Form 5500 Annual Return/Report of Employee Benefit Plan

Form 5500
Department of the Treasury
Internal Revenue Service

Annual Return/Report of Employee Benefit Plan
This form is required to be filed for employee benefit plans 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).

Department of Labor
Employee Benefits Security
Administration

This Form is Open to Public
Inspection

Annual Report Identification Information

For calendar plan year 2011 or fiscal plan year beginning

A

B

2011

 Complete all entries in accordance with
the instructions to the Form 5500.

Pension Benefit Guaranty Corporation

Part I

OMB Nos. 1210-0110
1210-0089

This return/report is for:

This return/report is:

X
X

a multiemployer plan;

X
X

the first return/report;

and ending

a single-employer plan;

an amended return/report;

X
X

a multiple-employer plan; or

X
X

the final return/report;

a DFE (specify)

_C_

a short plan year return/report (less than 12 months).

C

If the plan is a collectively-bargained plan, check here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

D

Check box if filing under:

X
X

X

Form 5558;

X

X the DFVC program;
ABCDEFGHI ABCDEFGHI ABCDE

automatic extension;

special extension (enter description) ABCDEFGHI

Part II
Basic Plan Information—enter all requested information
1a Name of plan
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

1b
1c

Three-digit plan
001
number (PN) 
Effective date of plan

YYYY-MM-DD
2a

Plan sponsor’s name and address; include room or suite number (employer, if for a single-employer plan)

2b

Employer Identification
Number (EIN)

012345678
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
D/B/A ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
123456789 ABCDEFGHI ABCDEFGHI ABCDE
123456789 ABCDEFGHI ABCDEFGHI ABCDE
CITYEFGHI ABCDEFGHI AB, ST 012345678901
UK

2c

Sponsor’s telephone
number

0123456789
2d

Business code (see
instructions)

012345

Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established.
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, and to the best of my knowledge and belief, it is true, correct, and complete.
SIGN
HERE

YYYY-MM-DD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Signature of plan administrator

Date

Enter name of individual signing as plan administrator

YYYY-MM-DD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Signature of employer/plan sponsor

Date

Enter name of individual signing as employer or plan sponsor

YYYY-MM-DD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

SIGN
HERE

SIGN
HERE

Signature of DFE
Date
Enter name of individual signing as DFE
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500.

Form 5500 (2011)
v.012611

Page 2

Form 5500 (2011)

3a Plan administrator’s name and address (if same as plan sponsor, enter “Same”)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
123456789 ABCDEFGHI ABCDEFGHI ABCDE
123456789 ABCDEFGHI ABCDEFGHI ABCDE
CITYEFGHI ABCDEFGHI AB, ST 012345678901
UK
4
a

3b

Administrator’s EIN

012345678
3c

Administrator’s telephone
number

0123456789

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:

4b

Sponsor’s name

4c

012345678

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
5
6

Total number of participants at the beginning of the plan year

EIN
PN

5

012
123456789012

Number of participants as of the end of the plan year (welfare plans complete only lines 6a, 6b, 6c, and 6d).

a

Active participants .....................................................................................................................................................................

6a

123456789012

b

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

6b

123456789012

c

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

6c

123456789012

d

Subtotal. Add lines 6a, 6b, and 6c...........................................................................................................................................

6d

123456789012

e

Deceased participants whose beneficiaries are receiving or are entitled to receive benefits. ..................................................

6e

123456789012

f

Total. Add lines 6d and 6e. ......................................................................................................................................................

6f

123456789012

g

Number of participants with account balances as of the end of the plan year (only defined contribution plans
complete this item) ....................................................................................................................................................................

6g

123456789012

Number of participants that terminated employment during the plan year with accrued benefits that were
less than 100% vested ..............................................................................................................................................................
Enter the total number of employers obligated to contribute to the plan (only multiemployer plans complete this item) ........

6h
7

123456789012

h
7
8a
b

9a

If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristic Codes in the instructions:

If the plan provides welfare benefits, enter the applicable welfare feature codes from the List of Plan Characteristic Codes in the instructions:

Plan funding arrangement (check all that apply)
(1)
X Insurance
(2)
(3)
(4)

10
a

X
X
X

9b

Plan benefit arrangement (check all that apply)
(1)
X Insurance

Code section 412(e)(3) insurance contracts

(2)

Trust

(3)

General assets of the sponsor

(4)

X
X
X

Code section 412(e)(3) insurance contracts
Trust
General assets of the sponsor

Check all applicable boxes in 10a and 10b to indicate which schedules are attached, and, where indicated, enter the number attached. (See instructions)
Pension Schedules
(1)
X R (Retirement Plan Information)
(2)

(3)

X

X

MB (Multiemployer Defined Benefit Plan and Certain Money
Purchase Plan Actuarial Information) - signed by the plan
actuary
SB (Single-Employer Defined Benefit Plan Actuarial
Information) - signed by the plan actuary

b

General Schedules
(1)

X

(2)

X
X
X
X
X

(3)
(4)
(5)
(6)

H (Financial Information)
I (Financial Information – Small Plan)
___ A (Insurance Information)
C (Service Provider Information)
D (DFE/Participating Plan Information)
G (Financial Transaction Schedules)