Form 5306-A (Rev. August 2013) Department of the Treasury Internal Revenue Service Application for Approval of Prototype Simplified Employee Pension (SEP) or Savings Incentive Match Plan for Employees of Small Employers (SIMPLE IRA Plan) (Under section 408(k) or (p) of the Internal Revenue Code) Information about Form 5306-A and its instructions is at www.irs.gov/form5306a. OMB No. 1545-0199 For IRS Use Only 1 Part 2 a b c Enter amount of user fee submitted (see Specific Instructions) $ I Identifying Information (see instructions before completing this part) File folder number Approval requested for: Type of plan-- (1) Prototype simplified employee pension (SEP) under section 408(k) Prototype savings incentive match plan for employees of small employers (SIMPLE IRA plan) under section 408(p) (2) Initial application Amendment--Enter (1) Latest letter serial number (2) Date letter issued (3) File folder number 3 4a If the SEP contains elective deferral provisions, check this box Name of applicant . . . . ...... 4b Applicant's employer identification number Number, street, and room or suite no. (If a P.O. box, see instructions.) City or town, state, and ZIP code 5a 5c 6 Name of person to be contacted Email address 5b Telephone number 5d If a power of attorney is attached, check box .. Type of submission (check one box): a Not a mass submitter b Mass submitter d Minor modification of a mass submitter c Identical adoption of a mass submitter 7a If 6c or 6d is checked, enter the mass submitter's name b File folder number of the mass submitter's SEP or SIMPLE IRA plan on which this submission is based: 8 Type of sponsoring organization: a Insurance company e Regulated investment company b f Trade or professional organization Federally insured credit union g Approved non-bank trustee (attach copy of approval Savings and loan association that qualifies as a bank c letter) d Bank Part II SEP Information Plan Article or Section Reference Plan For Page IRS Use Number Only Attach a copy of the SEP documents and indicate the article or section and the page number where the following provisions appear. If any item does not apply, write "N/A." Sample language, or a listing of required modifications (LRMs), is available on the IRS website at IRS.gov. Type "LRM" in the search box. Sponsors are encouraged to use LRM language. 9a Does the SEP cover all employees who have attained age 21, performed service for the employer in 3 of the immediately preceding 5 years, and received at least $550* in compensation from the employer for the year, other than employees who may be excluded under section 410(b)(3)(A) or (C)? . . . . . . . . . . b Does the SEP provide that all eligible employees will share in an allocation? . . c Does the SEP contain a definite allocation formula that does not discriminate in favor of highly compensated employees? . . . . . . . . . . . . . d Does the SEP require that it be used only with pre-approved traditional IRAs? . e Does the SEP prohibit restrictions on withdrawals (other than restrictions permitted under section 408(d)(7)(A) in the case of a salary reduction SEP)? . . f Does the SEP define "compensation" in a manner that satisfies one of the safe harbor definitions under section 414(s) and limit compensation under section 408(k)(3)(C)? . . . . . . . . . . . . . . . . . . . . . . . 1 2 3 5 6 7 * This is the amount for 2013. The amount may be increased in future years for cost-of-living adjustments. Please Sign Here 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 of officer Date Cat. No. 32621R Title Form 5306-A (Rev. 8-2013) American LegalNet, Inc. www.FormsWorkFlow.com For Paperwork Reduction Act Notice, see the instructions. Form 5306-A (Rev. 8-2013) Page 2 Part III SIMPLE IRA Plan Information Plan Article or Section Reference Plan For Page IRS Use Number Only 1 Attach a copy of the SIMPLE IRA plan documents and indicate the article or section and the page number where the following provisions appear. If an item does not apply, enter "N/A." Sample language, or a listing of required modifications (LRMs), is available on the IRS website at IRS.gov. Type "LRM" in the search box. Sponsors are encouraged to use LRM language. 10a Does the plan define the term "employer" to include all members of such groups or entities required to be aggregated with the employer? . . . . . . . . b Does the plan limit adoption to employers that have 100 or less employees who earned $5,000 or more in compensation from the employer during the preceding calendar year? . . . . . . . . . . . . . . . . . . . . . . c Does the plan limit adoption to employers that do not maintain another qualified plan to which contributions are made or benefits accrued? . . . . . . . d Does the plan define the term "employee" to include leased employees and employees described in section 401(c)(1)? . . . . . . . . . . . . . e Does the plan cover all employees except those that may be excluded under section 408(p)(4)? . . . . . . . . . . . . . . . . . . . . . f Does the plan provide that each eligible employee may make or modify a salary reduction agreement during the 60-day period immediately preceding the calendar year after receiving proper notice? . . . . . . . . . . . . g Does the plan provide that salary reduction contributions may not exceed the statutory limits? . . . . . . . . . . . . . . . . . . . . . . h Under the plan, is an eligible employee permitted to terminate a salary reduction election at any time? . . . . . . . . . . . . . . . . . . . . i j Is the interest of an eligible employee in the plan nonforfeitable at all times? . . Does the plan provide that the employer will make matching contributions to each eligible employee's SIMPLE IRA equal to the employee's salary reduction contribution, up to a limit of 3% of the employee's compensation for the calendar year? . . . . . . . . . . . . . . . . . . . . . . . . . Does the plan provide that the employer will make a 2% nonelective contribution to each eligible employee's SIMPLE IRA in lieu of matching contributions? . . 2 3 4 5 6 7 8 9 10 11 k l Does the plan require that the employer will make salary reduction contributions to eligible employees' SIMPLE IRAs no later than 30 days after the month in which the amounts would otherwise have been payable to the employee in cash? . . m Unless the employer h