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check the box and attach a completed

Line 5. Cash balance or similar plan.

section(s) 401(k) and/or 401(m) plan(s),

Form 2848 or Form 8821.

For this purpose, a ‘‘cash balance’’

complete lines 13b through 13o with

formula is a benefit formula in a defined

respect to each disaggregated portion

Line 3a. Section 3001 of ERISA

benefit plan by whatever name (for

of the plan. Attach additional schedules

requires the applicant to provide

example, personal account plan,

as necessary to identify the other

evidence that each employee who

pension equity plan, life cycle plan,

disaggregated portions of the plan and

qualifies as an interested party has

cash account plan, etc.) that rather

to provide the requested coverage

been notified of the filing of this

than, or in addition to, expressing the

information, in the same format as line

application. If ‘‘Yes’’ is checked, it

accrued benefit as a life annuity

13, separately with respect to the other

means that each employee has been

commencing at normal retirement age,

portions of the plan, or to otherwise

notified as required by regulations

defines benefits for each employee in

show that the other portions of the plan

under Section 7476 or this is a one

terms more common to a defined

separately satisfy section 410(b).

person plan. A copy of the notice is not

contribution plan such as a single sum

required to be attached to this

Example. If this plan benefits the

distribution amount (for example, 10

application. If ‘‘No’’ is checked or this

employees of more than one qualified

percent of final average pay times

line is blank, the application may be

separate line of business (QSLOB), the

years of service, or the amount of the

returned.

portion of the plan benefiting the

employee’s hypothetical account

employees of each QSLOB is treated

Rules defining ‘‘interested parties’’

balance).

as a separate plan maintained by that

and the form of notification are in

Line 6. If the plan employer/sponsor is

QSLOB and must separately satisfy

Regulations section 1.7476-1. For an

a member of a controlled group of

section 410(b) unless the

example of an acceptable format, see

corporations, trades or businesses

employer-wide plan testing rule in

Rev. Proc. 2006-6, 2006-1 I.R.B. 204.

under common control, or an affiliated

Regulations section 1.414(r)-1(c)(2)(ii)

Line 3c. If you do not have a copy of

service group, all employees of the

applies.

the latest determination letter, or if no

group will be treated as employed by a

Section(s) 401(k) and/or 401(m)

determination letter has ever been

single employer for purposes of certain

plan(s) must complete line 13(l) for the

received by the employer, submit

qualification requirements. Attach a

portion of the plan that is not a section

copies of the initial plan, or the latest

statement showing in detail:

401(k) or a 401(m) plan. Also complete

plan for which you do have a

1. All members of the group,

line 13(m)(1) to report the ratio

determination letter, and any

2. Their relationship to the plan

percentage for the section 401(k)

subsequent amendments and/or

sponsor,

portion of the plan and line 13(m)(2) to

restatements, including all adoption

3. The type(s) of plan(s) each

report the ratio percentage for the

agreements.

member has, and

section 401(m) portion of the plan.

If you check ‘‘Yes,’’ also attach a

4. Plans common to all members.

Line 13c. If, for purposes of satisfying

statement explaining how the

the minimum coverage requirements of

amendments affect or change this or

Note. If you want to apply for a

section 410(b), you are applying the

any other plan of the employer.

determination letter to determine if you

daily testing option in Regulations

are a member of an affiliated service

Line 4b. Enter the three-digit number,

section 1.410(b)-8(a)(2) or the quarterly

beginning with ‘‘001’’ and continuing in

group, do not file this form. File Form

testing option in Regulations section

numerical order for each plan you

5300.

1.410(b)-8(a)(3), or, if you are using

adopt (001-499). This numbering will

Line 7. Attach copies of records of all

single-day ‘‘snapshot’’ testing as

differentiate your plans. The number

actions taken to terminate the plan,

permitted under section 3 of Rev. Proc.

assigned to a plan must not be

such as board of directors’ resolutions.

93-42, 1993-2 C.B. 540, enter the most

changed or used for any other plan.

Line 7b. Assets must be distributed as

recent eight-digit date (MMDDYYYY)

This should be the same number that

soon as administratively feasible after

for which the coverage data is

was or will be used when the Form

the date of termination. See Rev. Rul.

submitted. If you are applying the

5500 series returns/reports are filed for

89-87, 1989-2 C.B. 81.

annual testing option in Regulations

the plan.

section 1.410(b)-8(a)(4), enter the year

Line 7c. Check ‘‘No’’ only if you are

Line 4c. Plan year means the

for which the coverage data is

certain that there will be no reversion of

calendar, policy, or fiscal year on which

submitted.

plan assets to the employer.

the records of the plan are kept.

Line 13d. Include all employees of all

Line 10d. If you checked adverse

Line 4e. Enter the total number of

entities combined under section 414(b),

business conditions as the reason for

participants. A participant means:

(c), (m), or (o). Also include all

filing for termination, attach an

1. The total number of employees

self-employed individuals, common law

explanation detailing the conditions that

participating in the plan including

employees, and leased employees as

require termination of the plan.

employees under a section 401(k)

defined in section 414(n) of any of the

Line 13. Complete this line to indicate

qualified cash or deferred arrangement

entities above, other than those

how the plan satisfied section 410(b).

who are eligible but do not make

excluded by section 414(n)(5). Certain

Complete lines 13a through 13n if the

elective deferrals,

other individuals may also be required

plan satisfied the ratio percentage test

2. Retirees and other former

to be counted as employees. See the

for the year of termination. Complete

employees who have a nonforfeitable

definition of employee in Regulations

line 13o if the plan satisfied the average

right to benefits under the plan, and

section 1.410(b)-9. Also see

benefit test for the year of termination.

3. The beneficiary of a deceased

Regulations section 1.410(b)-6(i), which

Complete line 13p if the plan satisfied

employee who is receiving or will in the

may permit the employer to exclude

coverage using one of the special

future receive benefits under the plan.

certain former nonhighly compensated

requirements of Regulations section

Include one beneficiary for each

employees.

1.410(b)-2(b)(5), (6), or (7). Plans that

deceased employee regardless of the

Note. This note applies only to plans

use the qualified separate lines of

number of individuals receiving

that include a qualified cash or deferred

business rules of section 414(r) must

benefits.

arrangement under section 401(k) or

attach Demo 1. See Guidelines for

employee or matching contributions

Demonstrations.

Example. The payment of a

under section 401(m).

deceased employee’s benefit to three

Line 13a. If the plan is disaggregated

children is considered a payment to

into two or more separate plans that

If there are any contributions under

one beneficiary.

are other than profit sharing and/or

the plan that are not subject to the

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Instructions For Form 5310 - Application For Determination For Terminating Plan - Department Of Treasury Page 3

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