SECTION 14. PAPERWORK — Internal Revenue Bulletin 2017-43

REDUCTION ACT

The collection of information included 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. section 3507) under control number 1545-2073.

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 OMB control number.

The collection of information in this revenue procedure is in sections 3 through 11 of this revenue procedure. This collection of information is required to provide sufficient information to enable the IRS to

Appendix A

evaluate, process, and rule on the request for approval to use substitute mortality tables. This information will be used to make determinations under § 430(h)(3) of the Code. The likely respondents are businesses or other for-profit institutions and nonprofit institutions.

The estimated total annual reporting/ recordkeeping burden is 60,000 hours.

The estimated annual burden per respondent/recordkeeper varies from 167 to 900 hours, depending on individual circumstances, with an estimated average burden of 267 hours. The estimated annual number of respondents/recordkeepers is 225.

The estimated annual frequency of responses is once every 10 years.

Books or records relating to a collection of information must be retained as long as their contents may become material in the administration of any internal revenue law. Generally, tax returns and tax return information are confidential, as required by 26 U.S.C. Section 6103.

DRAFTING INFORMATION

The principal author of this revenue procedure is Arslan Malik of the Office of the Associate Chief Counsel, Tax Exempt and Government Entities. For further information regarding the submission of a request for approval to use substitute mortality tables, please contact Michael Spaid at (206) 946-3480 (this is not a toll-free number).

REQUEST FOR APPROVAL TO USE SUBSTITUTE MORTALITY TABLES CHECKLIST Instructions You must include a completed copy of this checklist with your submission. Answer each question in the checklist by circling Yes, No, or N/A; explanations must be provided for “No” or “N/A” responses. If a completed checklist is not included, or if explanations are not provided for “No” and “N/A” responses, then your submission will be considered incomplete for purposes of section 4.02 of this revenue procedure. Sign and date the checklist (as plan sponsor or authorized representative) and place it on top of your request.

Page number in

Response

Response number Description of item application

Yes No 1. Have you included the user fee required under Rev. Proc. 2017–4 or its successors?

Item number Description of item

Yes No 1. Have you included the user fee required under Rev. Proc. 2017–4 or its successors?

N/A (See section 3.02)

Yes No 2. If you are designating an authorized representative, ³⁶ have you included a properly

N/A

If you are designating an authorized representative, ³⁶ have you included a properly executed Form 2848 (Power of Attorney)? (See section 3.03(1))

36It is recommended that an actuary who is able to answer technical questions about the construction of the substitute mortality tables be designated as an authorized representative. Not

Bulletin No. 2017–43 379 October 23, 2017

Page number in

Response number Description of item application

Yes No 3. Have you satisfied all the requirements of Rev. Proc. 2017–4 or its successors (espeN/A cially concerning original signatures, penalties of perjury statement, and statement of

Response

Item number Description of item

Yes No 3. Have you satisfied all the requirements of Rev. Proc. 2017–4 or its successors (espeN/A cially concerning original signatures, penalties of perjury statement, and statement of

proposed deletions)? (See section 3.03(2) and (3))

Yes No 4. If any separate application for approval to use substitute mortality tables will be made N/A for other plans maintained within the applicant’s controlled group, have you requested

that the 180-day review period be extended? (See section 4.03)

Yes No 5. Have you identified the first day of the first plan year for which approval to use substiN/A tute mortality tables is requested and the number of years for which the substitute mor

Yes No 5. Have you identified the first day of the first plan year for which approval to use substiN/A tute mortality tables is requested and the number of years for which the substitute mor tality tables would be used? (See section 5.03)

Yes No 6. Have you included a description of the populations for which approval to use substitute N/A mortality tables is requested? (See section 5.04)

Yes No 7. Have you included a description of the populations, if any, for which the generally apN/A plicable mortality tables will be used? (See section 5.04)

Yes No 8. Have you included the identification information required under section 6.01 for the N/A Plan (or for each plan in the Aggregated Group) for which approval to use substitute

mortality tables is requested?

Yes No 9. Have you provided the information required for each plan for which substitute N/A tables are not intended to be used? (See section 6.02)

Yes No 9. Have you provided the information required for each plan for which substitute mortality N/A tables are not intended to be used? (See section 6.02)

Yes No 10. Have you provided the information required for each other plan for which substitute N/A mortality tables are being used or are intended to be used? (See section 6.03)

Yes No 11. If the applicant is a plan sponsor of a multiple-employer plan, have you provided N/A (1) a statement that none of the employers whose employees participate in the plan

Yes No 11. If the applicant is a plan sponsor of a multiple-employer plan, have you provided either N/A (1) a statement that none of the employers whose employees participate in the plan are

treated as maintaining the plan under § 1.430(h)(3)–2(c)(7)(ii); or (2) if one or more of the participating employers is treated as maintaining the plan under § 1.430(h)(3)– 2(c)(7)(ii), the information specified in section 6.02 and 6.03 of this revenue procedure, as applicable, treating each such employer as the applicant? (See section 6.04)

Yes No 12. Have you provided the required information for any plans that were spun off from anN/A other plan maintained by the applicant or a member of the applicant’s controlled group

within the past 5 years? (See section 6.05)

Yes No 13. Have you identified the Experience Study Period and the base year for the Substitute N/A Base Tables? (See section 7.01)

Yes No 14. Have you provided the full credibility threshold and the number of actual deaths N/A the Experience Study Period for each population within the Plan (or within the Aggre

Yes No 14. Have you provided the full credibility threshold and the number of actual deaths during N/A the Experience Study Period for each population within the Plan (or within the Aggre gated Group) for which approval to use substitute mortality tables is requested (see section 7.02)?

