Form 5300 Draft - Application For Determination For Employee Benefit Plan Page 8
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127
Form 5300 (Rev. 2-2011)
Page
11b (continued)
(3) Money purchase plan - Enter rate of contribution
(4) Target benefit plan - State target benefit formula
Indicate the plan section where the allocation/benefit formula is located in the plan document.
12
Miscellaneous
N/A
Yes
No
Does any amendment to the plan reduce or eliminate any section 411(d)(6) protected benefit including an
a
amendment adopted after September 6, 2000, to eliminate the joint and survivor annuity form of benefit?
(See instructions)
Are trust earnings and losses allocated on the basis of account balances in a defined contribution plan? If
b
“No,” attach a statement explaining how they are allocated.
c Is this plan or trust currently under examination or is any issue related to this plan or trust currently pending before the:
Yes
No
Internal Revenue Service,
Department of Labor,
Pension Benefit Guaranty Corporation,
Voluntary Compliance Resolution Program of the Employee Plans Compliance Resolution System (EPCRS), or
Employee Benefits Security Administration,
Any Court?
If “Yes,” attach a statement explaining the issues involved and the contact person’s name (IRS Agent, DOL Investigator, etc.)
and telephone number.
Determination request regarding the ratio percentage test. A determination regarding the average benefit test may be
requested by attaching Schedule Q (Form 5300). See instructions.
Yes
No
Is this a request for a determination regarding the ratio percentage test of Regulations section 1.410(b)-2(b)(2) or a
13
request for a determination regarding one of the special requirements of Regulations section 1.410(b)-2(b)(5), (6), or (7)?
If “Yes,” complete only lines 13a through 13n for a ratio percentage test determination or complete only line
13o for a determination regarding one of the special requirements. If “No,” skip to line 14.
Yes
No
Is this plan disaggregated into two or more separate plans that are not section 401(k), 401(m), or profit sharing
a
plans? If “Yes,” see the instructions and attach separate schedules for each disaggregated portion.
b
Does the employer receive services from any leased employees as defined in section 414(n)?
5300
Form
(Rev. 2-2011)
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