5434 Application for Enrollment

Form 5434
(Rev. October 2004)

Joint Board for the Enrollment of Actuaries

OMB Clearance Number
1545-0951

Application for Enrollment

For Joint Board Use Only

Read instructions before completing - Please type or print. Mail to Executive Director,
Joint Board for the Enrollment of Actuaries, Department of the Treasury, Internal Revenue
Service, Washington, DC 20224.

Enrollment No.

Date Enrolled

1. Name (Last, First, Middle)

2. Other Names Used (Including Maiden
Name and Dates Used)

3. Social Security Number

4. Company Name

5. Home Address (Number, Street, City,
State, ZIP Code)

6. Date of Birth (Month, Day, Year)

4a. Office Address
7. E-mail Address

4b. Telephone number

8. Have you previously applied for enrollment by the Joint Board?

Yes

No

9. Have you read and are you familiar with the Joint Board's regulations?

Yes

No

10. Months of Experience Reported in Schedule A (See instructions on the back of this page)

Months

(A) Responsible Actuarial Experience from item (a) for all blocks of Schedule A . . . . . . . . . . . . . . . . . . .
(B) Responsible Pension Actuarial Experience from item (b) for all blocks of Schedule A . . . . . . . . . . . .
11. On what basis do you believe that you meet the basic actuarial knowledge requirement of section 901.13(c) of the regulations?
Joint Board basic examination. Month
Year
Organization basic examination(s) (please complete item 13).
Qualifying formal education (please complete Item 14). Have you requested all institutions involved to send transcripts to the
Executive Director of the Joint Board as required?
Yes
No
12. On what basis do you believe that you met the pension actuarial requirement of section 901.13(d) of the regulations?
Joint Board pension examination. Year
Organization pension examination(s) (please complete Item 13).
13. List all
actuarial
organization
examinations
passed. (See
instructions
on the back
of this page)
14.

Name of Actuarial Organization

Education in Accredited College and/or University
Name and Location (City and State)

Exam
When Taken
Part No. (month & year)

Years Attended
From
To

Name of Actuarial Organization

Major Area of Concentration

Exam
When Taken
Part No. (month & year)

Degree
(B.A., etc)

Year of Degree

15. In the last 10 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.
Yes
No
DECLARATION–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.
I hereby certify, that to the best of my knowledge, the statements contained in this application are correct.
(See note on right)
If I am enrolled, I agree to comply with all regulations of the Joint Board, including the Standards of
Performance contained in section 901.20 thereof.
17. Date
16. Signature

Department of the Treasury – Internal Revenue Service

Catalog Number 42528L

PLEASE NOTE–A willfully false statement
or material omission in the execution of this
application may be grounds for denial of
your application or subsequent suspension
or termination of your enrollment as an
actuary. Under Title 18, United States Code,
Section 1001 anyone who knowingly and
willfully falsifies, conceals or covers up a
material fact or anyone who uses a false
document or statement knowing it to be
false is subject to a fine of $10,000 or five
years imprisonment or both.

Form 5434 (Rev. 10-2004)

Instructions for Form 5434
General Instructions

Before filling out the Application for Enrollment (Form 5434),
read the regulations (Parts 901 and 902 of Chapter VII of Title
20 of the Code of Federal Regulations); if you do not have a
copy of these regulations, one may be obtained on request to
the Executive Director, Joint Board for the Enrollment of
Actuaries, Department of the Treasury, Internal Revenue
Service, Washington, D.C. 20224.
Form 5434 should not be completed and submitted for
consideration until you have, in your judgment, satisfied all
the requirements for enrollment that are stated in section
901.13 of the regulations, including in particular the
requirement for qualifying experience in section 901.13(b), the
requirement for basic actuarial knowledge in section 901.13(c)

and the requirement for pension actuarial knowledge in section
901.13(d).
To take either or both of the examinations given by the
Joint Board, you should submit an Application for Examination.
The application form is available from the Society of Actuaries.
If you believe that you satisfy the basic actuarial knowledge
requirement of section 901.13(c) because your formal education
qualifies under the terms of section 901.13(c)(3), you should
arrange to have all academic institutions involved send the
appropriate transcripts to the Executive Director.

