Form 5330 Form 5330 Return of Excise Taxes Related to Employee Benefit Plans

Form

Return of Excise Taxes
Related to Employee Benefit Plans

5330

(Rev. March 2007)

OMB No. 1545-0575

(Under sections 4965, 4971, 4972, 4973(a)(3), 4975, 4976, 4977, 4978,
4978A, 4979, 4979A, 4980, and 4980F of the Internal Revenue Code)

Department of the Treasury
Internal Revenue Service

Filer tax year beginning

,

and ending

A Name of filer (see page 3 of the instructions)

,
B Filer’s identifying number (see instructions)
Employer identification number (EIN)

Number, street, and room or suite no. (If a P.O. box, see page 3 of the instructions)
Social security number (SSN)
City or town, state, and ZIP code

C Name and address of plan sponsor

E Plan sponsor’s EIN

F

D Name of plan

Plan year ending

G Plan number

©

H Check here if this is an amended return

Part I
1
2
3
4a
b
5a
b
6a
b
7a
b
8
9
10
11
12a
b
13a
b
c

FOR
IRS
USE
ONLY

Summary of Taxes Due

161
Section 4972 tax on nondeductible contributions to qualified plans (from line 14l)
Section 4973(a)(3) tax on excess contributions to section 403(b)(7)(A) custodial accounts
164
(from line 24)
200
Section 4976 tax on disqualified benefits for funded welfare plans (see instructions)
209
Section 4978 and 4978A tax on certain ESOP dispositions (see instructions)
The tax on line 4a is a result of the application of:
Sec. 664(g)
Sec. 1042
Sec. 4978A
Section 4979A tax on certain prohibited allocations of qualified ESOP securities (see
203
instructions)
237
Section 4965 tax on prohibited tax shelter transactions
159
Section 4975(a) tax on prohibited transactions (from line 25c)
224
Section 4975(b) tax on failure to correct prohibited transactions (see Part IV instructions)
163
Section 4971(a) tax on failure to meet minimum funding standards (see instructions)
Section 4971(b) tax on failure to correct minimum funding standards (see Part VI
225
instructions)
201
Section 4977 tax on excess fringe benefits (from line 30d)
205
Section 4979 tax on excess contributions to certain plans (see instructions)
204
Section 4980 tax on reversion of qualified plan assets to an employer (from line 34)
Section 4980F tax on failure to provide notice of significant reduction in future accruals
228
(from line 41)
226
Section 4971(f)(1) tax on failure to pay liquidity shortfall (from line 45)
Section 4971(f)(2) additional tax on failure to correct liquidity shortfall (see Part XI
227
instructions)
Total tax. Add lines 1 through 12b (see page 5 of the instructions)
Enter amount of tax paid with Form 5558 or any other tax paid prior to filing this return
Total tax due. Subtract line 13b from line 13a. Attach check or money order payable to
“United States Treasury.” Write your name, identifying number, plan number, and “Form 5330,
©
Section(s)
” on your payment

Sign
Here
Paid
Preparer’s
Use Only

1
2
3
4a
4b
5a
5b
6a
6b
7a
7b
8
9
10
11
12a
12b
13a
13b

13c

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

©

©

Your signature

Preparer’s
signature

©

Firm’s name (or yours
if self-employed) and
address

(

)

Telephone number

©

For Privacy Act and Paperwork Reduction Act Notice, see page 11 of the instructions.

Cat. No. 11870M

©
©

Date

Date

Form

5330

(Rev. 3-2007)

Form 5330 (Rev. 3-2007)

Page

2

DUE DATE: The taxes listed on this page are due by the last day of the 7th month after the end of the tax year of the filer.

Part II

Tax on Nondeductible Employer Contributions to Qualified Plans (Section 4972)

14a Total contributions for your tax year to your qualified (under section 401(a), 403(a), or 408(k), or
408(p)) plan
b Amount allowable as a deduction under section 404
c Subtract line 14b from line 14a
d Enter amount of any prior year nondeductible contributions made for years
beginning after 12/31/86
e Amount of any prior year nondeductible contributions for years beginning after
12/31/86 returned to you in this tax year or any prior tax year
f Subtract line 14e from line 14d
g Amount of line 14f carried forward and deductible in this tax year
h Subtract line 14g from line 14f
i Tentative taxable excess contributions. Add lines 14c and 14h
j Nondeductible section 4972(c)(6) or (7) contributions exempt from excise tax
k Taxable excess contributions. Subtract line 14j from line 14i
l Multiply line 14k by 10%. Enter here and on line 1

Part III

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Tax on Excess Contributions to Section 403(b)(7)(A) Custodial Accounts (Section 4973(a)(3))

15

Total amount contributed for current year less rollovers (see page 6 of the instructions)

16

Amount excludable from gross income under section 403(b) (see page 6 of the instructions)

17

Current year excess contributions. Subtract line 16 from line 15; but not less than zero

