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Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security
Administration
Official Use Only
Annual Return/Report of Employee Benefit Plan
OMB Nos. 1210-0110 / 1210-0089
This form is required to be filed under sections 104 and 4065 of the Employee
Retirement Income Security Act of 1974 (ERISA) and sections 6047(e),
6057(b), and 6058(a) of the Internal Revenue Code (the Code).
2007
Complete all entries in accordance with
the instructions to the Form 5500.
This Form is Open to
Public Inspection.
▼
Form
Pension Benefit
Guaranty Corporation
Part I
Annual Report Identification Information
For the calendar plan year 2007
or fiscal plan year beginning
MM / D D / Y Y Y Y
A
(1)
a multiemployer plan;
(3)
a multiple-employer plan; or
(2)
a single-employer plan (other than
a multiple-employer plan);
(4)
a DFE (specify) .....................
(1)
the first return/report filed for the plan;
(3)
the final return/report filed for the plan;
(2)
an amended return/report;
(4)
This return/report is for:
C
a short plan year return/report
(less than 12 months).
If the plan is a collectively-bargained plan, check here ..............................................................................................................................
▼
This return/report is:
D
If filing under an extension of time or the DFVC program, check box and attach required information. (see instructions) ....................
▼
B
MM / D D / Y Y Y Y
and ending
Basic Plan Information -- enter all requested information.
1a
Name of plan
1b
Three-digit plan number (PN)
▼
Part II
1c
Effective date of plan
MM / D D / Y Y Y Y
Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established.
SIGN HERE
▼
Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return/report, including accompanying
schedules, statements and attachments, as well as the electronic version of this return/report if it is being filed electronically, and to the best of my
knowledge and belief, it is true, correct and complete.
Signature of plan administrator
Date
MM / D D / Y Y Y Y
Date
MM / D D / Y Y Y Y
Type or print name of individual signing as plan administrator
a
SIGN HERE
▼
Signature of employer/plan sponsor/DFE
Type or print name of individual signing as employer, plan sponsor or DFE
b
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500.
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Cat. No. 13500F
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Form 5500 (2007)
Form 5500 (2007)
Page
2
Official Use Only
2a
1)
Plan sponsor's name and address (employer, if for single-employer plan) (Address should include room or suite no.)
Name
Name Continued
2)
c / o
3)
Street
4)
City
5)
State
6)
Foreign Routing Code
7)
Foreign Country
8)
D/B/A
9)
Location Address if different than Street
2b Employer Identification Number (EIN)
Zip Code
2c Sponsor's telephone
number
2d Business code
(see instructions)
Location Address City/State/Zip if different than 4) or 5)
3a
1)
Plan administrator's name and address (If same as plan sponsor, enter "Same")
Name
Name Continued
2)
c / o
3)
Street
4)
City
5)
State
6)
Foreign Routing Code
7)
Foreign Country
4
3b Administrator's EIN
Zip Code
3c Administrator's telephone number
a
If the name and/or EIN of the plan sponsor has changed since the last return/report filed for this plan, enter the name, EIN and the plan
number from the last return/report below:
Sponsor's name
b
EIN
c PN
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Form 5500 (2007)
Page
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Official Use Only
5
Preparer information (optional)
a
1)
Name (including firm name, if applicable) and address
Name
Name Continued
2)
Street
3)
City
4)
State
5)
Foreign Routing Code
6)
Foreign Country
b
EIN
c
Telephone number
Zip Code
▲
▲
a Active participants .................................................................................................................................................
▲
▲
b Retired or separated participants receiving benefits ...........................................................................................
▲
▲
c Other retired or separated participants entitled to future benefits .....................................................................
▲
▲
d Subtotal. Add lines 7a, 7b, and 7c ......................................................................................................................
▲
▲
e Deceased participants whose beneficiaries are receiving or are entitled to receive benefits ..........................
▲
▲
f Total. Add lines 7d and 7e ...................................................................................................................................
▲
▲
g Number of participants with account balances as of the end of the plan year (only defined
contribution plans complete this item) .................................................................................................................
▲
▲
h Number of participants that terminated employment during the plan year with accrued benefits that
were less than 100% vested ................................................................................................................................
▲
▲
i If any participant(s) separated from service with a deferred vested benefit, enter the number of
separated participants required to be reported on a Schedule SSA (Form 5500) ...........................................
▲
▲
6
Total number of participants at the beginning of the plan year ..........................................................................
7
Number of participants as of the end of the plan year (welfare plans complete only lines 7a, 7b, 7c, and 7d)
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0
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Form 5500 (2007)
Page
4
Official Use Only
8
Benefits provided under the plan (complete 8a and 8b, as applicable)
a
Pension benefits (check this box if the plan provides pension benefits and enter below the applicable pension feature codes from the List
of Plan Characteristics Codes printed in the instructions):
b
Welfare benefits
(check this box if the plan provides welfare benefits and enter below the applicable welfare feature codes from the List
of Plan Characteristics Codes printed in the instructions):
9a Plan funding arrangement (check all that apply)
10
9b Plan benefit arrangement (check all that apply)
(1)
Insurance
(1)
Insurance
(2)
Code section 412(i) insurance contracts
(2)
Code section 412(i) insurance contracts
(3)
Trust
(3)
Trust
(4)
General assets of the sponsor
(4)
General assets of the sponsor
Schedules attached (Check all applicable boxes and, where indicated, enter the number attached. See instructions.)
b Financial Schedules
a Pension Benefit Schedules
1)
R
(Retirement Plan Information)
1)
H
(Financial Information)
2)
B
(Actuarial Information)
2)
I
(Financial Information--Small Plan)
3)
E
(ESOP Annual Information)
3)
A
(Insurance Information)
4)
SSA (Separated Vested
Participant Information)
4)
C
(Service Provider Information)
5)
D
(DFE/Participating Plan
Information)
6)
G
(Financial Transaction Schedules)
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v10.0
Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security Administration
Pension Benefit Guaranty Corporation
For the calendar plan year 2007
or fiscal plan year beginning
OMB No. 1210-0110
2007
This schedule is required to be filed under sections 104 and 4065 of the
Employee Retirement Income Security Act of 1974 (ERISA) and section 6058(a)
of the Internal Revenue Code (the Code).
This Form is Open to
Public Inspection.
File as an Attachment to Form 5500.
MM / D D / Y Y Y Y
MM / D D / Y Y Y Y
and ending
Name of plan
C
Plan sponsor's name as shown on line 2a of Form 5500
Part I
B
Three-digit
plan number
D
Employer Identification Number
▼
A
Official Use Only
Retirement Plan Information
▼
SCHEDULE R
(Form 5500)
Distributions
All references to distributions relate only to payments of benefits during the plan year.
1
2
Total value of distributions paid in property other than in cash
or the forms of property specified in the instructions ................................................
Enter the EIN(s) of payor(s) who paid benefits on behalf of the plan to
participants or beneficiaries during the year (if more than two, enter
EINs of the two payors who paid the greatest dollar amounts of benefits).
}
▲
▲
▲
.00
...............................
Profit-sharing plans, ESOPs, and stock bonus plans, skip line 3.
Number of participants (living or deceased) whose benefits were distributed in a single
sum, during the plan year ..................................................................................................................................
Part II
4
5
Funding Information (If the plan is not subject to the minimum funding requirements of section 412 of the
Internal Revenue Code or ERISA section 302, skip this Part)
Is the plan administrator making an election under Code section 412(c)(8) or
ERISA section 302(c)(8)? ...............................................................................................
If the plan is a defined benefit plan, go to line 7.
Yes
If a waiver of the minimum funding standard for a prior year is being amortized in this
plan year, see instructions, and enter the date of the ruling letter granting the waiver ................
▼
3
No
N/A
MM / D D / Y Y Y Y
If you completed line 5, complete lines 3, 9, and 10 of Schedule B and
do not complete the remainder of this schedule.
6a Enter the minimum required contribution for this plan year .......................................
▲
▲
▲
.00
b Enter the amount contributed by the employer to the plan for this plan year ..........
▲
▲
▲
.00
c Subtract the amount in line 6b from the amount in line 6a. Enter the result
(enter a minus sign to the left of a negative amount) ...............................................
▲
▲
▲
.00
If you completed line 6c, skip lines 7 and 8 and complete line 9.
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Cat. No. 24419B Schedule R (Form 5500) 2007
2
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Schedule R (Form 5500) 2007
Page
2
Official Use Only
7
If a change in actuarial cost method was made for this plan year pursuant to a
revenue procedure providing automatic approval for the change or a class ruling
letter, does the plan sponsor or plan administrator agree with the change? ...................
Part III
8
9
No
N/A
Increase
Decrease
No
Amendments
If this is a defined benefit pension plan, were any amendments adopted during
this plan year that increased or decreased the value of benefits? If yes, check the
appropriate box(es). If no, check the "No" box. (See instructions.) .................................
Part IV
Yes
Coverage (See instructions.)
Check the box for the test this plan used to satisfy the coverage requirements:
the ratio percentage test
average benefit test
2
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Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security Administration
Financial Information -- Small Plan
Pension Benefit Guaranty Corporation
For the calendar plan year 2007
or fiscal plan year beginning
OMB No. 1210-0110
2007
This Form is Open to
Public Inspection.
File as an attachment to Form 5500.
MM / D D / Y Y Y Y
and ending
MM / D D / Y Y Y Y
Name of plan
C
Plan sponsor's name as shown on line 2a of Form 5500
B
Three-digit
plan number
D
Employer Identification Number
▼
A
Official Use Only
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).
▼
SCHEDULE I
(Form 5500)
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
2
(a) Beginning of Year
Plan Assets and Liabilities:
(b) End of Year
a Total plan assets ........
▲
▲
▲
.00
▲
▲
▲
.00
b Total plan liabilities .....
▲
▲
▲
.00
▲
▲
▲
.00
c Net plan assets
(subtract line 1b
from line 1a) ...............
▲
▲
▲
.00
▲
▲
▲
.00
▲
.00
(a) Amount
Income, Expenses, and Transfers for this Plan Year:
a Contributions received or receivable
(1) Employers .........................................................
▲
▲
▲
.00
(2)
Participants ......................................................
▲
▲
▲
.00
(3)
Others (including rollovers) .............................
