Form 5300, Application for Determination for Employee Benefit Plan, Schedule Q (Form 5300), Elective Determination Requests

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Instructions for Form 5300

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The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Instructions for Form 5300

Department of the Treasury
Internal Revenue Service

(Rev. August 2004)
Application for Determination for Employee Benefit Plan
(including Collectively Bargained Plans formerly filed on Form 5303)
Section references are to the Internal Revenue Code unless otherwise noted.

Public Inspection. Form 5300 is
open to public inspection if there are
more than 25 plan participants. The
total number of participants must be
shown on line 4e. See the
instructions for line 4e for a definition
of participant.
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, for this
purpose.

General Instructions
Purpose of Form
File Form 5300 to request a
determination letter from the IRS for
the initial qualification of a defined
benefit or a defined contribution plan
and the exempt status of any related
trust. See Types of Determination
Letters on page 2 for more
information.
This form may also be filed to
request a determination letter on the
qualified status of a plan at any time
subsequent to initial qualification
even if the plan has not been
amended.
File Form 5307, Application for
Determination for Master or Prototype
or Volume Submitter Plans, instead of
Form 5300 if this is an M&P or
volume submitter plan. However, use
Form 5300 instead of Form 5307 if
you are also requesting a
determination on affiliated service
group status, leased employee
status, or a partial termination.
File Form 6406, Short Form
Application for Determination for
Minor Amendment of Employee
Benefit Plan, instead of Form 5300 to
apply for a determination letter on a
minor plan amendment to a plan that
has already filed Form 5300 and
received a favorable determination
letter for GUST. Form 6406 generally

may not be used to apply for a
determination on GUST, except as
provided in section 3.05 of Rev. Proc.
2000-27, 2000-26 I.R.B., 1272. You
can find Rev. Proc. 2000-27 on page
1272 of Internal Revenue Bulletin
2000-26 at http://www.irs.gov/pub/
irs-irbs/irb00-26.pdf.

Type of Plan

• A Defined Contribution Plan (DCP)

is a plan that provides an individual
account for each participant and for
benefits based only:
1. On the amount contributed to
the participant’s account, and
2. Any income, expenses, gains
and losses, and any forfeitures of
accounts of other participants that
may be allocated to the participant’s
account.
• A Defined Benefit Plan (DBP) is
any plan that is not a DCP.
A qualified plan must satisfy section
401(a) including, but not limited to,
participation, vesting,
nondiscriminatory contributions or
benefits, distributions, and
contribution and benefit limitations.

Who May File
This form may be filed by any:
• Employer, including a sole
proprietor, partnership, plan sponsor
or a plan administrator that has
adopted an individually designed plan
to request a determination letter on:
1. Initial qualification of a plan;
2. Qualification of an entire plan
as amended,
3. Partial termination of a plan;
4. Affiliated service group (ASG)
status (section 414(m)), or
5. Leased employee status
(section 414(n)).
• Plan sponsor or plan administrator
to request a determination letter for a
plan maintained by an employer that
is part of a controlled group of
corporations (section 414(b)), or
trades or businesses under common
control (section 414(c)), or an ASG
(section 414(m)).
• Plan sponsor or plan administrator
to request a determination letter for a
Cat. No. 10932P

multiemployer or multiple-employer
plan (a plan maintained by more than
one employer considering all
employers combined under section
414(b), (c), or (m) as one employer).
• Employer, plan sponsor, or plan
administrator desiring a determination
letter for compliance with the
applicable requirements of a foreign
situs trust for the taxability of
beneficiaries (section 402(c)) and
deductions for employer contributions
(section 404(a)(4)).

Where To File
File Form 5300 at the address
indicated below:
Internal Revenue Service,
P.O. Box 192,
Covington, KY 41012 –0192.
Requests shipped by express mail or
a delivery service should be sent to:
Internal Revenue Service,
201 West Rivercenter Blvd.,
Attn: Extracting Stop 312,
Covington, KY 41011.
Private Delivery Services. In
addition to the United States mail,
you can use certain private delivery
services designated by the IRS to
meet the “timely mailing as timely
filing/paying” rule for tax returns and
payments. The most recent list of
designated private delivery services
was published by the IRS in
September 2002 and includes only
the following:
• Airborne Express (Airborne):
Overnight Air Express Service, Next
Afternoon Service, Second Day
Service.
• DHL Worldwide Express (DHL):
DHL “Same Day” Service, DHL USA
Overnight.
• Federal Express (FedEx): FedEx
Priority Overnight, FedEx Standard
Overnight, FedEx 2Day, FedEx
International Priority, and FedEx
International First.
• 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.

