Form 5500-EZ Annual Return of One-Participant (Owners and Their Spous

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I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 5500-EZ, PAGE 1 of 2
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES.
PAPER: WHITE, WRITING, SUB. 20
FLAT SIZE: 203mm (8") 3 279mm (11")
PERFORATE: (NONE)

Date

Form

add a
blank line
space

Annual Return of One-Participant
(Owners and Their Spouses) Retirement Plan

OMB No. 1545-0956

2009

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This Form is Open
to Public Inspection.

Annual Return Identification Information

For the calendar plan year 2009 or fiscal plan year beginning

This return is:

(1)
(3)
1 (5)

for a one-participant plan;
the first return filed for the plan;
an amended return;

2

B

Revised proofs
requested

This form is required to be filed under section 6058(a) of the Internal Revenue Code.
Certain foreign retirement plans are also required to file this form (see instructions).
© Complete all entries in accordance with the instructions to the Form 5500-EZ

Department of the Treasury
Internal Revenue Service

A

Signature

If this return is for a foreign plan, check this box (see instructions) . . . . . . . . . . . . . . .> [ ]

5500-EZ

Part I

Date

O.K. to print

PRINTS: HEAD TO HEAD
INK: BLACK

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

C

Action

,

3

(2)
(4)
(6)

and ending

for a foreign plan (see instructions);
the final return filed for the plan;
a short plan year return (less than 12 months).

4

If filing under an extension of time, check box and attach required information (see instructions)

Part II

,

©

Basic Plan Information — enter all requested information.

1a Name of plan

2a Employer’s name

1b Three-digit
plan number (PN) ©
1c Date plan first became effective
(mo., day, yr.)
2b Employer Identification Number (EIN)
(Do not enter your Social Security Number)

2c Trade name of business (if different from name of employer)

2d Employer’s telephone number
c

2e In care of name
2f Business code (see instructions)
2g Mailing address (room, apt., suite no. and street, or P.O. Box)

d

2h City, state, and ZIP code (if foreign, see instructions)
3a Plan administrator’s name and address (If same as employer, enter “Same”)

3b Administrator’s EIN

3c Plan administrator’s name

3d Administrator’s telephone number
c

3e In care of name
3f Mailing address (room, apt., suite no. and street, or P.O. Box)
3g City, state, and ZIP code (if foreign, see instructions)
4

If the name and/or EIN of the employer has changed since the last return filed for this plan, enter the
name, EIN, and plan number for the last return in the appropriate space provided:
a Employer’s name

4c PN

5a

5a Total number of participants at the beginning of the year

5b

b Total number of participants at the end of the year

Part III

4b EIN

Financial Information
(1) Beginning of year

6a Total plan assets
b Total plan liabilities

6b

c Net plan assets (subtract line 6b from 6a)

6c

For Paperwork Reduction Act Notice, see the instructions for Form 5500-EZ.
Lines 2a and 3a will each have 5 fill-in line blocks each separated by a horizontal
line connecting to the vertical line on the right side.

(2) End of year

6a

Cat. No. 52729U

Form

5500-EZ

(2009)

2
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 5500-EZ, PAGE 2 of 2
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES.
PAPER: WHITE, WRITING, SUB. 20
FLAT SIZE: 203mm (8") 3 279mm (11")
PERFORATE: (NONE)

PRINTS: HEAD TO HEAD
INK: BLACK

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 5500-EZ (2009)

Part III
7

Page

(Continued)

7a

7b

b Participants
c Others (including rollovers)

Part IV

Plan Characteristics
two-character

8

7c

Enter the applicable feature codes from the List of Plan Characteristics Codes in the instructions:

Part V
9

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Amount

Contributions received or receivable from:

a Employers

increase
size of
boxes
and add
a vertical
divider
line in the
middle of
each box

2

Compliance and Funding Questions

During the plan year, did the plan have any participant loans?
If “Yes,” enter amount as of year end

Yes

No

Yes

No

Yes

No

©

10

Is this a defined benefit plan that is subject to minimum funding requirements?
If “Yes,” complete Schedule SB (Form 5500) and see instructions.
see instructions and
11 Is this a defined contribution plan subject to the minimum funding requirements of section
412 of the Code?
If “Yes,” complete lines 11a or 11b, 11c, 11d, and 11e below, as applicable:
a If a waiver of the minimum funding standard for a prior year is being amortized in this plan
year, see instructions and enter the date of the ruling letter granting the waiver:
Month
Day
Year
b Enter the minimum required contribution for this plan year

11b

c Enter the amount contributed by the employer to the plan for this plan year

11c

d Subtract the amount in line 11c from the amount in line 11b. (Enter a minus sign to the left
of a negative amount)

11d

e Will the minimum funding amount reported on line 11d be met by the funding deadline?
Yes
No
N/A
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, and to the best of my knowledge and belief, it is true, correct, and complete.

Sign
Here

©
Signature of employer or plan administrator

Date

Type or print name of individual signing as employer or
plan administrator
Form

Printed on recycled paper

5500-EZ

(2009)