Attachment I Attachment I for Application of Pre-approved Defined Con

OMB No.
1545-0169

Attachment I for Application for Approval of Pre-approved Defined
Contribution Plans (Revised 12/2017)
Indicate the article or section and page number of the plan where the following
provisions are contained. All questions must be answered. If not applicable, check
“N/A” column; otherwise complete the “Article or Section and Page Number”
column. Governmental and Non-electing church plans may not be subject to many
of the qualification requirements identified on this attachment. If not applicable,
check “N/A” column.

N/A

Article or Section
and Page Number

Change

For IRS Use
Only

Part I. Provisions applicable to all plans
a. Definitions:
Where does the plan define the following terms(1) Year of Service?
(2) Break in Service?
(3) Hour of service under Department of Labor Regulations, including
service with all employers aggregated under sections 414(b), (c), (m), or (o), and
service of any individual considered an employee for purposes of this plan under
section 414(n) or (o)?
(4) Elapsed time?
(5) Plan year?
(6) Compensation as defined in section 414(s) as limited by section
401(a)(17)?
(7) Earned income as defined in section 401(c)(2)?
(8) Disability?
(9) Employee as described in sections 414(b), (c), (m), (n), or (o)?
(10) Leased employee as described in section 414(n) or (o)?
(11) Highly compensated employee as defined in section 414(q)?
(12) Owner-Employee?
(13) Self-employed individual?
(14) Normal retirement age?
(15) Benefiting?
(16) Straight life annuity?
b. Minimum participation standards
(1) Are the requirements for participation under the plan determined without
regard to maximum age?
(2) Will a new employee, otherwise eligible, participate on the earlier of the
first day of the first plan year after meeting the minimum age and
service requirements of section 410(a)(1) or 6 months after satisfying
such requirements?
(3) Does the initial eligibility computation period begin with the date on
which the employee first performs an hour of service, and do
subsequent eligibility computation periods: (1) begin with the
anniversary of such date, or (2) shift to the plan year in accordance with
section 2530.202-2(b) of the Department of Labor regulations?
(4) Is the computation period for determining a break in service the same
as is used to compute a year of service for eligibility after the initial
computation period?
(5) If all years of service are not counted for participation purposes, is the
service not counted excludable under section 410(a)(5)(B), (C), or (D)?
(6) Does this plan include the one-year hold-out rule?
(7) Will an employee otherwise eligible, who is in an ineligible class of
employees, immediately participate on becoming a member of an
eligible class?
For Paperwork Reduction Act Notice, see separate instructions.

(1)
(2)

(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)

(18)

(19)

(20)

(21)
(22)
(23)

N/A

c. Employercontributions:
(1) If this is a money purchase plan, are contributions on behalf of each
participant determined under a definite, uniform formula?
(2) If this is a profit-sharing plan, are contributions allocated under a
definite, uniform formula?
(3) If the plan contains a uniform points allocation formula, does the
formula meet the requirements of section 1.401(a)(4)-2(b)(3)(i)(A) of
the Regulations?
(4) If this is a target benefit plan, answer (i) and (ii)
(i.) Does the plan include a target benefit with permitted disparity?
(ii.) Does the plan provide for the calculation of employer
contributions?
(5) Does the contribution or allocation formula provide for permitted
disparity per section 401(l)?
(6) Does the plan continue to allocate contributions to participants without
reduction in the rate of allocations on account of the attainment of any
specified age?
(7) Are annual additions limited as required by section 415?
(8) Does a participant’s account balance not include the value of any QLAC
for purposes of computing the minimum required distribution that must be
made to a participant or beneficiary in each distribution calendar year to
satisfy IRC 401(a)(9)?
(9) Does the plan require separate accounting for each employee’s
accrued benefit?
d. Employee contributions:
(1) If the plan permits:
(a) Does the plan comply with section 401(m)?
(b) Does the plan either provide for separate accounts for employer
contributions and nondeductible employee contributions, or identify
what portion of an account balance is attributable to employer
contributions and nondeductible employee contributions according
to section 411(c)(2)?
(c) Are all employee contributions and earnings thereon nonforfeitable
at all times?
(2) Does the plan prohibit deductible voluntary employee contributions for
a tax year beginning after 1986?
(3) If the plan permits deemed IRAs:
(a) Does the plan meet the applicable requirements of section 408 and
408A of the Code and address every applicable point of the IRA
LRMs?
e. Forfeiture provisions:
(1) Are forfeitures used either to reduce employer contributions or to
increase benefits according to a definite uniform formula?
(2) If participants may withdraw employee contributions or the earnings on
them, may the withdrawal be made without forfeiting vested benefits
based on employer contributions?
(3) If benefits under the plan are forfeited when a participant or beneficiary
cannot be located, does the plan provide for a reinstatement of the benefit
if a claim is made?
f. Distribution provisions:
(1) (a) If this is not a profit-sharing plan described in (6) below, does a married
participant receive a qualified joint and survivor annuity (QJSA) and
an unmarried participant a life annuity?
(b) Does the plan define spouse in accordance with Notice 2014-19 for
purposes of the survivor annuity requirements of section 401(a)(11)
and 417?

