Form 5500-EZ Annual Return of A One-Participant (Owners/Partners and

Form

5500-EZ

Annual Return of A One-Participant (Owners/Partners and
Their Spouses) Retirement Plan or A Foreign Plan

2019

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.
▶ Go to www.irs.gov/Form5500EZ for instructions and the latest information.

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 2019 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
1a

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Basic Plan Information — enter all requested information.
1b Three-digit
plan number (PN) ▶

Name of plan

1c Date plan first became effective
(MM/DD/YYYY)
2a

2b Employer Identification Number (EIN)

Employer’s name

(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)
4

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

4c

Employer’s name

4b EIN

Plan name

4d PN

5a(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
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b(2) Total number of active participants at the end of the plan year . . .
c Number of participants who 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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Financial Information

5a(1)
5a(2)
5b(1)
5b(2)
5c

(1) Beginning of year

6a

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6a

b Total plan liabilities .

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6b

Net plan assets (subtract line 6b from 6a)

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6c

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 (2019)

Form 5500-EZ (2019)

Part III
7

Page

Amount

Contributions received or receivable from:
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7a

b Participants .

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7b

Others (including rollovers) .

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7c

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Employers.

Part IV
8

2

Financial Information (continued)

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

9
10
a
11

a

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

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Amount

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Is this a defined benefit plan that is subject to minimum funding requirements?
10
If “Yes,” complete Schedule SB (Form 5500) and line 10a 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
of section 412 of the Code? . . . . . . . . . . . . . . . . . . .
11
If “Yes,” complete lines 11a or 11b, 11c, 11d, and 11e 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 11c from the amount in line 11b. Enter the result (enter a minus sign
to the left of a negative amount) . . . . . . . . . . . . . . . . . . . . .

10a

11a
11b
11c

11d
Yes No N/A

Will the minimum funding amount reported on line 11d be met by the funding
deadline? . . . . . . . . . . . . . . . . . . . . . . . . .
11e
Caution: A penalty for the late or incomplete filing of this return will be assessed unless reasonable cause is established.
e

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

Type or print name of individual signing as employer or
plan administrator
Form 5500-EZ (2019)