Lines 1b through 1g.
Enter the name, address, and telephone number of the plan sponsor/employer. A “plan sponsor
In the case of a plan that covers the employees of one employer, the employer;
In the case of a plan sponsored by two or more entities required to be combined under sections 414(b), (c), or (m), one of
participating in the plan; or
In the case of a plan that covers the employees and/or partner(s) of a partnership, the partnership.
The name of the plan sponsor/employer should be the same name that was or will be used when the Form 5500, Annual
Return/Report of Employee Benefit
Plan, or Form 5500-EZ, Annual Return of One-Participant (Owners and Their Spouses) Retirement Plan, is filed for the plan.
Include the suite, room, or other unit number after the street address. If the Post Office does not deliver mail to
the street address and the plan
has a P.O. box, show the box number instead of the street address. The address should be the address of the sponsor/employer.
Enter the nine-digit employer identification number (EIN) assigned to the plan sponsor/employer. This should be the
same EIN that was or will be
used when the Form 5500 or Form 5500-EZ is filed for the plan.
Do not use a social security number of the EIN of the trust.
The plan sponsor/employer must have an EIN. A plan sponsor/employer without an EIN can apply for one.
Online—Generally, a plan sponsor/employer can receive an EIN by Internet and use it immediately to file a return. Go to the
www.irs.gov/businesses/small and click on Employer ID
By telephone—Call 1-800-829-4933.
By mail or fax—Send in a completed Form SS-4, Application for Employer Identification Number. Form SS-4 can be obtained by
The plan of a group of entities required to be combined under section 414(b), (c), or (m) whose sponsor is more than
one of the entities required
to be combined should only enter the EIN of one of the sponsoring members.
This EIN must be used in all subsequent filings of determination letter requests and annual returns/reports unless
there is a change of sponsor.
Enter the two digits representing the month the employer's tax year ends. This is the employer whose EIN was entered
on line 1h.
The contact person will receive copies of all correspondence as authorized in a Power of Attorney and Declaration
of Representative, Form 2848, or
Tax Information Authorization, Form 8821. Either complete the contact's information on this line, or check the box and attach
a power of attorney or
other written designation.
Enter the number(s) that correspond to the request(s) being made.
Enter 1 if the IRS has not issued a determination letter for this plan.
Enter 2 if the IRS has previously issued a determination letter for this plan.
Enter 3 if this is a standardized plan. For additional guidance see Section 19 of Rev. Proc. 2005-16, which is on
page 674 of Internal Revenue
Bulletin 2005-10 at
If more than four amendments, list amendments on a separate piece of paper using the same format as shown on form
and label it as an attachment to
Enter the date(s) the amendment(s) was signed. If an amendment is proposed, enter “09/09/9999.
Enter the effective date(s) of each amendment listed in line 3d. The term “date amendment effective
” means the date the amendment becomes
operative or takes effect.
If you do not have a copy of the latest determination letter, or if no determination letter has ever been received
by the employer, submit copies
of the initial plan (or adoption agreement along with the appropriate opinion or advisory letter), or the latest plan (or
adoption agreement along
with the appropriate opinion or advisory letter), and any subsequent amendments and/or restatements.
If any amendments that are submitted predate the last favorable determination letter, they will not be ruled on. Also, if
any amendments are made
while the application is pending, it is recommended that you contact the Service to associate the amendment(s) with the current
application. See Rev.
Proc. 2008-6, which is on page 192 of Internal Revenue Bulletin 2008-1 at
Section 3001 of ERISA requires the applicants subject to section 410 to provide evidence that each employee who qualifies
as an interested party
has been notified of the filing of the application. If “Yes
” is checked, it means that each employee has been notified as required by Regulations
section 1.7476-1. If this is a one-person plan or if this plan is not subject to section 410, a copy of the notice is not
required to be attached to
this application. If “No
” is checked or this line is blank, your application will be returned.
Rules defining “interested parties
” and the form of notification are in Regulations section 1.7476-1. For an example of an acceptable format,
see Rev. Proc. 2008-6, which is on page 192 of Internal Revenue Bulletin 2008-1 at
Even if a ruling is not being requested on Schedule Q, Demo 8, submit a copy of the pertinent plan provisions regarding
Due to space restrictions, this field is limited to 70 characters, including spaces. Please complete this item with
how the plan name should read
on the determination letter to the extent permitted. Due to this restriction, please keep in mind that “Employees
” and “Trust
” are not
necessary in the plan name.
