Free Form 5307 (Rev. March 2008) - Federal

FILLABLE FIELD DATA SHOULD PRINT BLACK, NOT BLUE
Form

5307

(Rev. March 2008)
Department of the Treasury Internal Revenue Service

Application for Determination for Adopters of Master or Prototype or Volume Submitter Plans
(Under sections 401(a) and 501(a) of the Internal Revenue Code)

OMB No. 1545-0202

For IRS Use Only

Review the Procedural Requirements Checklist before submitting this application.

1a Number Assigned under Section 6.19 of Revenue Procedure 2007-6

-

1b Name of plan sponsor (employer if single-employer plan)

1c Address of plan sponsor (if a P.O. Box, see instructions)

1d City

1e State

1f Zip Code

1g Country 1k Employer's tax year end (MM)

1h Employer identification number

1i Telephone number

1j Fax number

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 Contact person's address

2c City

2d State

2e Zip Code

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

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 11832Y

Form

5307

(Rev. 3-2008)

*11832Y03200801*

Form 5307 (Rev. 3-2008)

Page

2

3a

Determination requested for (enter applicable number in box) 1 - Initial Qualification 2 - Request after Initial Qualification 3 - Standardized Plans (See instructions)

b c d

If line 3a is 1, please enter the date the plan was signed Enter number of amendments included Enter the date the amendment(s) reflected in 3c were signed (If more than 4 see instructions) (i) (ii) (iii) (iv)

e

Enter the date the amendment(s) were effective (If more than 4 see instructions) (i) Yes No Has the plan received a determination letter? If "No," submit copies of all prior plan(s) and/or adoption agreement(s). (ii) (iii) (iv)

f

g h i j k l m n

If 3f is "Yes," enter the date of the latest letter (See instructions) Enter the number of amendments since the last determination letter Have interested parties been given the required notification of this application? (See instructions) Does the plan have a cash or deferred arrangement (section 401(k))? Does the plan have matching contributions (section 401(m))? Does the plan have after-tax employee voluntary contributions (section 401(m))? Does the plan utilize the permitted disparity rules of section 401(l) when allocating contributions or benefits? Is this plan an offset arrangement with any other plans? (If "Yes," attach a separate statement providing the name, EIN, and plan type of the other plan that is part of the arrangement. See instructions)

Form

5307

(Rev. 3-2008)

*11832Y03200802*

Form 5307 (Rev. 3-2008)

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4a Name of plan (If plan name exceeds 70 characters, including spaces, see instructions):

b Enter 3-digit plan number (See instructions) d Enter plan's original effective date e Enter number of participants (See instructions) 5 Indicate type of plan by entering the number from the list below: 1 -- profit sharing and/or 401(k) 2 -- money purchase 3 -- target benefit Yes 6a b No

c Enter month plan year ends

4 -- defined benefit but not cash balance (See instructions) 5 -- 401(k) safe harbor

Is the employer a member of an affiliated service group? Is the employer a member of a controlled group of corporations or a group of trades or businesses under common control? If 6a and/or 6b is "Yes," see instructions.

7a(1)

Is this a master or prototype plan? a(2) If "Yes," Date of Opinion letter a(3) Serial Number

b(1)

Is this a volume submitter plan? b(2) If "Yes," Date of Advisory letter b(3) Serial Number

c d 8a b c d

Are there modifications to the volume submitter plan or are there addenda to the adoption agreement? Are there any "Other" boxes selected in the adoption agreement? (See instructions) Is this a governmental plan? If "Yes," is the plan a state level plan? Is this a nonelecting church plan? Is this a collectively bargained plan? (See Regulations section 1.410(b)-9)

Form

5307

(Rev. 3-2008)

*11832Y03200803*

Form 5307 (Rev. 3-2008)

