Form 5300 - Application For Determination For Employee Benefit Plan
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115300
Application for Determination for
Form
Employee Benefit Plan
(Rev. April 2011)
OMB No. 1545-0197
Department of the Treasury
See separate instructions.
Internal Revenue Service
Review the Procedural Requirements Checklist before submitting this application.
For Internal Use Only
1a Number Assigned under Section 6.19
—
of Revenue Procedure 2008-6
1b Name of plan sponsor (employer if single-employer plan)
1c
1d City
1e State
1f Zip Code
Address of plan sponsor (if a P.O. Box, see instructions)
1g
Country
1h Employer identification number (EIN)
1i Telephone number
1j Fax number
1k Employer’s tax year ends
2a Person to contact if more information is needed. (See instructions.)
(If a Power of Attorney is attached, check box, and do not complete this line.)
Contact person’s name
2b
2c City
2d State
2e Zip Code
Contact person’s address
2f Telephone number
2g Fax number
If more space is needed for any item, attach additional sheets the same size as this form. Identify each additional sheet with
the plan sponsor’s name and EIN and identify each item.
Under penalties of perjury, I declare that I have examined this application, including accompanying statements and schedules, and
to the best of my knowledge and belief, it is true, correct, and complete.
SIGN HERE
Date
▶
▶
Type or print name
Type or print title
5300
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Form
(Rev. 4-2011)
Cat. No. 11740X
11740X04201101
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