Form 5309 Application of Determination of Employee Stock Ownership

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I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 5309, PAGE 1 of 4
MARGINS: TOP 13mm (1⁄2 "), CENTER SIDES.
PAPER: WHITE, WRITING, SUB. 20 INK: BLACK
FLAT SIZE: 203mm (8") x 279mm (11")
PERFORATE: (NONE)

PRINTS: HEAD TO HEAD

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Signature

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CUMULATIVE CHANGES
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NOTE: See Specification
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COMPOSTION
Sheet for
information about anchor points, spacing around checkboxes, bar codes,
field font & size, and number of characters per field, etc.
May
Fillable Field Data prints BLACK, not BLUE.

Form

5309

Application for Determination of
Employee Stock Ownership Plan

OMB No. 1545-0284

(Rev. March 2010)
Department of the Treasury
Internal Revenue Service

(Under section 4975(e)(7) of the Internal Revenue Code)
䊳 Attach to Form 5300.

1

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

2

Employer identification number

3 Plan number

For IRS Use Only

(EIN)

All Plans (Complete lines 4a through 4j.)
deleted previous lines 4 and 5

Yes
4a

No
Is the plan designed as an employee stock ownership plan (ESOP) within the meaning of section 4975(e)(7)?

b

Is the plan designed to invest primarily in employer securities as defined in section 409(l)?

c

Is each participant or beneficiary entitled to direct the plan to vote the allocated securities as required by section
409(e)?

d

Does the p
plan p
provide that each p
participant
p
who is entitled to a distribution from the plan has a right to demand
that the benefit be distributed in the form of employer securities?
If the answer to d is “No,” please answer the following.

i

If the charter or bylaws
y
of the corporation
p
restrict stock ownersh
hip
p to employees
p y
of the ESOP, does the plan
ownership
provide that participants are entitled to receive distributions in cash? (See section 409(h)(2))

ii

p
p
Iff the plan
is maintained byy an S corporation,
does the plan provide that participants are entitled to receive
distributions in cash? (See section 409(h)(2))

e

If the trust makes a distribution in stock and the securities are not readily tradable on an established market, can
the participant require the employer to repurchase the securities under a fair valuation formula within the time
frames prescribed by law? (See section 409(h))

f

Does the plan provide that no portion of the assets attributable to employer securities in an S corporation may,
during a nonallocation year, accrue to the benefit of a disqualified person? (See section 409(p))

g

Does the plan provide that a participant may elect to diversify a portion of his or her account investment in
employer securities, as required by section 401(a)(28)(B)?

h

With respect to activities that are carried on by the plan, are all valuations of employer securities acquired after
December 31, 1986, which are not readily tradable on an established securities market made by an independent
appraiser? (See section 401(a)(28)(C))

For Paperwork Reduction Act Notice, see instructions.

Cat. No. 11835F

Form

5309
5

*11835F06201001*

(Rev. 3-2010)

3
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 5309, PAGE 2 of 4
MARGINS: TOP 13mm (1⁄2 "), CENTER SIDES.
PAPER: WHITE, WRITING, SUB. 20 INK: BLACK
FLAT SIZE: 203mm (8") x 279mm (11")
PERFORATE: (NONE)

PRINTS: HEAD TO HEAD

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

COMPOSTION SPECIALIST NOTE: See Specification Sheet for
information about anchor points, spacing around checkboxes, bar codes,
field font & size, and number of characters per field, etc.
Fillable Field Data prints BLACK, not BLUE.

5

MOVE NOTE TO NEXT LINE
Form 5309 (Rev. 3-2010)

Yes

Page

2

No
Does the plan provide that a participant may begin receiving a distribution of his or her account that is attributable
to employer securities acquired after December 31, 1986, (within the guidelines of section 409(o)) after reaching
normal retirement age, or after death, disability, or other separation from service? Note. If this plan is a leveraged
ESOP, the plan is permitted to delay distribution until the loan is fully repaid.

i

If the plan is applying under section 409(n) with respect to transactions under section 1042, does the plan provide
that the assets of the plan attributable to employer securities acquired by the plan (in a sale to which section 1042
applies) cannot accrue for the benefit of the persons specified in section 409(n) during the nonallocation period?
Not applicable for S corporation.

j

Plans Applying Under Section 4975(d)
4975(d)(3)
)(3
3) and Regulations Section 54.4975-7 (Leveraged ESOPs) (Complete lines 5a through 5g.)

