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pdfCUMULATIVE CHANGES
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 2008
or fiscal plan year beginning
C
OMB No. 1210-0110
2008
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
Asset and Liability Statement
Three-digit
plan number
D
Employer Identification Number
▼
B
O
O
F
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)
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 Receivables (less allowance for
doubtful accounts):
(1) Employer
contributions .......
▲
(2)
Participant
contributions .......
▲
(4)
(5)
▲
▲
▲
.00
▲
.00
▲
▲
▲
.00
▲
▲
.00
▲
▲
▲
.00
▲
▲
.00
▲
▲
▲
.00
▲
▲
.00
▲
▲
▲
.00
▲
▲
.00
▲
▲
▲
.00
▲
3R
(3)
U.S. Government
securities ............
.00
▲
(3) Other ...................
▲
c General investments:
(1) Interest-bearing cash (including money market
accounts and
certificates
of deposit) ..........
▲
(2)
▲
PR
▲
D
a Total noninterestbearing cash ...............
(b) End of Year
▲
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) 2008
1
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H
v11.0
Schedule H (Form 5500) 2008
Page
2
Official Use Only
(a) Beginning 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) .
▲
(7)
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 .......
▲
.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
(15) Other ...................
d Employer-related
investments:
(1) Employer
securities ............
Employer real
property ..............
e Buildings and other
property used in
plan operation ............
f Total assets
(add all amounts in
lines 1a through 1e) ...
Liabilities
▲
▲
3R
(2)
▲
PR
▲
D
(8)
(9)
O
O
F
1c (6)
(b) End of Year
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
7
0
8
0
0
0
2
0
I
v11.0
Schedule H (Form 5500) 2008
Page
3
Official Use Only
Part II
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
O
O
F
(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) .......................
(B) U.S. Government securities ......................
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
(D) Loans (other than to participants) ............
▲
▲
▲
.00
(E) Participant loans ........................................
▲
▲
▲
.00
(F) Other ..........................................................
▲
▲
▲
.00
D
PR
(C) Corporate debt instruments ......................
3R
2
▲
(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
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0
8
0
0
0
3
0
J
v11.0
Schedule H (Form 5500) 2008
Page
4
Official Use Only
2b (5)
Unrealized appreciation (depreciation)
of assets:
(a) Amount
(A) Real estate ................................................
▲
▲
▲
.00
(B) Other ..........................................................
▲
▲
▲
.00
(b) Total
▲
▲
▲
.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
O
O
F
(C) Total unrealized appreciation of assets. Add lines 2b(5)(A) and (B) .........
(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
▲
▲
▲
.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
Expenses
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) ..........................................
3R
(2)
D
(1)
PR
e Benefit payment and payments to provide benefits:
▲
▲
.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
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0
0
4
0
K
v11.0
Schedule H (Form 5500) 2008
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)? .................
▼
Name
EIN
Yes
No
O
O
F
c Enter the name and EIN of the accountant (or accounting firm):
(1)
Part IV
this form is filed for a CCT, PSA or MTIA.
Transactions During Plan Year
CCTs and PSAs do not complete Part IV.
103-12 IEs also do not complete 4j.
During the plan year:
(2)
it will be attached to the next Form 5500 pursuant to 29 CFR 2520.104-50.
MTIAs, 103-12 IEs, and GIAs do not complete 4a, 4e, 4f, 4g, 4h, 4k, or 5.
D
4
PR
d The opinion of an independent qualified public accountant is not attached because:
Yes
No
Amount
▲
▲
▲
.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.) ....................
▲
▲
▲
.00
Was this plan covered by a fidelity bond? ........................................
▲
▲
▲
.00
3R
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.) ......................
c
d
d
e
1
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5
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v11.1
Schedule H (Form 5500) 2008
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.) ..................................................................................
O
O
F
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 ......................
PR
▲
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(2) EIN
5b(3) PN
3R
D
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
5b(1) Name of plan
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v11.1
| File Type | application/pdf |
| File Title | 85500h.pmd |
| Author | rhodhm |
| File Modified | 2008-06-27 |
| File Created | 2008-05-01 |