Form (Rev. September 2016) Attach to determination letter application. Department of the Treasury For the latest information about this form, go to www.irs.gov/form8717. Internal Revenue Service 1 Name of plan sponsor (employer if single-employer plan) 2 Sponsor's employer identification number 3 Plan number 4 Plan name 8717 User Fee for Employee Plan Determination Letter Request For IRS Use Only OMB No. 1545-1772 Amount paid Caution: If you qualify for the exemption from user fees for small business employers, complete only the certification below. See the instructions on page 2 for details. For all other applications, leave the certification blank and check the appropriate box and enter the user fee in column B of line 5. Certification I certify that the application for a determination letter on the qualified status of the plan listed above meets the conditions for exemption from user fees described in section 7528(b)(2)(B) of the Internal Revenue Code. Sign Here Type or print name and title Date User Fee Form Submitted 5a b c d e f g Form 5300: Form 5307: Form 5310: Multiple employer plans (Form 5300) Multiple employer plans (Form 5310) Reserved (1a) . . . . . . . . . . . (1b) . . . . . . . . . . . (2a) . . . . . . . . . . . (2b) . . . . . . . . . . . (3) ........... (4) ........... Reserved (1a) . . . . . . . . . . . (1b) . . . . . . . . . . . (2) ........... (3) ........... (4a) . . . . . . . . . . . (4b) . . . . . . . . . . . (5) ........... (6) ........... ........... (7) Form 5316 (Group trusts) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A B no Demo 5 and no Demo 6: $ $ $ $ $ Attach Check or Money Order Here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . h i $ Form 8717 (Rev. 9-2016) Cat. No. 64727O American LegalNet, Inc. www.FormsWorkFlow.com Form 8717 (Rev. 9-2016) Page 2 Section references are to the Internal Revenue Code unless otherwise noted. Where To File (Include Form 8717 and user fee with your request or application.) IF you have this type of request or application . . . . THEN use this address if you send it by: U.S. mail Express Mail or private delivery service Future Developments For the latest information about developments related to Form 8717 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/form8717. What's New Specific user fee amounts are no longer listed on Form 8717. You must now enter the appropriate user fee when completing line 5. Determination letter Internal Revenue Service Internal Revenue Service (Form 5307, 5300, 5310, 5310-A, Attn: EP/EO Determination Attn: EP/EO Determination and Form 5316, Group trust Letters, Stop 31 Letters, Stop 31 applications) P.O. Box 12192 201 West Rivercenter Blvd. Covington, KY 41012-0192 Covington, KY 41011 Example. An employer maintains an individually designed plan first effective on July 1, 2001. Assume that the plan's 5-year remedial amendment cycle is Cycle A. Therefore, a submission period for the plan's cycle ended on January 31, 2012. Assume that the employer filed a determination letter application for the plan on January 31, 2012. If the employer is an eligible employer, the application was exempt from the user fee requirement because the application was filed by the last day of the submission period for the plan's current remedial amendment cycle and the date the plan was first in effect (July 1, 2001) is not before January 1, 2001 (that is, January 1 of the tenth calendar year immediately before 2011, the year in which the submission period for the plan's current remedial amendment cycle began). A determination letter application that was filed by an eligible employer for a defined benefit plan eligible for the 6-year remedial amendment cycle ending on April 30, 2012, also met the requirements for exemption if: (1) the application was filed before May 1, 2012, and (2) the plan was first in effect no earlier than January 3, 1996. See Notice 2002-1, 2002-1 C.B. 283 as amplified by Notice 2003-49, 2003-2 C.B. 294 and Notice 2011-86, 2011-45 I.R.B. 698. An eligible employer as defined in section 408(p)(2)(C)(i)(l) is an employer which had no more than 100 employees who received at least $5,000 of compensation from the employer for the preceding year. In addition, an eligible employer must have at least one employee who is not a highly compensated employee (as defined in section 414(q)) and is participating in the plan. The determination of whether an employer is an eligible employer is made as of the date of the request described above. If your application meets these requirements, complete only the Certification. Don't complete any part of line 5. Check the appropriate box and enter the user fee in Column B of line 5. Attach to the left side of the form a check or money order payable to the "United States Treasury" for the full amount of the user fee to Form 8717, if applicable. If you don't include the full amount, your application may be returned. Attach Form 8717 to your determination letter application. If you have multiple plans, submit a separate determination letter application and Form 8717 for each plan. Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. If you want to have your plan approved by the IRS, you are required to give us the information. We need it to determine whether you meet the legal requirements for plan approval. Section 7528 authorizes us to charge a user fee. You aren't required to provide the information requested on a form subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as req