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Form
5500 (20122013) 130118 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
20122013
This
Form is Open to Public Inspection
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Part
I
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Annual
Report Identification Information
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For
calendar plan year 2012 2013 or fiscal plan year beginning
and ending
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A
This return/report is for:
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X
a multiemployer plan;
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X
a multiple-employer plan; or
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X
a single-employer plan;
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X
a DFE (specify)
_C_
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|
|
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B
This return/report is:
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X
the first return/report;
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X
the final return/report;
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X
an amended return/report;
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X
a short plan year return/report (less than 12 months).
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C
If the plan is a collectively-bargained plan, check here. . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . .
X
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D
Check box if filing under:
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X
Form 5558;
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X
automatic extension;
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X
the DFVC program;
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X
special extension (enter description) ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDE
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Part
II
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Basic
Plan Information—enter
all requested information
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1a
Name of plan
ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
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1b Three-digit
plan number (PN)
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001
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1c Effective
date of plan
YYYY-MM-DD
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2a
Plan sponsor’s name and address; include room or suite
number (employer, if for a single-employer plan)
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2b Employer
Identification Number (EIN)
012345678
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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
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2c Sponsor’s
telephone number
0123456789
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2d Business
code (see instructions)
012345
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Caution:
A penalty for the late or incomplete filing of this return/report
will be assessed unless reasonable cause is established.
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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.
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SIGN
HERE
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YYYY-MM-DD
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ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDE
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Signature
of plan administrator
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Date
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Enter
name of individual signing as plan administrator
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SIGN
HERE
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YYYY-MM-DD
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ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDE
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Signature
of employer/plan sponsor
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Date
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Enter
name of individual signing as employer or plan sponsor
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SIGN
HERE
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YYYY-MM-DD
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ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDE
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Signature
of DFE
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Date
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Enter
name of individual signing as DFE
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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
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Preparer’s
telephone number (optional)
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For
Paperwork Reduction Act Notice and OMB Control Numbers, see the
instructions for Form 5500.
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Form
5500 (20122013)
v.
120126130118
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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
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3b
Administrator’s EIN
012345678
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3c
Administrator’s telephone number
0123456789
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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:
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4b EIN
012345678
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a Sponsor’s
name
ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
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4c PN
012
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5 Total
number of participants at the beginning of the plan year
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5
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123456789012
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6 Number
of participants as of the end of the plan year (welfare plans
complete only lines 6a,
6b, 6c,
and 6d).
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a Active
participants
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6a
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123456789012
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b Retired
or separated participants receiving benefits
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6b
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123456789012
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c Other
retired or separated participants entitled to future benefits
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6c
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123456789012
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d Subtotal.
Add lines 6a,
6b,
and 6c.
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6d
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123456789012
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e Deceased
participants whose beneficiaries are receiving or are entitled to
receive benefits.
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6e
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123456789012
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f Total.
Add lines 6d
and 6e.
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6f
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123456789012
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g Number
of participants with account balances as of the end of the plan
year (only defined contribution plans
complete this item)
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6g
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123456789012
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h Number
of participants that terminated employment during the plan year
with accrued benefits that were
less than 100% vested
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6h
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123456789012
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7 Enter
the total number of employers obligated to contribute to the plan
(only multiemployer plans complete this item)
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7
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8a If
the plan provides pension benefits, enter the applicable pension
feature codes from the List of Plan Characteristics Codes in the
instructions:
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b If
the plan provides welfare benefits, enter the applicable welfare
feature codes from the List of Plan Characteristics Codes in the
instructions:
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9a Plan
funding arrangement (check all that apply)
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9b Plan
benefit arrangement (check all that apply)
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(1)
X
Insurance
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(1)
X
Insurance
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(2)
X Code
section 412(e)(3) insurance contracts
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(2)
X
Code
section 412(e)(3) insurance contracts
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(3)
X Trust
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(3)
X
Trust
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(4)
X
General
assets of the sponsor
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(4)
X
General
assets of the sponsor
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10 Check
all applicable boxes in 10a and 10b to indicate which schedules
are attached, and, where indicated, enter the number attached.
(See instructions)
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a
Pension
Schedules
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b General
Schedules
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(1)
X
R
(Retirement Plan Information)
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(1)
X H
(Financial Information)
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(2)
X
MB
(Multiemployer Defined Benefit Plan and Certain Money Purchase
Plan Actuarial Information) - signed by the plan actuary
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(2)
X
I
(Financial Information – Small Plan)
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(3)
X
___ A
(Insurance Information)
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(4)
X
C
(Service Provider Information)
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(3)
X
SB
(Single-Employer
Defined Benefit Plan Actuarial Information) - signed by
the plan actuary
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(5)
X
D
(DFE/Participating Plan Information)
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(6)
X
G
(Financial Transaction Schedules)
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File Type | application/msword |
File Title | Form 5500 |
Author | Bruce Silver |
Last Modified By | St.Onge, Emily - EBSA CTR MPR |
File Modified | 2013-01-14 |
File Created | 2011-11-01 |