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pdfSCHEDULE 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
FI
LI
NG
This Form is Open to
Public Inspection.
File as an attachment to Form 5500.
Pension Benefit Guaranty Corporation
A
MM / D D / Y Y Y Y
MM / D D / Y Y Y Y
FO
R
For calendar plan year 2007
or fiscal plan year beginning
and ending
Name of plan
Plan sponsor's name as shown on line 2a of Form 5500
▲
DO
2
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)
ON
LY
,
1
Service Provider Information (see instructions)
Employer Identification Number
NO
T
Part I
D
Name
PU
RP
OS
ES
C
Three-digit
plan number
US
E
B
▼
▼
Department of Labor
Employee Benefits Security Administration
Official Use Only
(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)
Name
▲
(f) Fees and commissions paid by plan
.00
▲
IN
FO
RM
AT
IO
N
▲
a dm i n i s t r a t o r
▲
.00
(g) Nature of service code(s)
(see
instructions)
.00
(g) Nature of service code(s)
(see
instructions)
1 2
(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
FO
R
▲
▲
(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
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v10.1
Schedule C (Form 5500) 2007
Page
2
Official Use Only
Name
FI
LI
NG
(a)
(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
.00
▲
.00
▲
Name
(b) Employer identification number (see instructions)
▲
(f) Fees and commissions paid by plan
ON
LY
,
Gross salary or allowances paid by plan
▲
.00
▲
Name
▲
PU
RP
OS
ES
(a)
DO
(c) Official plan position
(d) Relationship to employer,
employee organization, or person
known to be a party-in-interest
(e)
(g) Nature of service code(s)
(see
instructions)
NO
T
(a)
▲
(f) Fees and commissions paid by plan
US
E
▲
FO
R
(b) Employer identification number (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)
(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)
Name
▲
.00
▲
IN
FO
RM
AT
IO
N
▲
(f) Fees and commissions paid by plan
▲
(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
FO
R
▲
▲
(f) Fees and commissions paid by plan
.00
0
▲
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0
▲
0
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Schedule C (Form 5500) 2007
Page
3
Part II Termination Information on Accountants and Enrolled Actuaries (see instructions)
Official Use Only
(b) EIN
(c) Position
Street Address
City
State
Telephone No.
(a)
Name
(b) EIN
(d)
Address
(c) Position
Street Address
City
IN
FO
RM
AT
IO
N
Telephone No.
State
FO
R
(e)
PU
RP
OS
ES
ON
LY
,
DO
NO
T
E
X
P
L
A
N
A
T
I
O
N
E
X
P
L
A
N
A
T
I
O
N
Zip Code
US
E
(e)
FO
R
(d)
Address
FI
LI
NG
(a)
Name
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0
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0
J
Zip Code
| File Type | application/pdf |
| File Title | 75500c.pmd |
| Author | rhodhm |
| File Modified | 2007-06-07 |
| File Created | 2007-06-06 |