18

Prior year excess contributions not previously eliminated. If zero, go to line 22a

19
20

Contribution credit. If line 16 is more than line 15, enter the excess; otherwise, enter -0Total of all prior years’ distributions out of the account included in your gross income under section
72(e) and not previously used to reduce excess contributions

21

Adjusted prior years’ excess contributions. Subtract the total of lines 19 and 20 from line 18

22a Taxable excess contributions. Add lines 17 and 21
b Multiply line 22a by 6%
23a Enter the value of your account as of the last day of the year
b Multiply line 23a by 6%
24

Excess contributions tax. Enter the lesser of line 22b or line 23b. Enter here and on line 2

©
Form

5330

(Rev. 3-2007)

Form 5330 (Rev. 3-2007)

Page

3

DUE DATE: Section 4975 taxes are due by the last day of the 7th month after the end of the tax year of the filer.
Part IV

Tax on Prohibited Transactions (Section 4975) (see instructions)

25a Is the excise tax a result of a prohibited transaction that was (check one or more):
discrete
other than discrete (a lease or a loan)
b Complete the table below to disclose the prohibited transactions and figure the initial tax (see instructions).

(a)
Transaction
number

(b) Date
of transaction
(see page 7 of
the instructions)

(c) Description of prohibited transaction

(d) Amount involved
in prohibited
transaction
(see page 7 of the
instructions)

(e) Initial tax on prohibited
transaction (multiply each
transaction in column (c) by
the appropriate rate (see
page 7 of the instructions))

(i)

(ii)

(iii)

(iv)

(v)

(vi)

(vii)

(viii)

(ix)

(x)
25c Add amounts in column (e). Enter here and on line 6a
26

©

Have you corrected all of the prohibited transactions that you are reporting on this return? (See page 8
of the instructions)
Yes
If “Yes,” complete Part V of this form. If “No,” complete Part V of this form and see page 8 of the instructions.

Form

5330

No

(Rev. 3-2007)

Form 5330 (Rev. 3-2007)

Part V

Page

4

Schedule of Other Participating Disqualified Persons and Description of Correction (see instructions)

27 Complete the schedule of other participating disqualified persons and description of correction (see instructions)
(a)
Item no.
from Part IV

(b)
Name and address of
disqualified person

(c)
EIN or SSN

(d)
Date of correction

(e)
Description of correction

Form

5330

(Rev. 3-2007)

Form 5330 (Rev. 3-2007)

Page

5

DUE DATE: See When To File on page 2 of the instructions for taxes due under sections 4971, 4977, 4979, 4980, 4971(f), and 4980F.

Part VI
28
29

Tax on Failure To Meet Minimum Funding Standards (Section 4971(a) and 4971(b))

Accumulated funding deficiency in the plan’s minimum funding standard account (see page 9 of
the instructions)
Multiply line 28 by tax rate (see instructions on page 9 for applicable tax rates). Enter here and on
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line 7a

Part VII

Tax on Excess Fringe Benefits (Section 4977)

Yes
No
30a Did you make an election to be taxed under section 4977?
b If “Yes,” enter the calendar year in which the excess fringe benefits were paid ©
c If line 30a is “Yes,” enter the excess fringe benefits on this line (see page 9 of the instructions)
©

d Enter 30% of line 30c on this line and on line 8

Part VIII

Tax on Excess Contributions to Certain Plans (Section 4979)

31a Enter the amount of any excess contributions under a cash or deferred arrangement that is part of
a plan qualified under section 401(a), 403(a), 403(b), 408(k), 501(c)(18) or excess aggregate
contributions described in section 401(m)
©

b Multiply line 31a by 10%. Enter here and on line 9

Part IX

Tax on Reversion of Qualified Plan Assets to an Employer (Section 4980) (See page 10 of instructions)

32 Date reversion occurred © month
day
year
33a Employer reversion amount
b Excise tax rate
34 Multiply line 33a by line 33b and enter the amount here and on line 10
35

%
©

Explain below why you qualify for a rate other than 50%:

Part X

Tax on Failure to Provide Notice of Significant Reduction in Future Accruals (Section 4980F)

36
37
38
39

Enter the number of applicable individuals who were not provided ERISA section 204(h) notice
Enter the effective date of the amendment
Enter the number of days in the noncompliance period
Enter the total number of failures to provide ERISA section 204(h) notice (see page 11 of
the instructions)

40

Provide a brief description of the failure, and of the correction made, if any

41

Multiply line 39 by $100. Enter here and on line 11

Part XI

©
©
©

Tax on Failure to Pay Liquidity Shortfall (Section 4971(f)(1))
1st Quarter

2nd Quarter

3rd Quarter

4th Quarter

42

Amount of shortfall

43

Shortfall paid by the due
date
Net shortfall amount
Multiply line 44 (total column) by 10% (5% for multiemployer plans). Enter here and on line 12a

44
45

©

Total

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Form

5330

(Rev. 3-2007)