Form 5500

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 Form 5500-SF
Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security Administration
Pension Benefit Guaranty Corporation
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).
 Complete all entries in accordance with the instructions to the Form 5500-SF.
OMB Nos. 1210-0110
1210-0089
2013
This Form is Open to Public Inspection
Part I
  Annual Report Identification Information
For calendar plan year 2013 or fiscal plan year beginning                                                                      and ending                                                       
A	This return/report is for:			
X  a single-employer plan
X  a multiple-employer plan (not multiemployer)
X  a one-participant plan
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 	Check box if filing under: 
X  Form 5558    
X  automatic extension   
X  DFVC program

X  special extension (enter description)                                                                                                                b

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) 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGH ABCDEFGHI ABCDEFGHI ABCDEFGHI I
2b	Employer Identification Number (EIN) 	012345678

2c	Sponsor’s telephone number	1234567890

2d	Business code (see instructions)	 
123456
3a  Plan administrator’s name and address  XSame as Plan Sponsor Name CXSame as Plan Sponsor Address EFGHI 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 012345678901I A
3b	Administrator’s EIN
	012345678

3c	Administrator’s telephone number	 1234567890
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.  
  a  Sponsor’s name DEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI CDEFGHI 
4b	EIN	012345678

4c	PN                                     012
5a	Total number of participants at the beginning of the plan year	
5a
12345678
b	Total number of participants at the end of the plan year	
5b
12345678
c	Number of participants with account balances as of the end of the plan year (defined benefit plans do not complete this item)	
5c
12345678
6a	 Were all of the plan’s assets during the plan year invested in eligible assets? (See instructions.)	
X Yes X No
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.)	
X Yes X No
	If you answered “No” to either line 6a or line 6b, the plan cannot use Form 5500-SF and must instead use Form 5500.













  c  If the plan is a defined benefit plan, is it covered under the PBGC insurance program (see ERISA section 4021)? ...... X  Yes   X No    X  Not determined
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




Signature of plan administrator
Date
Enter name of individual signing as plan administrator
SIGN
HERE




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)
       ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
Preparer’s telephone number (optional)


For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500-SF.
Form 5500-SF (2013) 
 v. 130118


Part III
  Financial Information
7	Plan Assets and Liabilities

(a) Beginning of Year
(b) End of Year
a	Total plan assets	
7a
-123456789012345
-123456789012345
b	Total plan liabilities	
7b
-123456789012345
123456789012345
c	Net plan assets (subtract line 7b from line 7a)	
7c
-123456789012345
-123456789012345
8	Income, Expenses, and Transfers for this Plan Year

(a) Amount
(b) Total
a	Contributions received or receivable from:
	(1)  Employers	
8a(1)
-123456789012345

  	(2)  Participants	
8a(2)
-123456789012345

	(3)  Others (including rollovers)	
8a(3)
-123456789012345

b	Other income (loss)	
8b
-123456789012345

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

-123456789012345
d	Benefits paid (including direct rollovers and insurance premiums to provide benefits)	
8d
-123456789012345

e	Certain deemed and/or corrective distributions (see instructions)	
8e
-123456789012345

f	Administrative service providers (salaries, fees, commissions)	
8f
-123456789012345

g	Other expenses	
8g
-123456789012345

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

-123456789012345
i	Net income (loss) (subtract line 8h from line 8c)	
8i

-123456789012345
j	Transfers to (from) the plan (see instructions)	
8j
-123456789012345

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:
Yes
No
Amount
a	Was there a failure to transmit to the plan any participant contributions within the time period described in 29 CFR 2510.3-102? (See instructions and DOL’s Voluntary Fiduciary Correction Program)	
10a


-123456789012345
b	Were there any nonexempt transactions with any party-in-interest? (Do not include transactions reported on line 10a.)	
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	Did the plan have any participant loans? (If “Yes,” enter amount as of year end.)	
10g


-123456789012345
h	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



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 5500) and line 11a below)	
X Yes X No
11a  Enter the unpaid minimum required contribution for current year from Schedule SB (Form 5500) 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
	(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.
b	Enter the minimum required contribution for this plan year	
12b
-123456789012345



c	Enter the amount contributed by the employer to the plan for this plan year	
12c
-123456789012345
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 negative amount)	
12d
YYYY-MM-DD
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
13a  Has a resolution to terminate the plan been adopted in any plan year? 	
      X   Yes   X  No
          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?	
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):
13c(2) EIN(s)
13c(3) PN(s)
	ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
123456789
012
Part VIII
Trust Information (optional)
14a Name of trust ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
14b Trust’s EIN