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Form 4461-A Application for Approval of Standardized or OMB No. 1545-0169
(Rev. November 2019) Nonstandardized Pre-Approved Defined
Benefit Plan This Form Is Open to Public Inspection
Department of the Treasury
Internal Revenue Service ▶ Go to www.irs.gov/Form4461A for the latest information.
File This Form With the Internal Revenue Service For IRS Use Only
File folder number
Section references are to the Internal Revenue Code unless otherwise noted.

Complete every applicable item on this form and Attachment 1-A. (See Rev. Proc. 2017-41, 2017-29 I.R.B. 92.)

See instructions before completing this form.
1 Enter amount of user fee submitted
$
2 a Approval requested: 2b File folder number 2c Date of last letter issued
Initial application
Amendment—Enter file folder number in line 2b
and date of last letter issued in line 2c . . ▶
3 a Name of applicant 3b Employer identification number
(EIN) of applicant
Address (number, street, room or suite no.) (If a P.O. box, see instructions.)

City State ZIP code 3c Applicant’s telephone number

3 d Type of applicant (see Definitions in the instructions):
Provider Mass submitter
4a Name of person to be contacted 4b Telephone number 4c Fax number

4 d Email address
4e If a power of attorney is attached, check box . . ▶
5a Basic plan document or single document plan number 5b Adoption agreement number, if applicable

6 Form of plan:
Adoption agreement plan Single document plan
7 Type of plan (select all that apply):
Without permitted disparity With permitted disparity Governmental
Nonelecting church Without cash balance features With cash balance features
8 Filing status of plan:
Standardized plan Nonstandardized plan
Under penalties of perjury, I declare that I have examined this application, including accompanying statements, and, to the best of my knowledge and
belief, it is true, correct, and complete.

Signature ▶ Title ▶ Date ▶
For Privacy Act and Paperwork Reduction Act Notice, see the instructions. Cat. No. 11416U Form 4461-A (Rev. 11-2019)

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Form 4461-A (Rev. 11-2019)                                                                                              Page  2 
9     Procedural requirements:                                                                                      Yes No 
a     Have the following been submitted as required by instructions:
      (1) Adoption agreement, if applicable?  .     .   .   .   . . . . .      .   .   .  .  . . . . . . . .     . .
      (2) Copy of plan?        . . . . . .  . .     .   .   .   . . . . .      .   .   .  .  . . . . . . . .     . .
      (3) Copy of Certification of Interim Amendments?  .       . . . . .      .   .   .  .  . . . . . . . .     . .
b     Do you have a procedure in place for the adoption and distribution of interim amendments made on behalf of
      adopting employers? .      . . . . .  . .     .   .   .   . . . . .      .   .   .  .  . . . . . . . .     . .
c     Is the plan patterned after, and substantially the same as, another plan submitted? (If “Yes,” see   Specific 
      Instructions.) .     . . . . . . . .  . .     .   .   .   . . . . .      .   .   .  .  . . . . . . . .     . .
d     Provider (non-mass submitter) request.
      (1) Do you have at least 15 employer-clients which are reasonably expected to adopt this plan’s basic plan 
          document and adoption agreement or single document plan? .           .   .   .  .  . . . . . . . .     . .
      (2) If you have more than one pre-approved plan, do you have at least 30 employer-clients in the aggregate 
          which are reasonably expected to adopt at least one of the plans? (If you don’t have more than one
          pre-approved plan, skip this question.)  .    .   .   . . . . .      .   .   .  .  . . . . . . . .     . .
e     Mass submitter request. 
      (1) Are applications on behalf of the requisite number of providers who are adopting the same basic plan 
          document on a word-for-word identical basis included? If “No,” complete (2)          . . . . . . .     . .
      (2) If “No” to (1), enter the file folder number of the basic plan document for which the requisite number 
          of adopting providers requirement is met: 
      (3) Is this a flexible plan? If “Yes,” answer (a) and (b). If “No,” skip (a) and (b) . . . . . . . . .     . .
          (a) Have you bracketed and identified the optional provisions of the plan?         . . . . . . . .     . .
          (b) Have you included a copy of the written representation describing the choices available to providers 
              and the coordination of optional provisions?  .     . . . .      .   .   .  .  . . . . . . . .     . .
Note: This application is designed to be used in conjunction with Rev. Proc. 2017-41. A List of Required Modifications (LRMs) is also 
recommended for use and may be obtained from the IRS website at www.irs.gov/lrms.
                                                                                                           Form 4461-A (Rev. 11-2019)

