8717, User Fee for Employee Plan Determination Letter Request? .

Have you attached a copy of the plan? (Initial applications and Restated plans only)

Have you attached a copy of the plan’s latest determination letter? (Previously approved plans only) .
Have you submitted page one in duplicate (at least one must be an original)?

Have you signed both copies of page one of the application? .

Have you entered the plan sponsor's 9-digit employer identification number in line 1b? .

If appropriate, have you attached Form 2848, Power of Attorney and Declaration of Representative, or Form 2848-D,

Tax Information Authorization and Declaration of Representative (see General Information)?

Have you entered the effective date of the plan in line 4d?

Affiliated Service Groups, Controlled Groups or Entities Under Common Control—Have you attached the information

requested in General Instructions B, “What To File,” and line 6 of the Specific Instructions?

Multiple-Employer Plans—Have you attached the information required by General Instruction B.II.g.?

Yes

No

THE RETURN OF THIS APPLICATION TO YOU.

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


< 5300 > Application for OMB No, 1545.0197

. Expires 1-31-93
<  Reve/50 > | Determination for Employee Benefit Plan For IRS Use Only
Department of the Treasury (Under sections 401(a) and 501(a) of the Internal Revenue Code) (le oer number ,

Internal Revenue Service

File page 1 of Form 5300 in duplicate.
Note: User fee must be attached to this application. (See Instruction B— What To File).

The information provided herein 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 before submitting this application.

la Name of pian sponsor (employer if single-employer plan) 1b Employer identification number
< > < >
‘Address (number and street) 1¢ Employer's tax year ends-Enter N/A
< > or (MM)
city State ZIP code 1d Telephone number
< > < > < > ¢ )
2 Person to be contacted if more information is needed. (See Specific Instructions.)
(If same as 1a, leave blank.) (Complete even if Power of Attorney is attached):
Name
< :
‘Address (number and street)
<
City State ZIP code Telephone number
< > < > < > ¢ )
3a Determination requested for (enter applicable number(s) at left and fill in required
information). (See Specific Instructions.)
< > — Enter 1 for Initial Qualification—Date plan signed , Lo Le
< > Enter 2 for Amendment after initial qualification—ls planrestated? . . . 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 Regulation section 1.7476-1) been given
the required notification of this application? . . Loe 2. Yes < > No< >
d_ Does the plan have a cash or deferred arrangement, or emplyee or mating contributions
(section 401(k)or(m))?. 6 2 2. ce ee ee Yes S > No< >
Name of Plan:
4a _ >
< > b_ Enter plan number (3 digits) —__ d_ Enter date plan effective (MMDDYY)
< > ¢ 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__ Ifthis 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 __!s 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 or church plan not subject to ERISA

Enter 2 if multiple employer plan (described in section 413(c)). Enter number of participating employers.
Enter 3 if other

Under penalties of perjury, | declare that I have examined this application, including accompanying statements, and to the best of my knowledge and belief, itis true, correct, and
complete. Both copies of this page must be signed.

Signature > Title > Dater

Instructions are separate. See page 1 for Paperwork Reduction Act Notice. Form 5300 (Rev. 2-90)


Form 5300 (Rev. 2-90)

Page 2

8a_ Do you maintain any other qualified plan(s)? (See Specific Instructions.)

b

tf “Yes,” complete 8b and 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 if you also maintain a defined contribution plan, when the plan is
top-heavy, do non-key employees covered under both plans receive:

(i) the top-heavy minimum benefit under the defined benefit plan?.. . . toe . oO N/A
(ii) at least a 5% minimum contribution under the defined contribution plan? 5 =... . . LI N/A
(ii) the minimum benefit offset by benefits provided by the defined contribution plan?. . . . .CIN/A
(iv) benefits under both plans that, using a comparability analysis, are at least equal to the
minimum benefit? (See Specific Instructions.) : ON/A

Do the provisions of the plan preclude the possibility that the section 415 limitations will be
exceeded with respect to any employee who is or has been a participant in this plan and any other
qualified plan of the employer? toe . . tone oe

. OYes

C1 Yes
O yes
O yes

OYes

. OyYes

CNo

ONo
CNo
CINo

ONo

ONo

c

°

COVERAGE (See Specific Instructions.):

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

(If “Yes,” see Specific Instructions.)

