7
Form 5300 (Rev. 12-2013)
Page
(Line 9 continued)
e
List the plan section(s) that satisfy the design-based safe harbor (including, if applicable, the permitted disparity requirements):
Yes
No
10a
Does this plan have a cash or deferred arrangement (CODA)?
If “Yes,” go to line 10b(1).
If “No,” go to line 10e.
b (1)
Does the CODA satisfy a safe harbor?
If “Yes,” go to line 10b(2).
If “No,” go to line 10d.
(2)
Indicate by using the corresponding number the type of section 401(k) safe harbor that was satisfied.
1. 401(k)(12)(B)
2. 401(k)(12)(C)
3. 401(m)(11)(B)
Does this plan contain a qualified automatic contribution arrangement (QACA) within the meaning of section
c
401(k)(13)?
Does this plan contain an eligible automatic contribution arrangement (EACA) within the meaning of section
d
414(w)?
e
Does this plan have matching contributions within the meaning of section 401(m)?
If “Yes,” go to line 10f.
If “No,” go to line 10g.
Yes
No
f
Does this plan satisfy the 401(m) safe harbor?
g
Does this plan have after-tax employee voluntary contributions within the meaning of section 401(m)?
11
Does this plan utilize the permitted disparity rules of section 401(l)?
12
Is this plan part of an offset arrangement with any other plans?
If “Yes,” attach the required statement.
13
Is this plan part of an eligible combined plan arrangement within the meaning of section 414(x)?
If “Yes,” include the EIN and Plan # of the other plan.
EIN:
Plan #:
14
Has this plan been involved in a merger, consolidation, spinoff, or a transfer of plan assets or liabilities
that was not considered under a previous DL?
If “Yes,” submit the required attachment.
15a
Has the plan been amended or restated to change the plan type?
If “Yes,” go to line 15b.
If “No,” go to line 16a.
b
Was the change considered in a prior DL?
If “No,” attach a statement explaining the change.
5300
Form
(Rev. 12-2013)
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