▲
▲
▲
.00
b Noncash contributions .............................................
▲
▲
▲
.00
c Other income ............................................................
▲
▲
▲
.00
(b) Total
▲
d Total income (add lines 2a(1), 2a(2), 2a(3), 2b, and 2c) ...........................................
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Cat. No. 24414Y
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Schedule I (Form 5500) 2007
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Schedule I (Form 5500) 2007
Page
2
Official Use Only
(a) Amount
2e Benefits paid (including direct rollovers) .................
▲
▲
▲
.00
f Corrective distributions (see instructions) ...............
▲
▲
▲
.00
g Certain deemed distributions of participant loans
(see instructions) ......................................................
▲
▲
▲
.00
h Other expenses ........................................................
▲
▲
▲
.00
(b) Total
i Total expenses (add lines 2e, 2f, 2g, and 2h) ...............................................................
▲
▲
▲
.00
j Net income (loss) (subtract line 2i from line 2d) ...........................................................
▲
▲
▲
.00
k Transfers to (from) the plan (see instructions) ..............................................................
▲
▲
▲
.00
3
Specific Assets: If the plan held assets at any time 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 .......................................................
▲
▲
▲
.00
b Employer real property ........................................................................
▲
▲
▲
.00
c Real estate (other than employer real property) ................................
▲
▲
▲
.00
d Employer securities ..............................................................................
▲
▲
▲
.00
e Participant loans ..................................................................................
▲
▲
▲
.00
f Loans (other than to participants) .......................................................
▲
▲
▲
.00
g Tangible personal property ..................................................................
▲
▲
▲
.00
Part II
4
Transactions During Plan Year
During the plan year:
Yes
No
Amount
a Did the employer fail to transmit to the plan any
participant contributions within the time period
described in 29 CFR 2510.3-102? (See instructions
and DOL's Voluntary Fiduciary Correction Program.) ........................
▲
▲
▲
.00
b 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 ........................................................
▲
▲
▲
.00
c Were any leases to which the plan was a party in default or
classified during the year as uncollectible? .......................................
▲
▲
▲
.00
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Schedule I (Form 5500) 2007
Page
3
Official Use Only
Yes
No
Amount
Were there any nonexempt transactions with any party-in-interest?
(Do not include transactions reported on line 4a.) .............................
▲
▲
▲
.00
e
Was the plan covered by a fidelity bond? ..........................................
▲
▲
▲
.00
f
Did the plan have a loss, whether or not reimbursed by the plan's
fidelity bond, that was caused by fraud or dishonesty? ....................
▲
▲
▲
.00
g 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? .....................................................
▲
▲
▲
.00
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? ................................................
▲
▲
▲
.00
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? .......................................................
▲
▲
▲
.00
▲
.00
4d
h
i
j Were all the plan assets either distributed to participants or
beneficiaries, transferred to another plan, or brought under the
control of the PBGC? ..........................................................................
k
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.) ....
5a
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 ..........................
5b
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
5b(2) EIN
5b(3) PN
5b(2) EIN
5b(3) PN
5b(2) EIN
5b(3) PN
5b(1) Name of plan
5b(1) Name of plan
1
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v10.0
Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security Administration
Financial Information
Pension Benefit Guaranty Corporation
For the calendar plan year 2007
or fiscal plan year beginning
C
OMB No. 1210-0110
2007
This Form is Open to
Public Inspection.
File as an attachment to Form 5500.
MM / D D / Y Y Y Y
and ending
MM / D D / Y Y Y Y
Name of plan
Plan sponsor's name as shown on line 2a of Form 5500
Part I
B
Three-digit
plan number
D
Employer Identification Number
▼
A
Official Use Only
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).
▼
SCHEDULE H
(Form 5500)
Asset and Liability Statement
1 Current value of plan assets and liabilities at the beginning and end of the plan year. Combine the value of plan assets held in more than one
trust. Report the value of the plan's interest in a commingled fund containing the assets of more than one plan on a line-by-line basis unless
the value is reportable on lines 1c(9) through 1c(14). Do not enter the value of that portion of an insurance contract which guarantees, during
this plan year, to pay a specific dollar benefit at a future date. Round off amounts to the nearest dollar. MTIAs, CCTs, PSAs, and 103-12 IEs
do not complete lines 1b(1), 1b(2), 1c(8), 1g, 1h, and 1i. CCTs, PSAs, and 103-12 IEs also do not complete lines 1d and 1e. See instructions.
Assets
(a) Beginning of Year
(b) End of Year
a Total noninterestbearing cash ...............
▲
▲
▲
.00
▲
▲
▲
.00
b Receivables (less allowance for
doubtful accounts):
(1) Employer
contributions .......
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
.00
▲
▲
▲
.00
▲
▲
.00
▲
▲
▲
.00
▲
▲
.00
▲
▲
▲
.00
(2)
Participant
contributions .......
(3) Other ...................
▲
c General investments:
(1) Interest-bearing cash (including money market
accounts and
certificates
of deposit) ..........
▲
(2)
(3)
(4)
(5)
U.S. Government
securities ............
▲
Corporate debt instruments (other than
employer securities):
(A) Preferred ......
▲
▲
▲
.00
▲
▲
▲
.00
(B) All other .......
▲
▲
▲
.00
▲
▲
▲
.00
(A) Preferred ......
▲
▲
▲
.00
▲
▲
▲
.00
(B) Common ......
▲
▲
▲
.00
▲
▲
▲
.00
Partnership/joint
venture interests.
▲
▲
▲
.00
▲
▲
▲
.00
Corporate stocks (other than
employer securities):
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Cat. No. 24420C Schedule H (Form 5500) 2007
1
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Schedule H (Form 5500) 2007
Page
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Official Use Only
(a) Beginning of Year
1c (6)
(b) End of Year
Real estate (other
than employer
real property) ......
▲
▲
▲
.00
▲
▲
▲
.00
Loans (other than
to participants) ...
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
(13) Value of interest
in registered
investment
companies (e.g.,
mutual funds) .....
▲
▲
▲
.00
▲
▲
▲
.00
(14) Value of funds
held in insurance
company general
account (unallocated contracts) .
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
g Benefit claims payable
▲
▲
▲
.00
▲
▲
▲
.00
h Operating payables ....
▲
▲
▲
.00
▲
▲
▲
.00
i Acquisition
indebtedness ..............
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
(7)
(8)
(9)
Participant loans.
Value of interest
in common/
collective trusts ..
(10) Value of interest
in pooled separate accounts .....
(11) Value of interest
in master trust
investment
accounts .............
(12) Value of interest
in 103-12 investment entities .......
(15) Other ...................
d Employer-related
investments:
(1) Employer
securities ............
(2)
Employer real
property ..............
e Buildings and other
property used in
plan operation ............
f Total assets
(add all amounts in
lines 1a through 1e) ...
Liabilities
j Other liabilities ............
k Total liabilities
(add all amounts in
lines 1g through 1j) ....
Net Assets
l Net assets (subtract
line 1k from line 1f) ....
1
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v10.0
Schedule H (Form 5500) 2007
Page
3
Official Use Only
Part II
2
Income and Expenses Statement
Plan income, expenses, and changes in net assets for the year. 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. MTIAs, CCTs,
PSAs, and 103-12 IEs do not complete lines 2a, 2b(1)(E), 2e, 2f, and 2g.
Income
(a) Amount
a Contributions:
(1) Received or receivable in cash from:
(A) Employers ..................................................
▲
▲
▲
.00
(B) Participants ................................................
▲
▲
▲
.00
(C) Others (including rollovers) .......................
▲
▲
▲
.00
(2) Noncash contributions .......................................
▲
▲
▲
.00
(b) Total
▲
(3) Total contributions. Add lines 2a(1)(A), (B), (C), and line 2a(2) ..........................
b Earnings on investments: (1) Interest:
(A) Interest-bearing cash
(including money market accounts
and certificates of deposit) .......................
▲
▲
▲
.00
(B) U.S. Government securities ......................
▲
▲
▲
.00
(C) Corporate debt instruments ......................
▲
▲
▲
.00
(D) Loans (other than to participants) ............
▲
▲
▲
.00
(E) Participant loans ........................................
▲
▲
▲
.00
(F) Other ..........................................................
▲
▲
▲
.00
▲
(G) Total interest. Add lines 2b(1)(A) through (F) ..............................................
(2) Dividends:
(A) Preferred stock ..........................................
▲
▲
▲
.00
(B) Common stock ..........................................
▲
▲
▲
.00
▲
▲
.00
▲
▲
.00
(C) Total dividends. Add lines 2b(2)(A) and (B) ................................................
▲
▲
▲
.00
(3) Rents ......................................................................................................................
(4) Net gain (loss) on sale of assets:
(A) Aggregate proceeds ..................................
▲
▲
▲
▲
.00
▲
▲
.00
(B) Aggregate carrying amount
(see instructions) .............................................
▲
▲
▲
.00
▲
▲
.00
▲
(C) Subtract line 2b(4)(B) from line 2b(4)(A) and enter result .........................
1
7
0
7
0
0
0
3
0
I
v10.0
Schedule H (Form 5500) 2007
Page
4
Official Use Only
2b (5)
Unrealized appreciation (depreciation)
of assets:
(a) Amount
(A) Real estate ................................................
▲
▲
▲
.00
(B) Other ..........................................................
▲
▲
▲
.00
(b) Total
(C) Total unrealized appreciation of assets. Add lines 2b(5)(A) and (B) .........
▲
▲
▲
.00
(6)
Net investment gain (loss) from common/collective trusts ................................
▲
▲
▲
.00
(7)
Net investment gain (loss) from pooled separate accounts ..............................
▲
▲
▲
.00
(8)
Net investment gain (loss) from master trust investment accounts ..................
▲
▲
▲
.00
(9)
Net investment gain (loss) from 103-12 investment entities .............................
▲
▲
▲
.00
(10) Net investment gain (loss) from registered investment companies
(e.g., mutual funds) ..............................................................................................
▲
▲
▲
.00
c Other income ................................................................................................................
▲
▲
▲
.00
d Total income. Add all income amounts in column (b) and enter total ......................
