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Mailing Address for Forms 1023, 1024, 1024-A, 1028, 5300, 5307, 5310, 5310-A, 5316, 
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Internal Revenue Service   
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                                        Application for Determination for 
            Form  5300
            (Rev. January 2017)                   Employee Benefit Plan                                              OMB No. 1545-0197
            Department of the Treasury (Under section 401(a) and 501(a) of the Internal Revenue Code)  
            Internal Revenue Service   ▶ Information about Form 5300 and its instructions is at www.irs.gov/form5300.
Review instructions and the Procedural Requirements Checklist before completing this application.                    For Internal Use Only
Submit all required attachments.

Complete lines 1j–1m and 2h–2k only if you have a foreign address. See instructions.
1a Name of plan sponsor (employer if single-employer plan)

b  Address of plan sponsor 

c  City                                                    d              State                 e Zip code

f  Employer identification number (EIN) g Telephone number                h Fax number                               i Employer’s tax year end (MM)

j  City or town                                            k              Country name

l  Province/country             m      Foreign postal code

2a Person to contact. If a Form 2848 or Form 8821 is attached, mark box, and do not complete lines 2a–2k.
   Contact person’s name

b  Contact person’s address

c  City                                                    d              State                 e Zip code

f  Telephone number                  g Fax number 

h  City or town                                            i              Country name

j  Province/country                  k Foreign postal code

If more space is needed for any item, attach additional sheets the same size as this form. Identify each additional sheet with 
the plan sponsor’s name and EIN and identify each item.
Under penalties of perjury, I declare that I have examined this application, including accompanying statements and schedules, and 
to the best of my knowledge and belief, it is true, correct, and complete.
SIGN HERE ▶                                                                                                          Date ▶
Type or print name                                        Type or print title

For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.                Cat. No. 11740X          Form 5300 (Rev. 1-2017)

Form 5300 (Rev. 1-2017)                                                                                                     Page 2
3a Name of plan (plan name cannot exceed 70 characters, including spaces):

b  Enter 3-digit plan number                           c Enter the month in which the plan year ends (MM)

d  Enter plan’s original                               e Enter number of participants
   effective date
   Yes No                                                If 100 or fewer, complete lines 3f and 3g. Otherwise, go to line 4a.
f                       Does the plan sponsor have 100 or fewer employees who received $5,000 or more of compensation for the 
                        preceding year?
g                       Is at least one employee a non-highly compensated employee?
4a Determination requested for (enter applicable number in box):
       1 – Initial Qualification – New Plan 2 – Initial Qualification – Existing Plan
       3 – Plan authorized to apply under current IRS guidance (attach required statement)
b  If line 4a is “1,” enter the date the plan was originally adopted.

5  Indicate the type of plan by entering the number from the list below.
       (Use the lowest number applicable to your plan)
       1 – Pension Equity Plan (PEP)                  5 – ESOP (see instructions)              9 – 401(k)
       2 – Cash balance conversion                    6 – Money purchase                       10 – Profit sharing plan
       3 – Cash balance (nonconversion)               7 – Target benefit
       4 – Defined benefit but not cash balance       8 – Stock bonus
   Yes No
6                       Is this a governmental plan under section 414(d)?

7                       Is this a church plan under section 414(e) that hasn’t elected to have participation, vesting, funding, etc., 
                        provisions apply in accordance with section 410(d)?
8                       Does this plan benefit any collectively bargained employees under Regulations section 1.410(b)-6(d)(2)?
9                       Is this an insurance contract plan under section 412(e)(3)?
10                      Is this a multiemployer plan under section 414(f)?
11                      Is this a multiple employer plan under section 413(c)?
12                      Have interested parties been given the required notification of this application? (attach statement)
13                      Is this an election for a determination regarding a design-based safe harbor? (attach statement)
14                      Does this plan utilize the permitted disparity rules of section 401(l)?
15                      Is this plan part of an offset arrangement with any other plans? (attach statement)
16                      Is this plan part of an eligible combined plan under section 414(x)? (attach statement)
17                      Has this plan been involved in a merger, consolidation, spinoff, or transfer of plan assets or liabilities? (attach 
                        statement) 
18                      Has the plan been amended or restated to change the plan type? (attach statement)
19                      Is any issue involving this plan currently pending? If “Yes,” attach the required statement. See instructions.

                                                                                                               Form 5300 (Rev. 1-2017)

Form 5300 (Rev. 1-2017)                                                                                                 Page 3
                                  Procedural Requirements Checklist
Use this list to ensure that your application package is complete. The application will be reviewed to determine if it is complete. If your 
application is incomplete, it will be closed, in which case it won’t be returned and any user fee won’t be refunded. See Rev. Proc. 
2016-6, 2016-1 I.R.B. 200 (updated annually).
      Yes No
1.                      Are you filing the January 2017 version of Form 5300?

2.                      Is Form 8717, User Fee for Employee Plan Determination Letter Request, attached to your submission and 
                        signed and dated if the application is exempt from the user fee?
3.                      Is the appropriate user fee for your submission attached to Form 8717 or the payment confirmation number 
                        from www.pay.gov as described in section 9.04 of Rev. Proc. 2016-8, 2016-1 I.R.B. 243 (updated annually)?
                        Is Form 2848, Power of Attorney and Declaration of Representative, Form 8821, Tax Information 
4.
                        Authorization, or a privately designed authorization attached? (For more information, see the Disclosure 
                        Request by Taxpayer in the instructions and Rev. Proc. 2016-4, 2016-1 I.R.B. 142, updated annually.) If the 
                        authorized representative would like to receive notices and communications, check the box on Form 2848, line 
                        2, for each individual.
5.                      Is a copy of the current plan document attached?

6.                      Are copies of any plan amendments attached?

7.                      Is the EIN of the plan sponsor/employer entered on line 1f (NOT the trust EIN)?

8.                      Have interested parties been given the required notification of this application? Complete line 12 and attach 
                        statement.
9.                      If line 13 is “Yes,” have you attached the required statement?

10.                     If line 15 is “Yes,” have you attached the required statement?

11.                     If line 16 is “Yes,” have you attached the required statement?

12.                     If line 17 is “Yes,” have you attached the required statement and additional documents?

13.                     If line 18 is “Yes,” have you attached the required statement?

14.                     If line 19 is “Yes,” have you attached the required statement?

15.                     Is the application signed and dated by an authorized officer/representative of the plan sponsor? (Stamped 
                        signatures aren’t acceptable; see Rev. Proc. 2016-4, updated annually.)
16.                     Are all Form 5300 questions answered?

Note: All questions must be answered to process your application.
                                                                                                               Form 5300 (Rev. 1-2017)