Form 5307 - Application For Determination For Adopters Of Master Or Prototype Or Volume Submitter Plans Page 2

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Form 5307 (Rev. 9-2001)

Page

Yes

Is the employer a member of an affiliated service group?

Is the employer a member of a controlled group of corporations or a group of trades or businesses under common

control?

If a and/or b above is “Yes,” complete required statement (see instructions).

Is this a master or prototype plan?

If “Yes,” Date of Opinion Letter

Serial Number

Is this an approved volume submitter plan?

If “Yes,“ Date of Advisory Letter

Serial Number

Are there modifications to the volume submitter plan or are there addenda to the adoption agreement?

If “Yes,” attach a list of the modifications and see the instructions under What to File and Who May Not File.

Are there any “Other” boxes selected in the adoption agreement?

Is this a governmental plan?

If “Yes,” is the plan a state level plan?

Is this a nonelecting church plan?

Is this a collectively bargained plan? (See Regulations section 1.410(b)-9)

Is this a section 412(i) plan?

Do you maintain any other qualified plan(s) under section 401(a)?

If “Yes,” attach required statement in the instructions for line 9a.

If “No,” skip to line 9d.

Do you maintain another plan of the same type (i.e., both this plan and the other plan are defined contribution

plans or both are defined benefit plans) that covers non-key employees who are also covered under this plan?

If “Yes,” when the plan is top-heavy, do the non-key employees covered under both plans receive the required

top-heavy minimum contribution or benefit under:

(1) This plan?

(2) The other plan?

If this is a defined contribution plan, do you maintain a defined benefit plan (or if this is a defined benefit plan,

do you maintain a defined contribution plan) that covers non-key employees who are also covered under this

plan?

If “Yes,” when the plan is top-heavy, do non-key employees covered under both plans receive:

(1) the top-heavy minimum benefit under the defined benefit plan?

(2) at least a 5% minimum contribution under the defined contribution plan?

(3) the minimum benefit offset by benefits provided by the defined contribution plan?

(4) benefits under both plans that, using a comparability analysis, are at least equal to the minimum benefit?

(See instructions.)

Does the plan prevent the possibility that the section 415 limitations will be exceeded for any employee who is

(or was) a participant in this plan and any other plan of the employer?

Miscellaneous

N/A

Yes

10a

Does any amendment to the plan reduce or eliminate any section 411(d)(6) protected benefit including an

amendment adopted after September 6, 2000, to eliminate a joint and survivor annuity form of benefit?

(See instructions.)

Are trust earnings and losses allocated on the basis of account balances in a defined contribution plan?

If “No,” attach a statement explaining how they are allocated.

Is this plan or trust currently under examination or is any issue related to this plan or trust currently pending

before:

● The Internal Revenue Service,

● The Department of Labor,

● The Pension Benefit Guaranty Corporation, or

● Any court

If “Yes,” attach a statement explaining the issues involved, the contact person’s name (IRS Agent, DOL

Investigator, etc.) and their telephone number. Do not answer “Yes” if the plan has been submitted under

the Voluntary Compliance Program of the Employee Plans Compliance Resolution System (EPCRS).

5307

Form

(Rev. 9-2001)

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