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check the box and attach a power of

provided by such services, if

possible member) of the same

attorney or other written designation.

available, and data as to whether

affiliated service group, accompanied

their services are a significant portion

by a statement as to whether the

Line 3a. Enter the number(s) that

of the member’s business and

facts upon which the ruling or

correspond to the request(s) being

whether or not, as of December 13,

determination letter was based have

made.

1980, it was unusual for the services

changed.

Enter 1 if the IRS has not issued a

to be performed by employees of

determination letter for this plan.

Enter 4 if you are not certain

organizations in that service field in

whether or not you have leased

Enter 2 if the IRS has previously

the United States.

employees and attach the following

6. A description of how the

issued a determination letter for this

information:

employer and the members (or

plan and enter the date the plan was

possible members) of the affiliated

signed.

1. A description of the nature of

service group associate in performing

the business of the recipient

In addition, enter the date the plan

services for other parties.

organization;

or amendment was signed. If a plan

7. a. A description of

2. A copy of the relevant leasing

or amendment is proposed, enter “9/

management functions, if any,

agreement(s);

9/9999.” Enter the effective date

performed by the employer for the

3. A description of the function of

where requested. The term “Date

members (or possible members) of

all leased employees in the trade or

amendment effective” means the date

the affiliated service group, or

business of the recipient organization

the amendment becomes operative

received by the employer from any

(including data as to whether all

or takes effect.

other members (or possible

leased employees are performing

Enter 3 if requesting a letter

members) of the group (including

services on a substantially full-time

concerning the effect of section

data as to whether such management

basis);

414(m) on the plan being submitted

functions are performed on a regular

4. A description of facts and

or because of a change in the

and continuous basis) and whether or

circumstances relevant to a

affiliated service group (ASG)

not it is unusual for such

determination of whether such leased

membership or if you are not certain if

management functions to be

employees’ services are performed

you are a member of an ASG, attach

performed by employees of

under primary direction or control by

the following information:

organizations in the employer’s

the recipient organization (including

1. A description of the nature of

business field in the United States.

whether the leased employees are

the business of the employer.

b. If management functions are

required to comply with instructions of

Specifically state whether it is a

performed by the employer for the

the recipient about when, where, and

service organization or an

members (or possible members) of

how to perform the services, whether

organization whose principal

the affiliated service group, describe

the services must be performed by

business is the performance of

what part of the employer’s business

particular persons, whether the

management functions for another

constitutes the performance of

leased employees are subject to the

organization, including the reason for

management functions for the

supervision of the recipient, and

performing the management function

members (or possible members) of

whether the leased employees must

or service,

the group (including the percentage

perform services in the order or

2. The identification of other

of gross receipts derived from

sequence set by the recipient), and

members (or possible members) of

management activities as compared

5. If the recipient organization is

the affiliated service group.

to the gross receipts from other

relying on any qualified plan(s)

3. A description of the nature of

activities).

maintained by the employee leasing

the business of each member (or

8. A brief description of any other

organization for purposes of

possible member) of the affiliated

plan maintained by the members (or

qualification of the recipient

service group including the type of

possible members) of the affiliated

organization’s plan, a description of

organization (corporation,

service group, if such other plan is

the plan(s) (including a description of

partnership, etc.) and indicate

designated as a unit for qualification

the contributions or benefits provided

whether such member is a service

purposes with the plan for which a

for all leased employees that are for

organization or an organization

determination letter has been

services performed for the recipient

whose principal business is the

requested.

organization, plan eligibility, and

performance of management

9. A description of how the plan(s)

vesting).

functions for the other group

satisfies the coverage requirements

member(s).

of section 410(b) if the members (or

Enter 5 if this is a request for the

4. The ownership interests

possible members) of the affiliated

effect a potential partial termination

between the employer and the

service group are considered part of

will have on the plan’s qualification.

members (or possible members) of

an affiliated service group with the

“Date Effective” means the date the

the affiliated service group (including

employer.

plan amendment, ASG status, or

ownership interests as described in

10. A copy of any ruling issued by

partial termination becomes

section 414(m)(2)(B)(ii) or

the National Office on whether the

operative, takes effect, or changes.

414(m)(6)(B)).

employer is an affiliated service

Enter 6 if a determination letter is

5. A description of services

group; a copy of any prior

requested on the termination of a

performed for employers by the

determination letter that considered

multiemployer plan covered by PBGC

members (or possible members) of

the effect of section 414(m) on the

insurance. Also enter the date the

the affiliated service group, or vice

qualified status of the employer’s

termination is effective.

versa. Include the percentage of each

plan; and, if known, a copy of any

member’s (or possible member’s)

such ruling or determination letter

Line 3b. If you do not have a copy of

gross receipts and service receipts

issued to any other member (or

the latest determination letter, or if no

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Instructions For Form 5300 - Application For Determination For Employee Benefit Plan - 2004 Page 4

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