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Instructions for Form 5300

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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, plan
administrator or authorized
representative. Incomplete
applications may be returned to the
applicant. For this reason, it is
important that an appropriate
response be entered for each line
item (unless instructed otherwise). In
completing the application, pay
careful attention to the following:
• N/A (not applicable) is accepted as
a response only if an N/A block is
provided.
• If a number is requested, a number
must be entered.
• If an item provides a choice of
boxes to check, check only one box
unless instructed otherwise.
• If an item provides a box to check,
written responses are not acceptable.
• Governmental plans and
nonelecting church plans do not have
to complete lines 10 and 12a.
• The IRS may, at its discretion,
require a plan restatement or
additional information any time it is
deemed necessary.

• Completion of page 4 of Form 5300
is optional. Complete page 4 for: (a) a
request for a determination regarding
the ratio percentage test under
Regulations section 1.410(b)-2(b)(2),
(b) a determination regarding one of
the special requirements under
Regulations section 1.410(b)-2(b)(5),
(6), or (7), or (c) a request for a
determination regarding the
nondiscrimination design-based safe
harbors of section 401(a)(4).
Revenue Procedure 2004-6
TIP publishes the guidance under
which the determination letter
program is administered. It is updated
annually and can be found in the
Internal Revenue Bulletin (I.R.B.).
Example. Rev. Proc. 2004-6, 2004-1
I.R.B. 197 superseded Rev. Proc.
2003-6.

What To File
All applications must contain an
original signature and must be
accompanied by the following
applicable items:
• A copy of the plan.
• The appropriate user fee, if
applicable, and Form 8717, User Fee
for Employee Plan Determination
Letter Request. Please submit a
separate check for each application.
Make checks payable to the “United
States Treasury.”

Figure 1. Partial Termination Worksheet
Partial Termination Worksheet

1

Year
----

Year of
partial
Year termination Year
-------

Participants employed: . . . . . . . . . . . . . . . . . .

a Number at beginning of plan year . . . . . . . . . . .
b Number added during the plan year . . . . . . . . .
c Total, add lines a and b . . . . . . . . . . . . . . . . . .
d Number dropped during the plan year . . . . . . . .
e Number at end of plan year, subtract d from c . .
f Total number of participants in this plan
separated from service without full vesting . . . .
2

Present value (as of month
/
/
day during the year of): . . . . . . . . . . . . . . . . . .

a Plan assets . . . . . . . . . . . . . . . . . . . . . . . . . .
b Accrued benefits . . . . . . . . . . . . . . . . . . . . . . .
c Vested benefits . . . . . . . . . . . . . . . . . . . . . . . .
3

Submit a description of the actions than may have resulted (or might result) in a
partial termination. Include an explanation of how the plan meets the requirements
of section 411(d)(3).

-2-

• All applications for plans that have

at any time in the past received a
favorable determination letter must
include a copy of the plan’s latest
determination letter and subsequent
amendments and/or restatements.
• Schedule Q (Form 5300), Elective
Determination Requests, if you want
to broaden the scope of a
determination letter by requesting a
determination that your plan satisfies
certain qualification requirements
relating to minimum participation,
coverage, and nondiscrimination.
Schedule Q is optional.
If Schedule Q is not filed, the
determination letter issued for
CAUTION this plan will not consider and
may not be relied upon with regard to
the general test and certain other
provisions under section 401(a)(4),
the average benefit test under section
410(b), and the definition of
compensation provisions of section
414(s).

!

Types of Determination
Letters
Initial Qualification. For initial
qualification of a plan or when
requesting a determination letter after
initial qualification for a plan that has
not been amended (for example,
because of changes in employee
demographics), file one copy of all
instruments that make up the plan.
Entire Plan as Amended. When
requesting a determination letter on
the entire plan as amended after
initial qualification file:
1. One copy of the plan and trust
plus all amendments made to date;
2. One copy of the latest
determination letter, including
caveats; and
3. A statement explaining how any
amendments made since the last
determination letter affect this or any
other plan of the employer.
Complex amendments. Use Form
5300, as described under Entire Plan
as Amended above, for complex
amendments, including amendments
with significant changes to plan
benefits or coverage. If there have
been four or more amendments to the
plan a restated plan is required. For
restatement purposes, do not count
an amendment making only minor
plan changes as a plan amendment.
Minor amendments. Use Form
6406, instead of Form 5300 to
request a determination letter on the

