5310 Application for Determination Upon Termination OMB No. 1545-0202

Rev 7/94 For IRS Use Only

Department of the Treasury

Internal Revenue Service

(Under section 401(a) of the Internal Revenue Code)

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

1c Employer’s tax year ends—N/A or (MM)

City State ZIP code 1d Telephone number

Person to contact if more information is needed. (See instructions, Disclosure Request by Taxpayers.) (If same as 1a, leave

blank.) (Complete even if Power of Attorney is attached):

2

Name

Address (number, street, room or suite no. (If a P.O. box, see page 2 of the instructions.))

Have interested parties (as defined in Treasury Regulations section 1.7476-1) been given the

required notification of this application?

3a

Yes No

b If 3a is “Yes,” enter date of notification (MMDDYY)

c Has the plan received a determination letter, or, if this plan is a standardized Master or Prototype or

Regional Prototype plan, an opinion, or notification letter? If “Yes,” attach a copy of the latest letter

4a Name of Plan (Plan name may not exceed 66 characters.):

b Enter plan number (3 digits) d Enter date plan effective (MMDDYY)

c Enter date plan year ends (MMDD) e Enter number of participants in plan

5a If this is a defined benefit plan, enter the appropriate number at left.

Enter 1 for unit benefit Enter 3 for flat benefit

Enter 2 for fixed benefit Enter 4 for other (specify)

b If this is a defined contribution plan, enter the appropriate number at left.

Enter 1 for profit sharing Enter 4 for target benefit

Enter 2 for stock bonus Enter 5 for ESOP

Enter 3 for money purchase

6a Is the employer a member of an affiliated service group?

Enter 1 if “Yes” Enter 2 if “No” Enter 3 if “Not Certain”

b Is the employer a member of a controlled group of corporations or a group of trades or businesses under common control?

Enter 1 if “Yes” Enter 2 if “No”

7 Enter type of plan:

Enter 1 if governmental plan

Enter 3 if multiple employer plan (described in section 413(c)). Enter number of participating

employers

Enter 5 if other

Proposed date of plan termination (MMDDYY)

8

a

Attach copies of records of all actions taken to terminate the plan (see instructions).

b

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

correct, and complete. Both copies of this page must be signed.

Signature © Title © Date ©

For Paperwork Reduction Act Notice, see page 1 of the instructions. Form 5310 (Rev. 7-94)

v

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Telephone number

( )

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v

Does the plan have a cash or deferred arrangement (section 401(k)) or employee matching

contributions (section 401(m))? vvv v v v v v

v

v

v

v

v

v

v

v

v

v

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Date

User fee must be attached to this application. (See What To File.)

You must file both the copy of page 1 printed in red ink and the duplicate page 1 of this application. The page 1 printed in red

ink is read by the computer and all the information filled in must be typed in either 10 pitch type, Elite type, Courier 12 type, or

Titan 12 type. If you wish to computer generate this form, contact your key district office for more information.

Cat. No. 11840Y

c Will any funds be, or have any funds been, returned to the employer? (See specific instructions.)

If “Yes,” enter the estimated amount ©

d If 3c is “Yes,” has the plan been amended since the last letter was received? If “Yes,” attach

a copy of the amendment(s) in addition to a copy of the plan documents

e

Will funds be distributed as soon as administratively feasible?

v

v

Enter 6 for other (specify)

Address (number and street)

v

v

Review the Procedural Requirements on page 6 before submitting this application.

City

v

( )

State ZIP code

v

vv

vv

Yes No v

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Yes No v

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Yes No v

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Yes No vv

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Yes No vv

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Enter 2 if church plan not subject to ERISA

Enter 4 if section 412(i) plan

5310 Application for Determination Upon Termination OMB No. 1545-0202

Rev 7/94 For IRS Use Only

Department of the Treasury

Internal Revenue Service

(Under section 401(a) of the Internal Revenue Code)

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

1c Employer’s tax year ends—N/A or (MM)

City State ZIP code 1d Telephone number

Person to contact if more information is needed. (See instructions, Disclosure Request by Taxpayers.) (If same as 1a, leave

blank.) (Complete even if Power of Attorney is attached):

2

Name

Address (number, street, room or suite no. (If a P.O. box, see page 2 of the instructions.))

