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 3

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Form 5310-A (Rev. 11-2010)
Page
Complete lines 4 through 6 if this is a notice of a plan merger or consolidation, spinoff, or transfer of
Part II
plan assets or liabilities to another plan.
4a
Name of plan (plan name may not exceed 70 characters including spaces):
4b
Enter 3-digit plan number:
5a
Is this a defined benefit plan? If “Yes,” enter “1.” If “No,” enter “2.”
If you enter 1, attach an actuarial statement of valuation showing compliance with the requirements of section 401(a)(12) and
the regulations under section 414(I). See instructions.
5b
If this is a defined contribution plan, enter the appropriate code. See instructions.
6
Other plan(s) involved in the transaction. See instructions.
a Enter the total number of plans involved in the transaction other than the plan listed on line 4a:
Complete the following information for the other plan. If more than one other plan, see instructions for the required attachment(s).
b If more than one other plan is involved in the transaction, enter the number of this statement (1 of 3, etc.):
c Plan name
d Name of employer
e EIN
f
Plan number (3 digits):
g Date of merger or consolidation, spinoff, or transfer of plan assets or liabilities:
h Type of plan (see instructions for code to enter):
Part III
Complete lines 7 through 12 if you are filing a notice of qualified separate lines of business (QSLOB).
7a
Has the employer previously filed a notice of QSLOB? See instructions.
If “Yes,” enter “1” and complete lines 7b and 7c. If “No,” enter “2” and skip lines 7b and 7c.
b Enter the first day of the first testing year for which such notice applied:
▶
c Enter the filing date:
▶
5310-A
Form
(Rev. 11-2010)

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