Form 5300 (6-76)

Page 4

Yes | No J SOS “ONE”
23 Miscellaneous:

(a) Has power of attorney been submitted with the application (or previously submitted)?. . . |__|

(b) Have you completed and attached Form 53027... . . . a

(c) Is the adopting employer a member of a controlled group of corporations o or under commonly
controlled trades or businesses?. © 6 ee ee ee ee ee ee
If “Yes,” see instructions. 7) 7

(d) Is any issue relating to this plan or trust currently pending before the Internal Revenue 4 U
Service, the Department of Labor, the Pension Benefit Guaranty Corporation or any Court? .

If “Yes,” attach explanation.

(e) 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 p>.

(ii) Type of plan &.

(iii) Rate of employer contribution, if fixed >.

(iv) Benefit formula or monthly benefit >...

(v)_ Number of participants >

Yes |_No

24 In the case of a request on an initial qualification, have the following documents been included: YU Ws

(a) Copies of all instruments constituting the plan or joinder agreement? .

(b) Copies of trust indentures or group annuity contracts? . . . .

(c) Evidence that retirement benefits for employees in 15(b)(ii) were the subject of good faith Vl) 7)
bargaining between employee representatives and employer(s)—where that has occurred Y// J)
and is the basis for excluding certain employees, see section 410(b)(2)(A)? . . wee

(d) A detailed description of all methods, factors and assumptions used in determining costs or 7] WY
actual experience under the plan (including any loading, contingency reserves, or special fac-
tors, and the basis of any insured costs or liabilities involved therein) explaining their source Uy,
and application in detail to permit ready analysis and verification? . ~-

25 In the case of a request involving an amendment, after initial qualification, have the following docu-

ments been included: U4) We

(a) A copy of the amendment(s)?. . . . . woe .

(b) A description of the amendment covering the items S changed and an explanation of the 5 pro-
visions before and after the amendment?. . . . . . . 6 ee ee ee ee

(c) A completely restated plan?t¢ . . . . . —

(a) A working copy of the plan in which there has been 1 incorporated all of the previous amend.
ments representing the provisions of the plan as currently in effect? t . . . . . . | __

(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? t+. . . . sone

+ If plan is being amended for the first time to conform to the participation and vesting standards of the Employee

Retirement Income Security Act of 1974, or if the plan has been amended at least three times since the last
restated plan was submitted, one of the documents specified under (c) or (d) must be attached.
If any item in 24 or 25 is answered “No,” please explain.
If more space is needed for any item, attach additional sheets of the same size.
“Ye US. GOVERNMENT PRINTING OFFICE : 157%—O-875-279 575-279-1


Application for File in Duplicate

om 9800 Determination for Defined Benefit Plan For IRS Use Only
(Rev. June 1976) For Pension Plans Other Than Money Purchase Plans Case number P.
Department of the Treasury (Under sections 401(a), 414() and 501(a) of the Internal Revenue Code) ot sane can Q
Internal Revenue Service This Form is Open to Public Inspection File folder ~
> Church and Governmental Plans.—All items need not be completed. See instruction | number >
“B. What to File.””
> Please complete every applicable 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) Name, address and ZIP code of plan administrator, if other than employer 4. Date incorporated or business commenced

5 Employer's taxable year ends

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

6 Determination requested for:
(a) (i) QJ Initial qualification—date plan adopted >.
(iii) If (li) is checked, enter file folder number >.
(b) Were employees who are interested parties given the required notification of the filing of this application? . [] 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 such other plan(s) >

7 Type of entity: (a) [7] Corporation (b) [_] Subchapter S corporation (c) [J Sole proprietor  (d) [-] Partnership

(ii) [] Amendment—date adopted >...

e) [] Tax exempt organization (f) (J Church (g) [5] Governmental organization
(h) [] Other (specify) >
8 (a) Name of Plan (b) Plan number >... ...- (¢) Plan yearends P>....

(d) Is this a Keogh (H.R. 10) plan?. . . .[] Yes [] No
(e) If “Yes,” is an owner-employee in the plan? [] Yes [] No

9 (a) If this is an adoption of a master or prototype plan (other than Keogh) or a district approved | (b) Letter serial number or

pattern plan, enter name of such plan notification letter number
10 (a) Type of plan: (i) (] Fixed benefit (b) Does plan provide for variable benefits? Yes [] No
(ii) (1) Unit benefit (iii) [] Flat benefit If “Yes,"’ check appropriate box to indicate type.
(iv) [] Other (specify) >. (i) Cost of living (ii) [| Asset fluctuation
(iii) [J Other (specify) >
11 Effective date of plan 12 Effective date of amendment | 13 Date plan was communicated to employees P ....

How communicated >
14 (a) Indicate the general eligibility requirements for participation under the plan and indicate the | section and
section and page number of plan or trust where each provision is contained: Page number *
(i) {J All employees (v) Length of service (number of years) D>.
(ii) [] Hourly rate employee only (vi) Minimum age (specify) >.
(iii) [[] Salaried employee only (vii) Maximum age (specify) >.