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Form 4461-A (Rev. 11-2019) Page 3
General Instructions For approval, file this application and Disclosure requested by taxpayer. A
each applicable document listed on line taxpayer may request the IRS to
Section references are to the Internal 9a. A mass submitter should also file disclose and discuss the return or return
Revenue Code unless otherwise noted. Form(s) 4461-B, Application for Approval information with any person(s) the
of Standardized or Nonstandardized Pre- taxpayer designates in a written request.
Future Developments Approved Plans, as needed. If you want to designate a person(s) to
For the latest information about Multiple adoption agreement plans. A assist in an application for approval, you
developments related to Form 4461-A, provider may use one basic plan must provide the IRS office of
such as legislation enacted after the document for several plans. A provider jurisdiction with a written request that
form was published, go to may, for example, use one basic plan contains the following.
www.irs.gov/Form4461A. document with a standardized plan with • The taxpayer’s name, address, EIN,
or without permitted disparity as well as and plan number(s).
Purpose of Form a nonstandardized plan with or without • The name, address, social security
Form 4461-A is used to apply for permitted disparity. Submit a separate number, and telephone number(s) of the
approval of standardized or adoption agreement and completed person or persons whom you are
nonstandardized pre-approved defined application for each such defined benefit authorizing to receive return information.
benefit plans. plan. See section 9.06 of Rev. Proc.
2017-41 for more details, including the • A paragraph that clearly describes the
Be sure to submit a complete and special rules for governmental and return or return information that you
accurate application, including Form nonelecting church plans. In the case of authorize the IRS to disclose.
4461-A and Attachment 1-A (see simultaneous submissions of plans using • An authorized signature (see above).
www.irs.gov/retirement-plans/ the same basic plan document, submit
preapproved-plan-submission- only one copy of the basic plan As an alternative to providing the
procedures or Rev. Proc. 2017-41, document. If the requests aren’t above statement, you may submit
2017-29 I.R.B. 92). Complete every simultaneous, submit separate basic Form 2848, Power of Attorney and
applicable line on the application. If an plan documents and include a cover Declaration of Representative.
item on the Attachment 1-A doesn’t letter identifying the original submission.
apply, check the “N/A” box or enter The number assigned to the basic plan Definitions
“N/A” on the line where indicated as an document of a standardized or Adoption agreement. An adoption
option. If your application isn’t complete, nonstandardized pre-approved plan agreement is the portion of the plan
we will return it without processing it. must remain the same as in the prior containing all the options that the
The first page must be typed. Unless submission. One basic plan document adopting employer may select. The
otherwise noted, the questions on Form may not be used for both defined benefit adoption agreement may include blanks
4461-A and Attachment 1-A apply to and defined contribution plans. or fill-in provisions for the employer to
both standardized and nonstandardized complete if it also includes parameters
pre-approved defined benefit plans. Two or more single document plans. A
provider may not combine different on these provisions that preclude an
Requests for additional information. If categories in a single document plan or employer from completing them in a
a letter requesting additional information application. See section 9.07 of Rev. manner that could violate the
or changes to plan documents is sent to Proc. 2017-41 for more details, including qualification requirements. Each
the pre-approved plan provider, or an the special rules for governmental and separate adoption agreement is treated
authorized representative, such nonelecting church plans. as a separate plan and will receive its
information and/or changes must be own opinion letter.
received no later than 30 days from the Where To File Basic plan document. A basic plan
date of the letter. Failure to respond document is the portion of the plan
timely may result in the application being Send Form 4461-A to:
containing all the nonelective provisions
considered withdrawn. An extension of Internal Revenue Service applicable to all adopting employers. No
the 30-day time limit will be granted only Attn: Pre-Approved Plans options (including blanks to be
for good cause. Coordinator completed) may be provided in the
Inadequate submissions. We will Room 6-403, Group 7521 basic plan document except for options
return, without further action, plansthat P.O. Box 2508 in flexible plans.
aren’t in substantial compliancewith the Cincinnati, OH 45201-2508
Single document plan. A single
qualification requirements or plans that If using Express Mail or a private document plan may contain alternate
are so deficient that theycan’t be delivery service, use this address: paragraphs and options that may be
reviewed in a reasonableamount of time. selected by an adopting employer. A
Internal Revenue Service
Who May File Attn: Pre-Approved Plans single document plan may include
Coordinator blanks or fill-in provisions for the
A provider or mass submitter of a pre- Room 6-403, Group 7521 employer to complete only if the plan
approved defined benefit plan may file a 550 Main Street also includes parameters on these
Form 4461-A. See Definitions, later. Cincinnati, OH 45202 provisions that preclude an employer
from completing them in a manner that
What To File Signature. The application must be could violate the qualification
signed by a partner or officer of the requirements.
Submit one copy of Form 4461-A and applicant who is authorized to sign, or
Attachment 1-A for each separate other person authorized by a power of
adoption agreement or for each single attorney. The power of attorney should
document plan where no adoption be filed with the application.
agreement is used.