▲
▲
▲
.00
Expenses
e Benefit payment and payments to provide benefits:
(1)
Directly to participants or beneficiaries,
including direct rollovers ..................................
▲
▲
▲
.00
To insurance carriers for
the provision of benefits ..................................
▲
▲
▲
.00
(3)
Other .................................................................
▲
▲
▲
.00
(4)
Total benefit payments. Add lines 2e(1) through (3) ..........................................
▲
▲
▲
.00
f Corrective distributions (see instructions) ...................................................................
▲
▲
▲
.00
g Certain deemed distributions of participant loans (see instructions) ........................
▲
▲
▲
.00
h Interest expense ...........................................................................................................
i Administrative expenses:
(1) Professional fees .............................................
▲
▲
▲
▲
.00
(2)
▲
▲
.00
(2)
Contract administrator fees .............................
▲
▲
▲
.00
(3)
Investment advisory and management fees ...
▲
▲
▲
.00
(4)
Other .................................................................
▲
▲
▲
.00
(5)
Total administrative expenses. Add lines 2i(1) through (4) ................................
▲
▲
▲
.00
j Total expenses. Add all expense amounts in column (b) and enter total ................
▲
▲
▲
.00
1
7
0
7
0
0
0
4
0
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v10.0
Schedule H (Form 5500) 2007
Page
5
Official Use Only
(b) Total
Net Income and Reconciliation
2k Net income (loss) (subtract line 2j from line 2d) ........................................................
l Transfers of assets
(1) To this plan ...........................................................................................................
(2)
From this plan ......................................................................................................
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
Accountant's Opinion
Part III
3
▲
Complete lines 3a through 3c if the opinion of an independent qualified public accountant is attached to this Form 5500.
Complete line 3d if an opinion is not attached.
a The attached opinion of an independent qualified public accountant for this plan is (see instructions):
(1)
Unqualified
(2)
Qualified
(3)
Disclaimer
(4)
Adverse
b Did the accountant perform a limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)? .................
Yes
No
c Enter the name and EIN of the accountant (or accounting firm):
▼
Name
EIN
d The opinion of an independent qualified public accountant is not attached because:
(1)
Part IV
4
this form is filed for a CCT, PSA or MTIA.
(2)
it will be attached to the next Form 5500 pursuant to 29 CFR 2520.104-50.
Transactions During Plan Year
CCTs and PSAs do not complete Part IV.
103-12 IEs also do not complete 4j.
MTIAs, 103-12 IEs, and GIAs do not complete 4a, 4e, 4f, 4g, 4h, 4k, or 5.
During the plan year:
Yes
No
Amount
a Did the employer fail to transmit to the plan any
participant contributions within the time period
described in 29 CFR 2510.3-102? (See instructions
and DOL's Voluntary Fiduciary Correction Program.) ......................
▲
▲
▲
.00
b 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. (Attach
Schedule G (Form 5500) Part I if "Yes" is checked) ........................
▲
▲
▲
.00
Were any leases to which the plan was a party in default or
classified during the year as uncollectible? (Attach Schedule G
(Form 5500) Part II if "Yes" is checked) ...........................................
▲
▲
▲
.00
Were there any nonexempt transactions with any party-in-interest?
(Do not include transactions reported on line 4a. Attach
Schedule G (Form 5500) Part III if "Yes" is checked on line 4d.) ...
▲
▲
▲
.00
Was this plan covered by a fidelity bond? ........................................
▲
▲
▲
.00
c
d
e
1
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0
7
0
0
0
5
0
K
v10.0
Schedule H (Form 5500) 2007
Page
6
Official Use Only
Yes
No
Amount
4 f Did the plan have a loss, whether or not reimbursed by the
plan's fidelity bond, that was caused by fraud or dishonesty? ......
▲
▲
▲
.00
g 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? .................................................
▲
▲
▲
.00
h 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? ............................................
▲
▲
▲
.00
▲
▲
▲
.00
i Did the plan have assets held for investment? (Attach schedule(s)
of assets if "Yes" is checked, and see instructions for format
requirements) ...................................................................................
j Were any plan transactions or series of transactions in excess
of 5% of the current value of plan assets? (Attach schedule of
transactions if "Yes" is checked and see instructions for format
requirements) ...................................................................................
k Were all the plan assets either distributed to participants or
beneficiaries, transferred to another plan, or brought under the
control of the PBGC? ......................................................................
5a 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 ......................
5b 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
5b(2) EIN
5b(3) PN
5b(2) EIN
5b(3) PN
5b(2) EIN
5b(3) PN
5b(2) EIN
5b(3) PN
5b(1) Name of plan
5b(1) Name of plan
5b(1) Name of plan
1
7
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7
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0
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0
L
v10.0
SCHEDULE G
(Form 5500)
Department of the Treasury
Internal Revenue Service
OMB No. 1210-0110
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).
2007
▼
Department of Labor
Employee Benefits Security
Administration
For calendar plan year 2007
or fiscal plan year beginning
C
MM / D D / Y Y Y Y
and ending
MM / D D / Y Y Y Y
Name of plan
Name of plan sponsor as shown on line 2a of Form 5500
Part I
(a)
This Form is Open to
Public Inspection.
File as an attachment to Form 5500.
B
Three-digit
plan number
D
Employer Identification Number
▼
A
Official Use Only
Financial Transaction Schedules
Schedule of Loans or Fixed Income Obligations in Default or Classified as Uncollectible
Party-in-interest
(b) Identity and address of obligor
Name
Street
City
(c)
State
Original amount of loan
Amount
received during
reporting year
▲
▲
▲
.00
(d) Principal
▲
▲
▲
.00
(e) Interest
▲
▲
▲
.00
Zip Code
(f) Unpaid balance at end of year
▲
▲
▲
.00
(g) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan
and the terms of the renegotiation, and other material items
Amt. overdue
(h) Principal
▲
▲
.00
▲
Amt. overdue
(i) Interest
▲
▲
▲
.00
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Cat. No. 14739A Schedule G (Form 5500) 2007
2
3
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1
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v10.0
Schedule G (Form 5500) 2007
Page
2
Official Use Only
(a)
Party-in-interest
(b) Identity and address of obligor
Name
Street
City
(c)
State
▲
▲
▲
.00
(d) Principal
▲
▲
▲
.00
(e) Interest
▲
▲
▲
.00
Original amount of loan
Amount
received during
reporting year
Zip Code
(f) Unpaid balance at end of year
▲
▲
▲
.00
(g) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan
and the terms of the renegotiation, and other material items
Amt. overdue
(h) Principal
(a)
▲
▲
.00
▲
Amt. overdue
(i) Interest
▲
▲
▲
.00
▲
.00
Party-in-interest
(b) Identity and address of obligor
Name
Street
City
(c)
State
Original amount of loan
Amount
received during
reporting year
▲
▲
▲
.00
(d) Principal
▲
▲
▲
.00
(e) Interest
▲
▲
▲
.00
Zip Code
(f) Unpaid balance at end of year
▲
▲
(g) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan
and the terms of the renegotiation, and other material items
Amt. overdue
(h) Principal
▲
▲
.00
▲
2
3
0
7
0
Amt. overdue
(i) Interest
0
0
2
▲
0
▲
▲
E
v10.0
.00
Schedule G (Form 5500) 2007
Page
3
Official Use Only
Part II
Schedule of Leases in Default or Classified as Uncollectible
(a) Party-in-interest
(b) Identity of lessor/lessee
(c)
Relationship to plan, employer, employee organization or other party-in-interest
(d) Terms and description (type of property, location and date it was purchased, terms regarding rent, taxes, insurance, repairs, expenses, renewal
options, date property was leased)
(e)
Original cost
(h) Expenses paid during the plan year
▲
(f)
▲
.00
▲
Current value at time of lease
▲
▲
(i)
(g) Gross rental receipts during the plan year
▲
▲
(j)
▲
.00
▲
▲
▲
.00
▲
▲
.00
Amount in arrears
.00
▲
▲
Net receipts
.00
▲
▲
▲
(a) Party-in-interest
(b) Identity of lessor/lessee
(c)
Relationship to plan, employer, employee organization or other party-in-interest
(d) Terms and description (type of property, location and date it was purchased, terms regarding rent, taxes, insurance, repairs, expenses, renewal
options, date property was leased)
(e)
Original cost
(h) Expenses paid during the plan year
▲
(f)
▲
.00
▲
Current value at time of lease
▲
▲
(i)
(g) Gross rental receipts during the plan year
▲
▲
(j)
2
3
0
▲
.00
▲
▲
▲
.00
▲
▲
.00
Amount in arrears
.00
▲
▲
Net receipts
.00
▲
▲
▲
7
0
0
0
3
0
F
v10.0
Schedule G (Form 5500) 2007
Page
4
Official Use Only
Part III
Nonexempt Transactions
If a nonexempt prohibited transaction occurred with respect to a disqualified person, file Form 5330 with the IRS to pay
the excise tax on the transaction.
(a)
Identity of party involved
(b) Relationship to plan, employer, or other party-in-interest
(c)
Description of transactions including maturity date, rate of interest, collateral, par or maturity value
(h) Cost of asset
(d) Purchase price
▲
(e)
.00
▲
▲
(i)
Selling price
▲
(f)
▲
▲
▲
(j)
Lease rental
▲
▲
.00
▲
▲
.00
▲
▲
.00
▲
▲
.00
▲
▲
.00
▲
.00
Net gain or (loss) on each transaction
.00
▲
▲
Current value of asset
.00
▲
▲
▲
(g) Expenses incurred in connection with transaction
▲
(a)
▲
.00
▲
Identity of party involved
(b) Relationship to plan, employer, or other party-in-interest
(c)
Description of transactions including maturity date, rate of interest, collateral, par or maturity value
(h) Cost of asset
(d) Purchase price
▲
(e)
.00
▲
▲
(i)
Selling price
▲
(f)
▲
▲
.00
▲
▲
(j)
Lease rental
▲
▲
Current value of asset
Net gain or (loss) on each transaction
.00
▲
▲
▲
(g) Expenses incurred in connection with transaction
▲
▲
.00
▲
2
3
0
7
0
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0
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v10.0
5500-EZ
▼
Department of the Treasury
Internal Revenue Service
Part I
B
OMB No. 1545-0956
This form is required to be filed under
section 6058(a) of the Internal Revenue Code.
