PDF document

- 1 -

The form you are looking for begins on the next page of this file. Before viewing it, 
please see the important update information below.

                           New Mailing Address

The mailing address for certain forms have change since the forms were last published. 
The new mailing address are shown below. 

Mailing Address for Forms 1023, 1024, 1024-A, 1028, 5300, 5307, 5310, 5310-A, 5316, 
8717, 8718, 8940:

Internal Revenue Service   
TE/GE Stop 31A Team 105                              
P.O. Box 12192       
Covington, KY 41012–0192

Deliveries by private delivery service (PDS) should be made to:

Internal Revenue Service 
7940 Kentucky Drive 
TE/GE Stop 31A Team 105 
Florence, KY 41042

This update supplements these forms’ instructions. Filers should rely on this update for 
the change described, which will be incorporated into the next revision of the form’s 
instructions.

- 2 -

This page intentionally left blank.

- 3 -

Application for Determination for
(Rev. June 2014)
Form 5307 Adopters of Modified OMB No. 1545-0200
Department of the Treasury Volume Submitter Plans
Internal Revenue Service (Under sections 401(a) and 501(a) of the Internal Revenue Code)
▶ Information about the Form 5307 and the instructions is at www.irs.gov/form5307. For IRS Use Only
For Internal Use Only
Review the Procedural Requirements Checklist before completing this application.
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

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

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 11832Y Form 5307 (Rev. 6-2014)

- 4 -

Form 5307 (Rev. 6-2014)                                                                                                                       Page 2 
3 a  Determination requested for (enter applicable number in box) 
      1 - Initial Qualification — New Plan
      2 - Initial Qualification — Existing Plan 
      3 - Request after Initial Qualification 

b     If 3a is "1" or "2," enter the date the plan was initially adopted. 
      Yes  No 
c                       Does the VS practitioner have the authority to amend on behalf of the adopting employer?
d                       Does the plan have a determination letter (DL) or did the plan rely on the opinion or advisory letter for the 
                        plan's remedial amendment cycle (RAC) immediately preceding the RAC in which the application is filed? 
                               If the plan relied on a DL, complete (i) and (ii). 
                               If the plan relied on an opinion or advisory letter, go to line 3e. 
                               If the plan did not have a DL or did not rely on the opinion or advisory letter, go to line 3f.

                                  (i)  Date the letter was issued
                                  (ii) Year of the Cumulative List considered in the letter
e    If the plan relied on a favorable opinion or advisory letter as an "identical adopter" of a pre-approved plan for the plan's RAC 
     immediately preceding the cycle in which the application is submitted, complete the following:

                   (i)   Name of sponsor or practitioner
                   (ii)  Date of opinion/advisory letter
                   (iii) Serial # of opinion/advisory letter
f                       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 subcolumn (a) of  
                        column (iv) in the table. 
                        If "Yes," and the amendment contains both interim and discretionary provisions, mark an "X" in subcolumns (a) 
                        and (b) of column (iv) in the table.
g    Complete the following table. If additional space is needed, attach a separate sheet of paper the same size, label it "Attachment to 3g" 
     using the same format as below.
                                                         
                                                       (iv)            (v)  
                         (ii)          (iii) Type of Amendment    Power to Amend       (vi)             (vii)              (viii)             (ix)  
                                                                                  Due Date of      Specific Section  
      (i)               Effective Adoption                        on Behalf of    Tax Return      of Plan, Adoption   Specific Section        Is Required 
      Amendment ID       Date          Date  (a)             (b)                       (including       Agreement or  of Amendment            Practitioner 
                                                                                  extensions)      Trust Changed           Creating the       Statement  
                   (MM/DD/YYYY) (MM/DD/YYYY) Interim   Discr.     (a)       (b)   (MM/DD/YYYY)          or Added      Change in (vii)         Attached 
                                                             .    Yes       No
                                                                                                                                              
3g(1)
3g(2)
3g(3)
3g(4)
3g(5)
3g(6)
3g(7)
3g(8)
3g(9)
3g(10)

h    Total amendments on line 3g.
i    Designate the specific tax return that the employer uses to file its federal income tax return.
                                                                                                                           Form 5307 (Rev. 6-2014)

- 5 -

Form 5307 (Rev. 6-2014)                                                                                                              Page 3 
4a Name of plan (Plan name cannot exceed 70 characters, including spaces.)

b  Enter 3-digit plan number

c  Enter the month on which the plan year ends (MM)

d  Enter plan’s original effective date 

e  Enter number of participants  
(If 100 or less, go to line 4f. Otherwise, go to line 5a.)
       Yes No 
f                       Does the plan sponsor have no more than 100 employees who received at least $5,000 of compensation for 
                        the preceding year? 
                        If "Yes," go to line 4g. 
                        If "No," go to line 5a.
g                       Is at least one employee a nonhighly compensated employee?
5 a        Indicate the type of plan by entering the number from the list below. 
           (Use the lowest number from the list below applicable to the plan.)

