Form 5307 - Application For Determination For Adopters Of Master Or Prototype Or Volume Submitter Plans Form - Internal Revenue Service Page 3

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3
Form 5307 (Rev. 3-2008)
Page
4a
Name of plan (If plan name exceeds 70 characters, including spaces, see instructions):
b
Enter 3-digit plan number (See instructions)
c
Enter month 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)
4 — defined benefit but not cash balance
(See instructions)
2 — money purchase
3 — target benefit
5 — 401(k) safe harbor
Yes
No
Is the employer a member of an affiliated service group?
6a
Is the employer a member of a controlled group of corporations or a group of trades or businesses under
b
common control?
If 6a and/or 6b is “Yes,” see instructions.
Is this a master or prototype plan?
7a(1)
a(2)
a(3)
If “Yes,” Date of Opinion letter
Serial Number
Is this a volume submitter plan?
b(1)
b(2)
b(3)
If “Yes,” Date of Advisory letter
Serial Number
Are there modifications to the volume submitter plan or are there addenda to the adoption agreement?
c
Are there any “Other” boxes selected in the adoption agreement? (See instructions)
d
8a
Is this a governmental plan?
If “Yes,” is the plan a state level plan?
b
c
Is this a nonelecting church plan?
d
Is this a collectively bargained plan? (See Regulations section 1.410(b)-9)
5307
Form
(Rev. 3-2008)
*11832Y03200803*

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