GOVERNMENT
USE ONLY

(iv) [J Other job class (specify) > (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 >

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

Number

(a) Total employed (if a Keogh plan, include all self-employed individuals) . . . . . . +
(b) Exclusions under plan (do not count an employee more than once): WWW,
(i) Minimum age or years of service required (specify) >..
(ii) Employees included in collective bargaining . . Le
(iii) Nonresident aliens who receive no earned income from United States sources |.
* of plan or trust or other document constituting the plan. :

Under penalties of perury, t declare that | have examined this application, including ‘accompanying statements, and to the best of my knowledge and belief it is true, correct
and complete.

Signature p> Title pp. Date p>.

575-279-1


Form 5300 (6-76) Page 2

(Section references are to the Internal Revenue Code) Number oO NENT

15 Coverage (continued): WY V7,

(c) Total exclusions, sum of (b)(i) through (iii) . woe
(d) Employees not excluded under the statute, (a) less (c) . 2... ew eee
(e) Ineligible under plan on account of (do not count an employee included in (b)):
(i) Minimum pay . oo . . oe
(ii) Hourly-paid .
(iii) Maximum age.
(iv) Other (specify) >
(f) Employees ineligible, sum of (e)(i) through (iv) .
(g) Employees eligible to participate, line (d) less line (f) . . . .
(h) Number of employees participating in plan .
(i Percent of nonexcluded employees who are participating, ny divided by @ .
Complete (j) only if (i) is less than 70% and complete (k) only if (j) is 70%

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or more.
(i) Percent of nonexcluded employees who are eligible to participate, (g) divided
by(d). 2 6 ee ee eee noe
(k) Percent of eligible employees who are participating, (h) divided by ®. L
If () and (j) are less than 70% or (k) is less than 80%, see instructions . . |Z
(1) Total number of participants, include certain retired and terminated employees, Section and
see instructions... . - + ee ee ee page number *

16 Employee contributions:
(a) Are mandatory contributions limited to 6%, or less, of compensation? .
(b) Are voluntary contributions limited to 10%, or less, of compensation for all

qualified plans?.. cee
(c) Are benefits unaffected by forfeitures?

17 Employer contributions:
(a) [] Full amount

(b) [[] Balance necessary
(c) Are employer contributions reduced by forfeitures? . . . . . . - -

18 Integration:
Is this plan integrated with Social Security or Railroad Retirement? . . . . . .
If “Yes,” see instructions.
19 Vesting—Check the appropriate box to indicate the vesting provisions of the plan:
(a) [] Full and immediate
(b) [J Full vesting after 10 years of service
(c) [7] 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
(d) [] Rule of 45 (see section 411(a)(2)(C))
(e) [J For each year of employment, commencing 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) [] Other (specify and see instructions) >

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20 Administration:
(a) Type of funding entity:
() (J Trust
(ii) [Custodial account
(ii) (] Non-trusteed
(iv) (| Trust with insurance contracts
If you checked (i) or (ii), enter date executed > _
(b) Enter name of trustee or custodian, if any >

(c) Does trust agreement prohibit reversion of funds to the employer? wee
(d) If borrowing on insurance contracts is permitted, is it on a pro-rata basis? .

(e) If Puerto Rican trust, does it qualify for tax exemption under the laws of
Puerto Rico?» ss

* of plan or trust or other document constituting the plan. 575-279-1


Form 5300 (6-76) Page 3

Yes | No | page numbers | SDSE ONLY
21 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?

(d) (i) Does the plan provide that the payment of benefits, unless the “employee
elects otherwise, will commence not later than the 60th day after the
latest of (1) the close 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 close of the plan year in which occurs the 10th anniversary
of the year in which participant commenced participation or (3) the
close of the plan year in which the participant terminates his service with
the employer? soe ee

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

(e) Benefit at normal retirement age is >...

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(f) Benefit at early retirement age is >

(g) Normal form of retirement benefits is >

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

(i) If benefits are measured by years of service—

(i) Are the years of service for eligibility purposes included in credited service?

(ii) Is only service as a common-law employee recognized?. . . . . .
(i) Are benefits computed on the basis of total compensation? . . . .

If “No,” see instructions.

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

()_ If participants may withdraw their contributions or earnings, may such with-
drawal be made without forfeiting vested benefits based on employer contri-
butions?. . . . 2. . . ey

(m) If the plan defers compensation ‘generated increases until compensation in-
creases sufficiently, does plan provide for increases of benefits of at least $10
per month? . . . . toe

(n) Is duplication of benefits upon re-t entry to the plan prohibited? . rr

(0) Is there a disability benefit under the plan? . . .

(p) Does the plan provide for a death benefit, other than survivor + annuity, before
retirement??. . . . soe ee eee ry
If “Yes,” indicate whether si such 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) [J] Other explain >.

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(q) Does plan provide for maximum limitation under section 415?

(r)_ In the case of a merger or consolidation with another plan or transfer of assets
or liabilities to another plan, will each participant be entitled to the same or
greater benefits as if the plan had terminated? . . .

(s) Does the plan prohibit the assignment or alienation of benefits? .

(t) Does the plan preclude divestment forcause?. . . . . . 1 ee

(u) Does plan prohibit distribution of benefits except for retirement, disability or
termination of employment or, in case of owner-employees, after age 5914?

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22 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?. . cee
(c) Has the early termination rule been included in the plan (see : section 1.4014

(c)(1) and (2) of the Income Tax Regulations)? . . te
(@) Have the plan benefits been increased since the plan’s inception?

ZT

* of plan or trust or other document constituting the plan. 575-279-1