Application for Approval of Master
OMB No. 1545-0169
or Prototype or Volume Submitter
(Rev. January 2012)
Defined Contribution Plans
Department of the Treasury
This Form Is Open to Public Inspection
Internal Revenue Service
For IRS Use Only
File This Form With the Internal Revenue Service
File folder number
Section references are to the Internal Revenue Code unless otherwise noted.
Complete every applicable item on this form and Attachment 1 (see Rev. Proc. 2011-49, 2011-44 I.R.B. 608).
See instructions before completing this form.
Enter amount of user fee submitted
2 a Approval requested:
2b M&P - File folder number or
2c Date of last
VS - Letter serial number
Amendment—Enter file folder number or letter serial
number and date of last letter issued
3 a Name of applicant
3b Employer identification number
Address (number, street, room or suite no.) (If a P.O. box, see instructions.)
3c Applicant’s telephone no.
3 d Type of applicant (see Definitions in the instructions):
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
Form of plan:
Volume submitter plan
Note: A master plan has only one trust or custodial account for all adopting employers.
Type of plan:
Filing status of 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.
For Paperwork Reduction Act Notice, see the instructions.
Cat. No. 41676M