Attachment I-A Attachment I-A for Form 4461-A, Application for Approval

Attachment I-A for Form 4461-A, Application for Approval of Pre-approved Defined Benefit Plan (revised 8/20)
Note: This application is designed to be used in conjunction with Rev. Proc. 2017-41. A list of required modifications is also recommended
for use and may be obtained from the IRS website at www.irs.gov/ep.
In items 9 through 11 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

OMB NO.
1545-0169
For IRS Use
Only

9 Provisions applicable to all plans:
a Definitions:
Where does the plan define the following terms(1) Year of Service?
(1)
(2)

Break in Service?

(3)

(4)

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)?
Elapsed time?

(5)

Plan year?

(6)

Compensation as defined in section 414(s) as limited by section
401(a)(17)?

(7)

Average annual compensation?

(8)

Earned income as defined in section 401(c)(2)?

(9)

Employee as described in sections 414(b), (c), (m), (n), or (o)?

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)
(10) Leased employee as described in section 414(n) or (o)?
(10)
(11) Highly compensated employee as defined in section 414(q)?
(11)
(12) Owner-Employee?
(12)
(13) Self-employed individual?
(13)
(14) Normal retirement age?
(14)
(15) Straight life annuity?
(15)

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For Paperwork Reduction Act Notice, see separate instructions.

9 (continued)

N/A

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?

Article or
Section
and Page
Number

Change For
IRS
Use
Only

(16)

(17)

(18)
(4)

(5)

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?
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)?

(19)

(20),
(21)
(6)

Will an employee otherwise eligible, who is in an ineligible class of employees,
immediately participate on becoming a member of
an eligible class?
c Accrual of benefits:
(1) Does the benefit formula provide for wear-away and fresh-start rules?

(22)

(23)
(2) Does the plan provide for the determination of a participant’s frozen accrued
benefit?
(24)
(3) Does the plan provide for adjustments to frozen accrued benefits?
(25)
(4) Does the current benefit formula provide for no permitted disparity and does it use the
fractional accrual rule?
(26)
(5)(a) Does the plan provide for a cash balance formula?

(26A)
(b) Is this a nonstandardized plan?

(26A)
(c) Is Hypothetical Account Balance defined?

(26A)
(d) Is Principal Credit defined?

(26A)
(e) Is Interest Credit defined?

(26A)
(f) Is there a preservation of capital requirement?

(26A)
(g) Does the plan allow for the Interest Crediting Rate applied to a Participant’s beginning
Hypothetical Account Balance for each Interest Credit Period to be the Actual Rate of
Return on the aggregate assets of the Plan for that period?

(26A)
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(g)(1) If the Actual Rate of Return is used does it include both positive and negative
returns?

(26A)
(g)(2) If an Actual Rate of Return is used are plan assets diversified so as to minimize the
volatility of returns in accordance with Reg. § 1.411(b)(5)-1(d)(5)(ii)(A)?

(26A)
(h) If there is a provision for offsets accrued under a defined contribution plan, does the
plan provide a minimum accrued benefit to participants (expressed as a lifetime annuity
commencing at normal retirement age) of no less than .5% of compensation for each year
of credited service, which is not reduced by the offset applied to other formulas under the
plan?

(26A)
(6) Does the current benefit formula provide for permitted disparity?
(27)
(7) Does the plan define covered compensation, final average compensation, and taxable
wage base?
(27A)
(8) Does the plan provide adjustments for benefits beginning at a time other than
normal retirement age?
(27B)
(9) If the plan provides for permitted disparity, must mandatory employee
contributions be allocated to a separate account?
(27C)
(10) If fully insured, does the plan provide for permitted disparity with respect to employerprovided benefits?
(27D)
(11) If the plan is integrated, is the employer-provided benefit limited in accordance with
section 401(a)(5)(D)?
(27E)
d Benefits Increases:
For a fully insured plan, or a plan that provides an insured death
benefit, is there a provision for purchasing additional contracts due to increases in
compensation?
e (1) Does the plan define an accrual computation period?

(28)

(29)
(2) Does the plan define a year of credited service?
(30)
(3) Does the rate of accrual under each benefit formula satisfy one of the following
tests at all times:
(a) 3 percent rule-section 411(b)(1)(A)?
(b) 133-1/3 percent rule-section 411(b)(1)(B)? (NOTE: A cash balance plan must
meet this rule exclusively.)

