Fillable Application for Enrollment Jan-2017 Form-5434

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Application for Enrollment Jan-2017 Form-5434

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Catalog Number 42528L www.irs.gov
Form
5434 (Rev. 1-2017)
Form 5434
(January 2017)
Joint Board for the Enrollment of Actuaries
Application for Enrollment
OMB Number
1545-0951
The application fee is $250. To apply and pay the application fee electronically, visit www.pay.gov.
Alternatively, complete this form and enclose with your check or money order for $250, payable to
the Internal Revenue Service, and submit by regular or USPS express mail to:
Internal Revenue Service, PO Box 301510, Los Angeles, CA 90030-1510.
Read the instructions on page 3 before completing this form.
For Joint Board Use Only
Enrollment number Date enrolled
1. Full legal name
a. Last name b. First name c. Middle name or initial
2. Other names used (including maiden name and dates used) 3. Business name (if using business address)
4a. Address (number, street, suite or apt) b. City c. State d. ZIP code
5. Email address 6. Daytime telephone number 7. Social Security Number 8. Date of birth (mm/dd/yyyy)
9. Which one of the following describes your enrollment status? (Check one)
(A)
I am applying for enrollment for the first time.
(B) I applied for enrollment previously but was not granted enrollment. Provide details on a separate page.
(C)
I was enrolled previously but my enrollment was terminated or I resigned my enrollment. (If your resignation or the
termination of your enrollment was related to a disciplinary matter, contact the Executive Director before completing this
application.) Provide details on a separate page.
10. How many months of responsible experience did you report on Schedule(s) A (Employment Record)?
(A) Responsible actuarial experience (from item 6(A) for all blocks of Schedule(s) A)
Month(s)
(B) Responsible pension actuarial experience (from item 6(B) for all blocks of Schedule
(s) A)
Month(s)
11. On what basis did you satisfy the basic actuarial knowledge requirement of section 901.12(c)? (Complete either A or B, as applicable)
(A) Joint Board EA-1 examination(s)
Name(s) of exam(s), month(s) and year(s) completed
(B) Waiver of Joint Board EA-1 examination(s)
Date waiver received
Qualifying formal education
Organization basic examination
Other
12. When did you satisfy the pension actuarial knowledge requirement of section 901.12(d) (EA-2 examination(s))?
Name(s) of exam(s), month(s) and year(s) completed
13. Have you read and are you familiar with the Joint Board regulations?
If No, provide details on a separate page.
Yes No
14. Have you timely filed your Federal tax returns and timely paid your Federal taxes for the three tax years
preceding your date of application?
If No, provide details on a separate page.
Yes No
15. In the last 15 years or since your 18th birthday, if sooner, have you ever been convicted or fined for a crime
under any revenue law or of a crime involving dishonesty or breach of trust?
If Yes, provide details on a separate page.
Yes No
Declaration and Signature
I hereby apply to be an enrolled actuary. I authorize the Joint Board to inquire about my qualifications and experience from educational institutions,
employers, supervisors, actuarial organizations, and any other individuals who may have knowledge related to my qualifications and experience. I
authorize all such institutions, employers, supervisors, organizations and others to provide any information requested concerning my education,
employment experience and qualifications as an actuary.
Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is true, correct, and complete.
16. Signature 17. Date signed
dd mmm yyyy
dd mmm yyyy
dd mmm yyyy
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dd mmm yyyy
Page 2
Catalog Number 42528L www.irs.gov
Form
5434 (Rev. 1-2017)
Schedule A (Employment Record)
Last name First name Middle name or initial
Account for the entire period of your employment in the actuarial profession within the last 10 years.
Block 1. Dates of employment (mm-yyyy)
From To
2. Exact title of position 3. Type of business or organization
4a. Provide the name, position title, address, email address (if known), and telephone number of your immediate supervisor who can
certify your responsible actuarial experience.
4b. If your experience includes responsible pension actuarial experience and your immediate supervisor is not an enrolled actuary, also
provide the name, position title, address, email address (if known), and telephone number of an enrolled actuary who can certify
your responsible pension actuarial experience.
5. Name of employer and address.
6. In your own words, describe IN DETAIL your actual duties and responsibilities in the above employment. Be sure to include all
relevant duties and responsibilities relating to those described in section 901.1. Estimate the proportion of the total period devoted to
each type of duty and responsibility.
6(A) How many months of this employment constitute "responsible actuarial experience" as defined in section 901.1(c)?
Month(s)
6(B) How many months of ''responsible pension actuarial experience'' as defined in section 901.1(e) are included in 6(A) above?
Month(s)
Page 3
Catalog Number 42528L www.irs.gov
Form
5434 (Rev. 1-2017)
Instructions for Form 5434, Joint Board for the Enrollment of Actuaries Application for Enrollment
General Instructions
Before completing Form 5434, Application for Enrollment, read the regulations (Parts 901 and 902 of Title 20 of the Code of Federal