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Form 4461-A (Rev. 11-2019) Page 4
Flexible plan. A flexible plan is a plan A provider also includes any person If multiple adoption agreements are
submitted by a mass submitter which that has an established place of linked to the same basic plan document,
contains certainoptional provisions as business in the United States where it is the same two-digit basic plan document
allowed by section 10.03(1) of Rev. Proc. accessible during every business day number should be used for all
2017-41. Providers that adopta flexible and offers a plan as a word-for-word applications.
plan may include or delete any optional identical adopter or minor modifier Line 5b. Enter the three-digit number
provision designated as such in the adopter of a plan of a mass submitter, you have assigned to the adoption
mass submitter’s plan. A flexible plan regardless of the number of employers agreement for which this application is
adopted by a provider which differsfrom that are expected to adopt the plan. submitted. Each different adoption
the mass submitter plan onlybecause of Standardized plan. A standardized plan agreement designed to accompany a
the deletion of certainoptional is a pre-approved plan (other than a single basic plan document should be
provisions will be treated as a plan that statutory hybrid plan) that meets the given a different three-digit number
isword-for-word identical to the mass requirements set forth in section 5.16 of beginning with “001.” For example, if the
submitter plan. Rev. Proc. 2017-41. first basic plan document of a sponsor
Mass submitter. As set forth in Rev. Nonstandardized plan. A has four different adoption agreements,
Proc. 2017-41, any entity that submits nonstandardized plan is a pre-approved they should be numbered “001” through
applications on behalf of at least 30 plan that isn’t a standardized plan and “004,” and the provider should submit
unaffiliated providers each of which is that satisfies section 5.15 of Rev. Proc. four separate Forms 4461-A. Adoption
sponsoring, on a word-for-word identical 2017-41. agreements submitted with the second
basis, the same plan is a mass or any subsequent basic plan
submitter. A mass submitter is treated as Statutory hybrid plan. A statutory documents (that aren’t word-for-word
a mass submitter with respect to all of its hybrid plan is a defined benefit plan that identical to a previously submitted basic
plans, provided the 30-unaffiliated- contains a statutory hybrid benefit plan document) should be similarly
provider requirement is met with respect formula, as defined in Regulations numbered beginning with “001.”
to at least one plan. section 1.411(a)(13)-1(d)(4). Section 6.03
of Rev. Proc. 2017-41 (as revised by Line 9. Procedural requirements.
Affiliation is determined under sections Rev. Proc. 2018-21, 2018-14 I.R.B. 467) Submit a separate application for each
414(b) and (c). Additionally, the following provides a list of areas not covered by different plan/adoption agreement
will be considered to be affiliated: any opinion letters. This list includes combination or single document plan.
law firm, accounting firm, consulting statutory hybrid plans with certain Line 9c. If you checked “Yes,” submit a
firm, etc., with its partners, members, features, such as a statutory hybrid copy of such plan with language
associates, etc. For purposes of benefit formula that isn’t a cash balance differences highlighted. Attach a cover
determining whether 30 unaffiliated formula. See section 6.03 of Rev. Proc. letter that includes the following.
providers sponsor on a word-for-word 2017-41 for the complete list. • The name and file folder number of the
identical basis the same plan document,
the mass submitter is treated as an plan, including the name and EIN of the
unaffiliated provider. Specific Instructions provider.
Pre-approved plan. A pre-approved Line 1. All applications submitted must • A list of all plans written by the plan
plan is a plan (including a plan covering be accompanied by the appropriate user drafter that are substantially identical to
self-employed individuals) that is made fee and Form 8717-A, User Fee for the lead plan, including the information
available by a provider for adoption by Employee Plan Opinion Letter Request, described above.
employers. The term pre-approved plan as determined from the schedule in Rev. • A description of each place where the
includes both standardized and Proc. 2019-4, 2019-1 I.R.B. 146 (or the plan for which the application is being
nonstandardized plans. A pre-approved latest annual update). Applications submitted isn’t word-for-word identical
plan may be an adoption agreement plan submitted without the proper user fee to the language of the lead plan,
or a single document plan. An adoption won’t be processed and will be returned including an explanation of the purpose
agreement plan consists of a basic plan to the applicant. and effect of each difference.
document and an adoption agreement. A Line 3a. Enter the name and address of • A certification made under penalty of
single document plan consists of a the applicant. If the Post Office doesn’t perjury by the plan drafter that the
single plan document offered by a deliver mail to the street address and information describing where the plan
provider without an adoption agreement. the applicant has a P.O. box number, language isn’t word-for-word identical is
Provider. A provider is any person show the P.O. box number instead of the true and complete.
(including a mass submitter, if street address. Line 9e. In addition to filing Form
applicable) that (1) has an established Line 4a. If the person to be contacted is 4461-A, the mass submitter should use
place of business in the United States other than an employee of the applicant, Form 4461-B, when submitting
where it is accessible during every please enclose an authorized power of applications on behalf of its adopting
business day; and (2) represents to the attorney. See Disclosure requested by providers, and submit Form 8717-A.
IRS that it has at least 15 employer- taxpayer, earlier.
clients, each of which is reasonably
expected to adopt the same pre- Line 4c. Enter a fax number to receive
approved plan of the provider. notice of preliminary approval of the
applicable plan, subject to final approval
A provider may request an opinion by opinion letter.
letter for more than one plan provided it
represents to the IRS that it has at least Line 5a. Enter the two-digit number you
30 employer-clients in the aggregate, have assigned to your single document
each of which is reasonably expected to plan or basic plan document that
adopt at least one of the provider’s accompanies theadoption agreement
plans. for which you arerequesting approval.

