Form 5310 (Rev. 12-81)

Page 4

General Instructions

Paperwork Reduction Act Notice.—
The Paperwork Reduction Act of
1980 says that we must tell you why
we are collecting this information,
how it is to be used, and whether you
have to give it to us. We need the in-
formation to carry out the laws of the
United States as defined in the In-
ternal Revenue Code. You are re-
quired to give us this information.

(Section references are to the Internal Reve-
nue Code.)

A. Who Must File.—Every employ-
er or plan administrator (if desig-
nated) must file this form for any plan
merger or consolidation or any trans-
fer of plan assets or liabilities to
another plan,

B. Who May Also File.—Any em-
ployer, plan administrator (if desig-
nated) or f duciary (trustee or custo-
dian) may tiie this form to request a
determination concerning a termina-
tion of a plan.

Do not file this application in the
case where one or more but less than
all participating employers in (1) a
multiemployer plan as defined in sec-
tion 414(f); (2) a multiple-employer-
collectively-bargained plan; or (3) a
plan of a controlled group of corpora-
tions or commonly controlled trades
or businesses ceases to participate in
such a plan. If a determination letter
on the continued qualification of the
plan is desired in this circumstance
the applicable Form(s) 5300, 5301,
or 5303 should be filed requesting
such a determination.

Note: When this form is filed as
an application for determination upon
termination, Parts | and Ill are open
to public inspection.

C. How and When to File.—File
the original of this form only. Those
required to file under A above must
complete Parts | and Il of this form
and file it at least 30 days prior to the
plan merger or consolidation, or the
transfer of plan assets or liabilities.

Those filing under B above should
complete Parts I, Ill and Schedule A of
this form. This form may be filed at
any time a determination is desired.

D. Where to File.—

(1) A single employer must file
with the District Director for the dis-
trict in which the employer’s principa!
place of business is located.

(2) In the case of a plan of multi-
ple employers, the plan sponsor must
file with the District Director for the
district in which is located the princi-
Pal place of business of the plan spon-
sox, that is, the association, com-
mittee, joint board of trustees, or
other similar group of representatives
of the parties who establish or main-
tain the plan.

E. Signatures.—This form must be
signed by an authorized officer of the
employer, the administrator (if desig-
nated), the authorized trustee or, in
the case of a joint employer-union
board or committee, by at least one
employer representative and one
union representative.

Specific Instructions
and Definitions

A defined contribution plan means
a plan which provides for an individ-
ual account for each participant and
for benefits based solely on the
amount contributed to the partici-
pant’s account, and any income, ex-
penses, gains and losses, and any for-
feitures of accounts of other partici-
pants which may be allocated to such
Participant's account. Profit-sharing
stock bonus and money purchase
plans are defined contribution plans.
See section 414(i).

A defined benefit plan means any
plan which is not a defined contribu-
tion plan. Such plans include unit
benefit, fixed benefit and flat benefit.
See section 414(j).

Line 1(b).—The term plan admin-
istrator means the person specifically
so designated by the terms of the in-
strument under which the plan is
operated. If no plan administrator is
designated in the instrument under
which the plan is operated, the plan
administrator is determined as fol-
lows:

‘Yr US, GOVERNMENT PRINTING OFFICE : 1991~O-363-435,

(i) Single employer plan—The
employer is considered the
plan administrator.

Plan maintained by two or
more employers or jointly by
one or more employers and
one or more employee orga-
nizations—-The association,
committee, joint board of
trustees or other similar group
of representatives of the
parties who maintain the plan
constitute the plan adminis-
trator. See section 414(g).

Line 3.—Enter the same business
code you entered on your Form 5500,
5500-C or 5500-K.

Line 11.—Enter the date and the
file folder number as they appear on
the latest determination letter you
received from the Internal Revenue
Service.

Line 13(d).—If the plan termina-
tion is due to adverse business con-
ditions attach an explanation of why
such adverse conditions require the
termination of this plan.

Line 18(a).—Each employer who
requests a determination must have
notified each employee who qualifies
as an interested party.

Line 18(c).—If the trust continues
to operate after the termination of a
plan, the employer or plan adminis-
trator must file financial information,
annually, on Form 5500, 5500-K or
5500-C.

Line 21.—If this is a request for an
advance determination letter for a
proposed termination, complete the
balance sheet using estimated figures
as of the proposed termination date.

Column (a), Schedule A.—Enter
the last name and initials of each ¢.s-
tributee up to a total of 25 in order of
the highest to the lowest of current
year compensation. Omit those em-
ployees who did not become partici-
pants under the plan prior to termi-
nation.

