Form 5500

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Form 5500

Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security
 Administration
Pension Benefit Guaranty Corporation
Annual Return/Report of Employee Benefit Plan
This form is required to be filed for employee benefit plans under sections 104 and 4065 of the Employee Retirement Income Security Act of 1974 (ERISA) and sections 6047(e), 6057(b), and 6058(a) of the Internal Revenue Code (the Code).
 Complete all entries in accordance with the instructions to the Form 5500.
OMB Nos. 1210-0110
1210-0089

2014

This Form is Open to Public Inspection
Part I
  Annual Report Identification Information
For calendar plan year 2014 or fiscal plan year beginning                                                                      and ending                                                       
A  This return/report is for:
      X  a multiemployer plan;
X a multiple-employer plan (Filers checking this box must attach a list of participating employer information in accordance with the form instructions); or

      X  a single-employer plan;
       X  a DFE (specify)        _C_
B  This return/report is:
      X  the first return/report;
       X  the final return/report;

      X  an amended return/report;
       X  a short plan year return/report (less than 12 months).
C  If the plan is a collectively-bargained plan, check here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X
D  Check box if filing under:                                                      
        X  Form 5558;    
         X  automatic extension;    
       X  the DFVC program;

        X  special extension (enter description) ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
Part II
  Basic Plan Information—enter all requested information
1a  Name of plan
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 
1b	Three-digit plan number (PN) 
001

1c	Effective date of plan
YYYY-MM-DD
2a  Plan sponsor’s name and address; include room or suite number (employer, if for a single-employer plan)
2b	Employer Identification Number (EIN)
012345678
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 
D/B/A ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 
c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 
123456789 ABCDEFGHI ABCDEFGHI ABCDE
123456789 ABCDEFGHI ABCDEFGHI ABCDE
CITYEFGHI ABCDEFGHI AB, ST 012345678901
UK 
2c	Plan Sponsor’s telephone number
0123456789

2d	Business code (see instructions)
012345


Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established. 
Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return/report, including accompanying schedules, statements and attachments, as well as the electronic version of this return/report, and to the best of my knowledge and belief, it is true, correct, and complete.
SIGN
HERE



YYYY-MM-DD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

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



YYYY-MM-DD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Signature of employer/plan sponsor
Date
Enter name of individual signing as employer or plan sponsor
SIGN
HERE



YYYY-MM-DD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Signature of DFE
Date
Enter name of individual signing as DFE
Preparer’s name (including firm name, if applicable) and address (include room or suite number) (optional) ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
Preparer’s telephone number (optional)


For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500.
Form 5500 (2014) 
v. 140124

3a	Plan administrator’s name and address  XSame as Plan Sponsor 

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 
c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 
123456789 ABCDEFGHI ABCDEFGHI ABCDE
123456789 ABCDEFGHI ABCDEFGHI ABCDE
CITYEFGHI ABCDEFGHI AB, ST 012345678901
UK 
3b  Administrator’s EIN
012345678

3c  Administrator’s telephone number
0123456789


4	If the name and/or EIN of the plan sponsor has changed since the last return/report filed for this plan, enter the name, EIN and the plan number from the last return/report:
4b	EIN
012345678
a	Sponsor’s name
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 
4c	PN
012
5	Total number of participants at the beginning of the plan year
5
123456789012
6	Number of participants as of the end of the plan year unless otherwise stated (welfare plans complete only lines 6a(1),   
        6a(2), 6b, 6c, and 6d).


 a(1)  Total number of active participants at the beginning of the plan year	
6a(1)

  
 a(2)  Total number of active participants at the end of  the plan year 	
6a(2)

 
 b	Retired or separated participants receiving benefits	
6b
123456789012

 c	Other retired or separated participants entitled to future benefits	
6c
123456789012
 
 d	Subtotal. Add lines 6a(2), 6b, and 6c.	
6d
123456789012
 
 e	Deceased participants whose beneficiaries are receiving or are entitled to receive benefits.	
6e
123456789012
 
 f	Total.  Add lines 6d and 6e.	
6f
123456789012
 
 g	Number of participants with account balances as of the end of the plan year (only defined contribution plans 
        complete this item)	
6g
123456789012
 
h	Number of participants that terminated employment during the plan year with accrued benefits that were 
      less than 100% vested	
6h
123456789012
7		Enter the total number of employers obligated to contribute to the plan (only multiemployer plans complete this item)	
7

8a		If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristics Codes in the instructions:

b		If the plan provides welfare benefits, enter the applicable welfare feature codes from the List of Plan Characteristics Codes in the instructions: 
         

9a	Plan funding arrangement (check all that apply)
9b	Plan benefit arrangement (check all that apply)
(1) 	X 	Insurance
(1) 	X 	Insurance
(2) 	X	Code section 412(e)(3) insurance contracts
(2) 	X 	Code section 412(e)(3) insurance contracts
(3) 	X	Trust 
(3) 	X 	Trust 
(4) 	X 	General assets of the sponsor
(4) 	X 	General assets of the sponsor
10	Check all applicable boxes in 10a and 10b to indicate which schedules are attached, and, where indicated, enter the number attached.  (See instructions)
a 	Pension Schedules
b	General Schedules
(1) 	X 	R  (Retirement Plan Information)

(1) 	X	H  (Financial Information)
(2) 	X 	MB  (Multiemployer Defined Benefit Plan and Certain Money Purchase Plan Actuarial Information) - signed by the plan actuary
(2) 	X 	I   (Financial Information – Small Plan)

(3) 	X    ___	A  (Insurance Information)

(4) 	X 	C  (Service Provider Information)
(3) 	X 	SB  (Single-Employer Defined Benefit Plan Actuarial          Information) - signed by the plan actuary
(5) 	X 	D  (DFE/Participating Plan Information)

(6) 	X 	G  (Financial Transaction Schedules)