Enter the three-digit number, beginning with "001" and continuing in numerical order for each plan you adopt (001-499).
This numbering will
differentiate your plans. The number assigned to a plan must not be changed or used for any other plan. This should be the
same number that was or
will be used when the Form 5500 or Form 5500-EZ is filed for the plan.
Plan month means the two-digit (mm) calendar, policy, or fiscal month on which the records of the plan are kept.
Enter the total number of participants. A “participant
The total number of employees participating in the plan including employees under a section 401(k) qualified cash or deferred
who are eligible but do not make elective deferrals,
Retirees and other former employees who have a nonforfeitable right to benefits under the plan, and
The beneficiary of a deceased employee who is receiving or will in the future receive benefits under the plan. Include one
each deceased employee regardless of the number of individuals receiving benefits. Payment of a deceased employee's benefit
to three children is
considered a payment to one beneficiary.
Line 5. Cash balance plan.
For this purpose, a "cash balance" formula is a benefit formula in a defined benefit plan by whatever name (for example,
personal account plan,
pension equity plan, life cycle plan, cash account plan, etc.) that rather than, or in addition to, expressing the accrued
benefit as a life annuity
commencing at normal retirement age, defines benefits for each employee in terms more common to a defined contribution plan
such as a single sum
distribution amount (for example, 10 percent of final average pay times years of service, or the amount of the employee's
balance). Use Form 5300 rather than Form 5307, to request a letter for a cash balance plan.
Lines 6a and 6b.
If the plan employer is a member of a controlled group of corporations, trades or businesses under common control,
or an affiliated service group,
all employees of the group will be treated as employed by a single employer for purposes of certain qualification requirements.
Attach a statement showing in detail:
All members of the group,
The relationship of each member to the plan sponsor,
The type(s) of plan(s) maintained by each employer, and
Plans common to all members.
If you want to apply for a determination letter to determine if you are a member of an affiliated service group, file Form
5300 instead of Form
Answer this "Yes" if you have selected any choice labeled "Other" in the adoption agreement.
If the plan has been involved in a merger, attach a statement which provides the following:
Name of plan,
Type of plan(s) involved,
Date(s) of merger(s),
Verification that each plan involved was qualified at the time of merger (copy of prior DL, if any, otherwise provide a signed
copy of the most recent restatement and subsequent amendments).
The plan and amendments submitted to verify that plans were qualified prior to the merger are for information purposes only
and will not be
If applicable, file Form 5310-A, Notice of Plan Merger or Consolidation, Spinoff, or Transfer of Plan Assets or Liabilities;
Qualified Separate Lines of Business, 30 days prior to the merger, consolidation, or transfer of assets or liabilities.
If the plan has been restated to change the type of plan under Regulations section 1.401-1, answer this question “Yes
” and attach a statement
explaining the change.
” is checked, attach a list for each plan, which includes the following information:
Name of plan,
Type of plan,
Form of plan (standardized, non-standardized, VS, or individually designed),
Whether the plan has received a determination letter or an application for a letter is pending with IRS.
Also indicate if the plan is paired (if paired, indicate the letter serial number of the paired plan).
Lines 9b and 9c.
See M-8, M-12, and M-14 of Regulations section 1.416-1.
Section 411(d)(6) protected benefits include:
The accrued benefit of a participant as of the later of the amendment's adoption date or effective date; and
Any early retirement benefit, retirement-type subsidy, or optional form of benefit for benefits from service before such
If the answer is “Yes,
” explain on an attachment how the amendment satisfies one of the exceptions to the prohibition on reduction or
elimination of section 411(d)(6) protected benefits.
Optional Ratio Percentage Test Determination
This question may be used to request an optional determination regarding the ratio percentage test under Regulations
section 1.410(b)-2(b)(2). If
"No" is checked and a request for a determination regarding the average benefit test is not made on Schedule Q, the determination
letter for the plan
will not be a determination regarding section 410(b). If "No" is checked but a request for a determination regarding the average
benefit test is made
on Schedule Q, the determination letter for the plan will also be a determination regarding the average benefit test. Plans
using the qualified
separate lines of business rules of section 414(r) must file Schedule Q if a determination is desired that the plan satisfies
the gateway test of
section 410(b)(5)(B) or the special requirements for employer-wide plans.
