Information at the Top of the Form
Check box A(1) if this is the first filing for this plan. Do not check this box if you have ever filed for this plan, even
if it was a different
form (for example, Form 5500).
Check box A(2) if you have already filed for the 2006 plan year and are now filing an amended return to correct errors and/or
omissions on the
previously filed return.
Check box A(3) if all assets under the plan(s) (including insurance/annuity contracts) have been distributed to the participants
and beneficiaries
or distributed to another plan. The final plan year is the year in which distribution of all plan assets is completed.
Check box A(4) if this form is filed for a period of less than 12 months. Show the dates at the top of the form.
Line 1a.
Enter the formal name of the plan or sufficient information to identify the plan.
Line 1b.
Enter the three-digit number the employer assigned to the plan. Plans should be numbered consecutively starting with
001.
Once a plan number is used for a plan, it must be used as the plan number for all future filings of returns for the
plan, and this number may not
be used for any other plan even after the plan is terminated.
Line 1c.
Enter the date the plan first became effective.
Line 2a.
Each row of boxes on the hand print forms is designed to contain specific information regarding the employer. Please
limit your response to the
information required in each row of boxes as specified below:
-
Enter in the first two rows of boxes labeled 1) the name of the employer.
-
Enter in row 2) any "in care of (C/O)" name.
-
Enter in row 3) the street address. A post office box number may be entered if the Post Office does not deliver mail to the
employer's street address.
-
Enter in row 4) the name of the city.
-
Enter in row 5) the two character abbreviation of the U.S. state or possession and zip code.
-
Enter in row 6) the foreign routing code, if applicable. Leave row 5), U.S. state and zip code, blank if entering
information in rows 6) and 7).
-
Enter in row 7) the foreign country, if applicable.
-
Enter in row 8) the "doing business as (D/B/A)" or trade name of the employer if different from the name entered in
1).
-
Enter in the rows of boxes labeled 9) any second address. Use only a street address, not a P.O. box, here. A P.O. box may be
entered only in row 3).
Line 2b.
Enter the employer's nine-digit employer identification number (EIN). For example, 00-1234567.
Do not enter your Social Security
Number.
Employers who do not have an EIN should apply for one on
Form SS-4, Application for Employer Identification Number, as soon as possible.
You can obtain Form SS-4 by calling
1-800-TAX-FORM (1-800-829-3676) or at the IRS website at
www.irs.gov. The EBSA does
not issue EINs.
Note.
Although EINs for funds (trusts or custodial accounts) associated with plans are generally not required to be furnished on
the Form 5500, 5500-EZ,
or schedules, the IRS will issue EINs for such funds for other reporting purposes. EINs may be obtained by filing Form SS-4
as explained above.
Line 2d.
Enter the six-digit business code that best describes the nature of the plan sponsor's business from the list of
business codes on pages 9, 10,
and 11.
Line 3a.
Each row of boxes on the hand print forms is designed to contain specific information regarding the plan administrator.
Please limit your response
to the information required in each row of boxes as specified below:
-
Enter in the first two rows of boxes labeled 1) the name of the plan administrator unless the administrator is the employer
identified in line 2. If this is the case, enter the word "same" on line 3a and leave the remainder of line 3a, and all of
lines 3b and 3c
blank.
-
Enter in row 2) any "in care of (C/O)" name.
-
Enter in row 3) the street address. A post office box number may be entered if the Post Office does not deliver mail to the
administrator's street address.
-
Enter in row 4) the name of the city.
-
Enter in row 5) the two character abbreviation of the U.S. state or possession and zip code.
-
Enter in rows 6) and 7) the foreign routing code and foreign country, if applicable. Leave row 5), U.S.
state and zip code, blank if entering information in rows 6) and 7).
Line 3b.
Enter the plan administrator's nine-digit EIN. A plan administrator must have an EIN for Form 5500-EZ reporting purposes.
If the plan
administrator does not have an EIN, apply for one as explained in the instructions for line 2b.
Line 4.
If the employer's name and/or EIN have changed since the last return was filed for this plan, enter the employer's
name, EIN, and the plan number
as it appeared on the last return filed for this plan.
Line 5.
(Optional) You may use this line to designate the person or entity that is principally responsible for the preparation of the annual
return.