Have interested parties (as defined in Treasury Regulations section 1.7476-1) been given the

required notification of this application?

3a

Yes No

b If 3a is “Yes,” enter date of notification (MMDDYY)

c Has the plan received a determination letter, or, if this plan is a standardized Master or Prototype or

Regional Prototype plan, an opinion, or notification letter? If “Yes,” attach a copy of the latest letter

4a Name of Plan (Plan name may not exceed 66 characters.):

b Enter plan number (3 digits) d Enter date plan effective (MMDDYY)

c Enter date plan year ends (MMDD) e Enter number of participants in plan

5a If this is a defined benefit plan, enter the appropriate number at left.

Enter 1 for unit benefit Enter 3 for flat benefit

Enter 2 for fixed benefit Enter 4 for other (specify)

b If this is a defined contribution plan, enter the appropriate number at left.

Enter 1 for profit sharing Enter 4 for target benefit

Enter 2 for stock bonus Enter 5 for ESOP

Enter 3 for money purchase

6a Is the employer a member of an affiliated service group?

Enter 1 if “Yes” Enter 2 if “No” Enter 3 if “Not Certain”

b Is the employer a member of a controlled group of corporations or a group of trades or businesses under common control?

Enter 1 if “Yes” Enter 2 if “No”

7 Enter type of plan:

Enter 1 if governmental plan

Enter 3 if multiple employer plan (described in section 413(c)). Enter number of participating

employers

Enter 5 if other

Proposed date of plan termination (MMDDYY)

8

a

Attach copies of records of all actions taken to terminate the plan (see instructions).

b

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

correct, and complete. Both copies of this page must be signed.

Signature © Title © Date ©

For Paperwork Reduction Act Notice, see page 1 of the instructions. Form 5310 (Rev. 7-94)

v

v

v

v

vvv

v

v

v

vv

vv

v

v

v

v

Telephone number

( )

v

v

v

v

v

v

v

Does the plan have a cash or deferred arrangement (section 401(k)) or employee matching

contributions (section 401(m))? vvv v v v v v

v

v

v

v

v

v

v

v

v

v

v

Date

User fee must be attached to this application. (See What To File.)

You must file both the copy of page 1 printed in red ink and the duplicate page 1 of this application. The page 1 printed in red

ink is read by the computer and all the information filled in must be typed in either 10 pitch type, Elite type, Courier 12 type, or

Titan 12 type. If you wish to computer generate this form, contact your key district office for more information.

Cat. No. 11840Y

c Will any funds be, or have any funds been, returned to the employer? (See specific instructions.)

If “Yes,” enter the estimated amount ©

d If 3c is “Yes,” has the plan been amended since the last letter was received? If “Yes,” attach

a copy of the amendment(s) in addition to a copy of the plan documents

e

Will funds be distributed as soon as administratively feasible?

v

v

Enter 6 for other (specify)

Address (number and street)

v

v

Review the Procedural Requirements on page 6 before submitting this application.

City

v

( )

State ZIP code

v

vv

vv

Yes No v

v

v

v

Yes No v

v

v

v

Yes No v

v

v

v

Yes No vv

v

v

Yes No vv

v

v

Enter 2 if church plan not subject to ERISA

Enter 4 if section 412(i) plan
If more space is needed for any item, attach additional sheets the same size as this Form 5310 (Rev. 7-94) form. Identify each sheet with the plan sponsor’s name and EIN and identify each item. Page 2

No

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If the plan has never received a determination or notification/opinion letter from IRS, attach a copy of the

executed original plan document or joinder/adoption agreement, all plan amendments, trust agreement,

group annuity contracts and custodial agreements. Do not complete 9b through 9d.

b

c

Since the last letter, have any of the amendments altered the plan’s vesting provisions?

d

Since the last letter, have any of the amendments (including the termination) decreased plan benefits for

any participant?