Does the employer receive services from any leased employees within the meaning of section 414(n)?
Coverage of plan at (give date) coe rs

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 percent or more, proceed to f.) os ow... DINYA
Divide the percentage of nonhighly compensated employees who benefit under the plan (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 [] N/A
Hf the plan contains a CODA, compute the ratio in line e above on the basis of employees eligible

to make elective deferrals underthe CODA portion oftheplan. 2. 1 2. we Oo N/A

If the plan provides for employee or matching contributions, compute ratio in line e above on the
basis of employees eligible to make employee contributions or to receive matching contributions
undertheplan . . . : . . N/A
Are the results in line e, f, org based on nthe aggregated coverage of more than one 2 plan? eee
(If “Yes,” see Specific Instructions.)
If line e, f, org is less than .7, does the plan pass the average benefittest? . . . . 2. . . . ON/A

(i) Enter the safe harbor percentage so
(ii) Enter the average benefit percentage

(See Specific Instructions.)

OC Yes

. OYes

. OYes

Ores

ONe
CNo

CINo
CNo

10

oc

°

PARTICIPATION (See Specific Instructions.):

Is a determination requested as to whether the plan satisfies the participation test under section
401(a)(26) with respect to each of the plan's current benefit structures? .

(For defined benefit plans only) Do at least the lesser of 50 employer's employees or 40 percent of

the employer’s employees accrue the minimum current accrual underthe plan? . . . . . . O N/A
(For defined benefit plans only) If the answer to b is “No,” does the plan satisfy section 401(a)(26)

with respect to its prior benefit structure under one of the other tests in the Proposed Regulations

under section 401(a)(26)? (See Specific Instructions.) . wo ee LIA

. OYes

O Yes

Dyes

CINo
CINo

ONo

11

|s a determination requested as to whether the plan satisfies the coverage or participation tests with

respect to former employees benefiting under the plan? .

If “Yes,” has a demonstration been attached showing fy how the e plen satisties sections. 41000) 2 and
401(a)(26) with respect to former employees? . . N/A

. OYes

O Yes

OONo
ONo



Form 5300 (Rev. 2-90)

Page 3

12

PERMITTED DISPARITY:

a If the plan provides for disparity in contributions or benefits, is the plan intended to meet the requirements of
section 401(I)?. oo .
If N/A, do not complete lines b through a if “Yes” or “No,” compiete lines b through ', and also see ‘the Specific
Instructions.

b 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? woe

Base Contribution Percentage ________=—=_=_=+_===_—-—~—=— Excess Contribution Percentage

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? . toe

Base Benefit Percentage __..o..._—_ Excess Benefit Percentage _____mm—

In the case of a defined benefit offset plan, is the offset uniform and is it less than the maximum offset allowance?

°

a

N/A! Yes | No

Benefit formula Offset
What is the plan's integration level?

°

In the case of a defined benefit plan, does the plan reduce the 3/4 percent factor by 1/15th for the first five years,
1/30th for the next five years and actuarially thereafter for benefits beginning before social security retirement age?

Mi

Mi

Ms

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

Check one box:

(@ D Allemployees

(ii) Hourly rate employees only
(iii) DD Salaried employees only
(iv) D) Other (Specify)
b Length of service (number of years) ——_____________ ONsa
c Minimum age (Specify) OON/A

14

Vesting:
Check one box to indicate the vesting provisions of the plan:
a C1 Fulland immediate.
b (1 Full vesting after two years of service.
c (1 Full vesting after three years of service.
d (1 Full vesting after five years of service.
e LJ Six year graded vesting.
t CO Three to seven year graded vesting.
g LJ Other (Specify—see Specific Instructions and attach a schedule)

15 Benefits and requirements for benefits:

For defined benefit plans—Method for determining accrued benefit:

(i) Benefit formula at normal retirement age is

(ii) Benefit formula at early retirement age is

(iii) Normal form of retirement benefit is

cs

For defined contribution plans—Employer contributions:

(i) Profit-sharing or stock bonus plan contributions are determined under:
CO) Adefinite formula [J An indefinite formula CO) Both

(ii) Money purchase—Enter rate of contribution

(iii) State target benefit formula

16 Miscellaneous Provisions:

oc.

Are contributions or benefits allocated on the basis of total compensation within the meaning of section aa) If
“No,” explain. (See Specific Instructions) - . .
Are forfeitures allocated, in the case of a defined contribution plan, on the basis of total compensation? it No,” explain .
Are trust earnings and losses allocated on the basis of account balances in a defined contribution plan?

ac

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 explanation . . .

's this application also expected to satisty the notice requirement for this plan for merger, consolidation, or
transfer of plan assets or liabilities involving another plan? (See Specific Instructions) .

Does any amendment to the plan reduce or eliminate any section 41 1(d)(6) protected benefit? (See Specific Instructions.)

N/A| Yes | No