Application for Determination for Adopters of OMB No. 1545-0200

Master or Prototype, Regional Prototype or Volume

Submitter Plans

5307

Rev 3/96 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)

You must file the original page 1 printed in special red ink and the duplicate page 1 of this application. The page 1 printed in red ink is read by

the computer and all the information filled in must be typed in either 10 pitch type, Elite type, Courier 12 type, or Titan 12 type. If you wish to

computer generate this form, contact your key district office for more information.

Review the list of Procedural Requirements on page 3 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 a request after Initial Qualification

Date amendment signed Date amendment effective

Enter 3 for Standardized Plans (See instructions)

Has the plan received a determination letter? (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 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 year plan originally effective

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 nonelecting church 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 ©

For Paperwork Reduction Act Notice, see page 1 of separate instructions. Form 5307 (Rev. 3-96)

v

v

v

v

v

v

v v

v

v

v

v

vv

v

v

v

v

v

v

State Telephone number ZIP code

( ) v

v

v

v

v

v

v v

v

v

v

v

v

v

v

v

v

v

v

v

v

v

v

v

v

v v v vvv v

v

v

v

v

v

v

v v

v

v

v

v

Cat. No. 11832Y

City

Enter 3 if collectively bargained plan Enter 5 if other

Enter 4 if section 412(i) plan

You must attach user fee and Schedule Q to this application. (See What To File.)

Application for Determination for Adopters of OMB No. 1545-0200

Master or Prototype, Regional Prototype or Volume

Submitter Plans

5307

Rev 3/96 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)

You must file the original page 1 printed in special red ink and the duplicate page 1 of this application. The page 1 printed in red ink is read by

the computer and all the information filled in must be typed in either 10 pitch type, Elite type, Courier 12 type, or Titan 12 type. If you wish to

computer generate this form, contact your key district office for more information.

Review the list of Procedural Requirements on page 3 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 a request after Initial Qualification

Date amendment signed Date amendment effective

Enter 3 for Standardized Plans (See instructions)

Has the plan received a determination letter? (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 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 year plan originally effective

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 nonelecting church 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 ©

For Paperwork Reduction Act Notice, see page 1 of separate instructions. Form 5307 (Rev. 3-96)

v

v

v

v

v

v

v v

v

v

v

v

vv

v

v

v

v

v

v

State Telephone number ZIP code

( ) v

v

v

v

v

v

v v

v

v

v

v

v

v

v

v

v

v

v

v

v

v

v

v

v

v v v vvv v

v

v

v

v

v

v

v v

v

v

v

v

Cat. No. 11832Y

City

Enter 3 if collectively bargained plan Enter 5 if other

Enter 4 if section 412(i) plan

You must attach user fee and Schedule Q to this application. (See What To File.)
Form 5307 (Rev. 3-96) Page 2

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

If “No,” skip to line 9d.

b Do you maintain another plan of the same type (i.e., both this plan and the other plan are defined contributions

plans or both are defined benefit plans) that covers non-key employees who are also covered under this plan?

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.)

d Does the plan prevent the possibility that the section 415 limitations will be exceeded for any employee who is

(or was) a participant in this plan and any other plan of the employer? (See Regulations sections 1.415-7

and 1.415-8.)

(1)

(2)

(3)

(4)

Yes No

This plan?

The other plan?

If yes, when the plan is top-heavy, do non-key employees covered under both plans receive:

If this is a defined contribution plan, do you maintain a defined benefit plan (or if this is a defined benefit plan,

do you maintain a defined contribution plan) that covers non-key employees who are also covered under this

plan?

If yes, when the plan is top-heavy, do the non-key employees covered under both plans receive the required

top-heavy minimum contribution or benefit under:

(1)

(2)

c

N/A No Yes

Miscellaneous

10a Does any amendment to the plan reduce or eliminate any section 411(d)(6) protected benefit? (See

instructions.)

b

c 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 a statement explaining the issues involved and who is considering them. Do

not answer “Yes” because the plan has been considered under IRS’s Voluntary Compliance Resolution

Program

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

If “No,” attach a statement explaining how they are allocated
Form 5307 (Rev. 3-96) Page 3

Procedural Requirements

Use this list to see what MUST be included with Form 5307.

Is Schedule Q (Form 5300) attached?

Is Form 8717 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 in the instructions.)

Is a copy of the master or prototype, regional prototype or volume submitter letter attached? (See What To File in the

instructions.)

Is a copy of the plan’s latest determination letter attached? (Previously approved plans only, see What To File in the instructions.)

Has page one been submitted in duplicate (one must be the original printed in special red ink)?

Are both copies of page one of the application signed?

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

If appropriate, is Form 2848, or a privately designed authorization, attached? (See Disclosure Request by Taxpayer in the

instructions.)

Is the year the plan was originally effective 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 and trust instrument attached? (See What To File 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.

1

2

3

4

5

6

7

8

9

10

11

12

Are the appropriate demonstrations attached to Schedule Q?

13