5500 Annual Return/Report of Employee Benefit Plan

CUMULATIVE CHANGES

5500

Official Use Only

Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security
Administration

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).

2008

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 2008
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;

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

O
O
F

This return/report is for:

MM / D D / Y Y Y Y

and ending

Part II

(4)

Basic Plan Information -- enter all requested information.

Name of plan

1b

Three-digit plan number (PN)

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3R

D

PR

1a

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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Form 5500 (2008)

Form 5500 (2008)

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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

O
O
F

2d Business code
(see instructions)

3a
1)

PR

Location Address City/State/Zip if different than 4) or 5)

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

Name
Name Continued

c / o

3)

Street

4)

City

5)

State

6)

Foreign Routing Code

7)

Foreign Country

4

3R

D

2)

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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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

O
O
F

Zip Code

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▲

▲

▲

b Retired or separated participants receiving benefits ...........................................................................................

▲

▲

c Other retired or separated participants entitled to future benefits .....................................................................

▲

▲

▲

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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)

D

PR

a Active participants .................................................................................................................................................

3R

d Subtotal. Add lines 7a, 7b, and 7c ......................................................................................................................

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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

O
O
F

(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)
(1)

Insurance

(2)

Code section 412(e)(3) insurance contracts

(3)

Trust

(4)

General assets of the sponsor

(1)

Insurance

(2)

Code section 412(e)(3) insurance contracts

(3)

Trust

(4)

General assets of the sponsor

PR

10

9b Plan benefit arrangement (check all that apply)

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

2)
3)
4)

R

(Retirement Plan Information)

1)

H

(Financial Information)

B

(Actuarial Information)

2)

I

(Financial Information--Small Plan)

E

(ESOP Annual Information)

3)

A

(Insurance Information)

4)

C

(Service Provider Information)

5)

D

(DFE/Participating Plan
Information)

6)

G

(Financial Transaction Schedules)

3R

1)

D

a Pension Benefit Schedules

SSA (Separated Vested
Participant Information)

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1

0

8

0

0

0

4

0

D
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