Form 5306-A - Application For Approval Of Prototype Simplified Employee Pension (Sep) Or Savings Incentive Match Plan For Employees Of Small Employers (Simple Ira Plan)

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5306-A
Application for Approval of Prototype Simplified Employee
Form
Pension (SEP) or Savings Incentive Match Plan for
(Rev. August 2013)
OMB No. 1545-0199
Employees of Small Employers (SIMPLE IRA Plan)
Department of the Treasury
(Under section 408(k) or (p) of the Internal Revenue Code)
Internal Revenue Service
Information about Form 5306-A and its instructions is at
For IRS Use Only
1
$
Enter amount of user fee submitted (see Specific Instructions)
Part I
Identifying Information (see instructions before completing this part)
File folder number
2
Approval requested for:
a Type of plan—
(1)
Prototype simplified employee pension (SEP) under section 408(k)
(2)
Prototype savings incentive match plan for employees of small employers (SIMPLE IRA plan) under section 408(p)
b
Initial application
c
Amendment—Enter
(1) Latest letter serial number
(2) Date letter issued
(3) File folder number
If the SEP contains elective deferral provisions, check this box .
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4a Name of applicant
4b Applicant’s employer identification number
Number, street, and room or suite no. (If a P.O. box, see instructions.)
City or town, state, and ZIP code
5a Name of person to be contacted
5b Telephone number
5c Email address
5d If a power of attorney is attached, check box
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6
Type of submission (check one box):
a
Not a mass submitter
b
Mass submitter
c
Identical adoption of a mass submitter
d
Minor modification of a mass submitter
7a If 6c or 6d is checked, enter the mass submitter’s name
b File folder number of the mass submitter’s SEP or SIMPLE IRA plan on which this submission is based:
8
Type of sponsoring organization:
a
Insurance company
e
Regulated investment company
b
Trade or professional organization
f
Federally insured credit union
g
Approved non-bank trustee (attach copy of approval
c
Savings and loan association that qualifies as a bank
letter)
d
Bank
Part II
SEP Information
Attach a copy of the SEP documents and indicate the article or section and the page number where
For
Plan Article or
Plan
the following provisions appear. If any item does not apply, write “N/A.” Sample language, or a listing
IRS Use
Section
Page
of required modifications (LRMs), is available on the IRS website at IRS.gov. Type “LRM” in the search
Reference
Number
Only
box. Sponsors are encouraged to use LRM language.
9a Does the SEP cover all employees who have attained age 21, performed service
for the employer in 3 of the immediately preceding 5 years, and received at least
$550* in compensation from the employer for the year, other than employees who
may be excluded under section 410(b)(3)(A) or (C)? .
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1
b Does the SEP provide that all eligible employees will share in an allocation? .
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2
c Does the SEP contain a definite allocation formula that does not discriminate in
favor of highly compensated employees?
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d Does the SEP require that it be used only with pre-approved traditional IRAs? .
5
e Does the SEP prohibit restrictions on withdrawals (other than restrictions
permitted under section 408(d)(7)(A) in the case of a salary reduction SEP)? .
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6
f
Does the SEP define “compensation” in a manner that satisfies one of the safe
harbor definitions under section 414(s) and limit compensation under section
408(k)(3)(C)? .
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7
*
This is the amount for 2013. The amount may be increased in future years for cost-of-living adjustments.
Please
Under penalties of perjury, I declare that I have examined this application, including accompanying statements, and to the best of my knowledge and belief, it
is true, correct, and complete.
Sign
Here
Date
Signature of officer
Title
5306-A
For Paperwork Reduction Act Notice, see the instructions.
Form
(Rev. 8-2013)
Cat. No. 32621R

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