Form 5500-SF Instructions (Red Line)

2014 2015

Instructions for Form 5500-SF

Short Form Annual Return/Report of Small Employee Benefit Plan

Code section references are to the Internal Revenue Code unless otherwise noted. ERISA refers to the Employee Retirement Income Security Act of 1974.

_{Changes to Note}

Signature and Date. The instructions for “Signature and Date” have been updated to caution filers to check the Filing Status and to advise that if the filing status is "Processing Stopped" or “Unprocessable”, it is possible your submission was not sent with a valid electronic signature as required, and depending on the error, may be considered not to have been filed. By looking closer at the Filing Status, you can see specific error messages applicable to the transmitted filing and determine whether it was sent with a valid electronic signature and what other errors may need to be corrected.

Active Participants Information. New questions on the “Total number of active participants at the beginning of the plan year” and “Total number of participants at the end of the plan year” have been added to Lines 5d(1) and d(2).

Vesting Information. A new question, “Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested,” has been added to Line 5e.

Foreign Plans. A new check Box has been added to Part I, A, for certain foreign plans that are submitting the Form 5500-SF in place of a Form 5500-EZ (on paper) to satisfy the annual return/report filing obligations under the Code.

One–Participant Plan and Foreign Plan Filers. A Form 5500-SF may be filed for one-participant plans and certain foreign plans in lieu of Form 5500-EZ regardless of whether or not the plan covered more than 100 participants at the beginning of the plan year.

Multiple-Employer Plan Information. The check box for “Multiple-Employer Plans” in Part I of the Form 5500-SF has been changed to indicate that multiple-employer pension plans must include an attachment that (1) lists each participating employer in the plan during the plan year, identified by name, employer identification number (EIN), and (2) includes a good faith estimate of each employer's percentage of the total contributions (including employer and participant contributions) made by all participating employers during the year.

Filers will need to complete as many entries as needed to report all applicable employers.

IRS Electronic Filing Requirements. On September 29, 2014, the Treasury Department issued final regulations under sections 6058 and 6059 of the Code providing that certain filers must electronically file the Form 5500 series returns/reports (including actuarial schedules). (See T.D. 9695, 79 FR 58256 at http://federalregister.gov/a/2014-23161). Under the regulations you are required to file a Form 5500 series return/report electronically if you are required to file at least 250 returns of all types during the calendar year that includes the first day of the applicable plan year. Because the IRS may now require certain filers to electronically file the Form 5500 series returns/reports, the IRS is adding questions to the Form 5500 and its Schedules relating solely to IRS compliance issues.

IRS Compliance Questions. New Line 10j, Part VIII (Trust Information), and new Part IX (IRS Compliance Questions) were added to this Form for purposes of satisfying the reporting requirements of section 6058 of the Code. Trust information is no longer optional. You are required to answer these questions relating to the name and EIN of the trust, and the trustee’s name and telephone number. Preparer information on the Form 5500-SF is also no longer optional. You are required to answer these questions relating to preparer’s name, address, and telephone number. You are required to answer these questions electronically through EFAST2 if you are required by the Treasury regulations to file the Form 5500 series returns/report electronically. If you are not required to file these returns/reports electronically, you may elect to answer the IRS compliance questions electronically through EFAST2, or you must answer these questions by filing paper Form 5500-SUP, Annual Return of Employee Benefit Plan Supplemental Information. The new IRS-only compliance questions must be answered for plan years beginning on or after January 1, 2015, but only for returns/reports with a filing deadline after December 31, 2015.

Form 5500-SF Final Return/Report for Plans Trusteed by PBGC. The instructions for “Line B – Box for Final Return/Report” are modified to add a statement that a filer for a terminated defined benefit plan for which PBGC has been appointed trustee may contact DOL at [email protected] for further information.

Table of Contents Page

EFAST2 Processing System 1

How To Get Assistance 1

General Instructions 2

Pension and Welfare Plans Required To File
Annual Return/Report 2

Plans Exempt from Filing 3

Who May File 4

What To File 4

When To File 4

Extension of Time To File 4

Delinquent Filer Voluntary Compliance (DFVC)
Program 5

Change in Plan Year 5

Penalties 5

How To File – Electronic Filing Requirement 65

Signature and Date 6 7

Specific Instructions Only for “One-Participant
Plans” and Certain Foreign Plans” 7

Specific Line-by-Line Instructions 8

Part I – Annual Report Identification
Information 8

Part II – Basic Plan Information 9 10

Part III – Financial Information 13

Part IV – Plan Characteristics 14 15

Part V – Compliance Questions 15

Part VI – Pension Funding Compliance 18

Part VII – Plan Terminations and Transfers of
Assets 18 19

Part VIII – Trust Information (Optional) ………………19

Paperwork Reduction Act Notice 19 21

List of Plan Characteristics Codes 20 22

Codes for Principal Business Activity 22 24

ERISA Compliance Quick Checklist 25 27

Index 26 28

EFAST2 Processing System

Under the computerized ERISA Filing Acceptance System (EFAST2), you must electronically file your 2014 2015 Form 5500-SF, Short Form Annual Return/Report of Small Employee Benefit Plan. You may file your 2014 2015 Form 5500-SF online using EFAST2’s web-based filing system or you may file through an EFAST2-approved vendor. You cannot file a paper Form 5500-SF by mail or other delivery service. For more information, see the instructions for How To File – Electronic Filing Requirement on page 6 and the EFAST2 website at www.efast.dol.gov.

How To Get Assistance

If you need help completing this form, or have other questions, call the EFAST2 Help Line at

1-866-GO-EFAST (1-866-463-3278) (toll free) or access the EFAST2 or IRS websites. The EFAST2 Help Line is available Monday through Friday from 8:00 am to 8:00 pm, Eastern Time.

You can access the EFAST2 website 24 hours a day, 7 days a week at www.efast.dol.gov to:

• File the Form 5500-SF or 5500 and any needed schedules or attachments.

• Check on the status of a filing you submitted.

• View filings posted by EFAST2.

• Register for electronic credentials to sign or submit filings.

• View forms and related instructions.

• Get information regarding EFAST2, including approved software vendors.

• See answers to frequently asked questions about the Form 5500-SF, the Form 5500 and its schedules, and EFAST2.

• Access the main Employee Benefits Security Administration (EBSA) and DOL websites for news, regulations, and publications.

You can access the IRS website 24 hours a day, 7 days a week at www.irs.gov to:

• View forms, instructions, and publications.

• See answers to frequently asked tax questions.

• Search publications online by topic or keyword.

• Send comments or request help by e-mail.

• Sign up to receive local and national tax news by e-mail.

You can order other IRS forms and publications by calling 1-800-TAX-FORM (1-800-829-3676). You can order EBSA publications by calling 1-866-444-EBSA (3272).

General Instructions

The Form 5500-SF, Short Form Annual Return/Report of Small Employee Benefit Plan, is a simplified annual reporting form for use by certain small pension and welfare benefit plans. To be eligible to use the Form

5500-SF, the plan must:

• Be a small plan (i.e., generally have fewer than 100 participants at the beginning of the plan year),

• Meet the conditions for being exempt from the requirement that the plan’s books and records be audited by an independent qualified public accountant (IQPA),

• Have 100% of its assets invested in certain secure investments with a readily determinable fair value,

• Hold no employer securities,

• Not be a multiemployer plan and,

• Not be required to file a Form M-1, Report for Multiple-Employer Welfare Arrangements (MEWAs) and Certain Entities Claiming Exception (ECEs) for the plan year.

Plans required to file an annual return/report that are not eligible to file the Form 5500-SF, must file a Form 5500, Annual Return/Report of Employee Benefit Plan, with all required schedules and attachments (Form 5500), or Form 5500-EZ, Annual Return of One-Participant (Owners and Their Spouses) Retirement Plan.

To reduce the possibility of correspondence and penalties, we remind filers that the Internal Revenue Service (IRS), Department of Labor (DOL), and Pension Benefit Guaranty Corporation (PBGC) have consolidated their annual return/report forms to minimize the filing burden for employee benefit plans. Administrators and sponsors of employee benefit plans generally will satisfy their IRS and DOL annual reporting requirements for the plan under ERISA sections 104 and 4065 and Code sections 6058 and 6059 by filing either the Form 5500, Form 5500-SF, or Form 5500-EZ. Defined contribution and defined benefit pension plans may have to file additional information with the IRS including: Form 8955-SSA, Annual Registration Statement Identifying Separated Participants with Deferred Vested Benefits.; Form 5330, Return of Excise Taxes Related to Employee Benefit Plans; Form 5310-A, Notice of Plan Merger or Consolidation, Spinoff, or Transfer of Plan Assets or Liabilities; Notice of Qualified Separate Lines of Business. See www.irs.gov for more information. Defined benefit pension plans covered by the PBGC have special additional requirements, including filing premiums and reporting certain transactions directly with that agency. See the PBGC’s website at www.pbgc.gov/practitioners for information on premium filings and reporting and disclosure requirements.

Note. The Form 5500-EZ generally is used by “one-participant plans” or certain foreign plans (as defined under Specific Instructions Only for “One-Participant Plans and certain Certain foreign Foreign plansPlans” on page 7) that are not subject to the requirements of section 104(a) of ERISA to satisfy certain annual reporting and filing obligations imposed by the Code. A “one-participant plan” or a certain foreign plan may also be eligible to file Form 5500-SF. See Specific Instructions Only for “One-Participant Plans and Certain Foreign Plans.” A “one-participant plan” or a certain foreign plan that is eligible to file Form 5500-SF may elect to file Form 5500-SF electronically with EFAST2 rather than filing a Form 5500-EZ on paper with the IRS. A “one-participant plan” or a certain foreign plan that is not eligible to file Form 5500-SF must file Form 5500-EZ on paper with the IRS. For more information on filing with the IRS, go to www.irs.gov or call 1-877-829-5500.

A bbreviated filing requirements apply for one-participant plan and certain foreign plan filers who are eligible to file Form 5500-SF. See Specific Instructions Only for “One-Participant Plans and Certain Foreign Plans” on page 7.

The Form 5500-SF must be filed electronically. See How To File – Electronic Filing Requirement instructions on page 6 and the EFAST2 website at www.efast.dol.gov. Your

Form 5500-SF entries will be initially screened electronically. Your entries must satisfy this screening for your filing to be received. Once received, your form may be subject to further detailed review, and your filing may be rejected based upon this further review.

ERISA and the Code provide for the assessment or imposition of penalties for not submitting the required information when due. See Penalties on page 5.

Annual returns/reports filed under Title I of ERISA must be made available by plan administrators to plan participants and beneficiaries and by the DOL to the public pursuant to ERISA sections 104 and 106. Pursuant to Section 504 of the Pension Protection Act of 2006 (PPA), this availability for defined benefit pension plans must include the posting of identification and basic plan information and actuarial information (Form 5500-SF, Schedule SB or MB, and all of the Schedule SB or MB attachments) on any plan sponsor intranet website (or website maintained by the plan administrator on behalf of the plan sponsor) that is used for the purpose of communicating with employees and not the public. Section 504 also requires DOL to display such information on DOL’s website within 90 days after the filing of the plan’s annual return/report. To see 2009 and later Forms 5500-SF, including actuarial information, see www.dol.gov/ebsa. See www.dol.gov/ebsa/actuarialsearch.html for 2008 and short plan year 2009 actuarial information filed under the previous paper-based system.

Pension and Welfare Plans Required To File Annual Return/Report

All pension benefit plans and welfare benefit plans covered by ERISA must file a Form 5500 or Form 5500-SF for a plan year unless they are eligible for a filing exemption. (See Code sections 6058 and 6059 and ERISA sections 104 and 4065). An annual return/report must be filed even if the plan is not “tax qualified,” benefits no longer accrue, contributions were not made during this plan year, or contributions are no longer made. Pension benefit plans required to file include both defined benefit plans and defined contribution plans. Profit-sharing plans, stock bonus plans, money purchase plans, 401(k) plans, Code section 403(b) plans covered by Title I of ERISA, and IRA plans established by an employer are among the pension benefit plans for which an annual return/report must be filed. Welfare benefit plans provide benefits such as medical, dental, life insurance, apprenticeship and training, scholarship funds, severance pay, disability, etc. Plans that cover residents of Puerto Rico, the U.S. Virgin Islands, Guam, Wake Island, or American Samoa also must file unless they are eligible for a filing exemption. This includes a plan that elects to have the provisions of section 1022(i)(2) of ERISA apply.

For more information about annual return/report filings for Code section 403(b) plans covered by Title I of

ERISA, see Field Assistance Bulletins 2009-02 and 2010-01, available on the DOL website at www.dol.gov.

Plans Exempt From Filing

Under regulations and applicable guidance, some pension benefit plans and many welfare benefit plans with fewer than 100 participants are exempt from filing an annual return/report. Do not file a Form 5500-SF for an employee benefit plan that is any of the following:

1. An unfunded excess benefit plan. See ERISA section 4(b)(5).

2. A pension benefit plan maintained outside the United States primarily for the benefit of persons substantially all of whom are nonresident aliens. However, certain foreign plans are required to file the Form 5500-EZ with the IRS. See the instructions to the Form 5500-EZ for the filing requirements. For more information, go to www.irs.gov/ep or call 1-877-829-5500.

3. An annuity or custodial account arrangement under Code section 403(b)(1) or (7) not established or maintained by an employer as described in DOL Regulations 29 CFR 2510.3-2(f).

4. A simplified employee pension (SEP) described in Code section 408(k) that conforms to the alternative

method of compliance described in 29 CFR 2520.104-48 or 29 CFR 104-49. A SEP is a pension plan that meets certain minimum qualifications regarding eligibility and employer contributions.

5. A Savings Incentive Match Plan for Employees of Small Employers (SIMPLE) that involves SIMPLE IRAs under Code section 408(p).

6. A church pension benefit plan not electing coverage under Code section 410(d).

7. An unfunded dues financed pension benefit plan that meets the alternative method of compliance provided by 29 CFR 2520.104-27.

8. An individual retirement account or annuity not considered a pension plan under 29 CFR 2510.3-2(d).

9. A “one-participant plan,” as defined on page 7. However, certain one-participant plans are required to file the Form 5500-EZ, Annual Return of One-Participant (Owners and Their Spouses) Retirement Plan, with the IRS or, if eligible, may file the Form 5500-SF, Short Form Annual Return/Report of Employee Benefit Plan, electronically with EFAST2. See page 7.

10. A governmental plan.

11. An unfunded pension benefit plan or an unfunded or insured welfare benefit plan: (a) whose benefits go only to a select group of management or highly compensated employees, and (b) which meets the terms of 29 CFR 2520.104-23 (including the requirement that a registration statement be timely filed with DOL) or 29 CFR 2520.104-24.

12. A welfare benefit plan that covers fewer than 100 participants as of the beginning of the plan year and is unfunded, fully insured, or a combination of insured and unfunded. For this purpose:

a. An unfunded welfare benefit plan has its benefits paid as needed directly from the general assets of the employer or the employee organization that sponsors the plan.

Note. Plans that are NOT unfunded include those plans that received employee (or former employee) contributions during the plan year and/or used a trust or separately maintained fund (including a Code section 501(c)(9) trust) to hold plan assets or act as a conduit for the transfer of plan assets during the plan year. A welfare benefit plan with employee contributions that is associated with a cafeteria plan under Code section 125 may be treated for annual reporting purposes as an unfunded welfare benefit plan if it meets the requirements of DOL Technical Release 92-01, 57 Fed. Reg. 23272 (June 2, 1992) and 58 Fed. Reg. 45359 (Aug. 27, 1993). The mere receipt of COBRA contributions or other after-tax participant contributions (e.g., retiree contributions) by a cafeteria plan would not by itself affect the availability of the relief provided for cafeteria plans that otherwise meet the requirements of DOL Technical Release 92-01. See 61 Fed. Reg. 41220, 41222-23 (Aug. 7, 1996).

b. A fully insured welfare benefit plan has its benefits provided exclusively through insurance contracts or policies, the premiums of which must be paid directly to the insurance carrier by the employer or employee organization from its general assets or partly from its general assets and partly from contributions by its employees or members (which the employer or employee organization forwards within 3 months of receipt). The insurance contracts or policies discussed above must be issued by an insurance company or similar organization (such as Blue Cross, Blue Shield or a health maintenance organization) that is qualified to do business in any state.

c. A combination unfunded/insured welfare benefit plan has its benefits provided partially as an unfunded plan and partially as a fully insured plan. An example of such a plan is a welfare benefit plan that provides medical benefits as in “a” above and life insurance benefits as in “b” above. See 29 CFR 2520.104-20.

Note. A voluntary employees’ beneficiary association, as used in Code section 501(c)(9) (VEBA), should not be confused with the employer or employee organization that sponsors the plan. See ERISA section 3(4).

13. Plans maintained only to comply with workers’ compensation, unemployment compensation, or disability insurance laws.

14. A welfare benefit plan maintained outside the United States primarily for persons substantially all of whom are nonresident aliens.

15. A church welfare benefit plan under ERISA section 3(33).

16. An unfunded dues financed welfare benefit plan that meets the alternative method of compliance provided by 29 CFR 2520.104-26.

17. A welfare benefit plan that participates in a group insurance arrangement that files a return/report on its behalf under 29 CFR 2520.104-43. A group insurance arrangement generally is an arrangement that provides benefits to the employees of two or more unaffiliated employers (not in connection with a multiemployer plan or a collectively bargained multiple-employer plan), fully insures one or more welfare benefit plans of each participating employer, uses a trust (or other entity such as a trade association) as the holder of the insurance contracts, and uses a trust as the conduit for payment of premiums to the insurance company.

18. An apprenticeship or training plan meeting all of the conditions specified in 29 CFR 2520.104-22.

For more information on plans that are exempt from filing an annual return/report, call the EFAST2 Help Line at 1-866-GO-EFAST (1-866-463-3278). For one-participant plan filers, see the Instructions for Form 5500-EZ or call the IRS Help Line at 1-877-829-5500.