2007
Complete all entries in accordance with
the instructions to the Form 5500-EZ.
This Form is Open to
Public Inspection.
Annual Return Identification Information
For the calendar plan year 2007
or fiscal plan year beginning
A
Official Use Only
This return is:
MM / D D / Y Y Y Y
and ending
MM / D D / Y Y Y Y
(1)
the first return filed for the plan;
(3)
the final return filed for the plan;
(2)
an amended return;
(4)
a short plan year return
(less than 12 months).
If filing under an extension of time, check box and attach required information. (see instructions) .............................................................
Part II
▼
Form
Annual Return of One-Participant
(Owners and Their Spouses) Retirement Plan
Basic Plan Information -- enter all requested information.
1a Name of plan
1c Date plan first
became effective
▼
1b Three-digit plan number (PN)
MM / D D / Y Y Y Y
Caution: A penalty for the late or incomplete filing of this return will be assessed unless reasonable cause is established.
Under penalties of perjury, I declare that I have examined this return (including, if applicable, any related Schedule B signed by an enrolled actuary, which I will retain)
and to the best of my knowledge and belief, it is true, correct, and complete.
SIGN HERE
▼
Signature of employer or plan administrator
Date
MM / D D / Y Y Y Y
Type or print name of individual signing as employer or plan administrator
Cat. No. 63263R
For Paperwork Reduction Act Notice, see the instructions for Form 5500-EZ.
0
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1
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Form 5500-EZ (2007)
B
v10.0
Form 5500-EZ (2007)
Page
2
Official Use Only
2a
1)
Employer's name and address (Address should include room or suite no.)
Name
Name Continued
2)
c / o
3)
Street
4)
City
5)
State
6)
Foreign Routing Code
7)
Foreign Country
8)
D/B/A
9)
Location Address if different than Street
2b Employer Identification Number (EIN)
(Do not enter your Social Security Number)
Zip Code
2c Employer's telephone
number
2d Business code
(see instructions)
Location Address if different than 4) or 5)
3a
1)
Plan administrator's name and address (If same as employer, enter "Same")
Name
Name Continued
2)
c / o
3)
Street
4)
City
5)
State
6)
Foreign Routing Code
7)
Foreign Country
4
3b Administrator's EIN
Zip Code
3c Administrator's telephone number
a
If the name and/or EIN of the employer has changed since the last return filed for this plan, enter the name, EIN and the plan number from the
last return below:
Employer's name
b
EIN
c PN
0
3
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7
0
0
0
2
0
C
v10.0
Form 5500-EZ (2007)
Page
3
Official Use Only
5
Preparer information (optional)
a
Name (including firm name, if applicable) and address
Name
1)
Name Continued
2)
Street
3)
City
4)
State
5)
Foreign Routing Code
6)
Foreign Country
EIN
c
Telephone number
Zip Code
Type of plan:
(a)
Defined benefit pension plan (other than a plan
described in Code section 412(i))
(d)
Profit-sharing plan
(b)
Defined benefit pension plan described in
Code section 412(i)
(e)
Stock bonus plan
(c)
Money purchase pension plan
(f)
ESOP plan
7a If this is a master/prototype, or regional prototype plan, enter the opinion/notification letter number ........
b Check if this plan covers:
(2)
(3)
Partner(s) in a partnership, or
100% owner of corporation
8a Enter the number of qualified pension benefit plans maintained by the employer (including this plan) ......................................
▼
Self-employed individuals,
b Check here if you have more than one plan and the total assets of all plans are more than $100,000 (see instructions) .......
▼
(1)
▼
6
b
Number
9
Enter the number of participants in each category listed below:
a Under age 59 1/2 at the end of the plan year ...................................................................................................................................
b Age 59 1/2 or older at the end of the plan year, but under age 70 1/2 at the beginning of the plan year ....................................
c Age 70 1/2 or older at the beginning of the plan year ......................................................................................................................
0
3
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7
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0
0
3
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v10.0
Form 5500-EZ (2007)
Page
4
▼
10a (1) Is this a fully insured pension plan which is funded entirely by insurance or annuity contracts?
If "Yes," complete lines 10a(2) through 10f and skip lines 10g through 13d.
(2) If 10a(1) is "Yes," are the insurance contracts held: ..................................................................
▼
Official Use Only
Yes
(1)
No
under a
trust
(2)
with no
trust
▲
▲
.00
c Noncash contributions received by the plan for this plan year .................................
▲
▲
▲
.00
d Total plan distributions to participants or beneficiaries (see instructions) ................
▲
▲
▲
.00
e Total nontaxable plan distributions to participants or beneficiaries ...........................
▲
▲
▲
.00
f Transfers to other plans ...............................................................................................
▲
▲
▲
.00
g Amounts received by the plan other than from contributions ....................................
▲
▲
▲
.00
h Plan expenses other than distributions .......................................................................
▲
▲
▲
.00
i (1) Is this a defined benefit plan subject to minimum funding requirements
(see instructions)? .........................................................................................................................
(2) If 10i(1) is "Yes," has the enrolled actuary for the plan certified that the
contributions for this plan year meet minimum funding requirements? ......................................
(3) If 10i(2) is "No," enter the amount of the funding deficiency as shown on line 10
of the Schedule B (Form 5500) (see instructions) ..............................................
▼
▲
Yes
No
▼
b Cash contributions received by the plan for this plan year .......................................
Yes
No
▲
(a) Beginning of Year
▲
▲
.00
(b) End of Year
11a Total plan assets ........
▲
▲
▲
.00
▲
▲
▲
.00
b Total plan liabilities .....
▲
▲
▲
.00
▲
▲
▲
.00
0
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0
4
0
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v10.0
Form 5500-EZ (2007)
Page
5
Official Use Only
12
Specific Assets: If the plan held assets at any time 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. Otherwise, check "No."
Yes
Amount
No
a Partnership/joint venture interests ..................................................
▲
▲
▲
.00
b Employer real property ...................................................................
▲
▲
▲
.00
c Real estate (other than employer real property) ...........................
▲
▲
▲
.00
d Employer securities .........................................................................
▲
▲
▲
.00
e Participant loans (see instructions) ................................................
▲
▲
▲
.00
f Loans (other than to participants) ..................................................
▲
▲
▲
.00
g Tangible personal property .............................................................
▲
▲
▲
.00
13
Check "Yes" and enter amount involved if any of the following
transactions took place between the plan and a disqualified
person during this plan year. Otherwise, check "No."
Yes
No
Amount
a Sale, exchange, or lease of property .............................................
▲
▲
▲
.00
b Payment by the plan for services ..................................................
▲
▲
▲
.00
c Acquisition or holding of employer securities ................................
▲
▲
▲
.00
d Loan or extension of credit .............................................................
▲
▲
▲
.00
0
3
0
7
0
0
0
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0
F
v10.0
Form 5500-EZ (2007)
Page
6
Official Use Only
No
▼
Yes
14a Does your business have any employees other than you and your spouse (and your partners and
their spouses)? ...................................................................................................................................................................
b During this plan year, did the plan make distributions to a married participant in a form other than a qualified
joint and survivor annuity or were any distributions on account of the death of a married participant made to
beneficiaries other than the spouse of that participant? .................................................................................................
▼
c During this plan year, did the plan make loans to married participants? .......................................................................
▼
15a Did the plan distribute any annuity contracts this plan year? .........................................................................................
▼
c Does this plan meet the coverage requirements of Code section 410(b)? ....................................................................
▼
b Total number of employees (including you and your spouse and your partners and their spouses) ............................
▼
If 14a is "No," do not complete line 14b or line 14c. See the specific instructions for line 14b and line 14c.
0
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v10.0
▲
SCHEDULE E
(Form 5500)
C
2007
▼
File as an attachment to Form 5500 or 5500-EZ.
MM / D D / Y Y Y Y
This Form is NOT Open
to Public Inspection.
MM / D D / Y Y Y Y
and ending
Name of plan
Plan sponsor's name as shown on line 2a of Form 5500 or 5500-EZ
B
Three-digit
plan number
D
Employer Identification Number
▼
A
OMB No. 1210-0110
Under Section 6047(e) of the Internal Revenue Code
Department of the Treasury
Internal Revenue Service
For calendar plan year 2007
or fiscal plan year beginning
Official Use Only
ESOP Annual Information
Yes
No
1a Is the ESOP maintained by an S corporation? ...............................................................................................................................
If "Yes," answer line 1b. (Also, "2Q" must be entered on Form 5500, line 8.)
b Were any prohibited allocations of securities in an S corporation made to any disqualified person? .........................................
2a Did the employee stock ownership plan (ESOP) have an outstanding securities acquisition loan
within the meaning of Code section 133 during the plan year? .....................................................................................................
▼
b Did the employer maintaining the ESOP pay dividends (deductible under section 404(k)) on the
employer's stock held by the ESOP during the employer's tax year in which the plan year ends? ............................................
If both line 2a and line 2b are "No," DO NOT complete any other questions on this schedule.
Attach the schedule to the Form 5500 or 5500-EZ you file for your ESOP plan.
▲
▲
What is the total value of the ESOP assets? .........................................................
4
If the ESOP holds preferred stock, under what formula(s) is the preferred stock
convertible into common stock of the employer corporation? ..........................................................
5
If unallocated employer securities were released from a loan suspense account, indicate below the methods used:
a
Principal and interest (Excise Tax Regulations section 54.4975-7(b)(8)(i));
b
Principal only (Excise Tax Regulations section 54.4975-7(b)(8)(ii));
c
Other (attach an explanation)
▲
Yes
6
.00
▼
3
No
Were unallocated securities or proceeds from the sale of unallocated securities used to repay any exempt loan
(within the meaning of Code section 4975(d)(3))? If "Yes," attach a description of the transaction ............................................
If the ESOP or the employer corporation has one or more outstanding securities acquisition loans
intended to satisfy Code section 133, complete lines 7 through 12, otherwise skip to line 13.
7a Was the ESOP loan part of a "back to back" loan? (See instructions for definition of "back to back" loan.) ............................
b If line 7a is "Yes," are the terms of the two loans substantially similar? .......................................................................................
c Do the two loans have the same amortization schedule?
