Form 5434 - Application For Enrollment - Joint Board For The Enrollment Of Actuaries - 2017

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Joint Board for the Enrollment of Actuaries

5434

OMB Number

Form

Application for Enrollment

1545-0951

(January 2017)

For Joint Board Use Only

The application fee is $250. To apply and pay the application fee electronically, visit

Enrollment number

Date enrolled

Alternatively, complete this form and enclose with your check or money order for $250, payable to

the Internal Revenue Service, and submit by regular or USPS express mail to:

Internal Revenue Service, PO Box 301510, Los Angeles, CA 90030-1510.

Read the instructions on page 3 before completing this form.

Full legal name

Last name

b. First name

c. Middle name or initial

Other names used

3. Business name

(including maiden name and dates used)

(if using business address)

4a. Address

b. City

c. State

d. ZIP code

(number, street, suite or apt)

Email address

6. Daytime telephone number 7. Social Security Number 8. Date of birth

(mm/dd/yyyy)

Which one of the following describes your enrollment status? (Check one)

(A)

I am applying for enrollment for the first time.

(B)

I applied for enrollment previously but was not granted enrollment. Provide details on a separate page.

(C)

I was enrolled previously but my enrollment was terminated or I resigned my enrollment. (If your resignation or the

termination of your enrollment was related to a disciplinary matter, contact the Executive Director before completing this

application.) Provide details on a separate page.

10. How many months of responsible experience did you report on Schedule

A (Employment Record)?

(s)

Month(s)

(A) Responsible actuarial experience (from item 6(A) for all blocks of Schedule

(s)

Month(s)

(B) Responsible pension actuarial experience (from item 6(B) for all blocks of Schedule

(s)

11. On what basis did you satisfy the basic actuarial knowledge requirement of section 901.12(c)?

(Complete either A or B, as applicable)

(A)

Joint Board EA-1 examination(s)

Name(s) of exam(s), month(s) and year(s) completed

Date waiver received

(B)

Waiver of Joint Board EA-1 examination(s)

Qualifying formal education

Organization basic examination

Other

12. When did you satisfy the pension actuarial knowledge requirement of section 901.12(d) (EA-2 examination(s))?

Name(s) of exam(s), month(s) and year(s) completed

13. Have you read and are you familiar with the Joint Board regulations?

Yes

If No, provide details on a separate page.

14. Have you timely filed your Federal tax returns and timely paid your Federal taxes for the three tax years

Yes

preceding your date of application?

If No, provide details on a separate page.

15. In the last 15 years or since your 18th birthday, if sooner, have you ever been convicted or fined for a crime

Yes

under any revenue law or of a crime involving dishonesty or breach of trust?

If Yes, provide details on a separate page.

Declaration and Signature

I hereby apply to be an enrolled actuary. I authorize the Joint Board to inquire about my qualifications and experience from educational institutions,

employers, supervisors, actuarial organizations, and any other individuals who may have knowledge related to my qualifications and experience. I

authorize all such institutions, employers, supervisors, organizations and others to provide any information requested concerning my education,

employment experience and qualifications as an actuary.

Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is true, correct, and complete.

16. Signature

17. Date signed

5434

Catalog Number 42528L

Form

(Rev. 1-2017)