Who May File Form 5500-SF

If your plan is required to file an annual return/report, you may file the Form 5500-SF instead of the Form 5500 only if you meet all of the eligibility conditions listed below.

1. The plan (a) covered fewer than 100 participants at the beginning of the plan year 20142015, or (b) under 29 CFR 2520.103-1(d) was eligible to and filed as a small plan for plan year 2012 2014 and did not cover more than 120 participants at the beginning of plan year 20142015(see instructions for line 5 on counting the number of participants);

2. The plan did not hold any employer securities at any time during the plan year;

3. At all times during the plan year, the plan was 100% invested in certain secure, easy to value assets that meet the definition of “eligible plan assets” (see the instructions for line 6a), such as mutual fund shares, investment contracts with insurance companies and banks valued at least annually, publicly traded securities held by a registered broker dealer, cash and cash equivalents, and plan loans to participants;

4. The plan is eligible for the waiver of the annual examination and report of an independent qualified public accountant (IQPA) under 29 CFR 2520.104-46 (but not by reason of enhanced bonding), which requirement includes, among others, giving certain disclosures and supporting documents to participants and beneficiaries regarding the plan’s investments (see instructions for line 6b); and

5. The plan is not a multiemployer plan.

6. The plan is not required to file a Form M-1, Report for Multiple-Employer Welfare Arrangements (MEWAs) and Certain Entities Claiming Exception (ECEs) during the plan year.

Notes. (1) Employee Stock Ownership Plans (ESOPs) and Direct Filing Entities (DFEs) may not file the Form 5500-SF. (2) One-participant plans and certain foreign plans should follow the Specific Instructions Only for “One-Participant Plans and Certain Foreign Plans” in place of the instructions 1–5 above to see if Form 5500-SF may be filed instead of Form 5500-EZ.

What To File

Plans required to file an annual return/report that meet all of the conditions for filing the Form 5500-SF may complete and file the Form 5500-SF in accordance with its instructions. Single-employer defined benefit pension plans using the Form 5500-SF must also file the Schedule SB (Form 5500), Single-Employer Defined Benefit Plan Actuarial Information, and its required attachments. Money purchase plans amortizing a funding waiver using the Form 5500-SF must also file the Schedule MB (Form 5500), Multiemployer Defined Benefit Plan and Certain Money Purchase Plan Actuarial Information, and its required attachments. For information about Schedule SB and Schedule MB, see the 2014 2015 Instructions for Form 5500, Annual Return/Report of Employee Benefit Plan. One-participant plans see Specific Instructions Only for “One-Participant Plans and Certain Foreign Plans.”

Eligible Combined Plans. The Pension Protection Act of 2006 (PPA) established rules for a new type of pension plan, an “eligible combined plan,” effective for plan years beginning after December 31, 2009. See Code section 414(x) and ERISA section 210(e). An eligible combined plan consists of a defined benefit plan and a defined contribution plan that includes a qualified cash or deferred arrangement under Code section 401(k), with the assets of the two plans held in a single trust, but clearly identified and allocated between the plans. The eligible combined plan design is available only to employers that employed an average of at least two, but not more than 500 employees, on business days during the calendar year preceding the plan year as of which the eligible combined plan is established and that employs at least two employees on the first day of the plan year that the plan is established. Because an eligible combined plan includes both a defined benefit plan and a defined contribution plan, the Form 5500-SF filed for the plan must include all the information, schedules, and attachments that would be required for either a defined benefit plan (such as a Schedule SB) or a defined contribution plan.

When To File

File the 2014 2015 Form 5500-SF for plan years that began in 20142015. The form, and any required schedules and attachments, must be filed by the last day of the 7th calendar month after the end of the plan year (not to exceed 12 months in length) that began in 20142015.

Short Years. For a plan year of less than 12 months (short plan year), file the form and applicable schedules by the last day of the 7th calendar month after the short plan year ends or by the extended due date, if filing under an authorized extension of time. Fill in the short plan year beginning and ending dates in the space provided and check the appropriate box in Part I, line B, of the

Form 5500-SF. For purposes of this return/report, a short plan year ends on the date of the change in accounting period or upon the complete distribution of assets of the plan. Also see the instructions for Final Return/Report to determine if “the final return/report” box in line B should be checked.

Extension of Time To File

Using Form 5558

If filing under an extension of time based on the filing of an IRS Form 5558, Application for Extension of Time To File Certain Employee Plan Returns, check the appropriate box on the Form 5500-SF, Part I, line C. A one-time extension of time to file the Form 5500-SF (up to 2 ½ months) may be obtained by filing Form 5558 on or before the normal due date (not including any extensions) of the return/report. You must file the Form 5558 with the Department of Treasury, Internal Revenue Service Center, Ogden, UT 84201-0045. Approved copies of the Form 5558 will not be returned to the filer. A copy of the completed extension request must be retained with the plan’s records.

Using Extension of Time To File Federal Income Tax Return

An automatic extension of time to file Form 5500-SF until the due date of the federal income tax return of the employer will be granted if all of the following conditions are met: (1) the plan year and the employer’s tax year are the same; (2) the employer has been granted an extension of time to file its federal income tax return to a date later than the normal due date for filing the

Form 5500-SF; and (3) a copy of the application for extension of time to file the federal income tax return is maintained with the filer’s records. An extension of time granted by using this automatic extension procedure CANNOT be extended further by filing an IRS Form 5558, nor can it be extended beyond a total of 9 ½ months beyond the close of the plan year.

Notes. (1) If the filing due date falls on a Saturday, Sunday, or Federal holiday, the return/report may be filed on the next day that is not a Saturday, Sunday, or Federal holiday. (2) If the 2015 2016 Form 5500 is not available before the plan or DFE filing, use the 2014 2015 Form 5500 and enter the 2015 2016 fiscal year beginning and ending dates on the line provided at the top of the form.

Other Extensions of Time

The IRS, DOL, and PBGC may announce special extensions of time under certain circumstances, such as extensions for Presidentially-declared disasters or for service in, or in support of, the Armed Forces of the United States in a combat zone. See www.irs.gov, www.efast.dol.gov, and www.pbgc.gov/practitioners for announcements regarding such special extensions. If you are relying on one of these announced special extensions, check the appropriate box on the Form 5500-SF, Part I, line C, and enter a description of the announced authority for the extension.

Delinquent Filer Voluntary Compliance (DFVC) Program

The DFVC Program facilitates voluntary compliance by plan administrators who are delinquent in filing annual return/report forms under Title I of ERISA by permitting administrators to pay reduced civil penalties for voluntarily complying with their DOL annual reporting obligations. If the Form 5500-SF is being filed under the DFVC Program, check the appropriate box on Form 5500-SF, Part I, line C to indicate that the Form 5500-SF is being filed under the DFVC Program. See www.efast.dol.gov for additional information.

Plan administrators are reminded that they can use the online calculator available at www.dol.gov/ebsa/ calculator/dfvcpmain.html to compute the penalties due under the program. Payments under the DFVC Program also may be submitted electronically. For information on how to pay DFVC Program payments online, go to www.dol.gov/ebsa.

Change in Plan Year

Generally, only defined benefit pension plans need to get approval for a change in plan year. See Code section 412(d)(1). However, under Rev. Proc. 87-27, 1987-1 C.B. 769, these pension plans may be eligible for automatic approval of a change in plan year.

If a change in plan year for a pension or a welfare benefit plan creates a short plan year, file the form and applicable schedules by the last day of the 7th calendar month after the short plan year ends or by the extended due date, if filing under an authorized extension of time. Fill in the short plan year beginning and ending dates in the space provided in Part I and check the appropriate box in Part I, line B of the Form 5500-SF. For purposes of this return/report, the short plan year ends on the date of the change in accounting period or upon the complete distribution of assets of the plan. Also, see the instructions for Final Return/Report to determine if “final return/report” in line B should be checked.

Penalties

Plan administrators and plan sponsors must provide complete and accurate information and must otherwise comply fully with the filing requirements. ERISA and the Code provide for the DOL and the IRS, respectively, to assess or impose penalties for not giving complete and accurate information and for not filing complete and accurate statements and returns/reports. Certain penalties are administrative (that is, they may be imposed or assessed in an administrative proceeding by one of the governmental agencies delegated to administer the collection of the Form 5500-SF data). Others require a legal conviction.

Administrative Penalties

Listed below are various penalties under ERISA and the Code that may be assessed or imposed for not meeting the annual return/report filing requirements. Generally, whether the penalty is under ERISA or the Code, or both, depends upon the agency for which the information is required to be filed. One or more of the following administrative penalties may be assessed or imposed in the event of incomplete filings or filings received after the due date unless it is determined that your failure to file properly is for reasonable cause.

1. A penalty of up to $1,100 a day (or higher amount if adjusted pursuant to the Federal Civil Penalties Inflation Adjustment Act of 1990, as amended) for each day a plan administrator fails or refuses to file a complete and accurate annual return/report. See ERISA section 502(c)(2) and 29 CFR 2560.502c-2.

2. A penalty of $25 a day (up to $15,000) for not filing the annual return/report for certain plans of deferred compensation, trusts and annuities, and bond purchase plans by the due date(s). See Code section 6652(e).

3. A penalty of $1,000 for not filing an actuarial statement (Schedule MB (Form 5500) or Schedule SB (Form 5500)) required by the applicable instructions. See Code section 6692.

Other Penalties

1. Any individual who willfully violates any provision of Part 1 of Title I of ERISA shall on conviction be fined not more than $100,000 or imprisoned not more than 10 years, or both. See ERISA section 501.

2. A penalty up to $10,000, five (5) years imprisonment, or both, may be imposed for making any false statement or representation of fact, knowing it to be false, or for knowingly concealing or not disclosing any fact required by ERISA. See section 1027, Title 18, U.S. Code, as amended by section 111 of ERISA.

How To File – Electronic Filing Requirement

Under the computerized ERISA Filing Acceptance System (EFAST2), you must file your 2014 2015 Form 5500-SF electronically. You may file your 2014 2015 Form 5500-SF online using EFAST2’s web-based filing system or you may file through an EFAST2-approved vendor. Detailed information on electronic filing is available at www.efast.dol.gov. For telephone assistance, call the EFAST2 Help Line at 1-866-GO-EFAST (1-866-463-3278). The EFAST2 Help Line is available Monday through Friday from 8:00 am to 8:00 pm, Eastern Time.

Annual returns/reports filed under Title I of ERISA, i ncluding those filed using the Form 5500-SF, must be made available by the plan administrators to plan participants and beneficiaries and by the DOL to the public pursuant to ERISA sections 104 and 106. Even though the Form 5500-SF must be filed electronically, the plan administrator must keep a copy of the Form 5500-SF, including schedules and attachments, with all required signatures on file as part of the plan’s records, and must make a paper copy available on request to participants, beneficiaries, and the DOL as required by section 104 of ERISA and 29 CFR 2520.103-1. Filers may use electronic media for record maintenance and retention, so long as they meet the applicable requirements.

Generally, questions on the Form 5500-SF relate to the plan year entered at the top of the first page of the form. Therefore, answer all questions on the 2014 2015

Form 5500-SF with respect to the 2014 2015 plan year unless otherwise explicitly stated in the instructions or on the form itself.

Your entries must be in the proper format in order for the EFAST2 system to process your filing. For example, if a question requires you to enter a dollar amount, you cannot enter a word. Your software will not let you submit your return/report unless all entries are in the proper format. To reduce the possibility of correspondence and penalties:

• Complete all lines on the Form 5500-SF unless otherwise specified. Also complete and electronically attach, as required, any applicable schedules and attachments.

• Do not enter “N/A” or “Not Applicable” on the Form 5500-SF or Schedules SB (Form 5500) and MB (Form 5500) unless specifically permitted. “Yes” or “No” questions on the form and schedules cannot be left blank, unless specifically permitted. Answer “Yes” or “No,” but not both.

• Use the correct employer identification number (EIN) and plan number (PN) for the plan.

You should check your return/report for errors before signing or submitting it to EFAST2. Your filing software or, if you are using it, the EFAST2 web-based filing system will allow you to check your return/report for errors. If, after reasonable attempts to correct your filing to eliminate any identified problem or problems, you are unable to address them, or you believe that you are receiving the message in error, call the EFAST2 Help Line at 1-866-GO-EFAST (1-866-463-3278) or contact the service provider you used to help prepare and file your annual return/report.

Once you complete the return/report and finish the electronic signature process, you can electronically submit it to EFAST2. When you electronically submit your return/report, EFAST2 is designed to immediately notify you if your submission was received and whether the return/report is ready to be processed by EFAST2. If EFAST2 does not notify you that your submission was successfully received and is ready to be processed, you will need to take steps to correct the problem or you may be deemed a non-filer subject to penalties from DOL, IRS, and/or PBGC.

Once EFAST2 receives your return/report, the EFAST2 system should be able to provide a filing status within 20 minutes. Check back into the EFAST2 system to determine the filing status of your return/report. The filing status message will include a list of any filing errors or warnings that EFAST2 may have identified in your filing. If EFAST2 did not identify any filing errors or warnings, EFAST2 will show the filing status of your return/report as “Filing_Received.” Persons other than the submitter can check whether the filing was received by the system by calling the EFAST2 Help Line at 1-866-GO-EFAST (1-866-463-3278) and using the automated telephone system.

To reduce the possibility of correspondence and penalties from the DOL, IRS, and/or PBGC, you should do the following: (1) Before submitting your return/report to EFAST2, check it for errors, and (2) after you have submitted it to EFAST2, verify that you have received a filing status of “Filing_Received” and attempt to correct and resolve any errors or warnings listed in the status report.

Note. Even after being received by the EFAST2 system, your return/report filing may be subject to further detailed review by DOL, IRS, and/or PBGC, and your filing may be deemed deficient based upon this further review. See Penalties on page 5.

The Form 5500-SF, Schedules SB (Form 5500) and MB (Form 5500), and any attachments that are filed under ERISA are open to public inspection, and the contents are public information subject to publication on the Internet.

D o not enter social security numbers in response to questions asking for an employer identification number (EIN). Because of privacy concerns, the inclusion of a social security number or any portion thereof on the Form 5500-SF or on a schedule or attachment that is open to public inspection may result in the rejection of the filing. If you discover a filing disclosed on the EFAST2 website that contains a social security number, immediately call the EFAST2 Help Line at 1-866-GO-EFAST (1-866-463-3278).

Do not attach a copy of the annual registration statement identifying separated participants with deferred vested benefits, or a previous year’s Schedule SSA (Form 5500) to your 2014 2015 Form 5500-SF annual return/report. The annual registration statement must be filed directly with the IRS and cannot be attached to a Form 5500-SF submission with EFAST2.

Employers without an employer identification number (EIN) must apply to the IRS for one as soon as possible. The EBSA does not issue EINs. To apply for an EIN from the IRS:

• Mail or fax Form SS-4, Application for Employer Identification Number, obtained by calling 1-800-TAX-FORM (1-800-829-3676) or at the IRS website at www.irs.gov.

• Call 1-800-829-4933 to receive your EIN by telephone.

• Select the Online EIN Application link at www.irs.gov.

The EIN is issued immediately once the application information is validated. (The online application process is not yet available for corporations with addresses in foreign countries or Puerto Rico.)

Signature and Date

For purposes of Title I of ERISA, the plan administrator is required to file the Form 5500 or 5500-SF. The plan administrator must electronically sign the Form 5500 or 5500-SF submitted to EFAST2.

A fter submitting your filing, you must check the Filing Status. If the filing status is "Processing Stopped" or “Unprocessable”, it is possible your submission was not sent with a valid electronic signature as required, and depending on the error, may be considered not to have been filed. By looking closer at the Filing Status, you can see specific error messages applicable to the transmitted filing and determine whether it was sent with a valid electronic signature and what other errors may need to be corrected.

Note. If the plan administrator is an entity, the electronic signature must be in the name of a person authorized to sign on behalf of the plan administrator.

If the plan administrator does not sign a filing, the filing status will indicate that there is an error with your filing, and your filing will be subject to further review, correspondence, rejection, and civil penalties.

Authorized Service Provider Signatures. If the plan administrator elects to have a service provider who manages the filing process for the plan get EFAST2 signing credentials and submit the electronic

Form 5500-SF for the plan: 1) the service provider must receive specific written authorization from the plan administrator to submit the plan’s electronic filing; 2) the plan administrator must manually sign a paper copy of the electronically completed Form 5500-SF, and the service provider must include a PDF copy of the entire three-page Form 5500-SF, excluding any attachments and associated schedules, submitted to EFAST2; 3) the service provider must communicate to the plan administrator any inquiries received from EFAST2, DOL, IRS or PBGC regarding the filing; 4) the service provider must communicate to the plan administrator that, by electing to use this option, the image of the plan administrator’s manual signature will be included with the rest of the return/report posted by the Labor Department on the Internet for public disclosure; and 5) the plan administrator must keep the manually signed copy of the Form 5500-SF, with all required schedules, as part of the plan’s records. For more information on the electronic signature option, see EFAST2 All-Electronic Filing System FAQs at www.dol.gov/ebsa/faqs/faq-EFAST2.html.

S ervice providers should consider implications of IRS tax return preparer rules.

Note. The Code permits either the plan sponsor/employer or the administrator to sign the filing. Therefore, in the case of a Form 5500-SF filed for a “one-participant plan” not subject to Title I of ERISA that is filing a Form 5500-SF with EFAST2 in lieu of filing a Form 5500-EZ on paper with the IRS (see Specific Instructions Only for “One-Participant Plans and certain Certain foreign Foreign plansPlans”), either may sign. However, any other Form 5500-SF that is not electronically signed by the plan administrator will be subject to rejection and civil penalties under Title I of ERISA.

