8717
User Fee for Employee Plan Determination
OMB No. 1545-1772
For
Letter Request
Form
IRS
(Rev. September 2017)
Use
Attach to determination letter application.
▶
Amount paid
Department of the Treasury
Only
Go to for the latest information.
▶
Internal Revenue Service
1 Name of plan sponsor (employer if single-employer plan)
2 Sponsor’s employer identification number
3 Plan number
4 Plan name
Caution: If you qualify for the exemption from user fees for small business employers, complete only the certification below. See the instructions on
page 2 for details. For all other applications, leave the certification blank and check the appropriate box and enter the user fee in column B of line 5.
Certification
I certify that the application for a determination letter on the qualified status of the plan listed above meets the conditions for
exemption from user fees described in section 7528(b)(2)(B) of the Internal Revenue Code.
Sign Here
Date
▶
▶
Type or print name and title
▶
User Fee
A
B
Form Submitted
5a Form 5300:
$
b Form 5307:
$
c Form 5310:
$
d
e Multiple employer plans (Form 5300)
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$
f
Multiple employer plans (Form 5310)
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g Reserved
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h Reserved
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(7)
i
Form 5316: .
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$
8717
Cat. No. 64727O
Form
(Rev. 9-2017)