(31)

(31)
(c) Fractional rule-section 411(b)(1)(C)?
(31)
(d) For a cash balance formula, is the accrued benefit expressed as a lifetime annuity
in the plan’s normal form commencing at a participant’s normal retirement age
calculated by projecting the participant’s hypothetical account balance to normal
retirement age with interest at the interest crediting rate in effect at the date of
determination and converting the projected account to an actuarial equivalent benefit
in the normal form payable at normal retirement age using the plan’s actuarial
assumptions?
(31)
(e) Fully insured plan rule-section 411(b)(1)(F)?
(32)
(4) Does the plan provide for pre-ERISA accruals?
(33)

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(5) For purposes of determining accrued benefits, is the normal retirement benefit
equal to the greater of the early retirement
benefit under the plan or the benefit beginning at normal retirement age?
(34)
(6) Do plan participants continue to accrue benefits without reduction in the rate of
accruals solely on account of the attainment of any
specified age?
f Employee contributions:

(35)

(1) If the plan is non-standardized, does the plan provide for nondeductible
voluntary employee contributions?
(36)
(2) Does the plan provide a separate account for the portion of each employee’s accrued
benefit derived from nondeductible voluntary employee contributions?
(37)
(3) Are nondeductible voluntary employee contributions (adjusted for investment
experience) nonforfeitable at all times?
(38)
(4) Does the plan require that deductible voluntary employee contributions will be
maintained in a separate account?
(39)
g Section 415 limitations:
(40)

Are annual benefits limited as required by section 415?
h Distribution provisions:
(1) Does the plan state the normal form in which benefits will be paid (life annuity, 10
years certain and life thereafter, etc.)?

(41)
(2) Does the plan specify the actuarial assumptions to be used in determining actuarial
equivalence which comply with Regulations
section 1.417(e)-1?
(3) Are the optional forms of benefits stated in the plan?

(42)

(43)
(4) If the plan disregards service attributable to a distribution in computing the
employer-derived accrued benefit, does the plan
contain provisions that satisfy Regulations section 1.411(a)- 7(d)(4)?
(44)
(5) If the present value of the accrued benefit is greater than $5,000, is consent of the
participant and spouse (if applicable) required when benefits are immediately
distributable within the meaning of
Regulations section 1.417(e)-1?
(6) (a) Does a married participant automatically receive a qualified
joint and survivor annuity (QJSA), and an unmarried participant the
normal form of life annuity?
NOTE: Effective 6/26/2013, a same sex spouse must be recognized
for purposes of sections 401(a)(11) and 417.
(b) Is the participant given an opportunity to make a qualified election to waive the
automatic form of payment in a manner which satisfies section 417(a)(2)
during the election period
described in section 417(a)(6)(A)?
(c) Is a married participant who waives the QJSA given an opportunity to elect
to receive a qualified optional survivor annuity in accordance with section
417(a)(1)(A)(ii)?

(45)

(46)

(46)

(46)

(7) (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)(1) in the event of death
before the annuity starting date?
(46)
(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
described in
section 417(a)(6)(B)?
(8) 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?

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(46)

(46)

(9) (a) Does the plan provide for a written explanation of the automatic form of
payment 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)?

(46)

(46)
(10) Do benefits under the plan begin, unless otherwise elected in writing, 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?
(47)
(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?
(48)
(12) 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?
(13) Are annuity contracts nontransferable when distributed?

(49)

(50)
(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?
(51)
(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?
(c) Payment of the participant’s interest be made within 5 years of the participant’s
death, unless one of the exceptions in section 401(a)(9)(B)(iii) or (iv) applies, when
payment of the
participant’s interest has not begun prior to death?
(d) Distributions, if not made in a single sum, will satisfy the minimum distribution
rules of section 401(a)(9) and the regulations thereunder, including the
minimum distribution
incidental benefit requirement of Regulations section 1.401(a)(9)-6,
Q&A-2?
NOTE: Effective 6/26/2013, any provision under section 401(a)(9)
applicable to a participant’s spouse includes a same sex spouse.
(15) Does the plan provide that any preretirement death benefits are incidental?

(51)

(51)

(51)

(52)
(16) Does the plan permit distributions only at normal retirement age, plan termination,
termination of employment, death, disability or
attainment of age 62?
(17) (a) Does the plan provide for the direct rollover of an eligible
rollover distribution to an eligible retirement plan?
NOTE: Effective 6/26/2013, a same sex spouse must be recognized for purposes
of the rollover rules of IRC 402(c).
(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?