Reason for termination. Check only one box to indicate primary reason for termination.

11

a Change in ownership by merger

b Liquidation or dissolution of employer

c Change in ownership by sale or transfer

d Adverse business conditions (see instructions and attach explanation)

e Adoption of new plan (see instructions and attach explanation)

f Other (specify) ©

Indicate funding arrangement:

12a

a Trust (benefits provided in whole from trust funds)

b Insurance contract plan described in Code section 412(i)

Trust or other arrangement providing benefits partially or exclusively through insurance and/or annuity contracts not

included in 11b above.

c

d Custodial account described in Code section 401(f) and not included in 11b or 11c above

e Other (specify) ©

Name(s) of trustee(s) or custodian(s) b Telephone number

13

Address (number and street)

City or town, state, and ZIP code

Coverage (see instructions): Certain collectively bargained plans do not complete 13a or 13b (see instructions).

Current year Complete the following for the proposed year of plan termination

(current year) and for the two prior plan years:

a

19

Did the plan satisfy the ratio percentage test of section Yes No Yes No Yes No

410(b)(1)(B)?

If the plan does not satisfy the ratio percentage test for any of the specified years, explain on a separate attachment how

the plan met the minimum coverage requirements of section 410(b).

19 19

9a

Is the employer using the qualified separate line of business rules in section 414(r) to satisfy the

minimum coverage requirements of section 410(b)? Yes No

b

Enter the total number of participants employed at any time during the current plan year and each of the 5 prior plan

years on the schedule below. If all such participants were fully vested at all times during such period, do not complete

lines 13c(1) through 13c(5) and enter -0- in each column next to line 13c(6).

c

Current year

19

Number at beginning of plan year

Number added during the plan year

Total (add lines (1) and (2))

Number dropped during the plan year

Number at end of plan year (subtract

(4) from (3))

Total number of participants in this plan

separated from vesting service during

the plan year without full vesting

(1)

(2)

(3)

(4)

(5)

(6)

19 19 19 19 19

(1)

(2) If (1) is “Yes,” was the IRS properly notified? (See instructions.) Yes No

( )

Yes N/A

Last contribution to the plan:

(1) Date (MMDDYY) $ (2) Amount (3) For plan year ending (MMDDYY) ©
Form 5310 (Rev. 7-94) Page 3

Amount of monthly benefits as

of the most recent payment date

Total

number

14 Summary of participants or claimants by category:

a Retirees and beneficiaries (including disability retirees) receiving benefits

b Active participants eligible for normal retirement

c Active participants eligible for early (but not normal) retirement

Active participants vested before termination (other than normal or early

retirement)

d

e All other active participants

f Participants separated from service with deferred vested benefits

g Total (Add lines 14a through 14f)

Not

Applicable 15 Miscellaneous: Yes No

As a result of the termination, are accrued benefits or account balances nonforfeitable as required under

section 411(d)(3)?

a

b If annuity contracts are distributed on plan termination, are the applicable consent, present value, waiver

and other rights and benefits protected by sections 401(a)(11) and 417 included in the annuity contracts?

Do the accrued benefits for each participant upon termination include the subsidized benefits that the

participant may become entitled to receive subsequent to the termination? (See instructions.)

c

Were any funds contributed in the form of, or invested in, obligations or property of the employer or

any controlled group of corporations or group of trades or businesses under common control?

d

e Will distribution include property other than cash?

If a defined benefit or money purchase plan, do you estimate there will be an accumulated funding

deficiency as of the end of the plan year during which the proposed termination date occurs if no

additional plan contributions are made and no additional funding waiver is granted?

f

If ‘‘Yes,’’ complete the following:

(1) Estimated accumulated funding deficiency $

(2) Was a Form 5330 filed?

(3) Was a funding waiver granted?

