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                                  Application for Determination of 
                                                                                         OMB No. 1545-0284
       Form  5309                 Employee Stock Ownership Plan 
       (Rev. January 2012)        (Under section 4975(e)(7) of the Internal Revenue Code)
       Department of the Treasury                                                        For IRS Use Only
       Internal Revenue Service                       ▶ Attach to Form 5300.

1  Name of plan sponsor (employer if single-employer plan)

2  Employer identification number (EIN)     3         Plan number

   All Plans (Complete lines 4a through 4k.)

   Yes No

4a           Is the plan designated as an employee stock ownership plan (ESOP) within the meaning of section 4975(e)(7)?

b            Is the plan designed to invest primarily in employer securities as defined in section 409(l)?

             Is each participant or beneficiary entitled to direct the plan to vote the allocated securities as required by section  
c
             409(e)?
             Does the plan provide that each participant who is entitled to a distribution from the plan has a right to demand  
d
             that the benefit be distributed in the form of employer securities?

   If the answer to d is “No,” please answer the following questions:
             If the charter or bylaws of the corporation restrict substantially all outstanding stock ownership to employees or to 
  (i)        a 401(a) trust, does the plan provide that participants are entitled to receive distributions in cash, except that such 
             plan may distribute employer securities subject to a requirement that such securities may be resold to the 
             employer under a fair valuation formula? (See section 409(h)(2))
             If the plan is maintained by an S corporation, does the plan provide that participants are entitled to receive 
  (ii)       distributions in cash, except that such plan may distribute employer securities subject to a requirement that such 
             securities may be resold to the employer under a fair valuation formula? (See section 409(h)(2))
e            If the plan is established and maintained by a bank which is legally prohibited from redeeming or purchasing its 
             stock, does the plan provide that participants are entitled to receive distributions in cash? (See section 409(h)(3))
             If the trust makes a distribution in stock and the securities are not readily tradable on an established market, can 
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             the participant require the employer to repurchase the securities under a fair valuation formula within the time 
             frames prescribed by law? (See section 409(h)(1)(B))

             If the plan holds employer securities consisting of stock in an S corporation, does the plan provide that no portion 
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             of the assets of the plan attributable to (or allocable in lieu of) such employer securities may, during a 
             nonallocation year, accrue (or be allocated directly or indirectly under any section 401(a) plan of the employer) for 
             the benefit of any disqualified person? (See section 409(p))
             Does the plan provide that a qualified participant may elect to diversify a portion of his or her account investment 
h
             in employer securities, as described in section 401(a)(28)(B)? 

   If the answer to h is “No,” please answer the following question:    
             Does the plan provide that an applicable individual may elect to diversify a portion of his or her account 
  (i)        investment in employer securities as described in section 401(a)(35)? 
             With respect to activities that are carried on by the plan, are all valuations of employer securities acquired after 
i
             December 31, 1986, which are not readily tradable on an established securities market, made by an independent 
             appraiser? (See section 401(a)(28)(C))
For Paperwork Reduction Act Notice, see instructions.            Cat. No. 11835F                          Form 5309 (Rev. 1-2012)

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Form 5309 (Rev. 1-2012)                                                                                                       Page 2 
  Yes No

            Does the plan provide that a participant may begin receiving a distribution of his or her account that is attributable  
j
            to employer securities after the participant has separated from service upon reaching normal retirement age, or after 
            death, disability, or other separation from service, within the time frames specified in section 409(o)?

            If the plan is maintained by a C corporation, does the plan provide that the assets of the plan attributable to (or 
k
            allocable in lieu of) employer securities acquired by the plan in a sale to which section 1042 applies cannot accrue 
            (or be allocated directly or indirectly under any section 401(a) plan of the employer) for the benefit of persons 
            specified in section 409(n) during the nonallocation period? 

  Plans Applying Under Section 4975(d)(3) and Regulations Section 54.4975-7 (Leveraged ESOPs) (Complete lines 5a through 5g.)
            Does the plan provide that the exempt loan proceeds must be used within a reasonable time to acquire qualifying  
5a
            employer securities, repay such loan, or repay a prior loan as required under Regulations section 54.4975-7(b)(4)?
            Does the plan provide for the establishment and maintenance of a suspense account as required under Regulations 
b
            section 54.4975-11(c)?
            Does the plan provide that the collateral must be limited to qualifying employer securities purchased with such 
c           exempt loan or qualifying employer securities used as collateral on a prior exempt loan repaid with the proceeds of 
            the current exempt loan as required under Regulations section 54.4975-7(b)(5)?

