Form 5434 - November 2023 - Joint Board for the Enrollment of Actuaries Application for Enrollment

Sep 26, 2026

Uploaded by Kurz

Application Form 5434 (November 2023) for enrollment of actuaries by the Joint Board for the Enrollment of Actuaries. Includes applicant identification and contact information, enrollment status selection, responsible actuarial and pension experience reporting, examination or waiver details, and required disclosures about prior tax compliance, conduct, and criminal history. Contains an authorization and declaration with signature and date, plus Schedule A (Employment Record) to document employment periods, positions, employer details, supervisors who certify experience, and detailed duties related to pension plan work.

LanguageEnglish

CategoryExam

FormatPDF

Pages4

Reading Time10 min

AccessFree to download

Application for Enrollment

Applicant information and enrollment status

Experience, examinations, waivers, and disclosures

Declaration and signature

Schedule A (Employment Record)

Employment blocks and supervisor certification

Detailed duties and responsibilities

| Form 5434
(November 2023) | Joint Board for the Enrollment of Actuaries
Application for Enrollment | | OMB Number
1545-0951 | | --- | --- | --- | --- | The application fee is $680.To apply and pay the application fee electronically,visit www.pay.gov. For Joint Board Use Only Alternatively,complete this form and enclose with your check or money order for $680,payable toEnrollment numberDate enrolledthe Internal Revenue Service,and submit to:Internal Revenue Service,Office of Enrollment,127 International Drive,Room-EA125,Franklin,TN 37067. Read the instructions on pages 3-4 before completing this form. | 1. | Full legal name | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | | a. | Last name | | b.First name | | | c.Middle name or initial | | | 2. | Other names used (including maiden name a | nd dates used) | | 3.Business name (if using business addr | | ess) | | | 4a. | Address (number,street,suite or apt) | | | b.City | | c.State | d.ZIP code | | 5. | Email address | 6.Telephone number | | | 7.Social Security Number | 8.Date of birth (mm/ddlyyy) | | | 9. | Which one of the following describes your | enrollment status(check one) | | | | | | (A)□ Iam applying for enrollment for the first time (B)□ Iapplied 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.(Ifyour resignation or thetermination of your enrollment was related to a disciplinary matter,contact the Executive Director before completing thisappication.)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 allblocks of Schedule(s)A) Month(s) (B)Responsible pension actuarial experience (from item 6(B)for all blocks of Schedule(s)A) 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 Date waiver received (B)□ Waiver of Joint Board EA-1 examination(s) 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.For any of the three tax years preceding your date of application,have you failed to timely file a requiredfederal tax return or pay a federal tax,or has an authoritative body issued a finding that you have evadedany federal tax or payment?If Yes,provide details on a separate page 14.In the last 15 years or since your 18th birthday,if more recent,has an authoritative body issued a findingthat you have engaged in conduct described in section 901.12(f)(1)?If Yes,provide details on a separate page 15.Have you been convicted of,or fined for,any criminal offenses listed in ERISA section 411 or has anYes □Noauthoritative body issued a finding that you have knowingly submitted false or misleading information on anapplication for enrollment,or in connection therewith,or in any actuarial report to any person?If Yes,provide details on a separate page Declaration and Signature Ihereby apply to be an enrolled actuary.I have read and m familiar with the Joint Board regulations.I authorize the Joint Board to inquire about myqualifications and experience from educational institutions,employers,supervisors,actuarial organizations,and any other individuals who may haveknowledge related to my qualifications and experience.I authorize all such institutions,employers,supervisors,organizations and others to provide anyinformation requested concerning my education,employment experience and qua

FAQs

What experience and knowledge requirements must be reported?

The form requires the number of months of responsible actuarial experience and responsible pension actuarial experience reported on Schedule A, and it asks for how the basic actuarial knowledge and pension actuarial knowledge requirements were satisfied (exam(s) or waiver).

What disclosures are required before enrollment?

The form asks whether the applicant failed to timely file a federal tax return or pay a federal tax, whether there were findings about conduct described in section 901.12(f)(1), and whether the applicant was convicted or fined for specified criminal offenses or submitted false or misleading information, with details provided on a separate page if yes.

Sep 26, 2026

Uploaded by Kurz