Free Form 5434 (Rev. 5-2008) - Federal

Form 5434 (Rev. May 2008)

Joint Board for the Enrollment of Actuaries

Application for Enrollment

OMB Clearance Number 1545-0951
For Joint Board Use Only
Enrollment No. Date Enrolled

Enclose with this form your check or money order for $250, payable to the Internal Revenue Service. By regular mail, send to: IRS; P.O. Box 894191; Los Angeles, CA 90189-4191. By overnight mail, send to: IRS- Box 4191; c/o Citibank; 5860 Uplander Way; Culver City, CA 90230. Read instructions on page 3 before completing this form. Type or print.
1. Full Legal Name (Last, First, Middle) 2. Other Names Used (Including Maiden Name and Dates Used)

3. Address (Number, Street, City, State, ZIP Code)

4. E-Mail Address (optional)

5. Daytime Telephone Number (optional) 6. Social Security Number

7. Date of Birth (Month, Day, Year)

8. How many months of responsible experience did you report on Schedule A? (A) Responsible actuarial experience (from item (a) for all blocks of Schedule A) . . . . . . . . . . . . . . . . . . . (B) Responsible pension actuarial experience (from item (b) for all blocks of Schedule A) . . . . . . . . . . . . 9. On what basis did you satisfy the basic actuarial knowledge requirement of section 901.13(c)? Joint Board basic examination(s) Name(s) of exam(s), month(s) and year(s) completed Month(s) Month(s)

Waiver of Joint Board basic examination Qualifying formal education Organization basic examination Other

Date Waiver Received

10. When did you satisfy the pension actuarial knowledge requirement of section 901.13(d)? Name(s) of exam(s), month(s) and year(s) completed

11. Have you previously applied for enrollment by the Joint Board? 12. Have you read and are you familiar with the Joint Board's regulations? 13. Have you timely filed your Federal tax returns and timely paid your Federal taxes for the three tax years preceding your date of application? If no, provide details on a separate page. 14. In the last 15 years or since your 18th birthday, if sooner, have you ever been convicted or fined for a crime under any revenue law or of a crime involving dishonesty or breach of trust? If yes, provide details on a separate page. Declaration and Signature

Yes Yes Yes

No No No

Yes

No

I hereby apply to be enrolled as an actuary. I authorize the Joint Board to inquire about my qualifications and experience from educational institutions, employers, supervisors, actuarial organizations, and any other individuals who may have knowledge related to my qualifications and experience. I authorize all such institutions, employers, supervisors, organizations and others to provide any information requested concerning my education, employment experience and qualifications as an actuary. Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is true, correct, and complete.
15. Signature 16. Date

Form 5434 (Rev. 5-2008)

Catalog Number 42528L

www.irs.gov

Department of the Treasury - Internal Revenue Service

Page 1 of 3

Employment Record-Schedule A
Start with your PRESENT position and work back. Account for the entire period within the last 10 years or, if shorter, since your completion of full-time studies. Account for periods of self-employment in separate blocks in chronological order. Block 1. Dates of Employment (Month, Year)
From To

2. Exact Title of Position

3. Type of Business or Organization

4. Name, position title, address, and telephone number of individual to whom you reported and who can verify and evaluate your experience.

5. Name of Employer and Address

6. In your own words, describe IN DETAIL your actual duties and responsibilities in the above employment. When more than one type of work is included, estimate the proportion of the total period devoted to each type.

(a) How many months of this employment constitute "responsible actuarial experience" as defined in section 901.1(c)? months (b) How many months of ''responsible pension actuarial experience'' as defined in section 901.1(e) are included in (a) above? months

Form 5434 (Rev. 5-2008)

Catalog Number 42528L

www.irs.gov

Department of the Treasury - Internal Revenue Service

Page 2 of 3

Instructions for Form 5434
General Instructions
Before filling out Form 5434, Application for Enrollment, read the regulations (Parts 901 and 902 of Title 20 of the Code of Federal Regulations). Unless otherwise indicated, section numbers (e.g., 901.13(b)) cited on the form and in the instructions refer to the regulations. You may download a copy of the regulations from www.irs.gov/taxpros/actuaries. You should not complete Form 5434 until you have satisfied the qualifying experience in section 901.13(b), the basic actuarial knowledge requirement in section 901.13(c), and the pension actuarial knowledge requirement in section 901.13(d). To register for a Joint Board examination, please contact the Society of Actuaries (www.soa.org). If you send us a check for the application fee, your check will be converted into an electronic fund transfer. The electronic fund transfer from your account will usually occur within 24 hours of receipt. For more information, see www.irs.gov/taxpros/actuaries.

Instructions for Certain Items
Items 6 and 13. As part of the application process, we may check your Federal tax history to verify that you have timely filed and paid your Federal taxes. Item 8. You must have, within the 10-year period immediately preceding the date of application, either (1) a minimum of 36 months of responsible pension actuarial experience or (2) a minimum of 60 months of responsible actuarial experience including at least 18 months of responsible pension actuarial experience. The terms "actuarial experience," "responsible actuarial experience," "responsible pension actuarial experience," and "month of responsible pension actuarial experience" are defined in section 901.1. You should account in Schedule A for all such experience within the last 10 years or, if shorter, since your completion of full-time studies. Item 9. If you are claiming transition credit for an examination taken prior to January, 2001, please so indicate. You may review the transition rules at www.irs.gov/taxpros/actuaries. Schedule A. You must complete and attach Schedule A for your application to be complete. If employment for an employer consisted of two (or more) periods, one of which consisted of responsible pension actuarial experience and the other(s) did not, treat this as different periods of employment in separate blocks of Schedule A. Attach additional Schedules A if needed. In general, the individual(s) asked to verify and evaluate your experience should be your immediate supervisor. However, if you believe that another individual is better able to verify and evaluate your experience, please explain and provide the individual's name, position title, and address in addition to the name, position title, and address of your immediate supervisor. If you believe it is appropriate for several individuals to verify and evaluate your experience for different periods of time with the same employer, please provide the names of such individuals, their position titles, and their addresses.

Privacy Act and Paperwork Reduction Act Notice
Section 1242 of title 29, United States Code, authorizes the Joint Board for the Enrollment of Actuaries (Joint Board) to collect this information. The primary use of the information is to enforce and administer the regulations of the Joint Board governing practice as an actuary under the Employee Retirement Income Security Act of 1974 (ERISA). Other information may be disclosed to: public authorities for use in law enforcement and in connection with employment, contracting, licensing, and other benefits; courts and other adjudicative bodies and to the Department of Justice for litigation purposes; employees of the Department of Labor or the Department of the Treasury for purposes of administering ERISA, including determinations concerning enrollment and discipline; investigative offices of other agencies for fuller development of facts concerning enrollment and discipline; the general public for verifying an individual's actuarial enrollment status. Applying for enrollment is voluntary, however, providing the information requested on this form is a requirement to obtain the benefit of enrollment. Failure to provide the requested information could delay or prevent processing of your application. Providing false information could subject you to penalties. Notwithstanding any other provision of law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act, unless that collection of information displays a currently valid OMB Control Number. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Joint Board for the Enrollment of Actuaries c/o IRS, Office of Professional Responsibility; SE:OPR; 1111 Constitution Avenue, NW; Washington, DC 20224. Form 5434 (Rev. 5-2008) Catalog Number 42528L www.irs.gov Department of the Treasury - Internal Revenue Service

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