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Instructions for Form 5300

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effect of a minor amendment on the
qualification of a plan. Form 6406
should not be used for plan
amendments made to comply with
GUST.
Partial Termination. For a partial
termination you must:
1. File the application form and
the appropriate documents and
statements.
2. Attach a statement indicating if
a partial termination may have
occurred or might occur as a result of
proposed actions.
3. Using the format in Figure 1.
Partial Termination Worksheet,
submit a schedule of information for
the plan year in which the partial (or
potential partial) termination began.
Also, submit a schedule for the next
plan year, as well as for the 2 prior
plan years, to the extent information
is available.
If the plan has more than one
benefit computation formula complete
the Partial Termination Worksheet for
the plan. Also attach a sheet showing
the information separately in the
same format as lines 1a through 1f
for each benefit computation formula.
4. Submit a description of the
actions that may have resulted in a
partial termination.
5. Include an explanation of how
the plan meets the requirements of
section 411(d)(3).
Termination of Plan. If you are
terminating your plan, file Form 5310,
Application for Determination for
Terminating Plan, to request a
determination letter for the complete
termination of a DBP or a DCP.
Form 5300 should be filed to
request a determination letter
involving the complete termination of
a multiemployer plan covered by the
PBGC insurance program.
In addition, file:
1. One copy of the plan;
2. One copy of the latest
determination letter, including
caveats;
3. A copy of all actions taken to
terminate the plan; and
4. If necessary, Form 6088,
Distributable Benefits From Employee
Pension Benefit Plans. Form 6088 is
required if the plan is a DBP or if the
plan is an underfunded DCP that
benefits noncollectively bargained
employees or more than 2% of the
employees who are covered under a
collectively bargained agreement are
professional employees. (See

Regulations section 1.410(b)-9 for
definitions.)
If you wish to stop benefit accruals
or stop making contributions to your
plan, and your plan trust will continue,
the plan will not be considered
terminated. If you want to receive a
determination letter, you must use
Form 5300. Do not file Form 5310 if
the plan trust will continue.
If a DBP is amended to
become a DCP, or if the
CAUTION merger of a DBP with a DCP
results solely in a DCP, the DBP is
considered terminated.

!

Specific Plans —
Additional Requirements
(See Procedural Requirements
Checklist.)
• For a determination on an affiliated
service group status, submit:
1. A copy of the appropriate
documents and
2. Statements listed in the
instructions for lines 3a and 6.
• For plans of controlled groups of
corporations, trades or businesses
under common control, and affiliated
service groups submit the statement
specified in the instructions for line 6.
• For multiple-employer plans that do
not involve collective bargaining,
submit:
1. One Form 5300 application for
the plan, omitting line 3, and
2. One Form 5300 (only lines 1
through 8 and, optionally, 13 and 14)
and, optionally, Schedule Q for each
other employer that chooses to
receive a separate determination
letter.
• For a governmental or nonelecting
church plan, skip lines 10 and 12a. A
nonelecting church plan is a plan for
which an election under section
410(d) has not been made.
• For an ESOP, attach Form 5309,
Application for Determination of
Employee Stock Ownership Plan for
an ESOP.

Specific Instructions
Line 1a. Enter the name, address,
and telephone number of the plan
sponsor/employer. A plan sponsor
means:
1. In the case of a plan that covers
the employees of one employer, the
employer;
2. In the case of a plan maintained
by two or more employers (other than
a plan sponsored by a group of
-3-

entities required to be combined
under section 414(b), (c), or (m)), the
association, committee, joint board of
trustees or other similar group of
representatives of those who
established or maintain the plan;
3. In the case of a plan sponsored
by two or more entities required to be
combined under sections 414(b), (c),
or (m), one of the members
participating in the plan; or
4. In the case of a plan that covers
the employees and/or partner(s) of a
partnership, the partnership.
The name of the plan sponsor/
employer should be the same name
that was or will be used when the
Form 5500 or Form 5500-EZ is filed
for the plan.
Address. Include the suite, room, or
other unit number after the street
address. If the Post Office does not
deliver mail to the street address and
the plan has a P.O. box, show the
box number instead of the street
address. The address should be the
address of the sponsor/employer.
Line 1b. Enter the 9-digit employer
identification number (EIN) assigned
to the plan sponsor/employer. This
should be the same EIN that was or
will be used when the Form 5500 or
Form 5500-EZ is filed for the plan. Do
not use a social security number or
the EIN of the trust. For a
multiple-employer plan, the EIN for
the application for the plan should be
the same EIN that was or will be used
when Form 5500 is filed.
File Form SS-4, Application for
Employer Identification Number, to
apply for an EIN. You can get Form
SS-4 by calling 1-800-TAX-FORM.
The plan of a group of entities
required to be combined under
section 414(b), (c), or (m) whose
sponsor is more than one of the
entities required to be combined
should only enter the EIN of one of
the sponsoring members. This EIN
must be used in all subsequent filings
of determination letter requests and
annual returns/reports unless there is
a change of sponsor.
Line 1c. Enter the two digits
representing the month the
employer’s tax year ends. This is the
employer whose EIN was entered on
line 1b.
Line 2. The contact person will
receive copies of all correspondence
as authorized in a power of attorney,
Form 2848, or other written
designation. Either complete the
contact’s information on this line, or

