Form 5434-A (Rev. 2-2017)
www.irs.govCatalog Number 63767O
5. Declaration and signature
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. In addition, I declare that I have reviewed the continuing professional education requirements set forth at
20 CFR 901.11, and to the best of my knowledge and belief, I have completed the minimum hours requirements of section 901.11(e) or
section 901.11(l)(7), as applicable, and I have satisfied the recordkeeping requirements of section 901.11(j).
5a. Signature 5b. Date signed
Privacy Act and Paperwork Reduction Act Notice
Section 1242 of 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 during a proceeding; 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 renewal of enrollment is voluntary;
however, providing the information requested on this form is a requirement to obtain the benefit of renewal of enrollment. Failure to
provide the requested information could delay or prevent processing of your application. Providing false information could subject you to
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 30 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; Park 4, Floor 4; 1111 Constitution Avenue, NW; Washington, DC
4. Please check one block for each of the following questions (see instructions)
A. Since the issuance or latest renewal of your enrollment, has an authoritative body issued a finding that you have
knowingly filed or used false or misleading information or made false or misleading representations on matters
relating to employee benefit plans or actuarial services? If Yes, provide details on a separate page.
B. Since the issuance or latest renewal of your enrollment, have you been convicted of, or fined for, any criminal
offenses (including those listed in ERISA section 411) under the laws of the United States, any State or the District of
Columbia, or any territory or possession of the United States, which evidences fraud, dishonesty, or breach of trust?
If Yes, provide details on a separate page.
C. Since the issuance or latest renewal of your enrollment, have you failed to timely file a required federal tax return
that became due, has the Internal Revenue Service issued a finding that you evaded any federal tax or payment, or
has an authoritative body issued a finding that you have engaged in conduct described in section 901.12(f)(1)? If
Yes, provide details on a separate page.
D. Since the issuance or latest renewal of your enrollment, has an authoritative body issued a finding that you have
failed to discharge your duties under ERISA or that you have willfully violated any of the regulations of the Joint
Board for the Enrollment of Actuaries? If Yes, provide details on a separate page.
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