The Form 5500-SF annual return/report must be filed electronically and signed. To obtain an electronic signature, go to www.efast.dol.gov and register in EFAST2 as a signer. You will be provided with a UserID and a PIN. Both the UserID and PIN are needed to sign the Form 5500-SF. The plan administrator must keep a copy of the Form 5500-SF, including schedules and attachments, with all required signatures on file as part of the plan’s records. See 29 CFR 2520.103-1. Electronic signatures on annual returns/reports filed under EFAST2 are governed by the applicable statutory and regulatory requirements.

Preparer Information (optional)

You may optionallymust enter the “Preparer’s name (including firm’s name, if applicable), address, and telephone number” at the bottom of the first page of Form 5500-SF. A preparer is any person who prepares an annual return/report for compensation, or who employs one or more persons to prepare for compensation. If the person who prepared the annual return/report is not the employer named in line 2a or the plan administrator named in line 3a, you may name the person on this line. If there are several people who prepare Form 5500-SF and applicable schedules, please name the person who is primarily responsible for the preparation of the annual return/report.

Note. Although preparer’s name, address, and phone number are optional, the IRS encourages filers to provide preparer information on these lines. Treasury regulations require all paid tax return preparers to obtain the Paid Preparer Tax Identification Numbers (PTINs) and put the PTIN on all tax forms. However, the Form 5500 series, at this time, is not subject to the PTIN requirements of section 1.6109-2 of the Treasury regulations.

Specific Instructions Only for “One-Participant Plans and Certain Foreign Plans”

A “one-participant plan” is: (1) a pension benefit plan that covers only an individual or an individual and his or her spouse who wholly own a trade or business, whether incorporated or unincorporated; or (2) a pension benefit plan for a partnership that covers only the partners or the partners and the partners’ spouses. Thus, a “one-participant plan” can cover more than one participant. On the other hand, merely covering only one participant does not make you eligible to file as a “one-participant plan” unless you are one of the types of plans described above.

A foreign plan is maintained outside the United States primarily for nonresident aliens, if (1) a plan is maintained by a domestic employer; or (2) a plan is maintained by a foreign employer with income derived from sources within the United States (including foreign subsidiaries of domestic employers) if contributions to the plan are deducted on its U.S. income tax return.

The Form 5500-EZ generally is used by one-participant plans and certain foreign plans that are not subject to the requirements of section 104(a) of ERISA to satisfy certain annual reporting and filing obligations imposed by the Code. One-participant plans and certain foreign plans that meet the Conditions for Filing below may file the Form 5500-SF electronically in place of a Form 5500-EZ (on paper) to satisfy the filing obligations under the Code. One-participant plans and certain foreign plans that file the Form 5500-SF electronically complete only certain questions on the Form 5500-SF. These are the questions that would be completed if the filer filed Form 5500-EZ on paper. For more information on filing with the IRS, go to www.irs.gov or call 1-877-829-5500.

Notes. (1) A Form 5500-SF may be filed for one-participant plans and certain foreign plans that are either defined contribution plans (which include profit-sharing and money purchase pension plans, but not an ESOP or stock bonus plan) or defined benefit plans. (2) The filer of a one-participant plan or a foreign plan that is required by the Code or regulations to file at least 250 returns with the IRS during the calendar year must use the Form 5500-SF to file the information required on the Form 5500-EZ, but will not be required to attach to the filing a Schedule MB or SB. For more information, see IRS regulations on “Employee Retirement Benefit Plan Returns Required on Magnetic Media”. (23) Information filed on Form 5500-EZ is required to be made available to the public. Form 5500-SF is open to public inspection and the contents are public information subject to publication on the Internet. However, the information on Form 5500-SF will not be subject to publication on the internet for a “one-participant plan” that is electronically filed using a Form 5500-SF with EFAST2 in lieu of filing a Form 5500-EZ on paper with the IRS.

Conditions for Filing. One-participant plan or certain foreign plan filers that meet the following conditions are eligible to file a Form 5500-SF.

1. The plan is a one-participant plan, if

a. The plan only covers you (or you and your spouse) and you (or you and your spouse) own the entire business (which may be incorporated or unincorporated); or

b. The plan only covers one or more partners (or partner(s) and spouse(s)) in a business partnership.

c. The plan does not provide benefits for anyone except you, or you and your spouse, or one or more partners and their spouses.

2. The plan is a foreign plan maintained outside the United States primarily for nonresident aliens, if

a. The plan is maintained by a domestic employer, or

b. The plan is maintained by a foreign employer with income derived from sources within the United States (including foreign subsidiaries of domestic employers) if contributions to the plan are deducted on its U.S. income tax return.

Eligible one-participant plans and certain foreign plans need complete only the following questions on the

Form 5500-SF:

Part I, lines A, B, and C;

• Part II, lines 1a-5b, 5d(1), 5d(2), and 5(e);

• Part III, lines 7a–c, and 8a;

• Part IV, line 9a;

• Part V, line 10g and 10j;

• Part VI, lines 11–12e;

• Part VIII, lines 14a-14d; and

• Part IX, lines 17 a, b, c, d, line 19, and line 20.

• Part I, lines A, B, and C;

• Part II, lines 1a–5b;

• Part III, lines 7a–c, and 8a;

• Part IV, line 9a;

• Part V, line 10g; and

• Part VI, lines 11–12e.

• Schedule MB (Form 5500). If a money purchase defined contribution plan (including a target benefit plan) has received a waiver of the minimum funding standard, and the waiver is currently being amortized, complete lines 3, 9, and 10 of Schedule MB (Form 5500). See the Instructions for Schedule MB in the Instructions for Form 5500. One-participant plans and certain foreign plans, however, do not attach Schedule MB to the Form 5500-SF. Instead, one-participant plans and certain foreign plans must keep the completed Schedule MB in accordance with the applicable records retention requirements.

Schedule SB (Form 5500). One-participant plans and certain foreign plans do not attach Schedule SB (Form 5500) to the Form 5500-SF. Instead, one-participant plans and certain foreign plans must keep the completed Schedule SB that is signed by the plan actuary in accordance with the applicable records retention requirements. Actuaries of one-participant plans that are defined benefit plans subject to the minimum funding standards for this plan year, must complete Schedule SB (Form 5500) and forward the completed and signed Schedule SB to the plan administrator no later than the filing due date. See the Instructions for Schedule SB in the Instructions for Form 5500.

Filing Form 5500-EZ with the IRS. If you are filing a paper form, you must file the Form 5500-EZ with the IRS using the following address: Department of the Treasury, Internal Revenue Service Center, Ogden, UT 84201-0027. You may order the paper Form 5500-EZ and its instructions by calling 1-800-TAX-FORM (1-800-829-3676) or visiting the IRS website at www.irs.gov/formspubs/.

Filing an amendment. If you are filing an amendment for a “one-participant plan or a certain foreign plan” that filed a Form 5500-SF electronically, you may submit the amendment either electronically using the Form 5500-SF with EFAST2 or on paper using the Form 5500-EZ with the IRS. If you are filing an amendment for a “one-participant plan” that previously filed on a paper Form 5500-EZ, you must submit the amendment using the paper Form 5500-EZ with the IRS. However, if you are filing an amendment for a one-participant plan or a certain foreign plan that is required by the Treasury Regulations to file electronically using the Form 5500-SF, you must submit the amendment electronically using the Form 5500-SF with EFAST2.

Specific Line-by-Line Instructions (Form 5500-SF)

Part I – Annual Report Identification Information

File the 2014 2015 Form 5500-SF annual report for a plan year that began in 20142015. Enter the beginning and ending dates in Part I. The 2014 2015 Form 5500-SF annual report must be filed electronically.

Check only one of the line A box choices.

Line A – Box for Single-Employer Plan. Check this box if the Form 5500-SF is filed for a single-employer plan. A single-employer plan for purposes of the Form 5500-SF is an employee benefit plan maintained by one employer or one employee organization.

Note. A “controlled group” is generally considered one employer for Form 5500 and Form 5500-SF reporting purposes. A “controlled group” is a controlled group of corporations under Code section 414(b), a group of trades or businesses under common control under Code section 414(c), or an affiliated service group under Code section 414(m). A separate annual return/report with line A (single-employer plan) checked must be filed by each employer participating in a plan or program of benefits in which the funds attributable to each employer are available to pay benefits only for that employer’s employees, even if the plan is maintained by a controlled group.

Line A – Box for Multiple-Employer Plan. Check this box if the Form 5500-SF is being filed for a multiple-employer plan. For purposes of the Form 5500-SF, a multiple-employer plan is a plan that is maintained by more than one employer and is not a single-employer plan or a multiemployer plan. Multiple-employer plans can be collectively bargained and collectively funded, but if covered by PBGC termination insurance, they must have properly elected before September 27, 1981, not to be treated as a multiemployer plan under Code section 414(f)(5) or ERISA sections 3(37)(E) and 4001(a)(3), and have not revoked that election or made an election to be treated as a multiemployer plan under Code section 414(f)(6) or ERISA section 3(37)(G). Participating employers do not file individually for multiple-employer plans.

Note. Do not check this box if all of the employers maintaining the plan are members of the same controlled group or affiliated service group under Code sections 414(b), (c), or (m).

Multiple-employer pension plans required to file a Form 5500-SF must include an attachment using the format below that (1) lists each participating employer in the plan during the plan year, identified by name and employer identification number (EIN), and (2) includes a good faith estimate of each employer’s percentage of the total contributions (including employer and participant contributions) made by all participating employers during the year. Any employer who was obligated to make contributions to the plan for the plan year, made contributions to the plan for the plan year, or whose employees were covered under the plan is a “participating employer” for this purpose. If a participating employer made no contributions, enter “-0-” in element (c).

The attachment must be properly identified at the top with the label “Multiple-Employer Plan Participating Employer Information,” and the name of the plan, EIN, and plan number (PN) as found on the plan’s Form 5500-SF.

Complete as many entries as needed to report the required information for all participating employers.

Multiple-Employer Plan Participating Employer Information (Insert Name of Plan and EIN/PN as shown on the Form 5500-SF)
(a) Name of participating employer	(b) EIN	(c) Percent of Total Contributions
(a) Name of participating employer	(b) EIN	(c) Percent of Total Contributions

Note. Do not check this box if all of the employers maintaining the plan are members of the same controlled group or affiliated service group under Code sections 414(b), (c), or (m). M ultiemployer plans cannot use the Form 5500-SF to satisfy their annual reporting obligations. They must file the Form 5500. For these purposes, a plan is a multiemployer plan if: (a) more than one employer is required to contribute; (b) the plan is maintained pursuant to one or more collective bargaining agreements between one or more employee organizations and more than one employer; (c) an election under Code section 414(f)(5) and ERISA section 3(37)(E) has not been made; and (d) the plan meets any other applicable conditions of 29 CFR 2510.3-37. A plan that made a proper election under ERISA section 3(37)(G) and Code section 414(f)(6) on or before Aug. 17, 2007, is also a multiemployer plan.

Line A – Box for One-Participant Plan. Check this box if the Form 5500-SF is being filed for a plan that is a “one-participant plan” (see page 7). Check the one-participant plan box only for those plans that are submitting the

Form 5500-SF in place of a Form 5500-EZ (on paper) to satisfy the annual return/report filing obligations under the Code. Plans checking the box for one-participant plan should not check either the box for single-employer plan or the box for multiple-employer plan. See Specific Instructions Only for “One-Participant Plans and certain Certain foreign Foreign plansPlans.”

Line A – Box for Foreign Plans. Check this box if the

Form 5500-SF is being filed for a plan that is a “foreign plan” (see page 7). Check the foreign plan box only for those plans that are submitting the Form 5500-SF in place of a Form 5500-EZ (on paper) to satisfy the annual return/report filing obligations under the Code. Plans checking the box for foreign plan should not check either the box for single-employer plan or the box for multiple-employer plan. See Specific Instructions Only for “One-Participant Plans and certain Certain foreign Foreign plansPlans.”

Line B – Box for First Return/Report. Check this box if an annual return/report has not been previously filed for this plan. For the purpose of completing this box, the Form 5500-EZ is not considered an annual return/report.

Line B – Box for Amended Return/Report. Check this box if you have already filed for the 2014 2015 plan year and are now filing an amended return/report to correct errors and/or omissions on the previously filed return/report.

C heck the line B box for an “amended return/report” if you filed a previous 2014 2015 annual return/report that was given a “Filing_Received,” “Filing_Error,” or “Filing_Stopped” status by EFAST2. Do not check the line B box for an “amended return/report” if your previous submission attempts were not successfully received by EFAST2 because of problems with the transmission of your return/report. For more information, go to the EFAST2 website at www.efast.dol.gov or call the EFAST2 Help line at 1-866-GO-EFAST (1-866-463-3278).

If you need to file an amended return/report to correct errors and/or omissions in a previously filed annual return/report for the 2014 2015 plan year AND you are eligible to file the Form 5500-SF, you may use the Form 5500-SF even if the original filing was a Form 5500. If you filed a Form 5500-SF, but determine that you were not eligible to file the Form 5500-SF, you must use the Form 5500 or Form 5500-EZ to amend your return/report.

Line B – Box for Final Return/Report. Check this box if this is the final report for the plan. Only check this box if all assets under the plan (including insurance/annuity contracts) have been distributed to the participants and beneficiaries or legally transferred to the control of another plan, and when all liabilities for which benefits may be paid under a welfare benefit plan have been satisfied. Do not mark the final return/report box if you are reporting participants and/or assets at the end of the plan year. If a trustee is appointed for a terminated defined benefit pension plan pursuant to ERISA section 4042, the last plan year for which a return/report must be filed is the year in which the trustee is appointed. If you are in this situation you may contact [email protected] for further information.

Examples:

Mergers/Consolidations. A final return/report should be filed for the plan year (12 months or less) that ends when all plan assets were legally transferred to the control of another plan.

Pension and Welfare Plans That Terminated Without Distributing All Assets. If the plan was terminated but all plan assets were not distributed, a return/report must be filed for each year the plan has assets. The return/report must be filed by the plan administrator, if designated, or by the person or persons who actually control the plan’s assets/ property.

Welfare Plans Still Liable To Pay Benefits. A welfare plan cannot file a final return/report if the plan is still liable to pay benefits for claims that were incurred prior to the termination date, but not yet paid. See 29 CFR 2520.104b-2(g)(2)(ii).

Line B – Box for Short Plan Year Return/Report. Check this box if this Form 5500-SF is being filed for a plan year period of less than 12 months. Provide the dates in Part I, Plan Year Beginning and Ending.

Line C – Box for Extension and DFVC Program. Check the appropriate box here if:

• You filed for an extension of time to file this form with the IRS using Form 5558, Application for Extension of Time To File Certain Employee Plan Returns, and maintain a copy of the Form 5558 with the filer’s records.

• You are filing using the automatic extension of time to file the Form 5500-SF return/report until the due date of the federal income tax return of the employer and maintain a copy of the employer’s extension of time to file the income tax return with the plan’s records.

• You are filing under the DFVC Program.

• You are filing using a special extension of time to file the Form 5500-SF annual return/report that has been announced by the IRS, DOL, or PBGC. If you checked that you are using a special extension of time, enter a description of the extension of time in the space provided.

Part II – Basic Plan Information

Line 1a. Enter the formal name of the plan or enough information to identify the plan. Abbreviate if necessary. If an annual return/report has previously been filed on behalf of the plan, regardless of the type of Form that was filed (Form 5500, Form 5500-EZ, or

Form 5500-SF), use the same name or abbreviations that were used on the prior filings. Once you use an abbreviation, continue to use it for that plan on all future annual return/report filings with the IRS, DOL, and PBGC. Do not use the same name or abbreviation for any other plan, even if the first plan is terminated.

Line 1b. Enter the three-digit plan or entity number (PN) that the employer or plan administrator assigned to the plan. This three-digit number, in conjunction with the employer identification number (EIN) entered on line 2b, is used by the IRS, DOL, and PBGC as a unique 12-digit number to identify the plan.

Start at 001 for plans providing pension benefits. Start at 501 for welfare plans. Do not use 888 or 999.

Once you use a plan number, continue to use it for that plan on all future filings with the IRS, DOL, and PBGC. Do not use it for any other plan, even if the first plan is terminated.

F  or each Form 5500-SF with the same EIN (line 2b), when	Assign PN 
Codes are entered in line 9a	001 to the first plan. Consecutively number others as 002, 003 . . .
Codes are entered in line 9b, and not in line 9a	501 to the first plan. Consecutively number others as 502, 503 . . .

Exception. If 333 (or a higher number in a sequence beginning with 333) was previously assigned to the plan, that number may be entered on line 1b.

Line 1c. Enter the date the plan first became effective.

Line 2a. Limit your response to the information required in each row as specified below:

1. Enter the plan sponsor’s (employer, if for a single-employer plan) name, current postal address (only use a P.O. Box number if the Post Office does not deliver mail to the employer’s street address), foreign routing code where applicable, and “D/B/A” (doing business as) or trade name of the employer if different from the employer’s name.

2. Enter any ‘‘in care of’’ (C/O) name.

3. Enter the street address. A post office box number may be entered if the Post Office does not deliver mail to the sponsor’s street address.

4. Enter the name of the city.

5. Enter the two-character abbreviation of the U.S. state or possession and zip code.

6. Enter the foreign routing code, if applicable. Leave U.S. state and zip code blank if entering a foreign routing code and country name.

7. Enter the foreign country, if applicable.

8. Enter the D/B/A (the doing business as) or trade name of the sponsor if different from the plan sponsor’s name.

9. Enter any second address. Use only a street address here, not a P.O. box.

Notes. (1) In the case of a multiple-employer plan, file only one annual return/report for the plan. If an association or other entity is not the sponsor, enter the name of a participating employer as sponsor. For a plan of a controlled group of corporations, the name of one of the sponsoring members should be entered. In either case, the same name must be used in all subsequent filings of the Form 5500 return/report or Form 5500-SF for the multiple-employer plan or controlled group (see instructions for line 4 concerning change in sponsorship). (2) You can also use the IRS Form 8822-B to notify the IRS if the address provided here is a change in your business mailing address or your business location.