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Instructions for Form 5300

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check the box and attach a power of
attorney or other written designation.
Line 3a. Enter the number(s) that
correspond to the request(s) being
made.
Enter 1 if the IRS has not issued a
determination letter for this plan.
Enter 2 if the IRS has previously
issued a determination letter for this
plan and enter the date the plan was
signed.
In addition, enter the date the plan
or amendment was signed. If a plan
or amendment is proposed, enter “9/
9/9999.” Enter the effective date
where requested. The term “Date
amendment effective” means the date
the amendment becomes operative
or takes effect.
Enter 3 if requesting a letter
concerning the effect of section
414(m) on the plan being submitted
or because of a change in the
affiliated service group (ASG)
membership or if you are not certain if
you are a member of an ASG, attach
the following information:
1. A description of the nature of
the business of the employer.
Specifically state whether it is a
service organization or an
organization whose principal
business is the performance of
management functions for another
organization, including the reason for
performing the management function
or service,
2. The identification of other
members (or possible members) of
the affiliated service group.
3. A description of the nature of
the business of each member (or
possible member) of the affiliated
service group including the type of
organization (corporation,
partnership, etc.) and indicate
whether such member is a service
organization or an organization
whose principal business is the
performance of management
functions for the other group
member(s).
4. The ownership interests
between the employer and the
members (or possible members) of
the affiliated service group (including
ownership interests as described in
section 414(m)(2)(B)(ii) or
414(m)(6)(B)).
5. A description of services
performed for employers by the
members (or possible members) of
the affiliated service group, or vice
versa. Include the percentage of each
member’s (or possible member’s)
gross receipts and service receipts

provided by such services, if
available, and data as to whether
their services are a significant portion
of the member’s business and
whether or not, as of December 13,
1980, it was unusual for the services
to be performed by employees of
organizations in that service field in
the United States.
6. A description of how the
employer and the members (or
possible members) of the affiliated
service group associate in performing
services for other parties.
7. a. A description of
management functions, if any,
performed by the employer for the
members (or possible members) of
the affiliated service group, or
received by the employer from any
other members (or possible
members) of the group (including
data as to whether such management
functions are performed on a regular
and continuous basis) and whether or
not it is unusual for such
management functions to be
performed by employees of
organizations in the employer’s
business field in the United States.
b. If management functions are
performed by the employer for the
members (or possible members) of
the affiliated service group, describe
what part of the employer’s business
constitutes the performance of
management functions for the
members (or possible members) of
the group (including the percentage
of gross receipts derived from
management activities as compared
to the gross receipts from other
activities).
8. A brief description of any other
plan maintained by the members (or
possible members) of the affiliated
service group, if such other plan is
designated as a unit for qualification
purposes with the plan for which a
determination letter has been
requested.
9. A description of how the plan(s)
satisfies the coverage requirements
of section 410(b) if the members (or
possible members) of the affiliated
service group are considered part of
an affiliated service group with the
employer.
10. A copy of any ruling issued by
the National Office on whether the
employer is an affiliated service
group; a copy of any prior
determination letter that considered
the effect of section 414(m) on the
qualified status of the employer’s
plan; and, if known, a copy of any
such ruling or determination letter
issued to any other member (or
-4-

possible member) of the same
affiliated service group, accompanied
by a statement as to whether the
facts upon which the ruling or
determination letter was based have
changed.
Enter 4 if you are not certain
whether or not you have leased
employees and attach the following
information:
1. A description of the nature of
the business of the recipient
organization;
2. A copy of the relevant leasing
agreement(s);
3. A description of the function of
all leased employees in the trade or
business of the recipient organization
(including data as to whether all
leased employees are performing
services on a substantially full-time
basis);
4. A description of facts and
circumstances relevant to a
determination of whether such leased
employees’ services are performed
under primary direction or control by
the recipient organization (including
whether the leased employees are
required to comply with instructions of
the recipient about when, where, and
how to perform the services, whether
the services must be performed by
particular persons, whether the
leased employees are subject to the
supervision of the recipient, and
whether the leased employees must
perform services in the order or
sequence set by the recipient), and
5. If the recipient organization is
relying on any qualified plan(s)
maintained by the employee leasing
organization for purposes of
qualification of the recipient
organization’s plan, a description of
the plan(s) (including a description of
the contributions or benefits provided
for all leased employees that are for
services performed for the recipient
organization, plan eligibility, and
vesting).
Enter 5 if this is a request for the
effect a potential partial termination
will have on the plan’s qualification.
“Date Effective” means the date the
plan amendment, ASG status, or
partial termination becomes
operative, takes effect, or changes.
Enter 6 if a determination letter is
requested on the termination of a
multiemployer plan covered by PBGC
insurance. Also enter the date the
termination is effective.
Line 3b. If you do not have a copy of
the latest determination letter, or if no

