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determination letter has ever been

children is considered a payment to

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

received by the employer, submit

one beneficiary.

list for each plan with the following

copies of the initial plan, or the latest

information:

Line 5, item 5. Cash balance. For

plan for which you do have a

1. Name of plan,

this purpose, a ‘‘cash balance’’

determination letter, and any

2. Type of plan,

formula is a benefit formula in a

subsequent amendments and/or

3. Plan number, and

defined benefit plan by whatever

restatements including all adoption

4. Indicate if another application is

name (e.g., personal account plan,

agreements.

simultaneously being submitted with

pension equity plan, life cycle plan,

Line 3c. Section 3001 of ERISA

this application.

cash account plan, etc.) that rather

requires the applicant to provide

than, or in addition to, expressing the

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

evidence that each employee who

accrued benefit as a life annuity

and M-14 of Regulations section

qualifies as an interested party has

commencing at normal retirement

1.416-1.

been notified of the filing of the

age, defines benefits for each

application. If “Yes” is checked, it

Lines 9b and 9c. If the plan is a

employee in terms more common to a

means that each employee has been

401(k) plan, complete these line

defined contribution plan such as a

notified as required by Regulations

items for the nonelective employer

single sum distribution amount (e.g.,

section 1.7476-1 or this is a

contribution portion of the plan, if

10 percent of final average pay times

one-person plan. A copy of the notice

applicable.

years of service, or the amount of the

is not required to be attached to this

employee’s hypothetical account

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

application. If “No” is checked or this

balance).

protected benefits include:

•

line is blank, your application will be

The accrued benefit of a participant

Line 6. If the plan employer is a

returned.

as of the later of the amendment’s

member of a controlled group of

Rules defining ‘‘interested parties’’

adoption date or effective date; and

corporations, trades or businesses

•

and the form of notification are in

Any early retirement benefit,

under common control, or an affiliated

Regulations section 1.7476-1. For an

retirement-type subsidy or optional

service group, all employees of the

example of an acceptable format, see

form of benefit for benefits from

group will be treated as employed by

Rev. Proc. 2004-6, 2004-1 I.R.B. 197

service before such amendment.

a single employer for purposes of

or the superseding revenue

certain qualification requirements.

If the answer is “Yes,” explain on

procedure published annually in the

an attachment how the amendment

Attach a statement showing in

Internal Revenue Bulletin.

satisfies one of the exceptions to the

detail:

Line 4b. Enter the three-digit

prohibition on reduction or elimination

1. All members of the group;

number, beginning with ‘‘001’’ and

of section 411(d)(6) protected

2. Their relationship to the plan

continuing in numerical order for each

benefits.

employer;

plan you adopt (001-499). This

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

Optional Ratio

numbering will differentiate your

member has, and

plans. The number assigned to a plan

Percentage Test

4. Plans common to all members.

must not be changed or used for any

other plan. This should be the same

Determination

number that was or will be used when

If you want to apply for a

Line 13. This question may be used

the Form 5500 or Form 5500-EZ is

TIP

determination letter to

to request an optional determination

filed for the plan.

determine if you are a

regarding the ratio percentage test

member of an affiliated service group,

Line 4c. “Plan year” means the

under Regulations section

attach the information described on

calendar, policy, or fiscal year on

1.410(b)-2(b)(2). If ‘‘No’’ is checked

line 3a, item 3 and leave this line

which the records of the plan are

and a request for a determination

blank.

kept.

regarding the average benefit test is

Line 4e. Enter the total number of

Line 7e. A “multiple-employer plan”

not made on Schedule Q, the

participants. A “participant” means:

is a plan maintained by more than

determination letter for the plan will

one employer, but which is not

not be a determination regarding

1. The total number of

maintained under a collective

section 410(b). If ‘‘No’’ is checked but

employees participating in the plan

bargaining agreement. Under this

a request for a determination

including employees under a section

plan type, contributions from each

regarding the average benefit test is

401(k) qualified cash or deferred

employer must be available to pay

made on Schedule Q, the

arrangement who are eligible but do

benefits of any participant, even if

determination letter for the plan will

not make elective deferrals,

employed by another employer. Also,

also be a determination regarding the

2. Retirees and other former

enter the number of employers

average benefit test. Plans using the

employees who have a nonforfeitable

adopting the plan. See section

qualified separate lines of business

right to benefits under the plan, and

413(c).

rules of section 414(r) must file

3. The beneficiary of a deceased

Schedule Q if a determination is

employee who is receiving or will in

Line 7f. A “multiemployer plan” (as

desired that the plan satisfies the

the future receive benefits under the

described in section 414(f)) is one to

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

plan. Include one beneficiary for each

which more than one employer is

or the special requirements for

deceased employee regardless of the

required to contribute and which is

employer wide plans.

number of individuals receiving

maintained under one or more

benefits.

collective bargaining agreements

Line 13a. If a determination is being

between one or more employee

requested and the plan is

Example: Payment of a

organizations and more than one

disaggregated into two or more

deceased employee’s benefit to three

employer.

separate plans, that are other than

-5-

Instructions For Form 5300 - Application For Determination For Employee Benefit Plan - 2004 Page 5

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