Line 2b. Enter the employer’s nine-digit employer identification number (EIN). Do not use a social security number (SSN). A Form 5500-SF that is filed under ERISA is open to public inspection and the contents are public information and are subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on this line may result in the rejection of the filing.

Employers without an EIN number must apply to the IRS for one as soon as possible. The EBSA does not issue EINs. To apply for an EIN from the IRS:

• Mail or fax Form SS-4, Application for Employer Identification Number, obtained by calling 1-800-TAX-FORM (1-800-829-3676) or at the IRS website at www.irs.gov.

• Call 1-800-829-4933 to receive your EIN by telephone.

• Select the Online EIN Application link at www.irs.gov.

The EIN is issued immediately once the application information is validated. (The online application process is not yet available for corporations with addresses in foreign countries.)

A multiple-employer plan or plan of a controlled group of corporations should use the EIN number of the sponsor identified in line 2a. The EIN must be used in all subsequent filings of the Form 5500-SF (or any subsequent Form 5500 or Form 5500-EZ in a year where the plan is not eligible to file the Form 5500-SF) for these plans. (See instructions to line 4 concerning change in EIN).

Note. EINs for funds (trusts or custodial accounts) associated with plans are generally not required to be furnished on the Form 5500-SF. The IRS, however, will issue EINs for such funds for other reporting purposes.

EINs may be obtained as explained above. Plan sponsors should use the trust EIN when opening a bank account or conducting other transactions for a trust.

Line 2c. Enter the telephone number for the plan sponsor. Use numbers only, including area code, and do not include any special characters.

Line 2d. Enter the six-digit business code that best describes the nature of the plan sponsor’s business from the list of business codes on pages 22-24. If more than one employer or employee organization is involved, enter the business code for the main business activity of the employers and/or employee organizations.

Line 3a. Limit your response to the information required in each row as specified below:

1. Enter the name of the plan administrator unless the administrator is the sponsor identified in line 2. If both the plan administrator name and address are the same as the plan sponsor name and address, check the “Same as Plan Sponsor” box and disregard items 2 through 6 below.

2. Enter any “in care of” (C/O) name.

3. Enter the current street address. A post office box number may be entered if the Post Office does not deliver mail to the administrator’s street address.

4. Enter the name of the city.

5. Enter the two-character abbreviation of the U.S. state or possession and zip code.

6. Enter the foreign routing code and foreign country, if applicable. Leave U.S. state and zip code blank if entering foreign routing code and country information.

Plan administrator for this purpose means:

• The person or group of persons specified as the administrator by the instrument under which the plan is operated;

• The plan sponsor/employer if an administrator is not so designated; or

• Any other person prescribed by applicable regulations if an administrator is not designated and a plan sponsor cannot be identified.

Line 3b. Enter the plan administrator’s nine-digit EIN. A plan administrator must have an EIN for Form 5500-SF reporting. If the plan administrator does not have an EIN, it must apply to the IRS for one as explained in the instructions for line 2b. One EIN should be entered for a group of individuals who are, collectively, the plan administrator.

Note. Employees of the plan sponsor who perform administrative functions for the plan are generally not the plan administrator unless specifically designated in the plan document. If an employee of the plan sponsor is designated as the plan administrator, that employee must obtain an EIN.

Line 3c. Enter the telephone number for the plan administrator.

Line 4. If the plan sponsor’s name and/or EIN have changed since the last annual return/report was filed for this plan, enter the plan sponsor’s name, EIN, and the plan number as it appeared on the last annual return/ report filed.

F ailure to indicate on line 4 that a plan sponsor was previously identified by a different name or a different employer identification number (EIN) could result in correspondence from the DOL and the IRS.

Line 5. Enter in element (a) the total number of participants at the beginning of the plan year. Enter in element (b) the total number of participants at the end of the plan year. Enter in element (c) the total number of participants with account balances as of the end of the plan year. Welfare benefit plans and defined benefit plans do not complete element (c). Enter in element (d)(1) the total number of active participants at the beginning of the plan year. Enter in element (d)(2) the total number of active participants at the end of the plan year.

The description of “participant” in the following instructions is only for purposes of these lines.

An individual becomes a participant covered under an employee welfare benefit plan on the earliest of:

• The date designated by the plan as the date on which the individual begins participation in the plan;

• The date on which the individual becomes eligible under the plan for a benefit subject only to occurrence of the contingency for which the benefit is provided; or

• The date on which the individual makes a contribution to the plan, whether voluntary or mandatory.

See 29 CFR 2510.3-3(d)(1). This includes former employees who are receiving group health continuation coverage benefits pursuant to Part 6 of ERISA and who are covered by the employee welfare benefit plan. Covered dependents are not counted as participants. A child who is an “alternate recipient” entitled to health benefits under a qualified medical child support order (QMCSO) should not be counted as a participant for line 5. An individual is not a participant covered under an employee welfare plan on the earliest date on which the individual (a) is ineligible to receive any benefit under the plan even if the contingency for which such benefit is provided should occur, and (b) is not designated by the plan as a participant. See 29 CFR 2510.3-3(d)(2).

B efore counting the number of participants, especially in a welfare benefit plan, it is important to determine whether the plan sponsor has established one or more plans for Form 5500/Form 5500-SF reporting purposes. As a matter of plan design, plan sponsors can offer benefits through various structures or combinations. For example, a plan sponsor could create (i) one plan providing major medical benefits, dental benefits, and vision benefits, (ii) two plans with one providing major medical benefits and the other providing self-insured dental and vision benefits; or (iii) three separate plans. You must review the governing documents and actual operations to determine whether welfare benefits are being provided under a single plan or separate plans.

The fact that you have separate insurance policies for each different welfare benefit does not necessarily mean that you have separate plans. Some plan sponsors use a “wrap” document to incorporate various benefits and insurance policies into one comprehensive plan. In addition, whether a benefit arrangement is deemed to be a single plan may be different for purposes other than Form 5500/Form 5500-SF reporting. For example, special rules may apply for purposes of HIPAA, COBRA, and Internal Revenue Code compliance. If you need help determining whether you have a single welfare benefit plan for Form 5500/Form 5500-SF reporting purposes, you should consult a qualified benefits consultant or legal counsel.

For pension benefit plans, “alternate payees” entitled to benefits under a qualified domestic relations order (QDRO) are not to be counted as participants for this line.

For pension benefit plans, “participant” for this line means any individual who is included in one of the categories below.

1. Active participants (i.e., any individuals who are currently in employment covered by the plan and who are earning or retaining credited service under the plan). This includes any individuals who are eligible to elect to have the employer make payments under a Code section 401(k) qualified cash or deferred arrangement. Active participants also include any nonvested individuals who are earning or retaining credited service under the plan. This does not include (a) nonvested former employees who have incurred the break in service period specified in the plan or (b) former employees who have received a “cash-out” distribution or deemed distribution of their entire nonforfeitable accrued benefit.

2. Retired or separated participants receiving benefits (i.e., individuals who are retired or separated from employment covered by the plan and who are receiving benefits under the plan). This does not include any individual to whom an insurance company has made an irrevocable commitment to pay all the benefits to which the individual is entitled under the plan.

3. Other retired or separated participants entitled to future benefits (i.e., any individuals who are retired or separated from employment covered by the plan and who are entitled to begin receiving benefits under the plan in the future). This does not include any individual to whom an insurance company has made an irrevocable commitment to pay all the benefits to which the individual is entitled under the plan.

4. Deceased individuals who had one or more beneficiaries who are receiving or are entitled to receive benefits under the plan. This does not include any individual to whom an insurance company has made an irrevocable commitment to pay all the benefits to which the beneficiaries of that individual are entitled under the plan.

Line 5e. Include any individual who terminated employment during this plan year, whether or not he or she (a) incurred a break in service, (b) received an irrevocable commitment from an insurance company to pay all the benefits to which he or she is entitled under the plan, and/or (c) received a cash distribution or deemed cash distribution of his or her nonforfeitable accrued benefit.

Line 6. If your plan is required to file an annual return/ report, you may file the Form 5500-SF instead of the Form 5500 only if you meet all of the eligibility conditions listed below.

1. The plan (a) covered fewer than 100 participants at the beginning of the plan year 20142015, or (b) under 29 CFR 2520.103-1(d) was eligible to and filed as a small plan for plan year 2013 2014 and did not cover more than 120 participants at the beginning of plan year 2014 2015 (see instructions for line 5 on counting the number of participants);

2. The plan did not hold any employer securities at any time during the plan year;

3. At all times during the plan year, the plan was 100% invested in certain secure, easy to value assets such as mutual fund shares, investment contracts with insurance companies and banks valued at least annually, publicly traded securities held by a registered broker dealer, cash and cash equivalents, and plan loans to participants that meet the definition of “eligible plan assets” (see the instructions for line 6a);

4. The plan is eligible for the waiver of the annual examination and report of an independent qualified public accountant (IQPA) under 29 CFR 2520.104-46 (but not by reason of enhanced bonding), which requirement includes, among others, giving certain disclosures and supporting documents to participants and beneficiaries regarding the plan’s investments (see instructions for line 6b);

5. The plan is not a multiemployer plan; and

6. The plan is not required to file a Form M-1, Report for Multiple-Employer Welfare Arrangements (MEWAs) and Certain Entities Claiming Exception (ECEs) during the plan year.

Special conditions for filing the Form 5500-SF apply to “one-participant plans.” See Specific Instructions for “One-Participant Plans” on page 7.

Line 6a – Eligible Plan Assets. To be eligible to file the Form 5500-SF, all of the plan’s assets must be “eligible plan assets.” Answer line 6a “Yes” or “No.” Do not leave this question blank. If the answer to line 6a is “No” you CANNOT file the Form 5500-SF and must file the Form 5500. See discussion under Who May File Form 5500-SF.

For the purposes of this line, “eligible plan assets” are assets that have a readily determinable fair market value for purposes of this annual reporting requirement as described in 29 CFR 2520.103-1(c)(2)(ii)(C), are not employer securities, and are held or issued by one of the following regulated financial institutions: a bank or similar financial institution as defined in 29 CFR 2550.408b-4(c) (for example, banks, trust companies, savings and loan associations, domestic building and loan associations, and credit unions); an insurance company qualified to do business under the laws of a state; organizations registered as broker-dealers under the Securities Exchange Act of 1934; investment companies registered under the Investment Company Act of 1940; or any other organization authorized to act as a trustee for individual retirement accounts under Code section 408. Examples of assets that would qualify as eligible plan assets for this annual reporting purpose are mutual fund shares, investment contracts with insurance companies or banks that provide the plan with valuation information at least annually, publicly traded stock held by a registered broker dealer, cash and cash equivalents held by a bank. Participant loans meeting the requirements of ERISA section 408(b)(1) are also “eligible plan assets” for this purpose whether or not they have been deemed distributed.

Line 6b. In addition to all of the plan’s assets being eligible plan assets as defined in line 6a, to be eligible to file the Form 5500-SF the plan also must be exempt from the requirement to be audited annually by an independent qualified public accountant (IQPA).

Welfare plans that cover fewer than 100 participants at the beginning of the plan year are exempt from the annual audit requirement.

A pension plan is exempt from the annual audit requirement if it covered fewer than 100 participants at the beginning of the plan year or under 29 CFR 2520.103-1(d) was eligible to and filed as a small plan for plan year 2013 2014 and did not cover more than 120 participants at the beginning of plan year 2014 2015 and meets the following three requirements for the audit waiver under 29 CFR 2520.104-46: (1) as the last day of the preceding plan year, at least 95% of a small pension plan’s assets were “qualifying plan assets;” (2) the plan includes the required audit waiver disclosure in the Summary Annual Report (SAR) furnished to participants and beneficiaries, in accordance with 29 CFR 2520.104b-10. For defined benefit pension plans that are required pursuant to section 101(f) of ERISA to furnish an Annual Funding Notice (AFN), the administrator must instead either provide the information to participants and beneficiaries with the AFN or as a stand-alone notification at the time an SAR would have been due and in accordance with the rules for furnishing an SAR, although such plans do not have to furnish an SAR; and (3) in response to a request from any participant or beneficiary, the plan administrator must furnish without charge copies of statements from the regulated financial institutions holding or issuing the plan’s “qualifying plan assets.”

I n order to be eligible to file the Form 5500-SF, a small pension plan must meet the audit waiver conditions by virtue of having 95% or more of its assets as “qualifying plan assets” in accordance with 29 CFR 2520.104-46(b)(1)(i)(A)(1). If the small plan satisfies the conditions of the audit waiver by virtue of having an enhanced fidelity bond under 29 CFR 2520.104-46(b)(1)(i)(A)(2), the plan does not satisfy the conditions for filing the Form 5500-SF and must file the Form 5500, along with the appropriate schedules and attachments. Also, although many “qualifying plan assets” for audit waiver purposes will also be “eligible plan assets” as described in the instructions for line 6a, the definitions are not the same. If, as of the last day of the preceding plan year, the plan was 100% invested in “eligible plan assets,” the plan would satisfy the “qualifying plan asset” prong of the audit waiver conditions. Holding all the plan’s investments in “qualifying plan assets,” however, would not necessarily satisfy the conditions for filing the

Form 5500-SF. For example, real estate held by a bank as trustee for a plan could be a qualifying plan asset for purposes of the small pension plan audit waiver conditions but it would not be an “eligible plan asset” for purposes of the plan being eligible to file the Form 5500-SF because real estate would not have a readily determinable fair market value as described in 29 CFR 2520.103-1(c)(2)(ii)(C).

Line 6c. If you are uncertain whether the plan is covered under the PBGC termination insurance program, check the box “Not determined” and contact the PBGC either by phone at 1-800-736-2444, by E-mail at [email protected], or in writing to Pension Benefit Guaranty Corporation, Standard Termination Compliance Division, Suite 930, Processing and Technical Assistance Branch, 1200 K Street, NW, Washington, DC 20005-4026. Defined contribution plans and welfare plans do not need to complete this item.

Part III – Financial Information

Note. The cash, modified cash, or accrual basis may be used for recognition of transactions in Parts I and II, as long as you use one method consistently. Round off all amounts reported on the Form 5500-SF to the nearest dollar. Any other amounts are subject to rejection. Check all subtotals and totals carefully.

Current value means fair market value where available. Otherwise, it means the fair value as determined in good faith under the terms of the plan by a trustee or named fiduciary, assuming an orderly liquidation at the time of the determination. See ERISA section 3(26).

Line 7 – Plan Assets and Liabilities. Amounts reported on lines 7a, 7b, and 7c of the Form 5500-SF for the beginning of the plan year must be the same as reported for the end of the plan year for the corresponding lines on the return/report for the preceding plan year. However, if the Form 5500 was filed the previous year, the amounts reported on the Form 5500-SF, lines 7a, column (a), 7b, column (a), and 7c, column (a), should correspond to the amounts entered in lines 1a, column (b), 1b, column (b), and 1c, column (b), of the 2013 2014 Schedule I (Form 5500) or the amounts entered in lines 1f, column (b), 1k, column (b), and 1l, column (b), of Schedule H (Form 5500) whichever schedule was filed.

Line 7a. Enter the total amount of plan assets at the beginning of the plan year in column (a). Do not include contributions designated for the 2014 2015 plan year in column (a).

Enter the total amount of plan assets at the end of the plan year in column (b). Do not include in column (b) a participant loan that has been deemed distributed during the plan year under the provisions of Code section 72(p) and Treasury Regulations section 1.72(p)-1 if both the following circumstances apply: (1) Under the plan, the participant loan is treated as a directed investment solely of the participant’s individual account; and (2) As of the end of the plan year, the participant is not continuing repayment under the loan.

If the deemed distributed participant loan is included in column (a) and both of these circumstances apply, include the value of the loan as a deemed distribution on line 8e. However, if either of these two circumstances does not apply, the current value of the participant loan (including interest accruing thereon after the deemed distribution) should be included in column (b) without regard to the occurrence of a deemed distribution.

After a participant loan that has been deemed distributed is included in the amount reported on line 8e, it is no longer to be reported as an asset on line 7a unless, in a later year, the participant resumes repayment under the loan. However, such a loan (including interest accruing thereon after the deemed distribution) that has not been repaid is still considered outstanding for purposes of applying Code section 72(p)(2)(A) to determine the maximum amount of subsequent loans. Also, the deemed distribution is not treated as an actual distribution for other purposes, such as the qualification requirements of Code section 401, including, for example, the determination of top-heavy status under Code section 416 and the vesting requirements of Treasury Regulations section 1.411(a)-7(d)(5). See Q&As 12 and 19 of Treasury Regulations section 1.72(p)-1.

The entry on line 7a, column (b) (plan assets at end of year) must include the current value of any participant loan included as a deemed distribution in the amount reported for any earlier year if, during the plan year, the participant resumes repayment under the loan. In addition, the amount to be entered on line 8e must be reduced by the amount of the participant loan reported as a deemed distribution for the earlier year.

Line 7b. Enter the total liabilities at the beginning and end of the plan year. Liabilities to be entered here do not include the value of future pension payments to participants. The amount to be entered in line 7b for accrual basis filers includes, among other things:

1. Benefit claims that have been processed and approved for payment by the plan but have not been paid (including all incurred but not reported (IBNR) welfare benefit claims);

2. Accounts payable obligations owed by the plan that were incurred in the normal operations of the plan but have not been paid; and

3. Other liabilities such as acquisition indebtedness and any other amount owed by the plan.

Line 7c. Enter the net assets as of the beginning and end of the plan year. (Subtract line 7b from 7a). Line 7c, column (b), must equal the sum of line 7c, column (a), plus lines 8i (net income (loss)) and 8j (transfers to (from) the plan).

