Form 5300 (10-75)

23

Yes | No
Miscellaneous:

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

(b) Have you completed and attached Form 5302? .

(c) Is the adopting employer a member of a controlled group of corporations ¢ or under commonly
controlled trades or businesses?
If “Yes,” see specific instructions.

(C)

Corporation or any Court? . .

If “Yes,” attach explanation.

Other qualified plans—Enter for each other qualified plan you maintain (do not include plans that were estab-
lished under union-negotiated agreements that involved other employers):

(i) Name of plan >...
(ii) Type of plan >...
(ili) Rate of employer contribution, if fixed >.
(iv) Benefit formula or monthly benefit p>.
(v)_Number of participants >

e)

YW,

gy
Is any issue relating to the qualification of this plan or exemption of the trust currently pending |// 7) ae
before the Internal Revenue Service, the Department of Labor, the Pension Benefit Guaranty

Page 4

GOVERNMENT
USE ONLY

No

x
®
&

In the case of a request on an initial qualification, have the following documents been included with

the application as required by instructions:

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

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

(c) Specimen copy of each type of individual insurance contract? .

(d) Balance sheet of the trust or custodial account? . . . .

(e) Statement of receipts and disbursements of the trust or custodial account? .

(f) Evidence that retirement benefits were the subject of good faith bargaining between "employee
representatives and employer(s)?. . . . . oe ee soe

(g) Specimen copy of formal announcement containing detailed description to employees? .

(h) 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 factors,
and the basis of any insured costs or liabilities involved therein) explaining their source and
application in detail to permit ready analysis and verification? . Coe ee

(i) Actuarial report? . . . ee ee ee

ll TTT
So

WH,

NY
.

25

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

ments been included:

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

(b) A description of the amendment covering the i items changed 2 and an 1 explanation of ‘the provi-
sions before and after the amendment? .

(c) Balance sheet of the trust or custodial account? .

(d) Statement of receipts and disbursements of the trust or custodial a account? .

(e) A completely restated plan? * . . oo

(f) Aworking copy of the plan in which there has s been incorporated all loft the previous ‘amendments
representing the provisions of the plan as currently in effect? *

(g) 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? * .

(h) Specimen copy of formal announcement containing description to employees?

* 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 re-
stated plan was submitted, one of the documents specified under (e) or (f) must be attached.

a

an

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.

‘¢ US, GOVERNMENT PRINTING OFFICE : 1975—-O-548-231

16—82550-1


rom 9300 Application for Determination for Defined Benefit Plan This Form is Open

(Getover, 1975) 5 For Pension Plans Other Than Money Purchase Plans to Public Inspection
Tatenal Revenue Service (Under sections 401(a), 414(j) and 501(a) of the Internal Revenue Code of 1954) File in Duplicate
1 (a) Name, address and ZIP code of employer 2 Employer's identification number

3 Business code number (see instructions)

. ____| 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) [J Initial qualitication—date plan adopted . (ii) [J] Amendment—date adopted m.
(b) Were employees who are interested parties given the required Notification of the filing of this application? . Oo Yes [] No
(©) 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) [] Corporation (b) [] Subchapter $ corporation  (c) [-] Sole proprietor (4) [7] Partnership

(e) [1] Tax exempt organization (f) ([] Other (specify) > .
8 (a) Name of Plan (b) Plan number >... (c) Plan yearends &.. wees
(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), enter name of such plan (b) Opinion letter serial number

(c) If this is not an adoption of a master or prototype plan, is the plan and trust (or custodial account) agree-
ment patterned after and substantially the same as another plan and trust (or custodial account) agreement
which conforms to the participation and vesting standards of the Employee Retirement Income Security Act

of 1974 and on which a favorable determination or opinion letter was issued? . . . . . . . - +] Yes [] No
If “Yes,” see specific instructions.
10 (a) Type of plan: (i) [] Fixed bent (b) Does plan provide for variable benefits? (J Yes [] No
ii) (I) Unit benefit (iii) [) Flat benefit If “‘Yes,"" check appropriate box to indicate type.
(iv) [[) Other (specify) > (i) Cost of living (ii) [] Asset fluctuation
(iii) [[] Other (specify) >
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
section and page number of plan or trust where each provision is contained: page number

GOVERNMENT
USE ONLY

(i) [7 All employees (v) Length of service (number of years) >...
(ii) [] Hourly rate employee only (vi) Minimum age (specify) >
(ii) [J Salaried employee only (vii) Maximum age (specify) >
(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 >
(a) Total employed (if a Keogh plan, include all self-employed individuals). See specific instruc-
tions for item 23(c) 2 6 6 ee ee ee
(b) Exclusions under plan (do not count an employee more than once): WY,
(i) Minimum age or years of service required (specify) > a eee
(ii) Employees included in collective bargaining (see specific instructions) .
(iii) Nonresident aliens who receive no earned income from United States sources .
(c) Total exclusions, sum of (b)(i) through
(d) Employees not excluded by statute, (a) tess ©

Under penalties of perjury, 1 declare that | have examined this application, including accompanying statements, and to the best of my Wowledge end boliot is tue, correct
and complete,

Number

Signature pp. Title pp. Date pp.

