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 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.
Enter the 9-digit employer identification number (EIN) assigned to the plan sponsor/employer. This should be the same
EIN that is used when the Form 5500 series annual return/report is filed for this plan. 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.
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/country, and
the postal code.
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/country, and
the postal code.
A VS plan may, but is not required to contain a provision that authorizes the VS practitioner to amend the plan on
behalf of employers who have previously adopted the plan. For purposes of reliance on the advisory letter, the practitioner
will no longer have the authority to amend the plan on behalf of the employer as of the date of the adoption of an employer
amendment to the plan to incorporate a type of plan not allowable in the VS program or as of the date the Service notifies
the practitioner that the plan is an individually designed plan. See section 15.03 of Rev. Proc. 2011-49, 2011-44 I.R.B.
608 available at www.irs.gov/irb/2011-44_IRB/ar08.html
An individually designed plan is eligible for the 6-year remedial amendment cycle (RAC) if the employer that sponsors
the plan and the sponsor of a preapproved M&P or VS plan document jointly executed Form 8905, Certification of Intent To Adopt
a Pre-approved Plan, before the end of the plan’s 5-year RAC. An individually designed plan is also eligible for the 6-year
cycle under certain other circumstances set forth in section 17 of Rev. Proc. 2007-44.
Use the table in this line to list all the amendments to the plan that have been adopted during the RAC of the plan
in which the application is submitted (the “current cycle
”), other than amendments described in the following paragraph.
Do not list:
any amendment that was adopted during the current cycle as a condition of a DL for the preceding cycle (but include a copy
of the amendment with the application); and/or
any amendment to a pre-approved plan that was adopted by the sponsor on behalf of the employer and considered by the Service
in issuing an opinion or advisory letter for the plan.
If the plan does not have a DL for the preceding RAC, the plan sponsor must include with this application filing copies of
interim and discretionary amendments adopted for the preceding cycle. See What To File; however, do not list these amendments in the table in line 3f.
Note each amendment using an identifying number or name (for example, Amendment 1, or PPA Amendment). An amendment may consist
of modifications made to several plan provisions that are adopted on the same date. Two or more amendments with the same
adoption date may be grouped and listed on a single line of the table. In this case, enter in column (ii) the effective date
of the amendment with the earliest effective date of any of the grouped amendments.
Enter the date the amendment is actually effective under the plan. For example, if an amendment is effective on the first
day of the first plan year beginning on or after January 1, 2013, and the plan year of the plan ends on June 30, the date
to be entered in column (ii) is 07/01/2013.
If the amendment is in proposed form enter 09/09/9999.
Mark with an “X” whether the amendment is an interim or a discretionary amendment. If the amendment contains both interim and discretionary
provisions, mark both columns (iv) and (v) with an “X.”
For each individual amendment listed, did the pre-approved plan sponsor have the power to amend the plan on behalf of the
adopting employer? If “Yes” enter “X” in this column.
Note the due date of the employer's tax return, including extensions, if applicable for the year in which the amendments were
adopted. If the relevant amendment is discretionary only, this field should be blank.
Designate the specific tax return the employer uses to file its return. For example, Form 1120, 1040, or Form 990
series (in the case of a tax-exempt employer). For a tax-exempt employer, the section 990 series is a substitute for an income
tax return. If no tax return is filed by the entity (such as a governmental employer), write “N/A
”. See section 5.06(2) of Rev. Proc. 2007-44 for details.
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.
Enter the three-digit plan number. This should be the same number that is used when the Form 5500 annual series return/report
Plan month means the month in which the plan year ends. Enter the two-digit month (MM).
Enter the total number of participants. A participant is:
Any employee 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 beneficiaries 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.
Payment of a deceased employee's benefit to three children is considered a payment to one beneficiary.
Lines 4f and 4g.
See Notice 2002-1, 2002-2 I.R.B. 283 (as amplified by Notice 2003-49, 2003-32 I.R.B. 294 and Notice 2011-86, 2011-45
I.R.B. 698), for further details, including how to determine compensation.
Attach copies of records of all actions taken to terminate the plan, such as board of directors’ resolutions, etc.
An application is deemed to be filed in connection with plan termination if it is filed no later than the later of
(i) 1 year from the effective date of termination or (ii) 1 year from the date on which the action terminating the plan is
adopted. However, in no event can the application be filed later than 12 months from the date of distribution of substantially
all plan assets in connection with the termination of the plan.
Assets must be distributed as soon as administratively feasible after the date of termination. See Rev. Rul. 89-87,
1989-2 C.B. 81.