If a determination is being requested and the plan is disaggregated into two or more separate plans that are other
than profit-sharing and/or
sections 401(k) and/or 401(m) plans, complete lines 11c through 11l with respect to each disaggregated portion of the plan.
schedules as necessary to identify the other disaggregated portions of the plan. Provide the requested coverage information,
in the same format as
line 11, separately with respect to the other portions of the plan, or to otherwise show that the other portions of the plan
If this plan benefits the employees of more than one qualified separate line of business (QSLOB), the portion of the plan
benefiting the employees
of each QSLOB is treated as a separate plan maintained by that QSLOB and must separately satisfy section 410(b) unless the
employer-wide plan testing
rule in Regulations section 1.414(r)-1(c)(2)(ii) applies.
If a determination is being requested for a section 401(k) and/or 401(m) plan, you must complete lines 11c through 11l for
the portion of the plan
that is not a section 401(k) or a 401(m) plan. Also complete line 11m(1) to report the ratio percentage for the section 401(k)
portion of the plan and
line 11m(2) to report the ratio percentage for the section 401(m) portion of the plan.
If, for purposes of satisfying the minimum coverage requirements of section 410(b), you are applying the daily testing
option in Regulations
section 1.410(b)-8(a)(2) or the quarterly testing option in Regulations section 1.410(b)-8(a)(3), or, if you are using single-day
as permitted under section 3 of Rev. Proc. 93-42, 1993-2 C.B. 540, enter the most recent eight-digit date (MMDDYYYY) for which
the coverage data is
submitted. If you are applying the annual testing option in Regulations section 1.410(b)-8(a)(4), enter the year for which
the coverage data is
Include all employees of all entities combined under sections 414(b), (c), (m), or (o). Also include all self-employed
individuals, common law
employees, and leased employees as defined in section 414(n) of any of the entities above, other than those excluded by section
individuals may also be required to be counted as employees. See the definition of employee in Regulations section 1.410(b)-9.
Also see Regulations
section 1.410(b)-6(i), which may permit the employer to exclude certain former nonhighly compensated employees.
This note applies only to plans that include a qualified cash or deferred arrangement under section 401(k) or employee or
under section 401(m). If there are any contributions under the plan that are not subject to the special rule for section 401(k)
plans and section
401(m) plans in Regulations section 1.401(a)(4)-1(b)(2)(ii)(B) (such as nonelective contributions), complete lines 11e through
11k with respect to the
portion of the plan that includes these contributions and enter the ratio percentage for this portion of the plan on line
11l. Otherwise, complete
lines 11e through 11k with respect to the section 401(k) part of the plan (or the section 401(m) plan if there is no section
401(k) arrangement) and
leave line 11l blank. In all cases, enter the ratio percentages for the section 401(k) and the section 401(m) parts of the
plan, as applicable, on
line 11m. These percentages should be based on the actual nonexcludables in the 401(k) and 401(m) portions, respectively.
It is suggested that these
calculations be submitted with the application but this is optional.
If the plan provides for nonelective profit-sharing contributions, do not base the calculations on lines 11m(1) and (2) on
employees reported on line 11g unless all of the disaggregated plans (profit-sharing, 401(k), and 401(m)) have the same nonexcludable
the same age and service requirements.
Enter the number of employees who are excluded because they have not attained the lowest minimum age and service requirements
for any employee
under this plan. If the employer is separately testing the portion of a plan that benefits otherwise excludable employees,
attach a separate schedule
describing which employees are treated as excludable employees on account of the minimum age and service requirements under
each separate portion of
Enter the number of employees who are excluded because they are collectively bargained employees as defined in Regulations
1.410(b)-6(d)(2), regardless of whether those employees benefit under the plan. For this purpose, an employee covered under
a CBA is not considered a
collectively bargained employee if more than 2% of the employees who are covered under the agreement are professional employees
as defined in
Regulations section 1.410(b)-9.
Enter the number of employees who do not receive an allocation or accrue a benefit under the plan only because they
do not satisfy a minimum hours
of service requirement or a last day of the plan year requirement, provided they do not have more than 500 hours of service,
and they are not employed
on the last day of the plan year. Do not enter on this line any employees who have more than 500 hours of service, even if
they are not employed on
the last day of the plan year.
If this plan benefits the employees of one QSLOB, enter on this line the number of employees of the employer's other
QSLOBs. This is not applicable
if the plan is tested under the special rule for employer-wide plans in Regulations section 1.414(r)-1(c)(2)(ii).
Enter the number of employees who are nonresident aliens with no earned income (as defined in section 911(d)(2)) from
the employer that constitutes
income from sources within the United States (as defined in section 861(a)(3)).
