Line 1.

Enter the name, address, and telephone number of the plan sponsor/employer.

A plan sponsor means:

Line 1f.

Enter the nine-digit employer identification number (EIN) assigned to the plan sponsor/employer or the organization sponsoring the 403(b) plan. For a 401(a) plan, this should be the same EIN that is used when the Form 5500 series annual return/report is filed for this plan, if applicable. For a multiple-employer plan, the EIN should be the same EIN that is used by the participating employer when Form 5500 is filed by the employer.

Do not use a social security number or the EIN of the trust.

Line 1i.

Enter the two digits representing the month the employer's tax year ends.

Lines 1j through 1m.

If a foreign entity, follow the country's practice for entering the name of the city or town, province/county, and the postal code.

Line 2.

The contact person will receive copies of all correspondence as authorized in a Form 2848 or Form 8821. Either complete the contact's information on this line, or mark the box and attach a completed Form 2848 or Form 8821.

Lines 2h through 2k.

If a foreign contact, follow the country's practice for entering the name of the city or town, province/county, and the postal code.

Line 3a.

This field is limited to 70 characters, including spaces. Fill in the name as it should appear on the DL to the extent permitted. Keep in mind that “Employees” and “Trust” are not necessary in the plan name and will be left off if space does not permit.

Line 3b.

Enter the three-digit plan number. This should be the same number that is used when the Form 5500 annual series return/report is filed.

Line 3c.

Plan month means the month in which the plan year ends. Enter the two-digit month (MM).

Line 3e.

Enter the total number of participants. A participant is:

Lines 3f and g.

See Notice 2002-1, 2002-2 I.R.B. 283 (as amplified by Notice 2003-49, 2003-32 I.R.B. 294, and Notice 2017-1, 2017-2 I.R.B. 367), for further details, including how to determine compensation.

Line 4b.

See section 11.01(2) of Rev. Proc. 2023-37 with respect to an individually designed plan's eligibility for the remedial amendment cycle system.

Line 5.

Attach copies of records of all actions taken to terminate the plan, such as board of directors’ resolutions, etc.

Line 5b(1).

Check “No” only if there will be no reversion of plan assets to the employer.

Line 6a.

A Pension Equity Plan (PEP) is a DB plan which, rather than or in addition to expressing the accrued benefit as a life annuity commencing at normal retirement age, defines benefits for each employee as an amount equal to an accumulated percentage of final pay. Benefits are generally described as a percentage of final pay with the percentage determined as the accumulation of percentage points or lump-sum credits received for each year of service. Generally, the accumulated percentage points or lump-sum credits are multiplied by final average or career average compensation to determine the lump-sum amount.

A cash balance plan is a DB plan which, 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 DC plan, that is, as a single-sum distribution amount equal to the employee’s hypothetical account balance. Benefits consist of an accumulation of hypothetical allocation credits to an account plus hypothetical accumulated interest credits on that account.

Line 6b(2).

If the plan’s normal retirement age is below 62, the employer (or trustees in the case of a multi-employer plan) must submit a signed statement that this is a good faith determination of the typical retirement age for the industry in which the covered workforce is employed. See Regulations section 1.401(a)-1. If this is a governmental plan, leave blank.

Line 7.

If “Yes,” complete only applicable sections of this form. Governmental plans under section 414(d) are exempt from certain qualification requirements and are deemed to satisfy certain other qualification requirements under certain conditions. For example, the nondiscrimination rules, minimum participation rules, top heavy rules, and minimum funding standards do not apply to governmental plans. In addition, such plans meet the vesting rules if they meet the pre-ERISA vesting requirements.

Line 8.

If a church plan has not made such an election, complete only the portions of this form that apply.

A church plan (for which no special election under section 410(d) has been made) is ordinarily not subject to various qualification requirements. Section provisions that do not apply to a nonelecting church plan include section 410 (relating to minimum participation standards), section 411 (relating to minimum vesting standards), section 412 (relating to minimum funding standards for pension plans), and section 4975 (relating to prohibited transactions). In addition, provisions relating to joint and survivor annuities, mergers and consolidations, assignment or alienation of benefits, time of benefit commencement, certain social security increases, withdrawals of employee contributions, and distributions after plan termination, respectively, also do not apply.