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determination letter has ever been
received by the employer, submit
copies of the initial plan, or the latest
plan for which you do have a
determination letter, and any
subsequent amendments and/or
restatements including all adoption
agreements.
Line 3c. Section 3001 of ERISA
requires the applicant to provide
evidence that each employee who
qualifies as an interested party has
been notified of the filing of the
application. If “Yes” is checked, it
means that each employee has been
notified as required by Regulations
section 1.7476-1 or this is a
one-person plan. A copy of the notice
is not required to be attached to this
application. If “No” is checked or this
line is blank, your application will be
returned.
Rules defining ‘‘interested parties’’
and the form of notification are in
Regulations section 1.7476-1. For an
example of an acceptable format, see
Rev. Proc. 2004-6, 2004-1 I.R.B. 197
or the superseding revenue
procedure published annually in the
Internal Revenue Bulletin.
Line 4b. Enter the three-digit
number, beginning with ‘‘001’’ and
continuing in numerical order for each
plan you adopt (001-499). This
numbering will differentiate your
plans. The number assigned to a plan
must not be changed or used for any
other plan. This should be the same
number that was or will be used when
the Form 5500 or Form 5500-EZ is
filed for the plan.
Line 4c. “Plan year” means the
calendar, policy, or fiscal year on
which the records of the plan are
kept.
Line 4e. Enter the total number of
participants. A “participant” means:
1. The total number of
employees participating in the plan
including employees under a section
401(k) qualified cash or deferred
arrangement who are eligible but do
not make elective deferrals,
2. Retirees and other former
employees who have a nonforfeitable
right to benefits under the plan, and
3. The beneficiary of a deceased
employee who is receiving or will in
the future receive benefits under the
plan. Include one beneficiary for each
deceased employee regardless of the
number of individuals receiving
benefits.
Example: Payment of a
deceased employee’s benefit to three

children is considered a payment to
one beneficiary.
Line 5, item 5. Cash balance. For
this purpose, a ‘‘cash balance’’
formula is a benefit formula in a
defined benefit plan by whatever
name (e.g., personal account plan,
pension equity plan, life cycle plan,
cash account plan, etc.) that rather
than, or in addition to, expressing the
accrued benefit as a life annuity
commencing at normal retirement
age, defines benefits for each
employee in terms more common to a
defined contribution plan such as a
single sum distribution amount (e.g.,
10 percent of final average pay times
years of service, or the amount of the
employee’s hypothetical account
balance).
Line 6. If the plan employer is a
member of a controlled group of
corporations, trades or businesses
under common control, or an affiliated
service group, all employees of the
group will be treated as employed by
a single employer for purposes of
certain qualification requirements.
Attach a statement showing in
detail:
1. All members of the group;
2. Their relationship to the plan
employer;
3. The type(s) of plan(s) each
member has, and
4. Plans common to all members.
If you want to apply for a
TIP determination letter to
determine if you are a
member of an affiliated service group,
attach the information described on
line 3a, item 3 and leave this line
blank.
Line 7e. A “multiple-employer plan”
is a plan maintained by more than
one employer, but which is not
maintained under a collective
bargaining agreement. Under this
plan type, contributions from each
employer must be available to pay
benefits of any participant, even if
employed by another employer. Also,
enter the number of employers
adopting the plan. See section
413(c).
Line 7f. A “multiemployer plan” (as
described in section 414(f)) is one to
which more than one employer is
required to contribute and which is
maintained under one or more
collective bargaining agreements
between one or more employee
organizations and more than one
employer.
-5-

Line 8a. If “Yes” is checked, attach a
list for each plan with the following
information:
1. Name of plan,
2. Type of plan,
3. Plan number, and
4. Indicate if another application is
simultaneously being submitted with
this application.
Lines 8b and 8c. See M-8, M-12,
and M-14 of Regulations section
1.416-1.
Lines 9b and 9c. If the plan is a
401(k) plan, complete these line
items for the nonelective employer
contribution portion of the plan, if
applicable.
Line 12a. Section 411(d)(6)
protected benefits include:
• The accrued benefit of a participant
as of the later of the amendment’s
adoption date or effective date; and
• Any early retirement benefit,
retirement-type subsidy or optional
form of benefit for benefits from
service before such amendment.
If the answer is “Yes,” explain on
an attachment how the amendment
satisfies one of the exceptions to the
prohibition on reduction or elimination
of section 411(d)(6) protected
benefits.

