CHECK APPROPRIATE BOX. [ ] The Transferee (A) is not an employee benefit plan or arrangement subject to Section 406 of ERISA or a plan subject to Section 4975 of the Code (a "Plan"), nor a person acting on behalf of a Plan nor using the assets of a Plan to effect such transfer, and (B) is not an insurance company purchasing a Class B Certificate with funds contained in an "insurance company general account" or an "insurance company separate account" (as defined in Section V(e) of Prohibited Transaction Class Exemption 95-60 ("PTCE 95-60")) as to which there is a Plan with respect to which the amount of such general account's reserves and liabilities for the contracts held by or on behalf of such Plan and all other Plans maintained by the same employer (or affiliate thereof as defined in Section V(a)(1) of PTCE 95-60) of by the same employee organization exceed 10% of the total of all reserves and liabilities of such general account (as such amounts are determined under Section I(a) of PTCE 95-60) at the date of acquisition; or [ ] The Transferee is a Plan or a person acting on behalf of a Plan or using the assets of a Plan to effect such transfer or is an insurance company purchasing a Class B Certificate with funds contained in an insurance company general account or separate account, but has attached hereto an opinion of counsel addressed to the Trustee to the effect that the purchase or holding of such Class B Certificate will not result in the assets of the Trust Fund being deemed to be "plan assets" and subject to the prohibited transaction provisions of ERISA and the Code and will not subject the Trustee to any obligation in addition to those expressly undertaken in the Agreement or to any liability.
CHECK APPROPRIATE BOX. [ ] The Transferee is not an employee benefit plan or arrangement subject to Section 406 of the Employee Retirement Income Security Act of 1974, as amended, or a plan subject to Section 4975 of the Internal Revenue Code of 1986, as amended (a "Plan"), nor a person acting on behalf of a Plan nor using the assets of a Plan to effect such transfer; or [ ] if such Transferee is a Plan, then
CHECK APPROPRIATE BOX. [ ] The Transferee is not an employee benefit plan or arrangement subject to Section 406 of the Employee Retirement Income Security Act of 1974, as amended, or a plan subject to Section 4975 of the Internal Revenue Code of 1986, as amended (a "Plan"), nor a person acting on behalf of a Plan nor using the assets of a Plan to effect such transfer; or [ ] The Transferee is an insurance company purchasing the Certificates or beneficial interest therein with funds contained in an "insurance company general account" (as defined in Section V(e) of Prohibited Transaction Class Exemption 95-60 ("PTCE 95-60")) as to which there is the Plan with respect to which the amount of such general account's reserves and liabilities for the contracts held by or on behalf of such Plan and all other Plans maintained by the same employer (or affiliate thereof as defined in Section V(a)(1) of PTCE 95-60) or by the same employee organization does not exceed 10% of the total of all reserves and liabilities of such general account (as such amounts are determined under Section I(a) of PTCE 95-60) at the date of acquisition.
CHECK APPROPRIATE BOX. |_| For employers who are required to make a determination letter submission to the IRS: The application will be filed on ____________________________ with the Key District Director, Internal Revenue Service at ___________________ for an advance determination as to whether the plan meets the qualification requirements of section 401, 403(a) or 405(a) of the Internal Revenue Code with respect to the plan's |_| initial qualification |_| amendment |_| termination |_| merger |_| consolidation or |_| transfer of plan assets or liabilities. |_| For employers who are not required to make a determination letter to the IRS. It is not contemplated that the plan will be submitted to the Internal Revenue Service for an advance determination as to whether it meets the qualification requirements of section 401 of the Internal Revenue Code with respect to either its initial qualification or any subsequent amendment. RIGHTS OF INTERESTED PARTIES
CHECK APPROPRIATE BOX. |_| For employers who are required to make a determination letter submission to the IRS: Detailed instruction regarding the requirements for notification of interested parties may be found in sections 6,7 and 8 of Revenue Procedure 80-30. Additional information concerning this adoption or amendment (including, where applicable, an updated copy of the plan and related trust; the application for determination; and any additional documents dealing with the application for determination; and copies of section 6 of Revenue Procedure 80-30) is available at _________________ during the hours of __________________ for inspection and copying. (There is a nominal charge for copying and/or mailing.) |_| For employers who are not required to make a determination letter submission to the IRS: Detailed instruction regarding the requirements for notification of interested parties may be found in sections 6,7 and 8 of Revenue Procedure 80-30. Additional information concerning this adoption or amendment (including, where applicable, a description of the provisions providing for nonforfeitable benefits; a description of the circumstances which may result in ineligibility or loss of benefits; a description of the source of financing of the plan; and copies of section 6 of Revenue Procedure 80-30) is available at _________________ during the hours of __________________ for inspection and copying. (There is a nominal charge for copying and/or mailing.) Appendix A Key District Addresses Key District IRS Districts Covered Mid Atlantic Region Baltimore Baltimore, Pittsburgh, Richmond 00 Xxxxxxx Xxxxx Baltimore, MD 21201 Newark Newark, Philadelphia, Wilmington 00 Xxxxx Xxxxxx Xxxxxx, XX 00000 North Atlantic Region Brooklyn Albany, Augusta, Boston, Brooklyn, 00 Xxxxxxx Xxxxxx Buffalo, Burlington, Hartford, Xxxxxxxx, XX 00000 Manhattan, Portsmouth, Providence Central Region Cincinnati Cincinnati, Cleveland, Detroit, 000 Xxxx Xxxxxx Xxxxxxxxxxxx, Xxxxxxxxxx, Xxxxxxxxxx, XX 00000 Parkersburg Midwest Region Chicago Aberdeen, Chicago, Des Moines, 000 X. Xxxxxxxx Street Fargo, Helena, Milwaukee, Omaha, Xxxxxxx, XX 00000 St. Louis, St. Xxxx, Springfield Southeast Region Atlanta Atlanta, Birmingham, Columbia, 000 Xxxxxxxxx Xxxxxx, XX Greensboro, Xxxxxxx, Jacksonville, Xxxxxxx, XX 00000 Little Rock, Nashville, New Orleans Southwest Region Dallas Albuquerque, Austin, Cheyenne, 0000 Xxxxxxxx Xxxxxx Xxxxxx, Xxxxxx, Xxxxxxx, Oklahoma Xxxxxx, XX 00000 City, Phoenix, Salt Lake City, Wichita Weste...
