Form 5300 Draft - Application For Determination For Employee Benefit Plan Page 5
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124
Form 5300 (Rev. 2-2011)
Page
4a
Name of plan (If plan name exceeds 70 characters, including spaces, see instructions):
b
Enter 3-digit plan number (see instructions)
c
Enter the month on which the plan year ends
d
Enter plan’s original effective date
e
Enter number of participants (see instructions)
5
Indicate type of plan by entering the number from the list below:
7 — non-leveraged ESOP (see instructions)
1 — profit sharing and/or 401(k)
4 — defined benefit but not cash balance
5 — cash balance (see instructions)
2 — money purchase
8 — stock bonus
3 — target benefit
6 — leveraged ESOP
9 — safe harbor 401(k)
If this plan contains any ESOP provisions, do not use 1 or 2, use 6 or 7, as applicable.
Yes
No
6a
Is the employer a member of an affiliated service group (ASG)?
Is the employer a member of a controlled group of corporations or a group of trades or businesses under common
b
control? If 6a and/or 6b is “Yes,” see instructions.
c
Were elections made to use “Cycle A” per Section 9 of Revenue Procedure 2007-44? (see instructions)
7a
Is this a governmental plan? Date of last legislative session.
b
If line 7a is “Yes,” is the plan a state level plan?
c
Is this a nonelecting church plan?
d
Is this a collectively bargained plan? (See Regulations section 1.410(b)-9)
e
Is this a section 412(e)(3) plan?
f
Has this plan been involved in a merger which was not considered in a prior favorable determination letter?
g
Has the plan been amended or restated to change the type of plan?
h
Is this a multiple employer plan?
If line 7h is “Yes,” enter the total number of participating employers.
i
If line 7h is “Yes,” enter the number of participating employers currently being submitted.
5300
Form
(Rev. 2-2011)
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