Form 5310-A Notice of Plan Merger or Consolidation, Spinoff, or Tran

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Form

I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 5310-A, Page 1 of 2
MARGINS: TOP 13mm (1⁄2 "), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: Black
FINISHED SIZE: 216mm (81⁄2 ") x 279mm (11")
PERFORATE: NONE
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

5310-A

(Rev. April 2006)

Department of the Treasury
Internal Revenue Service

Action

Date

Signature

O.K. to print
Revised proofs
requested

Notice of Plan Merger or Consolidation,
Spinoff, or Transfer of Plan Assets or
Liabilities; Notice of Qualified Separate
Lines of Business

OMB No. 1545-0202

1225

For IRS Use Only

Under sections 6058(b) and 414(r) of the Internal Revenue Code.
See Who Must File instructions before filing this form.

Reason for filing (see specific instructions for code to enter):

All filers must complete lines 1 and 2.

Part I
1a

Name of plan sponsor (employer if single-employer plan)

1b

Employer identification number

Number, street, and room or suite no. (If a P.O. box, see instructions.)

1c

Employer’s tax year ends—Enter (MM) or N/A

1d

Telephone number

1e

Fax number

City

State

ZIP code

(
2

Person to contact if more information is needed. (See instructions.) (If Form 2848 or Form 8821 is at䊳
tached, check box and do not complete this line.)

(

)
)

Name

Number, street, and room or suite no. (If a P.O. box, see instructions.)

Telephone number

(
City

State

ZIP code

(

Part II

)

Fax number

)

Complete lines 3 through 5 if this is a notice of a plan merger or consolidation, spinoff, or transfer
of plan assets or liabilities to another plan.

3a Name of plan (plan name may not exceed 66 characters):
b Enter 3-digit plan number
4a Is this a defined benefit plan?
If “Yes,” attach an actuarial statement of valuation showing compliance with the requirements of section
401(a)(12) and the regulations under section 414(l).

Yes

No

b If this is a defined contribution plan, enter the appropriate code (see instructions) AND attach an actuarial statement of
valuation showing compliance with the requirements of sections 401(a)(12) and 414(l)
5

Other plan(s) involved in the transaction (see instructions)
a Enter the total number of plans involved in the transaction other than the plan listed on line 3a:

b
c
d
e
g

Complete the following information for the other plan. If more than one other plan, see instructions for the required
attachment(s).
If more than one other plan is involved in the transaction, enter the number of this statement (1 of 3, etc.):
Plan name:
Name of employer:
f Plan number (3 digits):
Employer identification number:
/
/
Date of merger or consolidation, spinoff, or transfer of plan assets or liabilities (MMDDYYYY):
If “8,” specify

h Type of plan (see instructions for code to enter):

Part III

䊳

Complete lines 6 through 11 if you are filing a notice of qualified separate lines of business (QSLOB).

6a Has the employer previously filed a notice of QSLOB?
If “Yes,” complete lines 6b and 6c.
If “No,” skip lines 6b and 6c.
b Enter the first day of the first testing year for which such notice applied (MMDDYYYY)

7

Yes

No

䊳

/

/

c Enter the filing date (MMDDYYYY)

䊳

/

/

d Enter the filing location code (see instructions)

䊳

/

/

䊳

First testing year for which this notice applies (MMDDYYYY)

Under penalties of perjury, I declare that I have examined this notice, including accompanying statements, and to the best of my knowledge and belief, it is true, correct,
and complete.
Signature

䊳

For Paperwork Reduction Act Notice, see the instructions.

Title

䊳

Date
Cat. No. 12783Y

䊳

Form

5310-A

(Rev. 4-2006)

3
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 5310-A, Page 2 of 2
MARGINS: TOP 13mm (1⁄2 "), CENTER SIDES.
PRINTS: HEAD TO HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
FINISHED SIZE: 216mm (81⁄2 ") x 279mm (11")
PERFORATE: NONE
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Page 2
Complete lines 6 through 11 if you are filing a notice of qualified separate lines of business (QSLOB) (Continued).

Form 5310-A (Rev. 4-2006)

Part III
8

Are you filing this form to give notice that you are revoking a previously filed notice and that you are no
longer testing on a QSLOB basis?
Yes
No
If “Yes,” complete line 9 and skip lines 10 and 11.
If “No,” complete lines 9, 10, and 11.
9 Check the box(es) for the appropriate code section(s) for which the employer is testing on a QSLOB basis (or for which the
employer tested, if the answer to line 8 is “Yes”).
Section 410(b)
Section 401(a)(26)
Section 129(d)(8)
10 On an attached list, identify each QSLOB operated by the employer. See the line 10 instructions for more details.
11 Enter the following information relating to each plan maintained by the employer. If more than 1 plan, attach a schedule for
each plan showing the information requested on lines 11a through 11e. See instructions.
a Name of plan:
䊳
b Date (MMDDYYYY) of determination letter, if any
c If the plan is a master or prototype or volume submitter plan, enter:
䊳
(1) the date (MMDDYYYY) of the letter
䊳
the
serial
number
or
Advisory
letter
number
(2)
d Enter the appropriate code number that indicates the location of the pending letter
䊳
request, if applicable (see instructions)
e List each QSLOB that has employees benefiting under the plan:

Form

/

/

/

/

5310-A

(Rev. 4-2006)