Line 8 – Income, Expenses, and Transfers for this Plan Year.

Line 8a. Include the total cash contributions received and/or (for accrual basis plans) due to be received.

Line 8a(1). Plans using the accrual basis of accounting must not include contributions designated for years before the 2014 2015 plan year on line 8a(1).

Line 8a(2). For welfare plans, report all employee contributions, including all elective contributions under a cafeteria plan (Code section 125). For pension plans, participant contributions, for purposes of this line item, also include elective contributions under a qualified cash or deferred arrangement (Code section 401(k)).

Line 8a(3). Enter the current value, at date contributed, of all other contributions, including rollovers from other plans.

Line 8b. Enter all other plan income for the plan year. Do not include transfers from other plans that are reported on line 8j. Examples of other income received and/or receivable include:

1. Interest on investments (including money market accounts, sweep accounts, etc.)

2. Dividends. (Accrual basis plans should include dividends declared for all stock held by the plan even if the dividends have not been received as of the end of the plan year.)

3. Net gain or loss from the sale of assets.

4. Other income such as unrealized appreciation (depreciation) in plan assets.

To compute this amount, subtract the current value of all assets at the beginning of the year plus the cost of any assets acquired during the plan year from the current value of all assets at the end of the year minus assets disposed of during the plan year.

Line 8c. Enter the total of all cash contributions (line 8a(1) through line 8a(3)) and other plan income (line 8b) during the plan year. If entering a negative number, enter a minus sign (“–”) to the left of the number.

Line 8d. Include (1) payments made (and for accrual basis filers payments due) to or on behalf of participants or beneficiaries in cash, securities, or other property (including rollovers of an individual’s accrued benefit or account balance). Include all eligible rollover distributions as defined in Code section 401(a)(31)(D) paid at the participant’s election to an eligible retirement plan (including an IRA within the meaning of Code section 401(a)(31)(E)); (2) payments to insurance companies and similar organizations such as Blue Cross, Blue Shield, and health maintenance organizations for the provision of plan benefits (e.g., paid-up annuities, accident insurance, health insurance, vision care, dental coverage, etc.); and (3) payments made to other organizations or individuals providing benefits. Generally, these payments discussed in (3) are made to individual providers of welfare benefits such as legal services, day care services, and training and apprenticeship services. If securities or other property are distributed to plan participants or beneficiaries, include the current value as of the date of distribution.

Line 8e. Include on this line all distributions paid during the plan year of excess deferrals under Code section 402(g)(2)(A)(ii), excess contributions under Code section 401(k)(8), and excess aggregate contributions under Code section 401(m)(6). Include allocable income distributed. Also include on this line any elective deferrals and employee contributions distributed or returned to employees during the plan year as well as any attributable income that was also distributed.

For line 8e, also include in the total amount a participant loan included in line 7a, column (a) that has been deemed distributed during the plan year under the provisions of Code section 72(p) and Treasury Regulations section 1.72(p)-1 only if both of the following circumstances apply:

1. Under the plan, the participant loan is treated as a directed investment solely of the participant’s individual account; and

2. As of the end of the plan year, the participant is not continuing repayment under the loan.

If either of these circumstances does not apply, a deemed distribution of a participant loan should not be included in the total on line 8e. Instead, the current value of the participant loan (including interest accruing thereon after the deemed distribution) should be included on lines 7a, column (b) (plan assets – end of year), and 10g (participant loans – end of year), without regard to the occurrence of a deemed distribution.

Note. The amount to be reported on line 8e must be reduced if, during the plan year, a participant resumes repayment under a participant loan reported as a deemed distribution on line 2g of Schedule H or Schedule I of a prior Form 5500 or line 8e of a prior Form 5500-SF for any earlier year. The amount of the required reduction is the amount of the participant loan that was reported as a deemed distribution on such line for any earlier year. If entering a negative number, enter a minus sign (“–”) to the left of the number. The current value of the participant loan must then be included on line 7a, column (b) (plan assets – end of year).

Although certain participant loans deemed distributed are to be reported on line 8e, and are not to be reported on the Form 5500-SF or on the Schedule H or Schedule I of the Form 5500 as an asset thereafter (unless the participant resumes repayment under the loan in a later year), they are still considered outstanding loans and are not treated as actual distributions for certain purposes. See Q&As 12 and 19 of Treasury Regulations section 1.72(p)-1.

Line 8f. The amount to be reported for expenses involving administrative service providers (salaries, fees, and commissions) includes the total fees paid (or in the case of accrual basis plans, costs incurred during the plan year but not paid as of the end of the plan year) by the plan for, among others:

1. Salaries to employees of the plan;

2. Fees and expenses for accounting, actuarial, legal, investment management, investment advice, and securities brokerage services;

3. Contract administrator fees; and

4. Fees and expenses for individual plan trustees, including reimbursement for travel, seminars, and meeting expenses.

Line 8g. Other expenses (paid and/or payable) include other administrative and miscellaneous expenses paid by or charged to the plan, including among others office supplies and equipment, telephone, and postage.

Line 8h. Enter the total of all benefits paid or due reported on lines 8d and 8e and all other plan expenses reported on lines 8f and 8g during the year.

Line 8i. Subtract line 8h from line 8c.

Line 8j. Enter the net value of all assets transferred to and from the plan during the plan year including those resulting from mergers and spinoffs. A transfer of assets or liabilities occurs when there is a reduction of assets or liabilities with respect to one plan and the receipt of these assets or the assumption of these liabilities by another plan. Transfers out at the end of the year should be reported as occurring during the plan year.

Note. A distribution of all or part of an individual participant’s account balance that is reportable on Form 1099-R, Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc., should not be included on line 8j but must be included in benefit payments reported on line 8d. Do not submit IRS Form 1099-R with the

Form 5500-SF.

Part IV – Plan Characteristics

Line 9 - Benefits Provided Under the Plan. In the boxes for line 9a and 9b, as appropriate, enter all applicable plan characteristics codes from the List of Plan Characteristics Codes on pages 20 and 21 that describe the characteristics of the plan being reported.

Note. In the case of an eligible combined plan under Code section 414(x) and ERISA section 210(e), the codes entered in line 9a must include any codes applicable for either the defined benefit pension features or the defined contribution pension features of the plan.

F or plan sponsors of Puerto Rico plans, enter characteristic code 3C only if:

1. only Puerto Rico residents participate,

2. the trust is exempt from income tax under the laws of Puerto Rico, and

3. the plan administrator has not made the election under section 1022(i)(2), and, therefore, the plan is not intended to qualify under section 401(a) of the Internal Revenue Code (U.S).

Part V – Compliance Questions

Line 10. Answer all lines either “Yes” or “No.” Do not leave any answer blank unless otherwise directed. For lines 10a, b, c, d, e, f, g, and gj, if the answer is “Yes,” an amount must be entered.

Note. “One-participant plans” should complete only question 10g and j.

Line 10a. Amounts paid by a participant or beneficiary to an employer and/or withheld by an employer for contribution to the plan are participant contributions that become plan assets as of the earliest date on which such contributions can reasonably be segregated from the employer’s general assets. See 29 CFR 2510.3-102. In the case of a plan with fewer than 100 participants at the beginning of the plan year, any amount deposited with such plan not later than the 7^th business day following the day on which such amount is received by the employer (in the case of amounts that a participant or beneficiary pays to an employer), or the 7^th business day following the day on which such amount would otherwise have been payable to the participant in cash (in the case of amounts withheld by an employer from a participant’s wages), shall be deemed to be contributed or repaid to such plan on the earliest date on which such contributions or participant loan repayments can reasonably be segregated from the employer’s general assets. See 29 CFR 2510.3-102(a)(2). Plans that check “Yes,” must enter the aggregate amount of all late contributions for the year. The total amount of the delinquent contributions must be included on line 10a for the year in which the contributions were delinquent and must be carried over and reported again on line 10a for each subsequent year (or on line 4a of Schedule H or I of the Form 5500 if not eligible to file the Form 5500-SF in the subsequent year) until the year after the violation has been fully corrected by payment of the late contributions and reimbursement of the plan for lost earnings or profits. If no participant contributions were received or withheld by the employer during the plan year, answer “No.”

An employer holding participant contributions commingled with its general assets after the earliest date on which such contributions can reasonably be segregated from the employer’s general assets will have engaged in a prohibited use of plan assets (see ERISA section 406). If such a nonexempt prohibited transaction occurred with respect to a disqualified person (see Code section 4975(e)(2)), file IRS Form 5330, Return of Excise Taxes Related to Employee Benefit Plans, with the IRS to pay any applicable excise tax on the transaction.

Participant loan repayments paid to and/or withheld by an employer for purposes of transmittal to the plan that were not transmitted to the plan in a timely fashion must be reported either on line 10a in accordance with the reporting requirements that apply to delinquent participant contributions or on line 10b. See Advisory Opinion 2002-02A, available at www.dol.gov/ebsa.

Applicants that satisfy both the DOL Voluntary Fiduciary Correction Program (VFCP) and the conditions of Prohibited Transaction Exemption (PTE) 2002-51 are eligible for immediate relief from payment of certain prohibited transaction excise taxes for certain corrected transactions, and are also relieved from the requirement to file the IRS Form 5330 with the IRS. For more information on how to apply under the VFCP, the specific transactions covered (which transactions include delinquent participant contributions to pension and welfare plans), and acceptable methods for correcting violations, see 71 Fed. Reg. 20261 (Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19, 2006). All delinquent participant contributions must be reported on line 10a at least for the year in which they were delinquent even if violations have been fully corrected by the close of the plan year. Information about the VFCP is also available on the Internet at www.dol.gov/ebsa.

Line 10b. Plans that check “Yes” must enter the amount. Check “Yes” if any nonexempt transaction with a party-in-interest occurred. Do not check “Yes” with respect to transactions that are: (1) statutorily exempt under Part 4 of Title I of ERISA; (2) administratively exempt under ERISA section 408(a); (3) exempt under Code sections 4975(c) or 4975(d); (4) the holding of participant contributions in the employer’s general assets for a welfare plan that meets the conditions of ERISA Technical Release 92-01; or (5) delinquent participant contributions or delinquent loan repayments reported on line 10a. You may indicate that an application for an administrative exemption is pending. If you are unsure whether a transaction is exempt or not, you should consult either with a qualified public accountant, legal counsel, or both. If the plan is a qualified pension plan and a nonexempt prohibited transaction occurred with respect to a disqualified person, an IRS Form 5330 is required to be filed with the IRS to pay the excise tax on the transaction.

Nonexempt transactions. Nonexempt transactions with a party-in-interest include any direct or indirect:

A. Sale or exchange, or lease, of any property between the plan and a party-in-interest.

B. Lending of money or other extension of credit between the plan and a party-in-interest.

C. Furnishing of goods, services, or facilities between the plan and a party-in-interest.

D. Transfer to, or use by or for the benefit of, a party-in-interest, of any income or assets of the plan.

E. Acquisition, on behalf of the plan, of any employer security or employer real property in violation of ERISA section 407(a).

F. Dealing with the assets of the plan for a fiduciary’s own interest or own account.

G. Acting in a fiduciary’s individual or any other capacity in any transaction involving the plan on behalf of a party (or represent a party) whose interests are adverse to the interests of the plan or the interests of its participants or beneficiaries.

H. Receipt of any consideration for his or her own personal account by a party-in-interest who is a fiduciary from any party dealing with the plan in connection with a transaction involving the income or assets of the plan.

Party-in-Interest. For purposes of this form, party-in-interest is deemed to include a disqualified person. See Code section 4975(e)(2). The term “party-in-interest” means, as to an employee benefit plan:

A. Any fiduciary (including, but not limited to, any administrator, officer, trustee, or custodian), counsel, or employee of the plan;

B. A person providing services to the plan;

C. An employer, any of whose employees are covered by the plan;

D. An employee organization, any of whose members are covered by the plan;

E. An owner, direct or indirect, of 50% or more of:

1. the combined voting power of all classes of stock entitled to vote or the total value of shares of all classes of stock of a corporation;

2. the capital interest or the profits interest of a partnership; or

3. the beneficial interest of a trust or unincorporated enterprise which is an employer or an employee organization described in C or D;

F. A relative of any individual described in A, B, C, or E;

G. A corporation, partnership, or trust or estate of which (or in which) 50% or more of:

1. the combined voting power of all classes of stock entitled to vote or the total value of shares of all classes of stock of such corporation,

2. the capital interest or profits interest of such partnership, or

3. the beneficial interest of such trust or estate, is owned directly or indirectly, or held by persons described in A, B, C, D, or E;

H. An employee, officer, director (or an individual having powers or responsibilities similar to those of officers or directors), or a 10% or more shareholder directly or indirectly, of a person described in B, C, D, E, or G, or of the employee benefit plan; or

I. A 10% or more (directly or indirectly in capital or profits) partner or joint venturer of a person described in B, C, D, E, or G.

A pplicants that satisfy the VFCP requirements and the conditions of PTE 2002-51 (see the instructions for line 10a) are eligible for immediate relief from payment of certain prohibited transaction excise taxes for certain corrected transactions and the requirement to file the Form 5330 with the IRS. For more information, see 71 Fed. Reg. 20261 (Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19, 2006). When the conditions of PTE 2002-51 have been satisfied, the corrected transactions should be treated as exempt under Code section 4975(c) for the purposes of answering line 10b.

Line 10c. Plans that check “Yes” must enter the aggregate amount of fidelity bond coverage for all claims. Check “Yes” only if the plan itself (as opposed to the plan sponsor or administrator) is a named insured under a fidelity bond that is from an approved surety covering plan officials and that protects the plan from losses due to fraud or dishonesty as described in 29 CFR Part 2580. Generally, every plan official of an employee benefit plan who “handles” funds or other property of such plan must be bonded. Generally, a person shall be deemed to be “handling” funds or other property of a plan, so as to require bonding, whenever his or her duties or activities with respect to given funds are such that there is a risk that such funds could be lost in the event of fraud or dishonesty on the part of such person, acting either alone or in collusion with others. Section 412 of ERISA and 29 CFR Part 2580 describe the bonding requirements, including the definition of “handling” (29 CFR 2580.412-6), the permissible forms of bonds (29 CFR 2580.412-10), the amount of the bond (29 CFR Part 2580, Subpart C), and certain exemptions such as the exemption for unfunded plans, certain banks and insurance companies (ERISA section 412), and the exemption allowing plan officials to purchase bonds from surety companies authorized by the Secretary of the Treasury as acceptable reinsurers on federal bonds (29 CFR 2580.412-23). Information concerning the list of approved sureties and reinsurers is available on the Internet at www.fms.treas.gov/c570. For more information on the fidelity bonding requirements, see Field Assistance Bulletin 2008-04, available at www.dol.gov/ebsa.

Note. Plans are permitted under certain conditions to purchase fiduciary liability insurance. These fiduciary liability insurance policies are not written specifically to protect the plan from losses due to dishonest acts and cannot be reported as fidelity bonds on line 10c.

Line 10d. Check “Yes” if the plan had suffered or discovered any loss as a result of any dishonest or fraudulent act(s) even if the loss was reimbursed by the plan’s fidelity bond or from any other source. If “Yes” is checked enter the full amount of the loss. If the full amount of the loss has not yet been determined, provide an estimate as determined in good faith by a plan fiduciary. You must keep, in accordance with ERISA section 107, records showing how the estimate was determined.

W illful failure to report is a criminal offense. See ERISA section 501.

Line 10e. If any benefits under the plan are provided by an insurance company, insurance service, or other similar organization (such as Blue Cross Blue Shield or a health maintenance organization) or if the plan has investments with insurance companies such as guaranteed investment contracts (GICs), report the total of all insurance fees and commissions paid to agents, brokers and/or other persons directly or indirectly attributable to the contract(s) placed with or retained by the plan.

For purposes of line 10e, commissions and fees include sales or base commissions and all other monetary and non-monetary forms of compensation where the broker’s, agent’s, or other person’s eligibility for the payment or the amount of the payment is based, in whole or in part, on the value (e.g., policy amounts, premiums) of contracts or policies (or classes thereof) placed with or retained by an ERISA plan, including, for example, persistency and profitability bonuses. The amount (or pro rata share of the total) of such commissions or fees attributable to the contract or policy placed with or retained by the plan must be reported. Insurers must provide plan administrators with a proportionate allocation of commissions and fees attributable to each contract. Any reasonable method of allocating commissions and fees to policies or contracts is acceptable, provided the method is disclosed to the plan administrator. A reasonable allocation method could allocate fees and commissions based on a calendar year calculation even if the plan year or policy year was not a calendar year. For additional information on these reporting requirements, see ERISA Advisory opinion 2005-02A, available on the Internet at www.dol.gov/ebsa.

Where benefits under a plan are purchased from and guaranteed by an insurance company, insurance service, or other similar organization, and the total fees and commissions are reported on the Form 5500-SF, payments of reasonable monetary compensation by the insurer out of its general assets to affiliates or third parties for performing administrative activities necessary for the insurer to fulfill its contractual obligation to provide benefits, where there is no direct or indirect charge to the plan for administrative services other than the insurance premium, then the payments for administrative services by the insurer to the affiliates or third parties do not need to be reported on line 10e. This would include compensation for services such as recordkeeping and claims processing services provided by a third party pursuant to a contract with the insurer to provide those services but would not include compensation provided by the insurer incidental to the sale or renewal of a policy, such as finders’ fees, insurance brokerage commissions and fees, or similar fees.

Reporting also is not required for compensation paid by the insurer to a “general agent” or “manager” for that general agent’s or manager’s management of an agency or performance of administrative functions for the insurer. For this purpose, (1) a “general agent” or “manager” does not include brokers representing insureds, and (2) payments would not be treated as paid for managing an agency or performance of administrative functions where the recipient’s eligibility for the payment or the amount of the payment is dependent or based on the value (e.g., policy amounts, premiums) of contracts or policies (or classes thereof) placed with or retained by ERISA plan(s).

