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Due to this restriction, please keep in

requirements. Attach a statement which

which more than one employer is

mind that “Employees” and “Trust” are

provides the following in detail:

required to contribute and which is

not needed and will be left off if space

maintained under one or more

1. All members of the group;

does not permit.

collective bargaining agreements

2. The relationship of each member

between one or more employee

Line 4b. Enter the three-digit number,

to the plan sponsor;

organizations and more than one

beginning with ‘‘001’’ and continuing in

3. The type(s) of plan(s) maintained

employer.

numerical order for each plan you

by each employer;

adopt (001-499). The numbering will

4. Plans common to all members;

Line 7l . See Rev. Proc. 2011-6 and

differentiate your plans. The number

and

the Appendix thereto.

assigned to a plan cannot be changed

5. If the member of the controlled

Line 7m. A foreign trust is a trust that

or used for any other plan. This should

group is a foreign entity.

was not created or organized in the

be the same number that was or will be

United States. If you have a Puerto

Line 6c. If the election to use Cycle A

used when the Form 5500, Form

Rican plan, was the irrevocable election

under Rev. Proc. 2007-44 was made

5500-EZ, or Form 5500-SF is filed for

in ERISA section 1022(i) made? If

submit a copy of the signed and dated

the plan.

“Yes,” provide the election or provide

election. Include a copy of the

Line 4c. Plan year means the

the statement making the election with

controlled group election with each

calendar, policy, or fiscal year on which

the DL that the election is made in

submission of that controlled group.

the records of the plan are kept. Enter

accordance with ERISA section 1022(i).

Note. If you want to apply for a DL to

the two-digit month (mm) on which the

Line 8a. If “Yes” is checked, attach a

determine if you are a member of an

plan year ends.

statement for each plan with the

ASG, leave this line blank and enter “3”

Line 4e. Enter the total number of

following information:

on line 3a and attach the information

participants. A participant means:

1. Name of plan,

per the instructions for this item.

1. The total number of employees

2. Type of plan,

Line 7f. If the plan has been involved

participating in the plan including

3. Form of plan (standardized,

in a merger, attach a statement which

employees under a section 401(k)

nonstandardized, volume submitter, or

provides the following:

qualified cash or deferred arrangement

individually designed),

who are eligible but do not make

1. Name of the plan(s) involved;

4. Plan number,

elective deferrals,

2. Type of plan(s) involved;

5. Vesting schedule, and

2. Retirees and other former

3. Date(s) of merger(s); and

6. Whether the plan has received a

employees who have a nonforfeitable

4. Verification that each plan

DL or an application for a letter is

right to benefits under the plan, and

involved was qualified at the time of

pending with IRS.

3. The beneficiary of a deceased

merger (copy of prior DL, if any,

Lines 8b and 8c. See M-8, M-12, and

employee who is receiving or will in the

otherwise provide a signed and dated

future receive benefits under the plan.

M-14 of Regulations section 1.416-1.

copy of most recent restatement and

Include one beneficiary for each

subsequent amendments).

Line 12a. Section 411(d)(6) protected

deceased employee regardless of the

benefits include:

Notes.

number of individuals receiving

•

The accrued benefit of a participant

•

The plan and amendments submitted

benefits.

as of the later of the amendment’s

to verify that plans were qualified prior

adoption date or effective date; and

Example. Payment of a deceased

to the merger are for information

•

Any early retirement benefit,

employee’s benefit to three children is

purposes only and will not be ruled on.

retirement-type subsidy, or optional

•

considered a payment to one

If applicable, file Form 5310-A,

form of benefit for benefits from service

beneficiary.

Notice of Plan Merger or Consolidation,

before such amendment.

Spinoff, or Transfer of Plan Assets or

Line 5.

If “Yes,” attach a statement which

•

Liabilities; Notice of Qualified Separate

Cash balance plan. For this

provides how the amendment satisfies

Lines of Business, 30 days prior to the

purpose, a “cash balance” formula is a

one of the exceptions to the prohibition

merger, consolidation, or transfer of

benefit formula in a defined benefit plan

on reduction or elimination of section

assets or liabilities.

by whatever name (for example,

411(d)(6) protected benefits.

personal account plan, pension equity

Line 7g. If the plan has been restated

Line 13. This question may be used

plan, life cycle plan, cash account plan,

to change the type of plan under

to request a determination regarding

etc.) that rather than, or in addition to,

Regulations section 1.401-1, answer

the ratio percentage test under

expressing the accrued benefit as a life

this question “Yes” and attach a

Regulations section 1.410(b)-2(b)(2).

annuity commencing at normal

statement explaining the change.

retirement age, defines benefits for

Notes.

Line 7h. A multiple employer plan is

•

each employee in terms more common

If “No” is checked and a request for a

a plan maintained by more than one

to a defined contribution plan such as a

determination regarding the average

employer, but which is NOT maintained

single sum distribution amount (for

benefit test is not made on Schedule Q,

under a collective bargaining

example, 10 percent of final average

the DL for the plan will not be a

agreement. Under this plan type,

pay times years of service, or the

determination regarding section 410(b).

contributions from each employer must

amount of the employee’s hypothetical

•

If “No” is checked but a request for a

be available to pay benefits of any

account balance).

determination regarding the average

participant, even if employed by

•

For an ESOP. If the plan contains

benefit test is made on Schedule Q, the

another employer. Also, enter the total

the loan language for a leveraged

DL for the plan will also be a

number of employers adopting the plan.

ESOP, then the application should be

determination regarding the average

Include a statement in each plan that

marked as such, even though in

benefit test.

was submitted that includes the

operation the plan has not utilized this

•

Plans using the qualified separate

sponsor name(s) and EIN(s) of all the

provision.

lines of business rules of section 414(r)

cases that were submitted. See section

Lines 6a and 6b. If the employer is a

must file Schedule Q if a determination

413(c).

member of a controlled group of

is desired that the plan satisfies the

Line 7i. Attach a statement indicating

corporations, trades or businesses

gateway test of section 410(b)(5)(B) or

the plan sponsor name and EIN of all

under common control, or an ASG, all

the special requirements for employer

cases submitted with the lead plan.

employees of the group will be treated

wide plans.

•

as employed by a single employer for

Line 7k. A multi-employer plan (as

If “Yes” and 13(l) is 70% or more,

purposes of certain qualification

described in section 414(f)) is one to

then a request cannot be made for

-5-

Instructions For Form 5300 - Application For Determination For Employee Benefit Plan - Department Of Treasury Page 5

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