PART I – PLAN INFORMATION

1. APPLICANT’S NAME

2. APPLICANT’S ADDRESS

3. APPLICANT’S TELEPHONE NO. 4. FAX NO. (optional) (optional)

4. APPLICANT’S EIN 6. PLAN NO. (do not use a Social Security Number)

5. PLAN NAME

6. TYPE OF SUBMISSION

7. TYPE OF PLAN (CHECK ONE ONLY):

8. DATE (month and day) ON WHICH PLAN YEAR ENDS .

9. NUMBER OF PARTICIPANTS IN THE PLAN AS PROVIDED ON THE MOST RECENTLY FILED FORM 5500 SERIES (See Rev. Proc. 2008–50, section 12.07.):

10. ASSETS IN THE PLAN AS PROVIDED ON THE MOST RECENTLY FILED FORM 5500 SERIES (ROUND TO NEAREST DOLLAR): $ (See Rev. Proc. 2008–50, section 12.07)

If the Applicant is being represented by someone in connection with this matter or wishes to authorize someone to receive information from us in connection with this matter, submit a completed Form 2848 or Form 8821, and complete items 13 through 18.

September 2, 2008 521 2008–35 I.R.B.

13. NAME OF APPLICANT’S REPRESENTATIVE

14. NAME OF REPRESENTATIVE’S FIRM

15. REPRESENTATIVE’S ADDRESS:

16. REPRESENTATIVE’S PHONE NO. 17. FAX NO.

17. REPRESENTATIVE’S E-MAIL ADDRESS (optional)