Form 5500-SF Short Form Annual Return/Report of Small Employee Benefi

Department of the Treasury
Internal Revenue Service

Pension Benefit Guaranty Corporation

This Form is Open to Public
Inspection

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

Annual Report Identification Information

For calendar plan year 2011 or fiscal plan year beginning

A
B

2011

This form is required to be filed under sections 104 and 4065 of the Employee
Retirement Income Security Act of 1974 (ERISA), and sections 6057(b) and 6058(a) of
the Internal Revenue Code (the Code).

Department of Labor
Employee Benefits Security Administration

Part I

OMB Nos. 1210-0110
1210-0089

Short Form Annual Return/Report of Small Employee
Benefit Plan

Form 5500-SF

This return/report is for:

X

a single-employer plan

and ending

X a multiple-employer plan (not multiemployer)
X
X the final return/report
X a short plan year return/report (less than 12 months)
X automatic extension
X

X the first return/report
X an amended return/report
X Form 5558
C Check box if filing under:
X special extension (enter description)
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
This return/report is:

a one-participant plan

DFVC program

b
1b

Three-digit
plan number
(PN) 

1c

Effective date of plan

2a

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

2b

ABCDEFGHI
123456789 ABCDEFGHI ABCDEFGHI ABCDE
123456789 ABCDEFGHI ABCDEFGHI ABCDE
CITYEFGHI ABCDEFGHI AB, ST 012345678901 UK
3a Plan administrator’s name and address (if same as plan sponsor, enter “Same”)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
123456789 ABCDEFGHI ABCDEFGHI ABCDE123456789 ABCDEFGHI ABCDEFGHI A
4 If the name and/or EIN of the plan sponsor has changed since the last return/report filed for this plan, enter the

2c

Employer Identification Number
(EIN)
012345678
Sponsor’s telephone number

001
YYYY-MM-DD

a
5a
b
c
6a
b

name, EIN, and the plan number from the last return/report.
Sponsor’s name DEFGHI ABCDEFGHI ABCDEFGHI

1234567890
2d Business code (see instructions)
123456
3b Administrator’s EIN
012345678
3c Administrator’s telephone number
1234567890
4b EIN
012345678

Total number of participants at the end of the plan year ............................................................................................

4c
5a
5b

Number of participants with account balances as of the end of the plan year (defined benefit plans do not
complete this item) .....................................................................................................................................................

5c

ABCDEFGHI CDEFGHI

Total number of participants at the beginning of the plan year ..................................................................................

012
12345678
12345678

PN

Were all of the plan’s assets during the plan year invested in eligible assets? (See instructions.) ..........................................................
Are you claiming a waiver of the annual examination and report of an independent qualified public accountant (IQPA)
under 29 CFR 2520.104-46? (See instructions on waiver eligibility and conditions.) ................................................................................
If you answered “No” to either 6a or 6b, the plan cannot use Form 5500-SF and must instead use Form 5500.

Part III Financial Information
7 Plan Assets and Liabilities
a Total plan assets ................................................................................
b Total plan liabilities .............................................................................
c Net plan assets (subtract line 7b from line 7a) ...................................
8 Income, Expenses, and Transfers for this Plan Year
a Contributions received or receivable from:

(a) Beginning of Year
7a
7b
7c

-123456789012345
-123456789012345
-123456789012345
(a) Amount

(1) Employers ................................................................................... 8a(1)
(2) Participants ................................................................................. 8a(2)
(3) Others (including rollovers) .......................................................... 8a(3)

b
c
d

Other income (loss) ............................................................................

8b

Total income (add lines 8a(1), 8a(2), 8a(3), and 8b) .........................

8c

Benefits paid (including direct rollovers and insurance premiums
to provide benefits).............................................................................

8d

e
f
g
h
i
j

Certain deemed and/or corrective distributions (see instructions) .....

8e

Administrative service providers (salaries, fees, commissions) .........

8f

Other expenses ..................................................................................

8g

Total expenses (add lines 8d, 8e, 8f, and 8g) ....................................

