Form 5434 Form 5434 Joint Board for the Enrollment of Actuaries Application

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Joint Board for the Enrollment of Actuaries

Form 5434
(Rev. March 2012)

OMB Number
1545-0951

Application for Enrollment

Enclose with this form your check or money order for $250, payable to the Internal Revenue Service.
By regular mail, send to: Internal Revenue Service, PO Box 301510; Los Angeles CA 90030-1510.
By overnight mail, send to: Internal Revenue Service, Box 301510; 19220 Normandie Avenue, Suite B;
Torrance, CA 90502. Read the instructions on page 3 before completing this form. Type or print.
1. Full legal name (Last, First, Middle)

For Joint Board Use Only
Enrollment No.

Date Enrolled

2. Other names used (Including Maiden name and dates used)

3. Address (Number, Street, City, State, ZIP code)

4. E-Mail address (optional)

5. Daytime telephone number (optional) 6. Social Security Number

7. Date of birth (mm/dd/yyyy)

8. How many months of responsible experience did you report on Schedule A (Employment Record)
(A) Responsible actuarial experience (from item (a) for all blocks of Schedule A) . . . . . . . . . . .

Month(s)

(B) Responsible pension actuarial experience (from item (b) for all blocks of Schedule A) . . . .

Month(s)

9. On what basis did you satisfy the basic actuarial knowledge requirement of section 901.12(c)
Joint Board basic examination(s)
Name(s) of exam(s), month(s) and year(s) completed

Waiver of Joint Board basic examination

Date waiver received

Qualifying formal education
Organization basic examination
Other
10. When did you satisfy the pension actuarial knowledge requirement of section 901.12(d)
Name(s) of exam(s), month(s) and year(s) completed

11. Have you previously applied for enrollment by the Joint Board
12. Have you read and are you familiar with the Joint Board's regulations

Yes

No

Yes

No

Yes

No

Yes

No

If No, provide details on a separate page.
13. Have you timely filed your Federal tax returns and timely paid your Federal taxes for the
three tax years preceding your date of application
If No, provide details on a separate page.
14. In the last 15 years or since your 18th birthday, if sooner, have you ever been convicted or
fined for a crime under any revenue law or of a crime involving dishonesty or breach of trust
If Yes, provide details on a separate page.

Declaration and Signature
I hereby apply to be enrolled as an actuary. I authorize the Joint Board to inquire about my qualifications and experience from educational institutions,
employers, supervisors, actuarial organizations, and any other individuals who may have knowledge related to my qualifications and experience. I
authorize all such institutions, employers, supervisors, organizations and others to provide any information requested concerning my education,
employment experience and qualifications as an actuary.
Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is true, correct, and complete.
15. Signature

Form 5434 (Rev. 3-2012) Cat. Num. 42528L

16. Date signed

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Click here to create an additional Schedule A

Schedule A (Employment Record)
Start with your PRESENT position and work back. Account for the entire period within the last 10 years or, if shorter, since your completion of full-time
studies. Account for periods of self-employment in separate blocks in chronological order.
Block 1. Dates of employment (mm-yyyy)
2. Exact title of position
3. Type of business or organization
From

To

4a. Provide the name, position title, address, and telephone number of immediate supervisor who can certify your experience.

4b. If your experience includes responsible pension actuarial experience and your immediate supervisor is not an enrolled actuary, also provide
the name, position title, address, and telephone number of an enrolled actuary who can certify your responsible pension actuarial experience.

5. Name of employer and address

6. In your own words, describe IN DETAIL your actual duties and responsibilities in the above employment.
When more than one type of work is included, estimate the proportion of the total period devoted to each type.

(a) How many months of this employment constitute "responsible actuarial experience" as defined in section 901.1(c) . . . . . . . . . . .

months

(b) How many months of ''responsible pension actuarial experience'' as defined in section 901.1(e) are included in (a) above . . . . . .

months

Form 5434 (Rev. 3-2012) Cat. Num. 42528L

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Instructions for Form 5434, Joint Board for the Enrollment of Actuaries Application for Enrollment
General Instructions
Before filling out Form 5434, Application for Enrollment, read the regulations (Parts 901 and 902 of Title 20 of the Code of Federal
Regulations). Unless otherwise indicated, section numbers (e.g., 901.12(b)) cited on the form and in the instructions refer to the
regulations. You may download a copy of the regulations from www.irs.gov/taxpros/actuaries.
You should not complete Form 5434 until you have satisfied the qualifying experience in section 901.12(b), the basic actuarial
knowledge requirement in section 901.12(c), and the pension actuarial knowledge requirement in section 901.12(d).
To register for a Joint Board examination, please contact the Society of Actuaries (www.soa.org).
If you send us a check for the application fee, your check will be converted into an electronic fund transfer. The electronic fund transfer
from your account will usually occur within 24 hours of receipt. For more information, see www.irs.gov/taxpros/actuaries.

