Form 4461-B - Application For Approval Of Master Or Prototype Or Volume Submitter Plans

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4461-B

Application for Approval of Master or

Form

OMB No. 1545-0169

Prototype or Volume Submitter Plans

(Rev. January 2012)

Department of the Treasury

This Form Is Open to Public Inspection

Mass Submitter Adopting Sponsor or Practitioner

Internal Revenue Service

For IRS Use Only

File This Form With the Internal Revenue Service

Section references are to the Internal Revenue Code unless otherwise noted.

Complete every applicable item on this form.

Enter amount of user fee submitted

2 a Name of applicant

2 b Employer identification number

of applicant

Address (number, street, room or suite no.) (If a P.O. box, see the instructions.)

2 c Applicant’s telephone no.

City

State

ZIP code

3 b Telephone number

3a Name of person to be contacted

3 c If a power of attorney is attached, check the box

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4 a Basic plan document number

b Adoption agreement number

This plan is:

Word-for-word identical to an M&P plan or volume submitter plan

A minor modification to an M&P plan only (see instructions to line 5 for

specific requirements)

Name of mass submitter

Enter the following information for the mass submitter’s plan on which this plan is based (if this application is submitted

simultaneously with the mass submitter’s application, see instructions).

File folder number

Letter serial number

Date of letter

Type of plan:

Money purchase

Target benefit

Profit-sharing/401(k)

Profit-sharing

Defined benefit (with permitted disparity)

Defined benefit (without permitted disparity)

Filing status of plan (see General Instructions)

Standardized plan

Nonstandardized plan

Volume submitter governmental plan (i.e., described in section 414(d))

Volume submitter nongovernmental plan

For Master or Prototype: Under penalties of perjury, I declare that the sponsor has adopted a master or prototype plan that is word-for-word identical to, or a minor

modification of the mass submitter plan indicated in items 6 and 7 above.

For Volume Submitter: Under penalties of perjury, I declare that the practitioner has adopted a volume submitter plan that is word-for-word identical to the mass submitter

plan indicated in items 6 and 7 above.

(Sponsor or Practitioner)

Title

Signature

▶

Date

▶

(Mass Submitter)

Signature

Title

Date

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