Form (Rev. June 2014) 5307 Department of the Treasury Internal Revenue Service (Under sections 401(a) and 501(a) of the Internal Revenue Code) Application for Determination for Adopters of Modified Volume Submitter Plans OMB No. 1545-0200 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 Type or print name Date Type or print title For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 11832Y Form 5307 (Rev. 6-2014) American LegalNet, Inc. www.FormsWorkFlow.com Form 5307 (Rev. 6-2014) Page 2 3a Determination requested for (enter applicable number in box) 1 - Initial Qualification -- New Plan 2 - Initial Qualification -- Existing Plan 3 - Request after Initial Qualification b c d If 3a is "1" or "2," enter the date the plan was initially adopted. Yes No Does the VS practitioner have the authority to amend on behalf of the adopting employer? 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) (ii) (iii) f Name of sponsor or practitioner Date of opinion/advisory letter Serial # of opinion/advisory letter 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) Type of Amendment (ii) (iii) (i) Effective Adoption Amendment ID Date Date (a) (b) (MM/DD/YYYY) (MM/DD/YYYY) Interim Discr. . 3g(1) 3g(2) 3g(3) 3g(4) 3g(5) 3g(6) 3g(7) 3g(8) 3g(9) 3g(10) (v) Power to Amend on Behalf of (a) Yes (b) No (vi) (vii) Due Date of Specific Section Tax Return of Plan, Adoption (including Agreement or extensions) Trust Changed (MM/DD/YYYY) or Added (viii) Specific Section of Amendment Creating the Change in (vii) (ix) Is Required Practitioner Statement Attached 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) American LegalNet, Inc. www.FormsWorkFlow.com 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 f No 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. Is at least one employee a nonhighly compensated employee? 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 2 -- cash balance Yes b No 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. 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. 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? Is this a governmental plan under section 414(d)? Is this a church plan under section 414(e)? If "Yes," go to line 6(c)(2). If "No," go to line 6d. 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. Does this plan benefit any collectively bargained employees under Regulations section 1.410(b)-6(d)(2)? Is this an insurance contract plan under section 412(e)(3)? Have interested parties been given the required notification of this application? 3 -- money purchase 4 -- target benefit 5 -- 401(k) 6 -- profit sharing plan g 5a 6a(1) a(2) b c(1) c(2) d e 7 Form 5307 (Rev. 6-2014) American LegalNet, Inc. www.FormsWorkFlow.com Form 5307 (Rev. 6-2014) Page 4 Yes 8a b 9a No Is a separate DL application for this plan currently pending before the IRS? Is this application being filed during the