Optional Ratio
Percentage Test
Determination
Line 13. This question may be used
to request an optional determination
regarding the ratio percentage test
under Regulations section
1.410(b)-2(b)(2). If ‘‘No’’ is checked
and a request for a determination
regarding the average benefit test is
not made on Schedule Q, the
determination letter for the plan will
not be a determination regarding
section 410(b). If ‘‘No’’ is checked but
a request for a determination
regarding the average benefit test is
made on Schedule Q, the
determination letter for the plan will
also be a determination regarding the
average benefit test. Plans using the
qualified separate lines of business
rules of section 414(r) must file
Schedule Q if a determination is
desired that the plan satisfies the
gateway test of section 410(b)(5)(B)
or the special requirements for
employer wide plans.
Line 13a. If a determination is being
requested and the plan is
disaggregated into two or more
separate plans, that are other than

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profit sharing and/or sections 401(k)
and/or 401(m) plans, complete lines
13b through 13n with respect to each
disaggregated portion of the plan.
Attach additional schedules as
necessary to identify the other
disaggregated portions of the plan.
Provide the requested coverage
information, in the same format as
line 13, separately with respect to the
other portions of the plan, or to
otherwise show that the other
portions of the plan separately satisfy
section 410(b).
Example. If this plan benefits the
employees of more than one qualified
separate line of business (QSLOB),
the portion of the plan benefiting the
employees of each QSLOB is treated
as a separate plan maintained by that
QSLOB and must separately satisfy
section 410(b) unless the
employer-wide plan testing rule in
Regulations section
1.414(r)-1(c)(2)(ii) applies.
If a determination is being
requested for a section 401(k) and/or
401(m) plan you must complete line
13l for the portion of the plan that is
not a section 401(k) or a 401(m) plan.
Also complete line 13m(1) to report
the ratio percentage for the section
401(k) portion of the plan and line
13m(2) to report the ratio percentage
for the section 401(m) portion of the
plan.
Line 13c. If, for purposes of
satisfying the minimum coverage
requirements of section 410(b), you
are applying the daily testing option in
Regulations section 1.410(b)-8(a)(2)
or the quarterly testing option in
Regulations section 1.410(b)-8(a)(3),
or, if you are using single-day
‘‘snapshot’’ testing as permitted under
section 3 of Rev. Proc. 93-42, 1993-2
C.B. 540, enter the most recent
eight-digit date (MMDDYYYY) for
which the coverage data is submitted.
If you are applying the annual testing
option in Regulations section
1.410(b)-8(a)(4), enter the year for
which the coverage data is submitted.
Line 13d. Include all employees of
all entities combined under sections
414(b), (c), (m), or (o). Also include
all self-employed individuals,
common law employees, and leased
employees as defined in section
414(n) of any of the entities above,
other than those excluded by section
414(n)(5). Certain individuals may
also be required to be counted as
employees. See the definition of
employee in Regulations section
1.410(b)-9. Also see Regulations
section 1.410(b)-6(i), which may

permit the employer to exclude
certain former nonhighly
compensated employees.
Exception. This exception applies
only to plans that include a qualified
cash or deferred arrangement under
section 401(k) or employee or
matching contributions under section
401(m). If there are any contributions
under the plan that are not subject to
the special rule for section 401(k)
plans and section 401(m) plans in
Regulations section
1.401(a)(4)-1(b)(2)(ii)(B) (such as
nonelective contributions), complete
lines 13e through 13k with respect to
the portion of the plan that includes
these contributions and enter the ratio
percentage for this portion of the plan
on line 13l. Otherwise, complete lines
13e through 13k with respect to the
section 401(k) part of the plan (or the
section 401(m) plan if there is no
section 401(k) arrangement) and
leave line 13l blank. In all cases,
enter the ratio percentages for the
section 401(k) and the section 401(m)
parts of the plan, as applicable, on
line 13m. These percentages should
be based on the actual
nonexcludables in the 401(k) and
401(m) portions, respectively. It is
suggested that these calculations be
submitted with the application but this
is optional.
If the plan provides for
nonelective profit-sharing
CAUTION contributions, do not base the
calculations on lines 13m(1) and (2)
on the nonexcludable employees
reported on line 13g unless all of the
disaggregated plans (profit sharing,
401(k), and 401(m)) have the same
nonexcludable employees with the
same age and service requirements.
Line 13e(1). Enter the number of
employees who are excluded
because they have not attained the
lowest minimum age and service
requirements for any employee under
this plan. If the employer is separately
testing the portion of a plan that
benefits otherwise excludable
employees, attach a separate
schedule describing which employees
are treated as excludable employees
on account of the minimum age and
service requirements under each
separate portion of the plan.
Line 13e(2). Enter the number of
employees who are excluded
because they are collectively
bargained employees as defined in
Regulations section 1.410(b)-6(d)(2),
regardless of whether those
employees benefit under the plan.

