2016 Form 5500-SF 2016 Short Form Annual Return/Report of Small Employee B

Form 5500-SF
Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security Administration
Pension Benefit Guaranty Corporation

Part I

OMB Nos. 1210-0110
1210-0089

Short Form Annual Return/Report of Small Employee
Benefit Plan
This form is required to be filed under sections 104 and 4065 of the Employee Retirement
Income Security Act of 1974 (ERISA), and sections 6057(b) and 6058(a) of the Internal
Revenue Code (the Code).

20152016
This Form is Open to
Public Inspection

 Complete all entries in accordance with the instructions to the Form 5500-SF.

Annual Report Identification Information

For calendar plan year 20165 or fiscal plan year beginning

A This return/report is for:

B This return/report is

and ending

X a single-employer plan

X a multiple-employer plan (not multiemployer) (Filers checking this box must attach a

X a one-participant plan

X a foreign plan

X the first return/report
X an amended return/report

X the final return/report
X a short plan year return/report (less than 12 months)

list of participating employer information in accordance with the form instructions.)

C Check box if filing under:

X Form 5558
X automatic extension
X special extension (enter description)
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

X DFVC program

1b Three-digit
1c

2a Plan sponsor’s name (employer, if for a single-employer plan)
Mailing address (include room, apt., suite no. and street, or P.O. Box)
City or town, state or province, country, and ZIP or foreign postal code (if foreign, see instructions)

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGH ABCDEFGHI ABCDEFGHI ABCDEFGHI I
3a Plan administrator’s name and address X Same 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 012345678901I A
4 If the name and/or
EIN of the plan sponsor has changed since the last return/report filed for this plan, enter the

plan number
001
(PN) 
Effective date of plan

YYYY-MM-DD
2b Employer Identification Number
(EIN)
012345678
2c Sponsor’s telephone number
1234567890
2d Business code (see instructions)
123456

3b Administrator’s EIN
012345678
3c Administrator’s telephone number
1234567890

4b EIN

name, EIN, and the plan number from the last return/report.
Sponsor’s name DEFGHI ABCDEFGHI ABCDEFGHI

a
ABCDEFGHI CDEFGHI
4c PN
5a Total number of participants at the beginning of the plan year ..................................................................................... 5a
b Total number of participants at the end of the plan year ............................................................................................... 5b
c Number of participants with account balances as of the end of the plan year (defined benefit plans do not
5c

012345678
012
12345678
12345678

complete this itemonly defined contribution plans complete this item) ........................................................................

d(1) Total number of active participants at the beginning of the plan year ...................................................................... 5d(1)
d(2) Total number of active participants at the end of the plan year ................................................................................ 5d(2)
e Number of participants that terminated employment during the plan year with accrued benefits that were less
5e

than 100% vested ..........................................................................................................................................................
Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established.
Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return/report, including, if applicable, a Schedule
SB or Schedule MB completed and signed by an enrolled actuary, as well as the electronic version of this return/report, and to the best of my knowledge and
belief, it is true, correct, and complete.
SIGN
HERE

Signature of plan administrator

Date

Enter name of individual signing as plan administrator

SIGN
HERE

Signature of employer/plan sponsor
Date
Enter name of individual signing as employer or plan sponsor
Preparer’s name (including firm name, if applicable) and address (include room or suite number )
Preparer’s telephone number

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
For
Paperwork Reduction
Act Notice and OMB Control Numbers, see the Iinstructions for Form 5500-SF.

Form 5500-SF (20156)
v.1609270112

Form 5500-SF 20152016

Page 2

X Yes X No

6a Were all of the plan’s assets during the plan year invested in eligible assets? (See instructions.) .............................................................
b Are you claiming a waiver of the annual examination and report of an independent qualified public accountant (IQPA)

X Yes X No

under 29 CFR 2520.104-46? (See instructions on waiver eligibility and conditions.) ..................................................................................
If you answered “No” to either line 6a or line 6b, the plan cannot use Form 5500-SF and must instead use Form 5500.