Regulations). Unless otherwise indicated, section numbers (e.g., 901.12(b)) cited on the form and in the instructions refer to the
regulations. You may download a copy of the regulations from www.irs.gov/Tax-Professionals/Enrolled-Actuaries.
You should not complete Form 5434 until you have satisfied the qualifying experience in section 901.12(b), the basic actuarial
knowledge requirement in section 901.12(c), and the pension actuarial knowledge requirement in section 901.12(d).
Instructions for Certain Line Items
Items 7 and 14
As part of the application process, we may check your Federal tax history to verify that you have timely filed and paid your Federal
taxes.
Item 10
You must have, within the 10-year period immediately preceding the date of application, either
(1) a minimum of 36 months of certified responsible pension actuarial experience or
(2) a minimum of 60 months of certified responsible actuarial experience including at least 18 months of responsible pension actuarial
experience.
The terms "responsible actuarial experience," "responsible pension actuarial experience," "certified responsible actuarial experience,"
and "certified responsible pension actuarial experience" are defined in section 901.1. You should account in Schedule A (Employment
Record) for all such experience in the actuarial profession within the last 10 years.
Item 11
If you are claiming transition credit for an examination taken prior to January, 2001, please so indicate. You may review the transition
rules at www.irs.gov/Tax-Professionals/Enrolled-Actuaries.
Schedule A (Employment Record)
Complete a separate Schedule A for each employer or period of employment. If employment for an employer consisted of two (or more)
periods, one of which consisted of responsible pension actuarial experience and the other(s) did not, treat this as different periods of
employment in separate blocks of Schedule A. Attach additional Schedules A if needed. In general, the individual asked to certify your
experience should be your immediate supervisor. However, if your immediate supervisor is not an enrolled actuary, both your
immediate supervisor and an enrolled actuary must certify your responsible pension actuarial experience.
In addition, if you believe that another individual is better able to certify your experience, please explain and provide the individual's
name, position title, address, email address (if known), and telephone number in addition to the same information provided for your
immediate supervisor. If you believe it is appropriate for several individuals to certify your experience for different periods of time with
the same employer, provide the names of such individuals, their position titles, addresses and telephone numbers.
Privacy Act and Paperwork Reduction Act Notice
Section 1242, Title 29, United States Code, authorizes the Joint Board for the Enrollment of Actuaries (Joint Board) to collect this information. The
primary use of the information is to enforce and administer the regulations of the Joint Board governing the practice of an actuary under the Employee
Retirement Income Security Act of 1974 (ERISA). Information may be disclosed to: the Department of Justice when seeking advice or for use in any
proceeding; courts and other adjudicative bodies; public authorities for their use in connection with employment, contracting, licensing, and other
benefits; public authorities for their use in connection with their regulatory, enforcement, investigative, or prosecutorial responsibilities; contractors as
necessary for performance of the contract; third parties as necessary during an investigation; the Department of Labor, the Department of the Treasury,
and the Pension Benefit Guaranty Corporation for administering and enforcing ERISA or in connection with maintaining standards of integrity, conduct,
and discipline on the part of individuals who practice before such agencies; the general public (including disclosures via web sites) for the purpose of
publicizing or verifying the enrollment status and location of individuals who are, or were, enrolled actuaries; professional organizations or associations
for their use in connection with maintaining standards of integrity, conduct, and discipline; appropriate agencies, entities, and persons when the Joint
Board suspects or confirms that the security or confidentiality of information in a system of records has been compromised as necessary to prevent,
minimize, or remedy harm. Applying for enrollment is voluntary; however, providing the information requested on this form is a requirement to obtain the
benefit of enrollment. Failure to provide the requested information could delay or prevent processing of your application. Providing false information
could subject you to penalties.
Notwithstanding any other provision of law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with, a
collection of information subject to the requirements of the Paperwork Reduction Act, unless that collection of information displays a currently valid OMB
Control Number. Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for
reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden to: Joint Board for the Enrollment of Actuaries c/o IRS/Return Preparer Office SE:RPO; REFM, Park 4, Floor 4; 1111 Constitution Avenue, NW;
Washington, DC 20224.
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Application for Enrollment Jan-2017 Form-5434

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Completed 18 May 2019

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