    1 — defined benefit but not cash balance              3 — money purchase            5 — 401(k) 
    2 — cash balance                                      4 — target benefit            6 — profit sharing plan

       Yes No 
b                       If the response to 5a was "1," "2," "3," or "4," was the plan's normal retirement age below 62 any time after  
                        May 22, 2007?  
                        If "Yes," file Form 5300. 
                        If "No," go to line 6a.

6 a(1)                  Is the plan sponsor a member of an affiliated service group, controlled group of corporations, or a group of 
                        trades or businesses under common control within the meaning of section 414(b), (c), or (m)? 
                        If "Yes," attach the required statement.
a(2)                    Is the plan sponsor a foreign entity or is the plan sponsor a member of an affiliated service group, controlled 
                        group of corporations, or a group of trades or businesses under common control within the meaning of section 
                        414(b) or (c) that includes a foreign entity?
b                       Is this a governmental plan under section 414(d)?
c(1)                    Is this a church plan under section 414(e)? 
                        If "Yes," go to line 6(c)(2). 
                        If "No," go to line 6d.
c(2)                    Was an election made by the church to have participation, vesting, funding, etc. provisions apply in accordance 
                        with section 410(d)? If "No," file Form 5300. 
d                       Does this plan benefit any collectively bargained employees under Regulations section 1.410(b)-6(d)(2)?
e                       Is this an insurance contract plan under section 412(e)(3)?
7                       Have interested parties been given the required notification of this application?

                                                                                                         Form 5307 (Rev. 6-2014)

- 6 -

Form 5307 (Rev. 6-2014)                                                                                                     Page 4 
     Yes No 
8 a                     Is a separate DL application for this plan currently pending before the IRS?
b                       Is this application being filed during the applicable two-year window announced by the Service?
9a                      Does this plan satisfy one of the design-based safe harbor requirements for contributions or benefits under 
                        Regulations section 1.401(a)(4)-2(b) or 3(b)? 
                        If "Yes," go to line 9b. 
                        If "No," go to line 10a.
b                       Is this an election for a determination regarding a design-based safe harbor?                                                      
                        If "Yes," complete lines 9c through 9e. 
                        If "No," go to line 10a.
c Enter the letter ("A" - "E") from the list below that identifies the safe harbor intended to be satisfied.
     A = 1.401(a)(4)-2(b)(2) defined contribution (DC) plan with a uniform allocation formula
     B = 1.401(a)(4)-3(b)(3) unit credit defined benefit (DB) plan
     C = 1.401(a)(4)-3(b)(4)(i)(C)(1) unit credit DB fractional rule plan
     D = 1.401(a)(4)-3(b)(4)(i)(C)(2) flat benefit DB plan
     E = 1.401(a)(4)-3(b)(5) insurance contract plan
d                       Does this plan satisfy one of the safe harbor definitions of compensation under Regulation sections 
                        1.414(s)-1(c)(2) or (3)?
e List the plan sections that satisfy the design-based safe harbor (including, if applicable, the permitted disparity requirements).

10a                     Does this plan have a cash or deferred arrangement (CODA)? 
                        If "Yes," go to line 10b(1). 
                        If "No," go to line 10e.
b(1)                    Does the CODA satisfy a safe harbor? 
                        If "Yes," go to line 10b(2). 
                        If "No," go to line 10d.
b(2) Indicate by using the corresponding number from the instructions, the type of section 401(k) safe harbor that was satisfied.
     1. 401(k)(12)(B)
     2. 401(k)(12)(C)
     3. 401(m)(11)(B)
c                       Does this plan contain a qualified automatic contribution arrangement (QACA) within the meaning of 
                        section 401(k)(13)?
d                       Does this plan contain an eligible automatic contribution arrangement (EACA) within the meaning of 
                        section 414(w)?
e                       Does this plan have matching contributions within the meaning of section 401(m)? 
                        If "Yes," go to line 10f. 
                        If "No," go to line 10g.
f                       Does this plan satisfy the section 401(m) safe harbor?
g                       Does this plan have after-tax employee voluntary contributions within the meaning of section 401(m)?

11                      Does this plan utilize the permitted disparity rules of section 401(l)?
12                      Is this plan part of an offset arrangement with any other plans? 
                        If "Yes," attach the required statement.