c If the plan is a defined benefit plan, is it covered under the PBGC insurance program (see ERISA section 4021)? ...... X Yes X No X Not determined
Part III Financial Information
7 Plan Assets and Liabilities
a Total plan assets .........................................................................................7a
b Total plan liabilities .....................................................................................7b
c Net plan assets (subtract line 7b from line 7a) ..........................................7c
8 Income, Expenses, and Transfers for this Plan Year
a Contributions received or receivable from:
(1) Employers .............................................................................................
8a(1)
(2) Participants ...........................................................................................
8a(2)
(3) Others (including rollovers) ...................................................................
8a(3)

b Other income (loss) .....................................................................................
8b
c Total income (add lines 8a(1), 8a(2), 8a(3), and 8b) ..................................
8c
d Benefits paid (including direct rollovers and insurance premiums
8d
to provide benefits) ......................................................................................

e
f
g
h
i
j

Certain deemed and/or corrective distributions (see instructions) .............
8e
Administrative service providers (salaries, fees, commissions).................
8f
Other expenses............................................................................................
8g

(a) Beginning of Year

(b) End of Year

-123456789012345
-123456789012345
-123456789012345

-123456789012345
123456789012345
-123456789012345

(a) Amount

(b) Total

-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345

Total expenses (add lines 8d, 8e, 8f, and 8g) ............................................
8h
Net income (loss) (subtract line 8h from line 8c) ........................................
8i

Transfers to (from) the plan (see instructions) ............................................
-123456789012345
8j
Part IV Plan Characteristics
9a If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristic Codes in the instructions:

b If the plan provides welfare benefits, enter the applicable welfare feature codes from the List of Plan Characteristic Codes in the instructions:
B
Part V
Compliance Questions
10 During the plan year:
a Was there a failure to transmit to the plan any participant contributions within the time period

Yes

described in 29 CFR 2510.3-102? (See instructions and DOL’s Voluntary Fiduciary Correction
Program) ....................................................................................................................................................
10a

b Were there any nonexempt transactions with any party-in-interest? (Do not include transactions

No

N/A

Amount

-123456789012345

reported on line 10a.) ..................................................................................................................................
10b

-123456789012345

c Was the plan covered by a fidelity bond?..................................................................................................
10c

-123456789012345

d Did the plan have a loss, whether or not reimbursed by the plan’s fidelity bond, that was caused
10d
by fraud or dishonesty? ...............................................................................................................................

-123456789012345

e Were any fees or commissions paid to any brokers, agents, or other persons by an insurance
carrier, insurance service, or other organization that provides some or all of the benefits under
10e
the plan? (See instructions.) .......................................................................................................................

-123456789012345

f Has the plan failed to provide any benefit when due under the plan? .....................................................
10f

-123456789012345

g Did the plan have any participant loans? (If “Yes,” enter amount as of year-end.) ..................................
10g
h If this is an individual account plan, was there a blackout period? (See instructions and 29 CFR
2520.101-3.) ................................................................................................................................................
10h

i
i

-123456789012345

Formatted Table

Formatted: Font color: Gray-10%
If 10h was answered “Yes,” check the box if you either provided the required notice or one of the
exceptions to providing the notice applied under 29 CFR 2520.101-3 .................................................. h
10i If this is an individual account plan, was there a blackout period? (See instructions and 29 CFR 2520.101-3.)
If 10h was answered “Yes,” check the box if you either provided the required notice or one of the
exceptions to providing the notice applied under 29 CFR 2520.101-3 .....................................................
10i

j Did the plan trust incur unrelated business taxable income?
10j

Form 5500-SF 20152016

Page 3-

1

x

Part VI Pension Funding Compliance
11 Is this a defined benefit plan subject to minimum funding requirements? (If "Yes," see instructions and complete Schedule SB

X Yes X No

(Form 5500) and line 11a below) ......................................................................................................................................................................

