Form 5300

(Rev. April 2011)

Department of the Treasury 

Internal Revenue Service

Application for Determination for 

Employee Benefit Plan

See separate instructions.

OMB No. 1545-0197

Review the Procedural Requirements Checklist before submitting this application. For Internal Use Only

1a Number Assigned under Section 6.19 

of Revenue Procedure 2008-6 —

1b Name of plan sponsor (employer if single-employer plan)

1c Address of plan sponsor (if a P.O. Box, see instructions) 1d City 1e State 1f Zip Code

1g Country

1h Employer identification number (EIN) 1i Telephone number 1j Fax number 1k Employer’s tax year ends

2a Person to contact if more information is needed. (See instructions.) 

(If a Power of Attorney is attached, check box, and do not complete this line.)

Contact person’s name

2b Contact person’s address 2c City 2d State 2e Zip Code

2f Telephone number 2g Fax number

If more space is needed for any item, attach additional sheets the same size as this form. Identify each additional sheet with 

the plan sponsor’s name and EIN and identify each item.

Under penalties of perjury, I declare that I have examined this application, including accompanying statements and schedules, and 

to the best of my knowledge and belief, it is true, correct, and complete.

SIGN HERE ▶ Date ▶

Type or print name Type or print title

For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions. Cat. No. 11740X Form 5300 (Rev. 4-2011)
Form 5300 (Rev. 4-2011) Page 2

3a Determination requested for (enter applicable number in box) (See instructions.)

1 - Initial qualification

2 - Request after initial qualification

3 - Affiliated Service Group (ASG) status (IRC section 414(m))

4 - Leased employee status (IRC section 414(n))

5 - Partial termination

6 - Termination of collectively bargained multi-employer or 

multiple-employer plan covered by PBGC insurance

b (i) If line 3a is 1, enter the effective date of the plan

(ii) If line 3a is 1, enter the date the plan was signed

(iii) If line 3a is 2, enter the effective date of the restatement 

c If line 3a is 5, enter the effective date of the partial termination

d If line 3a is 6, enter the effective date of termination

e Enter number of amendments included 

f Enter the date the amendment(s) were signed (If more than 4, see instructions)

(i) (ii) (iii) (iv)

g Enter the date the amendment(s) were effective (If more than 4, see instructions)

(i) (ii) (iii) (iv)

Yes No

h Has the plan received a determination letter?

If “No,” submit copies of all prior plan(s) and/or adoption agreement(s) and/or amendments. (See instructions.)

i If 3h is “Yes,” enter the date of the latest letter

j Enter the number of amendments since the last determination letter. 

k Was this plan a prior adopter of a pre-approved plan? (See instructions.)

l If line 3k is “Yes,” enter the Serial Number.

m If line 3k is “Yes,” was the sponsor authorized to adopt amendments?

n Have interested parties been given the required notification of this application? (See instructions.)

o Does the plan have a cash or deferred arrangement (section 401(k) or 414(x))?

p Does the plan have matching contributions (section 401(m))?

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3 (continued)

Yes No

q Does the plan have after-tax employee voluntary contributions (section 401(m))?

r Does the plan benefit noncollectively bargained employees or are more than 2% of the employees who are 

covered under a collectively bargaining agreement professional employees? See Regulations section 1.410(b)-6(d).

s Does the plan utilize the permitted disparity rules of section 401(l) when allocating contributions or benefits?

t Is the plan being filed “on-cycle” pursuant to Section 13 of Revenue Procedure 2007-44?

If “Yes,” indicate the cycle the plan is being submitted in

If “No,” skip to question v.

Enter the applicable number in the box to indicate the reason the plan was submitted in the cycle listed above.

1 - Last digit of the EIN.

2 - Multiple employer plan.

3 - Governmental plan including governmental multiple employer plan.

4 - Multi-employer plan.

5 - Pre-approved plan filing in the 2-year Remedial Amendment Cycle window (including special ASG leased 

employee or partial termination) rulings.

6 - Cycle changing event (enter date and attach explanation of cycle changing event).

u Is the EIN of the parent company, jointly trusted single employer collective bargained plan (if the plan sponsor is 

the Joint Board of Trustees include the EIN of the Form 5500), or centralized organization (include the EIN of the 

centralized organization if that organization handles the administration and operations of the plan) being used?

(See instructions.)

(1) If line 3u is “Yes,” enter the EIN of parent, Joint Board 

of Trustees, or centralized organization.

v If 3t is “No,” are you requesting priority considerations as specified in Section 14.02 of Revenue Procedure 

2007-44? 

