Internal Revenue Bulletin:  2004-7 

February 17, 2004 

APPENDIX A

MODEL NOTICE OF FUNDING WAIVER APPLICATIONTO EMPLOYEE ORGANIZATIONS (UNIONS),PARTICIPANTS, BENEFICIARIES, AND ALTERNATE PAYEES

This notice is to inform you that an application for a waiver of the minimum funding standard under § 412(d) of the Internal Revenue Code (Code) and section 303 of the Employee Retirement Income Security Act of 1974 (ERISA) has been submitted by [INSERT PLAN SPONSOR'S NAME] to the Internal Revenue Service (Service) for the [INSERT PLAN NAME] for the plan year beginning [INSERT DATE].

Under § 412(f)(4)(B) of the Code and section 303(e)(2) of ERISA, the Service will consider any relevant information submitted concerning this application for a waiver of the minimum funding standard. You may send this information to the following address:

Director, Employee Plans Internal Revenue Service Attention: SE:T:EP:RA:T:A1111 Constitution Avenue, N.W. Washington, D.C. 20224

Any such information should be submitted as soon as possible after you have received this notice. Due to the disclosure restrictions of § 6103 of the Code, the Service can not provide any information with respect to the waiver request itself.

In accordance with section 104 of ERISA and § 2520.104b-10 of the Department of Labor Regulations (29 C.F.R. Part 2520), annual financial reports for this plan, which include employer contributions made to the plan and the accumulated funding deficiency for the plan for any plan year, are available for inspection at the Department of Labor in Washington, D.C. Copies of such reports may be obtained upon request and upon payment of copying costs from the following address:

Public Disclosure RoomRoom N-5507 Employee Benefits Security Administration U.S. Department of Labor200 Constitution Avenue, N.W. Washington, D.C. 20210

As required by section 104(b)(2) of ERISA, copies of the latest annual plan report are available for inspection at the principal office of the plan administrator, who is located at [INSERT ADDRESS]. Copies of the annual report may be obtained upon request and upon payment of a copying charge of [INSERT CHARGE] by writing to the plan administrator at the above address.

The following information is provided pursuant to § 412(f)(4)(A) of the Code and section 303(e)(1) of ERISA:

Present Value of Vested Benefits $

Present Value of Benefits, calculated as though the plan terminated $

Fair Market Value of Plan Assets $

The above present values were calculated using an interest rate of [INSERT INTEREST RATE].

[SIGNATURE OF APPROPRIATE OFFICER OF THE PLAN SPONSOR] [INSERT NAME] [INSERT TITLE]


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