Signature p> Title pp. Date pp.

16—82550-1


Form 5300-(10-75)

Page 2

(Section references are to the Internal Revenue Code)

Section and || GOVERNMENT
page number USE ONLY

15 Coverage (continued):

(e) Ineligible under plan on account of (do not count an employee included in (b)):

(i) Minimum pay
(ii) Hourly-paid
(iii) Maximum age .
(iv) Other (specify)

(f) Employees ineligible, sum of (e)(i) through wv).

(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, ) + @ .
Complete (j) only if (i) is less than 70% and complete (k) only if (j) is 70% or more .

: %

(i) Percent of nonexcluded employees who are eligible to participate, (g) = (d) a
(i) Percent of eligible employees who are participating (h) + (g) - .
If (i) and (j) are less than 70% or (k) is less than 80%, see instructions . \//Ml, Wii
(1)_Total number of participants, include certain retired and terminated employees, see instructions _. U
Yes |_No

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

plans?
(©) Are benefits unaffected by forfeitures?

17 Employer contributions:
(a) [J Full amount —(b) [Balance necessary
(c) Are employer contributions reduced by forfeitures?

18 Integration: Yes
Is this plan integrated with Social Security or Railroad Retirement? . . i
If “Yes,” see specific instructions. WUAWMA,

19 Vesting:

(a) Vesting Schedule—Check the appropriate box to indicate the vesting provisions of the plan:

(i) Full and immediate
(i) ©] Full vesting after 10 years of service

(iii) [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
(iv) [] Rule of 45 (see section 411(a)(2)(C))

(v) ([] For each year of service, 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

(vi) [] Other (specify) >

If box (a)(v) or (vi) was checked, check whether you include the following |

years of service under the vesting provisions of the plan:

(i) Years of service before age 22 .

(ii) Years of service for a period during which the employee declined to con-
tribute to plan requiring employee contributions .

(iii) Years of service during which the employer did not maintain the plan ora
predecessor plan .

(iv) Years of service excluded under s section 1 411(@)6) -

(v) Years of service described in section 411(a)(4)(E) .

(vi) Years of service described in section 411(a)(4)(F)_.

(b)

Yes

L

No

20 Administration:
(a) Type of funding entity: (i) [] Trust

(D Non-trusteed

(ii) [] Custodial account (iv) [] Trust with insurance contracts

If you checked (i) or (ii), enter date executed >.
(b) Enter name and identifying number of fiduciary (trustee or custodian), if any >

16—82550-1


Form 5300-(10-75) Page 3
——

ves | no | Siavenent. [ eRueraNsTM
20 Administration (continued):
(d) Does trust agreement prohibit reversion of funds to the employer? .
(e) If borrowing on insurance contracts is permitted, is it on a pro-rata basis and
only for payment of premiums? .
(f) If Puerto Rican trust, does it quality for tax exemption ‘under the laws of
Puerto Rico? eee .
21 Benefits:
(a) Normal retirement age is P .......... State years of service required > .

(b) Benefit at normal retirement age is >

|

(c) If benefits are measured by years of service—
(i) Are the years of service for eligibility purposes included in credited service?
(ii) 1s only service as a common-law employee recognized? .
(d) Are benefits computed on the basis of total compensation? .
If “No,” see specific instructions.
(e) Early retirement age is > ........
(f) Benefit at early retirement age is >

is

. State years of service required > .

|

(g) If employer's consent is required for early retirement, are benefits limited to
vested interest? . . . - . - so woe ee

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

(i) If the plan defers compensation generated increases until compensation in-
creases sufficiently, does plan Provide forir increases of benefits of at least $10
permonth?. .

(i) If participants may withdraw their contributions or earnings, may yy such withdraw-
al be made without forfeiting vested benefits based on employer contributions? .

(i) Is duplication of benefits upon re-entry into the plan prohibited? . .
(I) 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 benefit as if the plan had terminated? . rearanrnerraananns

(m) Is there a disability benefit underthe plan?. . . . .
(n) Normal form of retirement benefits is > _

7
|

i

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

(p) Does plan prohibit distribution of benefits except for retirement, disability or
termination of employment or, in case of self-employed individuals, after
age 59447. . 2.

(q) 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 com-
menced participation or (3) the close of the plan year in which the Participant
terminates his service ‘with the employer? .

(®) Does the plan prohibit the assignment or alienation of benefits?
(s) Does the plan preclude divestment for cause? . :
(t) Does the plan provide for a death benefit before retirement? .
If “Yes,” indicate whether such benefits are limited to—
(i) [] 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 ».

Y
22 Termination of plan or trust: WU

(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?

(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)? . . . . . .
(d)_Have the plan benefits been increased since the plan’s inception?

~
i

16-82550-1