If "No," attach an explanation of how the amortization schedules differ .......................................................................................
For Paperwork Reduction Act Notice and OMB Control Nos., see the inst. for Form 5500 or 5500-EZ. Cat. No. 12349Y Schedule E (Form 5500) 2007
1
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0
1
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v10.0
Schedule E (Form 5500) 2007
Page
2
Official Use Only
Yes
Is the loan an immediate allocation loan as defined in Code section 133(b)(1)(B)? ....................................................................
9a What was the date of the securities acquisition loan? ..................................................................
▼
8
No
MM / D D / Y Y Y Y
b At all times after the acquisition of the employer securities with the loan proceeds, did the ESOP own more than 50% of:
(i) each class of outstanding stock of the employer corporation, or
(ii) the total value of all outstanding stock of the corporation? ......................................................................................................
Yes
No
c If line 9b is "No," does the securities acquisition loan satisfy one of the transition rules of Act section 7301(f) of OBRA
1989 or satisfy the exception in Code section 133(b)(6)(B)(ii)? (See instructions for explanation of transition rules.) ..............
d If line 9c is "No," enter the name and address of payees to whom interest with respect to securities acquisition loans was paid.
Name
Street
10
State
What was the amount of interest paid on the securities acquisition loan? ............
▼
City
Zip Code
▲
▲
▲
Yes
11a Were any securities disposed of within 3 years after the plan acquired section 133
securities in a taxable event described in Code section 4978B(c)? ..............................................................................................
b If line 11a is "Yes," does one or more of the exceptions provided in Code section 4978B(d)
apply to all dispositions of employer securities? .............................................................................................................................
12a Were any of the ESOP's securities acquisition loans refinanced during this reporting period? ..................................................
b If line 12a is "Yes," does the refinancing meet the requirements of Act section 1602 of SBJPA 1996? ....................................
If the employer maintaining the ESOP deducted dividends under Code section 404(k),
answer the questions on lines 13 through 16, otherwise skip to line 17.
13a Did the amount of the dividends paid exceed the employer's current or accumulated earnings and
profits within the meaning of Code section 316? ............................................................................................................................
b Is the amount paid a dividend under applicable state law? ...........................................................................................................
14
If dividends deducted under Code section 404(k) were used to repay an exempt loan, were any dividends used
to repay the loan generated by securities that were not acquired with the proceeds of the loan being repaid? ........................
15
If the answer to line 14 is "Yes," were the dividends paid with respect to employer securities that satisfy the
transition rules of Act section 7302(b)(2) of OBRA 1989? .............................................................................................................
16
Did the employer make payments in redemption of stock held by an ESOP to terminating
ESOP participants and deduct them under Code section 404(k)(1)? ..........................................................................................
1
3
0
7
0
0
0
2
0
D
v10.0
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No
Schedule E (Form 5500) 2007
Page
3
Official Use Only
Yes
17a Were any dividends subject to an election by participants or their beneficiaries
under Code section 404(k)(2)(A)(iii) to reinvest the dividends in employer securities? ................................................................
If "Yes," answer lines 17b and 17c. If "No," skip to line 18a.
b Did the election comply with the requirements of Notice 2002-2? ................................................................................................
c Are dividends reinvested in employer securities pursuant to the election fully vested? ..............................................................
1
3
0
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E
v10.0
No
Schedule E (Form 5500) 2007
Page
4
Official Use Only
18
Complete the following information for each class of stock owned by the ESOP:
(a)
Class of stock
(b)
(d) Dividend rate
during plan year**
(f)
.
▲
(e)
%
Common stock (C)
Preferred stock (P)
Dividends paid
to participants***
▲
(1) allocated stock
Dividends used to
repay exempt loan
▲
▲
.00
▲
▲
(f)
Common stock (C)
Preferred stock (P)
Class of stock
(d) Dividend rate
during plan year**
.
▲
(e)
%
Dividends paid
to participants***
▲
(1) allocated stock
Dividends used to
repay exempt loan
▲
▲
.00
▲
▲
(f)
.
▲
Dividends used to
repay exempt loan
(e)
%
▲
.00
▲
▼
(e)
Dividends paid
to participants***
(1) allocated stock
▲
▲
.00
▲
▲
.00
(c)
Readily tradable*
Yes (Y) No (N)
▲
▲
.00
▲
▲
.00
(c)
Readily tradable*
Yes (Y) No (N)
▲
▲
.00
(2) unallocated stock
▲
Totals of dividends reported on lines 18(e) and (f)
for all classes of stock (including any reported on
attachments, see instructions)
Dividends used to
repay exempt loan
Dividends paid
to participants***
(1) allocated stock
▲
(f)
Common stock (C)
Preferred stock (P)
Class of stock
(d) Dividend rate
during plan year**
▲
(2) unallocated stock
(b)
(a)
Readily tradable*
Yes (Y) No (N)
(2) unallocated stock
(b)
(a)
(c)
▲
▲
▲
▲
.00
▲
▲
▲
.00
▲
.00
(2) unallocated stock
.00
▲
▲
▲
* If the stock is readily tradable on an established securities market within the meaning of Code section 409(l), enter "Y," otherwise enter "N."
** Dividend rate paid for each class of stock during the plan year.
*** Dividends paid directly to or distributed to participants.
1
3
0
7
0
0
0
4
0
F
v10.0
SCHEDULE D
(Form 5500)
Department of Labor
Employee Benefits Security Administration
For calendar plan year 2007
or fiscal plan year beginning
C
MM / D D / Y Y Y Y
and ending
MM / D D / Y Y Y Y
Name of plan or DFE
Plan or DFE sponsor's name as shown on line 2a of Form 5500
Part I
(a)
2007
This Form is Open to
Public Inspection.
File as an attachment to Form 5500.
B
Three-digit
plan number
D
Employer Identification Number
▼
A
OMB No. 1210-0110
This schedule is required to be filed under section 104 of the Employee
Retirement Income Security Act of 1974 (ERISA).
▼
Department of the Treasury
Internal Revenue Service
Official Use Only
DFE/Participating Plan Information
Information on interests in MTIAs, CCTs, PSAs, and 103-12 IEs (to be completed by plans and DFEs)
Name of MTIA, CCT, PSA, or 103-12IE
(b) Name of sponsor of entity listed in (a)
(c)
EIN
(e) Dollar value of interest in MTIA, CCT, PSA, or
103-12IE at end of year (see instructions)
(d) Entity
code
PN
▲
(a)
▲
▲
.00
Name of MTIA, CCT, PSA, or 103-12IE
(b) Name of sponsor of entity listed in (a)
(c)
EIN
(e) Dollar value of interest in MTIA, CCT, PSA, or
103-12IE at end of year (see instructions)
(d) Entity
code
PN
▲
▲
▲
.00
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Cat. No. 22774J Schedule D (Form 5500) 2007
1
1
0
7
0
0
0
1
0
A
v10.0
Schedule D (Form 5500) 2007
Page
2
Official Use Only
(a)
Name of MTIA, CCT, PSA, or 103-12IE
(b) Name of sponsor of entity listed in (a)
(c)
EIN
(e) Dollar value of interest in MTIA, CCT, PSA, or
103-12IE at end of year (see instructions)
(d) Entity
code
PN
▲
(a)
▲
▲
.00
Name of MTIA, CCT, PSA, or 103-12IE
(b) Name of sponsor of entity listed in (a)
(c)
EIN
(d) Entity
code
PN
(e) Dollar value of interest in MTIA, CCT, PSA, or
103-12IE at end of year (see instructions)
▲
(a)
▲
▲
.00
Name of MTIA, CCT, PSA, or 103-12IE
(b) Name of sponsor of entity listed in (a)
(c)
EIN
(d) Entity
code
PN
(e) Dollar value of interest in MTIA, CCT, PSA, or
103-12IE at end of year (see instructions)
▲
(a)
▲
▲
.00
Name of MTIA, CCT, PSA, or 103-12IE
(b) Name of sponsor of entity listed in (a)
(c)
EIN
(d) Entity
code
PN
(e) Dollar value of interest in MTIA, CCT, PSA, or
103-12IE at end of year (see instructions)
▲
1
1
0
7
0
0
0
2
0
▲
B
v10.0
▲
.00
Schedule D (Form 5500) 2007
Page
3
Official Use Only
Part II
(a)
Information on Participating Plans (to be completed by DFEs)
Plan name
(b) Name of plan sponsor
(c)
EIN
(a)
Plan name
PN
(b) Name of plan sponsor
(c)
EIN
(a)
Plan name
PN
(b) Name of plan sponsor
(c)
EIN
(a)
Plan name
PN
(b) Name of plan sponsor
(c)
EIN
(a)
Plan name
PN
(b) Name of plan sponsor
(c)
EIN
PN
1
1
0
7
0
0
0
3
0
C
v10.0
Schedule D (Form 5500) 2007
Page
4
Official Use Only
(a)
Plan name
(b) Name of plan sponsor
(c)
EIN
(a)
Plan name
PN
(b) Name of plan sponsor
(c)
EIN
(a)
Plan name
PN
(b) Name of plan sponsor
(c)
EIN
(a)
Plan name
PN
(b) Name of plan sponsor
(c)
EIN
(a)
Plan name
PN
(b) Name of plan sponsor
(c)
EIN
PN
1
1
0
7
0
0
0
4
0
D
v10.0
SCHEDULE C
(Form 5500)
Service Provider Information
OMB No. 1210-0110
Department of the Treasury
Internal Revenue Service
This schedule is required to be filed under section 104 of the
Employee Retirement Income Security Act of 1974.
2007
▼
Department of Labor
Employee Benefits Security Administration
Official Use Only
This Form is Open to
Public Inspection.
File as an attachment to Form 5500.
Pension Benefit Guaranty Corporation
For calendar plan year 2007
or fiscal plan year beginning
C
2
MM / D D / Y Y Y Y
Name of plan
Plan sponsor's name as shown on line 2a of Form 5500
Part I
1
and ending
B
Three-digit
plan number
D
Employer Identification Number
▼
A
MM / D D / Y Y Y Y
Service Provider Information (see instructions)
Enter the total dollar amount of compensation paid by the plan to all persons,
other than those listed below, who received compensation during the plan year: ..........
