Form 5625 - Employee Benefit Plan Joint And Survivor
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1
2Employee Benefit Plan
Joint and Survivor
(Worksheet Number 3 – Determination of Qualification)
The technical principles in this worksheet
INSTRUCTIONS – All items must be completed. A “Yes” answer generally indicates a
may be changed by future regulations or
favorable conclusion is warranted while a “No” answer indicates a problem exists. Please use
guidelines
the space on the worksheet to explain any “No” answer. See Publication 6391, Explanation
Name of Plan
Number 3, for guidance in completing this form.
Plan Reference
Yes No N/A
I.
APPLICABILITY
a.
Is the plan a defined contribution plan (other than a money purchase or target
benefit plan) that provides that the surviving spouse or, if the surviving spouse consents,
a designated beneficiary, shall upon the participant’s death receive the full nonforfeitable
accrued benefit of the participant? (If “Yes,” answer (b); if “No,” go to II.) [350]
b.
Is this a plan that:
(i)
offers benefits in the form of a life annuity, or [351]
(ii) is a transferee of benefits from a plan subject to sections 401(a)(11), and 417,
or [352]
(iii) offsets benefits under a defined benefit plan? [353]
(If the answer to b.(i), (ii), or (iii) is “Yes,” see Explanations and go to II; if “No,” do not
complete the rest of this worksheet.)
II.
JOINT AND SURVIVOR BENEFITS
a.
Does the plan provide for the payment of benefits in the form of a qualified joint and
survivor annuity (QJSA) in the case of a vested participant who survives until the
annuity starting date? [354]
b.
If the plan provides for disability benefits that are not auxiliary benefits, does the
plan treat the first day of the first period for which these benefits are to be paid as the
annuity starting date? [355]
c.
Is the QJSA under the plan an annuity that commences immediately? [356]
d.
Is the QJSA for a married participant at least as valuable as any other optional form
of benefit payable under the plan at the same time? [357]
e.
If the plan provides for two or more actuarially equivalent annuities that satisfy the
requirements for a QJSA, does it specify which is the automatic form? [358]
f.
Is the participant allowed to receive a QJSA distribution at earliest requirement age
under the plan? [359]
g.
Does the plan provide that the participant can elect during the applicable election
period not to take a QJSA only with the spouse’s consent to a specific beneficiary and a
particular optional form of benefit? [360, 361]
h.
Does the plan provide that a participant who is to receive a QJSA may elect, with
spousal consent, not to take the QJSA and may revoke the election, or choose again to
take the QJSA, at any time and any number of times within the applicable election
period? [362]
5625
Form
(Rev. 2-2006) (page 1) Cat. No. 42700L
Department of the Treasury - Internal Revenue Service
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