Subtract the total of lines 11e(1) through 11e(5) as reported on line 11f from the total employees reported on line
11d. The result is the number
of "nonexcludable employees." These are the employees who cannot be excluded from the plan for statutory or regulatory reasons
and must be considered
in the calculation of the ratio percentage even though they might not "benefit" under the plan. If they meet the age and service
section 410 and are not otherwise excludable employees, they must be included in this number.
Enter the number of employees on line 11g who are highly compensated employees (HCEs) as defined in section 414(q).
In general, an employee is treated as benefiting under the plan for coverage tests purposes only if the employee receives
an allocation of
contributions or forfeitures or accrues a benefit under the plan for the plan year. Certain other employees are treated as
benefiting if they fail to
receive an allocation of contributions and/or forfeitures, or to accrue a benefit, solely because they are subject to plan
provisions that uniformly
limit plan benefits, such as a provision for maximum years of service, maximum retirement benefits, application of offsets
or fresh start wear-away
formulas, or limits designed to satisfy section 415. An employee is treated as benefiting under a plan to which elective contributions
401(k) or employee contributions and matching contributions under section 401(m) may be made if the employee is currently
eligible to make such
elective or employee contributions, or to receive a matching contribution, whether or not the employee actually makes or receives
(Regulations section 1.401(k)-1(g)(4) and 1.401(m)-1(f)(4)). However, do not apply this rule to determine if an employee is
to be counted as
benefiting for lines 11i and 11k if, in accordance with the Note
following the instruction for line 11d, the information provided in lines
11e through 11k relates to the portion of the plan that is not subject to the rule in Regulations section 1.401(a)(4)-1(b)(2)(ii)(B).
See the instructions for line 11i for the meaning of "benefiting under the plan."
To obtain the ratio percentage:
Divide the number on line 11k (nonexcludable NHCEs benefiting under the plan) by the number on line 11j (nonexcludable
Divide the number on line 11i (nonexcludable HCEs benefiting under the plan) by the number on line 11h (nonexcludable
Divide the result from Step 1 by the result from Step 2.
If the ratio percentage entered on line 11l and/or line 11m is less than 70%, the plan does not satisfy the ratio percentage
test. In this case,
the plan must satisfy the average benefit test. A determination regarding the average benefit test can be requested using
See the Note
following the instructions for line 11d. To determine the ratio percentages for the section 401(k) and all section 401(m)
(matching and employee contribution) portions of the plan, follow the steps described in the instructions for lines 11d through
11l, but treat an
employee as benefiting under the rules for section 401(k) plans and section 401(m) plans described in the instruction for
Design-Based Nondiscrimination Safe Harbors
This question may be used by certain plans to request an optional determination regarding the design-based safe harbor
under section 401(a)(4).
If this is a section 401(k) and/or section 401(m) plan that does not contain a provision for nonelective employer
contributions, this option should
be marked “No.
If any disaggregated plan relies on a non-design based safe harbor or a general test this option must be marked "No."
The Schedule Q may be used to
request a determination regarding a non-design based safe harbor or a general test.
If this plan has been restructured into component plans, this option must be marked “No.
” The Schedule Q may be used to request a
determination regarding how each restructured component plan satisfies the nondiscrimination in amount requirement of Regulations
” is checked, or if “No
” is checked but a request for a determination regarding a non-design based safe harbor or a general test
is made on Schedule Q, the determination letter for the plan will also be a determination regarding the section 401(a)(4)
requirement that a plan not
discriminate in the amounts of contributions or benefits.
” is checked, and a request for a determination regarding a non-design based safe harbor or a general test is not made on
the determination letter for the plan will not be a determination regarding this requirement, unless the plan is a section
401(k) and/or section
401(m) plan only.
Check "Yes" if the plan is intended to satisfy the permitted disparity requirements of section 401(I).
To satisfy section 401(l), a plan must provide that the overall permitted disparity limits are not exceeded and specify
contributions or benefits under the plan are adjusted, if necessary, to satisfy the overall permitted disparity limits. See
The plan will not satisfy the safe harbor requirements of IRC section 401(a)(4) if it does not satisfy section 401(l).
This line provides a list of the design-based nondiscrimination safe-harbor regulations.
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The final release will ship the beginning of March 2008.
Purchase the CD/DVD from National Technical Information Service (NTIS) at www.irs.gov/cdorders for $35 (no handling fee) or call
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