Line 5a.
Each row of boxes on the hand print forms is designed to contain specific information regarding the preparer. Please
limit your response to the
information required in each row of boxes as specified below:
-
If the person who prepared the annual return is not the employer named in line 2a or the plan administrator named in line
3a, you may name
the person in the first two rows of boxes labeled 1).
-
Enter in row 2) the street address. If the Post Office does not deliver mail to the street address and the preparer has a P.O.
box, enter the box number.
-
Enter in row 3) the name of the city.
-
Enter in row 4) the two character abbreviation of the U.S. state or possession and zip code.
-
Enter in rows 5) and 6) the foreign routing code and foreign country, if applicable. Leave row 4), U.S.
state and zip code, blank if entering information in rows 5) and 6).
Line 6.
Check one box on this line. Profit-sharing, employee stock ownership (ESOP), stock bonus, and money purchase pension
plans are types of defined
contribution plans. A “
defined contribution plan” is a plan that provides for an individual account for each participant and for benefits based
solely on the amount in such account. If a plan is not a defined contribution plan, it is a defined benefit plan.
Line 6a.
Check this box if the plan is a defined benefit plan other than an insurance contract plan described in section 412(i)
(see line 6b). All defined
benefit pension plans are subject to the minimum funding requirements, except certain insurance contract plans described in
section 412(i), church
plans, governmental plans, and certain other plans described in section 412(h). Any defined benefit pension plan subject to
these minimum funding
requirements must maintain a funding standard account for each year. If Form 5500-EZ is filed for the plan, or if the plan
has not received
contributions sufficient to meet minimum funding requirements, a Schedule B (Form 5500) must be completed and retained with
the plan records.
Line 6b.
Check this box if the plan is an insurance contract plan described in section 412(i). For a defined benefit pension
plan, check either box 6a
or box 6b.
Line 6c.
Check this box if the plan is a defined contribution plan with or without a waived funding deficiency being amortized
in the current plan year. In
this situation, complete only lines 3, 8a, 9, and 10 of Schedule B and retain the schedule with the plan records. An enrolled
actuary does not have to
sign the Schedule B under these circumstances.
Line 7a.
If this plan is a master/prototype plan, enter the latest opinion letter number issued for the master/prototype plan.
If this plan is a regional
prototype plan, enter the latest notification letter number issued for the regional prototype plan. Leave line 7a blank if
this plan is not a
master/prototype plan or a regional prototype plan.
Line 7b.
Check box
(1) if you, or you and your spouse together, own 100% of the business which maintains the plan, and the business is
unincorporated. Check box
(2) if you are a partner in the partnership which maintains the plan. Check box
(3) if you, or you and
your spouse jointly, own 100% of the shares of the corporation which maintains the plan.
Line 8b.
File a separate Form 5500-EZ for each plan if you have two or more one-participant plans with combined total plan
assets that exceeded $100,000 at
the end of any plan year beginning on or after January 1, 1994.
Line 9.
In general, distributions received by participants from any qualified plan prior to attainment of age 59½, death,
or disability will
be subject to a 10% tax on the amount of the distributions (in addition to the income tax owed on the amount distributed).
In addition, individuals
generally must begin to receive distributions from qualified plans by April 1 of the calendar year following the calendar
year in which they reach age
70½.
For more details on early distributions and excess accumulations in qualified retirement plans, see
Pub. 560, Retirement Plans for Small
Business, and
Pub. 590, Individual Retirement Arrangements (IRAs). In addition,
Form 5329, Additional Taxes on Qualified Plans
(Including IRAs) and Other Tax-Favored Accounts, contains detailed information on how to report any excise tax or additional
income tax in connection
with your plan. These publications and the form can be downloaded at the IRS website
www.irs.gov.
Line 10.
Do not include transfers received or rollovers received from other plans on lines 10b and 10c. Those should be included
on line 11a.
Line 10b.
Enter the total cash contributions received by the plan during the year and the contributions owed to the plan at
the end of the plan year
including contributions for administrative expenses.
Line 10d.
Enter the total plan distributions made to participants or beneficiaries (including those distributions that are rolled
over, whether or not in a
direct transfer under section 401(a)(31)). If distributions include securities or other property, include the current value
of the securities or other
property at the date these assets were distributed. For distributions of insurance or annuity contracts to participants, enter
the cash value of the
contract when distributed.