(53)
(54)

(54)

(54)
(d) If the plan accepts rollovers made on or after January 1, 2013 and converts those
rollovers to additional annuity benefits for the participant, is the amount of the
additional annuity attributable to the rollover determined in accordance with
sections 411(c)(2)(B) and (C) and 411(c)(3) of the Code and
Rev. Rul. 2012-4?
(54)

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(18) If the plan provides for suspension of benefits upon reemployment with the
employer or continued employment beyond normal retirement age, does this
provision comply with Department of Labor regulations?
(55)
(19) If the plan offers a benefit payment option whereby a participant can elect to
bifurcate the distribution of their accrued benefit so that part of the benefit is
distributed in the form of an annuity and the remainder in a more accelerated
form of payment, does the method used to compute each portion satisfy one of
the two methods found under Regulations section 1.417(e)-1(d)(7)?
(20) Does the plan contain pre-termination restrictions?

(56)

(57)
(21) Does the plan limit the accrual and payment of benefits as required by section 436?
(57A)
i. Vesting provisions:
(1) Is a computation period for vesting purposes specified in the plan?
(58)
(2) Is the computation period for determining a break in service the same as is used to
compute a year of service for vesting?
(59)
(3) Does the plan provide that an employee will be fully vested on reaching normal
retirement age?
(60)
(4)(a) Are vesting options 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)?
(b) If this is a cash balance plan, is the minimum vesting required not less than 3
year cliff (3 year -100%)?

(61)

(61)
(5) If all years of service are not counted for vesting purposes, is the service not counted
excludable under section 411(a)(4)?
(62)
(6) Does the plan contain the vesting break in service one year holdout provision?
(63)
(7) Does the plan contain the vesting break in service rule of parity?
(64)
(8) 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?
(65)
(9) Does the plan provide protection against cutback of vested rights or rights to
accrued benefits under sections 411(a)(10)(A) and
411(d)(6)?
(10) If participants may withdraw their contributions or earnings on them, may the
withdrawal be made without forfeiting vested
benefits based on employer contributions?
(11) 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?
j Top-heavy:

(66)

(67)

(68)

(1) If this plan does not fulfill the basic top-heavy plan requirements at all times, does
the plan define the following terms(69)
(a) Key employee?
(69)

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(b) Top-heavy plan?
(69)
(c) Top-heavy ratio (as defined in section 416(g))?
(69)
(d) Permissive aggregation group?
(69)
(e) Required aggregation group?
(69)
(f) Determination date?
(69)
(g) Valuation date?
(69)
(h) Present value?
(69)
(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 lowest accrual rate permitted under section
411(b)(1)(C)?
(4) Does the plan provide an accrued benefit (determined without regard to social
security) which is at all times not less than 2% of the highest 5 consecutive years’
average compensation for each year of service (service may be limited to service
while the plan is top-heavy and to a maximum of 10 years of service) for each
nonkey employee participant who has completed 1,000 hours of service including
a nonkey employee who:

(69)

(69)

(a) fails to make mandatory contributions to the plan?
(70)
(b) is excluded from the plan because compensation is less than a stated amount?
(70)
(c) is not employed on the last day of the accrual computation period?
(70)
(d) has his or her accrued benefit reduced in any way because of permitted disparity?
(70)
(5) If the minimum accrued benefit in (4) is in a form other than a life annuity at normal
retirement age, is such minimum accrued benefit at least equal to the actuarial
equivalent of the required
minimum accrued benefit?
(6) Are forfeitures of the minimum accrued benefit prohibited in the event a
participant:
(a) works beyond the normal retirement age?
(b) withdraws mandatory employee contributions?

(71)

(7) (a) Does the plan provide for vesting not less favorable than the vesting described in
section 416(b)?
(73)
(b) If the any portion of the benefit is determined under a cash balance formula is
the vesting at least as favorable as 3 year cliff vesting?

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(73)

k Amendment and termination:
(1) Is there a provision for the Provider to amend the plan and does the provision
describe the circumstances under which the Provider will no longer be authorized to
amend the plan
on behalf of adopting employers?
(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) Does the plan prohibit adopting employers from amending other than elective
provisions (except to the extent necessary to satisfy section 415 or 416 because of
the required aggregation of multiple plans, or as permitted by section 8.03 of Rev.
Proc. 2017-41) unless the employer wants to cease participation in the plan?