If “Yes,” indicate the cycle the plan is being submitted in

Enter the applicable number in the box for the reason the plan was submitted in the cycle listed above.

1 - New plan exception.

2 - Urgent business need.

3 - Cycle changing event (date and explanation of cycle changing event).

w Is this plan an offset arrangement with any other plan? (If “Yes,” attach a separate statement providing the 

name, EIN, the plan provision, and type of the other plan including plan sections that is part of the 

arrangement.) (See instructions.)

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4a Name of plan (If plan name exceeds 70 characters, including spaces, see instructions):

b Enter 3-digit plan number (See instructions.)

c Enter the month on which the plan year ends

d Enter plan’s original effective date

e Enter number of participants (See instructions.)

5 Indicate type of plan by entering the number from the list below:

1 — profit sharing and/or 401(k)

2 — money purchase

3 — target benefit

4 — defined benefit but not cash balance

5 — cash balance (See instructions.)

6 — leveraged ESOP

7 — non-leveraged ESOP (See instructions.)

8 — stock bonus

9 — safe harbor 401(k)

If this plan contains any ESOP provisions, do not use 1 or 2, use 6 or 7, as applicable.

Yes No

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

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

control? If 6a and/or 6b is “Yes,” see instructions.

c Were elections made to use “Cycle A” per Section 9 of Revenue Procedure 2007-44? (See instructions.)

7a Is this a governmental plan? Date of last legislative session.

b If line 7a is “Yes,” is the plan a state level plan?

c Is this a nonelecting church plan?

d Is this a collectively bargained plan? (See Regulations section 1.410(b)-9)

e Is this a section 412(e)(3) plan?

f Has this plan been involved in a merger which was not considered in a prior favorable determination letter?

g Has the plan been amended or restated to change the type of plan?

h Is this a multiple employer plan?

If line 7h is “Yes,” enter the total number of participating employers.

i If line 7h is “Yes,” enter the number of participating employers currently being submitted.

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7 (continued)

j (i) If line 7h is “Yes,” enter the EIN of the employer submitting the lead plan.

(ii) If line 7h is “Yes,” enter the plan number of the lead plan.

k Is this a multi-employer plan as described in section 414(f)?

l Is this a request for a ruling under section 401(h) or section 420?

m Is this considered a foreign plan or is the trust a foreign trust?

If 7f, 7g, 7h, 7i, 7k, 7l, or 7m is “Yes,” see instructions.

Yes No

8a Do you maintain any other qualified plan(s) under section 401(a)? If “Yes,” attach required statement per 

instructions. If “No,” skip to line 8d.

b 

Do you maintain another plan of the same type (for example, both this plan and the other plan are defined 

contribution plans or both are defined benefit plans) that covers non-key employees who are also covered under 

this plan?

If “Yes,” when the plan is top-heavy, do the non-key employees covered under both plans receive the required 

top-heavy minimum contribution or benefit under (see instructions):

(1) This plan?

(2) The other plan?

c If this is a defined contribution plan, do you maintain a defined benefit plan (or if this is a defined benefit plan, do 

you maintain a defined contribution plan) that covers non-key employees who are also covered under this plan?

If “Yes,” when the plan is top-heavy, do the non-key employees covered under both plans receive (see instructions):

(1) The top-heavy minimum benefit under the defined benefit plan?

(2) At least a 5% minimum contribution under the defined contribution plan?

(3) The minimum benefit offset by benefits provided by the defined contribution plan?

(4) Benefits under both plans that, using a comparability analysis, are at least equal to the minimum benefit?

d Does the plan prevent the possibility that the section 415 limitations will be exceeded for any employee who is 

(or was) a participant in this plan and any other plan of the employer?

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9 General Eligibility Requirements

a Check all that apply:

(1) All employees

(2) Hourly rate employees

(3) Salaried employees

(4) Other: (Specify in box below)

b Minimum years of service required to participate. If no minimum, check

c Minimum age required to participate. If no minimum, check

10 Vesting Indicate the regular (non-top heavy) vesting provisions of the plan by entering the letter from the 

list below:

a – Full and immediate

b – Full vesting after 2 years 

of service

c – Full vesting after 3 years of service

d – Full vesting after 5 years of service

e – 2 to 6 year graded vesting

f – 3 to 7 year graded vesting

g – Other

11 Benefits and Requirements for Benefits

a For defined benefit plans - Method for determining accrued benefit:

(1) Benefit Formula at early retirement age is

(2) Benefit Formula at normal retirement age is

(3) Normal form of retirement benefit is

b For defined contribution plans - Employer contributions:

(1) Profit Sharing or stock bonus plan contributions are determined under (check box):

A definite formula A discretionary formula Both

(2) Matching contributions are determined under, check box:

A definite formula A discretionary formula Both

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11b (continued)

(3) Money purchase plan - Enter rate of contribution

(4) Target benefit plan - State target benefit formula

Indicate the plan section where the allocation/benefit formula is located in the plan document.