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Form 4461-A (Rev. 11-2019) Page 5
Privacy Act and Paperwork Reduction any Internal Revenue law. Generally, tax If you have comments concerning the
Act Notice. Weask for the information returns and return information are accuracy of these time estimates or
on this form tocarry out the Internal confidential, as required by Code section suggestions for making this form
Revenue laws ofthe United States. You 6103. simpler, we would be happy to hear from
are required togive us this information. The time needed to complete and file you. You can send us comments from
We need it todetermine whether you this form will vary depending on www.irs.gov/FormComments. Or you
meet the legalrequirements for plan individual circumstances. The estimated can write to the Internal Revenue
approval. average time is: Service, Tax Forms and Publications
Division, 1111 Constitution Ave. NW,
You aren’t required to provide the Recordkeeping . . . 42 hr., 5 min. IR-6526, Washington, DC 20224. Don’t
information requested on a form that is
subject to the Paperwork Reduction Act Learning about the law send Form 4461-A to this address.
unless the form displays a valid OMB or the form . . . . . 5 hr., 55 min. Instead, seeWhere To File, earlier.
control number. Books or records Preparing the form . . 7 hr., 48 min.
relating to a form or its instructions must
be retained as long as their content may Copying, assembling, and
become material in the administration of sending the form to the IRS . 16 min.

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