5500 Annual Return/Report of Employee Benefit Plan

Annual Return/Report of Employee Benefit Plan

111118 Clean Form5500

Annual Return/Report of Employee Benefit Plan

OMB: 1545-1610

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Form 5500 (2012) v. 111118 Page 3

Form 5500


Department of the Treasury

Internal Revenue Service

Department of Labor
Employee Benefits Security
Administration

Pension Benefit Guaranty Corporation

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).

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

OMB Nos. 1210-0110

1210-0089


2012


This Form is Open to Public Inspection

Part I

Annual Report Identification Information

For calendar plan year 2012 or fiscal plan year beginning and ending

A This return/report is for:

X a multiemployer plan;

X a multiple-employer plan; or


X a single-employer plan;

X a DFE (specify) _C_




B This return/report is:

X the first return/report;

X the final return/report;


X an amended return/report;

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

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

D Check box if filing under:

X Form 5558;

X automatic extension;

X the DFVC program;


X special extension (enter description) ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

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 Three-digit plan number (PN)

001

1c 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

SIGN
HERE




YYYY-MM-DD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Signature of employer/plan sponsor

Date

Enter name of individual signing as employer or plan sponsor

SIGN
HERE




YYYY-MM-DD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Signature of DFE

Date

Enter name of individual signing as DFE

Preparer’s name (including firm name, if applicable) and address; include room or suite number. (optional) ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

Preparer’s telephone number (optional)


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

Form 5500 (2012)

v. 111118

3a Plan administrator’s name and address XSame as Plan Sponsor Name XSame as Plan Sponsor Address


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

3b Administrator’s EIN
012345678

3c Administrator’s telephone number
0123456789


4 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 EIN
012345678

a Sponsor’s name

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

4c PN
012

5a Name of trust (optional) ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

5b Trust’s EIN (optional)ABCDEFGHI 555555555

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

6

123456789012

7 Number of participants as of the end of the plan year (welfare plans complete only lines 7a, 7b, 7c, and 7d).


a Active participants

7a

123456789012

b Retired or separated participants receiving benefits

7b

123456789012

c Other retired or separated participants entitled to future benefits

7c

123456789012

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

7d

123456789012

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

7e

123456789012

f Total. Add lines 7d and 7e.

7f

123456789012

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

7g

123456789012

h Number of participants that terminated employment during the plan year with accrued benefits that were
less than 100% vested

7h

123456789012

8 Enter the total number of employers obligated to contribute to the plan (only multiemployer plans complete this item)

8


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:


10a Plan funding arrangement (check all that apply)

10b Plan benefit arrangement (check all that apply)

(1) X Insurance

(1) X Insurance

(2) X Code section 412(e)(3) insurance contracts

(2) X Code section 412(e)(3) insurance contracts

(3) X Trust

(3) X Trust

(4) X General assets of the sponsor

(4) X General assets of the sponsor

11 Check all applicable boxes in 11a and 11b to indicate which schedules are attached, and, where indicated, enter the number attached. (See instructions)

a Pension Schedules

b General Schedules

(1) X R (Retirement Plan Information)


(1) X H (Financial Information)

(2) X MB (Multiemployer Defined Benefit Plan and Certain Money Purchase Plan Actuarial Information) - signed by the plan actuary

(2) X I (Financial Information – Small Plan)

(3) X ___ A (Insurance Information)

(4) X C (Service Provider Information)

(3) X SB (Single-Employer Defined Benefit Plan Actuarial Information) - signed by the plan actuary

(5) X D (DFE/Participating Plan Information)

(6) X G (Financial Transaction Schedules)


File Typeapplication/msword
File TitleForm 5500
AuthorBruce Silver
Last Modified BySt.Onge, Emily - EBSA CTR MPR
File Modified2011-11-14
File Created2011-11-01

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