SECTION 6. EFFECTIVE — Internal Revenue Bulletin 2014-16

The modification in this revenue procedure is effective as of April 14, 2014.

DRAFTING INFORMATION

The principal author of this revenue procedure is Eric Slack of the Employee Plans, Tax Exempt and Government Entities Division. For further information regarding this revenue procedure, please contact Mr. Slack via e-mail at RetirementPlanQuestions@irs. gov .

Bulletin No. 2014–16 945 April 14, 2014

APPENDIX Application for Approval of § 403(b) Pre-approved Plan

Enter amount of user fee submitted: $
Name of applicant: a. EIN: b. Address: c. Phone:
Person to contact: a. Phone: b. Email address: c. Power of attorney attached?
Type of applicant (check one): _____a. Prototype sponsor _____b. Prototype mass submitter _____c. Volume submitter practitioner _____d. Volume submitter mass submitter _____e. Identical adopter of mass submitter plan _____f. Minor modifier of mass submitter plan
Form of plan (check one); _____a. Prototype plan _____b. Volume submitter specimen plan without adoption agreement _____c. Volume submitter specimen plan with adoption agreement
If the plan is a prototype plan, indicate whether the plan is a (check one): _____a. Standardized plan _____b. Nonstandardized plan

7.a. Prototype plan basic plan document number (Each of the prototype sponsor’s or prototype mass submitter’s basic plan documents must be assigned a 2-digit number, starting with 01. Enter the number you have assigned to the basic plan document that is associated with the adoption agreement for which this application is filed.):

7.b. Prototype plan adoption agreement number (Each different adoption agreement associated with a single basic plan document must be assigned a 3-digit number, beginning with 001. Enter the number you have assigned to the adoption agreement for which this application is filed.):

7.c. Volume submitter specimen plan number (Each of the volume submitter practitioner’s or volume submitter mass submitter’s specimen plans must be assigned a 2-digit number, starting with 01. Enter the number you have assigned to the specimen plan for which this application is filed.):

7.d. Volume submitter plan adoption agreement number, if applicable (Each different adoption agreement associated with a single specimen plan must be assigned a 3-digit number, beginning with 001. Enter the number you have assigned to the adoption agreement for which this application is filed.):

If 4.e. or 4.f. is checked, complete the following information for the mass submitter’s plan on which this application is based, to the extent the information is available when this application is filed: a. Name of mass submitter: b. File folder number: c. Letter serial number: d. Date of letter: e. Basic plan document number or specimen plan number (if b, c, and d not available): f. Adoption agreement number, if applicable (if b, c, and d not available)
Investment arrangement(s) permitted under the prototype or specimen plan: _____a. Annuity contracts issued by an insurance company _____b. Custodial accounts _____c. Retirement income accounts
Type(s) of contributions permitted under the prototype or specimen plan: _____a. Elective deferrals (other than Roth)

April 14, 2014 946 Bulletin No. 2014–16

_____b. Roth elective deferrals _____c. After-tax employee contributions _____d. Matching contributions _____e. Other nonelective employer contributions

Are the following documents included with the application: a. Basic plan document or specimen plan? b. Adoption agreement (if the application is for a prototype plan or for a specimen plan that uses an adoption agreement)?
If 4.a. or 4.c. is checked, do you expect at least 15 eligible employers to adopt your § 403(b) prototype plan basic plan documents(s) or volume submitter specimen plan(s)?
If 4.b. or 4.d. is checked, are applications on behalf of at least 15 prototype sponsors or volume submitters who are sponsoring the identical basic plan document or specimen plan included with this application?
If the answer to 13 is “no,” enter the number of the basic plan document or specimen plan for which the requirement described in 13 is met:
Applicant’s signature under penalties of perjury (required if 4a, b, c, or d checked):

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: Title: Date:

Prototype sponsor’s or volume submitter’s and mass submitter’s signatures under penalties of perjury (required if 4e or 4f checked):

Under penalties of perjury, I declare that the prototype sponsor or volume submitter practitioner identified in line 2 of this application has adopted a prototype plan or a specimen plan that is identical to the mass submitter plan identified in line 7, or is a minor modifier of the mass submitter plan identified in line 7.

Prototype sponsor’s or volume submitter’s signature: Title: Date:

Mass submitter’s signature: Title: Date:

Bulletin No. 2014–16 947 April 14, 2014