Form 5300 (Rev. 12-81)

Section and
Yes | No | page number

Page 4

FOR IRS
USE ONLY

22 Benefits and requirements for benefits (continued).

(p) Does the plan provide for maximum limitation under section 4157. . . .

(q) For a merger or consolidation with another plan or transfer of assets or liabili-
ties to another plan, will each participant be entitled to the same or greater
benefits as if the plan had terminated?. . . . ee et

(r)_ Does the plan prohibit the assignment or alienation of benefits? . . . «

(s) Does the plan preclude forfeiture of an employee's vested benefits for cause? .

(t) Does the plan prohibit distribution of benefits except for retirement, disability,
or termination of employment, or, for owner-employees, until age 5914 or
disability? . . . .

23 Termination of plan or trust:
(a) Is there a provision in the plan for terminating the plan and/or trust? . . . |___|_
(b) Are the participants’ rights to benefits under the plan nonforfeitable upon

termination or partial termination of the plan?. . . . 6 e+ ee ee
(c) Has the early termination rule been included in the plan (see section 1.401-4
(c)(1) and (2) of the Income Tax Regulations)? . . . . et

(d)_Havethe plan benefits remained the same orincreased since theplan’ ‘sinception? .

24 Miscellaneous:
(a) Has power of attorney been submitted with the application (or previously submitted)?. . .
(b) Have you completed and attached Form 5302, Employee Census?. . . - - + + + +
(c) Is any issue relating 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.
(d) Other qualified plans—Enter for each other qualified plan you maintain (do not include plans that were

_ established under union-negotiated agreements that involved other employers):

(i) Name of plan Pm.
(ii) Type of plan >...
(iii) Rate of employer contribution, if fixed >.
(iv) Benefit formula or monthly benefit >.
(v) Number of participants »

CWWiG

Yes _|_No
WE] WH
25 For a request on an initial qualification, have the following documents been included: WN WN
(a) Copies of all instruments constituting the plan or joinder agreement?. . . . . +» + -

(b) Copies of trust indentures, group annuity contracts or custodial agreements?. . . . - +
(c) A detailed description of all methods, factors and assumptions used in determining costs or
actual experience under the plan (including any loading, contingency reserves, or special fac-
tors, and the basis of any insured costs or liabilities involved) explaining their source and
application in detail to permit ready analysis and verification?. . 9. . - + - + + + +
26 For a request involving an amendment after initial qualification, have the following documents
been included:
(a) Acopy of the amendment(s)?... . 6 6 ee 8 ee ee ee ee ee
(b) A description of the amendment covering the items changed and an explanation of the pro-
visions before and after the amendment?. . . . © + + + © ee ee ee ee
(c) A completely restated plan? (see instructions). ©. ©. 2 6-6 ee ee ee
(d) A working copy of the plan, in which has been incorporated all of the previous amendments,
representing the provisions of the plan currently in effect?. . . 2. 2 2 + s+ e+ es ee
(e) Copies of all amendments adopted since the date of the last determination letter for which no
determination letter has been issued by the Internal Revenue Service? . . - + + + ss

If any item in 25 or 26 is answered ‘‘No,” please explain.

\N

‘te US, GOVERNMENT PRINTING OFFICE : 1981—-O-343-510

343-510-1


rom 9300 Application for sites
(Rev. December 1981) Determination for Defined Benefit Plan For IRS Use Only
Department of the Treasury For Pension Plans Other Than Money Purchase Plans rie
Internal Revenue Service (Under sections 401(a), 414(j) and 501(a) of the Internal Revenue Code) number D>
—
> Church and Governmental Plans.—All items need not be completed. See instruction B. ‘‘What to File."”
> All others complete every item on this form. If an item does not apply, enter N/A.
1 (a) Name, address and ZIP code of employer 2 Employer's identification number

3 Business code number

Telephone number B_( )

(b) Name, address and ZIP code of plan administrator, if other than employer 4 Date incorporated or business began

5 Employer's tax year ends

(c) Administrator's identification number > _ Telephone number > (_

(d) Name, address and phone number of person to be contacted if more information is needed:
Name > _.. Telephone number B (
Address >

Determination requested for:

(a) (i) [[] Initial qualification—date plan adopted >.
(iii) If (i) is checked, enter file folder number >.

(b) Were employees who are interested parties given the required notification of the Yes [] No

(c) If this application involves a merger or consolidation with another plan, enter the employer identification number(s) and
the plan number(s) of the other plan(s) >

7 Type of entity:

a

(ii) [] Amendment—date adopted

ing of this application? .