5a

Does the plan provide that the exempt loan proceeds must be used within a reasonable time to acquire qualifying
employer securities, repay such loan, or repay a prior loan as required under Regulations section 54.4975-7(b)(4)?

b

Does the plan provide for the establishment and maintenance of a suspense account as required under
Regulations section 54.4975-11(c)?

c

Does the plan provide that the collateral must be limited to qualifying employer securities purchased with such
exempt loan or a prior exempt loan as required under Regulations section 54.4975-7(b)(5)?

d

Does the plan provide that no person entitled to payment under an exempt loan shall have any right to assets of
the ESOP other than collateral given for such loan, contributions (other than contributions of employer securities)
made to repay such exempt loan, and earnings attributable to such collateral and the investment of such
contributions as required under Regulations section 54.4975-7(b)(5)?

e

Does the plan provide that payments made with respect to an exempt loan by the ESOP during the year must not
exceed an amount equal to the sum of contributions and earnings received during or prior to such year less such
payments in prior years as required under Regulations section 54.4975-7(b)(5)?

f

Do plan terms provide that qualifying employer securities will be forfeited only after other assets as required under
Regulations section 54.4975-11(d)(4)?

g

Are the participants’ rights to plan assets acquired by use of the exempt loan protected as specified in Regulations
section 54.4975-11(a)(3)(i) and (ii)?

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.
deleted previous line 7, plans
applying under section 409
䊳
SIGN HERE
Date 䊳
Type or print name

Type or print title

Form

5309

(Rev. 3-2010)

5

*11835F06201001*

3
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 5309, PAGE 3 of 4, (Page 4 is blank)
MARGINS: TOP 13mm (1⁄2 "), CENTER SIDES.
PAPER: WHITE, WRITING, SUB. 20 INK: BLACK
FLAT SIZE: 203mm (8") x 279mm (11")
PERFORATE: (NONE)

PRINTS: HEAD TO HEAD

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

5

ADD HYPHEN
Form 5309 (Rev. 3-2010)

General Information
Section references are to the
Internal Revenue Code unless
otherwise noted.
Use this form to apply for a
determination letter for an employee
stock ownership plan (ESOP) that
meets the requirements of section
4975(e)(7). Attach Form 5309 to
Form 5300, Application for
Determination for Employee Benefit
Plan.
The plan you establish must be
designed to invest primarily in
employer securities. For a definition
of employer securities and how it
applies to your plan, see section
409(I) or section 4975(e)(8). Also see
Regulations section 54.4975-11 for
the formal plan requirements of an
ESOP.

General Instructions
A Change To Note
The form and the instructions have
undergone revisions in the format
and the information required.
The questions
q
g
to tax
with regard
credit ESOPs have been deleted. If
your plan involves such a plan,
please state so in the cover letter
and refer to Regulations section
1.46-8(d) for the formal requirements
of a tax credit ESOP. The question
relating to type of plan has been
deleted from the form.
Who May File
1. Any corporate employer who
has established an ESOP intended
to meet the requirements under
section 4975(e)(7).
2. Any corporate employer who
amends an ESOP under section
4975(e)(7).
(e)(7).
An S-corporation-sponsored
ESOP must provide that no
prohibited allocation of employer
stock may be made to a disqualified
person for a nonallocation year. This
applies to all plan years beginning
on or after January 1, 2005. This
applies to plan years ending after
March 14, 2001, if:

Page

1. The ESOP was established after
March 14, 2001, or
2. The ESOP was established on
or before March 14, 2001, if the
employer maintaining the ESOP had
not made an S corporation election
in effect on such date.
How To Complete the Application
q
,a
● If a number is requested,
number must be entered.
p
● If an item provides
a box to
check,, written responses are not
acceptable.
pp
● The application
has formatted
fields that will limit the number of
characters entered per field.
p will need to be
● All data input
entered in Courier 10 point font.
p characters should be
● Alpha
entered in all capital letters.
p
● Enter spaces
between anyy words.
Spaces do not count as characters.
What To File
To receive a determination on
whether a plan, initially or as a result
of a plan amendment, meets the
requirements of section 4975(e)(7),
submit Form 5309, Form 5300, and
a copy of all documents and
statements required by those forms.
Attach the completed Form 5309 to
Form 5300.
Signature
Form 5309 must be signed by the
principal officer authorized to sign.
Note. Stamped signatures
are not
g
acceptable;
p
; see Rev. Proc. 2010-4
which is on page
p g 122 of Internal
Revenue Bulletin 2010-1 at
g
p
www.irs.gov/pub/irs-irbs
/irb10-01.pdf.

3

Paperwork Reduction Act Notice.
We ask for the information on this
form to determine whether you meet
the legal requirements for the plan
approval you request. Your filing of
this information is only required if
you wish the IRS to determine if
your plan qualifies under section
4975(e)(7).
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 section
6103.
The time needed to complete and
file this form will vary depending on
individual circumstances. The
estimated average time is:
Recordkeeping

6 hr., 42 min.

Learning about the
law or the form

2 hr., 17 min.

Preparing and
sending the form
to the IRS

2 hr., 29 min.

If you have comments concerning
the accuracy of these time estimates
or suggestions for making this form
simpler, we would be happy to hear
from you. You can write to the
Internal Revenue Service, Tax
Products Coordinating Committee,
SE:W:CAR:MP:T:T:SP, 1111
Constitution Ave. NW, IR-6526,
Washington, DC 20224.