4461-A
Application for Approval of Master or
OMB No. 1545-0169
Form
Prototype or Volume Submitter Defined
(Rev. March 2013)
Benefit Plan
This Form Is Open to Public Inspection
Department of the Treasury
Internal Revenue Service
For IRS Use Only
File This Form With Internal Revenue Service
Section references are to the Internal Revenue Code unless otherwise noted.
Complete every applicable item on this form and Attachment 1-A. (See Rev. Proc. 2011-49, 2011-44 I.R.B. 608.)
See instructions before completing this form.
1
Enter amount of user fee submitted
$
2b M&P File folder number or
2c Date of last letter issued
2 a Approval requested:
VS-Letter serial number
Initial application
Amendment—Enter file folder number or letter
serial number and date of last letter issued
▶
3b Employer identification number
3 a Name of applicant
of applicant
Address (number, street, room or suite no.) (If a P.O. box, see instructions)
State
ZIP code
3c Applicant’s telephone no.
City
3 d Type of applicant (see Definitions in the instructions):
M&P sponsor
Volume submitter practitioner
M&P mass submitter
Volume submitter mass submitter
4a Name of person to be contacted
4b Telephone number
4 c Email address
4d If a power of attorney is attached, check box
.
.
▶
5a Basic plan document number
5b Adoption agreement number
6
Form of plan:
Prototype plan
Master plan
Volume submitter plan
Note: A master plan has only one trust or custodial account for all adopting employers.
7
Does the plan provide for permitted disparity in accordance with section 401(l)?
Yes
No
8
Filing status of plan:
Standardized plan
Nonstandardized plan
Volume submitter governmental plan (i.e., described in section 414(d))
Volume submitter nongovernmental plan
Under penalties of perjury, I declare that I have examined this application, including accompanying statements, and to the best of my knowledge and
belief, it is true, correct, and complete.
Signature
Date
▶
Title
▶
▶
4461-A
For Privacy Act and Paperwork Reduction Act Notice, see the instructions.
Form
(Rev. 3-2013)
Cat. No. 11416U