            Does the plan provide that no person entitled to payment under an exempt loan shall have any right to assets of the 
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            ESOP other than collateral given for such loan, contributions (other than contributions of employer securities) made 
            to repay such exempt loan, and earnings attributable to such collateral and the investment of such contributions as 
            required under Regulations section 54.4975-7(b)(5)?
            Does the plan provide that payments made with respect to an exempt loan by the ESOP during the year must not  
e
            exceed an amount equal to the sum of contributions and earnings received during or prior to such year less such  
            payments in prior years as required under Regulations section 54.4975-7(b)(5)?
            Do plan terms provide that qualifying employer securities will be forfeited only after other assets as required under  
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            Regulations section 54.4975-11(d)(4)?
            Does the plan provide that the protections and rights provided to participants and beneficiaries with respect to 
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            employer securities are nonterminable as required in Regulations section 54.4975-11(a)(3)(i) and (ii)?

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

                                                                                                Form 5309 (Rev. 1-2012)

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Form 5309 (Rev. 1-2012) Page 3

What's New An S corporation-sponsored ESOP Paperwork Reduction Act Notice.
must provide that no prohibited We ask for the information on this
The IRS has created a page on allocation of employer stock may be form to determine whether you meet
IRS.gov for information about made to a disqualified person for a the legal requirements for the plan
Form 5309 and its instructions, at nonallocation year. This applies to all approval you request. Your filing of
www.irs.gov/form5309. Information plan years beginning on or after this information is only required if you
about any recent developments January 1, 2005. This applies to plan wish the IRS to determine if your plan
affecting Form 5309 will be posted years ending after March 14, 2001, if: qualifies under section 4975(e)(7).
on that page.
1. The ESOP was established after You are not required to provide
General Information March 14, 2001, or the information requested on a form
Section references are to the Internal 2. The ESOP was established on that is subject to the Paperwork
Revenue Code unless otherwise or before March 14, 2001, if the Reduction Act unless the form
noted. employer maintaining the ESOP had displays a valid OMB control
not made an S-corporation election number. Books or records relating to
Use this form to apply for a in effect on such date. a form or its instructions must be
determination letter for an employee retained as long as their contents
stock ownership plan (ESOP) that How To Complete the Application may become material in the
meets the requirements of section • If a number is requested, a number administration of any Internal
4975(e)(7). Attach Form 5309 to must be entered. Revenue law. Generally, tax returns
Form 5300, Application for and return information are
• If an item provides a box to check,
Determination for Employee Benefit confidential, as required by section
written responses are not
Plan. 6103.
acceptable.
The plan you establish must be The time needed to complete and
• The application has formatted
designed to invest primarily in file this form will vary depending on
fields that will limit the number of
employer securities. For a definition individual circumstances. The
characters entered per field.
of employer securities and how it estimated average time is:
applies to your plan, see section • All data input will need to be Recordkeeping . . 6 hr., 13 min.
409(I) or section 4975(e)(8). Also see entered in Courier 10 point font.
Learning about the
Regulations section 54.4975-11 for • Alpha characters should be law or the form . . 2 hr., 10 min.
the formal plan requirements of an entered in all capital letters.
ESOP. Preparing and
• Enter spaces between any words. sending the form
More information. For more Spaces do not count as characters. to the IRS . . . . 2 hr., 22 min.
information about the latest
developments on Form 5309 and its What To File If you have comments concerning
instructions, go to www.irs.gov/ To receive a determination on the accuracy of these time estimates
form5309. whether a plan, initially or as a result or suggestions for making this form
of a plan amendment, meets the simpler, we would be happy to hear
General Instructions requirements of section 4975(e)(7), from you. You can write to the
A Change To Note submit Form 5309, Form 5300, and Internal Revenue Service, Tax
a copy of all documents and Products Coordinating Committee,
The questions with regard to tax statements required by those forms. SE:W:CAR:MP:T:M:S, 1111
credit ESOPs have been deleted. If Attach the completed Form 5309 to Constitution Ave. NW, IR-6526,
your plan involves such a plan, Form 5300. Washington, DC 20224.
please state so in the cover letter
and refer to Regulations section Signature
1.46-8(d) for the formal requirements Form 5309 must be signed by the
of a tax credit ESOP. The question principal officer authorized to sign.
relating to type of plan has been
deleted from the form. Note. Stamped signatures are not
acceptable; see Rev. Proc. 2012-4,
Who May File 2012-1 I.R.B. 125, at www.irs.gov/
1. Any corporate employer who pub/irs-irbs/irb12-01.pdf.
has established an ESOP intended
to meet the requirements under
section 4975(e)(7).
2. Any corporate employer who
amends an ESOP under section
4975(e)(7).

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