Form 14035 - Pilot Questionnaire For Governmental Plans Initiative Page 5
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24Pilot Questionnaire for Governmental Plans Initiative
ALERT FOR RESPONDERS USING CDs
Saving your work while completing the questionnaire
It is imperative to save your work before closing the questionnaire or all your work will be lost. To save, either
click on the “Save” icon or go to the “File” menu and click “Save.” This will save the work you have completed
to that point. You can open the file at a later time to continue your work. It is also important to frequently
save your work while completing the questionnaire.
PART 1 - DEMOGRAPHIC INFORMATION
This section requests general information relating to tax-qualified retirement plans adopted
for governmental employees as well as plan population characteristics. This information will
assist us in understanding the basic structures of the plans adopted by governmental entities
and who participates in these plans.
1. Name of Plan:
2. Plan EIN:
3. Is the Plan intended to be a qualified retirement plan established under Internal Revenue Code (Code)
section 401(a)?
Yes
No
If you responded “No,” do not complete any further questions and return the questionnaire to the address
noted on the cover letter.
If you responded “Yes,” proceed.
4. Is the Plan intended to be a governmental plan as defined in Code section 414(d)?
Yes
No
If you responded “No,” do not complete any further questions and return the questionnaire to the address
noted on the cover letter.
If you responded “Yes,” proceed.
5. a. Number of Active Participants (not in Benefit Pay Status)
b. Number of Payees in Benefit Pay Status
i. Non-disability related retired participants
ii. Disability related retired participants
c. Number of Unpaid Terminated Deferred Vested (not in Benefit Pay status)
d. Number of Other (please describe below):
Total Number of Participants (total of lines a. - d.):
14035
Form
(Rev. 02-2009)
Catalog Number 52098A
Page 5
Department of the Treasury - Internal Revenue Service
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