SECTION 9. PAPERWORK — Internal Revenue Bulletin 2004-7

REDUCTION ACT

The collection of information contained in this revenue procedure has been reviewed and approved by the Office of Management and Budget in accordance with the Paperwork Reduction Act (44 U.S.C. § 3507) under control number 1545–1873. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the collection of information displays a valid control number.

2004-7 I.R.B. 495 February 17, 2004

APPENDIX A

MODEL NOTICE OF FUNDING WAIVER APPLICATION

TO EMPLOYEE ORGANIZATIONS (UNIONS), PARTICIPANTS, BENEFICIARIES, AND ALTERNATE PAYEES

This notice is to inform you that an application for a waiver of the minimum funding standard under § 412(d) of the Internal Revenue Code (Code) and section 303 of the Employee Retirement Income Security Act of 1974 (ERISA) has been submitted by

[ INSERT PLAN SPONSOR'S NAME ] to the Internal Revenue Service (Service) for the [ INSERT PLAN NAME ] for the plan year beginning [ INSERT DATE ].

Under § 412(f)(4)(B) of the Code and section 303(e)(2) of ERISA, the Service will consider any relevant information submitted concerning this application for a waiver of the minimum funding standard. You may send this information to the following address:

Director, Employee Plans Internal Revenue Service Attention: SE:T:EP:RA:T:A 1111 Constitution Avenue, N.W. Washington, D.C. 20224

Any such information should be submitted as soon as possible after you have received this notice. Due to the disclosure restrictions of § 6103 of the Code, the Service can not provide any information with respect to the waiver request itself.

In accordance with section 104 of ERISA and § 2520.104b–10 of the Department of Labor Regulations (29 C.F.R. Part 2520), annual financial reports for this plan, which include employer contributions made to the plan and the accumulated funding deficiency for the plan for any plan year, are available for inspection at the Department of Labor in Washington, D.C. Copies of such reports may be obtained upon request and upon payment of copying costs from the following address:

Public Disclosure Room Room N–5507 Employee Benefits Security Administration U.S. Department of Labor 200 Constitution Avenue, N.W. Washington, D.C. 20210

As required by section 104(b)(2) of ERISA, copies of the latest annual plan report are available for inspection at the principal office of the plan administrator, who is located at [ INSERT ADDRESS ]. Copies of the annual report may be obtained upon request and upon payment of a copying charge of [ INSERT CHARGE ] by writing to the plan administrator at the above address.

The following information is provided pursuant to § 412(f)(4)(A) of the Code and section 303(e)(1) of ERISA:

Present Value of Vested Benefits $

Present Value of Benefits, calculated as though the plan terminated $

Fair Market Value of Plan Assets $

The above present values were calculated using an interest rate of [ INSERT INTEREST RATE ].

[ SIGNATURE OF APPROPRIATE OFFICER OF THE PLAN SPONSOR ]

[ INSERT NAME ]

[ INSERT TITLE ]

February 17, 2004 496 2004-7 I.R.B.

APPENDIX B

WAIVER OF MINIMUM FUNDING STANDARD REQUEST CHECKLIST

IS YOUR SUBMISSION COMPLETE?

INSTRUCTIONS

The Service will be able to respond more quickly to your waiver of minimum funding standard request if it is carefully prepared and complete. To ensure your request is in order, use this checklist. Answer each question in the checklist by inserting Y for yes, N for no, or N/A for not applicable, as appropriate, in the blank next to the item. Sign and date the checklist (as taxpayer or authorized representative) and place it on top of your request .

You must submit a completed copy of this checklist with your request. If a completed checklist is not submitted with your request, substantive consideration of your submission will be deferred until a completed checklist is received.

If you want to designate an authorized representative, have you included a properly executed Form 2848 ( Power of Attorney and Declaration of Representative )?
Have you satisfied all the requirements of Rev. Proc. 2003–4 or its successors (especially concerning signatures and penalties of perjury statement)? (See section 2.02(1) & (2))
Have you included statement of proposed deletions? (See §2.02(3))
Have you included the user fee required under Rev. Proc. 2003–8 or its successors? (See section 2.01 & 2.02(3))
Have you included a copy of the written notification that an application for a waiver has been submitted and a statement that such notice was delivered to each employee organization, participant, beneficiary and alternate payee? (See section 2.02(4) and Appendix A)
Have you included the general facts concerning the employer? (See section 2.03(1))
Have you included a description of the employer’s financial condition? (See section 2.03(2)).
If the plan is not a multiemployer plan, have you included a description of the employer’s executive compensation arrangements? (See section 2.03(3))
Have you included an explanation of the nature and extent of the business hardship, including financial projections if the waiver request exceeds $1,000,000 and the plan is not a multiemployer plan? (See section 2.03(4))
Have you included information concerning the pension plan? (See section 2.03(5))
Have you included information concerning other pension, profit-sharing, or stock bonus plans of the employer? (See section 2.03(6))
Have you included information concerning other matters pertaining to the plan? (See section 2.03(7))

2004-7 I.R.B. 497 February 17, 2004

Have you provided a digest of financial information? (See section 2.03(8))
Have you provided 2 copies of the necessary waiver information described in section 2.03 if the waiver request exceeds $1,000,000? (See section 2.04)
If the waiver request pertains to a defined contribution pension plan, have you provided a copy of the plan amendment or determination letter request, if applicable? (See section 3.01–3.04)
Have you submitted the request for a waiver no later than the 15 ^th day of the 3 ^rd month following the close of the plan year if the plan is not a multiemployer plan, or no later than the close of the plan year following the plan year for which the waiver is requested if the plan is a multiemployer plan? (See section 4)

Signature Date

Title or Authority

Typed or printed name of person signing checklist

February 17, 2004 498 2004-7 I.R.B.