Also report on line 10d a participant loan that is included in line 11a, column (a) (total plan assets - beginning
of year) and that has been
deemed distributed during the plan year or any prior year under the provisions of section 72(p) and Treasury Regulations section
1.72(p)-1 provided
both of the following circumstances apply:
-
Under the plan, the participant loan is treated as a directed investment solely of the participant's individual account; and
-
As of the end of the plan year, the participant is not continuing repayment under the loan.
If either of these circumstances does not apply, a deemed distribution of a participant loan should not be reported
on line 10d. Instead, the
current value of the participant loan (including interest accruing thereon after the deemed distribution) should be included
on line 11a, column (b)
(plan assets - end of year) and on line 12e (participant loans), without regard to the occurrence of a deemed distribution.
Note.
Although certain participant loans that are deemed distributions are to be reported on line 10d and are not to be reported
as an asset thereafter,
they are still considered outstanding loans and are not treated as actual distributions for certain purposes. See Q&As 12
and 19 of Regulations
section 1.72(p)-1.
Line 10e.
Enter the total plan distributions made during the year attributable to employee contributions or other basis under
the plan.
Line 10f.
Enter the amount of assets transferred (under section 414(l)) from this plan to another plan, if any. Do not include
rollovers or direct transfers
under section 401(a)(31) included on line 10d.
Line 10g.
Include rollovers, direct transfers under section 401(a)(31), transfers under section 414(l), and net income received
by the plan for the year. Do
not include unrealized gains or losses.
Line 10i(1).
This plan is subject to the minimum funding requirements (see Code section 412 and Part 3 of Title I of ERISA) if
the enrolled actuary must sign
the 2006 Schedule B (Form 5500). See the 2006 Instructions for Schedule B (Form 5500).
Line 10i(2).
The enrolled actuary must have signed the 2006 Schedule B (Form 5500) and line 10 of the Schedule B must be $0 or
blank to certify that the 2006
minimum funding requirements have been met. See the 2006 Instructions for Schedule B (Form 5500).
Line 10i(3).
If the plan has an accumulated funding deficiency, the amount of the deficiency will appear on line 10 of the 2006
Schedule B (Form 5500). The plan
does not have an accumulated funding deficiency if line 10 of the 2006 Schedule B (Form 5500) is $0 or blank. See the 2006
Instructions for Schedule B
(Form 5500).
Line 11a.
“
Total plan assets” includes rollovers and transfers received from other plans, and unrealized gains and losses such as
appreciation/depreciation in assets.
Note.
Do not include in column (b) a participant loan that has been deemed distributed if the loan has been reported on line 10d
in accordance with the
instructions for line 10d.
Line 11b.
Do not include the value of future distributions that will be made to participants.
Line 12a.
Enter the value of the plan's participation in a partnership or joint venture.
Line 12b.
The term “
employer real property” means real property (and related personal property) that is leased to an employer of employees covered by
the plan, or to an affiliate of such employer. For purposes of determining the time at which a plan acquires employer real
property for purposes of
this line, such property shall be deemed to be acquired by the plan on the date on which the plan acquires the property or
on the date on which the
lease to the employer (or affiliate) is entered into, whichever is later.
Line 12d.
An employer security is any security issued by an employer (including affiliates) of employees covered by the plan.
These may include common
stocks, preferred stocks, bonds, zero coupon bonds, debentures, convertible debentures, notes and commercial paper.
Line 12e.
Enter on this line all loans to participants including residential mortgage loans that are subject to section 72(p).
Include the sum of the value
of the unpaid principal balances, plus accrued but unpaid interest, if any, for participant loans made under an individual
account plan with
investment experience segregated for each account made in accordance with 29 CFR 2550.408b-1 and which are secured solely
by a portion of the
participant's vested accrued benefit. When applicable, combine this amount with the current value of any other participant
loans.
Note.
Do not include on line 12e a participant loan that has been deemed distributed if the loan has been reported on line 10d in
accordance with the
instructions for line 10d.