▲
▲
▲
.00
On the first item below list the contract administrator, if any, as defined in the instructions. On the other items, list service providers in
descending order of the compensation they received for the services rendered during the plan year. List only the top 40. 103-12 IEs should
enter N/A in (c) and (d).
(a)
Name
(b) Employer identification number (see instructions)
Co n t r a c t
(c) Official plan position
(d) Relationship to employer,
employee organization, or person
known to be a party-in-interest
(e) Gross salary or allowances paid by plan
▲
(a)
▲
a dm i n i s t r a t o r
(f) Fees and commissions paid by plan
.00
▲
▲
.00
(g) Nature of service code(s)
(see
instructions)
.00
(g) Nature of service code(s)
(see
instructions)
1 2
Name
(b) Employer identification number (see instructions)
(c) Official plan position
(d) Relationship to employer,
employee organization, or person
known to be a party-in-interest
(e) Gross salary or allowances paid by plan
▲
▲
(f) Fees and commissions paid by plan
.00
▲
▲
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Cat. No. 13515E Schedule C (Form 5500) 2007
0
9
0
7
0
0
0
1
0
H
v10.0
Schedule C (Form 5500) 2007
Page
2
Official Use Only
(a)
Name
(b) Employer identification number (see instructions)
(c) Official plan position
(d) Relationship to employer,
employee organization, or person
known to be a party-in-interest
(e) Gross salary or allowances paid by plan
▲
(a)
▲
(f) Fees and commissions paid by plan
.00
▲
▲
.00
(g) Nature of service code(s)
(see
instructions)
.00
(g) Nature of service code(s)
(see
instructions)
.00
(g) Nature of service code(s)
(see
instructions)
.00
(g) Nature of service code(s)
(see
instructions)
Name
(b) Employer identification number (see instructions)
(c) Official plan position
(d) Relationship to employer,
employee organization, or person
known to be a party-in-interest
(e)
Gross salary or allowances paid by plan
▲
(a)
▲
(f) Fees and commissions paid by plan
.00
▲
▲
Name
(b) Employer identification number (see instructions)
(c) Official plan position
(d) Relationship to employer,
employee organization, or person
known to be a party-in-interest
(e) Gross salary or allowances paid by plan
▲
(a)
▲
(f) Fees and commissions paid by plan
.00
▲
▲
Name
(b) Employer identification number (see instructions)
(c) Official plan position
(d) Relationship to employer,
employee organization, or person
known to be a party-in-interest
(e) Gross salary or allowances paid by plan
▲
▲
(f) Fees and commissions paid by plan
.00
0
▲
9
0
7
0
▲
0
0
2
0
I
v10.0
Schedule C (Form 5500) 2007
Page
Part II Termination Information on Accountants and Enrolled Actuaries
3
Official Use Only
(see instructions)
(a)
Name
(b) EIN
(d)
Address
(c) Position
Street Address
City
(e)
State
Zip Code
State
Zip Code
Telephone No.
E
X
P
L
A
N
A
T
I
O
N
(a)
Name
(b) EIN
(d)
Address
(c) Position
Street Address
City
(e)
Telephone No.
E
X
P
L
A
N
A
T
I
O
N
0
9
0
7
0
0
0
3
0
J
v10.0
Department of Labor
Employee Benefits Security
Administration
This schedule is required to be filed under section 104 of the Employee
Retirement Income Security Act of 1974, referred to as ERISA, except when
attached to Form 5500-EZ and, in all cases, under section 6059(a) of the
Internal Revenue Code, referred to as the Code.
Pension Benefit Guaranty Corporation
Attach to Form 5500 or 5500-EZ if applicable.
See separate instructions.
MM / D D / Y Y Y Y
and ending
OMB No. 1210-0110
2007
This Form is Open to Public
Inspection (except when
attached to Form 5500-EZ).
MM / D D / Y Y Y Y
Round off amounts to nearest dollar.
Caution: A penalty of $1,000 will be assessed for late filing of this report unless reasonable cause is established.
Name of plan
C
Plan sponsor's name as shown on line 2a of Form 5500 or 5500-EZ
E
Type of plan:
B
Three-digit
plan number
D
Employer Identification Number
F
(1)
Part I
Multiemployer
(2)
Single-employer
(3)
▼
▼ ▼
For calendar plan year 2007
or fiscal plan year beginning
A
Official Use Only
▼
Department of the Treasury
Internal Revenue Service
Actuarial Information
▼
SCHEDULE B
(Form 5500)
100 or fewer participants
in prior plan year
Multiple-employer
Basic Information (To be completed by all plans)
MM / D D / Y Y Y Y
1a Enter the actuarial valuation date:
b Assets:
(1) Current value of assets .......................................................................................
▲
▲
▲
.00
(2) Actuarial value of assets for funding standard account ....................................
▲
▲
▲
.00
Statement by Enrolled Actuary (see instructions before signing):
To the best of my knowledge, the information supplied in this schedule and on the accompanying schedules, statements, and attachments, if any, is complete and accurate,
and in my opinion each assumption, used in combination, represents my best estimate of anticipated experience under the plan. Furthermore, in the case of a plan other than
a multiemployer plan, each assumption used (a) is reasonable (taking into account the experience of the plan and reasonable expectations) or (b) would, in the aggregate,
result in a total contribution equivalent to that which would be determined if each such assumption were reasonable; in the case of a multiemployer plan, the assumptions used,
in the aggregate, are reasonable (taking into account the experience of the plan and reasonable expectations).
SIGN HERE
▼
Signature of actuary
MM / D D / Y Y Y Y
Date
Type or print
Name of actuary
Firm name
Address of the firm
City
G
State
Most recent
enrollment number
Zip Code
Telephone number
(including area code)
If the actuary has not fully reflected any regulation or ruling promulgated under the statute in completing this schedule,
check the box and see instructions ......................................................................................................................................................................
For Paperwork Reduction Act Notice and OMB Control Nos., see the inst. for Form 5500 or 5500-EZ. Cat. No. 13507E Schedule B (Form 5500) 2007
0
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0
7
0
0
0
1
0
F
v10.0
Schedule B (Form 5500) 2007
Page
2
Official Use Only
Accrued liability for plans using immediate gain methods ................................
Information for plans using spread gain methods:
▲
▲
▲
.00
(a) Unfunded liability for methods with bases ..................................................
▲
▲
▲
.00
(b) Accrued liability under entry age normal method ......................................
▲
▲
▲
.00
(c)
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
Current liability computed at highest allowable
interest rate (see instructions) ....................................................................
▲
▲
▲
.00
(d) Expected release from "RPA '94" current liability for the plan year ..........
▲
▲
▲
.00
(3) Expected plan disbursements for the plan year .................................................
2 Operational information as of beginning of this plan year:
a Current value of the assets (see instructions) ...........................................................
b "RPA '94" current liability:
▲
▲
▲
.00
▲
▲
▲
.00
1c (1)
(2)
Normal cost under entry age normal method ............................................
d Information on current liabilities of the plan:
(1) Amount excluded from current liability attributable to
pre-participation service (see instructions) .........................................................
(2) "RPA '94" information:
(a) Current liability .............................................................................................
(b) Expected increase in current liability due to
benefits accruing during the plan year .......................................................
(c)
(1) No. of Persons
(2) Vested Benefits
(3) Total Benefits
(1) For retired participants and beneficiaries receiving payments
▲
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
▲
.00
▲
▲
▲
.00
▲
(2) For terminated vested participants
▲
▲
(3) For active participants
▲
(4) Total
▲
c If the percentage resulting from dividing line 2a by line 2b(4), column (3), is less than 70%, enter such percentage ....
0
7
0
7
0
0
0
2
0
G
v10.0
.
▲
%
Schedule B (Form 5500) 2007
3
Page
3
Official Use Only
Contributions made to the plan for the plan year by employer(s) and employees:
(a) Month-Day-Year
(b) Amount paid by employer
(c) Amount paid by employees
▲
▲
▲
.00
▲
▲
▲
.00
MM/ D D / Y Y Y Y
▲
▲
▲
.00
▲
▲
▲
.00
MM/ D D / Y Y Y Y
▲
▲
▲
.00
▲
▲
▲
.00
MM/ D D / Y Y Y Y
▲
▲
▲
.00
▲
▲
▲
.00
MM/ D D / Y Y Y Y
▲
▲
▲
.00
▲
▲
▲
.00
MM/ D D / Y Y Y Y
▲
▲
▲
00
.
▲
▲
▲
.00
MM/ D D / Y Y Y Y
▲
▲
▲
.00
▲
▲
▲
.00
MM/ D D / Y Y Y Y
▲
▲
▲
.00
▲
▲
▲
.00
MM/ D D / Y Y Y Y
▲
▲
▲
.00
▲
▲
▲
.00
MM/ D D / Y Y Y Y
▲
▲
▲
.00
▲
▲
▲
.00
MM/ D D / Y Y Y Y
▲
▲
▲
.00
▲
▲
▲
.00
MM/ D D / Y Y Y Y
▲
▲
▲
.00
▲
▲
▲
.00
MM/ D D / Y Y Y Y
▲
▲
▲
.00
▲
▲
▲
.00
MM/ D D / Y Y Y Y
▲
▲
▲
.00
▲
▲
▲
.00
MM/ D D / Y Y Y Y
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
3
4
Totals ............................
▼
MM/ D D / Y Y Y Y
Quarterly contributions and liquidity shortfall(s):
a Plans other than multiemployer plans, enter funded current liability percentage for preceding year (see instructions) ...
b If line 4a is less than 100%, see instructions, and complete the following amount fields as applicable:
Liquidity shortfall as of end of Quarter of this plan year
.
▲
%
(1) 1st
▲
▲
▲
.00
(3)
3rd
▲
▲
▲
.00
(2) 2nd
▲
▲
▲
.00
(4)
4th
▲
▲
▲
.00
5
Actuarial cost method used as the basis for this plan year's funding standard account computation:
Attained age normal
(b)
Entry age normal
(c)
Accrued benefit (unit credit)
(d)
Aggregate
(e)
Frozen initial liability
(f)
Individual level premium
(g)
Individual aggregate
(h)
Other (specify)
▼
(a)
0
7
0
7
0
0
0
3
0
H
v10.0
Schedule B (Form 5500) 2007
Page
4
Official Use Only
5 i Has a change been made in funding method for this plan year? .......................................................
