Form 4461-C Application for Approval of Standardized or Nonstandardi

Form

4461-C

(April 2022)
Department of the Treasury
Internal Revenue Service

Application for Approval of
Standardized or Nonstandardized
403(b) Pre-Approved Plans

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OMB No. 1545-0169

This Form Is Open to Public Inspection

Go to www.irs.gov/Form4461-C for the latest information.

For IRS Use Only

File This Form With the Internal Revenue Service

File folder number

Section references are to the Internal Revenue Code unless otherwise noted.

Complete every applicable item on this form and on any attachment or other document required (see Rev. Proc. 2021-37).

See instructions before completing this form.
1
2a

3a

Enter amount of user fee submitted
$
Approval requested:
Initial application
Amendment—Enter file folder number in 2b and date
of last letter issued in 2c.
Name of applicant

2b File folder number

2c Date of last
letter issued

3b Employer identification number
of applicant

Address (number, street, room or suite no.) (If a P.O. box, see instructions.)
City

State

ZIP code

3c Applicant’s telephone no.

3d Type of applicant (see Definitions in the instructions and select only one of the below):
Provider
Mass submitter
Word-for-word identical adopter
4a

Name of person to be contacted

4b Telephone number

Minor modifier adopter
4c Fax number

4d Email address
5a

Basic plan document or single document plan number

6a

Name of mass submitter

4e If a power of attorney is attached, check the box
5b Adoption agreement number, if applicable

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6b Enter the following information for the mass submitter’s plan on which this plan is based (if this application is submitted
simultaneously with the mass submitter’s application, see the instructions)
File folder number
Letter serial number
Date of letter

7
8
9

10

11

NOTE: Item 6 should only be completed where the applicant is a word-for-word identical adopter or a minor modifier adopter of
a mass submitter plan. With the exception of 12a(3), a word-for-word identical adopter or minor modifier adopter does not need
to complete item 12.
Form of plan:
Adoption agreement plan
Single document plan
Filing status of plan:
Standardized plan
Nonstandardized plan
Investment arrangements permitted:
Annuity contracts issued by insurance company
Custodial accounts
Retirement Income Account
NOTE: Retirement Income Account plans must have a separate plan document.
If Retirement Income Account was selected in item 9, identify the types of employers which may use the plan:
Church
Qualified Church Controlled Organization
Non-Qualified Church Controlled Organization
Minister
Type(s) of contributions permitted under the pre-approved plan:
Elective deferrals (other than Roth)
Roth elective deferrals
After-tax employee contributions
Matching contributions
Other nonelective employer contributions

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

For Paperwork Reduction Act Notice, see the instructions.

Date ▶

Title ▶
Catalog Number 66434U

Form

4461-C (4-2022)

Form 4461-C (4-2022)

12
a

Procedural requirements:
Have the following been submitted as required by instructions—
(1) Adoption agreement, if applicable? . . . . . . . . .
(2) Copy of plan?
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(3) Copy of Certification of Interim Amendments? . . . . .

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Yes

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No

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b Do you have a procedure in place for the adoption and distribution of interim amendments made on behalf of
adopting employers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c

Is the plan patterned after, and substantially the same as, another plan submitted? (If “Yes,” see specific
instructions.)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

d Provider (non-mass submitter) request. Complete (1) and (2). Skip if sponsoring solely a 403(b) Retirement
Income Account plan.
(1) If you have only one pre-approved plan, do you have at least 15 eligible employers which are reasonably
expected to adopt this plan’s basic plan document and adoption agreement or single document plan? . .
(2) If you have more than one pre-approved plan, do you have at least 15 eligible employers that are
reasonably expected to adopt at least one of the plans? . . . . . . . . . . . . . . . . .
e

Mass submitter request. Complete (1), (2), and (3).
(1) Are applications on behalf of the requisite number of providers who are adopting the same basic plan
document or single document plan on a word-for-word identical basis included? If “No,” complete (2) . .
(2) If “No” to (1), enter the file folder number of the basic plan document or single document plan for which the
requisite number of adopting providers requirement is met.
(3) If this is a flexible plan, answer (a) and (b).
(a) Have you bracketed and identified the optional provisions of the plan? . . . . . . . . . .
(b) Have you included a copy of the written representation describing the choices available to providers
and the coordination of optional provisions? . . . . . . . . . . . . . . . . . . .
Note: This application is designed to be used in conjunction with Rev. Proc. 2021-37. A List of Required Modifications (LRMs) is also
recommended for use and may be obtained from the IRS website at www.irs.gov/ep.
Form 4461-C (4-2022)

Form 4461-C (4-2022)

General Instructions
Section references are to the Internal
Revenue Code unless otherwise noted.