!

-6-

For this purpose, an employee
covered under a CBA is not
considered a collectively bargained
employee if more than 2% of the
employees who are covered under
the agreement are professional
employees as defined in Regulations
section 1.410(b)-9.
Line 13e(3). Enter the number of
employees who do not receive an
allocation or accrue a benefit under
the plan only because they do not
satisfy a minimum hours of service
requirement or a last day of the plan
year requirement, provided they do
not have more than 500 hours of
service, and they are not employed
on the last day of the plan year. Do
not enter on this line any employees
who have more than 500 hours of
service, even if they are not
employed on the last day of the plan
year.
Line 13e(4). If this plan benefits the
employees of one QSLOB, enter on
this line the number of employees of
the employer’s other QSLOBs. This is
not applicable if the plan is tested
under the special rule for
employer-wide plans in Regulations
section 1.414(r)-1(c)(2)(ii).
Line 13e(5). Enter the number of
employees who are nonresident
aliens who receive no earned income
(as defined in section 911(d)(2)) from
the employer that constitutes income
from sources within the United States
(as defined in section 861(a)(3)).
Line 13g. Subtract the total of lines
13e(1) through 13e(5) as reported on
line 13f from the total employees
reported on line 13d. The result is the
number of ‘‘nonexcludable
employees.’’ These are the
employees who can not be excluded
from the plan for statutory or
regulatory reasons and must be
considered in the calculation of the
ratio percentage even though they
might not ‘‘benefit’’ under the plan. If
they meet the age and service
requirements of section 410 and are
not otherwise excludable employees,
they must be included in this number.
Line 13h. Enter the number of
employees on line 13g who are highly
compensated employees (HCEs) as
defined in section 414(q).
Line 13i. In general, an employee is
treated as benefiting under the plan
for coverage tests purposes only if
the employee receives an allocation
of contributions or forfeitures or
accrues a benefit under the plan for
the plan year. Certain other
employees are treated as benefiting if

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they fail to receive an allocation of
contributions and/or forfeitures, or to
accrue a benefit, solely because they
are subject to plan provisions that
uniformly limit plan benefits, such as
a provision for maximum years of
service, maximum retirement
benefits, application of offsets or
fresh start wear-away formulas, or
limits designed to satisfy section 415.
An employee is treated as benefiting
under a plan to which elective
contributions under section 401(k) or
employee contributions and matching
contributions under section 401(m)
may be made if the employee is
currently eligible to make such
elective or employee contributions, or
to receive a matching contribution,
whether or not the employee actually
makes or receives such contributions,
(Regulations section 1.401(k)-1(g)(4)
and 1.401(m)-1(f)(4)). However, do
not apply this rule to determine if an
employee is to be counted as
benefiting for lines 13i and 13k if, in
accordance with the exception
following the instruction for line 13d,
the information provided in lines 13e
through 13k relates to the portion of
the plan that is not subject to the rule
in Regulations section
1.401(a)(4)-1(b)(2)(ii)(B).
Line 13k. See the instructions for
line 13i for the meaning of ‘‘benefiting
under the plan.’’
Line 13l. To obtain the ratio
percentage:
Step 1. Divide the number on line
13k (nonexcludable NHCEs
benefiting under the plan) by the
number on line 13j (nonexcludable
NHCEs).
Step 2. Divide the number on line
13i (nonexcludable HCEs benefiting
under the plan) by the number on line
13h (nonexcludable HCEs).
Step 3. Divide the result from Step
1 by the result from Step 2.
Line 13m. See the exception
following the instructions for line 13d.
To determine the ratio percentages
for the section 401(k) and all section
401(m) (matching and employee
contribution) portions of the plan,
follow the steps described in the
instructions for lines 13d through 13l,
but treat an employee as benefiting
under the rules for section 401(k)
plans and section 401(m) plans
described in the instruction for line
13i.
If the ratio percentage entered
TIP on line 13l and/or line 13m is
less than 70%, the plan does
not satisfy the ratio percentage test.

In this case, the plan must satisfy the
average benefit test. A determination
regarding the average benefit test
can be requested using Schedule Q.