(74)

(75)

(75)
(4) Is there a provision for the employer to amend the plan to add certain model,
sample, or other required interim amendments that specifically provide that their
adoption will not cause the plan
to be treated as individually designed?
(5) Are the rights of all affected employees to benefits accrued to the
date of termination or partial termination, to the extent funded as of such date,
nonforfeitable?
(6) 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 section 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 annuity requirements, if
any?
(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) Does the plan provide that if it does not attain or retain qualification, the employer
can no longer participate under the plan?

(75)

(76)

(77)

(78)

(79)

(80)

(81)
(5) 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?
(6) Does the plan provide that in the event of any conflict between
provisions of the plan and the terms of the associated trust, custodial account,
or any other documents incorporated by reference, the provisions of the plan
will control?
(7) Does the plan provide that in the event of any conflict between the provisions of the
plan and any insurance contracts issued thereunder, the plan provisions shall
control?

(84)

(85)

(86)

(8) If the plan provides for investment in insurance contracts, does it provide for the
disposition of dividends and other credits?
(87)
(9)(a) Does the plan or adoption agreement if applicable, contain the Provider’s or
Provider’s authorized representative’s name, address, and telephone number for the
purpose of answering employer’s inquiries?
(b) Does the plan or adoption agreement if applicable, contain a cautionary statement
describing the limitations on employer reliance on an opinion letter and that the
failure to properly fill out the adoption agreement may result in disqualification of the
plan?

(88)

(88)
(c) Does the plan or adoption agreement if applicable, 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?
(88)

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(d) Does the plan or adoption agreement if applicable, provide that the employer must
complete a new adoption agreement or signature page upon first adopting the plan?
Does it also provide upon any modification to a prior election, the making of a new
election, or a restatement of the plan, a new signature page or adoption agreement must
be completed by the employer?
(88)
(e) Does the plan or adoption agreement if applicable, contain a dated employer
signature line?
(88)
(10) Does the plan contain provisions that satisfy section 401(a)(37) and incorporate
the requirements of section 414(u) of the Code
(USERRA)?
(11) Does the plan NOT contain any sub-trusts for life insurance?

(89)

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

(89A)
N/A

Complete if you are filing for a Standardized Plan

(10) With respect to this standardized plan:
a. Does the plan cover all employees (including individuals required
to be considered employees according to section 414(n) or (o)
and employees of other members of groups aggregated under
section 414(b), (c), (m), or (o)) other than employees who may
be excluded under section 410(a)(1) or (b)(3)?
b.

c.

Are the eligibility requirements not more favorable for highly
compensated employees, as defined in section 414(q), than for
other employees?
Does the plan document, or adoption agreement if applicable
contain, in close proximity to the employer’s signature line, the
circumstances under which the adopting employer may rely on
the opinion letter as well as those where they may not rely on
the opinion letter (as set forth in section 7 of Rev. Proc 201741)?

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(90)

(91)

(92)
d. If this plan is a restatement of a non- pre-approved plan which
allowed for mandatory employee contributions onto a
standardized pre-approved plan, do the mandatory employee
contributions cease at the point of restatement?
(102)

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e. If the plan previously provided for mandatory employee
contributions, does the plan define the accrued benefit derived
from employer contributions as the total accrued benefit, less
the accrued benefit derived from mandatory employee
contributions as provided in Regulations section 1.411(c)-1?
(103)

Complete if you are filing for a Nonstandardized Plan

N/A

Article or
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(11) With respect to this nonstandardized plan:
a.

Does the plan require mandatory employee contributions?
(102)

b.

c.

If the plan previously provided, or currently provides for
mandatory employee contributions, does the plan define the
accrued benefit derived from employer contributions as the total
accrued benefit, less the accrued
benefit derived from mandatory employee contributions as
provided in Regulations section 1.411(c)-1?

(103)

Is the accrued benefit attributable to mandatory employee
contributions nonforfeitable at all times?
(104)

d.

Does the plan meet the minimum age and service requirements
of section 410(a)(1)?
(105)

e.

f.

g.

Does the plan exclude categories of employees from
participation in addition to those who may be excluded under
section 410(a)(1) or section 410(b)(3)?
Does the plan document or adoption agreement if applicable,
contain in close proximity to the employer’s signature line, the
circumstances under which the adopting employer may or may
not rely on the opinion letter (as set forth in section 7 of Rev. Proc
2017-41), and if the employer cannot rely on the opinion letter, the
possibility of filing for a determination letter in accordance with
section 12B of Rev. Proc. 2020-4?

(105)

(106)

Does the plan give the employer the option to select total
compensation?
(107)

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