Employee Benefit Plan Declaration and Signature for

Electronic/Magnetic Media Filing

OMB No. 1545-1033 Form 8453-E

Department of the Treasury © See instructions on back.

Internal Revenue Service For the calendar plan year 1995 or the fiscal plan year beginning , 19 , and ending , 19

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

2a Name and address of plan administrator (if same as plan sponsor, enter “same”) 2b Administrator’s employer identification no.

Return/Report Information

3 Name of plan

4 Enter the three-digit plan number ©

5 Total assets at the end of the plan year

6a Is Schedule B (Form 5500) required? Yes No

Declaration of Employer/Plan Sponsor, Administrator, Fiduciary, Actuary, and Accountant

Under penalties of perjury, I declare that this information agrees with the corresponding information on my 1995 employee benefit plan information return/report. I

have also examined a copy of the return/report being filed electronically or on magnetic media with the Internal Revenue Service, including the accompanying schedules

and statements. To the best of my knowledge and belief, the return/report is true, correct, and complete.

If I am not the transmitter, I have consented that the return/report, including this declaration and accompanying schedules and statements, be sent to the Internal

Revenue Service by our return transmitter.

© Signature of employer/plan sponsor Date

Please

Sign

Here

Signature of plan administrator Date

Signature of fiduciary Date

To the best of my knowledge, the information supplied in this schedule and on the accompanying statements, if any, is complete and

accurate, and in my opinion each assumption used in combination, represents my best estimate of anticipated experience under the plan.

Furthermore, in the case of a plan other than a multiemployer plan, each assumption used (a) is reasonable (taking into account the experience

of the plan and reasonable expectations), or (b) would, in the aggregate, result in a total contribution equivalent to that which would be

determined if each such assumption were reasonable. In the case of a multiemployer plan, the assumptions used, in the aggregate, are

reasonable (taking into account the experience of the plan and reasonable expectations).

Signature of actuary Date

Declaration of Transmitter

If the transmitter also prepared the return/report, check this box ©

I declare that the employee benefit plan information return is based on all information of which I have knowledge. A copy of all

forms and information to be filed with the Internal Revenue Service has been (or will be) provided to the taxpayer.

Transmitter’s signature © Date ©

Address © ZIP Code ©

For Paperwork Reduction Act Notice, see back of form. Form 8453-E (1995)

©

Cat. No. 10331Y

©

©

If you are filing this form for an amended Form 5500, 5500-C/R, or 5500-EZ, check this box ©

b If the actuary wants to receive a printed copy of the Schedule B, check this box ©

$

© Signature of independent qualified public accountant Date

I have reviewed the audit report, and related statements and schedules, included as part of this Annual Return/Report Form 5500 being

filed electronically or on magnetic media with the Internal Revenue Service, and, as preparer of the audit report, consent to its inclusion as

part of this filing.
Form 8453-E (1995) Page 2

If you have comments concerning

the accuracy of these time

estimates or suggestions for making

this form simpler, we would be

happy to hear from you. You can

write to the Internal Revenue

Service, Attention: Tax Forms

Committee, T:FP; Washington, DC

20224.

General Instructions

Paperwork Reduction Act

Notice

We ask for the information on this

form to carry out the law as

specified in ERISA and Internal

Revenue Code sections 6039D,

6047(e), 6057(b), and 6058(a). You

are required to give us the

information. We need it to determine

whether the plan is operating

according to the law.

The time needed to complete and

file this form will vary depending on

individual circumstances. The

estimated average time is:

DO NOT send this form to this

office. Instead, see Where To File

on this page.

Where To File

Send Form 8453-E to:

Internal Revenue Service 

Attention: EFU (EPMF) 

Stop 37 

P.O. Box 30309, A.M.F.

Memphis, TN 38130.

Recordkeeping 7 min.

Purpose of Form

Learning about the 

law or the form 5 min.

Form 8453-E is the signature

document that completes the filing

of an employee benefit plan

return/report transmitted via

electronic or magnetic media.

Preparing the form 22 min.

Copying, assembling, 

and sending the form 

to the IRS 20 min.

Multiple-Return Filing

A single signature may be used to

transmit several returns if a

representative is authorized to sign

each employee benefit plan

return/report. A Multiple Return

Control Record may be used with

Form 8453-E to transmit the

authorized signature. See Pub. 1507

for more details.

Form 8453-E is used to:

● Authenticate the electronic/

magnetic media Form 5500,

5500-C/R, 5500-EZ, and related

schedules.

● Transmit the signature of the

employer/plan sponsor, plan

administrator, fiduciary, actuary, and

the signature of the return

transmitter.

● Transmit any accompanying paper

schedules and statements.

● Authorize the participant to

transmit via a third-party transmitter.

How To File

There are specific guidelines to

follow when filing Form 5500,

5500-C/R, and 5500-EZ. Get Pub.

1507, Procedures for

Electronic/Magnetic Media Filing of

Forms 5500, 5500-C/R, and

5500-EZ, for details.

When To File

An employee benefit plan

return/report must be filed by the

last day of the 7th month after the

plan year ends. This filing date also

applies to returns filed electronically

or on magnetic media. For returns

filed electronically, the transmitter

must send the signed Form 8453-E

the same day the transmission is

made. For returns filed on magnetic

tape or diskette, the transmitter

must send the signed Form 8453-E

in the same package with the

corresponding tape or diskette. ● Authorize the transmitter to file the

return on behalf of the employer/

plan sponsor.

Printed on recycled paper