Article or
Section
and Page
Number

Change

For IRS
Use Only

(24)
(25)

(25A)

(26),(27)
(28)
(29)

(30)
(31)
(32)
(

(34)

(35)

(36)
(37)
(38)

(38A)

(39)
(40)

(41)

(42)
(42)

N/A

(c) Is the participant given an opportunity to make a Qualified Election to
waive the QJSA and to elect to receive a qualified optional survivor
annuity in a manner which satisfies section 417(a)(2) during an
election period beginning no earlier than 180 days before the
annuity starting date?
(2) (a) Does the plan provide that the spouse of a deceased participant
will receive a qualified preretirement survivor annuity (QPSA) that
requires payments not less than the amount specified in section
417(c)(2) in the event of death before the annuity starting date?
(b) Is the participant given an opportunity to make a Qualified Election to
waive the QPSA in a manner which satisfies section 417(a)(2) during
the election period beginning on the first day of the plan year in
which the participant attains 35 and ending on the date of the
participant’s death?
(3) Does the plan designate or enable the employer to elect the percentage
(not less than 50% nor more than 100%) of the survivor annuity provided
under the QJSA?
(4) Does the plan define annuity starting date in a manner that satisfies Q
& A 10(b) of Regulations section 1.401(a)-20?
(5) (a) Does the plan provide for a written explanation of the QJSA in a
manner which satisfies section 417(a)(3)(A)?
(b) Does the plan provide for a written explanation of the QPSA in a
manner which satisfies section 417(a)(3)(B)?
(6) If this is a profit-sharing plan which does not offer a life annuity form of
payment, does the plan satisfy the conditions described in Q & A 3 of
section 1.401(a)-20 of the Regulations, including the requirement that the
value of the participant’s vested account balance on the date of death be
paid in full to the surviving spouse?
(7) If the plan permits distributions prior to 5 consecutive 1-year breaks in
service (upon termination of employment, hardship distributions, change to
an ineligible class, etc.), does the plan contain either (A) cashout, buyback, or (B) separate account provisions required under section 1.411(a)7(d)(4) and (5) of the Regulations?
(8) If the vested account balance is greater than $5,000, is consent of the
participant and spouse (if applicable) required when benefits are
immediately distributable within the meaning of section 1.411(a)-11 of
the regulations?
(9) If the plan is a money purchase pension plan (including a target benefit
plan), may distributions be made only upon the participant’s attainment of
age 62, or, if earlier, separation from employment, attainment of normal
retirement age, death, or disability, or termination of the plan?
(10) Do benefits under the plan begin, unless otherwise elected
inwriting, no later than the 60th day after the latest of the close
of the plan year in which: (i) the participant attains the earlier of
age 65 or the plan’s normal retirement age, (ii) the 10th
anniversary of the year in which the participant began
participation under the plan occurs, or (iii) the participant
terminates his or her service with the employer?

Article or
Change
Section and
Page Number

For IRS Use
Only

(42)

(42)

(42)

(42)
(42)
(42)
(42)

(42)

(43)

(44)

(44A)

(45)

N/A

(11) If the plan contains an early retirement provision which requires or could
require both a minimum age and service for eligibility, does a participant who
meets the service requirement but separates from service before meeting the
age requirement begin to receive benefits (unless otherwise elected) upon
meeting the age requirement?
(12) Are annuity contracts nontransferable when distributed?
(13) Does the plan provide that the terms of any annuity contract purchased and
distributed by the plan to a participant or spouse shall comply with the
requirements of the plan?
(14) Does the plan require, in accordance with section 401(a)(9) that:
(a) Distributions be made beginning not later than the required beginning
date?
(b) Payment of the participant’s interest be made at least as rapidly as under
the method used prior to death, when the participant dies after
distribution has started, using the participant’s remaining life expectancy
if there is no designated beneficiary and if there is a designated
beneficiary using the remaining life expectancy of either the participant or
the designated beneficiary, whichever is longer?
(c) Payment of the participant’s interest be made either within 5 years of the
participant’s death or over the life expectancy method under either
sections 401(a)(9)(B)(iii) or (iv) when payment of the participant’s interest
has not begun prior to death?
(d) Distributions, if not made in a single sum, will satisfy minimum distribution
rules of section 401(a)(9) and the regulations thereunder, including the
minimum distribution incidental benefit requirement of section
1.401(a)(9)-6, Q&A-2 of the Regulations?
(e) Does the plan define spouse in accordance with Notice 2014-19 for
purposes of the requirements of section 401(a)(9)?