Instructions for Certain Line Items
Items 6 and 13
As part of the application process, we may check your Federal tax history to verify that you have timely filed and paid your
Federal taxes.
Item 8
You must have, within the 10-year period immediately preceding the date of application, either
(1) a minimum of 36 months of certified responsible pension actuarial experience or
(2) a minimum of 60 months of certified responsible actuarial experience including at least 18 months of responsible pension
actuarial experience.
The terms "responsible actuarial experience," "responsible pension actuarial experience," "certified responsible actuarial experience,"
and "certified responsible pension actuarial experience" are defined in section 901.1. You should account in Schedule A (Employment
Record) for all such experience within the last 10 years or, if shorter, since your completion of full-time studies.
Item 9
If you are claiming transition credit for an examination taken prior to January, 2001, please so indicate. You may review the transition
rules at www.irs.gov/taxpros/actuaries.
Schedule A (Employment Record)
You must complete and attach Schedule A for your application to be complete. If employment for an employer consisted of two (or
more) periods, one of which consisted of responsible pension actuarial experience and the other(s) did not, treat this as different
periods of employment in separate blocks of Schedule A. Attach additional Schedules A if needed. In general, the individual asked to
certify your experience should be your immediate supervisor. However, if your immediate supervisor is not an enrolled actuary, both
your immediate supervisor and an enrolled actuary must certify your responsible pension actuarial experience.
In addition, if you believe that another individual is better able to certify your experience, please explain and provide the individual's
name, position title, address, and telephone number in addition to the same information provided for your immediate supervisor. If you
believe it is appropriate for several individuals to certify your experience for different periods of time with the same employer, provide
the names of such individuals, their position titles, addresses and telephone numbers

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Privacy Act and Paperwork Reduction Act Notice
Section 1242, United States Code, authorizes the Joint Board for the Enrollment of Actuaries (Joint Board) to collect this information. The primary use of
the information is to enforce and administer the regulations of the Joint Board governing the practice of an actuary under the Employee Retirement
Income Security Act of 1974 (ERISA). Information may be disclosed to: the Department of Justice when seeking advice or for use in any proceeding;
courts and other adjudicative bodies; public authorities for their use in connection with employment, contracting, licensing, and other benefits; public
authorities for their use in connection with their regulatory, enforcement, investigative, or prosecutorial responsibilities; contractors as necessary for
performance of the contract; third parties as necessary during an investigation; the Department of Labor, the Department of the Treasury, and the
Pension Benefit Guaranty Corporation for administering and enforcing ERISA or in connection with maintaining standards of integrity, conduct, and
discipline on the part of individuals who practice before such agencies; the general public (including disclosures via web sites) for the purpose of
publicizing or verifying the enrollment status and location of individuals who are, or were, enrolled actuaries; professional organizations or associations
for their use in connection with maintaining standards of integrity, conduct, and discipline; appropriate agencies, entities, and persons when the Joint
Board suspects or confirms that the security or confidentiality of information in a system of records has been compromised as necessary to prevent,
minimize, or remedy harm. Applying for enrollment is voluntary; however, providing the information requested on this form is a requirement to obtain the
benefit of enrollment. Failure to provide the requested information could delay or prevent processing of your application. Providing false information
could subject you to penalties.
Notwithstanding any other provision of law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with, a
collection of information subject to the requirements of the Paperwork Reduction Act, unless that collection of information displays a currently valid OMB
Control Number. Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for
reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden to: Joint Board for the Enrollment of Actuaries c/o IRS/Office of Professional Responsibility; SE:OPR; 1111 Constitution Avenue, NW;
Washington, DC 20224.
Form 5434 (Rev. 3-2012) Cat. Num. 42528L

www.irs.gov

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