Schedule I Financial Information - Small Plan

SCHEDULE I
(Form 5500)
Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security
Administration

Financial Information -- Small Plan
This schedule is required to be filed under Section 104 of the Employee
Retirement Income Security Act of 1974 (ERISA) and section 6058(a) of the
Internal Revenue Code (the Code).

έ File as an attachment to Form 5500.

For calendar year 2007 or fiscal plan year beginning
Name of plan

,

C

and ending

B

Plan sponsor's name as shown on line 2a of Form 5500

OMB No. 1210-0110

2007
This Form is Open to
Public Inspection.

Pension Benefit Guaranty Corporation

A

Official Use Only

D

,
Three-digit
plan number έ
Employer Identification Number

Complete Schedule I if the plan covered fewer than 100 participants as of the beginning of the plan year. You may also complete Schedule I if you
are filing as a small plan under the 80-120 participant rule (see instructions). Complete Schedule H if reporting as a large plan or DFE.

Part I

Small Plan Financial Information

Report below the current value of assets and liabilities, income, expenses, transfers and changes in net assets during the plan year. Combine the
value of plan assets held in more than one trust. Do not enter the value of the portion of an insurance contract that guarantees during this plan year to
pay a specific dollar benefit at a future date. Include all income and expenses of the plan including any trust(s) or separately maintained fund(s) and
any payments/receipts to/from insurance carriers. Round off amounts to the nearest dollar.

1

Plan Assets and Liabilities:
(a) Beginning of Year
(b) End of Year
Total plan assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1a
Total plan liabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
Net plan assets (subtract line 1b from line 1a) . . . . . . . . . . . . . . . . . . . .
1c
2 Income, Expenses, and Transfers for this Plan Year:
(a) Amount
(b) Total
a Contributions received or receivable
(1) Employers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a(1)
(2) Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a(2)
(3) Others (including rollovers) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a(3)
b Noncash contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2b
c Other income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2c
d Total income (add lines 2a(1), 2a(2), 2a(3), 2b, and 2c) . . . . . . . . . . . . .
2d
e Benefits paid (including direct rollovers) . . . . . . . . . . . . . . . . . . . . . . . . .
2e
f Corrective distributions (see instructions) . . . . . . . . . . . . . . . . . . . . . . . .
2f
g Certain deemed distributions of participant loans (see instructions) . . . .
2g
h Other expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2h
i Total expenses (add lines 2e, 2f, 2g, and 2h) . . . . . . . . . . . . . . . . . . . . .
2i
j Net income (loss) (subtract line 2i from line 2d) . . . . . . . . . . . . . . . . . . .
2j
k Transfers to (from) the plan (see instructions) . . . . . . . . . . . . . . . . . . . . .
2k
3 Specific Assets: If the plan held assets at anytime during the plan year in any of the following categories, check "Yes" and enter the current
value of any assets remaining in the plan as of the end of the plan year. Allocate the value of the plan's interest in a commingled trust containing
the assets of more than one plan on a line-by-line basis unless the trust meets one of the specific exceptions described in the instructions.
Yes No
Amount
a Partnership/joint venture interests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3a
b Employer real property . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3b
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500.
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3c Real estate (other than employer real property) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d Employer securities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e Participant loans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
f Loans (other than to participants) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
g Tangible personal property . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Part II
Transactions During Plan Year
4 During the plan year:
a Did the employer fail to transmit to the plan any participant contributions within the time

b

c
d
e
f
g
h
i
j
k

5a
5b

Yes

No

Amount

Yes

No

Amount

3c
3d
3e
3f
3g

period described in 29 CFR 2510.3-102? (See instructions and DOL's Voluntary Fiduciary
Correction Program.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4a
Were any loans by the plan or fixed income obligations due the plan in default as of the
close of the plan year or classified during the year as uncollectible? Disregard participant
loans secured by the participant's account balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4b
Were any leases to which the plan was a party in default or classified during the year as
uncollectible? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4c
Were there any nonexempt transactions with any party-in-interest? (Do not include
transactions reported on line 4a.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4d
Was the plan covered by a fidelity bond? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4e
Did the plan have a loss, whether or not reimbursed by the plan's fidelity bond, that was
caused by fraud or dishonesty? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4f
Did the plan hold any assets whose current value was neither readily determinable on an
established market nor set by an independent third party appraiser? . . . . . . . . . . . . . . . . . . . 4g
Did the plan receive any noncash contributions whose value was neither readily
determinable on an established market nor set by an independent third party appraiser? . . . . 4h
Did the plan at any time hold 20% or more of its assets in any single security, debt,
mortgage, parcel of real estate, or partnership/joint venture interest? . . . . . . . . . . . . . . . . . . . 4i
Were all the plan assets either distributed to participants or beneficiaries, transferred to
another plan, or brought under the control of the PBGC? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4j
Are you claiming a waiver of the annual examination and report of an independent qualified
public accountant (IQPA) under 29 CFR 2520.104-46? If no, attach an IQPA's report or
2520.104-50 statement. (See instructions on waiver eligibility and conditions.) . . . . . . . . . . . . . 4k
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year? If yes, enter the amount of any plan assets that
reverted to the employer this year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
Amount
If during this plan year, any assets or liabilities were transferred from this plan to another plan(s), identify the plan(s) to which assets or liabilities
were transferred. (See instructions.)
5b(1) Name of plan(s)
5b(2) EIN(s)
5b(3) PN(s)

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