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This form is required to be filed under
section 6058(a) of the Internal Revenue Code.
Department of the Treasury
Internal Revenue Service
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MM / D D / Y Y Y Y
and ending
(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).
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This return is:
MM / D D / Y Y Y Y
If filing under an extension of time, check box and attach required information. (see instructions) .............................................................
Part II
Basic Plan Information -- enter all requested information.
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This Form is Open to
Public Inspection.
Annual Return Identification Information
For the calendar plan year 2008
or fiscal plan year beginning
2008
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Part I
Complete all entries in accordance with
the instructions to the Form 5500-EZ.
OMB No. 1545-0956
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5500-EZ
Official Use Only
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Form
Annual Return of One-Participant
(Owners and Their Spouses) Retirement Plan
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1b Three-digit plan number (PN)
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1a Name of plan
1c Date plan first
became effective
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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 MB (Form 5500) or Schedule SB (Form 5500) signed
by an enrolled actuary, which I will retain) and to the best of my knowledge and belief, it is true, correct, and complete.
Signature of employer or plan administrator
SIGN HERE
Date
MM / D D / Y Y Y Y
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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.
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Form 5500-EZ (2008)
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v11.3
Form 5500-EZ (2008)
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Official Use Only
1)
Employer's name and address (Address should include room or suite no.)
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2a
Name
Name Continued
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
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2)
Zip Code
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2c Employer's telephone
number
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
3b Administrator's EIN
IN
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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
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4
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1)
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2d Business code
(see instructions)
Location Address if different than 4) or 5)
3a
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2b Employer Identification Number (EIN)
(Do not enter your Social Security Number)
c PN
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Form 5500-EZ (2008)
Page
3
Official Use Only
Preparer information (optional)
a
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Name (including firm name, if applicable) and address
Name
1)
3)
City
4)
State
5)
Foreign Routing Code
6)
Foreign Country
Zip Code
Defined benefit pension plan (other than a plan
described in Code section 412(e)(3))
(b)
Defined benefit pension plan described in
Code section 412(e)(3)
(c)
Money purchase pension plan
EIN
Telephone number
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(a)
(d)
Profit-sharing plan
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Type of plan:
c
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b
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Street
(e)
Stock bonus plan
(f)
ESOP plan
(2)
(3)
Partner(s) in a partnership, or
100% owner of corporation
b Check here if you have more than one plan and the total assets of all plans are more than $250,000 (see instructions) .......
Number
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 ......................................................................................................................
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IN
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8a Enter the number of qualified pension benefit plans maintained by the employer (including this plan) ......................................
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Self-employed individuals,
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(1)
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7a If this is a master/prototype, or regional prototype plan, enter the opinion/notification letter number ........
b Check if this plan covers:
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2)
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Name Continued
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Form 5500-EZ (2008)
Page
4
Yes
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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 line 10a(1) is "Yes," are the insurance contracts held: ...........................................................
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Official Use Only
under a
trust
(1)
(2)
No
with no
trust
.00
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.00
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.00
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.00
f Transfers to other plans ...............................................................................................
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.00
g Amounts received by the plan other than from contributions ....................................
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.00
h Plan expenses other than distributions .......................................................................
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.00
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d Total plan distributions to participants or beneficiaries (see instructions) ................
(2) If line 10i(1) is "Yes," has the enrolled actuary for the plan certified that the
contributions for this plan year meet minimum funding requirements? ......................................
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(3) If line 10i(2) is "No," enter the amount of the unpaid minimum contribution on
line 40 of Schedule SB (Form 5500) (see instructions) ......................................
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i (1) Is this a defined benefit plan subject to minimum funding requirements
(see instructions)? .........................................................................................................................
Yes
No
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e Total nontaxable plan distributions to participants or beneficiaries ...........................
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c Noncash contributions received by the plan for this plan year .................................
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b Cash contributions received by the plan for this plan year .......................................
Yes
No
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(a) Beginning of Year
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.00
(b) End of Year
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.00
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.00
b Total plan liabilities .....
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.00
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.00
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11a Total plan assets ........
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Form 5500-EZ (2008)
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Official Use Only
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."
Amount
No
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.00
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.00
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.00
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.00
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.00
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.00
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.00
b Employer real property ...................................................................
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c Real estate (other than employer real property) ...........................
d Employer securities .........................................................................
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e Participant loans (see instructions) ................................................
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g Tangible personal property .............................................................
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f Loans (other than to participants) ..................................................
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
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a Partnership/joint venture interests ..................................................
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Yes
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Amount
▲
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.00
b Payment by the plan for services ..................................................
▲
▲
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.00
c Acquisition or holding of employer securities ................................
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.00
d Loan or extension of credit .............................................................
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.00
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a Sale, exchange, or lease of property .............................................
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Form 5500-EZ (2008)
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6
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Official Use Only
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Yes
14a Does your business have any employees other than you and your spouse (and your partners and
their spouses)? ...................................................................................................................................................................
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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? .................................................................................................
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IN
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c During this plan year, did the plan make loans to married participants? .......................................................................
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15a Did the plan distribute any annuity contracts this plan year? .........................................................................................
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c Does this plan meet the coverage requirements of Code section 410(b)? ....................................................................
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b Total number of employees (including you and your spouse and your partners and their spouses) ............................
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If line 14a is "No," do not complete line 14b or line 14c. See the specific instructions for line 14b and line 14c.
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No
| File Type | application/pdf |
| File Title | 55500ez |
| Subject | 55500ez |
| Author | RhodHM |
| File Modified | 2008-06-05 |
| File Created | 2008-06-03 |