Form 5300 - Application For Determination For Employee Benefit Plan
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35300
Application for Determination for
Form
Employee Benefit Plan
(Rev. January 2017)
OMB No. 1545-0197
(
)
Under section 401(a) and 501(a) of the Internal Revenue Code
Department of the Treasury
Internal Revenue Service
Information about Form 5300 and its instructions is at
▶
Review instructions and the Procedural Requirements Checklist before completing this application.
For Internal Use Only
Submit all required attachments.
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 code
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 Form 2848 or Form 8821 is attached, mark box, and do not complete lines 2a–2k.
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
5300
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Form
(Rev. 1-2017)
Cat. No. 11740X
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