Yes
No
j If line i is "Yes," was the change made pursuant to Revenue Procedure 2000-40? .........................
Yes
No
k If line i is "Yes," and line j is "No" enter the date of the ruling letter
(individual or class) approving the change in funding method ............................................................
6
MM / D D / Y Y Y Y
N/A
Checklist of certain actuarial assumptions:
a Interest rate for "RPA '94" current liability .........................................................................................................
.
%
▲
b Weighted average retirement age ......................................................................................................................
Pre-retirement
c Rates specified in insurance
or annuity contracts ..........................................
d Mortality table code for valuation purposes:
(1) Males .........................................................
Yes
Post-retirement
No
N/A
(2) Females .....................................................
Yes
No
N/A
N/A
.
.
▲
f Expense loading ................................................
.
%
▲
e Valuation liability interest rate .........................
.
.
▲
.
▲
.
▲
.
%
▲
(3) Age 55 .......................................................
h Salary scale ......................................................
%
%
.
.
▲
.
▲
.
▲
N/A
%
i Estimated investment return on actuarial value of
assets for year ending on the valuation date ...................................................................................................
(3)
%
%
N/A
%
.
.
▲
▲
j Estimated investment return on current value of
assets for year ending on the valuation date ...................................................................................................
New amortization bases established in the current plan year:
(1) Type of Base
(2) Initial Balance
%
▲
Rate Code
(2) Age 40 .......................................................
%
Female
%
▲
Rate Code
g Annual withdrawal rates:
(1) Age 25 .......................................................
%
▲
Male
7
N/A
%
%
Amortization Charge/Credit
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
0
7
0
7
0
0
0
4
0
I
v10.0
Schedule B (Form 5500) 2007
Page
8 Miscellaneous information:
a If a waiver of a funding deficiency or an extension of an amortization period has been
approved for this plan year, enter the date of the ruling letter granting the approval ........................
Official Use Only
MM / D D / Y Y Y Y
▼
b If one or more alternative methods or rules (as listed in the instructions) were used for this
plan year, enter the appropriate code in accordance with the instructions ...................................
5
c Is the plan required to provide a Schedule of Active Participant Data? (see instructions) ...............
If "Yes," attach schedule.
Funding standard account statement for this plan year:
Charges to funding standard account:
a Prior year funding deficiency, if any ............................................................................
No
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
d Interest as applicable on line 9a, 9b, and 9c .............................................................
▲
▲
▲
.00
e Additional interest charge due to late quarterly contributions, if applicable .............
▲
▲
▲
.00
f Adjusted additional funding charge from Part II, line 12q, if applicable ... N/A
▲
▲
▲
.00
g Total charges. Add lines 9a through 9f .......................................................................
Credits to funding standard account:
h Prior year credit balance, if any ..................................................................................
▲
▲
▲
.00
▲
▲
▲
.00
i Employer contributions. Total from column (b) of line 3 .............................................
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
Waived funding deficiency ...................................................................................
▲
▲
▲
.00
(2) Other credits ........................................................................................................
▲
▲
▲
.00
n Total credits. Add lines 9h through 9k, 9l(3), 9m(1), and 9m(2) ................................
▲
▲
▲
.00
b Employer's normal cost for plan year as of valuation date .......................................
Outstanding Balance
c Amortization charges as of valuation date:
▼
(2) Funding waivers
($
▲
▲
▲
▼
(1) All bases except
funding waivers
($
▲
▲
▲
.00 )
.00 )
Outstanding Balance
j Amortization credits
as of valuation date
▼
9
Yes
($
▲
▲
.00 )
▲
k Interest as applicable to end of plan year on lines 9h, 9i, and 9j .............................
l Full funding limitation (FFL) and credits
(1) ERISA FFL (accrued liability FFL) ...................
▲
▲
(2) "RPA '94" override (90% current liability FFL) .
▲
▲
.00
▲
▲
.00
(3) FFL credit .............................................................................................................
m (1)
0
7
0
7
0
0
0
5
0
J
v10.0
Schedule B (Form 5500) 2007
Page
6
Official Use Only
9 o Credit balance: If line 9n is greater than line 9g, enter the difference .....................
▲
▲
▲
.00
p Funding deficiency: If line 9g is greater than line 9n, enter the difference ..............
Reconciliation account:
q Current year's accumulated reconciliation account:
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
(1) Due to additional funding charges
as of the beginning of the plan year ...............
▲
▲
.00
▲
▲
▲
.00
(a) Reconciliation outstanding balance as
of valuation date ......................................
▲
▲
▲
.00
(b) Reconciliation amount.
Line 9c(2) balance minus line 9q(3)(a) ...
▲
▲
▲
.00
(2) Due to additional interest charges
as of the beginning of the plan year ...............
(3) Due to waived funding deficiencies:
(4) Total as of valuation date ...............................................................................
10
11
▼
▲
Contribution necessary to avoid an accumulated funding deficiency.
Enter the amount in line 9p or the amount required under the alternative
funding standard account if applicable ..............................................................................
Has a change been made in the actuarial assumptions for the current plan year? If "Yes," see instructions.
Part II
Yes
No
Additional Information for Certain Plans Other Than Multiemployer Plans
Please see Who Must File in the Schedule B instructions to determine if you must complete Part II.
12 Additional required funding charge (see instructions):
a Enter "Gateway %." Divide line 1b(2) by line 1d(2)(c) and multiply by 100.
If line 12a is at least 90%, go to line 12q and enter -0-. If line 12a is less than 80%, go to line 12b.
If line 12a is at least 80% (but less than 90%), see instructions and, if applicable,
go to line 12q and enter -0-. Otherwise, go to line 12b .............................................
.
▲
%
b "RPA '94" current liability. Enter line 1d(2)(a) .............................................................
▲
▲
▲
.00
c Adjusted value of assets (see instructions) ................................................................
▲
▲
▲
.00
.
▲
d Funded current liability percentage. Divide line 12c by 12b and multiply by 100 ....
%
e Unfunded current liability. Subtract line 12c from line 12b ........................................
▲
▲
▲
.00
f Liability attributable to any unpredictable contingent event benefit ...........................
▲
▲
▲
.00
g Outstanding balance of unfunded old liability .............................................................
▲
▲
▲
.00
h Unfunded new liability. Subtract the total of lines 12f and 12g from line 12e.
Enter -0- if negative .....................................................................................................
▲
▲
▲
.00
of line 12h ..................
▲
▲
▲
.00
j Unfunded old liability amount ......................................................................................
▲
▲
▲
.00
k Deficit reduction contribution. Add lines 12i, 12j, and 1d(2)(b) .................................
▲
▲
▲
.00
i Unfunded new liability amount
(
.
%
▲
0
7
0
)
7
0
0
0
6
0
K
v10.0
Schedule B (Form 5500) 2007
Page
7
Official Use Only
12 l Net charges in funding standard account used to offset the deficit reduction
contribution. Enter a negative number if less than zero ............................................
m Unpredictable contingent event amount:
(1) Benefits paid during year attributable to
unpredictable contingent event .......................
▲
▲
▲
▲
.00
.00
▲
(2) Unfunded current liability percentage.
Subtract the percentage on line 12d from 100% ......................................................
▲
.
%
▲
(3) Enter the product of lines
12m(1) and 12m(2) ..........................................
▲
▲
▲
.00
(4) Amortization of all unpredictable
contingent event liabilities ...............................
▲
▲
▲
.00
(5) "RPA '94" additional amount (see instructions)
▲
▲
▲
.00
(6) Enter the greatest of lines 12m(3), 12m(4), or 12m(5) ......................................
▲
▲
▲
.00
n Preliminary additional funding charge: Enter the excess of line 12k over
line 12l (if any), plus line 12m(6), adjusted to end of year with interest ..................
▲
▲
▲
.00
o Contributions needed to increase current liability percentage to 100%
(see instructions) ..........................................................................................................
▲
▲
▲
.00
p Additional funding charge prior to adjustment: Enter the lesser of
line 12n or 12o .............................................................................................................
▲
▲
▲
.00
▲
▲
▲
.00
q Adjusted additional funding charge.
▲0 %
(
.
0
7
0
7
)
of line 12p ............
0
0
0
7
0
L
v10.0
SCHEDULE A
(Form 5500)
2007
▼
▼
Department of Labor
Employee Benefits Security
Administration
Pension Benefit Guaranty Corporation
For calendar plan year 2007
or fiscal plan year beginning
C
OMB No. 1210-0110
This schedule is required to be filed under section 104 of the
Employee Retirement Income Security Act of 1974.
Department of the Treasury
Internal Revenue Service
File as an attachment to Form 5500.
Insurance companies are required to provide this information
pursuant to ERISA section 103(a)(2).
MM / D D / Y Y Y Y
and ending
This Form is Open to
Public Inspection.
MM / D D / Y Y Y Y
Name of plan
Plan sponsor's name as shown on line 2a of Form 5500
Part I
B
Three-digit
plan number
D
Employer Identification Number
▼
A
Official Use Only
Insurance Information
Information Concerning Insurance Contract Coverage, Fees, and Commissions
Provide information for each contract on a separate Schedule A. Individual contracts grouped as a unit in Parts II and III
can be reported on a single Schedule A.
1 Coverage:
(a)
Name of insurance carrier
(b) EIN
(c) NAIC code
(d) Contract or identification number
(e)
Approximate number of persons covered at end of policy or contract year
Policy or contract year
2
(f) From
▲
MM / D D / Y Y Y Y
▲
(g) To
MM / D D / Y Y Y Y
Insurance fees and commissions paid to agents, brokers and other persons. Enter the total fees and total commissions
below and list agents, brokers and other persons individually in descending order of the amount paid in the items on
the following page(s) in Part I.