Reporting is not required for occasional gifts or meals of insubstantial value which are tax deductible for federal income tax purposes by the person providing the gift or meal and would not be taxable income to the recipient. For this exemption to be available, the gift or gratuity must be both occasional and insubstantial. For this exemption to apply, the gift must be valued at less than $50, the aggregate value of gifts from one source in a calendar year must be less than $100, but gifts with a value of less than $10 do not need to be counted toward the $100 annual limit. If the $100 aggregate value limit is exceeded, then the aggregate value of all the gifts will be reportable. For this purpose, non-monetary gifts of less than $10 also do not need to be included in calculating the aggregate value of all gifts required to be reported if the $100 limit is exceeded.

Gifts from multiple employees of one service provider should be treated as originating from a single source when calculating whether the $100 threshold applies. On the other hand, in applying the threshold to an occasional gift received from one source by multiple employees of a single service provider, the amount received by each employee should be separately determined in applying the $50 and $100 thresholds. For example, if six employees of a broker attend a business conference put on by an insurer designed to educate and explain the insurer’s products for employee benefit plans, and the insurer provides, at no cost to the attendees, refreshments valued at $20 per individual, the gratuities would not be reportable on this line even though the total cost of the refreshments for all the employees would be $120.

These thresholds are for purposes of line 10e reporting. Filers are cautioned that the payment or receipt of gifts and gratuities of any amount by plan fiduciaries may violate ERISA and give rise to civil liabilities and criminal penalties.

Important Reminder. The insurance company, insurance service, or other similar organization is required under ERISA section 103(a)(2) to provide the plan administrator with the information needed to complete this return/report. Your insurance company must provide you with the information you need to answer this question. If your insurance company, insurance service, or other similar organization does not automatically send you this information, you should make a written request for the information. If you have difficulty getting the information from your insurance company, contact the nearest office of the DOL’s Employee Benefits Security Administration.

Line 10f. You must check “Yes” if any benefits due under the plan were not timely paid or not paid in full. Include in this amount the total of any outstanding amounts that were not paid when due in previous years that have continued to remain unpaid.

Line 10g. You must check “Yes” if the plan had any participant loans outstanding at any time during the plan year and enter the amount outstanding as of the end of the plan year. If no participant loans are outstanding as of the end of the plan year, enter “0”.

Line 10h. Code section 401(k) and other individual account pension plans must complete line 10h. Other filers should leave line 10h blank. Check “Yes” if there was a “blackout period.” A blackout period is a temporary suspension of more than three consecutive business days during which participants or beneficiaries of a 401(k) or other individual account pension plan were unable, or were limited or restricted in their ability, to direct or diversify assets credited to their accounts, obtain loans from the plan, or obtain distributions from the plan. A “blackout period” generally does not include a temporary suspension of the right of participants and beneficiaries to direct or diversify assets credited to their accounts, obtain loans from the plan, or obtain distributions from the plan if the temporary suspension is: (1) part of the regularly scheduled operations of the plan that has been disclosed to participants and beneficiaries; (2) due to a qualified domestic relations order (QDRO) or because of a pending determination as to whether a domestic relations order is a QDRO; (3) due to an action or a failure to take action by an individual participant or because of an action or claim by someone other than the plan regarding a participant’s individual account; or (4) by application of federal securities laws. For more information, see the DOL’s regulation at 29 CFR 2520.101-3 (available at www.dol.gov/ebsa).

Line 10i. Code section 401(k) and other individual account pension plans who answered “Yes” to line 10h must complete line 10i. Other filers should leave line 10i blank. If there was a blackout period, did you provide the required notice not less than 30 days nor more than 60 days in advance of restricting the rights of participants and beneficiaries to change their plan investments, obtain loans from the plan, or obtain distributions from the plan? If so, check “Yes.” See 29 CFR 2520.101-3 for specific notice requirements and for exceptions from the notice requirement. Also, answer “Yes” if one of the exceptions to the notice requirement under 29 CFR 2520.101-3 applies.

Line 10j. Plans that check “Yes” must enter any amount of unrelated business taxable income as a result of gross income derived from any trade or business regularly carried on and not substantially related to the plan’s exempt purpose under Code section 512. Form 990-T is required for any gross income of $1000 or more generated by an employer’s trust by the 15th day of the 4th month following the end of the trust’s tax year. See Instructions to Form 990-T for more details.

Note. You are required to complete Line 10j if you are required to file at least 250 returns of any type with the IRS during the calendar year. However, if you are a small filer (file fewer than 250 returns of any type with the IRS during the calendar year) and you do not voluntarily complete this Line 10j, then you must file the Form 5500-SUP with the IRS on paper.

Part VI – Pension Funding Compliance

Complete Part VI only if the plan is subject to the minimum funding requirements of Code section 412 or ERISA section 302.

All qualified defined benefit and defined contribution plans are subject to the minimum funding requirements of Code section 412 unless they are described in the exceptions listed under Code section 412(e)(2). These exceptions include profit-sharing or stock bonus plans, insurance contract plans described in Code section 412(e)(3), and certain plans to which no employer contributions are made.

Nonqualified employee pension benefit plans are subject to the minimum funding requirements of ERISA section 302 unless specifically exempted under ERISA sections 4(a) or 301(a).

The employer or plan administrator of a single-employer or multiple-employer defined benefit plan that is subject to the minimum funding requirements must file the Schedule SB (Form 5500) as an attachment to the

Form 5500-SF. The employer or plan administrator of a money purchase plan that is currently amortizing a waiver of the minimum funding requirements must complete lines 3, 9, and 10 of the Schedule MB (Form 5500) and file it as an attachment to the Form 5500-SF.

Line 11. If “Yes” is checked, attach a completed and signed Schedule SB (Form 5500), and complete line 11a. See the instructions for the Schedule SB in the Instructions for Form 5500. If this is a defined contribution pension plan, leave blank.

Line 11a. Enter the amount from line 39 40 of Schedule SB (Form 5500).

Line 12. Check the “Yes” box if the plan is a defined contribution plan subject to the minimum funding requirements of Code section 412 and ERISA section 302. Those money purchase plans (including target benefit plans) that are amortizing a waiver of the minimum funding standard for a prior year should fill out line 12a and then skip to line 13. Those defined contribution plans answering “Yes” to the line 12 question that do not fill out line 12a should fill out lines 12b-12e.

Line 12a. If a money purchase defined contribution plan (including a target benefit plan) has received a waiver of the minimum funding standard, and the waiver is currently being amortized, complete lines 3, 9, and 10 of Schedule MB (Form 5500). See instructions for Schedule MB in the Instructions for Form 5500. The Schedule MB for a money purchase defined contribution plan does not need to be signed by an enrolled actuary.

Line 12b. The minimum required contribution for a money purchase defined contribution plan (including a target benefit plan) for a plan year is the amount required to be contributed for the year under the formula set forth in the plan document. If there is an accumulated funding deficiency for a prior year that has not been waived, that amount should also be included as part of the contribution required for the current year.

Line 12c. Include all contributions for the plan year made not later than 8 ½ months after the end of the plan year. Show only contributions actually made to the plan by the date the form is filed. For example, do not include receivable contributions for this purpose

Line 12d. If the minimum required contribution exceeds the contributions for the plan year made not later than 8 ½ months after the end of the plan year, the excess is an accumulated funding deficiency for the plan year. File IRS Form 5330, Return of Excise Taxes Related to Employee Benefit Plans, with the IRS to pay the excise tax on the deficiency. There is a penalty for not filing Form 5330 on time.

Line 12e. Check “Yes” if the minimum required contribution remaining in line 12d will be made not later than 8 ½ months after the end of the plan year. If “Yes,”

and contributions are actually made by this date, then there will be no reportable deficiency and IRS Form 5330 will not need to be filed.

Part VII – Plan Terminations and Transfers of Assets

Line 13a. Check “Yes” if a resolution to terminate the plan was adopted during this or any prior plan year, unless the termination was revoked and no assets reverted to the employer. If “Yes” is checked, enter the amount of plan assets that reverted to the employer during the plan year in connection with the implementation of such termination. Enter “0” if no reversion occurred during the current plan year.

A Form 5500 or a Form 5500-SF must be filed for each year the plan has assets, and, for a welfare benefit plan, if the plan is still liable to pay benefits for claims incurred before the termination date, but not yet paid. See 29 CFR 2520.104b-2(g)(2)(ii).

Line 13b. Check “Yes” if all of the plan assets (including insurance/annuity contracts) were distributed to the participants and beneficiaries, legally transferred to the control of another plan, or brought under the control of the PBGC.

Check “No” for a welfare benefit plan that is still liable to pay benefits for claims that were incurred before the termination date, but not yet paid. See 29 CFR 2520.104b-2(g)(2)(ii).

Line 13c. Enter information concerning assets and/or liabilities transferred from this plan to another plan(s) (including spinoffs) during the plan year. A transfer of assets or liabilities occurs when there is a reduction of assets or liabilities with respect to one plan and the receipt of these assets or the assumption of these liabilities by another plan. Enter the name, EIN, and PN of the transferee plan(s) involved on lines 13c(1), c(2), and c(3).

Do not use a social security number in place of an EIN or include an attachment that contains visible social security numbers. The Form 5500-SF is open to public inspection, and the contents are public information and are subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on this Form 5500-SF may result in the rejection of the filing.

Note. A distribution of all or part of an individual participant’s account balance that is reportable on Form 1099-R should not be included on line 13c. Do not submit Form 1099-R with the Form 5500-SF.

IRS Form 5310-A, Notice of Plan Merger or Consolidation, Spinoff, or Transfer of Plan Assets or Liabilities; Notice of Qualified Separate Lines of Business, must be filed at least 30 days before any plan merger or consolidation or any transfer of plan assets or liabilities to another plan. There is a penalty for not filing

I RS Form 5310-A on time. In addition, a transfer of benefit liabilities involving a plan covered by PBGC insurance may be reportable to the PBGC. See PBGC Form 10, Post-Event Notice of Reportable Event, and PBGC Form 10-Advance, Advance Notice of Reportable Event (see the “Reportable Events and Large Unpaid Contributions” section of the Practitioners page on PBGC’s website, which is available at www.pbgc.gov/practitioners).

Part VIII – Trust Information (Optional)

Line 14a. (Optional) You may use this line to enter the “Name of trust.” If a plan uses more than one trust or custodial account for its fund, you should enter the primary trust or custodial account in which the greatest dollar amount or largest percentage of the plan assets as of the end of the plan year is held on this Line. For example, if a plan uses three different trusts, X, Y, Z, with the percentages of plan assets, 35%, 45%, and 20%, respectively, trust Y that held the 45% of plan assets would be entered in Line 14a.

Line 14b. (Optional) You may use this line to enter the “Trust’s Employer Identification Number (EIN)” assigned to the employee benefit trust or custodial account, if one has been issued to you. The trust EIN should be used for transactions conducted for the trust. If you do not have a trust EIN, enter the EIN you would use on Form 1099-R, Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc., to report distributions from employee benefit plans and on Form 945, Annual Return of Withheld Federal Income Tax, to report withheld amounts of income tax from those payments.

Do not use a social security number in lieu of an EIN. Form 5500 and its attachments are open to public inspection, and the contents are public information and are subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof may result in the rejection of the filing.

Trust EINs can be obtained from the IRS by applying for one on Form SS-4, Application for Employer Identification Number. See Instructions to Line 2b (Form 5500) for applying for an EIN. Also see IRS EIN application link page for further information.

Note. Although Lines 14a and 14b are optional, the IRS encourages filers to provide trust information on these lines.Line 14c..Enter the name of the plan trustee or custodian.

Line 14d. Enter the telephone number for the plan trustee or custodian.

Part IX – IRS Compliance Questions

Note. Plan administrators who are required to file an annual return of employee benefit plans, as required under Code section 6058, must complete Lines 15 through 20, unless you are required to file fewer than 250 returns of any type with the IRS, including information returns (for example, Forms W-2 and Forms 1099), income tax returns, employment tax returns, and excise tax returns during the calendar year, then you can alternatively file Form 5500-SUP with the IRS on paper. See the Treasury Regulations on “Employee Retirement Benefit Plan Returns Required on Magnetic Media” and Instructions for Form 5500-SUP for more information [T.D. 9695, 79 FR 58256 at http://federalregister.gov/a/2014-23161].

Line 15a. Check “Yes” if the plan includes a cash or deferred arrangement (CODA) under which a covered employee may elect to have the employer either contribute an amount to the plan’s trust on behalf of the employee or to pay the employee directly in a cash or some other taxable benefit. A 401(k) is a feature of a qualified profit-sharing plan that allows employees to contribute a portion of their wages to individual accounts. The contributions go into a 401(k) account, with the employee often choosing the investments based on options provided under the plan. In some plans, the employer also makes contributions, such as matching the employee’s contributions up to a certain percentage. SIMPLE and safe harbor 401(k) plans have mandatory employer contribution requirements.

Line 15b. If Line 15a is “Yes,” check the applicable testing method being used to satisfy the nondiscrimination requirements of Code sections 401(k) and (m). A safe harbor 401(k) plan is similar to a traditional 401(k) plan but, among other things, it must provide for employer contributions that are fully vested when made. These contributions may be employer matching contributions, limited to employees who defer, or employer contributions made on behalf of all eligible employees, regardless of whether they make elective deferrals. The safe harbor 401(k) plan is not subject to the complex annual nondiscrimination tests that apply to traditional 401(k) plans. Check “Design-based safe harbor method” if this is a safe harbor 401(k) plan that includes a SIMPLE 401(k) plan under Code sections 401(k)(11) and 401(m)(10), a safe harbor 401(k) plan under Code sections 401(k)(12) and 401(m)(11), and a safe harbor plan using automatic contribution arrangements under Code sections 401(k)(13) and 401(m)(12). If the plan, by its terms, does not satisfy the safe harbor method, it must satisfy the regular nondiscrimination test, actual deferral percentage (ADP)/actual contribution percentage (ACP) test.

Line 15c If the ADP/ACP test was used to satisfy nondiscrimination requirements under Code section 401(k)(3), check “Yes” if an election was made to use the current year testing method under which the ADP test is performed by comparing the current plan year’s ADP for highly-compensated employees (HCEs) with the current plan year’s (rather than the prior plan year’s) ADP for nonhighly-compensated employees (NHCEs).

Line 16a. Check the applicable testing method below used to satisfy the minimum coverage requirements under Code section 410(b). A plan satisfies the “ratio percentage test” of Code section 410(b)(1)(B) with respect to employees if the percentage of the employer’s nonhighly-compensated employees (NHCEs) who benefit under the plan divided by the percentage of highly-compensated active employees (HCEs) who benefit under the plan is at least 70 percent (percentages are calculated to the nearest hundredth). For example, if Employer Y has 100 employees, of which 30 are HCEs and 70 are NHCEs, and Employer Y maintains a pension Plan A that benefits 15 of the 30 HCEs (that is, 50 percent of the HCEs) and 25 of the 70 NHCEs (that is, 35.71 percent of all NHCEs), then the ratio percentage of 71.42 percent (35.71% / 50%) is greater than 70 percent. Thus, Plan A satisfies the minimum coverage requirement as required under Code section 410(b)(1). The average benefit test is a two-part test. First, the plan must satisfy the nondiscriminatory classification test. Second, the plan must satisfy the average benefit percentage test. See Treasury Regulations sections 1.410(b)-4 and 1.410(b)-5 for more information.

Line 16b. Check “Yes” if this plan was permissively aggregated with another plan to satisfy requirements under Code sections 410(b) and 401(a)(4). Generally, each single plan must separately satisfy the coverage and nondiscrimination requirements. However, an employer may designate two or more separate plans as a single plan for purposes of applying the ratio percentage test of Treasury Regulations section 1.410(b)-2(b)(2) or the nondiscretionary classification test of Treasury Regulations section 1.401(b)-4. Two or more plans that are permissively aggregated and treated as a single plan for purposes of the minimum coverage test of Code section 410(b) must also be treated as a single plan for purpose of the nondiscrimination test under Code section 401(a)(4). See Treasury Regulations sections 1.410(b)-7 and 1.401(a)(4)-(9) for more information.

Line 17a. Check box “Yes” if a plan has timely adopted the amendments for all required tax law changes. Check “N/A’ if it is a newly established plan. In order to be a qualified plan and to retain these tax advantages, a pension plan must be timely amended for all required tax law changes and operate in accordance with the plan document. The IRS generally establishes a deadline by which plan amendments that reflect tax law changes must be adopted. See Rev. Proc. 2007-44, 2007-28 I.R.B. 54, for more information.

Line 17b. Enter the date of the last plan amendment or restatement for the required tax law changes, and enter the applicable code indicating the tax law changes below:

Tax Law	Code
Pension Protection Act of 2006 (PPA 06)	J
Economic Growth and Tax Relief Reconciliation Act of 2001 (EGTRRA)	M
GATT, USERRA, SBJPA, and TRA (GUST)	K

Line 17c. If a plan sponsor or an employer adopted a pre-approved plan that includes a master & prototype plan (a standardized or nonstandardized M&P) or a volume submitter plan, enter the date of the most recent favorable opinion or advisory letter issued by the IRS and the serial number listed on that favorable letter.

Line 17d. If it is an individually-designed plan and received a favorable determination letter from the IRS, enter the date of the most recent determination letter. Leave it blank if this individually-designed plan never received a favorable determination letter.

Line 18. Check “Yes” if a plan is in a U.S territory, including Puerto Rico (if no election under ERISA section 1022(i)(2) has been made), American Samoa, Guam, the Commonwealth of the Northern Mariana Islands or the U.S. Virgin Islands.