CHECK APPROPRIATE BOX. Check Appropriate Box: Individual/Sole Proprietor Disregard Entity Corporation Name Corporation Corporation Shown is Subject to Partnership Partnership Backup Withholding Corporation Name Federal ID Number Legal Name (as it appears on your Social Security Card) Professional Name (if di¶erent) Legal Residence: (Unemployment and Withholding will be based on this address) Street Address City State Zip Phone Number Email Under penalties of perjury, I certify that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete:
CHECK APPROPRIATE BOX. The result of this acquisition is that a displaced person as defined in regulation is required to relocate. Therefore, any relocation benefits payable to such displaced person shall be governed by applicable regulations implementing the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970, as amended (42 U.S.C. 4601, et seq.). See: 49 C.F.R. 24. No relocation benefits are to be claimed under this Option as the Vendor who voluntarily conveys his or her property without recourse to the power of eminent domain is not a displaced person.
CHECK APPROPRIATE BOX. This serves as notification that a well is located on the property at the following address: This serves as notification that a well is not located on the property at the following address: I (we) understand and agree that this system is and shall remain totally segregated from the public water supply, and no unapproved or unauthorized cross connections; auxiliary intakes; bypasses; or interconnections will be permitted without the written approval of the Chuckey Utility District. I (we) further understand and agree that should an auxiliary water supply be connected to the public water system at the above address, maximum cross connection control equipment in the form of an approved air gap or Reduced Pressure Backflow Preventer shall be installed to protect the public water supply. Date: Name: Signature: RESIDENTIAL CROSS-CONNECTION SURVEY Chuckey Utility District is required by the Tennessee Department of Environment and Conservation to have this completed form on file Definitions Backflow: the reversal of the intended direction of the flow of water or mixtures of the water and other liquids, gasses, or other substances into the distribution pipes of a potable water system from any source.
CHECK APPROPRIATE BOX. Whole (all species) 1/2 (sheep, hog, beef only) 1/4 (beef only) Check appropriate xxxxxxxxx house: Catskill Packaging-Xxxxxx, NY Quail Custom Meats-Marathon, NY (000)000-0000 (000)000-0000 Beef, Sheep or Goats only Beef or Pigs only Other (you will be responsible for transportation)
CHECK APPROPRIATE BOX. ☐ Xxxxx-Xxxxxxx Center - Location Code 4086 ☐ XxXxxxxxx Auditorium - Location Code 4087 ☐ Xxxx Xxxxx Xxxxxx Memorial Chapel- Location Code 4090 ☐ Xxxxx Recreation Center - Location Code 4088 ☐ Diboll Conference Center - Location Code 4241 ☐ Quads/Green Spaces- Location Code 4683 ☐ Xxxxxxx Art Gallery and/or Woodway Way- Location Code 4089 ☐ Devlin Fieldhouse - Location Code 4093 ☐ Xxxxxxx Stadium - Location Code 4092 ☐ Xxxxx Xxxxxx Center - Location Code 4242 ☐ Hertz Center - Location Code 4243 ☐ Other Athletic Facilities - Location Code 4244 ☐ Xxxxx Xxxx or Xxxxx Annex Recital Hall- Location Code 4216 ☐ Theatre Venues (Lupin or XxXxxxxxxx Lab Theatre, XxXxxxxxxx Hall) - Location Code 4091 ☐ XxXxxxxxxx Xxxx Dance Studios- (Rooms 105, 300, 301, 302) - Location Code 4568 ☐ Stone Auditorium - Location Code 4589 ☐ Xxxxxxx Auditorium - Location Code 4681 ☐ Bea Field Alumni House – Location Code 4408 ☐ Xxxxxxxxxx Memorial Hall- Location Code 4450 ☐ Xxxx X. Xxxxxx/Tulane Community Health Center (community room/grounds)- Location Code 4505 ☐ Tidewater Gallery Room and/or Auditorium – Location Code 4506 ☐ Xxxxxxxx Hall - Location Code 4675 ☐ Goldring/Woldenberg I or II - Location Code 4676 ☐ School of Medicine Auditorium - Location Code 4678 ☐ Xxxxxx Auditorium - Location Code 4679 ☐ Debakey Center - Location Code 4680 ☐ Elmwood Campus Classrooms - Location Code 4677 ☐ Uptown General Pool Classrooms- Location Code 4556 ☐ Woldenberg Art Center Classrooms- Location Code 4686 ☐ Studio in the Xxxxx Location Code 4696 ☐ Other (Describe)
