Form 5310-A - Notice Of Merger, Consolidation Or Transfer Of Plan Assets Or Liabilities

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Notice of Merger, Consolidation or Transfer

OMB No. 1545-1225

Expires 4-30-94

of Plan Assets or Liabilities

(Under section 6058(b) of the Internal Revenue Code)

For Agency Use Only

File Form 5310-A in duplicate.

Department of the Treasury

See the Who Must File instructions before filing this form.

Internal Revenue Service

The information provided on this form will be read by computer. Therefore page 1 must be typed (except the signature). Please

enter information exactly as requested and only in the space provided. Do not type in shaded areas.

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

1b Employer identification number

Address (number, street, room, or suite no. (If a P.O. box, see page 1 of the instructions)

Employer’s tax year ends—N/A or (MM)

City

State

ZIP code

Telephone number

(

)

Person to be contacted if more information is needed. (If same as 1a, leave blank.)

(Complete even if Power of Attorney is attached):

Name

Address (number, street, room, or suite no. (If a P.O. box, see page 1 of the instructions)

Telephone number

City

State

ZIP code

(

)

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

Enter plan number (3 digits)

Enter date plan effective (MMDDYY)

Enter date plan year ends (MMDD)

Enter number of participants in plan

If this is a defined benefit plan, enter the appropriate number in box at left AND attach an actuarial statement of valuation

showing compliance with the requirements of Code section 401(a)(12) and the regulations under section 414(l).

Enter 1 for unit benefit

Enter 3 for flat benefit

Enter 2 for fixed benefit

Enter 4 for other (specify)

If this is a defined contribution plan, enter the appropriate number in box at left AND attach an actuarial statement of

valuation showing compliance with the requirements of Code section 401(a)(12) and the regulations under section 414(l).

Enter 1 for profit sharing

Enter 4 for target benefit

Enter 2 for stock bonus

Enter 5 for other (specify)

Enter 3 for money purchase

Is the employer a member of an affiliated service group?

Enter 1 if “Yes”

Enter 2 if “No”

Enter 3 if “Not Certain”

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”

Enter type of plan:

Enter 1 if governmental plan or church plan not subject to ERISA

Enter 2 if multiple employer plan (described in section 413(c)). Enter number of participating

employers

Enter 3 if other

Other plan(s) involved in transaction (see instructions):

Plan name

Name of employer

Employer Identification number

Plan number (3 digits)

Date of merger, consolidation or transfer (MMDDYY)

Type of plan

. Enter the number to indicate type of plan:

1 defined benefit,

2 401(k) arrangement,

3 ESOP

4 money purchase, or

5 Other.

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

5310-A

For Paperwork Reduction Act Notice, see page 1 of the instructions.

Cat. No. 12783Y

Form

(5-91)