For Paperwork Reduction Act Notice, see the instructions.

Department of the Treasury

Internal Revenue Service

If this is a defined contribution plan, enter the appropriate code (see instructions) AND attach an actuarial statem

valuation showing compliance with the requirements of sections 401(a)(12) and 414(l)

Cat. No. 12783Y Form 5310-A 

3a Name of plan (plan name may not exceed 66 characters):

Under penalties of perjury, I declare that I have examined this notice, including accompanying statements, and to the best of my knowledge and belief, it 

and complete.

Signature Title Date 

b

See Who Must File instructions before filing this form.

Reason for filing (see specific instructions for code to enter):

All filers must complete lines 1 and 2.

Complete lines 3 through 5 if this is a notice of a plan merger or consolidation, spinoff, 

of plan assets or liabilities to another plan.

5 Other plan(s) involved in the transaction (see instructions)

Plan name:

Name of employer:

Employer identification number: Plan number (3 digits):

Date of merger or consolidation, spinoff, or transfer of plan assets or liabilities (MMDDYYYY):

Type of plan (see instructions for code to enter):

c

e f

g

h

d

a Enter the total number of plans involved in the transaction other than the plan listed on line 3a:

Complete the following information for the other plan. If more than one other plan, see instructions for 

attachment(s).

b If more than one other plan is involved in the transaction, enter the number of this statement (1 of 3, etc.):

4a Is this a defined benefit plan?

If “Yes,” attach an actuarial statement of valuation showing compliance with the requirements of section

401(a)(12) and the regulations under section 414(l).

Complete lines 6 through 11 if you are filing a notice of qualified separate lines of business 

6a

Part III

Part I

Part II

If “Yes,” complete lines 6b and 6c.

Has the employer previously filed a notice of QSLOB?

b Enter the first day of the first testing year for which such notice applied (MMDDYYYY)

c

b Enter 3-digit plan number

If “No,” skip lines 6b and 6c.

/ 

/ /

If “8,” specify 

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

1c Employer’s tax year ends—E

City State ZIP code 1d Telephone number

Person to contact if more information is needed. (See instructions.) (If Form 2848 or Form 8821 is attached, check box and do not complete this line.) 

2

Name

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

Fax number

( )

City

( )

State ZIP code

1e Fax number

( )

Telephone number

( )

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

Yes 

Yes 

/ 

d Enter the filing location code (see instructions) 

7 First testing year for which this notice applies (MMDDYYYY) / 

Enter the filing date (MMDDYYYY) 

Enter the following information relating to each plan maintained by the employer. If more than 1 plan, attach a sc

each plan showing the information requested on lines 11a through 11e. See instructions.

11

a Name of plan:

b Date (MMDDYYYY) of determination letter, if any 

c If the plan is a master or prototype or volume submitter plan, enter:

d

e List each QSLOB that has employees benefiting under the plan:

On an attached list, identify each QSLOB operated by the employer. See the line 10 instructions for more detail

9 Check the box(es) for the appropriate code section(s) for which the employer is testing on a QSLOB basis (or for 

employer tested, if the answer to line 8 is “Yes”).

10

Section 410(b) Section 401(a)(26) Section 129(d)(8)

If No,complete lines 9, 10, and 11.

/ /

the serial number or Advisory letter number 

Enter the appropriate code number that indicates the location of the pending letter

request, if applicable (see instructions) 

/ /

Form 5310-A 

(1)

(2)

the date (MMDDYYYY) of the letter