(4) Have you attached a copy of Form 5330 or a waiver ruling?

g (1) If there are unallocated funds which can be reallocated to participants without exceeding the

limitations of section 415, have these funds been reallocated to participants?

(2) If 15g(1) is “Yes,” did the plan originally contain a provision allowing this reallocation?

(3) If 15g(2) is “No,” was the plan amended to provide for this reallocation?

h

Has the terminating plan been involved in a spinoff or other transfer of assets or liabilities, subject

to Code section 414(l), within 60 months preceding the proposed date of termination? If “Yes,”

attach a list and an explanation of the transaction(s) involved

If 15h(1) is “Yes,” answer (A) and (B):

(1)

(A) Are the accrued benefits of all participants, in the other plan(s) included in 15h(1), fully vested

and nonforfeitable as of the date of this plan termination? (See instructions.)

If any funds will be or have been returned to the employer, complete 15h(1) through 15h(10) below,

if applicable.

(2)

(4)

Was proper notice filed with the IRS on Form 5310-A?

(3) Was the only transaction in 15h(1) above, a transfer of assets before any employer reversions?

(Continued on page 4.)
Form 5310 (Rev. 7-94) Page 4

Not No Applicable Yes

Have cash distributions or guaranteed annuity contracts been provided for all accrued

benefits, as of the date of this plan termination, of all participants in the other plan(s) included

in 15h(1)? (See instructions.)

(B)

Note: Distributions generally may not be made to employed participants in nonterminating plans.

15

Have cash distributions or guaranteed annuity contracts been provided for all accrued benefits

of all participants in this plan?

Attach a statement providing the dates and amounts of these cash distributions or purchases of

annuity contracts.

If this is a defined benefit plan, is it intended, or is it a fact, that any or all of the participants in

the terminating plan will be covered by a new or existing defined benefit plan of the employer?

(5)

If ‘‘Yes,’’ does the new plan give full prior service credit for vesting and entitlement purposes?

If 15h(1) or 15h(7) is “Yes,” then—

(6)

(A) Has a Form 5300 been submitted for a determination letter for the other plan(s) involved?

Has the IRS granted approval for a change in funding method in connection with this

termination for the other plan(s) involved? If “Yes,” attach a copy of the approval letter(s)

(B)

Did the employer previously receive a reversion of assets upon termination of a defined benefit

plan in the past 15 years? If “Yes,” attach explanation

(7)

(8)

Is this plan or trust currently under examination or 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 a statement naming the agency(s) and/or court and briefly

describe the issues

Did any plan participant during the current plan year or in the 5 prior plan years, receive a single-sum

distribution (see instructions) or have an annuity contract purchased by the plan from an insurance

company on his or her behalf?

(9)

Does the value of plan assets at termination exceed the present value of a plan’s liabilities within

the meaning of section 401(a)(2)?

(10)

If the answer to 15k(1) is “Yes,” is the excess value the result of a change in the plan provisions

other than the mere termination of the plan?

If the plan has been top-heavy, have top-heavy minimum benefits accrued or minimum contributions

been made for non-key employees?

Is or was the plan integrated with social security (or railroad retirement) or does or did it provide for

permitted disparity under section 401(l)?

Does or did the plan depend on another plan to satisfy coverage or discrimination requirements under

section 401(a)(4) or 410(b)?

For defined benefit plans, specify the interest rate used for computation of single-sum distributions © %

16 For defined contribution plans enter the information for the current plan year and the 5 prior plan years on the following

schedule:

Employer contributions

Forfeitures

Attach a statement explaining the manner in which forfeitures were allocated.

Current year

17 Indicate how distributions will be made on termination (check applicable box(es)):

Single-sum distribution

Transfer of assets and liabilities to another plan Other (specify) ©

(con’t)

i

j

k

l

m

n

o

If ‘‘Yes,’’ attach plan numbers.