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8 (continued) Yes No e f g 9a Is this a section 412(i) plan? Has this plan been involved in a merger? (If "Yes," see instructions) Has the plan been amended or restated to change the type of plan? (If "Yes," see instructions) Do you maintain any other qualified plan(s) under section 401(a)? If "Yes," attach required statement per instructions. If "No," skip to line 9d. b Do you maintain another plan of the same type (i.e. both this plan and the other plan are defined contribution plans or both are defined benefit plans) that covers non-key employees who are also covered under this plan? If "Yes," when the plan is top-heavy, do the non-key employees covered under both plans receive the required top-heavy minimum contribution or benefit under: (See instructions) (1) This plan, or (2) The other plan? c If this is a defined contribution plan, do you maintain a defined benefit plan (or if this is a defined benefit plan, do you maintain a defined contribution plan) that covers non-key employees who are also covered under this plan? If "Yes," when the plan is top-heavy, do non-key employees covered under both plans receive: (See instructions) (1) The top-heavy minimum benefit under the defined plan, (2) At least a 5% minimum contribution under the defined contribution plan, (3) The minimum benefit offset by benefits provided by the defined contribution plan, or (4) Benefits under both plans that, using a comparability analysis, are at least equal to the minimum benefit? Does the plan prevent the possibility that the section 415 limitations will be exceeded for any employee who is (or was) a participant in this plan and any other plan of the employer?

d

Form

5307

(Rev. 3-2008)

*11832Y03200804*

Form 5307 (Rev. 3-2008)

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Yes 10a

No Does any amendment to the plan reduce or eliminate any section 411(d)(6) protected benefit including an amendment adopted after September 6, 2000, to eliminate the joint and survivor annuity form of benefit? (See instructions) Are trust earnings and losses allocated on the basis of account balances in a defined contribution plan? If "No," attach a statement explaining how they are allocated. Is this plan or trust currently under examination or is any issue related to this plan or trust currently pending before the:

b

c d e f g

Internal Revenue Service, Department of Labor, Pension Benefit Guaranty Corporation, Voluntary Compliance Resolution Program of the Employee Plans Compliance Resolution System (EPCRS), or Any Court. If "Yes," attach a statement explaining the issues involved and the contact person's name (IRS Agent, DOL Investigator, etc.) and telephone number.

Optional determination request regarding the ratio percentage test. A determination regarding the average benefit test may be requested by attaching Schedule Q (Form 5300). (See instructions) 11 Is this a request for a determination regarding the ratio percentage test of Regs. section 1.410(b)-2(b)(2) or a request for a determination regarding one of the special requirements of Regs. section 1.410(b)-2(b)(5), (6), or (7)? If "Yes," complete only lines 11a through 11n for a ratio percentage test determination, or complete only line 11o for a determination regarding one of the special requirements. If "No," skip to line 12. Is this plan disaggregated into two or more separate plans that are not section 401(k), 401(m), or profit sharing plans? If "Yes," see the instructions and attach separate schedules for each disaggregated portion. Does the employer receive services from any leased employees as defined in section 414(n)?

a b

c d e

Coverage date (MMDDYYYY). See instructions for inserting date. Total number of employees (including self-employed individuals) (employer-wide) Statutory and regulatory exclusions under this plan (do not count an employee more than once): (1) Number of employees excluded because of minimum age or years of service required (2) Number of employees excluded because of inclusion in a collective bargaining unit (3) Number of employees excluded because they terminated employment with less than 501 hours of service and were not employed on the last day of the plan year
Form

5307

(Rev. 3-2008)

*11832Y03200805*

Form 5307 (Rev. 3-2008)

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11e (continued) (4) Number of employees excluded because employed by other qualified separate lines of business (QSLOBs)

(5) Number of employees excluded because they were nonresident aliens with no earned income from sources within the United States

f Total statutory and regulatory exclusions (add lines 11e(1) through 11e(5))

g Nonexcludable employees (subtract line 11f from line 11d)

h Number of nonexcludable employees on line 11g who are highly compensated employees (HCEs)

i Number of nonexcludable HCEs on line 11h benefiting under the plan j Number of nonexcludable employees who are nonhighly compensated employees (NHCEs) (subtract line 11h from 11g) k Number of nonexcludable NHCEs on line 11j benefiting under the plan

l Ratio percentage (See instructions) m Enter the ratio percentage for the following, if applicable: (1) Section 401(k) part of the plan

(2) Section 401(m) part of the plan Yes n No Are the results on line 11l or 11m based on the aggregated coverage of more than one plan? If "Yes," attach a statement listing the names, plan numbers, EINs, and benefit/allocation formula of the other plans. All aggregated plans should be filed concurrently.

