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

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5307

Application for Determination for

Adopters of Modified

Form

(Rev. June 2014)

OMB No. 1545-0200

Volume Submitter Plans

Department of the Treasury

(Under sections 401(a) and 501(a) of the Internal Revenue Code)

Internal Revenue Service

For IRS Use Only

Information about the Form 5307 and the instructions is at

▶

For Internal Use Only

Review the Procedural Requirements Checklist before completing this application.

Complete lines 1j-1m and 2h-2k only if you have a foreign address, see instructions.

1a Name of plan sponsor (employer if single-employer plan)

b Address of plan sponsor

c City

d State

e ZIP

f Employer identification number (EIN)

g Telephone number

h Fax number

i Employer’s tax year end (MM)

j City or town

k Country name

l Province/country

m Foreign postal code

2a Person to contact. If a Power of Attorney is attached, mark box and do not complete this line.

Contact person’s name

b Contact person’s address

c City

d State

e ZIP code

f Telephone number

g Fax number

h City or town

i Country name

j Province/country

k Foreign postal code

If more space is needed for any item, attach additional sheets the same size as this form. Identify each additional sheet with the plan

sponsor’s name and EIN and identify each item.

Under penalties of perjury, I declare that I have examined this application, including accompanying statements and schedules, and to the best of my knowledge and belief,

it is true, correct, and complete.

SIGN HERE

Date

▶

Type or print name

Type or print title

5307

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Form

(Rev. 6-2014)

Cat. No. 11832Y