PDF《5310》

Form

5310 (Rev.

12-2013) Form

5310 (Rev. December 2013) Department of the Treasury Internal Revenue Service Application for Determination for Terminating Plan (Under sections 401(a) and 501(a) of the Internal Revenue Code) ? Information about Form

5310 and its instructions is at www.irs.gov/form5310. OMB No. 1545-0202 Review instructions and the Procedural Requirements Checklist before completing this application. For Internal Use Only Complete lines 1j-1m and 2h-2k only if you have a foreign address, see instructions. 1a Name of plan sponsor (employer if single-employer plan) b Address of plan sponsor c City d State e Zip code f Employer identification number (EIN) g Telephone number h Fax number i Employer'

s tax year end (MM) j City or town k Country name l Province/country m Foreign postal code 2a Person to contact. If a Power of Attorney is attached, mark box, and do not complete this line. Contact person'

s name b Contact person'

s address c City d State e Zip code f Telephone number g Fax number h City or town i Country name j Province/country k Foreign postal code If more space is needed for any item, attach additional sheets the same size as this form. Identify each additional sheet with the plan sponsor'

s name and EIN and identify each item. Under penalties of perjury, I declare that I have examined this application, including accompanying statements and schedules, and to the best of my knowledge and belief, it is true, correct, and complete. SIGN HERE ? Date ? Type or print name Type or print title Cat. No. 11840Y For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions. Form

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2 Yes No 3a (1) Is this plan a pre-approved Volume Submitter (VS) plan that relied on the advisory letter for the immediately preceding remedial amendment cycle (RAC)? (2) Is this plan a pre-approved Master &

Prototype Plan (M&

P) plan that relied on the opinion letter for the immediately preceding RAC? If line 3a(1) or 3a(2) is Yes, then complete lines 3(a)(3), (4) and (5). If No, go to line 3b. (3) Name of sponsor or practitioner (4) Date of opinion/advisory letter (5) Serial # of opinion/advisory letter b If the plan is a VS plan, does the VS practitioner have the authority to amend on behalf of the adopting employer? c Is the plan an individually designed plan that is eligible for the six-year RAC? Yes No NA d Does the plan have a determination letter (DL) for the plan'

s RAC preceding the cycle in which this application is filed? If Yes, complete lines 3d(i), (ii), and (iii) below. If No, go to line 3e. (i) Date the letter was issued (ii) Year of the Cumulative List considered in the letter (iii) Expiration date of the letter Form

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3 (Line

3 continued) Yes No e Do any amendments not considered in a prior DL have any discretionary provisions? If Yes, and the amendment contains only discretionary provisions, mark an X in column (v) in the table. If Yes, and the amendment contains both interim and discretionary provisions, mark an X in columns (iv) and (v) in the table. f Complete the following table (for (iv), (v), and (vi) mark with an X in the applicable boxes). If additional space is needed, attach a separate sheet of paper the same size, label it Attachment to 3f using the same format as below. (i) Amendment ID (ii) Effective Date (MMDDYYYY) (iii) Adoption Date (MMDDYYYY) Type of Amendment (iv) Interim Amnd. (v) Discr. Amnd. (vi) Power to Amend on Behalf of (vii) Due Date of Tax Return (including extensions) (MMDDYYYY) 3f(1) 3f(2) 3f(3) 3f(4) 3f(5) 3f(6) 3f(7) 3f(8) 3f(9) 3f(10) g List total amendments on line 3f h Designate the specific tax return that the employer uses to file its return Form