Form 5434-A - Application For Renewal Of Enrollment
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1
2Joint Board for the Enrollment of Actuaries
5434-A
OMB Number
Form
Application for Renewal of Enrollment
1545-0951
(Rev. March 2012)
All individuals enrolled before January 1, 2011, are required by 20 CFR 901.11(d) to renew their enrollment in order to maintain active
enrollment to perform actuarial services. Enclose with this form your check or money order for $250 (two hundred fifty) payable to the
Internal Revenue Service.
If you want to send your form by regular mail, send to: Internal Revenue Service, PO Box 301510; Los Angeles, CA 90030-1510.
If you want to send your form by overnight mail, send to: Internal Revenue Service, Box 301510; 19220 Normandie Avenue, Suite B;
Torrance, CA 90502.
Enrollment Number
1. Provide the following information
Name
Address (Street)
City
State
ZIP Code
Daytime phone number (
)
Email address
Include Area Code
Check here if any information
has changed since
the last submission.
2. Please check one block for each of the following questions
A. Since the issuance or latest renewal of your enrollment, have you been disciplined for alleged misconduct
Yes
No
by any professional body or licensing authority? If Yes, attach a statement specifying the date, name, and
location of the disciplinary authority, the nature of the misconduct, and the type of discipline imposed.
B. Since the issuance or latest renewal of your enrollment, have you been convicted of, or fined for, a crime
Yes
No
under the revenue laws or a crime involving dishonesty or breach of trust? If Yes, attach a statement
providing details.
C. Since the issuance or latest renewal of your enrollment, have you timely filed all required U.S. tax returns
Yes
No
which became due? If No, attach a statement specifying the type of return, the taxable period covered by
the return, and the type and amount of any penalties imposed.
D. Are you familiar with those portions of the Employee Retirement Income Security Act of 1974 and the
Yes
No
regulations of the Joint Board for the Enrollment of Actuaries that relate directly or indirectly to the
responsibilities of an enrolled actuary? If No, attach a statement explaining your response.
3. Enter the total hours of qualifying continuing professional education completed in each category shown in the
space provided below.
(Core Hours)
(Non-Core Hours)
A. Participant in a formal program and/or correspondence or individual study
programs, including audio and video taped programs, and/or
teleconferencing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B. Serving as an instructor, discussion leader, or speaker . . . . . . . . . . . . . . . . . . .
C. Credit for published articles, books, films, audio and video tapes, etc. . . . . . . .
D. Service on Joint Board advisory committees or preparation of
Joint Board examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
E. Credit earned by examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total Hours
5434-A
Catalog Number 63767O
Department of the Treasury - Internal Revenue Service
Form
(Rev. 3-2012)
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