Form 4461-B - Application For Approval Of Master Or Prototype Or Volume Submitter Plans

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4461-B
Application for Approval of Master or
Form
OMB No. 1545-0169
Prototype or Volume Submitter Plans
(Rev. January 2012)
Department of the Treasury
This Form Is Open to Public Inspection
Mass Submitter Adopting Sponsor or Practitioner
Internal Revenue Service
For IRS Use Only
File This Form With the Internal Revenue Service
Section references are to the Internal Revenue Code unless otherwise noted.
Complete every applicable item on this form.
1
Enter amount of user fee submitted
$
2 a Name of applicant
2 b Employer identification number
of applicant
Address (number, street, room or suite no.) (If a P.O. box, see the instructions.)
2 c Applicant’s telephone no.
City
State
ZIP code
3 b Telephone number
3a Name of person to be contacted
3 c If a power of attorney is attached, check the box
4 a Basic plan document number
b Adoption agreement number
5
This plan is:
Word-for-word identical to an M&P plan or volume submitter plan
A minor modification to an M&P plan only (see instructions to line 5 for
specific requirements)
6
Name of mass submitter
7
Enter the following information for the mass submitter’s plan on which this plan is based (if this application is submitted
simultaneously with the mass submitter’s application, see instructions).
File folder number
Letter serial number
Date of letter
8
Type of plan:
Money purchase
Target benefit
Profit-sharing/401(k)
Profit-sharing
Defined benefit (with permitted disparity)
Defined benefit (without permitted disparity)
9
Filing status of plan (see General Instructions)
Standardized plan
Nonstandardized plan
Volume submitter governmental plan (i.e., described in section 414(d))
Volume submitter nongovernmental plan
For Master or Prototype: Under penalties of perjury, I declare that the sponsor has adopted a master or prototype plan that is word-for-word identical to, or a minor
modification of the mass submitter plan indicated in items 6 and 7 above.
For Volume Submitter: Under penalties of perjury, I declare that the practitioner has adopted a volume submitter plan that is word-for-word identical to the mass submitter
plan indicated in items 6 and 7 above.
(Sponsor or Practitioner)
Title
Signature
Date
(Mass Submitter)
Signature
Title
Date
4461-B
For Paperwork Reduction Act Notice, see the instructions.
Form
(Rev. 1-2012)
Cat. No. 10235P

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