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profit sharing and/or sections 401(k)

permit the employer to exclude

For this purpose, an employee

and/or 401(m) plans, complete lines

certain former nonhighly

covered under a CBA is not

13b through 13n with respect to each

compensated employees.

considered a collectively bargained

disaggregated portion of the plan.

employee if more than 2% of the

Exception. This exception applies

Attach additional schedules as

employees who are covered under

only to plans that include a qualified

necessary to identify the other

the agreement are professional

cash or deferred arrangement under

disaggregated portions of the plan.

employees as defined in Regulations

section 401(k) or employee or

Provide the requested coverage

section 1.410(b)-9.

matching contributions under section

information, in the same format as

Line 13e(3). Enter the number of

401(m). If there are any contributions

line 13, separately with respect to the

employees who do not receive an

under the plan that are not subject to

other portions of the plan, or to

allocation or accrue a benefit under

the special rule for section 401(k)

otherwise show that the other

the plan only because they do not

plans and section 401(m) plans in

portions of the plan separately satisfy

satisfy a minimum hours of service

Regulations section

section 410(b).

requirement or a last day of the plan

1.401(a)(4)-1(b)(2)(ii)(B) (such as

Example. If this plan benefits the

year requirement, provided they do

nonelective contributions), complete

employees of more than one qualified

not have more than 500 hours of

lines 13e through 13k with respect to

separate line of business (QSLOB),

service, and they are not employed

the portion of the plan that includes

the portion of the plan benefiting the

on the last day of the plan year. Do

these contributions and enter the ratio

employees of each QSLOB is treated

not enter on this line any employees

percentage for this portion of the plan

as a separate plan maintained by that

who have more than 500 hours of

on line 13l. Otherwise, complete lines

QSLOB and must separately satisfy

service, even if they are not

13e through 13k with respect to the

section 410(b) unless the

employed on the last day of the plan

section 401(k) part of the plan (or the

employer-wide plan testing rule in

year.

section 401(m) plan if there is no

Regulations section

section 401(k) arrangement) and

Line 13e(4). If this plan benefits the

1.414(r)-1(c)(2)(ii) applies.

leave line 13l blank. In all cases,

employees of one QSLOB, enter on

enter the ratio percentages for the

If a determination is being

this line the number of employees of

section 401(k) and the section 401(m)

requested for a section 401(k) and/or

the employer’s other QSLOBs. This is

parts of the plan, as applicable, on

401(m) plan you must complete line

not applicable if the plan is tested

line 13m. These percentages should

13l for the portion of the plan that is

under the special rule for

be based on the actual

not a section 401(k) or a 401(m) plan.

employer-wide plans in Regulations

nonexcludables in the 401(k) and

Also complete line 13m(1) to report

section 1.414(r)-1(c)(2)(ii).

401(m) portions, respectively. It is

the ratio percentage for the section

Line 13e(5). Enter the number of

suggested that these calculations be

401(k) portion of the plan and line

employees who are nonresident

submitted with the application but this

13m(2) to report the ratio percentage

aliens who receive no earned income

is optional.

for the section 401(m) portion of the

(as defined in section 911(d)(2)) from

plan.

the employer that constitutes income

If the plan provides for

Line 13c. If, for purposes of

from sources within the United States

nonelective profit-sharing

satisfying the minimum coverage

(as defined in section 861(a)(3)).

contributions, do not base the

CAUTION

requirements of section 410(b), you

calculations on lines 13m(1) and (2)

Line 13g. Subtract the total of lines

are applying the daily testing option in

on the nonexcludable employees

13e(1) through 13e(5) as reported on

Regulations section 1.410(b)-8(a)(2)

reported on line 13g unless all of the

line 13f from the total employees

or the quarterly testing option in

disaggregated plans (profit sharing,

reported on line 13d. The result is the

Regulations section 1.410(b)-8(a)(3),

401(k), and 401(m)) have the same

number of ‘‘nonexcludable

or, if you are using single-day

nonexcludable employees with the

employees.’’ These are the

‘‘snapshot’’ testing as permitted under

same age and service requirements.

employees who can not be excluded

section 3 of Rev. Proc. 93-42, 1993-2

from the plan for statutory or

Line 13e(1). Enter the number of

C.B. 540, enter the most recent

regulatory reasons and must be

employees who are excluded

eight-digit date (MMDDYYYY) for

considered in the calculation of the

because they have not attained the

which the coverage data is submitted.

ratio percentage even though they

lowest minimum age and service

If you are applying the annual testing

might not ‘‘benefit’’ under the plan. If

requirements for any employee under

option in Regulations section

they meet the age and service

this plan. If the employer is separately

1.410(b)-8(a)(4), enter the year for

requirements of section 410 and are

testing the portion of a plan that

which the coverage data is submitted.

not otherwise excludable employees,

benefits otherwise excludable

Line 13d. Include all employees of

they must be included in this number.

employees, attach a separate

all entities combined under sections

schedule describing which employees

Line 13h. Enter the number of

414(b), (c), (m), or (o). Also include

are treated as excludable employees

employees on line 13g who are highly

all self-employed individuals,

on account of the minimum age and

compensated employees (HCEs) as

common law employees, and leased

service requirements under each

defined in section 414(q).

employees as defined in section

separate portion of the plan.

414(n) of any of the entities above,

Line 13i. In general, an employee is

other than those excluded by section

Line 13e(2). Enter the number of

treated as benefiting under the plan

414(n)(5). Certain individuals may

employees who are excluded

for coverage tests purposes only if

also be required to be counted as

because they are collectively

the employee receives an allocation

employees. See the definition of

bargained employees as defined in

of contributions or forfeitures or

employee in Regulations section

Regulations section 1.410(b)-6(d)(2),

accrues a benefit under the plan for

1.410(b)-9. Also see Regulations

regardless of whether those

the plan year. Certain other

section 1.410(b)-6(i), which may

employees benefit under the plan.

employees are treated as benefiting if

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Instructions For Form 5300 - Application For Determination For Employee Benefit Plan - 2004 Page 6

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