12 Miscellaneous

N/A Yes No

a 

Does any amendment to the plan reduce or eliminate any section 411(d)(6) protected benefit including an 

amendment adopted after September 6, 2000, to eliminate the joint and survivor annuity form of benefit? 

(See instructions.)

b Are trust earnings and losses allocated on the basis of account balances in a defined contribution plan? If 

“No,” attach a statement explaining how they are allocated.

c Is this plan or trust currently under examination or is any issue related to this plan or trust currently pending before the:

Yes No

(1) Internal Revenue Service,

(2) Department of Labor,

(3) Pension Benefit Guaranty Corporation,

(4) Voluntary Compliance Resolution Program of the Employee Plans Compliance Resolution System (EPCRS), or 

Employee Benefits Security Administration,

(5) Any Court?

If “Yes,” attach a statement explaining the issues involved and the contact person’s name (IRS Agent, DOL Investigator, etc.) 

and telephone number.

Determination request regarding the ratio percentage test. A determination regarding the average benefit test may be 

requested by attaching Schedule Q (Form 5300), Elective Determination Requests. See instructions.

Yes No

13 Is this a request for a determination regarding the ratio percentage test of Regulations section 1.410(b)-2(b)(2) or a 

request for a determination regarding one of the special requirements of Regulations section 1.410(b)-2(b)(5), (6), or (7)?

If “Yes,” complete only lines 13a through 13n for a ratio percentage test determination or complete only line 

13o for a determination regarding one of the special requirements. If “No,” skip to line 14.

Yes No

a Is this plan disaggregated into two or more separate plans that are not section 401(k), 401(m), or profit sharing 

plans? If “Yes,” see the instructions and attach separate schedules for each disaggregated portion.

b Does the employer receive services from any leased employees as defined in section 414(n)?

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13 (continued)

c Coverage date (MMDDYYYY). See instructions for inserting date . . . . . . . . . . . .

d Total number of employees (include self-employed individuals) (employer-wide) . . . . . . .

e Statutory and regulatory exclusions under this plan (do not count an employee more than once):

(1) Number of employees excluded because of minimum age or years of service required . . . .

(2) Number of employees excluded because of inclusion in a collective bargaining unit . . . . .

(3) Number of employees excluded because they terminated employment with less than 501 hours of 

service and were not employed on the last day of plan year . . . . . . . . . . . . .

(4) Number of employees excluded because employed by other qualified separate lines of business 

(QSLOBs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(5) Number of employees excluded because they were nonresident aliens with no earned income 

from sources within the United States . . . . . . . . . . . . . . . . . . . .

f Total statutory and regulatory exclusions (add lines 13e(1) through 13e(5)) . . . . . . . . .

g Nonexcludable employees (subtract line 13f from line 13d) . . . . . . . . . . . . . .

h Number of nonexcludable employees on line 13g who are highly compensated employees (HCEs) .

i Number of nonexcludable HCEs on line 13h benefiting under the plan . . . . . . . . . .

j Number of nonexcludable employees who are nonhighly compensated employees (NHCEs) (subtract 

line 13h from line 13g) . . . . . . . . . . . . . . . . . . . . . . . . . .

k Number of nonexcludable NHCEs on line 13j benefiting under the plan . . . . . . . . . .

l Ratio percentage (see instructions) . . . . . . . . . . . . . . . . . . . . . .

m Enter the ratio percentage for the following, if applicable:

(1) Section 401(k) part of the plan . . . . . . . . . . . . . . . . . . . . . .

(2) Section 401(m) part of the plan . . . . . . . . . . . . . . . . . . . . . .

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13 (continued)

Yes No

n Are the results on line 13l or 13m based on the aggregated coverage of more than one plan? If “Yes,” attach a 

statement listing the names, plan numbers, EINs, and benefit/allocation formula of the other plans. All on-cycle 

individually designed aggregated plans should be filed concurrently.

o If the plan satisfied coverage using one of the special requirements of Regulations section 1.410(b)-2(b)(5), (6), or (7), enter the 

letter from the list below that identifies the special rule.

