Form EFAST-1 Application for EFAST Electronic Signature and Codes for

Official Use Only

Form

EFAST-1

Department of Labor
Employee Benefits
Security Administration

Application for EFAST Electronic Signature
and Codes for EFAST Transmitters and
Software Developers

OMB No. 1210-0117

Please read the instructions before completing this application.
Part I

Type of Application

Each applicant must check all appropriate boxes in Part I, complete Parts II and III, and sign the Applicant Agreement.
A

This is an application for an EFAST electronic signature.

B

This is an application for EFAST codes for the purpose of being an EFAST Transmitter.

C

This is an application for EFAST codes for the purpose of being an EFAST Software Developer.

D

This application is being submitted to update information for an EFAST Transmitter or an EFAST Software Developer.

Part II

Applicant Agreement

If this application results in the issuance of an electronic signature, I understand and agree that the electronic signature is not transferable
and that the inclusion of such electronic signature in a Form 5500 return/report or Form 5500-EZ return filed in electronic form shall have the
same legal force and effect as my hand written signature. If I am not the Transmitter, I also agree that my electronic signature on a Form 5500
or Form 5500-EZ constitutes consent for EFAST personnel to send my Transmitter an acknowledgment of receipt of transmission and to
communicate with my Transmitter about the success or failure of the transmission and the specific reason(s) for any failure(s).
If this is an application to be an EFAST Software Developer or EFAST Transmitter, I declare that I am authorized to make and sign this
statement on behalf of the applicant. The applicant agrees that it and its employees will comply with all provisions of the EFAST procedures
for the electronic/magnetic/optical media filing of Forms 5500 and 5500-EZ for each year in which the applicant participates. Noncompliance
will result in the applicant no longer being allowed to participate as an EFAST Software Developer or Transmitter. The applicant understands
that acceptance as an EFAST Software Developer or Transmitter is not transferable. If applying to be an EFAST Transmitter, the applicant
further agrees that a copy of all returns/reports that the applicant transmits electronically to the Department of Labor will be provided to the
plan administrator, employer or direct filing entity on whose behalf the return/report was transmitted.
Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this application, and to the best of
my knowledge and belief the information provided is true, correct, and complete. I agree that this application can be made public information.

Date

▼

▼

Signature of applicant

MM / D D / Y Y Y Y

Name (last, first, and initial) and title of applicant

Name
Title

For Paperwork Reduction Act Notices, see instructions.

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Part III

EFAST Electronic Signature, Transmitter and Software Developer Applicant Information

A

Name (last, first, and initial) of Individual Applying for an EFAST Electronic Signature:

B

Name of Company, Trade, Business or Other Person Applying to be an EFAST Transmitter or Software Developer:

C

Employer Identification Number (EIN)

D

Mailing address (Street, P.O. Box)

City

State

ZIP Code

E

Name of contact person

F

Daytime telephone number (Include area code.)

G

FAX telephone number (Include area code.)

H

If you would like to receive EFAST materials by E-mail, please enter your E-mail address below:

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