Yes No 15. Have you identified whether the applicant used either or both of the optional rules specN/A ified in section 7.03?

Yes No 16. Have you included a table showing the required information for each applicable populaN/A tion within the Plan (or within the Aggregated Group), for each year of the Experience

Study Period and also as an aggregate amount for all years in the Experience Study Period? (See section 7.04)

Yes No 17. Have you included the relevant standard mortality tables (which is the base mortality N/A table under § 1.430(h)(3)–1(d) projected with mortality improvement to the base year

for the Substitute Base Tables)? (See section 7.05)

Yes No 18. Have you included a description of the methods used to reflect exposure periods of N/A than one year? (See section 7.06)

Yes No 18. Have you included a description of the methods used to reflect exposure periods of less N/A than one year? (See section 7.06)

Yes No 19. Have you included a description of any methods used to adjust the experience study N/A data? (See section 7.07 and 7.08)

Have you included a description of any methods used to adjust the experience study data? (See section 7.07 and 7.08)

having an actuary available to discuss these tables with the IRS may cause a delay in the processing of your request for approval.

October 23, 2017 380 Bulletin No. 2017–43

Page number in

Response number Description of item application

Yes No 20. Have you included a table showing the average number of individuals during the ExpeN/A rience Study Period and the number of individuals within the population as of the last

Response

Item number Description of item

Yes No 20. Have you included a table showing the average number of individuals during the ExpeN/A rience Study Period and the number of individuals within the population as of the last

day of the plan year immediately preceding the date of this application, for each population within the Plan (or within the Aggregated Group) for which the approval to use substitute mortality tables is requested? (See section 8.01)

Yes No 21. Have you provided information and analysis required if the population has had a signifN/A icant change in the number of participants, as described in section 8.02?

Yes No 22. Have you identified the Demonstration Period for all plans maintained by the applicant N/A or a member of the applicant’s controlled group other than a plan for which approval to

use substitute mortality tables is requested or used for all populations or a newlyaffiliated plan with respect to which the transition period has not ended before the first day of the Requested Effective Plan Year? (See section 9.01(1))

Yes No 23. Have you identified the number of deaths during the Demonstration Period for all plans N/A maintained by the applicant or a member of the applicant’s controlled group (other than

Have you identified the number of deaths during the Demonstration Period for all plans maintained by the applicant or a member of the applicant’s controlled group (other than a plan for which approval to use substitute mortality tables is requested or used for all populations or a newly affiliated plan with respect to which the transition period has not ended before the first day of the Requested Effective Plan Year) for any population for which there is a lack of credible mortality information (such that substitute mortality tables may not be used for that population)? (See section 9.01(2))

Alternatively, have you provided other information for a population that demonstrates that the number of deaths during the Demonstration Period would not exceed 100? (See section 9.02)

Yes No 24. Have you provided the mortality ratio for each population for which approval to use N/A substitute mortality tables is requested? (See section 10.01)

Yes No 25. For each population within the Plan (or within the Aggregated Group) whose N/A experience has full credibility, have you provided a full copy of the Substitute Base

Yes No 25. For each population within the Plan (or within the Aggregated Group) whose mortality N/A experience has full credibility, have you provided a full copy of the Substitute Base

Table? (See section 10.02)

Yes No 26. For each population within the Plan (or within the Aggregated Group) for which apN/A proval to use substitute mortality tables is requested but for which mortality experience

does not have full credibility, have you provided a full copy of the base substitute mortality table constructed as if the population’s mortality information had full credibility, the partial credibility weighting factor, and a full copy of the Substitute Base Table reflecting credibility adjustments? (See section 10.03)

Yes No 27. Have you included a comparison of hypothetical funding targets determined using genN/A erally applicable mortality tables and the proposed substitute mortality tables? (See sec

Yes No 27. Have you included a comparison of hypothetical funding targets determined using genN/A erally applicable mortality tables and the proposed substitute mortality tables? (See sec tion 11.01)

Yes No 28. Have you included the required sample generational mortality tables as of the ReN/A quested Effective Plan Year, developed from each Substitute Base Table? (See section

11.02)

Yes No 29. Have you included annuity factors for each Substitute Base Table based on the substiN/A tute mortality table for an individual whose year of birth is 20 years before the base

year for the Substitute Base Table? (See section 11.03)

Yes No 30. For a request for approval to use substitute mortality tables submitted on or before N/A ruary 28, 2018, have you included a request for a 90-day extension of the 180-day re

Yes No 30. For a request for approval to use substitute mortality tables submitted on or before FebN/A ruary 28, 2018, have you included a request for a 90-day extension of the 180-day re view period? (see section 4.04)

Signature Date

Title or Authority

Typed or printed name of person signing checklist

Bulletin No. 2017–43 381 October 23, 2017