Form (June 2011) 5316 Application for Group or Pooled Trust Ruling (Under section 401(a) and 501(a) of the Internal Revenue Code) For Internal Use Only OMB No. 1545-2166 Department of the Treasury Internal Revenue Service Review the Procedural Requirements Checklist on page 3 before submitting this application. 1a Name of the trust sponsor 1b Address of trust sponsor (if a P.O. Box, see instructions) 1c City 1d State 1e Zip Code 1f Country 1g Trust sponsor's employer identification number (EIN) 1h Telephone number 1i Fax number 2a Person to contact if more information is needed, see instructions (If a Power of Attorney is attached, check box and do not complete this line.) Contact person's name 2b Contact person's address 2c City 2d State 2e Zip Code 2f Telephone number 2g Fax number If more space is needed for any item, attach additional sheets the same size as this form. Identify each additional sheet with the trust sponsor's name and EIN and identify each item. 3a Name of trust (If trust name exceeds 70 characters, including spaces, see instructions) 3b Enter date trust agreement was executed 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 Paperwork Reduction Act Notice, see instructions. Cat. No. 49983G Form 5316 (6-2011) American LegalNet, Inc. www.FormsWorkFlow.com Form 5316 (6-2011) Page 2 Yes 4 5 No Is the group trust adopted as part of each adopting group trust retiree benefit plan? (See instructions.) Does the group trust instrument expressly limit participation to: pension, profit-sharing, and stock bonus trusts or custodial accounts qualifying under section 401(a) that are exempt under section 501(a); individual retirement accounts that are exempt under section 408(e); eligible governmental plan trusts or custodial accounts under section 457(b) that are exempt under section 457(g); custodial accounts under section 403(b)(7); retirement income accounts under section 403(b)(9); and section 401(a)(24) governmental plans? Does the group trust instrument expressly prohibit any part of its corpus or income that equitably belongs to any adopting group trust retiree benefit plan from being used for, or diverted to, any purpose other than for the exclusive benefit of the participants and the beneficiaries of the group trust retiree benefit plan? Is each group trust retiree benefit plan entity which adopts the group trust itself a trust, a custodial account, or a similar entity that is tax-exempt under section 408(e) or section 501(a) (or is treated as tax-exempt under section 501(a))? Does each group trust retiree benefit plan which adopts the group trust expressly provide in its governing document that it is impossible for any part of the corpus or income of the group trust retiree benefit plan to be used for, or diverted to, purposes other than for the exclusive benefit of the plan participants and their beneficiaries? Does the group trust instrument expressly limit the assets that may be held by the group trust to assets that are contributed by, or transferred from, a group trust retiree benefit plan to the group trust (and the earnings on such assets), and does the group trust instrument expressly provide for separate accounts (and appropriate records) to reflect the interest which each adopting group trust retiree benefit plan has in the group trust? Does the group trust instrument expressly prohibit an assignment by an adopting group trust retiree benefit plan of any part of its equity or interest in the group trust? Was the group trust created or organized in the United States and is the group trust maintained at all times as a domestic trust in the United States? 6 7 8 9 10 11 Form 5316 (6-2011) American LegalNet, Inc. www.FormsWorkFlow.com Form 5316 (6-2011) Page 3 Procedural Requirements Checklist Use this list to ensure that your submitted package is complete. Failure to supply the appropriate information may result in a delay in the processing of the application. 1. 2. 3. Is Form 8717, User Fee for Employee Plan Determination, Opinion, and Advisory Letter Request, attached to your submission? Is the appropriate user fee for your submission attached to Form 8717? If appropriate, is Form 2848, Power of Attorney and Declaration of Representative, Form 8821, Tax Information Authorization, or a privately designated authorization attached? (For more information, see the Disclosure Request by Taxpayer in the instructions and Rev. Proc. 2011-4.) Is a copy of your group trust's determination letter, if any, attached? Have you included a copy of the group trust instrument and all amendments since your last determination letter? Is the Employer Identification Number (EIN) of trust sponsor entered on line 1g? Does line 3b provide the trust's original effective date? Is the application signed and dated? (Stamped signatures are not acceptable; see Rev. Proc. 2011-4.) 4. 5. 6. 7. 8. Form 5316 (6-2011) American LegalNet, Inc. www.FormsWorkFlow.com Form 5316 (6-2011) Page 4 What's New This is a new form. Prior to this form, a letter was submitted in lieu of a form. Review the Procedural Requirements Checklist and these instructions before completing the application. Public inspection. The group trust is open to public inspection. Disclosure request by taxpayer. The Tax Reform Act of 1976 permits a taxpayer to request the IRS to disclose and discuss the taxpayer's return and/or return information with any person(s) the taxpayer designates in a written request. Use Form 2848, Power of Attorney and Declaration of Representative, if the representative is qualified to sign, or Form 8821, Tax Information Authorization, for this purpose. See Pub. 947, Practice Before the IRS and Power of Attorney, for more information. · United Parcel Service (UPS): UPS Next Day Air, UPS Next Day Air Saver, UPS 2nd Day Air, UPS 2nd Day Air A.M., UPS Worldwide Express Plus, and UPS Worldwide Express. The private delivery service can tell you how to get written proof of the mailing date. How To Complete the Application Applications are screened for completeness. The application must be signed by the employer or plan administrator. Stamped signatures are not acceptable; see Rev. Proc. 2011-4, 2011-1 I.R.B. 123, available at www.irs.gov/irb/2011-01_IRB/ar09.html. CAUTION ! General Instructions