After a participant loan that has been deemed distributed is reported on line 10d, it is no longer to be reported as an asset
unless the
participant resumes repayment under the loan in a later year. However, such a loan (including interest accruing thereon after
the deemed distribution)
that has not been repaid is still considered outstanding for purposes of applying section 72(p)(2)(A) to determine the maximum
amount of subsequent
loans. The loan is also considered outstanding for other purposes, such as the qualification requirements of section 401(a),
including, for example,
the determination of top-heavy status under section 416. See Q&As 12 and 19 of Regulations section 1.72(p)-1.
Line 12f.
Enter all loans made by the plan except participant loans reported on line 12e. These include loans for construction,
securities loans, mortgage
loans (either by making or participating in the loans directly or by purchasing loans originated by a third party), and other
miscellaneous loans.
Include on this line residential mortgage loans that are not subject to section 72(p).
Line 12g.
Include all property that has concrete existence and is capable of being processed, such as goods, wares, merchandise,
furniture, machines,
equipment, animals, automobiles, etc. This includes collectibles, such as works of art, rugs, antiques, metals, gems, stamps,
coins, alcoholic
beverages, musical instruments, and historical objects (documents, clothes, etc.). Do not include the value of a plan's interest
in property reported
on lines 12a through 12f, or intangible property, such as patents, copyrights, goodwill, franchises, notes, mortgages, stocks,
claims, interests, or
other property that embodies intellectual or legal rights.
Line 13.
Section 4975 prohibits certain transactions between a plan and any disqualified person and imposes an excise tax on
each prohibited transaction.
The section 4975 tax is paid with the filing of
Form 5330, Return of Excise Taxes Related to Employee Benefit Plans. References to
disqualified person transactions refer to all such transactions, not only those that are prohibited.
See
Definitions on page 4 for the meaning of “
disqualified person.”
Line 14b.
Count your spouse and your partners' spouses only if they work in the business and benefit under the plan.
Line 14c.
Your plan meets the minimum coverage requirements of section 410(b), for purposes of Form 5500-EZ, if the employees
of your business (other than
those benefiting under the plan) are:
-
Covered by a collective-bargaining agreement, under which retirement benefits were subject to good-faith bargaining,
-
Nonresident aliens who receive no earned income from you that constitutes income from sources within the United States, or
-
Not eligible because they do not meet the plan's minimum age or years-of-service requirements.
Note.
You cannot use Form 5500-EZ if you have employees covered by another plan and this one-participant plan relies on that plan to meet
the
minimum coverage requirements. Use Form 5500 instead.
Line 15b.
A qualified joint and survivor annuity is an immediate annuity for the life of the participant, with a survivor annuity
for the life of the spouse
that is not less than 50% of, and is not greater than 100% of, the amount of the annuity that is payable during the joint
lives of the participant and
the spouse. The qualified joint and survivor annuity may be provided either by the purchase of an annuity contract from an
insurance company or
directly from the plan's trust. See section 417(b).
Privacy Act and Paperwork Reduction Act Notice.
We ask for the information on this form to carry out the Internal Revenue laws of the United States. This form is
required to be filed under
section 6058(a) of the Internal Revenue Code. Section 6109 requires you to provide your taxpayer identification number (SSN
or EIN). If you fail to
provide this information in a timely manner, you may be liable for penalties and interest. Section 6104(b) makes the information
contained in this
form publicly available. Therefore, the information will be given to anyone who asks for it and may be given to the Pension
Benefit Guaranty
Corporation (PBGC), Department of Justice for civil and criminal litigation, and cities, states and the District of Columbia
for use in administering
their tax laws.
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act
unless the form displays a valid
OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may
become material in the
administration of ERISA or the Internal Revenue Code. Generally, the Form 5500 series return/reports and some of the related
schedules are open to
public inspection.
The time needed to complete and file this form will vary depending on individual circumstances. The estimated average
time is:
| Recordkeeping |
18 hr., 24 min.
|
| Learning about the law or the form |
2 hr., 55 min.
|
| Preparing the form |
5 hr., 12 min.
|
| Copying, assembling, and sending the form |
32 min.
|
If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler,
we would be happy to hear from
you. You can write to the Internal Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution
Ave. NW, IR-6406,
Washington, DC 20224.
Do not send this form to this address. Instead, see
Where To File on page 3.
