Form 5310 Application for Determination for Terminating Plan OMB No. 1545-0202 (Rev. December 2013) Department of the Treasury Internal Revenue Service (Under sections 401(a) and 501(a) of the Internal Revenue Code) Information about Form 5310 and its instructions is at www.irs.gov/form5310. For Internal Use Only Review instructions and 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 code 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 Type or print title Date For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions. Cat. No. 11840Y Form 5310 (Rev. 12-2013) Form 5310 (Rev. 12-2013) Page 2 Yes 3a (1) No Is this plan a pre-approved Volume Submitter (VS) plan that relied on the advisory letter for the immediately preceding remedial amendment cycle (RAC)? Is this plan a pre-approved Master & Prototype Plan (M&P) plan that relied on the opinion letter for the immediately preceding RAC? If line 3a(1) or 3a(2) is "Yes," then complete lines 3(a)(3), (4) and (5). If "No," go to line 3b. (2) (3) (4) (5) b Name of sponsor or practitioner Date of opinion/advisory letter Serial # of opinion/advisory letter If the plan is a VS plan, does the VS practitioner have the authority to amend on behalf of the adopting employer? Is the plan an individually designed plan that is eligible for the six-year RAC? Yes No NA Does the plan have a determination letter (DL) for the plan's RAC preceding the cycle in which this application is filed? If "Yes," complete lines 3d(i), (ii), and (iii) below. If "No," go to line 3e. (i) Date the letter was issued (ii) Year of the Cumulative List considered in the letter (iii) Expiration date of the letter c d Form 5310 (Rev. 12-2013) Form 5310 (Rev. 12-2013) Page 3 (Line 3 continued) Yes e No 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 column (v) in the table. If "Yes," and the amendment contains both interim and discretionary provisions, mark an "X" in columns (iv) and (v) in the table. Complete the following table (for (iv), (v), and (vi) mark with an "X" in the applicable boxes). If additional space is needed, attach a separate sheet of paper the same size, label it "Attachment to 3f" using the same format as below. Type of Amendment (i) Amendment ID (ii) Effective Date (MMDDYYYY) (iii) Adoption Date (MMDDYYYY) (vi) Power to Amend on Behalf of (vii) Due Date of Tax Return (including extensions) (MMDDYYYY) f (iv) Interim Amnd. (v) Discr. Amnd. 3f(1) 3f(2) 3f(3) 3f(4) 3f(5) 3f(6) 3f(7) 3f(8) 3f(9) 3f(10) g h List total amendments on line 3f Designate the specific tax return that the employer uses to file its return Form 5310 (Rev. 12-2013) Form 5310 (Rev. 12-2013) Page 4 4a Name of plan (plan name cannot exceed 70 characters, including spaces): b d Enter 3-digit plan number Enter plan's original effective date Yes No c e Enter month on which the plan year ends (MM) Enter number of participants If 100 or less, complete line 4f. Otherwise, go to line 5 f 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(1). Is at least one employee a non highly compensated employee? Was this application filed in connection with a plan termination? If "Yes," attach copies of all actions taken to terminate the plan. If "No," do not submit this application. (2) Proposed date of plan termination (3) Date of board of directors action (or other documentation) formally terminating the plan g 5a (1) b c (1) Will plan assets be distributed as soon as administratively feasible? Will plan assets be, or have plan assets been, returned to the employer? If "Yes," complete lines 5c(2) and (3). If "No," go to line 6a. Enter the estimated amount of plan assets to be returned to the employer . . . . . . . (2) (3) 6a Has the employer established or does the employer intend to establish a Qualified Replacement Plan? 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 � Pension Equity Plan (PEP) 2 � cash balance conversion 3 � cash balance (not converted) 4 � defined benefit but not cash balance 5 � ESOP 6 � money purchase 7 � target benefit 8 � stock bonus 9 � 401(k) 10 � profit sharing plan Form 5310 (Rev. 12-2013) Form 5310 (Rev. 12-2013) Page 5 (Line 6 continued) Yes b (1) No If the response to line 6a was "1," "2," "3," "4," "6," or "7," is the plan's normal retirement age below 62 at any time after 5/22/07? If "Yes," go to line 6b(2). If "No," go to line 6c(1). Has the employer (or trustees, if this is a multiemployer plan) made a good faith determination that the plan's normal retirement age is not lower than an age that reasonably represents the typical retirement age for the industry in which the covered workforce is employed? If "Yes," attach required statement. Governmental plans see instructions. If the response to line 6a was "5," mark the applicable box to indicate whether the plan sponsor is an S Corporation or a C Corporation. S Corp. (2) C Corp. (2) c (1) If there has been a change to the corporate status (from S to C or C to S election/revocation), provide the effective date of such change. Is the plan sponsor a member of an affiliated service group (ASG), controlled group of corporations, or a group of trades or busines