Free Form 5434-A (Rev. 1-2008) - Federal

Form 5434-A (Rev. January 2008)

Joint Board for the Enrollment of Actuaries

Application for Renewal of Enrollment

OMB Clearance Number 1545-0951

Instructions: This application form MUST be received by the Internal Revenue Service by March 1, 2008. All individuals enrolled before January 1, 2008, are required by 20 CFR 901.11(d) to renew their enrollment in order to maintain active enrollment to perform actuarial services. Enclose with this form your check or money order for $250 (two hundred fifty) payable to the Internal Revenue Service. If you want to send your form by regular mail, send it to: IRS; P.O. Box 894191; Los Angeles, CA 90189-4191. If you want to send your form by overnight mail, send it to: IRS - Box 4191; C/O Citibank; 5860 Uplander Way; Culver City, CA 90230. Enrollment Number:

1. Provide the following information.
Name

Address (Street)

City

State

Zip Code

Home Telephone Number (Include Area Code)

Business Telephone Number (Include Area Code)

Check here if any information has changed since the last submission.

2. Please check one block for each of the following questions. A. Since the issuance or latest renewal of your enrollment, have you been disciplined for alleged misconduct (Yes) (No) by any professional body or licensing authority? If Yes, attach a statement specifying the date, name, and location of the disciplinary authority, the nature of the misconduct, and the type of discipline imposed. B. Since the issuance or latest renewal of your enrollment, have you been convicted of, or fined for, a crime under the revenue laws or a crime involving dishonesty or breach of trust? If Yes, attach a statement providing details. C. Since the issuance or latest renewal of your enrollment, have you timely filed all required U.S. tax returns which became due? If No, attach a statement specifying the type of return, the taxable period covered by the return, and the type and amount of any penalties imposed. D. Are you familiar with those portions of the Employee Retirement Income Security Act of 1974 and the regulations of the Joint Board for the Enrollment of Actuaries that relate directly or indirectly to the responsibilities of an enrolled actuary? (Yes) (No)

(Yes) (No)

(Yes) (No)

3. Enter the total hours of qualifying continuing professional education completed in each category shown in the space provided below: (Core Hours) A. Participant in a formal program and/or correspondence or individual study programs, including audio and video taped programs, and/or teleconferencing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. Serving as an instructor, discussion leader, or speaker . . . . . . . . . . . . . . . . . C. Credit for published articles, books, films, audio and video tapes, etc. . . . . . . D. Service on Joint Board advisory committees or preparation of Joint Board examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E. Credit earned by examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Total Hours
Form

(Non-Core Hours)

5434-A (Rev. 01-2008)

Catalog Number 63767O

publish.no.irs.gov

Department of the Treasury - Internal Revenue Service

4. If you are not reporting continuing education credit because you were initially enrolled between January 1, 2007 and December 31, 2007, check here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. If you are not reporting continuing education credit because you have received a waiver of that requirement, attach a copy of the waiver and check here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. If you are not reporting continuing education credit because you wish to be placed in retirement status, check here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. Declaration and Signature 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.
7a. Signature 7b. Date Signed

7c. Email Address (optional):

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). 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 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 renewal of enrollment is voluntary; however, providing the information requested on this form is a requirement to obtain the benefit of renewal 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 27 minutes 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-A (Rev. 01-2008)

Catalog Number 63767O

publish.no.irs.gov

Department of the Treasury - Internal Revenue Service