Article or
Section and
Page Number

Change

For IRS
Use Only

(46)

(47)
(48)

(49)

(49)

(49)

(49)
(49)

(15) Are optional forms of benefit:
(a) Stated in the plan?

(50)

(b) Made available to employees in a manner that does not discriminate in
favor of highly compensated employees?
(c) Not subject to employer discretion?

(50)

(16) (a) Does the plan provide for the direct rollover of an eligible rollover
distribution to an eligible retirement plan?
(b) Does the plan provide for the automatic rollover of a mandatory
distribution over $1,000 to an individual retirement plan, unless the
participant elects otherwise?
(c) If provided in the adoption agreement, does the plan specify the types of
plans that it will accept rollovers from?
g. Vesting provisions:
(1) Is a computation period for vesting purposes specified in the plan?
(2) Is the computation period for determining a break in service the same as is
used to compute a year of service for vesting?
(3) Does the plan provide that an employee will be fully vested on reaching
normal retirement age?
(4) If the plan contains vesting options, are they limited so that at all times they
will provide a percentage of nonforfeitable rights which is not less than the
percentage that would be provided under one of the options under section
411(a)(2)?
(5) If all years of service are not counted for vesting purposes, is the service not
counted excludable under section 411(a)(4)?
(6) If the plan contains the vesting break in service rules, does the plan comply
with sections 411(a)(6)(B), (C), or (D), as applicable?

(50)
(51)

(51)
(51)
(52)
(52)
(53)

(54)
(55)
(56, 57, 58)

N/A

(7) Does the participant who has at least 3 years of service have a reasonable
period of time after the adoption of an amendment which directly or indirectly
affects the calculation of his or her nonforfeitable percentage (including a
change to or from a top-heavy vesting schedule) to elect to have his or her
nonforfeitable percentage computed without regard to the amendment?
(8) Does the plan provide protection against cutback of vested rights or rights to
accrue benefits under sections 411(a)(10)(A) and 411(d)(6)?
h. Top-heavy:
(1) If this plan is not designed to operate as if it were top-heavy at all times, does
the plan define the following terms(a) Key employee?
(b) Top-heavy plan?
(c) Top-heavy ratio (as defined in section 416(g))?
(d) Permissive aggregation group?
(e) Required aggregation group?
(f) Determination date?
(g) Valuation date?
(h) Present value?
(2) Does the adoption agreement provide a section for the employer to specify the
interest rate and mortality table used in determining the top-heavy ratio
because of the required aggregation of multiple plans?
(3) Does the plan provide that for the purpose of determining the top-heavy ratio,
the accrual rate used will be that used to accrue benefits under all defined
benefit plans of the employer, or where there is no such uniform rate, the
slowest accrual rate permitted under section 411(b)(1)(C)?
(4) Does the plan provide for a minimum contribution (determined without
regard to social security) for each non-key employee participant, who has
not separated from service at the end of the plan year, equal to the lesser
of: (a) 3% of compensation, or (b) the highest contribution rate applicable to
any k employee, including minimum contributions for non-key employees
(a) fail to complete 1,000 hours of service?
who:
(b) fail to make mandatory contributions, or in the case of a cash or
deferred arrangement, elective contributions to the plan?
(5) Does the plan prohibit forfeitures of required minimum contributions because of
withdrawal of mandatory contributions described in section 411(a)(3)(B) or 411
(a)(3)(D)?
(6) Does the plan provide for vesting not less favorable than the vesting described
in section 416(b)?
i. Death benefits:
(1) If life insurance is provided, are premiums properly limited?
(2) If ordinary life insurance contracts are purchased, will such contracts be either
converted to cash or an annuity contract at or before retirement, or distributed
to the participant?
(3) Are insurance contracts owned and held by the trustee or custodian, if
applicable, in accordance with the terms of the plan, including joint and
survivor annuity requirements, if any?
j. Plan Asset Issues:
(1) Are assets valued at least annually, on a specified date, and at current fair
market value, if this requirement is contained in the plan?

