5500-SUP Annual Return of Employee Benefit Plan Supplemental Info

Version A, Cycle 8

Form

Annual Return of Employee Benefit Plan
Supplemental Information

5500-SUP

This form is required to be filed under section 6058(a) of the Internal Revenue Code.
a Complete all entries in accordance with the instructions to Form 5500-SUP.

Department of the Treasury
Internal Revenue Service

Part I

OMB No. 1545-1610

2015
This Form is Open
to Public Inspection.

Annual Return Identification Information

For the calendar plan year 2015 or fiscal plan year beginning (MM/DD/YYYY)
and ending
A
This return is: (1)
(3)
the first return filed for the plan;
the final return filed for the plan;
(2)
(4)
an amended return;
a short plan year return (less than 12 months).
B

EFAST2 Acknowledgement ID (21 characters)

C

Check box if filing under

Part II
1a

2a

Form 5558
automatic extension
special extension (enter description)

Basic Plan Information — enter all requested information.

Name of plan

1b Three-digit
plan number (PN) a
1c Date plan first became effective
(MM/DD/YYYY)
/
/
2b Employer Identification Number (EIN)

Plan sponsor’s name (employer, if for a single-employer plan)

INTERNAL USE ONLY
DRAFT AS OF
September 17, 2014
Mailing address (include room, apt., suite no. and street, or P.O. Box)

2c Plan Sponsor’s telephone number

2d Business code (see instructions)

City or town, state or province, country, and ZIP or foreign postal code (if foreign, see instructions)

3a
3c

Name of trust

3b Trust's EIN

Name of trustee or custodian

3d Trustee or custodian's telephone
number

Part III
4a

Supplemental Information

Is the plan a section 401(k) plan? Check box.

Yes

No

4b If “Yes,” how does the plan satisfy the nondiscrimination requirements for employee deferrals and employer matching
contributions (as applicable) under sections 401(k)(3) and 401(m)(2)?
Check box.
4c

Design-based safe harbor method

ADP/ACP test

If the ADP/ACP test is used, did the plan perform ADP/ACP testing for the plan year using the “current year testing method” for
nonhighly compensated employees (Regulations section 1.401(k)-2(a)(2)(ii))?
Check box.

Yes

No

For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 5500-SUP.

Cat. No. 66349S

Form 5500-SUP (2015)

Version A, Cycle 8
Form 5500-SUP (2015)

Part III

Page

2

Supplemental Information (Continued)

5a

Check the box to indicate the method used by the plan to satisfy the coverage requirements under section 410(b):
Ratio Percentage Test
Average Benefit Test
5b Does the plan satisfy the coverage and nondiscrimination tests of sections 410(b) and 401(a)(4) by combining this plan with any
other plans under the permissive aggregation rules? Check box.
Yes
No
6a Has the plan been timely amended for all required tax law changes? Check box.
Yes
No
N/A
/
/
.
6b Date the last plan amendment/restatement for the required tax law changes was adopted
Enter the applicable Code
(See instructions for tax law changes and Codes).
6c If the Employer is an adopter of a pre-approved master and prototype (M&P), or volume submitter plan that is subject to a
favorable IRS opinion or advisory letter, enter the date of that favorable letter
/
/
and the
letter's serial number
.
6d If the plan is an individually designed plan and received a favorable determination letter from the IRS, please enter the date of the
plan's last favorable determination letter (MM/DD/YYYY)
7a
7b
(i)
(ii)
(iii)
8

9
9a
9b
9c
10

11

Is the plan an ESOP that received dividends on employer stock that were tax-deductible under section 404(k)?
Check box.
Yes
No
If "Yes":
What was the total dividend amount?
What was the dividend rate?
Were any dividends, payments in redemption of stock?
Check box.
Yes

No

INTERNAL USE ONLY
DRAFT AS OF
September 17, 2014
Is the plan maintained in a U.S. territory (i.e., 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)?
Check box.
Yes
No
Amount of contributions deducted
Enter the taxable year ending within the plan year
Enter the total contributions deducted for the taxable year in 9a
Do the contributions in 9b exceed the deductible limit for the taxable year in 9a? Check box.

Yes

No

Did the plan trust incur unrelated business taxable income?
Check box.
If “Yes,” Amount
Yes
No
N/A
Were in-service distributions made during the plan year?
Check box.
If “Yes,” Amount
Yes
No

Part IV

Signatures

D

Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return and to the best of
my knowledge and belief, it is true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of
which preparer has any knowledge.
F

Sign
Here

Signature of plan administrator

Date

a Type or print name of individual signing as plan administrator
F

Sign
Here

Signature of employer/plan sponsor/DFE

Date

b Type or print name of employer/plan sponsor/DFE
Preparer's name (including firm name, if applicable) and address, including room or suite number

Preparer's telephone number

Form 5500-SUP (2015)