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

Form 5500-EZ Department of the Treasury Internal Revenue Service	Annual Return of A One-Participant (Owners/Partners and Their Spouses) Retirement Plan or A Foreign Plan 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.	OMB No. 1545-1610
		2021
		This Form is Open to Public Inspection.

Part I Annual Return Identification Information

For the calendar plan year 2021 or fiscal plan year beginning (MM/DD/YYYY) and ending

A

This return is:

(1)

Th 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

Check box if filing under

Form 5558

automatic extension

special extension (enter description) ____________________________________________________

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) . . . . . . . . . . . . .

▶

E

If this is a retroactively adopted plan permitted by SECURE Act section 201, check here . . . . . . . . . . . . . . .

▶

Part II

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)

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 Employer’s name

4b EIN

4c 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 . . . . . . . . . . . b(2) Total number of active participants at the end of the plan year . . . . . . . . c Number of participants who terminated employment during the plan year with accrued benefits that were less than 100% vested . . . . . . . . . . . . . . .

5a(1)

5a(2)

5b(1)

5b(2)

5c

Part III Financial Information

					(1) Beginning of year	(2) End of year
6a		Total plan assets . . . . . . . . . . . . . . . . . . . .		6a
b		Total plan liabilities . . . . . . . . . . . . . . . . . . . .		6b
c		Net plan assets (subtract line 6b from 6a . . . . . . . . . . . .		6c

^{For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 5500-EZ.} Cat. No. 63263R ^{Form 5500-EZ (2021)}

Part III Financial Information

7	Contributions received or receivable from:																						Amount
a	Employers. . . . . . . . . . .	.	.	.	.	.	.	.	.	.		.	.	.	.	.	.	.		.	.	7a
b	Participants . . . . . . . . . .	.	.	.	.	.	.	.	.	.		.	.	.	.	.	.	.		.	.	7b
c	Others (including rollovers) . . . . .	.	.	.	.	.	.	.	.	.		.	.	.	.	.	.	.		.	.	7c

Part IV Plan Characteristics

8 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	Amount
During the plan year, did the plan have any participant loans? If “Yes,” enter amount as of year end . . . . . . . . . . . . . . . . Is this a defined benefit plan that is subject to minimum funding requirements? If “Yes,” complete Schedule SB (Form 5500) and line 10a below. (See instructions.)	9
	10
a Enter the unpaid minimum required contributions for all years from Schedule SB (Form 5500), line 40 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .			10a
11 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) . . . . . . . . . . . . . . . . . . . . . . . . . . Enter the minimum required contribution for this plan year . . . . . . . . . . . . . Enter the amount contributed by the employer to the plan for this plan year . . . . . . . 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) . . . . . . . . . . . . . . . . . .
			11a
			11b
			11c
			11d
		Yes	No	N/A
e 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.

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 (2021)