Form 5310 - Application For Determination For Terminating Plan Page 11
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1311
Form 5310 (Rev. 12-2013)
Page
Yes
No
Is any issue involving this plan currently pending or has any issue related to this plan been resolved during the
18
current RAC by:
(1) Internal Revenue Service,
(2) Department of Labor,
(3) Pension Benefit Guaranty Corporation,
(4) Any court (including bankruptcy), or
(5) The Voluntary Correction Resolution Program of the Employee Plans Compliance Resolution System.
If “Yes,” attach a statement with the contact person’s name (IRS Agent, DOL Investigator, etc.) and telephone
number.
19
Enter the information listed on lines 19a through 19c for the plan year of termination and the 5 prior plan years on the
following schedule.
(i)
(ii)
(iii)
(iv)
(v)
(vi)
Enter Plan Year
▶
Employer contributions
a
(do not include elective
deferrals)
b Forfeitures
Qualified transfer/rollover
c
amount(s) received
20
Indicate how distributions will be made on termination (mark the applicable box(es)):
(1)
In accordance with the plan provisions including notices and consents.
(2)
Qualified Replacement Plan
(3)
Transfer of assets and liabilities to another plan
(4)
Other (specify)
21
Statement of net assets available to pay benefits as of the proposed date of plan termination or latest valuation date.
All “Other” items must be fully explained in an attachment.
Date of valuation
▶
Assets
a
Total noninterest-bearing cash .
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21a
b
Receivables:
(1) Employer contributions
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21b(1)
(2) Participant contributions .
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21b(2)
(3) Income .
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21b(3)
(4) Other (Attach a detailed explanation) .
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21b(4)
(5) Allowance for doubtful accounts
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21b(5)
(6) Total. Add 21b(1) through 21b(4) and subtract 21b(5) .
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21b(6)
▶
5310
Form
(Rev. 12-2013)
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