Rev. Proc. 2013-6 contains the guidance under which the DL program is administered, and is updated annually. The application
should be filed in accordance with Rev. Proc. 2007-44 (as revised by Ann. 2011-82), and Rev. Proc. 2013-6, as updated.
” only if there will be no reversion of plan assets to the employer.
For the definition of a qualified replacement plan, see section 4980(d)(2).
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.
If the plan’s normal retirement age is below 62, the employer (or trustees in the case of 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 1.401(a)-1. If this is a governmental plan leave blank.
If the employer is a member of a controlled group of corporations, trades or businesses under common control, or
an ASG, all employees of the group will be treated as employed by a single employer for purposes of certain qualification
requirements. Attach a statement that provides the following in detail:
All members of the controlled 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 the plan sponsor is a member of an ASG, controlled group of corporations or group of trades or businesses under common
control within the meaning of section 414(b) or (c); is a foreign entity, a nonresident alien individual, foreign corporations,
foreign partnerships, foreign trusts, foreign estates, and any other person that is not a United States person. See sections
1473(5) and 7701(a)(30).
” 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, 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.
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.
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.
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.
” is marked, 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 marked 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.
” 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.
” attach a statement that provides the following:
Name of plans involved,
Type of plan,
Date of merger, consolidation, spinoff, or a transfer of plan assets or liabilities, and
Verification that each plan involved was qualified at the time of the merger, consolidation, spinoff, or a transfer of plan
assets or liabilities.
Verification includes a copy of a prior DL, if any, the appropriate opinion or advisory letter, and adoption agreement/plan
document. Otherwise, provide a signed and dated copy of the most recent restatement and any subsequent amendments.
The plan and amendments submitted to verify the plan was qualified prior to the merger, consolidation, spinoff, or a transfer
of plan assets or liabilities are for information purposes only and will not be ruled on.
If applicable, file Form 5310-A, Notice of Plan Merger or Consolidation, Spinoff, or Transfer of Plan Assets or Liabilities;
Notice of Qualified Separate Lines of Business, 30 days prior to the merger, consolidation, or transfer of assets or liabilities.
A termination/reestablishment transaction occurs when an employer terminates an overfunded DB plan, receives the excess assets,
and then establishes a new DB plan covering the active employee.
If “adverse business conditions
” is marked as the reason for termination, attach an explanation detailing the conditions that require termination of the
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.
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.
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.
” if any plan assets 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)).
Section 436 requires the calculation of the Adjusted Funding Target Attainment Percentage (AFTAP) to determine whether
the plan is subject to limits on plan amendments, lump sum distributions, or benefit accruals. Attach copies of the AFTAP
certification. If the employer has filed for bankruptcy, please provide the type and date of the bankruptcy filing.
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)
and Regulations section 1.401-2(a)(1). 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).
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) EIN(s),
Administrator's identification number(s),
An explanation of the transaction(s) including:
The amount(s) of any 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.
Attach a statement for each plan that includes the following information:
Name of plan,
Type of plan,
Form of plan (standardized, non-standardized, VS, or individually designed),
Vesting schedule, and
Whether the plan has received a DL or an application for a letter is pending with IRS.
Applicable DC plans are required to contain the participant diversification rights under section 401(a)(35). In general,
an applicable DC plan means any DC plan that holds publicly traded employer securities. DC plans are required to have plan
language reflecting the section 401(a)(35) rights, with exceptions including the following:
The terms of the plan do not permit any investments in employer securities.
The terms of the plan provide that the plan may invest in employer securities, but only if these securities are held indirectly
as part of a broader fund that is:
a regulated investment company described in section 851(a),
a common or collective trust fund or pooled investment fund maintained by a bank or trust company supervised by a State or
a Federal agency,
a pooled investment fund of an insurance company that is qualified to do business in a State, or
an investment fund managed by an investment manager within the meaning of section (3)(38) of ERISA for a multiemployer plan.
The terms of the plan state that the plan is a one-participant retirement plan as defined in section 401(a)(35)(E)(iv).
The plan is an ESOP, described in section 4975(e)(7), that does not hold any amounts subject to sections 401(k) or (m) and
is separate from any other plan of the employer.
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.
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).
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 21e (building equipment, and other property used in plan operations).
Line 21c(9) and (10).
Attach a list of outstanding loans from the plan. Include the following information:
Signed and dated loan agreement,
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(e), and
Include allocated and unallocated contracts including plan-owned life insurance.
” 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).