Line 9.

If “Yes,” attach a statement that provides the following:

Line 10.

Check “Yes” and attach an explanation if the plan has any matter pending before:

The attachment should include a contact person's name and telephone number and agency or court.

Line 16.

If “Yes,” attach a statement identifying the plan sections that satisfy the safe harbor (including, if applicable, permitted disparity requirements) and specify which of the following regulations is intended to be satisfied.

1.401(a)(4)-2(b)(2) DC plan with uniform allocation formula.

1.401(a)(4)-3(b)(3) unit credit DB plan.

1.401(a)(4)-3(b)(4)(i)(C)(1) unit credit DB fractional rule plan.

1.401(a)(4)-3(b)(4)(i)(C)(2) flat benefit DB plan.

1.401(a)(4)-3(b)(5) insurance contract plan.

Line 17.

If “Yes,” attach a separate statement providing the name, EIN, and plan type of the other plan, and a copy of pertinent plan provisions from the related plan regarding the offset.

Line 18.

If this is a request for an individually designed plan that consists of a DB plan and a qualified cash or deferred arrangement, submit two Forms 5300 and two applicable user fees and provide an attachment with the plan sponsor/employer EIN and plan number of the other plan.

Line 19.

Section 3001 of the Employee Retirement Income Security Act (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, the application will be returned.

Rules defining “interested parties” and the form of notification are in Regulations section 1.7476-1.

Line 20.

If the plan involves a section 401(h) feature, reference the feature in the cover letter and note that this feature is part of the termination application. The cover letter must specifically state the location of plan provisions that relate to the section 401(h) feature.

Line 21.

If the plan has been restated to change the type of plan under Regulations section 1.401-1, check “Yes” and attach a statement explaining the change.

Line 22.

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), Regulations section 1.411(d)-3, and Rev. Rul. 85-6, 1985-1 C.B. 133.

Line 23.

This question applies to single employer DB plans that must comply with section 436. Skip to line 26 if this does not apply. A DB plan must attach copies of the Adjusted Funding Target Attainment Percentage (AFTAP) certification(s) and the Schedule SB (Form 5500), Single-Employer Defined Benefit Plan Actuarial Information, for the year of termination and the prior 2 years. Also, see Notice 2012-46, 2012-30 I.R.B. 86 for additional information concerning notice requirements of ERISA 101(j).

Line 28.

If the answer to this item is “Yes,” attach a list that includes the:

Line 37.

Enter the number that corresponds to the 403(b) eligible employer defined in Regulations Section 1.403(b)-2(b)(8):

Enter 1

if the eligible employer is a tax-exempt organization under 501(c)(3) including but not limited to a church defined under 3121(w)(3)(A) or Qualified church-controlled organizations under 3121(w)(3)(B).

Enter 2

if the eligible employer is a State, as defined by Regulations Section 1.403(b)-2(b)(20), a political subdivision of a State, or any agency or instrumentality of a State with respect to an employee performing services in a public school, as defined by Regulations Section 1.403(b)-2(b)(14).

Enter 3

if the eligible employer is the employer of a minister described in section 414(e)(5)(A), but only with respect to the minister or a self-employed minister described in 414(e)(5)(A).

Line 38.

Check “Yes” if the eligible employer is a 501(c)(3) organization that satisfies the requirements of section 3121(w)(3)(B).

Line 39.

Check “Yes” if the church-controlled organization is a non-QCCO as defined in section 414(c)(2)(B).

Line 40.

Check “Yes” if the plan is a church plan under section 414(e) that hasn't made a section 410(d) election.

Line 41.

Check “Yes” if this plan allows for employee after-tax contributions.

Line 42.

Check “Yes” if this plan offers elective deferrals.

