Form 5300 - Application For Determination For Employee Benefit Plan Page 2
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Form 5300 (Rev. 1-2017)
Page
3a
Name of plan (plan name cannot exceed 70 characters, including spaces):
c
b
Enter 3-digit plan number
Enter the month in which the plan year ends (MM)
d
Enter plan’s original
e
Enter number of participants
effective date
Yes
No
If 100 or fewer, complete lines 3f and 3g. Otherwise, go to line 4a.
Does the plan sponsor have 100 or fewer employees who received $5,000 or more of compensation for the
f
preceding year?
g
Is at least one employee a non-highly compensated employee?
4a
Determination requested for (enter applicable number in box):
1 – Initial Qualification – New Plan
2 – Initial Qualification – Existing Plan
3 – Plan authorized to apply under current IRS guidance (attach required statement)
b
If line 4a is “1,” enter the date the plan was originally adopted.
5
Indicate the type of plan by entering the number from the list below.
(Use the lowest number applicable to your plan)
1 – Pension Equity Plan (PEP)
5 – ESOP (see instructions)
9 – 401(k)
2 – Cash balance conversion
6 – Money purchase
10 – Profit sharing plan
3 – Cash balance (nonconversion)
7 – Target benefit
4 – Defined benefit but not cash balance
8 – Stock bonus
Yes
No
6
Is this a governmental plan under section 414(d)?
Is this a church plan under section 414(e) that hasn’t elected to have participation, vesting, funding, etc.,
7
provisions apply in accordance with section 410(d)?
8
Does this plan benefit any collectively bargained employees under Regulations section 1.410(b)-6(d)(2)?
9
Is this an insurance contract plan under section 412(e)(3)?
10
Is this a multiemployer plan under section 414(f)?
11
Is this a multiple employer plan under section 413(c)?
12
Have interested parties been given the required notification of this application? (attach statement)
13
Is this an election for a determination regarding a design-based safe harbor? (attach statement)
14
Does this plan utilize the permitted disparity rules of section 401(l)?
15
Is this plan part of an offset arrangement with any other plans? (attach statement)
16
Is this plan part of an eligible combined plan under section 414(x)? (attach statement)
Has this plan been involved in a merger, consolidation, spinoff, or transfer of plan assets or liabilities? (attach
17
statement)
18
Has the plan been amended or restated to change the plan type? (attach statement)
19
Is any issue involving this plan currently pending? If “Yes,” attach the required statement. See instructions.
5300
Form
(Rev. 1-2017)
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