Enter the name, address, and telephone number of the plan sponsor/employer.
A plan sponsor means:
In the case of a plan that covers the employees of one employer, the employer;
In the case of a plan maintained by two or more employers (other than a plan sponsored by a group of entities required to
be combined under section 414(b), (c), or (m)), the association, committee, joint board of trustees or other similar group
of representatives of those who established or maintain the plan;
In the case of a plan sponsored by two or more entities required to be combined under section 414(b), (c), or (m), one of
the members 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 series annual
returns/reports are 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. This address should be
the address of the sponsor/employer.
Enter the 9-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 series annual returns/reports are filed for the plan. For a multiple employer
plan, the EIN should be the same EIN that was or will be used by the participating employer when Form 5500 is filed by the
Do not use a social security number or 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
IRS website at www.irs.gov/businesses/small and click on Employer ID Numbers.
By telephone—Call 1-800-829-4933.
By mail or fax—Send in a completed Form SS-4, Application for Employer Identification Number.
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 for filing annual returns/reports unless there is a change
Enter the two digits representing the month the employer's tax year ends. This is the employer whose EIN was entered
on line 1b.
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 completed Form 2848 or Form 8821.
Section 3001 of ERISA requires the applicant to provide evidence that each employee who qualifies as an interested
party has been notified of the filing of this application. If "Yes" is checked, it means that each employee has been notified
as required by regulations under Section 7476 or this is a one person plan. A copy of the notice is not required to be attached
to this application. If "No" is checked or this line is blank, the application may 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. 2006-6, 2006-1 I.R.B. 204.
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 the latest plan for which you do have a determination letter, and any
subsequent amendments and/or restatements, including all adoption agreements.
If you check "Yes," also attach a statement explaining how the amendments affect or change this or any other plan
of the employer.
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 series returns/reports are filed for the plan.
Plan year means the calendar, policy, or fiscal year on which the records of the plan are kept.
Enter the total number of participants. A participant means:
The total number of employees participating in the plan including employees under a section 401(k) qualified cash or deferred
arrangement 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
beneficiary for each deceased employee regardless of the number of individuals receiving benefits.
The payment of a deceased employee's benefit to three children is considered a payment to one beneficiary.
Line 5. Cash balance or similar 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 hypothetical account balance).
If the plan employer/sponsor 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,
Their relationship to the plan sponsor,
The type(s) of plan(s) each member has, 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, do not file
this form. File Form 5300.
Attach copies of records of all actions taken to terminate the plan, such as board of directors' resolutions.
Assets must be distributed as soon as administratively feasible after the date of termination. See Rev. Rul. 89-87,
1989-2 C.B. 81.
Check "No" only if you are certain that there will be no reversion of plan assets to the employer.
If you checked adverse business conditions as the reason for filing for termination, attach an explanation detailing
the conditions that require termination of the plan.
Complete this line to indicate how the plan satisfied section 410(b). Complete lines 13a through 13n if the plan satisfied
the ratio percentage test for the year of termination. Complete line 13o if the plan satisfied the average benefit test for
the year of termination. Complete line 13p if the plan satisfied coverage using one of the special requirements of Regulations
section 1.410(b)-2(b)(5), (6), or (7). Plans that use the qualified separate lines of business rules of section 414(r) must
attach Demo 1. See Guidelines for Demonstrations
If the plan is disaggregated into two or more separate plans that are other than profit sharing and/or section(s)
401(k) and/or 401(m) plan(s), complete lines 13b through 13o with respect to each disaggregated portion of the plan. Attach
additional schedules as necessary to identify the other disaggregated portions of the plan and to provide the requested coverage
information, in the same format as line 13, separately with respect to the other portions of the plan, or to otherwise show
that the other portions of the plan separately satisfy section 410(b).
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.
Section(s) 401(k) and/or 401(m) plan(s) must complete line 13(l) for the portion of the plan that is not a section 401(k)
or a 401(m) plan. Also complete line 13(m)(1) to report the ratio percentage for the section 401(k) portion of the plan and
line 13(m)(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 "snapshot" testing 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 submitted.
Include all employees of all entities combined under section 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 414(n)(5). Certain other 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
matching contributions 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 13e through
13k 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 13l.
Otherwise, complete lines 13e through 13k 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 13l 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 13m. These percentages should be based on the actual
nonexcludables in the sections 401(k) and 401(m) portions, respectively. It is suggested that these calculations be submitted
with the application, but this is optional.