(a) [J Corporation (b) [] Subchapter S corporation (c) [] Sole proprietor (d) [] Partnership
(e) [J Tax-exempt organization (f) [ Church (g) [] Governmental organization
(h) [J Other (specify) >

8 (a) Name of plan (b) Plan number Pm.

(c) Plan year ends >.

(a) Is this a Keogh (H.R. 10) plan? . .[] Yes [] No

(e) If “Yes,” is an owner-employee in the plan? [J Yes [j] No

9 (a) If this is an adoption of a key district approved pattern plan, enter the name of the plan (b) Notification letternumber

10 (a) Type of plan: (i) (7 Fixed benefit (b) Does plan provide for variable benefits? OO Yes [] No
(ii) [] Unit benefit (iii) (J Flat benefit If “Yes,” check box to indicate type.

(iv) [] Other (specify) P... (i) Cost of living (ii) (J Asset fluctuation
Gii) ] Other (specify) >
(c) Is this a defined benefit plan covered under the Pension Benefit Guaranty Corpo-
ration termination insurance program?. . sos ee ee ee + PP Yes [J No [j Not determined

11 Effective date of plan 12 Effective date of amendment | 13 Date plan was communicated to employees > .... _

How communicated >

14 (a) Indicate the general eligibility requirements for participation under the plan and indicate the Section and FOR IRS
section and page number of plan or trust where each provision is contained: Page number | USE ONLY

(i) [[] All employees (v) Length of service (number of years) >.
(ii) [Hourly rate employee only (vi) Minimum age (specify) >
iii) [Salaried employee only (vii) Maximum age (specify) >.
(iv) [[] Other job class (specify) p>. (viii) Minimum pay (specify) >.
(b) Are the eligibility requirements the same for future employees?. . . « (Yes [] No
If “No,” explain ® ___ —_
(c) Does the plan recognize service only with this employer? . . . . . .([] Yes No

If “No,” explain

ani/det penalties of perjury, 1 declare that | have examined this application, including accompanying statements, and to the best of my knowledge and bellet it is true, correct
my

Signature p> Title p> Date >

For Paperwork Reduction Act Notice, see page 1 of the instructions. 343-510-1 Form 5300 (Rev. 12-81)


Form 5300 (Rev. 12-81)

15

Yes | No

(a) (i) Is the employer a member of an affiliated service group?. . . . . .

Not Certain

Page 2

FOR IRS
USE ONLY

If you are uncertain whether the employer is a member of an affiliated Y 7
service group, check the ‘Not Certain” column. YY)
(ii) If 15(a)(i) is “Yes,” or “Not Certain,” did a prior ruling letter rule on what
organizations were members of the employer's affiliated service group, or
did the employer receive a determination letter that considered the effect

of Code section 414(m) on this plan?. 2 2. we ee ee
(iii) If (ji) is “"Yes,"" have the facts on which that letter was based materially
changed? (see instructions). . . . . . « « ct ee
(b) Is the employer a member of a controlled group of corporations or a group
of trades or businesses under common control?. . . ss

LO

1,

16

Coverage of plan at (give date) > ___..
Enter here the number of self-employed individuals

(a) Total employed (if a Keogh plan, include all self-employed individuals) . . . . - - «+
(b) Exclusions under plan (do not count an employee more than once):
(i) Minimum age or years of service required (specify) P___.

(ii) Employees included in collective bargaining . . . 2 6 6 e+ ee we ee ee
(iii) Nonresident aliens who receive no earned income from United States sources. . . «
(c) Total exclusions (add (b){i) through (b)(iii)) . . . 6 ee ee ee ee
(d) Employees not excluded under the statute (subtract (c) from (a)). . . «6 se eee
(e) Ineligible under plan because of (do not count an employee included in (b)):
(i) Minimumpay. 2. ee ee ee ee
(ii) Hourlypaid 6 6 6 ee ee ee
(iii) Maximumage. © 6 6 6 ee ee ee
(iv) Other (specify) >.
(f) Employees ineligible (add (e)(i) through (e)(iv)). 2. 6 ee ee ee
(g) Employees eligible to participate (subtract (f) from (4)... ee ee ee
(h) Number of employees participating in plan. . . 2. se ee ne

(i) Percent of nonexcluded employees who are participating (divide (h) by @). ‘Lb %
Complete (j) only if (i) is less than 70% and complete (k) only if (j) is 70% |F 7
Yi,

or more.
(j) Percent of nonexcluded employees who are eligible to participate (divide (g)

by d)). 6 ee woe . %
(k) Percent of eligible employees who are participating (divide (h) by ®). %

