Form 5306 Application for Approval of Prototype or Employer Sponsored Individual Retirement Arrangement (IRA) (Under section 408(a), (b), (c), or (p) or section 408A of the Internal Revenue Code) Information about Form 5306 and its instructions is at www.irs.gov/form5306. (Rev. August 2013) Department of the Treasury Internal Revenue Service OMB No. 1545-0390 For IRS Use Only 1 2 a Enter amount of user fee submitted (see Specific Instructions) Approval requested for: Type of individual retirement arrangement-- Prototype traditional IRA under section 408(a) or 408(b) (1) Prototype dual-purpose IRA (3) (5) Roth or traditional IRA established by employer or employee association under section 408(c) Initial application Amendment--Enter (1) Latest letter serial number $ File folder number Part I Identifying Information (see instructions before completing this part) (2) (4) Prototype Roth IRA under section 408A Prototype SIMPLE IRA under section 408(p) b c (2) Date letter issued (3) File folder number 3a Name of applicant 3b Employer identification number of applicant Number, street, and room or suite no. (If a P.O. box, see instructions.) City or town, state, and ZIP code 4a 4c 5a Name of person to be contacted Email address 4b Telephone number 4d If a power of attorney is attached, check box . . . . . Type of sponsoring organization (if you are applying for a ruling under section 408(c), do not complete this item): (1) Insurance company Regulated investment company (5) Trade or professional association Federally insured credit union (2) (6) (3) (7) Savings and loan association that qualifies as a bank Approved non-bank trustee (attach copy of approval letter) (4) Bank b Type of submission (check one box): (1) Not a mass submitter (2) Mass submitter (3) Identical adoption of a mass submitter (4) Minor modification of a mass submitter 6 Name of trustee or custodian Number, street, and room or suite no. (If a P.O. box, see instructions.) City or town, state, and ZIP code 7 a b Type of funding entity: Trust Custodial account c Insurance company Annuity contract or endorsement number (see instructions) 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. 11830C Title Form 5306 (Rev. 8-2013) For Privacy Act and Paperwork Reduction Act Notice, see instructions. American LegalNet, Inc. www.FormsWorkFlow.com Form 5306 (Rev. 8-2013) Page 2 Part II Plan Information Article or Section Reference Page Number For IRS Use Only Attach a copy of the plan documents and indicate the article or section reference 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. 8a Does the IRA provide that the trust is created for the exclusive benefit of the participant or his or her beneficiaries, or that the annuity contract must be owned only by the annuitant? . . . . . . . . . . . . . . . . . . . . . . . . . b Does the IRA describe the type of allowable contributions (that is, only cash except for rollovers) and maximum limitation? . . . . . . . . . . . . . . . . c Does the IRA prohibit the investment of trust assets in collectibles, or contain a statement informing individuals that an investment in collectibles, except for investments in certain coins and precious metals, will be treated as a taxable distribution? . . . . . . . . . . . . . . . . . . . . . . . . . Does the IRA prohibit investment in life insurance contracts? . . . . . . . . . Does the IRA provide the rules on required distributions commencing before death? . Does the IRA provide the rules on required distributions commencing after death? . Does the IRA provide that the account is nonforfeitable? . . . . . . . . . . Does the IRA provide that the contract is nontransferable? . . . . . . . . . Does the IRA provide for application of premium refund (other than refunds attributable to excess contributions) before the end of the calendar year following the year of the refund toward the payment of future premiums or the purchase of additional benefits? Does the IRA prohibit commingling assets of trusts? ........... Does the IRA provide that annuity contracts must have flexible premiums? . . . . Does the IRA provide for a separate accounting for the interest of each employee or member of the association? . . . . . . . . . . . . . . . . . . . . 1/13 2/14 d e f g h i 3 4 5/15 6/16 7/17 18 j k l 19 8 20 9 10/21 11 12/22 Form 5306 (Rev. 8-2013) m Does the IRA provide for annual calendar-year reports by trustees or issuers? . . . n Does the IRA require substitution of non-bank trustee or custodian when notified by the Commissioner of the Internal Revenue Service? . . . . . . . . . . . . o Does the IRA define compensation? . . . . . . . . . . . . . . . . . American LegalNet, Inc. www.FormsWorkFlow.com Form 5306 (Rev. 8-2013) Page 3 General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form 5306 and its instructions, such as legislation enacted after this form and instructions were published, go to www.irs.gov/form5306. Purpose of form. Sponsoring organizations, employers, or employee associations, use Form 5306 to request a ruling as to: � Whether a trust or custodial account agreement meets the requirements of section 408(a), 408(c), 408(p), or 408A, or � Whether an individual annuity meets the requirements of section 408(b), 408(p), or 408A. Where to file. File Form 5306 with the Internal Revenue Service, Attention: EP Opinion Letters, P.O. Box 27063, McPherson Station, Washington, DC 20038. Address. Include the suite, room, or other unit number after the street number. If the Post Office does not deliver mail to the street address and you have a P.O. box, show the box number instead of the street address. Signature. An officer who is authorized to sign or another person authorized under a power of attorney must sign this application. Send the power of attorney with this application when you file it. Specific Instructions User fee. All applications must be accompanied by the appropriate user fee. Applications submitted witho