Line 19. Plans that check “Yes” must enter amounts of any distributions made prior to attainment of retirement, death, disability, and severance of employment or termination of the plan. These amounts would include any distribution allowed under a profit sharing plan after a fixed number of years. See Treasury Regulations 1.401-1(b)(1)(ii). This includes any hardship distributions under Code section 401(k)(2)(B)(i)(IV) or any distribution allowed under terms of plan upon attainment of age 62 under a money purchase plan or defined benefit plan for plan years beginning after December 31, 2006.

Line 20. Check “Yes” if required minimum distributions were made to 5% owners who attained age 70 ½ and older. Required Minimum Distributions (RMDs) generally are minimum amounts that a retirement plan account owner must withdraw annually starting with the year that he or she reaches 70 ½ years of age or, if later, the year in which he or she retires. However, if the account owner is a 5% owner of the business sponsoring the retirement plan, the RMDs must begin once the account holder is age 70 ½, regardless of whether he or she is retired.

OMB Control Numbers

Agency OMB Number

Employee Benefits Security Administration 1210–0110

1210–0089

Internal Revenue Service 1545–1610

Pension Benefit Guaranty Corporation 1212–0057

Paperwork Reduction Act Notice

We ask for the information on this form to carry out the law as specified in ERISA and in Code sections 6058(a) and 6059(a). You are required to give us the information. We need it to determine whether the plan is operating according to the law.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books and records relating to a form or its instructions must be retained as long as their contents may become material in the administration of the Internal Revenue Code or are required to be maintained pursuant to Title I or IV of ERISA. The Form 5500-SF return/reports are open to public inspection and are subject to publication on the Internet.

The time needed to complete and file the Form 5500-SF and the Schedules SB (Form 5500) and MB (Form 5500) shown in the list below reflects the combined requirements of the Internal Revenue Service, Department of Labor, and Pension Benefit Guaranty Corporation. These times will vary depending on individual circumstances. The estimated average times are:

Form	Pension Plans	Welfare Plans
Form 5500-SF Schedule MB (Form 5500) Schedule SB (Form 5500)	2 hr., 32 min. 3 hr., 20 min. 6 hr., 49 min.	2 hr., 32 min. N/A N/A

If you have comments concerning the accuracy of these time estimates or suggestions for making these forms simpler, we would be happy to hear from you. You can write to the Internal Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, IR-6526, Washington, DC 20224. Do not send this form or these schedules to this address. The form and schedules must be filed electronically. See How To File – Electronic Filing Requirement.

LIST OF PLAN CHARACTERISTICS CODES FOR LINES 9a AND 9b

CODE	Defined Benefit Pension Features
1A	Benefits are primarily pay related.
1B	Benefits are primarily flat dollar (includes dollars per year of service).
1C	Cash balance or similar plan – Plan has a “cash balance” formula. For this purpose, a “cash balance” formula is a benefit formula in a defined benefit plan by whatever name (for example, personal account plan, pension equity plan, life cycle plan, cash account plan, etc.) that rather than, or in addition to, expressing the accrued benefit as a life annuity commencing at normal retirement age, defines benefits for each employee in terms more common to a defined contribution plan such as a single sum distribution amount (for example, 10 percent of final average pay times years of service, or the amount of the employee’s hypothetical account balance).
1D	Floor-offset plan – Plan benefits are subject to offset for retirement benefits provided by an employer-sponsored defined contribution plan.
1E	Code section 401(h) arrangement – Plan contains separate accounts under Code section 401(h) to provide employee health benefits.
1F	Code section 414(k) arrangement – Benefits are based partly on the balance of the separate account of the participant (also include appropriate defined contribution pension feature codes).
1H	Plan covered by PBGC that was terminated and closed out for PBGC purposes – Before the end of the plan year (or a prior plan year), (1) the plan terminated in a standard (or distress) termination and completed the distribution of plan assets in satisfaction of all benefit liabilities (or all ERISA Title IV benefits for distress termination); or (2) a trustee was appointed for a terminated plan pursuant to ERISA section 4042.
1I	Frozen plan – As of the last day of the plan year, the plan provides that no participant will get any new benefit accrual (whether because of service or compensation).
CODE	Defined Contribution Pension Features
2A	Use this code if employer contributions in the return year were based on one of the following allocation types: Age/service weighted or new comparability or similar plan – Age/service weighted plan: Allocations are based on age, service, or age and service. New comparability or similar plan: Allocations are based on participant classifications and a classification(s) consists entirely or predominantly of highly compensated employees; or the plan provides an additional allocation rate on compensation above a specified threshold, and the threshold or additional rate exceeds the maximum threshold or rate allowed under the permitted disparity rules of Code section 401(l).
2B	Target benefit plan.
2C	Money purchase (other than target benefit).

2D	Offset plan – Plan benefits are subject to offset for retirement benefits provided in another plan or arrangement of the employer.
2E	Profit-sharing.
2F	ERISA section 404(c) plan – This plan, or any part of it, is intended to meet the conditions of 29 CFR 2550.404c-1.
2G	Total participant-directed account plan – Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
2H	Partial participant-directed account plan – Participants have the opportunity to direct the investment of a portion of the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
2J	Code section 401(k) feature – A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
2K	Code section 401(m) arrangement – Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contributions to the plan. Not applicable if plan is 401(k) with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7), or 408 arrangement/ accounts annuities.
2L	An annuity contract purchased by Code section 501(c)(3) organization or public school as described in Code section 403(b)(1) arrangement.
2M	Custodial accounts for regulated investment company stock as described in Code section 403(b)(7).
2N	Code section 408 accounts and annuities.
2R	Participant-directed brokerage accounts provided as an investment option under the plan.
2S	401(k) plan or 403(b) plan that provides for automatic enrollment in plan that has elective contributions deducted from payroll.
2T	Total or partial participant-directed account plan – plan uses default investment account for participants who fail to direct assets in their account.
CODE	Other Pension Benefit Features
3B	Use this code if the plan covered self-employed individuals in the return year.Plan covering self-employed individuals.
3C	Plan not intended to be qualified – A plan not intended to be qualified under Code sections 401, 403, or 408.
3D	Pre-approved pension plan – A master, prototype, or volume submitter plan that is the subject of a favorable opinion or advisory letter from the IRS.
3E	A one-participant plan that satisfies minimum coverage requirements of Code section 410(b) only when combined with another plan of the employer.
3F	Plan sponsor(s) received services of leased employees, as defined in Code section 414(n), during the plan year.

LIST OF PLAN CHARACTERISTICS CODES FOR LINES 9a AND 9b (Continued)

3H	Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).
3J	U.S.-based plan that covers residents of Puerto Rico and is qualified under both Code section 401 and section 1165 of Puerto Rico Code.
CODE	Welfare Benefit Features
4A	Health (other than vision or dental).
4B	Life insurance.
4C	Supplemental unemployment.
4D	Dental.
4E	Vision.
4F	Temporary disability (accident and sickness).
4G	Prepaid legal.
4H	Long-term disability.
4I	Severance pay.
4J	Apprenticeship and training.

4K	Scholarship (funded).
4L	Death benefits (include travel accident but not life insurance).
4P	Taft-Hartley Financial Assistance for Employee Housing Expenses.
4Q	Other.
4R	Unfunded, fully insured, or combination unfunded/fully insured welfare plan that will not file an annual report for next plan year pursuant to 29 CFR 2520.104-20.
4S	Unfunded, fully insured, or combination unfunded/fully insured welfare plan that stopped filing annual reports in an earlier plan year pursuant to 29 CFR 2520.104-20.
4T	10 or more employer plan under Code section 419A(f)(6).