If (i) and (j) are less than 70% or (k) is less than 80%, see instructions . . .Y~WWW
(1) Total number of participants, including certain retired and terminated em-
ployees (see instructions)... - - - . + + + ee ee ee

Ty

Number

Section and
Page number

17

Employee contributions:
(a) Does the plan provide for mandatory contributions? . . . . =...
(b) Are voluntary contributions limited to 10%, or less, of compensation for all

qualified plans?. . Se
(©) Are employee contributions non-forfeitable?. . . . 1 + +. + +

18

Employer contributions:
(a) [J Full amount

(b) [] Balance necessary

Hk

(c) Are employer contributions reduced by forfeitures?_. . . . . . -
19 Is this plan integrated with Social Security or Railroad Retirement?. . . . . «|__|
If “Yes,” see instructions. WHMAUUA,

20

Vesting—Check box to indicate the vesting provisions of the plan:
(a) [] Full and immediate

(b) [[] Full vesting after 10 years of service
(c) [] 5- to 15-year vesting, i.e., 25% after 5 years of service, 5% additional for each of
the next 5 years, then 10% additional for each of the next 5 years

343-510-2


Form 5300 (Rev. 12-81) Page 3

20 Vesting—(continued). Section and, ff FOR IES,

(d) [5] Rule of 45 (see section 411(a)(2)(C))

(e) [J For each year of employment, beginning with the 4th such year, vesting not less than
40% after 4 years of service, 5% additional for each of the next 2 years, and 10%
additional for each of the next 5 years

(f) [J Other (specify and see instructions) p>

21 Administration: Yes |_Ni

(a) Type of funding entity:

(i) ( Trust

(ii) [] Custodial account

(iii) [] Non-trusteed

(iv) (] Trust with insurance contracts

If you checked (i) or (ii), enter date signed >.
(b) Enter name of trustee or custodian, if any >

6

(c) Does the trust agreement prohibit reversion of funds to the employer?. .

(d) If borrowing on insurance contracts is permitted, is it on a pro-rata basis? .  .

(e) If a Puerto Rican trust, does it qualify for tax exemption under the laws of
Puerto Rico? . . - - + + + + ee ee

22 Benefits and requirements for benefits:
(a) Normal retirement age is > State years of service required >
(b) Early retirement age is > State years of service required >
(c) If employer's consent is required for early retirement, are benefits limited to
vested interest? © 6. ee ee ee ee ee ee ee

(d) (i) Does the plan provide that the payment of benefits, unless the employee
elects otherwise in writing, will begin not later than the 60th day after the
latest of: (1) the end of the plan year in which the participant attains the
earlier of age 65 or the normal retirement age specified under the plan, (2)
the end of the plan year in which occurs the 10th anniversary of the year in
which the participant began participation, or (3) the end of the plan year in
which the participant terminates his or her service with the employer? .

(ii) Does the plan provide for payment of benefits if claim is not filed? . . .

(e) Benefit at normal retirement age is

| I

(f) Benefit at early retirement age is

(h) If plan provides for payment of benefits in the form of a life annuity, does the
plan provide a joint and survivor benefit unless the participant elects otherwise

inwriting?. 6 ee ee ee /
(i) If benefits are measured by years of service— YU Yus
(i) Are the years of service for eligibility purposes included in credited service?
(ii) Is only service as a common-law employee recognized?. . . ....

(j) Are benefits figured on the basis of total compensation? . . . . . . «
If “No,” see instructions and attach schedule.

(k) Does the plan provide for determining an employee’s accrued benefit?. . .

()_ If participants may withdraw their mandatory contributions or earnings, may
the withdrawal be made without forfeiting vested benefits based on employer
contributions? 2. 1 6 ew ee ee ee

(m) If the plan defers compensation-generated increases until compensation grows
sufficiently, does the plan provide for increases of benefits of at least $10 a

ZA

Ll
LE

|
|

month?. 2 6 ee ee ee
(n) Is there a disability benefit under the plan?. . 2 2 1 2 we eee
(0) Does this plan provide for a death benefit, other than survivor annuity, before
retirement?. © 6 1 6 ee ee

If “Yes,” indicate whether these benefits are limited to—

(i) [J] 100 times the monthly pension, or the reserve, if larger.

(ii) [] The actuarial equivalent of the benefits accrued to the date of death.
(iii) Other (explain) p>

a

343-510-2