A = 1.410(b)-2(b)(5) - No NHCEs employed

B = 1.410(b)-2(b)(6) - No HCEs benefit

C = 1.410(b)-2(b)(7) - Collectively bargained only

Determination request regarding the nondiscrimination design-based safe harbors of section 401(a)(4). See instructions.

Yes No

14 Is this a request for a determination regarding a design-based safe harbor under section 401(a)(4)? If 

“Yes,” complete a-d. 

Note. Section 401(k) and/or section 401(m) plans that do not contain a provision for discretionary 

contributions should not complete this line.

Design-based nondiscrimination safe harbors:

a Does the plan provide for disparity in contributions or benefits that is intended to meet the permitted disparity 

requirements of section 401(l)? If “Yes,” answer line 14b. Otherwise, skip to line 14c.

b Do the provisions of the plan ensure that the overall permitted disparity limits will not be exceeded?

c Enter the letter (“A” - “G”) from the list below that identifies the safe harbor intended to be satisfied.

A = 1.401(a)(4)-2(b)(2) defined contribution (DC) plan with uniform allocation formula

B = 1.401(a)(4)-3(b)(3) unit credit defined benefit (DB) plan

C = 1.401(a)(4)-3(b)(4)(i)(C)(1) unit credit DB fractional rule plan

D = 1.401(a)(4)-3(b)(4)(i)(C)(2) flat benefit DB plan

E = 1.401(a)(4)-3(b)(5) insurance contract plan

F = 1.401(a)(4)-8(b)(3) target benefit plan

G = 1.401(a)(4)-8(c)(3)(iii)(B) cash balance plan

d List the plan section(s) that satisfy the safe harbor (including, if applicable, the permitted disparity requirements):

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Form 5300 (Rev. 4-2011) Page 10

Procedural Requirements Checklist

Use this list to ensure that your submitted package is complete. Failure to supply the appropriate information may result in a delay in 

the processing of the application.

1. Is Form 8717, User Fee for Employee Plan Determination, Opinion, and Advisory Letter Request, attached to your 

submission?

2. Is the appropriate user fee for your submission attached to Form 8717?

3. If appropriate, is Form 2848, Power of Attorney and Declaration of Representative, Form 8821, Tax Information 

Authorization, or a privately designed authorization attached? (For more information, see the Disclosure Request by 

Taxpayer in the instructions and Rev. Proc. 2011-4, 2011-1 I.R.B. 123.)

4. Is a copy of your plan’s latest determination letter, if any, attached?

5. Have you included a copy of the plan, trust, and all amendments since your last determination letter?

6. Is the EIN of the plan sponsor/employer (NOT the trust’s EIN) entered on line 1h?

7. Does line 4d provide the plan’s original effective date?

8. Is the application signed and dated? (Stamped signatures are not acceptable; see Rev. Proc. 2011-4.)

9. Have interested parties been given the required notification of this application? Make sure line 3n is completed. (See 

instructions.)

10. If you are requesting a determination for an Affiliated Service Group Status, have you included the information requested 

in the instructions?

11. If you answered “Yes” to line(s) 6a and/or 6b, have you included the information requested in the instructions?

12. For Multiple Employer Plans: Have you included the required information as specified in the instructions under Specific 

Plans—Additional Requirements?

13. For Partial Termination Requests: Have you included the required information as specified in the instructions under

Type of Determination Letter Requested, Partial Termination?

14. If you answered “Yes” to line 8a, have you included the requested information?

15. If lines 13 and 14 are “No,” and you are requesting additional determinations, are Schedule Q (Form 5300) and the 

applicable demonstrations attached? (See instructions for Schedule Q.)

Demo 1

Demo 3

Demo 4

Demo 5

Demo 6

Demo 7

Demo 8

Demo 9

Demo 10

Demo 11

Form 5300 (Rev. 4-2011)
Form 5300 (Rev. 4-2011) Page 11

Procedural Requirements Checklist (continued)

16. For Employee Stock Ownership Plans (ESOP): Have you attached Form 5309, Application for Determination of

Employee Stock Ownership Plan, to your submission?

17. For Pension Benefit Guaranty Corporation Terminations (PBGC): Have you included the required information as

specified in the instructions under Type of Determination Letter Requested?

18. Have you included the signed and dated Form 8905, Certification of Intent To Adopt a Pre-approved Plan, if applicable?

Form 5300 (Rev. 4-2011)