Line 1a.   Enter the name and address of the employer or plan sponsor. A plan sponsor means:

  The name of the plan sponsor/employer should be the same name that was or will be used when the Form 5500 series returns/reports are 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. This 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 series annual returns/reports are filed for the plan. For a multiple employer plan, the EIN should be the same EIN that was or will be used when Form 5500 is filed.

  

Do not use a social security number or the EIN of the trust.

  The plan sponsor/employer must have an EIN. A plan sponsor/employer without an EIN can apply for one.

   For the plan of a group of entities required to be combined under sections 414(b), (c), or (m), whose sponsor is more than one of the entities required to be combined, enter the EIN of only one of the sponsoring members. This EIN must be used in all subsequent filings of determination letter requests, and for filing 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 and Declaration of Representative, Form 2848, or Tax Information Authorization, Form 8821. Either complete the contact's information on this line, or check the box and attach a completed Form 2848 or Form 8821.

Line 3a.   Enter the name you designated for your plan.

Line 3b.   Enter the three-digit number that the employer or plan administrator has assigned to the plan. 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 series returns/reports are filed for the plan.

Lines 4a and 4b.   Attach an actuarial statement of valuation showing compliance with section 414(l). The statement must (1) identify the type of transaction involved (for example, merger or consolidation, spinoff, or transfer of assets or liabilities), and (2) provide information verifying compliance with the requirements of sections 401(a)(12) and 414(l). This statement need not be signed by an actuary.

Line 4b.   Enter the code that describes your plan.

  Enter 1 for a profit-sharing plan.

  Enter 2 for a stock bonus plan.

  Enter 3 for a money purchase plan.

  Enter 4 for a target benefit plan.

  Enter 5 for a profit-sharing/401(k) plan.

  Enter 6 for an ESOP plan.

  Enter 7 for other and specify the type of plan.

Line 5a.   Enter the total number of plans, other than the plan named on line 3a, involved in this transaction.

Lines 5c through 5h.   Complete lines 5c through 5h for the other plan(s) involved in the merger or consolidation, spinoff, or transfer of plan assets or liabilities with the plan named on line 3a. If there is more than one other plan, attach a separate statement showing the information requested for lines 5a through 5h.

Example:   Plans A, B, and C are merging with Plan D. Plan D would complete a Form 5310-A, reporting information about itself on line 3. Plan D would then complete the line 5 information for Plan A and attach two statements showing the line 5 information for Plans B and C. In addition, Plans A, B, and C must each file a separate Form 5310-A (see the example of a plan merger on page 3).

Lines 5h.   On line 5h, enter the code that describes the other plan.

  Enter 1 for a defined benefit plan.

  Enter 2 for a profit-sharing plan.

  Enter 3 for a profit-sharing/401(k) plan.

  Enter 4 for a stock bonus plan.

  Enter 5 for an ESOP plan.

  Enter 6 for a money purchase plan.

  Enter 7 for a target benefit plan.

  Enter 8 for other and specify the type of plan.

Line 6.   If you previously filed a notice of QSLOB for a testing year, enter the first testing year for which such notice applied on line 6b. Enter the date the notice was filed on line 6c. Also, enter on line 6d the appropriate code number listed below for the location you filed the prior notice.

Line 7.   Enter the first testing year for which this notice applies. See When To File for the definition of “Testing Year.”

Line 8.   Indicate whether you are filing this form to give notice that you are no longer testing on a QSLOB basis. If your answer to line 8 is “yes,” complete line 9 and skip lines 10 and 11. Answer line 9 based on the previously filed notice that you are now revoking. If your answer to line 8 is “no,” complete lines 9 through 11. See Who Must File for an example of a revocation.

Line 9.   Section 414(r) provides rules for determining whether an employer operates QSLOBs for purposes of applying sections 410(b) (relating to minimum coverage), 401(a)(26) (relating to minimum participation rules), and 129(d)(8) (relating to dependent care assistance programs). If you are treated as operating QSLOBs under section 414(r), you will be permitted to apply the aforementioned Code provisions separately for the employees in each QSLOB. Check the appropriate box(es) for the Code section(s) you are testing on a QSLOB basis. See instructions for line 8 to determine how to answer this question if you answered "yes" to line 8.

Line 10.   Attach a list identifying the part or parts of the employer that make up each QSLOB of the employer. The list should include, for example, the type of business or industry in which the QSLOB is involved, the business unit (such as corporation, partnership, or division) the qualified line of business comprises, and the name (formal or informal) of the QSLOB.

Line 11.   Enter the information requested on lines 11a through 11e. If there is more than one plan, attach a separate statement showing the information requested on lines 11a through 11e for each plan.

Line 11b.   Enter the date of the determination letter, if any. Otherwise, leave blank.

Line 11c.   If the plan is a master or prototype or volume submitter plan, enter the date of the letter and the serial number or the Advisory letter number, as applicable.

Line 11d.   Enter the appropriate code number that indicates the location of the pending letter request, if any. See instructions for line 6 for a code list. If this question is not applicable, leave blank.

Line 11e.   List on this line the QSLOBs identified on line 10 that have employees benefiting under the plan. If you need additional space to list the QSLOBs, use the area below line 11e.