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Application for OMB No. 1545-0197

Determination for Employee Benefit Plan

5300

Rev 1/96 For IRS Use Only

File folder number © Department of the Treasury

Internal Revenue Service

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

Case number ©

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.

1a Name of plan sponsor (employer if single-employer plan) 1b Employer identification number

Employer’s tax year ends-Enter N/A

or (MM)

Number, street, and room or suite no. (If a P.O. box, see instructions.) 1c

City State ZIP code Telephone number 1d

( )

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

City State ZIP code Telephone number

( )

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

(See instructions.)

3a

Enter 1 for Initial Qualification—Date plan signed

Enter 2 for a request after initial qualification—Is complete plan attached?

(See instructions.) 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 been given the required notification of this application? (See

instructions)

c

Yes No

Does the plan have a cash or deferred arrangement, or employee or matching contributions

(section 401(k) or (m))?

d

Yes No

Name of Plan:

4a

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 ESOP

Enter 3 for money purchase

6a Is 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

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

Enter 4 if section 412(i) 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 5300 (Rev. 1-96)

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

Enter 6 for other (Specify)

Enter 2 if nonelecting church plan (see

instructions)

Enter 5 if other

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

Review the list of Procedural Requirements on page 3 before submitting this application.

v

Application for OMB No. 1545-0197

Determination for Employee Benefit Plan

5300

Rev 1/96 For IRS Use Only

File folder number © Department of the Treasury

Internal Revenue Service

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

Case number ©

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.

1a Name of plan sponsor (employer if single-employer plan) 1b Employer identification number

Employer’s tax year ends-Enter N/A

or (MM)

Number, street, and room or suite no. (If a P.O. box, see instructions.) 1c

City State ZIP code Telephone number 1d

( )

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

City State ZIP code Telephone number

( )

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

(See instructions.)

3a

Enter 1 for Initial Qualification—Date plan signed

Enter 2 for a request after initial qualification—Is complete plan attached?

(See instructions.) 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 been given the required notification of this application? (See

instructions)

c

Yes No

Does the plan have a cash or deferred arrangement, or employee or matching contributions

(section 401(k) or (m))?

d

Yes No

Name of Plan:

4a

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 ESOP

Enter 3 for money purchase

6a Is 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

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

Enter 4 if section 412(i) 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 5300 (Rev. 1-96)

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

Enter 6 for other (Specify)

Enter 2 if nonelecting church plan (see

instructions)

Enter 5 if other

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

Review the list of Procedural Requirements on page 3 before submitting this application.
Form 5300 (Rev. 1-96) Page 2

8a Do you maintain any other qualified plan(s)? (See instructions.)

Yes No

If “No,” skip to line 8d.

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

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

b

(1) the top-heavy minimum benefit under the defined benefit plan?

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

(3) the minimum benefit offset by benefits provided by the defined contribution plan?

(4) 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?

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:

This plan?

The other plan?

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 non-key employees covered under both plans receive:

c

(1)

(2)

General Eligibility Requirements (Complete all lines.)

9a Check one box:

(1) All employees

(2) Hourly rate employees only

(3) Salaried employees only

(4) Other (Specify)

b Minimum years of service required to participate

c Minimum age required to participate (Specify)

Vesting (Check one box to indicate the regular (non-top heavy) vesting provisions of the plan.)

10a Full and immediate

b Full vesting after 2 years of service

c Full vesting after 3 years of service

d Full vesting after 5 years of service

e 6 year graded vesting

f 3 to 7 year graded vesting

g Other (Attach a statement showing your vesting schedule.)

Benefits and Requirements for Benefits

11a For defined benefit plans—Method for determining accrued benefit:

(1) Benefit formula at normal retirement age is

(2) Benefit formula at early retirement age is

(3) Normal form of retirement benefit is

b For defined contribution plans—Employer contributions:

(1) Profit-sharing or stock bonus plan contributions are determined under:

A definite formula An indefinite formula Both

(2) Money purchase plan—Enter rate of contribution

(3) Target benefit plan—state target benefit formula

N/A Yes No

Miscellaneous (See instructions.)

12a Does any amendment to the plan reduce or eliminate any section 411(d)(6) protected benefit? (See instructions.)

b

c

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.

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

If no minimum, check ©

If no minimum, check ©
Form 5300 (Rev. 1-96) Page 3

Procedural Requirements

Use this list to see what MUST be included with Form 5300.

1 Is Schedule Q (Form 5300) attached?

2 Is Form 8717 and the appropriate user fee attached?

3 Is a copy of the plan and, if applicable, amendments attached?

4 Is a copy of the plan’s latest determination letter attached? (Previously approved plans only.)

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

5

Are both copies of page one of the application signed?

6

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

7

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

8

Is the year the plan was originally effective entered on line 4d?

9

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

File and the line 6 instructions attached?

10

Multiple-Employer Plans—Is the information required under What To File and Specific Plans—Additional Requirements attached?

11

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

IN THE RETURN OF THIS APPLICATION TO YOU.

Are the appropriate demonstrations attached to Schedule Q?

12

13 ESOPs—Is Form 5309 attached?

Printed on recycled paper