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

Form 5434-A
(Rev. March 2012)

Joint Board for the Enrollment of Actuaries

OMB Number
1545-0951

Application for Renewal of Enrollment

All individuals enrolled before January 1, 2011, are required by 20 CFR 901.11(d) to renew their enrollment in order to maintain active
enrollment to perform actuarial services. Enclose with this form your check or money order for $250 (two hundred fifty) payable to the
Internal Revenue Service.
If you want to send your form by regular mail, send to: Internal Revenue Service, PO Box 301510; Los Angeles, CA 90030-1510.
If you want to send your form by overnight mail, send to: Internal Revenue Service, Box 301510; 19220 Normandie Avenue, Suite B;
Torrance, CA 90502.
Enrollment Number

1. Provide the following information
Name

Address (Street)

City

State

Daytime phone number (Include Area Code)

Email address

ZIP Code

Check here if any information
has changed since
the last submission.

2. Please check one block for each of the following questions
A. Since the issuance or latest renewal of your enrollment, have you been disciplined for alleged misconduct Yes
by any professional body or licensing authority? If Yes, attach a statement specifying the date, name, and
location of the disciplinary authority, the nature of the misconduct, and the type of discipline imposed.

No

B. Since the issuance or latest renewal of your enrollment, have you been convicted of, or fined for, a crime
under the revenue laws or a crime involving dishonesty or breach of trust? If Yes, attach a statement
providing details.

Yes

No

C. Since the issuance or latest renewal of your enrollment, have you timely filed all required U.S. tax returns
which became due? If No, attach a statement specifying the type of return, the taxable period covered by
the return, and the type and amount of any penalties imposed.

Yes

No

D. Are you familiar with those portions of the Employee Retirement Income Security Act of 1974 and the
regulations of the Joint Board for the Enrollment of Actuaries that relate directly or indirectly to the
responsibilities of an enrolled actuary? If No, attach a statement explaining your response.

Yes

No

3. Enter the total hours of qualifying continuing professional education completed in each category shown in the
space provided below.
(Core Hours)

(Non-Core Hours)

A. Participant in a formal program and/or correspondence or individual study
programs, including audio and video taped programs, and/or
teleconferencing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B. Serving as an instructor, discussion leader, or speaker . . . . . . . . . . . . . . . . . . .
C. Credit for published articles, books, films, audio and video tapes, etc. . . . . . . .
D. Service on Joint Board advisory committees or preparation of
Joint Board examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
E. Credit earned by examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total Hours
Form

5434-A (Rev. 3-2012)

Catalog Number 63767O

www.irs.gov

Department of the Treasury - Internal Revenue Service

4. If you are not reporting continuing education credit because you were initially enrolled between
January 1, 2010 and December 31, 2010, check this box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. If you are not reporting continuing education credit because you have received a waiver of that requirement,
attach a copy of the waiver and check here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6. Declaration and Signature
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.
6a. Signature

6b. Date Signed

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 during a proceeding; public authorities for their
use in connection with employment, contracting, licensing, and other benefits; pubic 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 renewal of enrollment is
voluntary; however, providing the information requested on this form is a requirement to obtain the benefit of renewal 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 30 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-A (Rev. 3-2012)

Catalog Number 63767O

www.irs.gov

Department of the Treasury - Internal Revenue Service