Future Developments
For the latest information about
developments related to Form 4461-C,
such as legislation enacted after the form
was published, go to www.irs.gov/
Form4461-C.

Purpose of Form
Form 4461-C is used to apply for
approval of a standardized or
nonstandardized 403(b) pre-approved
plan.
Be sure to submit a complete and
accurate application, including Form
4461-C, and any attachment or other
document required (see www.irs.gov/
retirement-plans/preapproved-plansubmission-procedures or Rev. Proc.
2021-37, 2021-38 I.R.B. 385). Complete
every applicable line on the application
and on any attachment or other required
document. If an item doesn’t apply, check
the “N/A” box or enter “N/A” on the line
where indicated as an option. If your
application isn’t complete, we will return it
without processing it. The first page must
be typed. Unless otherwise noted, the
questions on Form 4461-C and any
attachment or other required document
apply to both standardized and
nonstandardized 403(b) pre-approved
plans.
Requests for additional information. If
a letter requesting additional information
or changes to plan documents is sent to
the pre-approved plan provider or an
authorized representative, such
information and/or changes must be
received no later than 30 days from the
date of the letter. Failure to respond
timely may result in the application being
considered withdrawn. An extension of
the 30-day time limit will only be granted
for good cause.
Inadequate submissions. We will
return, without further action, plans that
aren’t in substantial compliance with the
403(b) requirements or plans that are so
deficient that they can’t be reviewed in a
reasonable amount of time.

Who May File
A provider or mass submitter of a 403(b)
pre-approved plan may file a Form 4461C. See Definitions, later.

What To File
Submit one copy of Form 4461-C for
each separate adoption agreement or for
each single document plan where no
adoption agreement is used. For
approval, file this application and each
applicable document listed in line 12(a).
A mass submitter should also file a

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separate Form 4461-C for each word-forword identical adopter or minor modifier
adopter of the plan.
Multiple adoption agreement plans. A
provider may use one basic plan
document for several plans. A provider
may, for example, use one basic plan
document for a governmental plan, a
plan of a church or qualified church
controlled organization (QCCO), and a
plan of a non-QCCO that use separate
adoption agreements. In addition, a
single adoption agreement may be
drafted to cover multiple types of eligible
employers. However, the same basic
plan document may not be used for a
403(b) plan intended to be a Retirement
Income Account and a 403(b) plan not
intended to be Retirement Income
Account. See section 4 of Rev. Proc.
2021-37 for the definitions of
governmental plan, church, QCCO, nonQCCO, Retirement Income Account, and
eligible employer. In the case of a
simultaneous submission of plans using
the same basic plan document, submit
only one copy of the basic plan
document. If the requests aren’t
simultaneous, submit separate basic plan
documents and include a cover letter
identifying the original submission. The
number assigned to the basic plan
document must remain the same as in
the prior submission. Standardized and
Nonstandardized plans may not be set
forth in a single adoption agreement.
Two or more single document plans. A
single document plan may be used by
more than one type of eligible employer;
however, a Retirement Income Account
plan must always be filed as a separate
single document plan. Standardized and
Nonstandardized plans may not be
combined in one single document plan.

Where To File
Send Form 4461-C to:
Internal Revenue Service
Attn: Pre-Approved Plans Coordinator
Room 6-403, Group 7521
P.O. Box 2508
Cincinnati, OH 45201-2508
If using Express Mail or a private
delivery service, send to:
Internal Revenue Service
Attn: Pre-Approved Plans Coordinator
Room 6-403, Group 7521
550 Main Street
Cincinnati, OH 45202
Signature. The application must be
signed by a partner or officer of the
applicant who is authorized to sign on
behalf of the applicant, or other person
authorized by a power of attorney. The
power of attorney should be filed with the
application.