Column (j), Schedule A.—Enter
compensation as of the 12 month
period ending on the termination date
or the proposed termination date.

363-435-1

(ii)


rom 5310 Application for Determination Upon Termination | Esprevii*3c-22”
(Rev. Dec. 1981) Notice of Merger, Consolidation or Transfer of Plan Assets or Liabilities For IRS Use Only
Rae evcroe seen (Under sections 401(a) and 6058(b) of the Internal Revenue Code of 1954) ff C2S® ae

EPMF status code D>.

Please complete all items in Part | and all the items in either Part II, Ill or Schedule A,
File folder number D>

whichever is applicable to you. If any item does rot apply, enter N/A."

Reason for filing (check one box only):
A [J Notice of plan merger, consolidation or transfer of plan assets or liabilities—Complete Parts | and I!

B [) Application for a determination letter regarding a plan termination—Complete Parts |, lll and Schedule A
1 (a) Name of employer or association of employers or employees 2 Employer identification number
Address (number and street) 3 Business code number
City or town, State and ZIP code Employer's telephone number | 4 Date incorporated or business commenced
¢ )
(b) Name of plan administrator if other than person(s) named in 1(a) above 5 Employer's taxable year ends

Address (number and street)

City or town, State and ZIP code

(c) Administrator's employer identification number (d) Telephone number > ( )
6 Check appropriate box(es) to indicate type of plan entity: (a) [] Single employer plan, (b) [7 Plan of con group of corpora-
tions or commonly controlled employers, (c) [] Multiemployer plan, (d) [] Other multiple employer plan, (e) [] Keogh (HR 10) plan

(b) Plan number | (e) Plan year ends

7 (a) Plan name

[e¥aMle To be Completed ONLY for a Plan Merger or Consolidation or Transfer of Plan Assets or Liabilities to Tnother Plan

8 Other plan(s): (a) Plan name (b) Name of employer

(c) Employer identification number (d) Plan number (e) Date of merger, consolidation or transfer

(f) In the case of a defined benefit plan attach an actuarial statement of valuation evidencing compliance with the requirements
of section 401(a)(12) of the Code. (See also section 414(I) of the Code.)

9 Type of plan (check appropriate box):

(a) [[] Defined benefit (c) [7] Profit-sharing
(b) [_] Money purchase (d) [_] Other (specify) >
10 Effective date of plan 11 Date and file folder number of last determination letter 12 Proposed date of termination

13 Reason for termination (check applicable box):

(a) [J Change in ownership by merger (d) [] Adverse business conditions (see instructions)
(b) ([) Liquidation or dissolution of employer (e) [] Adoption of new, superseding plan
(c) [1 Change in ownership by sale or transfer (f) [J Other (specify) >
14 Type of funding (check appropriate box(es)): (b) (] Fully insured (non-trusteed)
(a) [_] Trust or custodial account (c) [_] Other (specify) >

Under penalties of perjury, 1 declare that | have examined this application, including accompanying statements, and to the best of my knowledge and belief it is true,
cotrect, and complete,

Title > Date >

Signature >

Signature > Title > Date >

For Paperwork Reduction Act Notice, see instructions on page 4.

363-435-1


Page 2
(b) Date accounting period ends

Form 5310 (Rev. 12-81)
15 (a) Name of trustee or custodian (if none, enter "N/A" in 15(a) and (b))

Address (number and street)

City or town, State and ZIP code

16 Number of active employee participants for current plan year and each of the five prior plan years:

19... 19. 19...

Item 19...

(a) Beginning of year. . .
(b) Added during the year . .
(c) Total of lines (a) and (b)
(d) Dropped during the year
(e) Total end of year, (c) less (d) .
17 Summary of distributable benefits from terminated plan:
Category of participant or claimant number __|_ distributable ‘Upon termination

(a) Retirees and beneficiaries (including disability retirees). . . . . +
(b) Eligible for normal retirement . . . See ee ee
(¢) Eligible for early (but not normal) retirement . wees soe

(d) Vested prior to termination (other than normal or early retirement) .

(e) Former employees with vested deferred benefits. .

