Form 5307 - Application For Determination For Adopters Of Master Or Prototype Or Volume Submitter Plans Page 3

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Form 5307 (Rev. 9-2001)
Page
Optional determination request regarding the ratio percentage test. A determination regarding the average benefit test may
be requested by attaching Schedule Q (Form 5300).
Yes
No
11
Is this a request for a determination regarding the ratio percentage test of Regs. section 1.410(b)-2(b)(2) or a
request for a determination regarding one of the special requirements of Regs. section 1.410(b)-2(b)(5), (6), or (7)?
If “Yes,” complete only lines 11a through 11n for a ratio percentage test determination, or complete only
line 11o for a determination regarding one of the special requirements.
If “No,” skip to line 12.
a
Is this plan disaggregated into two or more separate plans that are not 401(k), 401(m), or profit-sharing plans?
If “Yes,” see the instructions and attach separate schedules for each disaggregated portion
b
Does the employer receive services from any leased employees as defined in section 414(n)?
c
Coverage date (MMDDYYYY). See instructions for inserting date
d
Total number of employees (include self-employed individuals) (employer-wide)
e
Statutory and regulatory exclusions under this plan (do not count an employee more than once):
(1) Number of employees excluded because of minimum age or years of service required
(2) Number of employees excluded because of inclusion in a collective bargaining unit
(3) Number of employees excluded because they terminated employment with less than 501 hours
of service and were not employed on last day of plan year
(4) Number of employees excluded because employed by other qualified separate lines of business
(QSLOBs)
(5) Number of employees excluded because they were nonresident aliens with no earned income
from sources within the United States
f
Total statutory and regulatory exclusions (add lines 11e(1) through 11e(5))
g
Nonexcludable employees (subtract line 11f from line 11d)
h
Number of nonexcludable employees on line 11g who are highly compensated employees (HCEs)
Number of nonexcludable HCEs on line 11h benefiting under the plan
i
Number of nonexcludable employees who are nonhighly compensated employees (NHCEs) (subtract
j
line 11h from line 11g)
k
Number of nonexcludable NHCEs on line 11j benefiting under the plan
l
Ratio percentage (See instructions.)
m
Enter the ratio percentage for the following, if applicable:
(1) Section 401(k) part of the plan
(2) Section 401(m) part of the plan
Yes
No
n
Are the results on line 11l or 11m based on the aggregated coverage of more than one plan?
If “Yes,” attach a statement showing the names, plan numbers, EINs, and benefit/allocation formulas of the other plans.
All aggregated plans should be filed concurrently.
o
If the plan satisfied coverage using one of the special requirements of Regulations section 1.410(b)-2(b)(5), (6), or (7), enter
the letter from the list below that identifies the special requirement:
A—1.410(b)-2(b)(5)—No NHCEs employed
B—1.410(b)-2(b)(6)—No HCEs benefit
C—1.410(b)-2(b)(7)—Collectively bargained only
Optional determination request regarding the nondiscrimination design-based safe harbors of section 401(a)(4).
Section 401(k) and/or section 401(m) plans that do not contain a provision for discretionary contributions
should not complete this line.
Yes
No
12
Is this a request for a determination regarding a design-based safe harbor under section 401(a)(4)?
If “Yes,” complete the following:
Design-based nondiscrimination safe harbors:
a
Does the plan provide for disparity in contributions or benefits that is intended to meet the permitted disparity
requirements of section 401(l)?
If “Yes,” answer line 12b. Otherwise, skip to line 12c.
b
Do the provisions of the plan ensure that the overall permitted disparity limits will not be exceeded?
c
Enter the letter (“A” – “G“) from the list below that identifies the safe harbor intended to be satisfied
A—1.401(a)(4)-2(b)(2) defined contribution (DC) plan with uniform allocation formula
B—1.401(a)(4)-3(b)(3) unit credit defined benefit (DB) plan
E—1.401(a)(4)-3(b)(5) insurance account
C—1.401(a)(4)-3(b)(4)(i)(C)(1) unit credit DB fractional rule plan
F—1.401(a)(4)-8(b)(3) target benefit plan
D—1.401(a)(4)-3(b)(4)(i)(C)(2) flat benefit DB plan
G—1.401(a)(4)-8(c)(3)(iii)(b) cash balance plan
d
List the plan section(s) that satisfy the safe harbor (including, if applicable, the permitted disparity requirements)
here:
5307
Form
(Rev. 9-2001)

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