8h

Net income (loss) (subtract line 8h from line 8c) ................................

8i

Transfers to (from) the plan (see instructions) ...................................

8j

For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500-SF.

X
X

12345678
Yes X No
Yes

X

No

(b) End of Year

-123456789012345
123456789012345
-123456789012345
(b) Total

-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
Form 5500-SF (2011)
v.012611

Page 2

Form 5500-SF 2011

-1 x

Part IV
Plan Characteristics
9a If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristic Codes in the instructions:
b

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

Part V Compliance Questions
10 During the plan year:
a Was there a failure to transmit to the plan any participant contributions within the time period described in

Yes

No

Amount

29 CFR 2510.3-102? (See instructions and DOL’s Voluntary Fiduciary Correction Program) ..............
Were there any nonexempt transactions with any party-in-interest? (Do not include transactions reported
on line 10a.) .............................................................................................................................................

10a

-123456789012345

10b

-123456789012345

c

Was the plan covered by a fidelity bond? ...............................................................................................

10c

-123456789012345

d

Did the plan have a loss, whether or not reimbursed by the plan’s fidelity bond, that was caused by fraud
or dishonesty? .........................................................................................................................................

10d

-123456789012345

e

Were any fees or commissions paid to any brokers, agents, or other persons by an insurance carrier,
insurance service or other organization that provides some or all of the benefits under the plan? (See
instructions.) ............................................................................................................................................

10e

-123456789012345

f

Has the plan failed to provide any benefit when due under the plan? ....................................................

10f

-123456789012345

g
h

Did the plan have any participant loans? (If “Yes,” enter amount as of year end.)..................................

10g

-123456789012345

If this is an individual account plan, was there a blackout period? (See instructions and 29 CFR
2520.101-3.) ............................................................................................................................................

10h

i

If 10h was answered “Yes,” check the box if you either provided the required notice or one of the
exceptions to providing the notice applied under 29 CFR 2520.101-3 ....................................................

10i

b

Part VI Pension Funding Compliance
11 Is this a defined benefit plan subject to minimum funding requirements? (If "Yes," see instructions and complete Schedule SB (Form

X
X

5500)) ...........................................................................................................................................................................................................

12

Is this a defined contribution plan subject to the minimum funding requirements of section 412 of the Code or section 302 of ERISA? ..

Yes
Yes

X
X

No
No

(If "Yes," complete 12a or 12b, 12c, 12d, and 12e 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 letter ruling
granting the waiver. ................................................................................................................................. Month _______ Day _______ Year ________
If you completed line 12a, complete lines 3, 9, and 10 of Schedule MB (Form 5500), and skip to line 13.

b
c
d

Enter the minimum required contribution for this plan year..........................................................................................

12b

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

12c

-123456789012345
-123456789012345

Subtract the amount in line 12c from the amount in line 12b. Enter the result (enter a minus sign to the left of a
negative amount) .........................................................................................................................................................

12d

YYYY-MM-DD

e

Will the minimum funding amount reported on line 12d be met by the funding deadline? .......................................................

Part VII Plan Terminations and Transfers of Assets
13a Has a resolution to terminate the plan been adopted in any plan year?

.................................................................................

X

X

Yes

Yes

X

X

No

X

N/A

No

If “Yes,” enter the amount of any plan assets that reverted to the employer this year ......................................... 13a

b
c

Were all the plan assets distributed to participants or beneficiaries, transferred to another plan, or brought under the control
of the PBGC? ...........................................................................................................................................................................

X

Yes

X

No

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.)
13c(1) Name of plan(s):

13c(2) EIN(s)

13c(3) PN(s)

123456789

012

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, if applicable, a Schedule
SB or Schedule MB completed and signed by an enrolled actuary, 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
SIGN
HERE

Signature of plan administrator

Signature of employer/plan sponsor

YYYY-MM-DD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Date

Enter name of individual signing as plan administrator

YYYY-MM-DD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Date

Enter name of individual signing as employer or plan sponsor