Article or
Section and
Page Number

Change

For IRS
Use Only

(59)
(60)

(61)
(61)
(61)
(61)
(61)
(61)
(61)
(61)
(61)

(61)

(61)

(62)
(62)

(63)
(64)
(65)

(66)

(67)
(68)

N/A

Article or
Section and
Page Number

Change

For IRS
Use Only

(2) If the plan, as adopted by an employer, is an “applicable defined contribution
plan” within the meaning of Treasury regulation 1.401(a)(35)-1(f), does the
plan give participants (to the extent required by the regulations) the
opportunity to elect to diversify the portion of their accounts invested in
employer securities and offer such participants at least three investment
options (other than employer securities)?
k. Amendment andtermination:
(1) Is there a provision for the provider to amend the plan?
(2) Is there a provision for the employer to amend the plan to satisfy sections 415
and 416 because of the required aggregation of multiple plans?
(3) Is there a provision for the employer to amend the plan to add certain model
or sample amendments that specifically provide that their adoption will not
cause such plan to fail to be identical to the Pre-approved plan?
(4) Is there a provision for the employer to add interim or discretionary
amendments that are related to a change in qualification requirements?

(70A)

(5) Are amounts credited to participants’ accounts nonforfeitable upon termination
or partial termination of the plan?
(6) Under a profit-sharing plan, are the employees’ rights under the plan
nonforfeitable upon complete discontinuance of contributions?
(7) Does the plan provide that after merger or consolidation with, or transfer of
assets or liabilities to any other plan, benefits on a termination basis will be no
less than before the merger, consolidation, or transfer?
l. Miscellaneous plan provisions:
(1) Does the plan prohibit the assignment or alienation of benefits except as
provided by sections 401(a)(13) and 414(p)?
(2) Do loans to plan participants satisfy the requirements of section 4975(d)(1)
and the joint and survivor requirements, if any?

(73)

(3) Does the plan provide that corpus or income may not be diverted for purposes
other than the exclusive benefit of employees or their beneficiaries?
(4) If a nontrusteed plan, do insurance contracts provide for refunds or credits for
the exclusive benefit of the participants?
(5) Does the plan provide that if the employer’s plan does not attain or retain
qualification, the employer can no longer participate under the plan?
(6) Does the plan provide that in the event of any conflict between the terms
of the plan and any provision contained in any associated trust
document, custodial account document, or any other document
incorporated by reference, the terms of the plan will govern?
(7) Does the plan provide that if the employer maintains a plan of a predecessor
employer, service with the predecessor employer is counted as service with
the employer?
(8) Does the adoption agreement contain the provider’s name, address, and
telephone number for the purpose of answering employer’s inquiries?
(9) Does the adoption agreement contain a cautionary statement describing the
limitations on employer reliance on an opinion letter without a
determination letter and that the failure to properly fill out the adoption
agreement may result in disqualification of the plan?
(10) Does the adoption agreement contain a statement which provides that the
provider will inform the adopting employer of any amendments made to the
plan or of the discontinuance or abandonment of the plan?
(11) Does the adoption agreement contain an employer signature line?
(12) Does the plan contain a provision that incorporates the requirements of
sections 414(u) and 401(a)(37) of the Code (USERRA)?

(71)
(72)
(72)

(74)
(75)

(76)

(77)

(78)
(79)
(80)
(81)

(83)

(85)
(85)

(85)

(85)
(86)

(13) If the plan may be adopted as a multiple employer plan within the meaning of
section 413(c), does the plan:

(86A)

(i) include, as an addendum to the adoption agreement, a participation agreement,
to be signed by any employer that adopts the plan (other than the “lead” employer
that signs the adoption agreement), which provides that the participating employer
agrees to be bound by the terms of the plan and trust as adopted by the lead
employer, including any amendments thereto and any elections made by the lead
employer, except to the extent the participation agreement allows for, and the
participating employer makes, separate elections with respect to its employees; and
(ii) provide that for purposes of participation and vesting the adopting employer and
all participating employers are considered a single employer, and an employee’s
service includes all service with the adopting employer or any participating
employer?

Part II. Complete This Part if you Are Filing for a Standardized Plan
With respect to this standardized plan:

a. Does the plan cover all employees (including individuals required to be

(87)

considered employees according to section 414(n) or (o) and employees of
other members of groups aggregated under sections 414(b), (c), (m), or (o))
other than employees who may be excluded under sections 410(a)(1) or
(b)(3)?
b. Are the eligibility requirements not more favorable for highly
compensated employees as defined in section 414(q) than for other
employees?

