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Form
5500-EZ
Department
of the Treasury Internal
Revenue Service
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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.
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OMB
No. 1545-1610
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2023
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This
Form is Open to Public Inspection.
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Part
I
Annual Return Identification
Information
For
the calendar plan year 2023 or fiscal plan year beginning
(MM/DD/YYYY) and ending
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A
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This
return
is:
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(1)
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the
first return filed for the plan;
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(3)
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the
final return filed for the plan;
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(2)
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an
amended return;
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(4)
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a
short plan year return (less than 12 months)
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B
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Check
box if filing under
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Form
5558
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automatic
extension
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special
extension (enter description)
____________________________________________________
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C
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If
this return is for a foreign plan, check this box (see
instructions) .
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D
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If
this return is for the IRS Late Filer Penalty Relief Program,
check this box (Must be filed on a paper Form with the IRS. See
instructions) .
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E
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If
this is a retroactively adopted plan permitted by SECURE Act
section 201, check here .
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Part
II
Basic Plan Information — enter all
requested information.
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1a Name
of plan
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1b
Three-digit
plan
number (PN)
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1c
Date plan
first became effective (MM/DD/YYYY)
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2a
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Employer’s
name
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2b
Employer
Identification Number (EIN)
(Do
not enter your Social Security Number)
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Trade
name of business (if different from name of employer)
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2c
Employer’s
telephone number
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In
care of name
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2d
Business code
(see instructions)
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Mailing
address (room, apt., suite no. and street, or P.O. box)
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City
or
town,
state
or
province,
country,
and
ZIP
or
foreign
postal
code
(if
foreign,
see
instructions)
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3a
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Plan
administrator’s name (If same as employer, enter “Same”)
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3b
Administrator’s
EIN
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In
care of name
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3c
Administrator’s
telephone number
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Mailing
address (room, apt., suite no. and street, or P.O. box)
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City
or
town,
state
or
province,
country,
and
ZIP
or
foreign
postal
code
(if
foreign,
see
instructions)
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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
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4b
EIN
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4c
Plan name
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4d
PN
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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 . . .
. . . . . . . . . . . .
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5a(1)
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5a(2)
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5b(1)
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5b(2)
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5c
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Part
III
Financial Information
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(1)
Beginning of
year
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(2)
End of year
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6a
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Total
plan assets .
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6a
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b
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Total
plan liabilities .
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6b
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c
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Net
plan assets (subtract line 6b from 6a .
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6c
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For
Privacy Act and Paperwork Reduction Act Notice, see the Instructions
for
Form
5500-EZ. Cat.
No.
63263R Form
5500-EZ
(2023)
Part
III
(Continued)
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7
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Contributions
received or receivable from:
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Amount
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a
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Employers
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7a
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b
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Participants
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7b
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c
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Others
(including rollovers) . . . . .
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7c
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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
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Yes
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No
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Amount
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During
the plan year, did the plan have any participant
loans?
If
“Yes,” enter amount as of year end . . . .
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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.)
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9
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10
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a Enter
the unpaid minimum required contributions for all years from
Schedule SB (Form 5500), line
40
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10a
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11 Is
this a defined contribution plan subject to the minimum funding
requirements
of
section 412 of the Code?
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11
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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)
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Enter
the minimum required contribution for this plan year . . .
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Enter
the amount contributed by the employer to the plan for this plan
year . . . . .
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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) .
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11a
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11b
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11c
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11d
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Yes
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No
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N/A
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e Will
the minimum funding amount reported on line 11d be met by the
funding deadline?
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11e
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12 If
the plan sponsor is an adopter of a pre-approved plan that
received a favorable IRS Opinion Letter, enter the date of the
Opinion Letter __/__/____ (MM/DD/YYYY) and the Opinion Letter
serial number__________.
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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 (2023)
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Form 5500-EZ |
Subject | Annual Return of A One-Participant (Owners/Partners and Their Spouses) Retirement Plan or A Foreign Plan |
Author | SE:W:CAR:MP |
File Modified | 0000-00-00 |
File Created | 2023-09-03 |