Application For Determination For Adopters Of Master Or Prototype Or Volume Submitter Plans

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Application for Determination for Adopters of
5307
OMB No. 1545-0200
Form
For IRS Use Only
Master or Prototype or Volume Submitter Plans
(Rev. September 2001)
Department of the Treasury
(Under sections 401(a) and 501(a) of the Internal Revenue Code)
Internal Revenue Service
Review the Procedural Requirements Checklist on page 4 before submitting this application.
1a
Name of plan sponsor (employer if single-employer plan)
1b Employer identification number
Number, street, and room or suite no. (If a P.O. box, see instructions.)
1c
Employer’s tax year ends—Enter (MM)
City
State
ZIP code
1d
Telephone number
(
)
2a
Person to contact if more information is needed. (See instructions.) (If Form 2848, Power of Attorney
1e
Fax number
and Declaration of Representative, or other written designation is attached, check box and do not
(
)
complete the rest of this line.)
Name
Number, street, and room or suite no. (If a P.O. box, see instructions.)
2b
Telephone number
(
)
City
State
ZIP code
2c
Fax number
(
)
3a
Determination requested for (enter applicable number(s) in the box and fill in required information.) (See instructions.)
/
/
Enter 1 for Initial Qualification—Date plan signed
Enter 2 for a request after Initial Qualification
/
/
Date amendment signed
/
/
Date amendment effective
Enter 3 for Standardized Plans (See instructions)
b
Has the plan received a determination letter?
Yes
No
/
/
Date of letter
If “Yes” submit a copy of the latest letter and subsequent amendments.
Number of amendments
If “No,” submit all prior plan(s) and/or adoption agreement(s). (See instructions.)
c
Have interested parties been given the required notification of this application? (See instructions)
Yes
No
d
Does the plan have a cash or deferred arrangement (section 401(k))?
Yes
No
e
Does the plan have matching contributions (section 401(m))?
Yes
No
f
Does the plan have after-tax employee voluntary contributions (section 401(m))?
Yes
No
g
Does the plan provide for disparity in contributions or benefits that is intended to meet the permitted
disparity requirements of section 401(l)?
Yes
No
4a
Name of plan (Plan name may not exceed 66 characters, including spaces.):
/
/
b
Enter 3-digit plan number
d
Enter plan’s original effective date (MMDDYYYY)
/
c
Enter date plan year ends (MMDD)
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
4—defined benefit but not cash balance
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.
Print Name
Title
Signature
Date
5307
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 11832Y
Form
(Rev. 9-2001)

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