Form 5300 Draft - Application For Determination For Employee Benefit Plan Page 10
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129
Form 5300 (Rev. 2-2011)
Page
13
(continued)
Yes
No
Are the results on line 13l or 13m based on the aggregated coverage of more than one plan? If “Yes,” attach a
n
statement listing the names, plan numbers, EINs, and benefit/allocation formula of the other plans. All on-cycle
individually designed aggregated plans should be filed concurrently.
o If the plan satisfied coverage using one of the special requirements of Regulations section 1.410(b)-2(b)(5), (6), or (7), enter the
letter from the list below that identifies the special rule.
A = 1.410(b)-2(b)(5) - No NHCEs employed
B = 1.410(b)-2(b)(6) - No HCEs benefit
C = 1.410(b)-2(b)(7) - Collectively bargained only
Determination request regarding the nondiscrimination design-based safe harbors of section 401(a)(4). See instructions.
Yes
No
Is this a request for a determination regarding a design-based safe harbor under section 401(a)(4)? If
14
“Yes,” complete a-d.
Note. Section 401(k) and/or section 401(m) plans that do not contain a provision for discretionary
contributions should not complete this line.
Design-based nondiscrimination safe harbors:
Does the plan provide for disparity in contributions or benefits that is intended to meet the permitted disparity
a
requirements of section 401(l)? If “Yes,” answer line 14b. Otherwise, skip to line 14c.
b
Do the provisions of the plan ensure that the overall permitted disparity limits will not be exceeded?
c Enter the letter (“A” - “G”) from the list below that identifies the safe harbor intended to be satisfied.
A = 1.401(a)(4)-2(b)(2) defined contribution (DC) plan with uniform allocation formula
B = 1.401(a)(4)-3(b)(3) unit credit defined benefit (DB) plan
C = 1.401(a)(4)-3(b)(4)(i)(C)(1) unit credit DB fractional rule plan
D = 1.401(a)(4)-3(b)(4)(i)(C)(2) flat benefit DB plan
E = 1.401(a)(4)-3(b)(5) insurance contract plan
F = 1.401(a)(4)-8(b)(3) target benefit plan
G = 1.401(a)(4)-8(c)(3)(iii)(B) cash balance plan
d
List the plan section(s) that satisfy the safe harbor (including, if applicable, the permitted disparity requirements):
5300
Form
(Rev. 2-2011)
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