Form 5500-EZ Annual Return of One-Participant (Owners and Their Spous

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Form

5500-EZ

Annual Return of One-Participant
(Owners and Their Spouses) Retirement Plan

2016

This form is required to be filed under section 6058(a) of the Internal Revenue Code.
Certain foreign retirement plans are also required to file this form (see instructions).
▶ Complete all entries in accordance with the instructions to the Form 5500-EZ.
▶ Information about Form 5500-EZ and its instructions is at www.irs.gov/form5500ez.

Department of the Treasury
Internal Revenue Service

Part I

OMB No. 1545-0956

This Form is Open
to Public Inspection.

Annual Return Identification Information

For the calendar plan year 2016 or fiscal plan year beginning (MM/DD/YYYY)
and ending
A
This return is: (1) the first return filed for the plan;
(3) the final return filed for the plan;
(2) an amended return;
(4) a short plan year return (less than 12 months).
B
If filing under an extension of time, check this box (see instructions) . . . . . . . . . . . . . . . . .
C
If this return is for a foreign plan, check this box (see instructions) . . . . . . . . . . . . . . . . .
D
If this return is for the IRS Late Filer Penalty Relief Program, check this box (see instructions) . . . . . . . .

Part II

DRAFT AS OF
August 24, 2016
DO NOT FILE

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Basic Plan Information — enter all requested information.

1a

Name of plan

1b Three-digit
plan number (PN) ▶
1c Date plan first became effective
(MM/DD/YYYY)

2a

Employer’s name

2b Employer Identification Number (EIN)
(Do not enter your Social Security Number)

Trade name of business (if different from name of employer)

2c Employer’s telephone number

In care of name

2d Business code (see instructions)
Mailing address (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)
3a

Plan administrator’s name (If same as employer, enter “Same”)

3b Administrator’s EIN

In care of name

3c Administrator’s telephone number

Mailing address (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)
4a

Name of trust

4b Trust’s EIN

4c

Name of trustee or custodian

4d Trustee or custodian’s telephone number

5

If the name and/or EIN of the employer has changed since the last return filed for this plan,
enter the name, EIN, and plan number for the last return in the appropriate space provided:
Employer’s name

a

6a(1) Total number of participants at the beginning of the plan year . . .
a(2) Total number of active participants at the beginning of the plan year .
b(1) Total number of participants at the end of the plan year
. . . . .
b(2) Total number of active participants at the end of the plan year . . .
c Number of participants that terminated employment during the plan
benefits that were less than 100% vested . . . . . . . . . .

Part III

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year with accrued
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5b

EIN

5c

PN

6a(1)
6a(2)
6b(1)
6b(2)
6c

Financial Information
(1) Beginning of year

7a

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7a

b Total plan liabilities .

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7b

Net plan assets (subtract line 7b from 7a)

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7c

c

Total plan assets

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 5500-EZ.

Cat. No. 63263R

(2) End of year

Form 5500-EZ (2016)

Form 5500-EZ (2016)

Part III
8

Page

Contributions received or receivable from:
a

Amount

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8a

b Participants .

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8b

Others (including rollovers) .

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8c

c

Employers.

Part IV
9

2

(Continued)

DRAFT AS OF
August 24, 2016
DO NOT FILE
Plan Characteristics

Enter the applicable two-character feature codes from the List of Plan Characteristics Codes in the instructions:

Part V

Compliance and Funding Questions

Yes No

10

During the plan year, did the plan have any participant loans?
If “Yes,” enter amount as of year end . . . . . . . . .

11
a
12

a

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Amount

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10
Is this a defined benefit plan that is subject to minimum funding requirements?
11
If “Yes,” complete Schedule SB (Form 5500) and line 11a below. (See instructions.)
Enter the unpaid minimum required contributions for all years from Schedule SB (Form 5500), line 40
Is this a defined contribution plan subject to the minimum funding requirements
12
of section 412 of the Code? . . . . . . . . . . . . . . . . . . .
If “Yes,” complete lines 12a or 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, enter the month, day, and year (MM/DD/YYYY) of the letter ruling granting the waiver
(see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . .

b Enter the minimum required contribution for this plan year . . . . . . . . . . . . .
c Enter the amount contributed by the employer to the plan for this plan year . . . . . . .
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 negative amount) . . . . . . . . . . . . . . . . . . . . .

11a

12a
12b
12c

12d
Yes No N/A

e
13a

Will the minimum funding amount reported on line 12d be met by the funding deadline? 12e
If the plan is a master and prototype plan (M&P) or volume submitter plan that received a favorable IRS opinion letter or advisory
and the serial number
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letter, enter the date of the letter (MM/DD/YYYY)
b If the plan is an individually-designed plan that received a favorable determination letter from the IRS, enter the date of the
most recent determination letter (MM/DD/YYYY)
.
Yes No

14

Was any plan participant a 5% owner who had attained at least age 70½ during the
prior plan year? . . . . . . . . . . . . . . . . . . . . . . .

14
Defined Benefit Plan or Money Purchase Pension Plan only: Were any distributions
made during the plan year to an employee who attained age 62 and had not
separated from service? . . . . . . . . . . . . . . . . . . . .
15
Caution: A penalty for the late or incomplete filing of this return will be assessed unless reasonable cause is established.

15

Under penalties of perjury, I declare that I have examined this return including, if applicable, any related Schedule MB (Form 5500) or Schedule SB (Form 5500)
signed by an enrolled actuary, and to the best of my knowledge and belief, it is true, correct, and complete.
▲

Sign
Here

Signature of employer or plan administrator

Date

Preparer’s name (including firm name, if applicable) and address, including room or suite number

Type or print name of individual signing as employer or
plan administrator
Preparer’s telephone number

Form 5500-EZ (2016)