Form 4632-A - Employee Plans Referral Checksheet

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EP Classification Unit,
Forward to:
Employee Plans Referral Checksheet
9350 Flair Drive, 2nd Floor
El Monte, CA 91731-2885
(See instructions on reverse)
Phone: (626) 312-2933
Employer's Name
TIN
Tax year ending
Plan Number
Plan Name
Date of most recent
determination letter
Referral Not
Referral
Required
Required
N/A
Yes
No
1. Have all Forms 5500, 5500-C/R or 5500-EZ been filed, if required?
2. Does the plan have a determination letter issued after 02-28-02?
N/A
Yes
No
If no - Is the plan a regional or Master prototype for which an individual determination letter
will not be issued?
3. Did the distributions during the past year exceed 50% of the asset balance as of the beginning of the
N/A
No
Yes
plan year? If the plan has terminated or merged, answer N/A.
4. If the plan has terminated:
i) Did the termination result in a reversion to the employer of more than $10,000?
N/A
No
Yes
Include a copy of the Form 5330, if filed.
ii) Has any participant received a distribution in excess of $1,000,000?
N/A
No
Yes
5. Has the number of participants in the plan decreased more than 40% from the prior year?
N/A
No
Yes
6. If the employer is a member of a controlled group of corporations, do the employees of all
members of the controlled group participate in this plan?
N/A
Yes
No
7. Are there any significant adjustments to compensation or any unreasonable
N/A
No
Yes
compensation issues involving plan participants?
8. Were any independent contractors converted to employees?
N/A
No
Yes
9. Is this plan an Employee Stock Ownership Plan (ESOP) which is sponsored
N/A
No
Yes
by a subchapter S Corporation?
10. Is this plan a Cash Balance Conversion Plan?
N/A
No
Yes
11. Were any contributions made in a form other than cash to a plan subject to the
N/A
No
Yes
minimum funding requirements of IRC 412?
12. Does the plan have a minimum funding deficiency?
N/A
No
Yes
If yes - provide a copy of the Form 5330, if filed.
13. Have there been any non-exempt transactions involving plan assets in excess of $25,000 with a
N/A
No
Yes
disqualified person as defined in IRC 4975(e)(2)? Attach a copy of Form 5330, if filed.
14. Were any plan assets used to secure employer loans?
N/A
No
Yes
15. Did the plan hold or acquire any employer real property?
N/A
No
Yes
16. Has the plan and/or trust incurred any acquisition indebtedness liability in
N/A
No
Yes
excess of $20,000 for which it has not filed a Form 990-T?
17. Has the plan and/or trust engaged in a trade or business for which it has received in excess
N/A
No
Yes
of $1,000 and for which it has not filed a Form 990-T?
18. If this is an IRC §401(k) plan, did any of the elective deferrals exceed the limits of IRC §402(g)?
N/A
No
Yes
If the error was corrected by the taxpayer, answer N/A.
19. Other issues that warrant referral? (Attach explanation).
N/A
No
Yes
4632-A
Form
(Rev. 12-2004)
Catalog No. 23241T
publish.no.irs.gov
Department of the Treasury-Internal Revenue Service

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