Design-Based
Nondiscrimination Safe
Harbors
Line 14. This question may be used
by certain plans to request an
optional determination regarding the
design-based safe harbor under
section 401(a)(4).
If this is a section 401(k) and/or
section 401(m) plan that does not
contain a provision for nonelective
employer contributions, this option
should be marked “No.”
If any disaggregated plan relies on
a non-design based safe harbor or a
general test this option must be
marked ‘‘No.’’ The Schedule Q may
be used to request a determination
regarding a non-design based safe
harbor or a general test.
If this plan has been restructured
into component plans, this option
must be marked “No.” The Schedule
Q may be used to request a
determination regarding how each
restructured component plan satisfies
the nondiscrimination in amount
requirement of Regulations section
1.401(a)(4)-1(b)(2).
If “Yes” is checked, or if “No” is
checked but a request for a
determination regarding a non-design
based safe harbor or a general test is
made on Schedule Q, the
determination letter for the plan will
also be a determination regarding the
section 401(a)(4) requirement that a
plan not discriminate in the amounts
of contributions or benefits.
If “No” is checked, and a request
for a determination regarding a
non-design based safe harbor or a
general test is not made on Schedule
Q, the determination letter for the
plan will not be a determination
regarding this requirement, unless the
plan is a section 401(k) and/or
section 401(m) plan only.
Line 14a. Check ‘‘Yes’’ if the plan is
intended to satisfy the permitted
disparity requirements of section
401(I).
Line 14b. To satisfy section 401(l), a
plan must provide that the overall
permitted disparity limits are not
exceeded and specify how
employer-provided contributions or
benefits under the plan are adjusted,
if necessary, to satisfy the overall
-7-

permitted disparity limits. See
Regulations section 1.401(l)-5.
Line 14c. This line provides a list of
the design-based nondiscrimination
safe-harbor regulations.

How To Get Forms
and Publications
Personal computer. You can
access the IRS Web Site 24 hours a
day, 7 days a week at www.irs.gov to:
• Download forms, instructions, and
publications.
• See answers to frequently asked
tax questions.
• Search publications on-line by topic
or keyword.
• Send us comments or request help
by email.
• Sign up to receive local and
national tax news by e-mail.
You can also reach us using file
transfer protocol at ftp.irs.gov.
CD-ROM for tax products. You can
order Pub. 1796, Federal Tax
Products on CD-ROM, and get:
• Current year forms, instructions,
and publications.
• Prior year forms, instructions, and
publications.
• Frequently requested tax forms
that may be filled in electronically,
printed out for submission, and saved
for recordkeeping.
• The Internal Revenue Bulletin.
Buy the CD-ROM on the Internet
at www.irs.gov/cdorders from the
National Technical Information
Service (NTIS) for $22 (plus a $5
handling fee).
By phone and in person. You can
order forms and publications by
calling 1-800-TAX- FORM
(1-800-829-3676). You can also get
most forms and publications at your
local IRS office.
For questions regarding this form,
call the Tax Exempt and Government
Entities Customer Service, toll-free
Monday through Friday, at
1-877-829-5500 between 8:00 a.m.
and 6:30 p.m. eastern time.
Privacy Act and 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 6109 requires you to provide
your taxpayer identification number

Page 8 of 8

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(SSN or EIN). If you fail to provide
this information in a timely manner,
you may be liable for penalties and
interest. Routine uses of this
information include giving it to the
Department of Justice for civil and
criminal litigation, and cities, states,
and the District of Columbia for use in
administering their tax laws. We may
also disclose this information to
federal and state or local agencies to
enforce federal nontax criminal laws
and to combat terrorism. The
authority to disclose information to
combat terrorism expired on
December 31, 2003. Legislation is
pending that would reinstate this
authority.
You are not required to provide the
information requested on a form that
is 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 required by section
6103.
The time needed to complete and
file this form will vary depending on
individual circumstances. The
estimated average time is:
Form 5300

Sch. Q (Form
5300)

Recordkeeping

41 hr., 7 min.

6 hr., 13 min.

Learning about
the law or the
form

7 hr., 54 min.

9 hr., 14 min.

-8-

Preparing the
form
Copying,
assembling,
and sending the
form to the IRS

13 hr., 34
min.

9 hr., 45 min.

1 hr., 20 min.

If you have comments concerning
the accuracy of these time estimates
or suggestions for making this form
simpler, we would be happy to hear
from you. You can write to the
Internal Revenue Service, Tax
Products Coordinating Committee,
SE:W:CAR:MP:T:T:SP, 1111
Constitution Ave., NW, Washington,
DC 20224.
Do not send any of these forms or
schedules to this address. Instead,
see Where To File on page 1.