5500 Annual Return/Report of Employee Benefit Plan

Form

5500

Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security
Administration
Pension Benefit Guaranty Corporation

Part I

Annual Return/Report of Employee Benefit Plan
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).
έ Complete all entries in accordance with
the instructions to the Form 5500.

2007
This Form is Open to
Public Inspection.

Annual Report Identification Information

For the calendar plan year 2007 or fiscal plan year beginning
A This return/report is for: (1)
a multiemployer plan;
(2)
a single-employer plan (other than a
multiple-employer plan);

B

Official Use Only
OMB Nos. 1210 - 0110
1210 - 0089

,
(3)
(4)

and ending
a multiple-employer plan; or
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)
a short plan year return/report (less than 12 months).
C If the plan is a collectively-bargained plan, check here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . έ
D If filing under an extension of time or the DFVC program, check box and attach required information. (see instructions). . . . . . . . . . . . . . . . . . . έ
Part II
Basic Plan Information -- enter all requested information.
1a Name of plan
1b Three-digit
plan number (PN) έ

2a

This return/report is:

Plan sponsor's name and address (employer, if for a single-employer plan)
(Address should include room or suite no.)

1c

Effective date of plan (mo., day, yr.)

2b

Employer Identification Number (EIN)

2c

Sponsor's telephone number

2d

Business code (see instructions)

Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established.
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.

SIGN
HERE
Signature of plan administrator

Date

Type or print name of individual signing as plan administrator

SIGN
HERE
Signature of employer/plan sponsor/DFE
Date
Type or print name of individual signing as employer, plan sponsor or DFE
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500.
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Form 5500 (2007)

Page

2
Official Use Only

3a

4
a
5

Plan administrator's name and address (If same as plan sponsor, enter "Same")

a
b
c
d
e
f
g
h
i
8
a
b

9a

Administrator's EIN

3c

Administrator's telephone number

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
Preparer information (optional)

6
7

3b

a

Name (including firm name, if applicable) and address

b

EIN

c

PN

b

EIN

c

Telephone number

Total number of participants at the beginning of the plan year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
Number of participants as of the end of the plan year (welfare plans complete only lines 7a, 7b, 7c, and 7d)
Active participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7a
Retired or separated participants receiving benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7b
Other retired or separated participants entitled to future benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7c
Subtotal. Add lines 7a, 7b, and 7c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7d
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits . . . . . . . . . . . . . . . . . . . . 7e
Total. Add lines 7d and 7e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7f
Number of participants with account balances as of the end of the plan year (only defined contribution plans
complete this item) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7g
Number of participants that terminated employment during the plan year with accrued benefits that were less than
100% vested . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7h
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) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7i
Benefits provided under the plan (complete 8a and 8b, as applicable)
Pension benefits (check this box if the plan provides pension benefits and enter the applicable pension feature codes from the List of Plan
Characteristics Codes printed in the instructions):
Welfare benefits (check this box if the plan provides welfare benefits and enter the applicable welfare feature codes from the List of Plan
Characteristics Codes printed in the instructions):
Plan funding arrangement (check all that apply)
(1)
Insurance
(2)
Code section 412(i) insurance contracts
(3)
Trust
(4)
General assets of the sponsor

9b

Plan benefit arrangement (check all that apply)
(1)
Insurance
(2)
Code section 412(i) insurance contracts
(3)
Trust
(4)
General assets of the sponsor
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10
a

Schedules attached (Check all applicable boxes and, where indicated, enter the number attached. See instructions.)
Pension Benefit Schedules
b Financial 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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