Form 5307 - Application For Determination For Adopters Of Master Or Prototype Or Volume Submitter Plans Form - Internal Revenue Service Page 5
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95
Form 5307 (Rev. 3-2008)
Page
Yes
No
Does any amendment to the plan reduce or eliminate any section 411(d)(6) protected benefit including an
10a
amendment adopted after September 6, 2000, to eliminate the joint and survivor annuity form of benefit?
(See instructions)
Are trust earnings and losses allocated on the basis of account balances in a defined contribution plan?
b
If “No,” attach a statement explaining how they are allocated.
Is this plan or trust currently under examination or is any issue related to this plan or trust currently pending
before the:
c
Internal Revenue Service,
Department of Labor,
d
Pension Benefit Guaranty Corporation,
e
Voluntary Compliance Resolution Program of the Employee Plans Compliance Resolution System
f
(EPCRS), or
g
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.
Optional determination request regarding the ratio percentage test. A determination regarding the average benefit test may
be requested by attaching Schedule Q (Form 5300). (See instructions)
Is this a request for a determination regarding the ratio percentage test of Regs. section 1.410(b)-2(b)(2) or a
11
request for a determination regarding one of the special requirements of Regs. section 1.410(b)-2(b)(5), (6), or
(7)? If “Yes,” complete only lines 11a through 11n for a ratio percentage test determination, or complete only
line 11o for a determination regarding one of the special requirements.
If “No,” skip to line 12.
Is this plan disaggregated into two or more separate plans that are not section 401(k), 401(m), or profit sharing
a
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)?
c
Coverage date (MMDDYYYY). See instructions for inserting date.
d
Total number of employees (including 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 the plan year
5307
Form
(Rev. 3-2008)
*11832Y03200805*
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