(88)

c. Does the contribution formula satisfy the safe harbor requirements of
section 1.401(a)(4)-2(b)(2) or section 1.401(a)(4)-8(b)(3) of the
Regulations?

(89)

d. Does the adoption agreement contain, in close proximity to the employer’s
signature line, the circumstances under which the adopting employer may not
rely on the opinion letter (as set forth in section 5.08 of Rev. Proc. 2017 -41),
including a statement that the employer, in order to obtain or retain reliance,
must obtain a determination letter if the employer ever has maintained any
other plan (including a welfare benefit plan)?
e. Does the plan prohibit adopting employers from amending other than elective
provisions (except to the extent necessary to satisfy section 415 and 416
because of the required aggregation of multiple plans, and other amendments
as permitted by section 5.05 of Rev. Proc. 2017-41) unless the employer wants
the
plan?participation in
to cease

(90)

(72)

Part III. Complete This Part if you Are Filing for a
Nonstandardized Plan
With respect to this nonstandardized plan:
a. Does the plan meet the minimum age and service requirements of section
410(a)(1)?

(91)

b. Does the adoption agreement contain, in close proximity to the employer’s
signature line, the circumstances under which adopting employers may not rely
on an opinion letter issued by EP Rulings and Agreements, with respect to the
qualification of the plan unless they apply to EP Determinations for a
determination letter?

(92)

c. Does the plan give the employer the option to select total compensation?

(93)

d. If the plan contains language that allows adopting employers to adopt an
allocation formula designed to be cross -tested for nondiscrimination on the
basis of equivalent benefits under section 1.401(a)(4) -8 of the Regulations,
does the employer’s allocation formula meet the cross-testing rules?

(94)

e. Does the plan give the employer the option to select a design -based safe
contribution/allocation formula and/or a uniform points allocation formula?

(95)

Part IV. Complete This Part if you Are Filing for a Profit-Sharing/401(k)
Plan

N/A Article or
Section and
Page Number

Change

For IRS Use
Only

With respect to this section 401(k) plan Cash or Deferred Arrangement (CODA):
a. Are contributions pursuant to an election permitted before the related
compensation is earned?

(I)

b. Is an employee’s eligibility to make elective deferrals conditioned on no more
than one year of service or attainment of no more than age 21?

(II)

c. Does the plan provide for a reasonable period during which participants may
once a year elect to commence elective deferrals?

(III)

d. Are participants’ elective deferrals limited to the dollar limit in effect in section
402(g)?

(IV)

e. Will elective deferrals be distributed no later than April 15 to any participant
who has excess elective deferrals for the preceding tax year?

(V)

f. Do the elective deferrals meet the nondiscrimination test of section 401(k)(3)?

(VI)

g. Does the plan provide for the distribution of excess contributions no later than
12 months after the plan year, if such excess contributions were allocated to
the previous plan year?

(VII)

h. May a participant recharacterize an excess contribution?

(VIII)

i. Can the employer make matching contributions?

(IX)

j. Do matching contributions satisfy the minimum vesting requirements of section
411(a)(2)?

(X)

k. Can the employer make qualified matching contributions?

(XI)

l. Do employee contributions and matching contributions meet the ACP test of
section 401(m)?

(XII)

m. Are the excess aggregate contributions distributed or forfeited no later than 12
months after the plan year?

(XIII)

n. May the employer make qualified non-elective contributions?

(XIV)
(XV)

o. Are the participant’s rights to his or her accrued benefit derived from employee
contributions, qualified non-elective contributions, qualified matching
contributions, and elective deferrals nonforfeitable? Proposed regulations
issued January 18, 2017 allow for employer contributions to qualify as qualified
non-elective contributions or qualified matching contributions if they satisfy the
nonforfeitability and distribution requirements at the time they are allocated to a
participant’s account, but need not meet these requirements when they are
contributed to the plan.
p. Do distributions of elective deferrals, qualified non-elective contributions,
qualified matching contributions, and income allocable to each comply with
section 401(k)(2)(B)?

(XVI)

q. Does the plan permit hardship distributions of elective deferrals?

(XVII)

r. Does the plan provide that elective deferrals are not taken into account to
satisfy the minimum top-heavy contribution requirements?

(XVIII)

s. Does the plan contain section 401(k) SIMPLE provisions?

(XIX)

t. Does the plan contain section 401(k) safe harbor provisions?

(XX)

u. Does the plan allow the employer to elect to provide a qualified automatic
contribution arrangement?

(XX)

v. Does the plan allow the employer to elect to provide an eligible automatic
contribution arrangement?

(XXI)