Form 5306 - Application For Approval Of Prototype Or Employer Sponsored Individual Retirement Arrangement (Ira)

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5306
Application for Approval of Prototype or Employer
Form
Sponsored Individual Retirement Arrangement (IRA)
OMB No. 1545-0390
(Rev. September 2010)
Department of the Treasury
(Under section 408(a), (b), (c), or (p) or section 408A of the Internal Revenue Code)
Internal Revenue Service
For IRS Use Only
1
Enter amount of user fee submitted (see Specific Instructions)
$
File folder number
▶
Part I
Identifying Information (see instructions before completing this part)
2
Approval requested for:
a Type of individual retirement arrangement—
(1)
(2)
Prototype traditional IRA under section 408(a) or 408(b)
Prototype Roth IRA under section 408A
(3)
Prototype dual-purpose IRA
(4)
Prototype SIMPLE IRA under section 408(p)
(5)
Roth or traditional IRA established by employer or
employee association under section 408(c)
b
Initial application
c
Amendment—Enter
(1) Latest letter serial number
(2) Date letter issued
(3) File folder number
▶
3a Name of applicant
3b Employer identification
number of applicant
Number, street, and room or suite no. (If a P.O. box, see instructions on page 2.)
City or town, state, and ZIP code
4a Name of person to be contacted
4b Telephone number
4 c Email address
4d If a power of attorney is attached, check box . . . . .
▶
5 a Type of sponsoring organization (if you are applying for a ruling under section 408(c), do not complete this item):
(1)
(5)
Insurance company
Regulated investment company
(2)
Trade or professional association
(6)
Federally insured credit union
(3)
Savings and loan association that qualifies as a bank
(7)
Approved non-bank trustee (attach copy of approval
letter)
(4)
Bank
b Type of submission (check one box):
(1)
Not a mass submitter
(2)
Mass submitter
(3)
Identical adoption of a mass submitter
(4)
Minor modification of a mass submitter
6
Name of trustee or custodian
Number, street, and room or suite no. (If a P.O. box, see instructions on page 2.)
City or town, state, and ZIP code
7
Type of funding entity:
a
Trust
c
Insurance company
b
Custodial account
Annuity contract or endorsement number (see instructions)
▶
Under penalties of perjury, I declare that I have examined this application, including accompanying statements, and to the best of my knowledge
Please
and belief, it is true, correct, and complete.
Sign
Here
Signature of officer
Date
Title
5306
For Paperwork Reduction Act Notice, see back of form.
Form
(Rev. 9-2010)
Cat. No. 11830C

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