11a Enter the unpaid minimum required contributions for all years from Schedule SB (Form 5500) line 40 ............................................
11a
12 Is this a defined contribution plan subject to the minimum funding requirements of section 412 of the Code or section 302 of
a

X Yes X No
ERISA?...............................................................................................................................................................................................................
(If "Yes," complete line 12a or lines 12b, 12c, 12d, and 12e below, as applicable.)
If a waiver of the minimum funding standard for a prior year is being amortized in this plan year, see instructions, and enter the date of the letter ruling
granting the waiver. .................................................................................................................................... Month _______ Day _______ Year ________

If you completed line 12a, complete lines 3, 9, and 10 of Schedule MB (Form 5500), and skip to line 13.

b Enter the minimum required contribution for this plan year ...................................................................................................12b

123456789012345

Enter the amount contributed by the employer to the plan for this plan year ........................................................................12c

-123456789012345

c
d Subtract the amount in line 12c from the amount in line 12b. Enter the result (enter a minus sign to the left of a

YYYY-MM-DD

12d
negative amount) ...................................................................................................................................................................

e Will the minimum funding amount reported on line 12d be met by the funding deadline? ........................................................X Yes

X No

X N/A

Part VII Plan Terminations and Transfers of Assets
X Yes
X No
13a Has a resolution to terminate the plan been adopted in any plan year? .............................................................................................................................................
13a
If “Yes,” enter the amount of any plan assets that reverted to the employer this year ................................................................................................................

b Were all the plan assets distributed to participants or beneficiaries, transferred to another plan, or brought under the
control of the PBGC? ..........................................................................................................................................................................

X Yes X No

c If, during this plan year, any assets or liabilities were transferred from this plan to another plan(s), identify the plan(s) to
which assets or liabilities were transferred. (See instructions.)
13c(1) Name of plan(s):

13c(2) EIN(s)

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

13c(3) PN(s)

123456789

Part VIII Trust Information
14a Name of trust ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
14c Name of trustee or custodian

012

14b Trust’s EIN

14d Trustee’s or custodian’s
telephone number

Part IX

IRS Compliance Questions

X Yes
X No
15a Is the plan a 401(k) plan? If “No,” skip b ...............................................................................................................................................................
Design-based
year” ADP
X safe harbor
X “prior
test
employee deferrals and employer matching contributions (as applicable) under sections 401(k)(3) for the
method
plan yearand 401(m)(2)? Check all that apply: ........................................................................................ (See instructions.)…………………..
year”
X “current
X N/A
ADP test

15b IfHow did the plan “Yes,” how does the 401(k) plan satisfy the nondiscrimination requirements for

Yes
X No
"current year testing method" for nonhighly compensated employees (Treasury . Regulations sections
1.401(k)-(2)(a)(2)(ii)) and 1.401(m)-2(a)(2)(ii))? ...................................................................................................................................................
16a Check the box to indicate theWhat testing method was used by the plan to satisfy the coverage
Ratio
X percentage X Average
requirements under section 4410(b) for the plan year? Check all that apply: ...................................................................................................
benefit test
test

15c If the ADP/ACP test is used, did the 401(k) plan perform ADP/ACP testing for the plan year using the

16b Does Did the plan satisfy the coverage and nondiscrimination tests requirements of sections 410(b) and

Formatted: Space Before: 0 pt

X N/A

X Yes
X No
401(a)(4) for the plan year by combining this plan with any other plans under the permissive aggregation
rules? ........................................................................................................................................................................................................
17b 17a Date the most recent last plan amendment/restatement for the required tax law changes was adopted____/____/____.
17c 17ba If the plan sponsor is an adopter of a pre-approvedis a master and prototype plan (M&P) or volume submitter plan that is subject toreceived a
favorable IRS opinion letter or advisory letter, enter the date of that the favorable letter _______/_______/_______ and the letter’s serial number
________________.
17d 17cb If the plan is an individually-designed plan and that received a favorable determination letter from the IRS, enter the date of the plan’s last most
recent favorable determination letter ______/_______/_______.
18a If this is a section 401(k) plan, were hardship distributions made during the plan year?
18b Defined Benefit Plan or Money Purchase Pension Plan Only:
If this is a defined benefit plan or a money purchase pension plan, did the plan makeWere any distributions made
during the plan year to an employees who have attained age 62 and who werehad not separated from service when

X Yes

X No

X Yes

X No

Form 5500-SF 20152016
Page 4
thedistributions were made?
………………………………………………………………………………………………….....................

19 Were required minimum distributions made toWas any participant a 5% owners who have had attained at least age

X Yes
X No
70 ½ (regardless of whether or not retired), as required under section 401(a)() (9)) (C)during the prior plan year? ........................................

X N/A