19 19 19 19 19 19

(1)

(2)

Participating annuity contract(s) Non-participating annuity contract(s)

a

b

ab c

d e

If “Yes,” state the largest amount so distributed or applied to purchase an annuity

contract $

Has the annual compensation of each participant taken into account under the plan been limited in

accordance with section 401(a)(17)?

Does the plan permit the direct rollover of eligible rollover distributions in accordance with section

401(a)(31)?

p

q
Form 5310 (Rev. 7-94) Page 5

18 Statement of net assets available to pay benefits as of the proposed date of plan termination.

At proposed date of termination Assets

a Total noninterest-bearing cash © a

b(1)

Receivables:

Participant contributions (2)

(3) (3) Income

(4) Other. (Attach a detailed explanation.) (4)

(5) Allowance for doubtful accounts (5)

(6) Total. Add lines 18b(1) through 18b(4) and subtract 18b(5) © (6)

c(1)

General Investments:

Certificates of deposit (2) (2)

(3) (3) U.S. Government securities

(4)(A)

(4) Corporate debt instruments:

(4)(B) (B) All other. (Attach a detailed explanation.)

(5)(A)

(5) Corporate stocks:

(5)(B) (B) Common

Partnership/joint venture interests (6) (6)

(7)(A)

(7) Real estate:

(7)(B) (B) Nonincome-producing

(8)(A)

(8) Loans (other than to participants) secured by mortgages:

(8)(B) (B) Commercial

(9)(A)

(9) Loans to participants:

(9)(B) (B) Other. (Attach a detailed explanation.)

Other loans (10) (10)

(11) (11)

(12) (12)

(13) (13)

(14) (14)

Value of funds held in insurance company general account (unallocated contracts)

Other. (Attach a detailed explanation.)

Total. Add lines 18c(1) through 18c(13) ©

d(1)

Employer-related investments: 

Employer real property © (2)

e Buildings and other property used in plan operation © e

Total assets. Add lines 18a f f , 18b(6), 18c(14), 18d(1), 18d(2), and 18e ©

Liabilities

Benefit claims payable g g

h Operating payables h

i i Acquisition indebtedness

Other liabilities j j

k Total liabilities. Add lines 18g through 18j © k

Net Assets

l Net assets. Subtract line 18k from line 18f © l

(2)

d

b

c

(2)

All “Other” items must be fully explained in an attachment.

(1) Employer securities ©

(A) Preferred

(1) Interest-bearing cash (including money market funds)

(1) Employer contributions

(A) Preferred

(A) Residential

(A) Income-producing

(A) Mortgages

Value of interest in registered investment companies

( )
Form 5310 (Rev. 7-94) Page 6

Procedural Requirements

This list identifies certain forms and information required to process your application. These items MUST be included with your

application.

Is Form 6088, Distributable Benefits from Employee Pension Benefit Plans, attached if required?

Note: Multiple-employer plans and certain collectively bargained plans may have to attach a Form 6088 for each employer

that adopts the plan.

1 Is the appropriate user fee and Form 8717, User Fee for Employee Plan Determination Letter Request, attached?

2 Is a copy of the plan attached?

3 Is a copy of the amendment(s), if any, attached?

4 Is a copy of your plan’s latest determination letter, if any, attached? If this plan is a standardized master or prototype or

regional prototype plan, is a copy of your plan’s latest opinion letter or notification letter attached?

5 Are both copies of page 1 of Form 5310 signed?

6 Is the plan sponsor’s 9-digit employer identification number entered on line 1b?

7 Is Form 2848, Power of Attorney and Declaration of Representative, attached? (See Disclosure Request by Taxpayers, on

page 1 of the separate instructions.)

8 Is the effective date of the plan entered on line 4d?

9 Affiliated service groups—Is the information requested in the instructions for line 6a attached if applicable?

10 Are copies of all records of all actions taken to terminate the plan attached?

ALL APPLICATIONS ARE SCREENED BY COMPUTER. FAILURE TO INCLUDE A REQUIRED ITEM WILL RESULT IN THE RETURN

OF THIS APPLICATION TO YOU.

11