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

Form 5500-SF
Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security Administration
Pension Benefit Guaranty Corporation

Part I

OMB Nos. 1210-0110
1210-0089

Short Form Annual Return/Report of Small Employee
Benefit Plan
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).

20121
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 20121 or fiscal plan year beginning

and ending

X a single-employer plan

X a multiple-employer plan (not multiemployer)
X a one-participant plan
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)
X Form 5558
X automatic extension
X DFVC program
C Check box if filing under:
X special extension (enter description)
b
Part II Basic Plan Information—enter all requested information
1b Three-digit
1a Name of plan ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
plan number
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
001
(PN) 
ABCDEFGHI ABCDEFGHI ABCDEFGHI
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
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
(EIN)
012345678
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
2c Sponsor’s telephone number
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
1234567890
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
2d Business code (see instructions)
ABCDEFGHI ABCDEFGH ABCDEFGHI ABCDEFGHI ABCDEFGHI I
123456
3b Administrator’s EIN
3a Plan administrator’s name and address (if same as plan sponsor, enter “Same”) X Same as Plan Sponsor
012345678
Name X Same as Plan Sponsor Address
3c Administrator’s telephone number
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
1234567890
ABCDEFGHI
123456789 ABCDEFGHI ABCDEFGHI ABCDE123456789 ABCDEFGHI ABCDEFGHI A
A This return/report is for:
B This return/report is:

4
a
5a
b
c

Formatted Table

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.
Sponsor’s name DEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI CDEFGHI

4b EIN

4c PN
Total number of participants at the beginning of the plan year ..................................................................................... 5a
Total number of participants at the end of the plan year ............................................................................................... 5b
Number of participants with account balances as of the end of the plan year (defined benefit plans do not
complete this item) .........................................................................................................................................................

5c
6a Were all of the plan’s assets during the plan year invested in eligible assets? (See instructions.) .............................................................
b 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 line 6a or 6b, the plan cannot use Form 5500-SF and must instead use Form 5500.
Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established.

Formatted Table

012345678
012
12345678
12345678
12345678
X Yes X No
X Yes X No
Formatted Table

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

Date

Enter name of individual signing as plan administrator

Formatted: Normal, Space Before: 0 pt,
After: 0 pt, Tab stops: Not at 0.25" + 6.6"
Formatted: Default Paragraph Font, Font: Not
Bold

Signature of employer/plan sponsor

Date

Enter name of individual signing as employer or plan sponsor

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-SF.

Preparer’s telephone number (optional)

Form 5500-SF (2012)
v. 120126

Formatted: Font: Not Bold
Formatted: Justified

Formatted: Font: 7 pt
Formatted: Font: 7 pt

Form 5500-SF 20121 v. 120126

Part III Financial Information
7 Plan Assets and Liabilities
a Total plan assets .........................................................................................7a
b Total plan liabilities .....................................................................................7b
c Net plan assets (subtract line 7b from line 7a) ..........................................7c
8 Income, Expenses, and Transfers for this Plan Year
a Contributions received or receivable from:
(1) Employers .............................................................................................
8a(1)
(2) Participants ...........................................................................................
8a(2)
(3) Others (including rollovers) ...................................................................
8a(3)

b Other income (loss) .....................................................................................8b
c Total income (add lines 8a(1), 8a(2), 8a(3), and 8b) ..................................8c
d 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

Page 2

-1 x
Formatted Table

(a) Beginning of Year

(b) End of Year

-123456789012345
-123456789012345
-123456789012345

-123456789012345
123456789012345
-123456789012345

(a) Amount

(b) Total

-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345

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

-123456789012345

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

Form 5500-SF (2011)
v.012611

Formatted Table

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

10a

-123456789012345

on line 10a.) .................................................................................................................................................

10b

-123456789012345

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

10c

-123456789012345

10d

-123456789012345

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 Did the plan have any participant loans? (If “Yes,” enter amount as of year end.) ..................................
h If this is an individual account plan, was there a blackout period? (See instructions and 29 CFR

10g

-123456789012345

2520.101-3.) ................................................................................................................................................

10h

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

29 CFR 2510.3-102? (See instructions and DOL’s Voluntary Fiduciary Correction Program) ...............

b Were there any nonexempt transactions with any party-in-interest? (Do not include transactions reported

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

Formatted Table

e Were any fees or commissions paid to any brokers, agents, or other persons by an insurance carrier,

i

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

Formatted Table

5500) and line 12a below) .................................................................................................................................................................................

X Yes X No

11a Enter the amount from Schedule SB line 39
.........................
11a
12 Is this a defined contribution plan subject to the minimum funding requirements of section 412 of the Code or section 302 of ERISA? ...

X Yes X No

Formatted: Font: Bold

(If "Yes," complete line 12a or lines 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.
12b
-123456789012345
b Enter the minimum required contribution for this plan year ...........................................................................................

Formatted: Font: Bold

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

12c

Formatted Table

-123456789012345

Formatted: Font: 8 pt
Formatted: Tab stops: 6.14", Left

Form 5500-SF 20121 v. 120126
Page 3 - 1 x
d Subtract the amount in line 12c from the amount in line 12b. Enter the result (enter a minus sign to the left of a

YYYY-MM-DD

12d

negative amount) .............................................................................................................................................................

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

X Yes

X No

X N/A

Part VII Plan Terminations and Transfers of Assets
X Yes X No
13a Has a resolution to terminate the plan been adopted in any plan year? .............................................................................................................................................
13a

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

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

Formatted Table

X Yes X No

c 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):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

13c(2) EIN(s)

123456789

13c(3) PN(s)

012

Formatted Table

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.

Part VIII Trust Information (optional)
14a Name of trust

Formatted Table

14b Trust’s EIN

Formatted: Font: 11 pt