Do not base the calculations on lines 13(m)(1) and (2) on the nonexcludable employees reported on line 13(g) unless
all of the disaggregated plans (profit sharing, section 401(k), and section 401(m)) have the same nonexcludable employees
with 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 the plan.
Enter the number of employees who are excluded because they are collectively bargained employees as defined in Regulations
section 1.410(b)-6(d)(2), regardless of whether those employees benefit under the plan. For this purpose, an employee covered
under a Collective Bargaining Agreement (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
Enter the number of employees who are nonresident aliens who receive 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 13(e)(1) through 13(e)(5) as reported on line 13(f) from the total employees reported
on line 13(d). 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 requirements of section 410 and are not otherwise
excludable employees, they must be included in this number.
Enter the number of employees on line 13g 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
An employee is treated as benefiting under a plan to which elective contributions under section 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
such contributions, (Regulations sections 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 13i and 13k if, in accordance with the note following the instruction
for line 13d, the information provided in lines 13e through 13k 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 13i for the meaning of "benefiting under the plan."
To obtain the ratio percentage:
Divide the number on line 13k (nonexcludable NHCEs benefiting under the plan) by the number on line 13j (nonexcludable NHCEs).
Divide the number on line 13i (nonexcludable HCEs benefiting under the plan) by the number on line 13h (nonexcludable HCEs).
Divide the result from Step 1 by the result from Step 2.
If the ratio percentage entered on line 13l and/or line 13m 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 on line 13o by submitting a Demo 5.
See the Note following the instructions for line 13d. 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 13d through 13l, but treat an employee as benefiting under the rules for section 401(k) plans and section 401(m)
plans described in the instruction for line 13i.
Plans that use the average benefit test to satisfy section 410(b) for the year of termination must attach a Demo 5
(see Guidelines for Demonstrations
) unless the plan has received a favorable determination regarding the average benefit test in the 3 years preceding the date
of termination and the plan has not experienced a material change in the facts (including benefits provided and employee demographics)
on which the determination was based.
Do not complete line 14 if line 13p is completed. Complete line 14 to indicate how the plan satisfied the requirements
of section 401(a)(4). Complete this line as of the date entered in line 13c. If this plan has been disaggregated into separate
plans or restructured into component plans, attach a Demo 4 indicating how each separate disaggregated plan or restructured
component plan satisfies the nondiscrimination in amount requirement of Regulations section 1.401(a)(4)-1(b)(2).
If any restructured component plan or disaggregated plan relies on a nondesign-based safe harbor or a general test,
leave line 14c blank.
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
how employer-provided contributions or benefits under the plan are adjusted, if necessary, to satisfy the overall permitted
disparity limits. See Regulations section 1.401(l)-5.
Plans that use a nondesign-based safe harbor or a general test to satisfy section 401(a)(4) for the year of termination
must attach a Demo 6 (see Guidelines for Demonstrations
) unless: (1) the plan has received a favorable determination regarding the nondesign-based safe harbor or general test in
the 3 years preceding the date of termination, and (2) the plan has not experienced a material change in the facts (including
benefits provided and employee demographics) on which the determination was based.
A dropped participant means any participant who has terminated employment even if their benefits have not been distributed.
Enter the number of participants separated from vesting service with less than 100% vesting in their accrued benefit
or account balance.
Attach a schedule with the following information for each participant who has separated from vesting service with
less than 100% vesting:
Name of participant,
Date of hire,
Date of termination,
Years of participation,
Account balance/account benefit at the time of separation from service,
Amount of distribution,
Date of distribution, and
Reason for termination.
If there is a 20% reduction in participants, explain why this would not constitute a partial termination.
Regulations section 1.401(a)-20, Q&A-2 provides, in part, that the requirements of sections 401(a)(11) and 417 apply
to the payments under annuity contracts, not to the distributions of annuity contracts.
The accrued benefits of a plan participant may not be reduced on plan termination. A plan amendment (including an
amendment terminating a plan) that effectively eliminates or reduces an early retirement benefit or a retirement type subsidy
for benefits attributable to pre-amendment service is treated as reducing the accrued benefit of a participant if subsequent
to termination the participant could satisfy the conditions necessary to receive such benefits. See section 411(d)(6) and
Regulations section 1.411(d)-3 and Rev. Rul. 85-6, 1985-1 C.B. 133.