o If the plan satisfied coverage using one of the special requirements of Regulations section 1.410(b)-2(b)(5), (6), or (7) enter the letter from the list below that identifies the special rule. A = 1.410(b)-2(b)(5) - No NHCEs employed B = 1.410(b)-2(b)(6) - No HCEs benefit C = 1.410(b)-2(b)(7) - Collectively bargained only
Form

5307

(Rev. 3-2008)

*11832Y03200806*

Form 5307 (Rev. 3-2008)

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7

Determination request regarding the nondiscrimination design-based safe harbors of section 401(a)(4). See instructions

Yes 12

No Is this a request for a determination regarding a design-based safe harbor under section 401(a)(4)?

Design-based nondiscrimination safe harbors: a b c Does the plan provide for disparity in contributions or benefits that is intended to meet the permitted disparity requirements of section 401(l)? If "Yes," answer line 12b. Otherwise, skip to line 12c. Do the provisions of the plan ensure that the overall permitted limits will not be exceeded? Enter the letter ("A" - "G") from the list below that identifies the safe harbor intended to be satisfied. A = 1.401(a)(4)-2(b)(2) defined contribution (DC) plan with uniform allocation formula B = 1.401(a)(4)-3(b)(3) unit credit defined benefit (DB) plan C = 1.401(a)(4)-3(b)(4)(i)(C)(1) unit credit DB fractional rule plan D = 1.401(a)(4)-3(b)(4)(i)(C)(2) flat benefit DB plan E = 1.401(a)(4)-3(b)(5) insurance contract plan F = 1.401(a)(4)-8(b)(3) target benefit plan G = 1.401(a)(4)-8(c)(3)(iii)(b) cash balance plan d List the plan section(s) that satisfy the safe harbor (including, if applicable, the permitted disparity requirements)

Form

5307

(Rev. 3-2008)

*11832Y03200807*

Form 5307 (Rev. 3-2008)

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8

Procedural Requirements Checklist
Use this list to ensure that your submitted package is complete. Failure to supply the appropriate information may result in a delay in the processing of the application. 1. 2.
3.

Is Form 8717, User Fee for Employee Plan Determination, Opinion, and Advisory Letter Request, attached to your submission? Is the appropriate user fee for your submission attached to Form 8717? If appropriate, is Form 2848, Power of Attorney and Declaration of Representative, Form 8821, Tax Information Authorization, or a privately designed authorization attached? (For more information, see the Disclosure Request by Taxpayer in the instructions and Rev. Proc. 2007-4.) Is a copy of your plan's latest determination letter, if any, attached? Have you included a copy of the plan, trust, and all amendments since your last determination letter? Is the Employer Identification Number (EIN) of the plan sponsor/employer (not the trust's EIN) entered on line 1h? Does line 4d provide the plan's original effective date? Is the application signed and dated? (Stamped signatures are not acceptable; see Rev. Proc. 2007-4.) Have interested parties been given the required notification of this application? Make sure line 3i is completed. (See instructions) If your plan is a master or prototype, have you included a copy of the adoption agreement and opinion letter? If your plan is a volume submitter, have you included: (See What To File in the instructions.) A copy of the plan document and/or adoption agreement; The current advisory letter; A list of modifications, if applicable; A copy of the trust instrument; and A copy of all amendments?

4. 5. 6. 7. 8. 9. 10. 11.

12.

If you answered "Yes" to line(s) 6a and/or 6b, have you included the information requested in the instructions for those lines? If you answered "Yes" to line 9a, have you included the information requested in the instructions for line 9a?

13.

Form

5307

(Rev. 3-2008)

*11832Y03200808*

Form 5307 (Rev. 3-2008)

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Procedural Requirements Checklist (continued) Have all questions on Form 5307, (1-12) been answered? If you answered "No" to lines 11 and 12, and you are requesting additional determinations, are the Schedule Q and applicable Demos attached? (See instructions for Schedule Q) Demo 1 Demo 3 Demo 4
16.

14. 15.

Demo 5 Demo 6 Demo 7

Demo 8 Demo 9 Demo 10

Demo 11

If applicable, have you included the signed and dated Form 8905, Certification of Intent To Adopt a Pre-approved Plan?

Form
Printed on recycled paper

5307

(Rev. 3-2008)

*11832Y03200809*