Form 2017 Form 5500 2017 Form 5500 2017 Annual Return/Report of Employee Benefit Plan (Clea

Form 5500

Annual Return/Report of Employee Benefit Plan

Department of the Treasury
Internal Revenue Service

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 6057(b) and 6058(a) of the Internal Revenue Code (the Code).

Department of Labor
Employee Benefits Security
Administration

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

2017
This Form is Open to Public
Inspection

Pension Benefit Guaranty Corporation

Part I

OMB Nos. 1210-0110
1210-0089

Annual Report Identification Information

For calendar plan year 2017 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

B This return/report is:

X a single-employer plan
X the first return/report
X an amended return/report

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

participating employer information in accordance with the form instructions.)

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
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
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

1b Three-digit plan

001
number (PN) 
1c Effective date of plan
YYYY-MM-DD
2b Employer Identification
Number (EIN)

012345678
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
Signature of plan administrator
SIGN
HERE
Signature of employer/plan sponsor
SIGN
HERE

YYYY-MM-DD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Date

Enter name of individual signing as plan administrator

YYYY-MM-DD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Date

Enter name of individual signing as employer or plan sponsor

YYYY-MM-DD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Signature of DFE
Date
For Paperwork Reduction Act Notice, see the Instructions for Form 5500.

Enter name of individual signing as DFE
Form 5500 (2017)
v. 170203

Page 2

Form 5500 (2017)

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 012345678901
UK
4 If the name and/or EIN of the plan sponsor or the plan name has changed since the last return/report filed for this plan,
a
c
5
6

enter the plan sponsor’s name, EIN, the plan name and the plan number from the last return/report:
Sponsor’s name
Plan Name

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

0123456789

4b EIN012345678
4d PN
012

Total number of participants at the beginning of the plan year

5

123456789012

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
6g
complete this item) ........................................................................................................................................................................

123456789012

h Number of participants who terminated employment during the plan year with accrued benefits that were

123456789012
6h
less than 100% vested ....................................................................................................................................................................
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
(1)
X R (Retirement Plan Information)
(2)

(3)

X

X

MB (Multiemployer Defined Benefit Plan and Certain Money
Purchase Plan Actuarial Information) - signed by the plan
actuary
SB (Single-Employer Defined Benefit Plan Actuarial
Information) - signed by the plan actuary

b General Schedules
(1)
X
H (Financial Information)
(2)

X

(3)

X ___ A (Insurance Information)

(4)

X

C (Service Provider Information)

(5)

X

D (DFE/Participating Plan Information)

(6)

X

G (Financial Transaction Schedules)

I (Financial Information – Small Plan)

Page 3

Form 5500 (2017)

Part III Form M-1 Compliance Information (to be completed by welfare benefit plans)
11a If the plan provides welfare benefits, was the plan subject to the Form M-1 filing requirements during the plan year? (See instructions and 29 CFR
2520.101-2.) ........................………..…. X

Yes

X

No

If “Yes” is checked, complete lines 11b and 11c.

11b Is the plan currently in compliance with the Form M-1 filing requirements? (See instructions and 29 CFR 2520.101-2.) ……..... X Yes X No
11c Enter the Receipt Confirmation Code for the 2017 Form M-1 annual report. If the plan was not required to file the 2017 Form M-1 annual report, enter the
Receipt Confirmation Code for the most recent Form M-1 that was required to be filed under the Form M-1 filing requirements. (Failure to enter a valid
Receipt Confirmation Code will subject the Form 5500 filing to rejection as incomplete.)
Receipt Confirmation Code______________________