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Enter 7 for other and specify the type

By mail or fax — Send in a completed

first testing year for which such notice

Form SS-4, Application for Employer

of plan.

applied on line 7b. Enter the date the

Identification Number, to apply for an

notice was filed on line 7c.

Line 6a. Enter the total number of

EIN.

plans, other than the plan named on

Line 8. Enter the first testing year for

Note. Form SS-4 can be obtained at

line 4a, involved in this transaction.

which this notice applies. See When To

Social Security Administration (SSA)

Lines 6c through 6h. Complete lines

File for the definition of “testing year.”

offices or by calling 1-800-TAX-FORM.

6c through 6h for the other plan(s)

Line 9. Indicate whether you are filing

involved in the merger or consolidation,

For the plan of a group of entities

this form to give notice that you are no

spinoff, or transfer of plan assets or

required to be combined under sections

longer testing on a QSLOB basis. If

liabilities with the plan named on line

414(b), (c), or (m), whose sponsor is

your answer to line 9 is “Yes,” complete

4a. If there is more than one other plan,

more than one of the entities required

line 10 and skip lines 11 and 12.

attach a separate statement showing

to be combined, enter the EIN of only

Answer line 10 based on the previously

the information requested for lines 6c

one of the sponsoring members. This

filed notice that you are now revoking. If

through 6h.

EIN must be used in all subsequent

your answer to line 9 is “No,” complete

filings of determination letter requests,

Example: Plans A, B, and C are

lines 10 through 12. See Who Must File

and for filing annual returns/reports

merging with Plan D. Plan D would

for an example of a revocation.

unless there is a change of sponsor.

complete a Form 5310-A, reporting

Line 10. Section 414(r) provides rules

Line 3. The contact person will receive

information about itself on line 4. Plan

for determining whether an employer

copies of all correspondence as

D would then complete the line 6

operates QSLOBs for purposes of

authorized in a Form 2848, or Tax

information for Plan A and attach two

applying sections 410(b) (relating to

statements showing the line 6

Information Authorization, Form 8821.

minimum coverage), 401(a)(26)

information for Plans B and C. In

Either complete the contact’s

(relating to minimum participation

information on this line, or check the

addition, Plans A, B, and C must each

rules), and 129(d)(8) (relating to

box and attach a completed Form 2848

file a separate Form 5310-A (see the

dependent care assistance programs).

example of a plan merger).

or Form 8821.

If you are treated as operating QSLOBs

Line 6h. Enter the code that describes

Part II—Plan Merger,

under section 414(r), you will be

the other plan.

permitted to apply the aforementioned

Consolidation, Spinoff,

Enter 1 for a defined benefit plan.

Code provisions separately for the

employees in each QSLOB. Check the

Enter 2 for a profit-sharing plan.

or Transfer

appropriate box(es) for the section(s)

Enter 3 for a profit-sharing/401(k)

you are testing on a QSLOB basis. See

Line 4a. Enter the name you

plan.

instructions for line 9 to determine how

designated for your plan. Due to space

Enter 4 for a stock bonus plan.

to answer this question if you answered

restrictions, this field is limited to 70

‘‘Yes’’ to line 9.

characters, including spaces. Due to

Enter 5 for an ESOP plan.

this restriction, “Employee” and “Trust”

Enter 6 for a money purchase plan.

Line 11. Attach a list identifying the

are not necessary in the plan name.

part or parts of the employer that make

Enter 7 for a target benefit plan.

Line 4b. Enter the 3-digit number,

up each QSLOB of the employer. The

beginning with “001” and continuing in

Part III—Qualified

list should include, for example, the

numerical order for each plan you

type of business or industry in which

Separate Lines of

adopt (001 – 499). The number

the QSLOB is involved, the business

assigned to a plan must not be

unit (such as corporation, partnership,

Business

changed or used for any other plan.

or division) the qualified line of business

This should be the same number that

Rev. Proc. 93-40, 1993-2 C.B. 535,

comprises, and the name (formal or

was or will be used when the Form

contains procedures relating to the

informal) of the QSLOB.

5500 series returns/reports are filed for

notification requirements of section

Line 12. Enter the information

the plan.

414(r)(2)(B).

requested on lines 12a through 12e. If

Lines 5a. Attach an actuarial

Notice given by an employer applies

there is more than one plan, attach a

statement of valuation showing

to all plans maintained by the employer

separate statement showing the

compliance with section 414(l). The

for plan years beginning in the testing

information requested on lines 12a

statement must (1) identify the type of

year. Once the notification date (see

through 12e for each plan.

transaction involved (for example,

When To File) for a testing year has

merger or consolidation, spinoff, or

Line 12b. Enter the date of the

passed, the employer is deemed to

transfer of plan assets or liabilities), and

determination letter, if any. Otherwise,

have irrevocably elected to apply the

(2) provide information verifying

leave blank.

specified section(s) on the basis of

compliance with the requirements of

QSLOBs for all plan years beginning in

Line 12c. If the plan is a master or

sections 401(a)(12) and 414(l). This

the testing year.

prototype or volume submitter plan,

statement need not be signed by an

In addition, after the notification

enter the date of the letter and the

actuary.

date, notice cannot be modified,

serial number or the advisory letter

Line 5b. Enter the code that describes

withdrawn, or revoked, and will be

number, as applicable.

your plan.

treated as applying to subsequent

Line 12d. Enter the appropriate date

Enter 1 for a profit-sharing plan.

testing years unless the employer takes

of any pending letter request. If this

timely action to provide new notice (see

Enter 2 for a stock bonus plan.

question is not applicable, leave blank.

examples under Who Must File). Timely

Enter 3 for a money purchase plan.

action will be deemed to have been

Line 12e. List on this line the QSLOBs

Enter 4 for a target benefit plan.

taken any time prior to the notification

identified on line 11 that have

Enter 5 for a profit-sharing/401(k)

date for any subsequent testing year.

employees benefiting under the plan. If

plan.

Line 7a. If you previously filed a notice

you need additional space to list the

Enter 6 for an ESOP plan.

of QSLOB for a testing year, enter the

QSLOBs, use the area below line 12e.

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Instruction For Form 5310-A - Notice Of Plan Merger Or Consolidation, Spinoff, Or Transfer Of Plan Assets Or Liabilities; Notice Of Qualified Separate Lines Of Business Page 4

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