(f) All other active participants ©. 2. 1... ee ee ee ee

{@) Total, add tines (6) through ( . woe ee ee

(bh) Nex amount, if any, returned or to be returned to employer . oe ee te te

18 Miscellaneous: Yes_|_No

(a) Has each employee who quetifies as an interested party been informed of the filing of this application?. . . |

(b) Have benefits been liberalized in the 60 months prior to termination?. ©. 2. 6 6 ee ee ee

(c) Will the trust continue to operate after termination of the plan?. . . . es ee Saas

(d) Were any funds contributed in the form of, or invested in, obligations or property of the employer or any
controlled corporation?. 2 2. . 6 ee ee ee ee ee ee ee a

(e) Will distributions include property other thancash?. 2. 2 1 6 ee ee ee ee ee

(f) Will distributions to owner-employees be made prior to age 59147. «2 1 6 ee ee ee ee

(g) Will any funds revert to or become available to the employer?. . . eee woe

(h) Is any issue relating to this plan, or trust, currently pending before Oo the Internal Revenue Service, o ‘the 77) Yyfyy
Department of Labor, [_] the Pension Benefit Guaranty Corporation, « or oO: any court? If “Yes,” check box TT
above to indicate where issue is pending. . . .- . .

19 Ifa defined contribution plan, other than a money purchase pension plan, enter forfeiture informa-
tion as follows:

“zz

(a) Total forfeitures for all plan years. . . ee ee ee
(b) Percent of total forfeitures to total contributions for all planyears. . 2. 2 we we ee %
(c) Explain basis on which forfeitures were allocated D>
20 Indicate how distributions will be made: (c) [[] Periodic payments from trust
(a) (J Lump-sum (d) ([] Transfer of assets and liabilities to another plan
(b) [7] Annuity (e) [-] Other (specify) >
21 Trust balance sheet (complete only if trusteed). Show figures as of termination date. (If advance determination is being requested see instructions.)
Assets Current value Liabilities and Reserves Current vatue
Cash. . ee ee ee ee ee Accounts and notes payable to:
Bonds and debentures: (a) Governmental (a) Employer . 2. we
(b) Foreign. . 2. © 2. wwe (b) Others 2 2. 2 1 ww .
(c) Nongovernmental. . . . . | Mortgages payable . . . . .
Stock: (a) Employer . . 6 ee ee J Accrued expenses. . . . . «
(b) Other «6 2 ew ee eee
Loans to: (a) Employer. . . . . «{ Other liabilities ©. 2 6 ee ef
(b) Party in interest. . . . « |_———_______
(c) Others . 2 2. 1 we eee | Total liabilities. ©. . 2. 6 2 6 fe
Real estate loans and mortgages. . .{____#+¥_=s=_.§.__/ Reserves (total assets less total
Real estate (net). 2. 2. 2 ee ee fe liabilities) 2 2 2 ee ee
Other assets 2 6 2 ew ee ee
Totalassets. . . . ss we ee Total liabilities and reserves. .

t
¢



Form 5310 (Rev. 12-81)

= Page 3
Schedule A Distributable Benefits to Individual Participants Note: This schedule is NOT open to public inspection
Name of employer >

| Employer identification number b>
Check applicable Fill in .
columns columns (Money amounts should be in whole dollars)
. 2 Ze ae Compensation
sie] Sle] ss go ra . _.» [Percent of
Participant's 3/8) 2) 3] 88] s fe Amount of employer contributions | Defined contribution | benefit to
lastname and intiats, =| §| 2] 2] 3] 72] 58 Es aifisttibuted or proposed to be plans other than {total com-
dist'in order of compenst gle, 5|e| 2 | os 3 giistributed as of plan termination money purchase | pensation
Sie] 2 3€ | 48 ‘ss | current 12 month For alt full contribution plans list | pension plans only: | or ten
Ble) s5]s| 2s | 3s 3H | Cered ending om lyears ‘of participation allocations in column (A). Defined benefit | Forfeitures tor all full | years
Ble] e] se] se] $s © | date of termination |" or for last ten plan see note* below. years of service or | compen,
sl | #§ 3 st ten ye sation
e]/d)2}s) eg] * BS] oCprepesed date | years, whichever whichever is lesser | divided
s ° ty a2 oz by (kK)
é é
2 0)
: @ m)@l@)@)o | @] mw] a @ ) A (8) (TM )
as
2
3 |_|
— |_|]
5 |__ |_|
—§) |_| Z
2 —_|—_}|__}_]
—2 |]
—2 |__| |_|
10)
1
2 —_|__}_|__]
3B
14
15 {
16
17
18
19
20
21
22
23
24
25
26 | Totals for above... . . .
27 _|_Totals for all others... -
28 | Totals for lines 26 and 27
* Defined benefit plans list amounts allocated in accordance with section 4044(a)(1), (2), (3) and (4)(A) of the Employee Retirement Income Security Act of 1974 under column (I)(A), and list under column
((B) all other allocated amounts,

363-435-1