Form 5 3 0 7 Short Form Application for OMB No, 1545-0200
Determination for Employee Benefit Plan NS ae
(Other than Collectively Bargained Plans) rile ¥

folder
Department of the Treasury (Under sections 401(a) and 501(a) of the Internal Revenue Code) number >

> Please complete every item on this form. If an item does not apply, enter N/A. If amendment, complete only pertinent parts.
Church and Governmental Plans.—All items need not be completed. See instructions "What to File.”

CAUTION: Before submitting this application, be sure that all items (other than as indicated above) are complete, that all information requested in the form
or instructions is included, and the application is signed by the employer, plan administrator, or authorized representative. If we have to request missing
information or return the application for completion, there will be a delay in processing your application.

1 (a) Name, address and ZIP code of employer 2 (a) Employer's identification number

(Rev. October 1984)

(b) Employer's tax year ends

[Telephone number > (+)
(b) Name, address and ZIP code of plan administrator, if other than employer 3 Administrator's identification number

Lelephone number ® (+)
(c) Name, address, ZIP code, and phone number of person to be contacted if more information is needed:

Name > _
Address >
4 Determination requested for:
(a) (i) O Initial qualification—date plan adopted ® o_o... eee eee eee
(ii) C1 Amendment—date adopted >
(iii) If (ii) is checked, enter file folder number >

(b) Were employees who are interested parties given the required notification of the filing of this application? ._. 0) Yes (1 No
5 Check appropriate box to indicate the type of plan entity:
(a) © Single-employer plan (4) O Church plan
(b) O Plan of controlled group of corporations, common (e) C1 Governmental plan
control employers, or affiliated service group (f) (1 Other (specify) > _
(c) (1 Multiple-employer plan
6 (a) Name of plan (b) Plannumber ® ___8 ee
(c) Planyearends >
7 (a) Thisisa: (b) Letter serial number or notification letter number
(i) 0 Master or prototype plan
(ii) 0 Field prototype plan
ii) [Other (see instructions)
8 (a) Defined benefit plan—Indicate whether:
(i) 1 Unit benefit (ii) (1 Flat benefit
(ii) OO Fixed benefit (iv) 0 Other (specify) > _
(b) Defined contribution plan—Indicate whether:
(i) (2 Profit-sharing (ii) (1 Stock bonus
(ii) 1 Money purchase (iv) O Target benefit
(c) (i) 8a) (i), (ii), (ill), oF (iv) is checked, is this a defined benefit plan covered (ii) If 4(@) (ii) and 8(b) (i), (ii), (iii), or (iv) are checked, was the
under the Pension Benefit Guaranty Corporation termination insurance plan covered by the termination insurance program before
pogem" 1 Yes [1 No [1 Notdetermined theamendment? O Yes 0 No
9 Effective date of plan 10 Effective date of amendment

11 Date plan was communicated to employees P ______ een eee eee eee eee
How communicated >

12 __ Integration: Is this plan integrated with social security or railroad retirement (see instructions)? . . . . . . . O1 Yes [J No
13 Type of funding entity:

(a) O Trust (c) 1 Non-trusteed

(b) (1) Custodial account (d) C1 Trust with insurance contracts

Under penalties of perjury, | 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 > Title > Date >

Signature & Title > Date >

For Paperwork Reduction Act Notice, see page 1 of the instructions. Form 5307 (Rev. 10-84)


Form 5307 (Rev. 10-84)

Page 2

14 (a) Does plan provide for maximum limitation under section 415? (see instructions) . . O Yes 1 No
(b) Do you maintain any other qualified plan(s)? (see instructions) . we _ _O Yes [1 No
15 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? . O Yes O No
If Yes,” attach explanation
Yes | No Not Certain
16 (a) (i) __ Is the employer a member of an affiliated service group? . .
If there is uncertainty whether the employer is a member of an affiliated : service e group,
check the ‘‘Not Certain’’ column.
(ii) \f 16(a)(i) is “Yes,” or ‘Not Certain,’ did a prior ruling or determination letter rule on
what organizations were members of the employer's affiliated service group?
(see instructions)
(iii) \f (ii) is ‘“Yes,"’ have the facts on which that letter w was ‘based materially changed?
(see instructions) .
(b) Is the employer a member of a controlled group sof corporations oragroup of trades 0 or
businesses under common control?
Number

17 Coverage of plan at (give date) > _
(a) Total employed .
(b) Exclusions under plan (do not count a an employee more than once)

(i) Minimum age (specify) ® ______.....------ Years of service (speci) P >
(ii) Employees included in collective bargaining
(iii) Nonresident aliens who receive no earned income from United States sources

(©) Total exclusions (add (b)(i) through (iii)) .
(d) Employees not excluded under the statute (subtract © from @) .
(e) Ineligible under plan because of (do not count an employee included in (b)):

(i) Minimum pay (specify) ® _____. 2-2-2 een ene nee eee eee eee eee ee

(ii) Hourly-paid

(iii) | Maximum age (specify) >

(iv) Other (specify) >
(f) Total employees ineligible (add (e)(i) through (iv))
(g) Employees eligible to participate (subtract (f) from (d))
(h) Number of employees participating in plan Co
(i) Percent of nonexcluded employees who are participating (divide (hy by @) re %

(11TTe#

U7 UT

Complete (j) only if (i) is less than 70%; complete (k) only if (j) is 70% or more.
(j) Percent of nonexcluded employees who are eligible to participate (divide (g) by(d)) . . %

(k) Percent of eligible employees who are participating (divide(h)by(g)) . . ..... %
If (i) and (j) are less than 70%, or (k) is less than 80%, see instructions.
(1) Total number of participants, including certain retired and terminated employees (see instructions)

18 Vesting—Check the proper box for the vesting provisions of the plan:

(a) OO Fulland immediate

(b) C1 Full vesting after 10 years of service (see instructions)

(c) 0 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 (see instructions)
0 Rule of 45 (section 411(a)(2)(C)) (see instructions)

CO For each year of employment, beginning with the 4th 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) (1 Other (specify and see instructions) >

(d)
(e)

19 Complete only for a plan of more than one employer:
(a) Total number of participants (including certain retired and terminated employees)
(b) Participants whose benefits or accounts are fully vested woe ee
(c) Number of contributingemployers . 2 6. 1 1 ee ee ee

20 Isthe plansponsoranSCorporation?. . . . ......=.=.~.~.~.~. =~. ~.2) Yes [J No

UL,