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 4

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Form 5310-A (Rev. 11-2010)
Page
8
First testing year for which this notice applies:
▶
9
Are you filing this form to give notice that you are revoking a previously filed notice and that you are no longer testing on a
QSLOB basis?
If “Yes,” enter “1” and complete line 10 and skip lines 11 and 12. If “No,” enter “2” and complete lines 10-12.
10
Check the box(es) for the appropriate code section(s) for which the employer is testing on a QSLOB basis (or for which the
employer tested, if the answer to line 9 is “Yes”).
Section 410(b)
Section 401(a)(26)
Section 129(d)(8)
11
On an attached list, identify each QSLOB operated by the employer. See instructions.
12
Enter the following information relating to each plan maintained by the employer. If more than 1 plan, attach a
schedule for each plan showing the information requested on lines 12a through 12e. See instructions.
a Name of plan:
b Date of determination letter, if any:
▶
c If this is a pre-approved plan, enter:
(1) Date of the letter
▶
(2) Serial or advisory letter number, if any:
▶
d Date of the pending determination letter request, if any:
▶
e List each QSLOB that has employees benefiting under the plan: See instructions.
5310-A
Form
(Rev. 11-2010)

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