Forms 5500, 5500-SF, and 5500-EZ Codes for Principal Business Activity		This list of principal business activities and their associated codes is designed to classify an enterprise by the type of activity in which it is engaged.		These principal activity codes are based on the North American Industry Classification System.
Code	Code		Code		Code
Agriculture, Forestry, Fishing	Specialty Trade Contractors		Printing and Related Support		Computer and Electronic Product
and Hunting	238100 Foundation, Structure, &		Activities		Manufacturing
Crop Production	Building Exterior Contractors		323100 Printing & Related Support		334110 Computer & Peripheral
111100 Oilseed & Grain Farming	(including framing carpentry,		Activities		Equipment Mfg
111210 Vegetable & Melon Farming	masonry, glass, roofing, &		Petroleum and Coal Products		334200 Communications Equipment
(including potatoes & yams)	siding)		Manufacturing		Mfg
111300 Fruit & Tree Nut Farming	238210 Electrical Contractors		324110 Petroleum Refineries		334310 Audio & Video Equipment Mfg
111400 Greenhouse, Nursery, &	238220 Plumbing, Heating, &		(including integrated)		334410 Semiconductor & Other
Floriculture Production	Air-Conditioning Contractors		324120 Asphalt Paving, Roofing, &		Electronic Component Mfg
111900 Other Crop Farming	238290 Other Building Equipment		Saturated Materials Mfg		334500 Navigational, Measuring,
(including tobacco, cotton,	Contractors		324190 Other Petroleum & Coal		Electromedical, & Control
sugarcane, hay, peanut,	238300 Building Finishing		Products Mfg		Instruments Mfg
sugar beet, & all other crop	Contractors (including		Chemical Manufacturing		334610 Manufacturing & Reproducing
farming)	drywall, insulation, painting,		325100 Basic Chemical Mfg		Magnetic & Optical Media
Animal Production	wallcovering, flooring, tile, &		325200 Resin, Synthetic Rubber, &		Electrical Equipment, Appliance, and
112111 Beef Cattle Ranching &	finish carpentry)		Artificial & Synthetic Fibers &		Component Manufacturing
Farming	238900 Other Specialty Trade		Filaments Mfg		335100 Electric Lighting Equipment
112112 Cattle Feedlots	Contractors (including site		325300 Pesticide, Fertilizer, & Other		Mfg
112120 Dairy Cattle & Milk	preparation)		Agricultural Chemical Mfg		335200 Household Appliance Mfg
Production	Manufacturing		325410 Pharmaceutical & Medicine Mfg		335310 Electrical Equipment Mfg
112210 Hog & Pig Farming	Food Manufacturing		325500 Paint, Coating, & Adhesive Mfg		335900 Other Electrical Equipment &
112300 Poultry & Egg Production	311110 Animal Food Mfg		325600 Soap, Cleaning Compound, &		Component Mfg
112400 Sheep & Goat Farming	311200 Grain & Oilseed Milling		Toilet Preparation Mfg		Transportation Equipment
112510 Aquaculture (including	311300 Sugar & Confectionary		325900 Other Chemical Product &		Manufacturing
shellfish & finfish farms &	Product Mfg		Preparation Mfg		336100 Motor Vehicle Mfg
hatcheries)	311400 Fruit & Vegetable Preserving		Plastics and Rubber Products		336210 Motor Vehicle Body & Trailer
112900 Other Animal Production	& Specialty Food Mfg		Manufacturing		Mfg
Forestry and Logging	311500 Dairy Product Mfg		326100 Plastics Product Mfg		336300 Motor Vehicle Parts Mfg
113110 Timber Tract Operations	311610 Animal Slaughtering and		326200 Rubber Product Mfg		336410 Aerospace Product & Parts
113210 Forest Nurseries & Gathering	Processing		Nonmetallic Mineral Product		Mfg
of Forest Products	311710 Seafood Product Preparation		Manufacturing		336510 Railroad Rolling Stock Mfg
113310 Logging	& Packaging		327100 Clay Product & Refractory Mfg		336610 Ship & Boat Building
Fishing, Hunting and Trapping	311800 Bakeries, Tortilla & Dry Pasta		327210 Glass & Glass Product Mfg		336990 Other Transportation
114110 Fishing	Mfg		327300 Cement & Concrete Product Mfg		Equipment Mfg
114210 Hunting & Trapping	311900 Other Food Mfg (including		327400 Lime & Gypsum Product Mfg		Furniture and Related Product
Support Activities for Agriculture	coffee, tea, flavorings &		327900 Other Nonmetallic Mineral		Manufacturing
and Forestry	seasonings)		Product Mfg		337000 Furniture & Related Product
115110 Support Activities for Crop	Beverage and Tobacco Product		Primary Metal Manufacturing		Manufacturing
Production (including cotton	Manufacturing		331110 Iron & Steel Mills & Ferroalloy		Miscellaneous Manufacturing
ginning, soil preparation,	312110 Soft Drink & Ice Mfg		Mfg		339110 Medical Equipment &
planting, & cultivating)	312120 Breweries		331200 Steel Product Mfg from		Supplies Mfg
115210 Support Activities for Animal	312130 Wineries		Purchased Steel		339900 Other Miscellaneous Mfg
Production	312140 Distilleries		331310 Alumina & Aluminum		Wholesale Trade
115310 Support Activities for	312200 Tobacco Manufacturing		Production & Processing		Merchant Wholesalers, Durable
Forestry	Textile Mills and Textile Product		331400 Nonferrous Metal (except		Goods
Mining	Mills		Aluminum) Production &		423100 Motor Vehicle, & Motor
211110 Oil & Gas Extraction	313000 Textile Mills		Processing		Vehicle Parts & Supplies
212110 Coal Mining	314000 Textile Product Mills		331500 Foundries		423200 Furniture & Home Furnishings
212200 Metal Ore Mining	Apparel Manufacturing		Fabricated Metal Product		423300 Lumber & Other Construction
212310 Stone Mining & Quarrying	315100 Apparel Knitting Mills		Manufacturing		Materials
212320 Sand, Gravel, Clay, &	315210 Cut & Sew Apparel		332110 Forging & Stamping		423400 Professional & Commercial
Ceramic & Refractory	Contractors		332210 Cutlery & Handtool Mfg		Equipment & Supplies
Minerals Mining, & Quarrying	315220 Men’s & Boys’ Cut & Sew		332300 Architectural & Structural		423500 Metal & Mineral (except
212390 Other Nonmetallic Mineral	Apparel Mfg.		Metals Mfg		petroleum)
Mining & Quarrying	315240 Women’s, Girls’ and Infants’		332400 Boiler, Tank, & Shipping		423600 Household Appliances and
213110 Support Activities for Mining	Cut & Sew Apparel Mfg.		Container Mfg		Electrical & Electronic Goods
Utilities	315280 Other Cut & Sew Apparel Mfg		332510 Hardware Mfg		423700 Hardware, Plumbing, &
221100 Electric Power Generation,	315990 Apparel Accessories & Other		332610 Spring & Wire Product Mfg		Heating Equipment &
Transmission & Distribution	Apparel Mfg		332700 Machine Shops; Turned		Supplies
221210 Natural Gas Distribution	Leather and Allied Product		Product; & Screw, Nut, & Bolt		423800 Machinery, Equipment, &
221300 Water, Sewage & Other	Manufacturing		Mfg		Supplies
Systems	316110 Leather & Hide Tanning, &		332810 Coating, Engraving, Heat		423910 Sporting & Recreational
221500 Combination Gas & Electric	Finishing		Treating, & Allied Activities		Goods & Supplies
Construction	316210 Footwear Mfg (including		332900 Other Fabricated Metal		423920 Toy, & Hobby Goods, &
Construction of Buildings	rubber & plastics)		Product Mfg		Supplies
236110 Residential Building	316990 Other Leather & Allied		Machinery Manufacturing		423930 Recyclable Materials
Construction	Product Mfg		333100 Agriculture, Construction, &		423940 Jewelry, Watch, Precious
236200 Nonresidential Building	Wood Product Manufacturing		Mining Machinery Mfg		Stone, & Precious Metals
Construction	321110 Sawmills & Wood		333200 Industrial Machinery Mfg		423990 Other Miscellaneous Durable
Heavy and Civil Engineering	Preservation		333310 Commercial & Service		Goods
Construction	321210 Veneer, Plywood, &		Industry Machinery Mfg		Merchant Wholesalers, Nondurable
237100 Utility System Construction	Engineered Wood Product		333410 Ventilation, Heating,		Goods
237210 Land Subdivision	Mfg		Air-Conditioning, &		424100 Paper & Paper Products
237310 Highway, Street, & Bridge	321900 Other Wood Product Mfg		Commercial Refrigeration		424210 Drugs & Druggists’ Sundries
Construction	Paper Manufacturing		Equipment Mfg		424300 Apparel, Piece Goods, &
237990 Other Heavy & Civil	322100 Pulp, Paper, & Paperboard		333510 Metalworking Machinery Mfg		Notions
Engineering Construction	Mills		333610 Engine, Turbine & Power		424400 Grocery & Related Products
	322200 Converted Paper Product Mfg		Transmission Equipment Mfg		424500 Farm Product Raw Materials
			333900 Other General Purpose		424600 Chemical & Allied Products
			Machinery Mfg
Forms 5500, 5500-SF, and 5500-EZ Codes for Principal Business Activity (continued)
Code	Code		Code		Code
424700 Petroleum & Petroleum	448140 Family Clothing Stores		Support Activities for Transportation		Securities, Commodity Contracts,
Products	448150 Clothing Accessories Stores		488100 Support Activities for Air		and Other Financial Investments and
424800 Beer, Wine, & Distilled	448190 Other Clothing Stores		Transportation		Related Activities
Alcoholic Beverages	448210 Shoe Stores		488210 Support Activities for Rail		523110 Investment Banking &
424910 Farm Supplies	448310 Jewelry Stores		Transportation		Securities Dealing
424920 Book, Periodical, &	448320 Luggage & Leather Goods		488300 Support Activities for Water		523120 Securities Brokerage
Newspapers	Stores		Transportation		523130 Commodity Contracts Dealing
424930 Flower, Nursery Stock, &	Sporting Goods, Hobby, Book, and		488410 Motor Vehicle Towing		523140 Commodity Contracts
Florists’ Supplies	Music Stores		488490 Other Support Activities for		Brokerage
424940 Tobacco & Tobacco Products	451110 Sporting Goods Stores		Road Transportation		523210 Securities & Commodity
424950 Paint, Varnish, & Supplies	451120 Hobby, Toy, & Game Stores		488510 Freight Transportation		Exchanges
424990 Other Miscellaneous	451130 Sewing, Needlework, & Piece		Arrangement		523900 Other Financial Investment
Nondurable Goods	Goods Stores		488990 Other Support Activities for		Activities (including portfolio
Wholesale Electronic Markets and	451140 Musical Instrument &		Transportation		management & investment
Agents and Brokers	Supplies Stores		Couriers and Messengers		advice)
425110 Business to Business	451211 Book Stores		492110 Couriers		Insurance Carriers and Related
Electronic Markets	451212 News Dealers & Newsstands		492210 Local Messengers & Local		Activities
425120 Wholesale Trade Agents &	General Merchandise Stores		Delivery		524130 Reinsurance Carriers
Brokers	452110 Department Stores		Warehousing and Storage		524140 Direct Life, Health, & Medical
Retail Trade	452900 Other General Merchandise		493100 Warehousing & Storage		Insurance Carriers
Motor Vehicle and Parts Dealers	Stores		(except lessors of		524150 Direct Insurance (except Life,
			miniwarehouses & self-storage		Health & Medical) Carriers
441110 New Car Dealers	Miscellaneous Store Retailers		units)		524210 Insurance Agencies &
441120 Used Car Dealers	453110 Florists				Brokerages
441210 Recreational Vehicle Dealers	453210 Office Supplies & Stationery		Information		524290 Other Insurance Related
441222 Boat Dealers	Stores		Publishing Industries (except Internet)		Activities (including third-
441228 Motorcycle, ATV, and All	453220 Gift, Novelty, & Souvenir		511110 Newspaper Publishers		party administration of
Other Motor Vehicle Dealers	Stores		511120 Periodical Publishers		Insurance and pension funds)
441300 Automotive Parts,	453310 Used Merchandise Stores		511130 Book Publishers		Funds, Trusts, and Other Financial
Accessories, & Tire Stores	453910 Pet & Pet Supplies Stores		511140 Directory & Mailing List		Vehicles
Furniture and Home Furnishings	453920 Art Dealers		Publishers		525100 Insurance & Employee
Stores	453930 Manufactured (Mobile) Home		511190 Other Publishers		Benefit Funds
442110 Furniture Stores	Dealers		511210 Software Publishers		525910 Open-End Investment Funds
442210 Floor Covering Stores	453990 All Other Miscellaneous Store		Motion Picture and Sound Recording		(Form 1120-RIC)
442291 Window Treatment Stores	Retailers (including tobacco,		Industries		525920 Trusts, Estates, & Agency
442299 All Other Home Furnishings	candle, & trophy shops)		512100 Motion Picture & Video		Accounts
Stores	Nonstore Retailers		Industries (except video rental)		525990 Other Financial Vehicles
Electronics and Appliance Stores	454110 Electronic Shopping &		512200 Sound Recording Industries		(including mortgage REITs &
443141 Household Appliance Stores	Mail-Order Houses		Broadcasting (except Internet)		closed-end investment funds)
443142 Electronics Stores (including	454210 Vending Machine Operators		515100 Radio & Television		“Offices of Bank Holding Companies”
Audio, Video, Computer, and	454310 Fuel Dealers (including Heating		Broadcasting		and “Offices of Other Holding Companies”
Camera Stores)	Oil and Liquefied Petroleum)		515210 Cable & Other Subscription		are located under Management
Building Material and Garden	454390 Other Direct Selling		Programming		of Companies (Holding Companies).
Equipment and Supplies Dealers	Establishments (including		Telecommunications		Real Estate and Rental and
444110 Home Centers	door-to-door retailing, frozen		517000 Telecommunications		Leasing
444120 Paint & Wallpaper Stores	food plan providers, party		(including paging, cellular,		Real Estate
	plan merchandisers, &		satellite, cable & other program		531110 Lessors of Residential
444130 Hardware Stores	coffee-break service providers)		distribution, resellers, other		Buildings & Dwellings
444190 Other Building Material	Transportation and		telecommunications, &		(including equity REITs)
Dealers	Warehousing		internet service providers)		531120 Lessors of Nonresidential
444200 Lawn & Garden Equipment &	Air, Rail, and Water Transportation		Data Processing Services		Buildings (except
Supplies Stores	481000 Air Transportation		518210 Data Processing, Hosting, &		Miniwarehouses) (including
Food and Beverage Stores	482110 Rail Transportation		Related Services		equity REITs)
445110 Supermarkets and Other	483000 Water Transportation		Other Information Services		531130 Lessors of Miniwarehouses &
Grocery (except	Truck Transportation		519100 Other Information Services		Self-Storage Units (including
Convenience) Stores	484110 General Freight Trucking,		(including news syndicates,		equity REITs)
445120 Convenience Stores	Local		libraries, internet publishing &		531190 Lessors of Other Real Estate
445210 Meat Markets	484120 General Freight Trucking,		broadcasting)		Property (including equity
445220 Fish & Seafood Markets	Long-distance		Finance and Insurance		REITs)
445230 Fruit & Vegetable Markets	484200 Specialized Freight Trucking		Depository Credit Intermediation		531210 Offices of Real Estate Agents
445291 Baked Goods Stores	Transit and Ground Passenger		522110 Commercial Banking		& Brokers
445292 Confectionery & Nut Stores	Transportation		522120 Savings Institutions		531310 Real Estate Property
445299 All Other Specialty Food	485110 Urban Transit Systems		522130 Credit Unions		Managers
Stores	485210 Interurban & Rural Bus		522190 Other Depository Credit		531320 Offices of Real Estate
445310 Beer, Wine, & Liquor Stores	Transportation		Intermediation		Appraisers
Health and Personal Care Stores	485310 Taxi Service		Nondepository Credit Intermediation		531390 Other Activities Related to
446110 Pharmacies & Drug Stores	485320 Limousine Service		522210 Credit Card Issuing		Real Estate
446120 Cosmetics, Beauty Supplies,	485410 School & Employee Bus		522220 Sales Financing		Rental and Leasing Services
& Perfume Stores	Transportation		522291 Consumer Lending		532100 Automotive Equipment Rental &
446130 Optical Goods Stores	485510 Charter Bus Industry		522292 Real Estate Credit		Leasing
446190 Other Health & Personal	485990 Other Transit & Ground		(including mortgage bankers &		532210 Consumer Electronics &
Care Stores	Passenger Transportation		originators)		Appliances Rental
Gasoline Stations	Pipeline Transportation		522293 International Trade Financing		532220 Formal Wear & Costume Rental
447100 Gasoline Stations (including	486000 Pipeline Transportation		522294 Secondary Market Financing		532230 Video Tape & Disc Rental
convenience stores with gas)	Scenic & Sightseeing Transportation		522298 All Other Nondepository
Clothing and Clothing Accessories	487000 Scenic & Sightseeing		Credit Intermediation
Stores	Transportation		Activities Related to Credit
448110 Men’s Clothing Stores			Intermediation
448120 Women’s Clothing Stores			522300 Activities Related to Credit
448130 Children’s & Infants’ Clothing			Intermediation (including loan
Stores			brokers, check clearing, &
			money transmitting)
Forms 5500, 5500-SF, and 5500-EZ Codes for Principal Business Activity (continued)
Code	Code		Code		Code
532290 Other Consumer Goods	Administrative and Support and		Medical and Diagnostic Laboratories		Other Services
Rental	Waste Management and		621510 Medical & Diagnostic		Repair and Maintenance
532310 General Rental Centers	Remediation Services		Laboratories		811110 Automotive Mechanical, &
532400 Commercial & Industrial	Administration and Support Services		Home Health Care Services		Electrical Repair &
Machinery & Equipment	561110 Office Administrative Services		621610 Home Health Care Services		Maintenance
Rental & Leasing	561210 Facilities Support Services		Other Ambulatory Health Care Services		811120 Automotive Body, Paint,
Lessors of Nonfinancial Intangible	561300 Employment Services		621900 Other Ambulatory Health Care		Interior, & Glass Repair
Assets (except copyrighted works)	561410 Document Preparation Services		Services (including ambulance		811190 Other Automotive Repair &
533110 Lessors of Nonfinancial	561420 Telephone Call Centers		services & blood & organ banks)		Maintenance (including oil
Intangible Assets (except	561430 Business Service Centers		Hospitals		change & lubrication shops &
copyrighted works)	(including private mail centers		622000 Hospitals		car washes)
Professional, Scientific, and	& copy shops)		Nursing and Residential Care		811210 Electronic & Precision
Technical Services	561440 Collection Agencies		Facilities		Equipment Repair &
Legal Services	561450 Credit Bureaus		623000 Nursing & Residential Care		Maintenance
541110 Offices of Lawyers	561490 Other Business Support		Facilities		811310 Commercial & Industrial
541190 Other Legal Services	Services (including		Social Assistance		Machinery & Equipment
Accounting, Tax Preparation,	repossession services, court		624100 Individual & Family Services		(except Automotive &
Bookkeeping, and Payroll Services	reporting, & stenotype		624200 Community Food & Housing, &		Electronic) Repair &
541211 Offices of Certified Public	services)		Emergency & Other Relief		Maintenance
Accountants	561500 Travel Arrangement &		Services		811410 Home & Garden Equipment &
541213 Tax Preparation Services	Reservation Services		624310 Vocational Rehabilitation		Appliance Repair &
541214 Payroll Services	561600 Investigation & Security		Services		Maintenance
541219 Other Accounting Services	Services		624410 Child Day Care Services		811420 Reupholstery & Furniture
Architectural, Engineering, and	561710 Exterminating & Pest Control		Arts, Entertainment, and		Repair
Related Services	Services		Recreation		811430 Footwear & Leather Goods
541310 Architectural Services	561720 Janitorial Services		Performing Arts, Spectator Sports,		Repair
541320 Landscape Architecture	561730 Landscaping Services		and Related Industries		811490 Other Personal & Household
Services	561740 Carpet & Upholstery Cleaning		711100 Performing Arts Companies		Goods Repair & Maintenance
541330 Engineering Services	Services		711210 Spectator Sports (including		Personal and Laundry Services
541340 Drafting Services	561790 Other Services to Buildings &		sports clubs & racetracks)		812111 Barber Shops
541350 Building Inspection Services	Dwellings		711300 Promoters of Performing Arts,		812112 Beauty Salons
541360 Geophysical Surveying &	561900 Other Support Services		Sports, & Similar Events		812113 Nail Salons
Mapping Services	(including packaging &		711410 Agents & Managers for		812190 Other Personal Care
541370 Surveying & Mapping (except	labeling services, & convention		Artists, Athletes, Entertainers, &		Services (including diet &
Geophysical) Services	& trade show organizers)		Other Public Figures		weight reducing centers)
541380 Testing Laboratories	Waste Management and		711510 Independent Artists, Writers, &		812210 Funeral Homes & Funeral
Specialized Design Services	Remediation Services		Performers		Services
541400 Specialized Design Services	562000 Waste Management and		Museums, Historical Sites, and Similar		812220 Cemeteries & Crematories
(including interior, industrial,	Remediation Services		Institutions		812310 Coin-Operated Laundries &
graphic, & fashion design)	Educational Services		712100 Museums, Historical Sites, &		Drycleaners
Computer Systems Design and	611000 Educational Services		Similar Institutions		812320 Drycleaning & Laundry
Related Services	(including schools, colleges,		Amusements, Gambling, and		Services (except
541511 Custom Computer	& universities)		Recreation Industries		Coin-Operated)
Programming Services	Health Care and Social Assistance		713100 Amusement Parks & Arcades		812330 Linen & Uniform Supply
541512 Computer Systems Design	Offices of Physicians and Dentists		713200 Gambling Industries		812910 Pet Care (except Veterinary)
Services	621111 Offices of Physicians (except		713900 Other Amusement &		Services
541513 Computer Facilities	mental health specialists)		Recreation Industries		812920 Photofinishing
Management Services	621112 Offices of Physicians, Mental		(including golf courses, skiing		812930 Parking Lots & Garages
541519 Other Computer Related	Health Specialists		facilities, marinas, fitness		812990 All Other Personal Services
Services	621210 Offices of Dentists		centers, & bowling centers)		Religious, Grantmaking, Civic,
Other Professional, Scientific, and	Offices of Other Health Practitioners		Accommodation and Food Services		Professional, and Similar
Technical Services	621310 Offices of Chiropractors		Accommodation		Organizations
541600 Management, Scientific, &	621320 Offices of Optometrists		721110 Hotels (except Casino Hotels) &		813000 Religious, Grantmaking,
Technical Consulting Services	621330 Offices of Mental Health		Motels		Civic, Professional, & Similar
541700 Scientific Research &	Practitioners (except		721120 Casino Hotels		Organizations (including
Development Services	Physicians)		721191 Bed & Breakfast Inns		condominium and
541800 Advertising & Related	621340 Offices of Physical,		721199 All other Traveler		homeowners associations)
Services	Occupational & Speech		Accommodation		813930 Labor Unions and Similar
541910 Marketing Research & Public	Therapists, & Audiologists		721210 RV (Recreational Vehicle)		Labor Organizations
Opinion Polling	621391 Offices of Podiatrists		Parks & Recreational Camps		921000 Governmental Instrumentality
541920 Photographic Services	621399 Offices of all Other		721310 Rooming & Boarding Houses		or Agency
541930 Translation & Interpretation	Miscellaneous Health		Food Services and Drinking Places
Services	Practitioners		722300 Special Food Services
541940 Veterinary Services	Outpatient Care Centers		(including food service
541990 All Other Professional,	621410 Family Planning Centers		contractors & caterers)
Scientific, & Technical	621420 Outpatient Mental Health &		722410 Drinking Places (Alcoholic
Services	Substance Abuse Centers		Beverages)
Management of Companies	621491 HMO Medical Centers		722511 Full-Service Restaurants
(Holding Companies)	621492 Kidney Dialysis Centers		722513 Limited-Service Restaurants
551111 Offices of Bank Holding	621493 Freestanding Ambulatory		722514 Cafeterias and Buffets
Companies	Surgical & Emergency Centers		722515 Snack and Non-alcoholic
551112 Offices of Other Holding	621498 All Other Outpatient Care		Beverage Bars
Companies	Centers

ERISA COMPLIANCE QUICK CHECKLIST

Compliance with the Employee Retirement Income Security Act (ERISA) begins with knowing the rules. Plan administrators and other plan officials can use this checklist as a quick diagnostic tool for assessing a plan’s compliance with certain important ERISA rules; it is not a complete description of all ERISA’s rules and it is not a substitute for a comprehensive compliance review. Use of this checklist is voluntary, and it is not be filed with your Form 5500-SF.

If you answer “No” to any of the questions below, you should review your plan’s operations because you may not be in full compliance with ERISA’s requirements.

1. Have you provided plan participants with a summary plan description, summaries of any material modifications of the plan, and annual summary financial reports or annual pension funding reports?

2. Do you maintain copies of plan documents at the principal office of the plan administrator for examination by participants and beneficiaries?

3. Do you respond to written participant inquires for copies of plan documents and information within 30 days?

4. Does your plan include written procedures for making benefit claims and appealing denied claims, and are you complying with those procedures?

5. Is your plan covered by fidelity bonds protecting the plan against losses due to fraud or dishonesty by persons who handle plan funds or other property?

6. Are the plan’s investments diversified so as to minimize the risk of large losses?

7. If the plan permits participants to select the investments in their plan accounts, has the plan provided them with enough information to make informed decisions?

8. Has a plan official determined that the investments are prudent and solely in the interest of the plan’s participants and beneficiaries, and evaluated the risks associated with plan investments before making the investments?

9. Did the employer or other plan sponsor send participant contributions to the plan on a timely basis?

10. Did the plan pay participant benefits on time and in the correct amounts?

11. Did the plan give participants and beneficiaries 30 days advance notice before imposing a “blackout period” of at least three consecutive business days during which participants or beneficiaries of a 401(k) or other individual account pension plan were unable to change their plan investments, obtain loans from the plan, or obtain distributions from the plan?

If you answer “Yes” to any of the questions below, you should review your plan’s operations because you may not be in full compliance with ERISA’s requirements.

1. Has the plan engaged in any financial transactions with persons related to the plan or any plan official? (For example, has the plan made a loan to or participated in an investment with the employer?)

2. Has a plan official used the assets of the plan for his/her own interest?

3. Have plan assets been used to pay expenses that were not authorized in the plan document, were not necessary for the proper administration of the plan, or were more than reasonable in amount?

If you need help answering these questions or want additional guidance about ERISA requirements, a plan official should contact the U.S. Department of Labor Employee Benefits Security Administration office in your region or consult with the plan’s legal counsel or professional employee benefit advisor.

Index

A

Annual Report Identification

Information 8

B

Basic Plan Information 910

C

Change in Plan Year 5

Codes for Principal Business

Activity 2224

Compliance Questions 15

D

Delinquent Filer Voluntary Compliance (DFVC)

Program 5

E

EFAST2 Processing System 1

ERISA Compliance Quick

Checklist 2527

Extension of Time To File 4

F

Financial Information 13

H

How To File – Electronic Filing Requirement 56

How To Get Assistance 1

N

Nonexempt Transactions 1516

O

One-Participant Plans and Certain Foreign Plans 7

P

Paperwork Reduction Act

Notice 1921

Party-In-Interest 1516

Penalties:

Administrative 5

Other 5

Pension and Welfare Plans Required To File Annual Return/Report 2

Pension Funding

Compliance 1718

Plan Assets and Liabilities 13

Plan Characteristics Codes 2022

Plan Terminations 1819

Plans Exempt From Filing 3

S

Signature and Date 67

Specific Line-by-Line Instructions (Form 5500-SF) 8

T

Transfers of Assets 1819

W

What To File 4

When To File 4

Who May File 4

General Instructions to Form 5500-SF -0-