                                                                                                            Form 5307 (Rev. 6-2014)

- 7 -

Form 5307 (Rev. 6-2014) Page 5
Yes No
13 Has this plan been involved in a merger, consolidation, spinoff, or a transfer of plan assets or liabilities that was
not considered under a previous DL?
If "Yes," submit the required attachment.
14 a Has the plan been amended or restated to change the plan from a DB plan to a DC plan?
If "Yes," go to line 14b.
If "No," go to line 15a.
b Was the change considered in a prior DL?
If "No," attach a statement explaining the change.
15 a Does the plan sponsor maintain any other qualified plans under section 401(a)?
If "Yes," attach required statement and complete lines 15b and 15c.
If "No," go to line 16.
b(1) Does the plan sponsor maintain another plan of the same type (i.e. both this plan and the other plan are DC
plans or both are DB plans) that covers non-key employees who are also covered under this plan?
If "No," go to line 15c(1).
If "Yes," when the plan is top-heavy, do non-key employees covered under both plans receive the
top-heavy minimum contribution or benefit under:
b(2) This plan, or
b(3) The other plan?

c(1) If this is a DC plan, does the plan sponsor maintain a DB plan (or if this is a DB plan, does the plan sponsor
maintain a DC plan) that covers non-key employees who are also covered under this plan?
If "No," go to line 16.
If "Yes," when the plan is top-heavy, do non-key employees covered under both plans receive:
c(2) The top-heavy minimum benefit under the DB plan,
c(3) At least a 5% minimum contribution under the DC plan,
c(4) The minimum benefit offset by benefits provided by the DC plan, or
c(5) Benefits under both plans, using a comparability analysis, at least equal to the minimum benefit.
16 Does any amendment to the plan reduce or eliminate any section 411(d)(6) protected benefit?
If "Yes," attach the required statement.
Yes No NA
17 If this is a DC plan, are trust earnings and losses allocated on the basis of account balances?
If "No," attach a statement explaining how they are allocated.
Yes No
18 Is any issue involving this plan currently pending or has any issue related to this plan been resolved during the
current RAC by:
(1) Internal Revenue Service,
(2) Department of Labor,
(3) Pension Benefit Guaranty Corporation,
(4) Any court (including bankruptcy), or
(5) The Voluntary Correction Program of the Employee Plans Compliance Resolution System.
If "Yes," attach a statement with the contact person's name (IRS Agent, DOL Investigator, etc.) and telephone
number.
Form 5307 (Rev. 6-2014)

- 8 -

Form 5307 (Rev. 6-2014) Page 6
Procedural Requirements Checklist

Use this list to ensure that your submitted package is complete. Failure to supply the appropriate information may result in a delay in
the processing of the application.
Yes No
1. Is Form 8717, User Fee for Employee Plan Determination Request, attached to your submission?

2. Is the appropriate user fee for your submission attached to Form 8717?
3. If appropriate, is Form 2848, Power of Attorney and Declaration of Representative, Form 8821, Tax Information
Authorization, or a privately designed authorization attached? (For more information, see the Disclosure
Request by Taxpayer in the instructions and Rev. Proc. 2014-4, 2014-1 I.R.B. 125, updated annually.)
4. Is a copy of your plan’s latest determination letter or advisory letter, if any, attached?
5. Have you included a copy of the plan, trust, and all amendments adopted or effective during the current RAC?
6. Is the EIN of the plan sponsor/employer (NOT the trust’s EIN) entered on line 1i?
7. If you answered "Yes" to line 6a(1) have you included the information requested in the instructions?
8. Have you included:
Form 8905, Certification of Intent to Adopt a Pre-approved Plan, if applicable;
A copy of the plan document and adoption agreement, if applicable;
The current advisory letter;
A list of modifications (For each modification of the approved specimen, is a separate written representation
made by the VS practitioner that explains how the plan or trust instrument differs from the approved specimen
plan and explains the effect of the modification of the approved specimen plan attached?);
A copy of the trust instrument; and
A copy of all amendments?
9. Have interested parties been given the required notification of this application? Make sure line 7 is completed.

10. If line 12 is "Yes," is the required statement attached?
11. If line 13 is "Yes," is the required statement attached?
12. If line 14b is "No," is the required statement attached?
13. If line 15a is "Yes," is the required statement attached?
14. If line 16 is "Yes," is the required statement attached?
15. If line 17 is "No," is the required statement attached?
16. If line 18 is "Yes," is the required statement attached?
17. Is the application signed and dated? (Stamped signatures are not acceptable; see Rev. Proc. 2014-4 updated
annually.)
Form 5307 (Rev. 6-2014)

PDF file checksum: 311791397

(Plugin #1/8.13/12.0)