Line 43.

Check “Yes” if this plan offers matching contributions.

Line 44.

Check “Yes” if this plan allows for non-elective employer contributions other than matching contributions.

Line 45.

Check “Yes” if this plan sponsor has less than 1,000 employees.

Line 46.

Check “Yes” if this plan is sponsored by an educational organization as defined in section 170(b)(1)(A) in which the employee contributions were contributed to a credit union described in section 501(c)(14) that maintains separate nonforfeitable special share accounts for each employee. A plan established on or before May 17, 1982, has grandfathered status for accounts administered by the credit union but no employee first covered by the plan after May 17, 1982, is covered by Revenue Ruling 82-102, 1982-1 C.B. 62. A “Yes” answer is also required if the submitted plan was established by a church-related organization and was a defined benefit plan effective September 3, 1982, when 403(b) treatment was established.

Line 47.

Check “Yes” if distributions of all accounts have been made as either (1) delivery of a fully paid (individual) annuity contract, (2) delivery of a certificate of fully paid benefits under a group annuity contract, or (3) distributions in cash or in kind of the investments held in section 403(b)(7) custodial accounts.

Line 48.

Check “Yes” if the plan administrator will distribute to an individual custodial account in-kind per Rev. Rul. 2020-23, 2020-47 I.R.B. 1028 if the participants or beneficiary does not elect a distribution.

Line 49.

Check “Yes” if all participants are fully vested in accordance with 1.403(b)-10(a). To the extent a contract fails to satisfy the nonforfeitability requirement of 1.403(b)-3(a)(2) as of the date of plan termination, the contract is not, and cannot later become, a 403(b) contract.

Line 50.

Check “Yes” to attest that the employer satisfies the applicable termination requirements provided in Regulations section 1.403(b)-10(a).

Line 51.

Check “Yes” if a plan-to-plan transfer has occurred as defined under 1.403(b)-10(b).

Line 52.

Line 53.

If “adverse business conditions” is checked as the reason for termination, attach an explanation detailing the conditions that require termination of the plan.

For ESOP Plans, if Line 53(c) on the Form 5310 indicates that the plan is terminating due to a change of ownership:

If the plan is terminating due to a reason other than a change in ownership:

Line 55a.

A dropped participant means any participant who has terminated employment even if their benefits have not been distributed.

Enter the number of participants who separated from vesting service with less than 100% vesting in their accrued benefit or account balance. If there is a 20% reduction in participants for any period, attach an explanation as to why this would not constitute a partial termination.

Line 56b.

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.

Line 56c.

If the plan sponsor has readily tradable employer securities, provide the ticker symbol. If there are no readily tradable securities, then provide the last three independent appraisals (valuations) for the employer securities.

Line 57b.

Enter the amount of forfeitures for each of the plan years on the chart. If these forfeitures resulted from a cashout for a year not listed on line 19, attach a statement indicating the year of the cashout.

Line 57c.

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. Submit proof that any rollovers or asset transfers received were from a qualified plan or IRA (for example, DL and timely interim amendments).

Line 59.

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.

For ESOP plans, if line 59(d)(1) doesn't show an investment in employer securities, provide a statement regarding if the plan sponsor repurchased the employer securities or if a stock or asset sale occurred before the plan termination.

If any stock was attributable to a 1042 transaction, please provide the following:

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.

Line 59c(4).

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.

Line 59c(7)(A).

Include the current value of real property owned by the plan which produces income from rentals, etc. Do not include this property on line 21e (building equipment, and other property used in plan operations).

Line 59c(9) and (10).

Attach a list of outstanding loans from the plan. Include the following information:

Line 59c(12).

Include allocated and unallocated contracts including plan-owned life insurance.

Line 59i.

“Acquisition indebtedness” for debt-financed property other than real property, means the outstanding amount of the principal debt incurred:

For ESOP plans, if line 59i indicates any acquisition indebtedness, provide a copy of the exempt loan agreements, amortization schedules, and release schedules for the last 6 years.