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

Form

5500-EZ

2011
Annual Return of One-Participant
(Owners and Their Spouses) Retirement Plan

Annual Return Identification Information

,
and ending
the final return filed for the plan;
a short plan year return (less than 12 months).

(3)
(4)

If filing under an extension of time, check this box (see instructions) .
If this return is for a foreign plan, check this box (see instructions) .

Part II

This Form is Open
to Public Inspection.

2011

For the calendar plan year 2010 or fiscal plan year beginning
A
This return is: (1) the first return filed for the plan;
(2) an amended return;
B
C

2010

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

Part I

OMB No. 1545-0956

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▶
▶

Basic Plan Information — enter all requested information.

1a

Name of plan

1b Three-digit
plan number (PN) ▶
1c Date plan first became effective
(MM,DD,YYYY)

2a

Employer’s name

2b Employer Identification Number (EIN)
(Do not enter your Social Security Number)

Trade name of business (if different from name of employer)
2c Employer’s telephone number
In care of name
2d Business code (see instructions)
Mailing address (room, apt., suite no. and street, or P.O. Box)
City, state, and ZIP code (if foreign, see instructions)
3a

Plan administrator’s name (If same as employer, enter “Same”)

3b Administrator’s EIN

In care of name

3c Administrator’s telephone number

Mailing address (room, apt., suite no. and street, or P.O. Box)
City, state, and ZIP code (if foreign, see instructions)
4
a

5a

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:

4b

EIN

Employer’s name

4c

PN

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

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

Part III

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5a

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5b

Financial Information
(1) Beginning of year

6a

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6a

b Total plan liabilities .

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6b

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

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6c

c

Total plan assets

For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 5500-EZ.

Cat. No. 63263R

(2) End of year

Form 5500-EZ (2010)

2011

2011
Form 5500-EZ (2010)

Part III
7

Page

(Continued)
Amount

Contributions received or receivable from:
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7a

b Participants .

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7b

Others (including rollovers) .

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7c

a

c

Employers.

Part IV
8

2

Plan Characteristics

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

Compliance and Funding Questions

Part V

Yes No
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9

10

Is this a defined benefit plan that is subject to minimum funding requirements? .
If “Yes,” complete Schedule SB (Form 5500). (See instructions.)

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11

Is this a defined contribution plan subject to the minimum funding requirements
of section 412 of the Code? . . . . . . . . . . . . . . . . . . . . 11
If “Yes,” complete lines 11a or 11b, 11c, 11d, and 11e below, as applicable:
If a waiver of the minimum funding standard for a prior year is being amortized in this plan
year, enter the month, day, and year (MM,DD,YYYY) of the letter ruling granting the waiver
(see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . .

9

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

a

b Enter the minimum required contribution for this plan year .

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11a

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11b

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

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11c

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

11d

c

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Amount

Yes No N/A
e

Will the minimum funding amount reported on line 11d be met by the funding
deadline? . . . . . . . . . . . . . . . . . . . . . . . . .
11e
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 5500-EZ (2010)

2011