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Disclosure requested by taxpayer. A
taxpayer may request the IRS to disclose
and discuss the return or return
information with any person the taxpayer
designates in a written request. If you
want to designate a person or persons to
assist in an application for approval, you
must provide the IRS office of jurisdiction
with a written request that contains:
• The taxpayer’s name, address,
employer identification number, and plan
number(s).
• The name, address, Social Security
number, and telephone number of the
person or persons whom you are
authorizing to receive return information.
• A paragraph that clearly describes the
return or return information that you
authorize the IRS to disclose.
• An authorized signature (see above).
As an alternative to providing the above
statement, you may submit Form 2848,
Power of Attorney and Declaration of
Representative.

Definitions
Adoption agreement. The portion of the
plan containing all the options the
adopting employer may select. The
adoption agreement may include blanks
or fill-in provisions for the employer to
complete if it also includes parameters on
these provisions that preclude an
employer from completing them in a
manner that could violate the 403(b)
requirements. Each separate adoption
agreement is treated as a separate plan
and will receive its own opinion letter.
Basic plan document. The portion of
the plan containing all the nonelective
provisions applicable to all adopting
employers. No options (including blanks
to be completed) may be provided in the
basic plan document except for options in
flexible plans.
Single document plan. A single
document plan consists of a single plan
document without an adoption
agreement. A single document plan may
contain alternate paragraphs and options
that may be selected by an adopting
employer. A single document plan may
include blanks or fill-in provisions for the
employer to complete only if the plan also
includes parameters on these provisions
that preclude an employer from
completing them in a manner that could
violate the 403(b) requirements.

Form 4461-C (4-2022)

Flexible plan. A plan submitted by a
mass submitter which contains certain
optional provisions as allowed by section
11.03(1) of Revenue Procedure (Rev.
Proc.). 2021-37. Providers who adopt a
flexible plan may include or delete any
optional provision designated as such in
the mass submitter’s plan. A flexible plan
adopted by a provider that differs from
the mass submitter plan only because of
the deletion of certain optional provisions
will be treated as a plan that is word-forword identical to the mass submitter plan.
Mass submitter. As set forth in Rev.
Proc. 2021-37, any entity that submits
applications on behalf of at least 15
unaffiliated providers each of which is
sponsoring, on a word-for-word identical
basis, the same plan. A mass submitter
is treated as a mass submitter with
respect to all its plans, provided the 15unaffiliated-provider requirement is met
with respect to at least one plan.
Affiliation is determined under Sections
414(b) and (c). Any law firm, accounting
firm, consulting firm, or similar
organization, will be considered to be
affiliated with its partners, members,
associates, or similar affiliated persons.
For purposes of determining whether 15
unaffiliated providers offer, on a word-forword identical basis, the same 403(b)
pre-approved plan, a mass submitter that
is also a provider is treated as an
unaffiliated provider.
Opinion letter. An opinion letter is a
written statement issued by the IRS to a
provider or mass submitter that the form
of a 403(b) pre-approved plan satisfies
the 403(b) requirements.
403(b) Pre-approved plan. A 403(b)
pre-approved plan is a plan (including a
plan covering self-employed individuals)
that is made available by a provider for
adoption by eligible employers. The term
403(b) pre-approved plan includes both
standardized and nonstandardized plans.
A 403(b) pre-approved plan may be an
adoption agreement plan or a single
document plan. An adoption agreement
plan consists of a basic plan document
and an adoption agreement. A single
document plan consists of a single plan
document offered by a provider without
an adoption agreement.

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Provider. A provider is any person
(including a mass submitter, if applicable)
that (1) has an established place of
business in the United States where it is
accessible during every business day;
and (2) represents to the IRS that it has
at least 15 eligible employers, each of
which is reasonably expected to adopt
one of the 403(b) pre-approved plans of
the provider. A provider may apply for
opinion letters for any number of 403(b)
pre-approved plans.
A provider also includes any person
that has an established place of business
in the United States where it is
accessible during every business day
and offers a plan as a word-for-word
identical adopter or minor modifier
adopter of a plan of a mass submitter,
regardless of the number of eligible
employers that are expected to adopt the
plan.
Standardized plan. A standardized plan
is a 403(b) pre-approved plan that meets
the requirements of section 5.18 of Rev.
Proc. 2021-37.
Nonstandardized plan. A
nonstandardized plan is a 403(b) preapproved plan that is not a standardized
plan.