Totals
Total amount of commissions paid
▲
▲
Total fees paid / amount
.00
▲
▲
▲
▲
.00
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Cat. No. 13505I Schedule A (Form 5500) 2007
0
5
0
7
0
0
0
1
0
D
v10.0
Schedule A (Form 5500) 2007
Page
2
Official Use Only
(a)
Name and address of the agents, brokers or other persons to whom commissions or fees were paid
Name
Street Address
City
State
(b) Amount of commissions paid
▲
▲
(c)
Fees paid / Amount
.00
▲
Zip Code
(e)
▲
▲
▲
Organization
code
.00
(d) Fees paid / Purpose
(a)
Name and address of the agents, brokers or other persons to whom commissions or fees were paid
Name
Street Address
City
State
(b) Amount of commissions paid
▲
▲
(c)
Fees paid / Amount
.00
▲
Zip Code
▲
▲
▲
(e)
Organization
code
(e)
Organization
code
.00
(d) Fees paid / Purpose
(a)
Name and address of the agents, brokers or other persons to whom commissions or fees were paid
Name
Street Address
City
State
(c)
(b) Amount of commissions paid
▲
▲
Fees paid / Amount
.00
▲
Zip Code
▲
▲
▲
.00
(d) Fees paid / Purpose
0
5
0
7
0
0
0
2
0
E
v10.0
Schedule A (Form 5500) 2007
Page
3
Official Use Only
Part II
Investment and Annuity Contract Information
Where individual contracts are provided, the entire group of such individual contracts with each carrier may be treated as
a unit for purposes of this report.
3
Current value of plan's interest under this contract in the general account at year end
▲
▲
▲
.00
4
Current value of plan's interest under this contract in separate accounts at year end
▲
▲
▲
.00
b Premiums paid to carrier ..............................................................................................
▲
▲
▲
.00
c Premiums due but unpaid at the end of the year .......................................................
▲
▲
▲
.00
d If the carrier, service, or other organization incurred any
specific costs in connection with the acquisition or retention
of the contract or policy, enter amount .........................................................................
▲
▲
▲
.00
Contracts With Allocated Funds
a State the basis of premium rates
▼
5
▼
Specify nature of costs
e Type of contract
individual policies
(2)
group deferred annuity
other (specify below)
f
If contract purchased, in whole or in part, to distribute benefits from a terminating plan check here ...
0
5
0
7
0
0
0
3
0
▼
▼
(3)
(1)
F
v10.0
Schedule A (Form 5500) 2007
Page
4
Official Use Only
Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts)
a Type of contract
(1)
deposit administration
(4)
other (specify below)
(2)
immediate participation guarantee
(3)
guaranteed investment
▼
6
▲
b Balance at the end of the previous year ....................................................................
▲
▲
▲
.00
(2) Dividends and credits ......................................
▲
▲
▲
.00
(3) Interest credited during the year .....................
▲
▲
▲
.00
(4) Transferred from separate account .................
▲
▲
▲
.00
(5) Other (specify below) .......................................
▲
▲
▲
.00
▲
.00
▼
c Additions:
(1) Contributions deposited during the year .........
▲
(6) Total additions ......................................................................................................
▲
▲
▲
.00
d Total of balance and additions (add b and c(6)) ........................................................
e Deductions:
▲
▲
▲
.00
(1)
▲
▲
▲
.00
(2) Administration charge made by carrier ...........
▲
▲
▲
.00
(3) Transferred to separate account .....................
▲
▲
▲
.00
(4) Other (specify below) .......................................
▲
▲
▲
.00
▼
Disbursed from fund to pay benefits or
purchase annuities during year .......................
(5) Total deductions ...................................................................................................
▲
▲
▲
.00
f Balance at the end of the current year (subtract e(5) from d) ..................................
▲
▲
▲
.00
0
5
0
7
0
0
0
4
0
G
v10.0
Schedule A (Form 5500) 2007
Page
5
Official Use Only
Part III
Welfare Benefit Contract Information
If more than one contract covers the same group of employees of the same employer(s) or members of the same employee
organization(s), the information may be combined for reporting purposes if such contracts are experience-rated as a unit.
Where individual contracts are provided, the entire group of such individual contracts with each carrier may be treated as a
unit for purposes of this report.
7
Benefit and contract type (check all applicable boxes)
(a)
Health (other than
dental or vision)
(b)
Dental
(c)
Vision
(d)
Life Insurance
(e)
Temporary disability
(accident and sickness)
(f)
Long-term disability
(g)
Supplemental
unemployment
(h)
Prescription drug
(i)
Stop loss (large deductible)
(j)
HMO contract
(k)
PPO contract
(l)
Other (specify below)
▼
(m)
Indemnity contract
8
Experience-rated contracts
a Premiums:
(1) Amount received ..............................................
▲
▲
▲
.00
(2) Increase (decrease)
in amount due but unpaid ...............................
▲
▲
▲
.00
(3) Increase (decrease) in
unearned premium reserve .............................
▲
▲
▲
.00
▲
(4) Earned ((1) + (2) - (3)) ........................................................................................
b Benefit charges:
(1) Claims paid ......................................................
▲
▲
▲
.00
(2) Increase (decrease) in claim reserves ...........
▲
▲
▲
.00
▲
▲
.00
(3) Incurred claims (add (1) and (2)) ........................................................................
▲
▲
▲
.00
(4) Claims charged ....................................................................................................
▲
▲
▲
.00
0
5
0
7
0
0
0
5
0
H
v10.0
Schedule A (Form 5500) 2007
Page
6
Official Use Only
8 c Remainder of premium:
(1) Retention charges (on an accrual basis) -(A) Commissions ...........................................
▲
▲
▲
.00
(B) Administrative service or other fees .......
▲
▲
▲
.00
(C) Other specific acquisition costs ..............
▲
▲
▲
.00
(D) Other expenses .......................................
▲
▲
▲
.00
(E) Taxes ........................................................
▲
▲
▲
.00
(F) Charges for risks or other contingencies
▲
▲
▲
.00
(G) Other retention charges ..........................
▲
▲
▲
.00
▲
▲
▲
.00
credited.) ..
▲
▲
▲
.00
d Status of policyholder reserves at end of year:
(1) Amount held to provide benefits after retirement ...............................................
▲
▲
▲
.00
(2) Claim reserves .....................................................................................................
▲
▲
▲
.00
(3) Other reserves .....................................................................................................
▲
▲
▲
.00
e Dividends or retroactive rate refunds due.
(Do not include amount entered in c(2).) ...................................................................
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
(H) Total retention ..............................................................................................
(2) Dividends or retroactive rate refunds.
(These amounts were 1)
9
paid in cash, or
2)
Nonexperience-rated contracts:
a Total premiums or subscription charges paid to carrier .............................................
b If the carrier, service, or other organization incurred any specific costs
in connection with the acquisition or retention of the contract or policy,
other than reported in Part I, item 2 above, report amount ......................................
Specify nature of costs below
0
5
0
7
0
0
0
6
0
I
v10.0
Official Use Only
SCHEDULE SSA
(Form 5500)
Annual Registration Statement Identifying Separated
Participants With Deferred Vested Benefits
Department of the Treasury
Internal Revenue Service
For calendar plan year 2007
or fiscal plan year beginning
▼
Under Section 6057(a) of the Internal Revenue Code
A
Name of plan
C
Plan sponsor's name as shown on line 2a of Form 5500
B
Three-digit
plan number
1
2
▼
D
and ending
2007
This Form is NOT Open
to Public Inspection.
File as an attachment to Form 5500 unless box 1 is checked.
MM / D D / Y Y Y Y
OMB No. 1210-0110
MM / D D / Y Y Y Y
Employer Identification Number
Check here if plan is a government, church or other plan that elects to voluntarily file Schedule SSA. If so, complete lines 2 through
3c, and the signature area.
Plan sponsor's address (number, street, and room or suite no.) (If a P.O. box, see the instructions for line 2.)
City or town
State
ZIP code
3a Name of plan administrator (if other than sponsor)
3b Administrator's EIN
3c Number, street, and room or suite no. (If a P.O. box, see the instructions for line 2.)
City or town
State
Date
▼
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500.
2
9
0
7
0
0
0
1
MM / D D / Y Y Y Y
▼
SIGN HERE
▼
Under penalties of perjury, I declare that I have examined this report, and to
the best of my knowledge and belief, it is true, correct, and complete.
Phone number of
Signature of plan administrator
plan administrator
ZIP code
0
Cat. No. 13506T
Schedule SSA (Form 5500) 2007
J
v10.0
Schedule SSA (Form 5500) 2007
Page
2
Official Use Only
4
Enter one of the following Entry Codes in column (a) for each separated participant with deferred vested benefits that:
Code A -- has not previously been reported.
Code B -- has previously been reported under the above plan number but requires revisions to the information previously reported.
Code C -- has previously been reported under another plan number but will be receiving their benefits from the plan listed above instead.
Code D -- has previously been reported under the above plan number but is no longer entitled to those deferred vested benefits.
Use with entry code "A", "B", "C", or "D"
(a) Entry code
(b) Social security number
(First)
(c) Name of participant
(M. I.)
(Last)
Use with entry code "A" or "B"
Amount of vested benefit
Defined contribution plan
Enter code for
nature and
form of benefit
(d)
Type of
annuity
(e)
Payment
frequency
Share
indicator
(g) Units or shares
(f) Defined benefit plan -- periodic payment
▲
▲
▲
.
▲
▲
▲
.
▲
▲
▲
▲
(h) Total value of account
▲
▲
(i) Previous sponsor's employer identification number
.
(j) Previous plan number
Use with entry code "C"
Use with entry code "A", "B", "C", or "D"
(a) Entry code
(b) Social security number
(c) Name of participant
(First)
(Last)
(M. I.)
Use with entry code "A" or "B"
Amount of vested benefit
Defined contribution plan
Enter code for
nature and
form of benefit
(d)
Type of
annuity
(e)
Payment
frequency
Share
indicator
(g) Units or shares
(f) Defined benefit plan -- periodic payment
▲
▲
▲
.
▲
▲
▲
.
▲
▲
▲
▲
(h) Total value of account
▲
▲
(i) Previous sponsor's employer identification number
.
(j) Previous plan number
Use with entry code "C"
2
9
0
7
0
0
0
2
0
K
v10.0
| File Type | application/pdf |
| File Title | 75500.pmd |
| Author | rhodhm |
| File Modified | 2007-05-29 |
| File Created | 2007-02-09 |