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

20121

 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 Form is Open to Public
Inspection

Annual Report Identification Information

For calendar plan year 20121 or fiscal plan year beginning

and ending

A This return/report is for:

X a multiemployer plan;
X a single-employer plan;

X a multiple-employer plan; or
X a DFE (specify)
_C_

B This return/report is:

X the first return/report;
X an amended return/report;

X the final 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
X Form 5558;
X automatic extension;
X the DFVC program;
D Check box if filing under:
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
2a Plan sponsor’s name and address; include room or suite number (employer, if for a single-employer plan)

1b Three-digit plan

001
number (PN) 
1c Effective date of plan
YYYY-MM-DD
2b Employer Identification
Number (EIN)

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

012345678
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
Signature of plan administrator
SIGN
HERE
Signature of employer/plan sponsor
SIGN
HERE
Signature of DFE

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

YYYY-MM-DD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Date

Enter name of individual signing as DFE
Preparer’s telephone number
(optional)

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

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

Form 5500 (20121)
v. 120126012611

Page 2

Form 5500 (20121) v. 120126

3a Plan administrator’s name and address (if same as plan sponsor, enter ―Same‖) X Same as Plan Sponsor Name
Same as Plan Sponsor Address

X

3b Administrator’s EIN
012345678
3c Administrator’s telephone

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
number
0123456789
123456789 ABCDEFGHI ABCDEFGHI ABCDE
123456789 ABCDEFGHI ABCDEFGHI ABCDE
CITYEFGHI ABCDEFGHI AB, ST 012345678901
UK
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
4b EIN
the plan number from the last return/report:
012345678
a Sponsor’s name
4c PN
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
012
5 Total number of participants at the beginning of the plan year
123456789012
5
6 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
6g
complete this item) ..........................................................................................................................................................................

123456789012

h Number of participants that terminated employment during the plan year with accrued benefits that were

123456789012
6h
less than 100% vested ....................................................................................................................................................................
7 Enter the total number of employers obligated to contribute to the plan (only multiemployer plans complete this item) ...................
7
8a If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristics Codes in the instructions:
b If the plan provides welfare benefits, enter the applicable welfare feature codes from the List of Plan Characteristics Codes in the instructions:

9a Plan funding arrangement (check all that apply)
9b 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
10 Check all applicable boxes in 10a and 10b to indicate which schedules are attached, and, where indicated, enter the number attached. (See instructions)
a Pension Schedules
(1)
X R (Retirement Plan Information)
(2)

(3)

X

X

b General Schedules
(1)

X

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

(2)

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

(5)

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

(3)
(4)
(6)

H (Financial Information)