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Specific Instructions
Line 1. All applications submitted must
be accompanied by the appropriate user
fee and Form 8717-A, User Fee for
Employee Plan Opinion Letter Request,
as determined from the schedule in Rev.
Proc. 2022-4, 2022-1 I.R.B. 161 (or the
most recent version, updated annually).
Applications submitted without the proper
user fee won’t be processed and will be
returned to the applicant. Additionally,
the IRS requests that applications be
submitted by thumb or flash drive instead
of being submitted as paper files, and
that the documents be saved in Microsoft
Word or Adobe Acrobat PDF format. The
IRS strongly encourages providers to
take advantage of this electronic
submission format. To pay a fee, a
provider must continue to submit a paper
check and a paper Form 8717-A.
Line 3a. Enter the name and address of
the applicant. If the post office doesn’t
deliver mail to the street address and the
applicant has a P.O. box number, show
the P.O. box number instead of the street
address.
Line 4a. If the person to be contacted is
other than an employee of the applicant,
please enclose an authorized power of
attorney. See Disclosure requested by
taxpayer, earlier.
Line 4c. Enter a fax number to receive
notice of preliminary approval of the
applicable plan, subject to final approval
by opinion letter.
Line 5a. Enter the two-digit number you
have assigned to your single document
plan or basic plan document that
accompanies the adoption agreement for
which you are requesting approval. If
multiple adoption agreements are linked
to the same basic plan document, use
the same two-digit basic plan document
number for all applications.

Form 4461-C (4-2022)

Line 5b. Enter the three-digit number you
have assigned to the adoption
agreement for which this application is
submitted. Each different adoption
agreement designed to accompany a
single basic plan document should be
given a different three-digit number
beginning with “001.” For example, if the
first basic plan document of a provider
has four separate adoption agreements,
they should be numbered “001” through
“004,” and the provider should submit
four separate Forms 4461-C. Adoption
agreements submitted with the second or
any subsequent basic plan documents
(that aren’t word-for-word identical to a
previously submitted basic plan
document) should be similarly numbered
beginning with “001.”
Line 6. If the mass submitter does not
know the file folder number, letter serial
number, and date of letter to use here,
then instead on the file folder number line
provide the plan number of the mass
submitter plan for which the word-forword identical adopter or minor modifier
adopter is basing its application for an
opinion letter.
Line 12. Procedural requirements.
Submit a separate application for each
different basic plan document/adoption
agreement combination or single
document plan.
Line 12c. If you checked “Yes,” submit a
copy of such plan with language
differences highlighted. Attach a cover
letter which provides the name and file
folder number of the plan (including the
name and employer identification

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number of the provider), a list of all plans
written by the plan drafter which are
substantially identical to the lead plan
(including the information described
above), a description of each place
where the plan for which the application
is being submitted isn’t word-for-word
identical to the language of the lead plan
(including an explanation of the purpose
and effect of each difference), and a
certification, made under penalty of
perjury by the plan drafter, that the
information describing where the plan
language isn’t word-for-word identical is
true and complete.
Line 12e. A mass submitter should file a
separate Form 4461-C for each provider
who is a word-for-word identical adopter
or minor modifier adopter.
Paperwork Reduction Act Notice.
We ask for the information on this form to
carry out the Internal Revenue laws of
the United States. You are required to
give us the information. We need it to
determine whether you meet the legal
requirements for plan approval.

5

You aren’t 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 content may
become material in the administration of
any Internal Revenue law. Generally,
tax return 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 .

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. 9 hr., 34 min.

Learning about the law
or the form . . . . . 1 hr., 9 min.
Preparing the form

.

. 2 hr., 18 min.

Copying, assembling, and
sending the form to the IRS 16 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 send us comments
from www.irs.gov/FormComments. Or
you can write to the Internal Revenue
Service, Tax Forms and Publications
Division, 1111 Constitution Ave. NW,
IR-6526, Washington, DC 20224. Don’t
send Form 4461-C to this address.
Instead, see Where To File, earlier.