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

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4461

Application for Approval of Master

Form

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

Initial application

VS - Letter serial number

letter issued

Amendment—Enter file folder number or letter serial

number and date of last letter issued

▶

3 a Name of applicant

3b Employer identification number

of applicant

Address (number, street, room or suite no.) (If a P.O. box, see instructions.)

City

State

ZIP code

3c Applicant’s telephone no.

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

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.

Type of plan:

Money purchase

Target benefit

Profit-sharing

Profit-sharing/401(k)

Filing status of plan:

Standardized plan

Volume submitter governmental plan (i.e., described in section 414(d))

Nonstandardized plan

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

For Paperwork Reduction Act Notice, see the instructions.

Form

(Rev. 1-2012)

Cat. No. 41676M