Form 5310 - Application For Determination For Terminating Plan

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5310

Application for Determination for

Terminating Plan

Form

OMB No. 1545-0202

(Rev. December 2013)

Department of the Treasury

(Under sections 401(a) and 501(a) of the Internal Revenue Code)

Internal Revenue Service

Information about Form 5310 and its instructions is at

▶

Review instructions and the Procedural Requirements Checklist before completing this application.

For Internal Use Only

Complete lines 1j-1m and 2h-2k only if you have a foreign address, see instructions.

1a Name of plan sponsor (employer if single-employer plan)

b Address of plan sponsor

c City

d State

e Zip code

f Employer identification number (EIN)

g Telephone number

h Fax number

i Employer’s tax year end (MM)

j City or town

k Country name

l Province/country

m Foreign postal code

2a Person to contact. If a Power of Attorney is attached, mark box, and do not complete this line.

b Contact person’s address

Contact person’s name

c City

d State

e Zip code

f Telephone number

Fax number

h City or town

i Country name

j Province/country

k Foreign postal code

If more space is needed for any item, attach additional sheets the same size as this form. Identify each additional sheet with the plan

sponsor’s name and EIN and identify each item.

Under penalties of perjury, I declare that I have examined this application, including accompanying statements and schedules, and to the best of my knowledge and belief,

it is true, correct, and complete.

SIGN HERE

Date

▶

Type or print name

Type or print title

5310

For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.

Form

(Rev. 12-2013)

Cat. No. 11840Y

11840Y12201301