Answer "Yes" if any funds were contributed in the form of, or invested in, obligations or property of the employer
(including any entity related to the employer under section 414(b) or 414(c)).
If there is a contribution receivable that the employer intends to make by the required due date for section 412,
and no funding deficiency will exist after the contribution is made, this line should be answered "No."
Provide a description of the transaction(s) and attach a statement which must include the:
Name(s) of the sponsor(s) involved,
Employer identification number(s) of the sponsor(s),
Plan administrator's name(s) and EIN, and
Plan name(s) and plan numbers.
All plan liabilities must be satisfied before assets can revert to the employer upon termination of the plan. All
liabilities will not be satisfied if the value of retirement-type subsidies are not provided participants who, after the date
of the proposed termination, satisfy certain pre-termination conditions necessary to receive such benefits. See section 401(a)(2),
Regulations section 1.401-2(a)(1) and Rev. Rul. 85-6.
The annuity contracts purchased must be guaranteed for each participant. However, in order to maintain qualification
of a continuing pension plan, the contracts covering participants' accrued benefits in the plan must not be distributed except
in accordance with Regulations section 1.401-1(b)(1)(i).
Answer "Yes" if your plan is a defined benefit plan and you intend that any or all of your participants will be covered
by a new or existing defined benefit plan of the employer.
If the answer to this item is "Yes," attach a list that includes the:
Name(s) of the plan sponsor(s),
Employer or sponsor's EINs,
Administrator's identification number(s),
Plan number(s), and
An explanation of the termination(s) including:
The amount(s) of the reversion(s),
The date(s) of termination, and
The reason(s) for termination.
For this question only, "single-sum distribution" will mean a single payment of the value of a participant's benefits
or a series of payments that do not provide substantially equal payments (either alone or in conjunction with other benefit
payments) over the life of the participant.
Section 416 provides that plan participants in a top-heavy plan who are non-key employees must accrue a minimum benefit
or receive a minimum contribution.
If "Yes" is checked, attach a list for each plan with the following information:
Name of plan,
Type of plan,
Plan number, and
Indicate if another application is simultaneously being submitted with this application.
Complete this only for defined contribution plans. Enter the date of the current plan year and the prior 5 plan-years
in the columns indicated.
Enter the amount of forfeitures for each of the plan years entered. If these forfeitures resulted from a cashout for
a year not listed on line 15a, attach a statement indicating the year of the cashout.
Enter the amount of transfers and rollovers received from qualified plans (under section 401(a) and/or conduit IRAs)
for each of the plan years entered.
Check the box or boxes that indicate the form(s) of distribution of benefits for your plan upon termination. Submit
a statement that all distributions have been or will be made in accordance with plan provisions and proper spousal consents
will be secured, when applicable.
Complete the statement showing the estimated fair market value of the plan assets and liabilities as of the proposed
date of termination or the latest valuation date.
Include and clearly identify all liabilities (other than liabilities for benefit payments due after the date of plan
termination) that are unpaid as of the proposed termination date or that are paid or payable from plan assets after the proposed
date of plan termination under the provisions of the plan. Liabilities include expenses, fees, other administrative costs,
and benefit payments due and not paid before the proposed termination date or latest valuation date.
Include investment securities issued by a corporate entity at a stated interest rate repayable on a particular future
date such as most bonds, debentures, convertible debentures, commercial paper and zero coupon bonds. Do not include debt securities
of governmental units or municipalities.
Include the current value of real property owned by the plan which produces income from rentals, etc. Do not include
this property in line 20e (buildings and other property used in plan operations).
Include the current value of real property owned by the plan which is not producing income or used in plan operations.
Line 20c(9) and (10).
Attach a list regarding loans from the plan. Include the following information:
Dollar amount of each loan(s),
Date of loan,
Balance of the loan at the date of termination,
Account balance prior to the date of the loan,
Identify all disqualified persons as described by section 4975(f), and
Amortization and/or repayment schedule.
Include allocated and unallocated contracts including plan-owned life insurance.
"Acquisition indebtedness," for debt-financed property other than real property, means the outstanding amount of the
principal debt incurred:
By the organization in acquiring or improving the property,
Before the acquisition or improvement of the property if the debt was incurred only to acquire or improve the property, or
After the acquisition or improvement of the property if the debt was incurred only to acquire or improve the property and
was reasonably foreseeable at the time of such acquisition or improvement. For more details, see section 514(c).