Instructions for Certain Items

Item 3. Providing your social security number, which will be
used by the Joint Board for identification purposes only, is
voluntary.
Item 10. You must have, within the 10-year period
immediately preceding the date of your Application for
Enrollment, either (1) a minimum of 36 months of responsible
pension actuarial experience or (2) a minimum of 60 months
of responsible actuarial experience including at least 18
months of responsible pension actuarial experience. The
terms
''actuarial
experience",
"responsible
actuarial
experience" , "responsible pension actuarial experience'',
"month of responsible actuarial experience'', and ''month of
responsible pension actuarial experience'' are defined in
section 901.1 of the regulations. You should account in
Schedule A for all such experience within the last 10 years.
Item 13. List the examination(s) which you have passed of any
actuarial organization that is being presented as satisfying
section 901.13(c) and (d). If an examination has been passed
in more than one part, list all the parts.

Item 14. If none, enter ''none''
Schedule A. 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 to account for the
entire 10 years before application. Duplicated copies of Schedule
A may be used or additional copies of Schedule A may be
obtained
from the Executive Director. The Joint Board
anticipates that the individual(s) who will be asked to verify and
evaluate your experience will generally be your supervisor(s).
However, if you feel that some other individual(s) would be better
able than your immediate supervisor to verify and evaluate your
experience, please explain and then provide the appropriate
name(s) and address(es) in addition to the name and address of
the immediate supervisor. If you believe it is appropriate for
several individuals to verify and evaluate your experience for
anyone block of experience for different periods of time, provide
the names of all such individuals, their addresses, and their
positions.

Paperwork Reduction Act Notice
We are requesting the information to determine the qualifications for enrollment to perform actuarial services under the Employee Retirement Income
Security Act of 1974. The information is required for those who wish enrollment to perform these services.
You are not required to provide the information requested on a form that is subject to the Paperwork reduction Act unless the form displays a valid
OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the
administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code Section 6103.
The time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is 1 hour.
If you have comments concerning the accuracy of this time estimate or suggestions for making this form simpler, we would be happy to gear from you.
You can write to the Tax Forms Committee, Western Area Distribution Center, Rancho Cordova, CA 95743-0001. DO NOT SEND THE FORM TO
THIS ADDRESS. Instead, mail it to the address in the instructions.

Employment Record-Schedule A
Start with your PRESENT position and work back. Account for the entire period since your completion of full time studies and within the last 10 years.
Account for periods of self-employment in separate blocks in order.
Block 1. Dates of Employment (Month, Year)
From
To
1
4. Final Annual Salary or Earnings
Over $25,000

2. Exact Title of Position

5. Avg. Hrs. 6. Location of Office
per Week
City:
State:

Other (specify) $

8. Name of Employer (Firm, Organization, etc.) and Full Mailing Address

3. Kind of Business or Organization

7. Name and title of individual to whom you
reported and who can verify and evaluate
your experience.

9. Area Code and Telephone
Number (If Known)

10. 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) of the regulations?
months
(b) How many months of ''responsible pension actuarial experience'' as defined in section 901.1(e) of the regulations are included in (a) above?
months
(c) Did the experience in (b) above involve performance or supervision of actuarial valuations for defined benefit pension plans (other than valuation
of contractual liabilities of an insurance company)?
Yes
No
If yes, estimate how many such plans.
If yes, did you participate in the determination that the methods and assumptions adopted and the procedures followed were appropriate?
Yes

No

Department of the Treasury - Internal Revenue Service

Form 5434 (Rev. 10-2004)

Employment Record-Schedule A (Cont.)
Continue to account for the entire period of your employment since your completion of full time studies and within the last 10 years.
NUMBER each continuation sheet, working backward, in the space marked 'BLOCK.'
1. Dates of Employment (Month, Year)
From

2. Exact Title of Position

3. Kind of Business or Organization

To

4. Final Annual Salary or Earnings
Over $25,000

5. Avg. Hrs. 6. Location of Office
per Week
City:
State:

Other (specify) $

8. Name of Employer (Firm, Organization, etc.) and Full Mailing Address

7. Name and title of individual to whom you
reported and who can verify and evaluate
your experience.

9. Area Code and Telephone
Number (If Known)

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) of the regulations?
months
(b) How many months of ''responsible pension actuarial experience'' as defined in section 901.1(e) of the regulations are included in (a) above?
months
(c) Did the experience in (b) above involve performance or supervision of actuarial valuations for defined benefit pension plans (other than valuation
of contractual liabilities of an insurance company)?
Yes
No
If yes, estimate how many such plans.
If yes, did you participate in the determination that the methods and assumptions adopted and the procedures followed were appropriate?
Yes

No

Department of the Treasury - Internal Revenue Service

Form 5434 (Rev. 10-2004)