Form 5434-A Application for Renewal of Enrollment

Form 5434-A
(Rev. February 2005)

Joint Board for the Enrollment of Actuaries

Application for Renewal of Enrollment

OMB Clearance Number
1545-0951

Instructions: This application form MUST be received by the Internal Revenue Service by March 1, 2005.
All individuals enrolled before January 1, 2005 are required by 20 CFR 901.11(d) to renew their enrollment in order to maintain active
enrollment to perform actuarial Services. Please attach your check or money order for $25.00 payable to the Internal Revenue Service,
and mail the completed application form to: Internal Revenue Service. P.O. Box 894191, Los Angeles, CA 90189-4191.

Enrollment Number:
Name:
Address:

1. Please review the name and address printed above, show any necessary Corrections below.
Name

Address (Street)

State

City

Home Telephone Number (Include Area Code)

Zip Code

Business Telephone Number (Include Area Code)

2. Please check one block for each of the following questions.

A. Have you been disciplined for alleged misconduct by any professional body or licensing authority since the (Yes) (No)
issuance or latest renewal of your enrollment? (If "Yes," attach statement specifying the date, name, and
location of disciplining authority, nature of misconduct and discipline imposed.)
B. Since the date of your most recent renewal of enrollment, have you been convicted or fined for a crime
under the revenue laws or of a crime involving dishonesty or breach of trust? If yes, provide details on
a separate page.

(Yes) (No)

C. Have you timely filed all required U.S. tax returns which became due since the issuance or latest renewal (Yes) (No)
of your enrollment? (if ''No," attach statement specifying the type of return, the taxable period covered and
any penalties imposed.)
D. Are you familiar with those portions of the Employee Retirement Income Security Act of 1974 and the Joint (Yes) (No)
Board for the Enrollment of Actuaries' regulations that relate directly or indirectly to the responsibilities of
an enrolled actuary?

Department of the Treasury
Internal Revenue Service

Catalog Number 63767O

Form 5434-A (Rev. 2-2005)

3. Enter 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
-

4. If you are not reporting continuing education credit because you were initially enrolled between
January 1, 2004 and December 31, 2004, check here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. If you are not reporting continuing education credit because you have received a waiver of that requirement,
attach a copy of waiver and check here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..........

6. If you are not reporting continuing education credit because you wish to be placed in retirement
status, Check here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Declaration: I hereby certify that, to the best of my knowledge, the statements contained in this application for renewal of
my enrollment are correct.
Please Note: A willfully false statement or material omission in the execution of this application
may be grounds for 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.
7. Signature

8. Date of Application

Paperwork Reduction Act Notice: We are requesting the information to determine the qualifications for renewal of enrollment to perform actuarial services under the
Employee Retirement Income Security Act of 1974. The information is required for those who desire to renew their application for 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 27 minutes.
If you have comments concerning the accuracy of this time estimate or suggestions for making this form simpler, we would be happy to hear 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".

Form

5434-A (Rev. 2-2005)