Form 5310-A Draft - Notice Of Plan Merger Or Consolidation, Spinoff, Or Transfer Of Plan Assets Or Liabilities; Notice Of Qualified Separate Lines Of Business - Internal Revenue Service Page 2

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5310-A
Notice of Plan Merger or Consolidation, Spinoff, or
Form
Transfer of Plan Assets or Liabilities; Notice of
Qualified Separate Lines of Business
(Rev. November 2010)
OMB No. 1545-1225
Department of the Treasury
Under sections 6058(b) and 414(r) of the Internal Revenue Code.
Internal Revenue Service
See Who Must File instructions before filing this form.
For Internal Use Only
1
Reason for filing (see specific instructions for code to enter):
Part I
All filers must complete lines 1 and 2.
2a
Name of plan sponsor (employer if single-employer plan)
2b
Address of plan sponsor (if a P.O. Box, see instructions)
2c City
2d State
2e Zip Code
2f
Country
2g
2h Telephone number
2i Fax number
Employer identification number (EIN)
3a
Person to contact if more information is needed. (See instructions.)
(If a Power of Attorney is attached, check box and do not complete this line.)
Contact person’s name
3b
Contact person’s address
3c City
3d State
3e Zip Code
3f
3g Fax number
Telephone number
If more space is needed for any item, attach additional sheets the same size as this form. Identify each additional sheet with the plan
sponsor’s name and EIN and identify each item.
Under penalties of perjury, I declare that I have examined this notice, including accompanying statements and schedules, and to the
best of my knowledge and belief, it is true, correct, and complete.
SIGN HERE
Date
Type or print name
Type or print title
5310-A
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Form
(Rev. 11-2010)
Cat. No. 12783Y

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