4461-A
Application for Approval of Master or
Form
OMB No. 1545-0169
(Rev. March 2008 )
Prototype or Volume Submitter Defined
Department of the Treasury
Benefit Plan
This Form Is Open to Public Inspection
Internal Revenue Service
For IRS Use Only
File This Form With Internal Revenue Service
Section references are to the Internal Revenue Code unless otherwise noted.
Complete every applicable item on this form. You may only answer “not applicable” (N/A) where an N/A
answer is indicated as one of your options.
Part I
All Filers Complete This Part. See instructions before completing this form.
1
Enter amount of user fee submitted
$
M&P File folder number or
Date of last letter issued
2a
Approval requested:
2b
2c
VS-Letter serial number
Initial application
Amendment—Enter file folder number or letter
serial number and date of last letter issued
3a Name of applicant
3b Employer identification number
of applicant
Address (number, street, room or suite no.) (If a P.O. box, see instructions)
City
State
ZIP code
3c Applicant’s telephone no.
(
)
3d Type of applicant (see Definitions in the instructions):
M&P sponsor
Volume submitter practitioner
M&P mass submitter
Volume submitter mass submitter
M&P national sponsor
Volume submitter national sponsor
4a
Name of person to be contacted
4b Telephone number
(
)
4c Email address
4d If a power of attorney is attached, check box
5a
Basic plan document number
5b
Adoption agreement number
6
Form of plan:
Prototype plan
Master plan
Volume submitter
Note: A master plan has only one trust or custodial account for all adopting employers.
7
Does the plan provide for permitted disparity in accordance with section 401(l)?
Yes
No
8
Filing status of plan:
Standardized plan
Nonstandardized plan
Volume submitter plan
Under penalties of perjury, I declare that I have examined this application, including accompanying statements, and to the best of my knowledge
and belief it is true, correct and complete.
Signature
Title
Date
4461-A
For Paperwork Reduction Act Notice, see page 12 of the instructions.
Cat. No. 11416U
Form
(Rev. 3-2008)