Form 5300 Draft - Application For Determination For Employee Benefit Plan Page 3
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122
Form 5300 (Rev. 2-2011)
Page
3a Determination requested for (enter applicable number in box) (see instructions)
1 - Initial qualification
2 - Request after initial qualification
3 - Affiliated Service Group (ASG) status (IRC section 414(m))
4 - Leased employee status (IRC section 414(n))
5 - Partial termination
6 - Termination of collectively bargained multi-employer or
multiple-employer plan covered by PBGC insurance
b
(i) If line 3a is 1, enter the effective date of the plan
(ii) If line 3a is 1, enter the date the plan was signed
c
If line 3a is 5, enter the effective date of the partial termination
d
If line 3a is 6, enter the effective date of termination
e
Enter number of amendments included
f
Enter the date the amendment(s) were signed (If more than 4, see instructions)
(i)
(ii)
(iii)
(iv)
g
Enter the date the amendment(s) were effective (If more than 4, see instructions)
(i)
(ii)
(iii)
(iv)
Yes
No
h
Has the plan received a determination letter?
If “No,” submit copies of all prior plan(s) and/or adoption agreement(s) and/or amendments. (see instructions)
i
If 3h is “Yes,” enter the date of the latest letter
j
Enter the number of amendments since the last determination letter. (see instructions)
k
Was this plan a prior adopter of a pre-approved plan? (see instructions)
l
If line 3k is “Yes,” enter the Serial Number.
m
If line 3k is “Yes,” was the sponsor authorized to adopt amendments?
n
Have interested parties been given the required notification of this application? (see instructions)
o
Does the plan have a cash or deferred arrangement (section 401(k) or 414(x))?
p
Does the plan have matching contributions (section 401(m))?
5300
Form
(Rev. 2-2011)
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