us internal revenue service: i5500--1993

8/14/2019 US Internal Revenue Service: i5500--1993

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Cat. No. 13502B

Pension BenefitGuaranty Corporation

Department of LaborPension and WelfareBenefits Administration

Department of the TreasuryInternal Revenue Service

Instructions for Form 5500Annual Return/ Report of Employee BenefitPlan (With 100 or more participants)Code references are to the Internal Revenue Code. ERISA

refers to the Employee Retirement Income Security Act of 1974.

Paperwork Reduction Act Notice

The time needed to complete and file the forms listed below reflects the combinedrequirements of the Internal Revenue Service, Department of Labor, Pension BenefitGuaranty Corporation, and the Social Security Administration. These times will varydepending on individual circumstances. The estimated average times are:

Copying,assembling, andsending the form

to the IRS

Learning aboutthe law or the

form Preparing the formRecordkeeping

87 hr., 3 min. 48 min.13 hr., 52 min.9 hr., 15 min.Form 5500 (initial filers)

81 hr., 33 min. 48 min.13 hr., 47 min.9 hr., 15 min.Form 5500 (all other filers)1 hr., 42 min.28 min.17 hr., 28 min. 16 min.Schedule A (Form 5500)

3 hr., 16 min.2 hr., 35 min.34 hr., 41 min.Schedule B (Form 5500)

23 min.18 min.5 hr., 16 min.Schedule C (Form 5500)

Schedule E (Form 5500)(nonleveraged ESOP) 13 min.12 min.1 hr., 12 min.

Schedule E (Form 5500)(leveraged ESOP) 1 hr., 56 min.1 hr., 41 min.10 hr., 2 min.

1 hr., 55 min.Schedule P (Form 5500) 33 min.30 min.

6 hr., 42 min.Schedule SSA (Form 5500) 19 min.12 min.

If you have comments concerning the accuracy of these time estimates or suggestionsfor making these forms more simple, we would be happy to hear from you. You can writeto both the Internal Revenue Service, Attention: Reports Clearance Officer, PC:FP,Washington, DC 20224; and the Office of Management and Budget, PaperworkReduction Project (1210-0016), Washington, DC 20503. DO NOT send this form to either

of these offices. Instead, see Where To File on page 2.

How To Use This InstructionBookletThe instructions are divided into four mainsections.

Section 1 Page

Who Must File 2

When To File 2

Extension of Time To File 2

Where To File 2Section 2

Kinds of Plans 2

Pension benefit 2

Welfare benefit 2

Fringe benefit 3

Plans Excluded From Filing 3

Kinds of Filers 3

Investment Arrangements FilingDirectly With DOL 4

What To File 5

Forms 5

Items To Complete on Form 5500 5

Schedules 6

Other Filings 6Section 3

Section 4

Plan Year 1

Schedule F (Form 5500)

Schedule G (Form 5500)

Final Return/Report 7

Signature and Date 7

Reproductions 7

Change in Plan Year 7

Amended Return/Report 8

How the Annual Return/Report InformationMay Be Used 8

Informat ion at the Top of the Form 8

Line-By-Line Instructions 8

Codes for Principal Business Activity andPrincipal Product or Service 22

2 hr., 52 min. 28 min.24 min.

15 hr., 4 min. 21 min.6 min.

Electronic Filing of Form 5500 1

Penalties 1

We ask for the information on this form to carry out the law as specified in ERISA andCode section 6039D. You are required to give us the information. We need it todetermine whether the plan is operating according to the law.

A Change To Note for 1994The Revenue Reconciliation Act of 1993(Title XIII of OBRA 93) amended Codesection 401(a)(17) to reduce the maximumamount of annual compensation that maybe taken into account under a qualifiedplan to $150,000 for benefits accruing inplan years beginning on or after January 1,1994. See Act Section 13212 for thedifferent effective dates and the transitionrules.

Section 1

Plan Year

File 1993 forms for plan years that startedin 1993. If the plan year differs from thecalendar year, fill in the fiscal year spacejust under the form title. For a short planyear, see When To File on page 2.

Electronic Filing of Form 5500

Form 5500 and the related schedules canbe filed by magnetic media (magnetictapes, floppy diskettes) or electronically. Ifthe plan administrator files the

return/report electronically or on magneticmedia, he or she must also file Form8453-E, Employee Benefit Plan Declarationand Signature for Electronic/MagneticMedia Filing. This is the declaration andsignature form for the electronic/magneticmedia return. For more information, seePub. 1507, Procedures forElectronic/Magnetic Media Filing ofEmployee Benefit Plan Returns Forms5500, 5500-C/R, and 5500-EZ for PlanYear 1993.

Reminder

Most qualified plans must be amendedby the end of the 1994 plan year forseveral recent changes in the law. See IRSNotice 92-36, 1992-2 C.B. 364, and Rev.Proc. 93-39, 1993-31 I.R.B. 7, for morespecific information.

Many filers receive rejection notices forfailing to complete items 4 and 6 properly.The return/report will also be consideredincomplete and penalties may be assessedif information required on a schedule is nottyped or printed on the appropriateschedule, such as the Schedule A (Form

5500). See Schedules on page 6. Anannual return/report must be filed foremployee welfare benefit plans whichprovide benefits wholly or partially througha Multiple Employer Welfare Arrangement(MEWA) as defined in ERISA section 3(40),unless otherwise exempt (see page 3).

In addition to filing this form with theIRS, plans covered by the Pension BenefitGuaranty Corporation (PBGC) terminationinsurance program must file their AnnualPremium Payment, PBGC Form 1, directlywith that agency.

PenaltiesERISA and the Code provide for theassessment or imposition of penalties fornot giving complete information and for notfiling statements and returns/reports.Certain penalties are administrative (i.e.,they may be imposed or assessed by oneof the governmental agencies delegated toadminister the collection of the Form 5500series data). Others require a legalconviction.


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Administrative Penalties

Listed below are various penalties for notmeeting the Form 5500 series filingrequirements. One or more of the followingfive penalties may be assessed or imposedin the event of incomplete filings or filingsreceived after the due date unless it isdetermined that your explanation for failureto file properly is for reasonable cause:

1. A penalty of up to $1,000 a day foreach day a plan administrator fails orrefuses to file a complete return/report.

See ERISA section 502(c)(2) and 29 CFR2560.502c-2.

2. A penalty of $25 a day (up to $15,000)for not filing returns for certain plans ofdeferred compensation, certain trusts andannuities, and bond purchase plans by thedue date(s). See Code section 6652(e).This penalty also applies to returnsrequired to be filed under Code section6039D.

3. A penalty of $1 a day (up to $5,000)for each participant for whom a registrationstatement (Schedule SSA (Form 5500)) isrequired but not filed. See Code section6652(d)(1).

4. A penalty of $1 a day (up to $1,000)

for not filing a notification of change ofstatus of a plan. See Code section6652(d)(2).

5. A penalty of $1,000 for not filing anactuarial statement. See Code section6692.

Other Penalties

1. Any individual who willfully violatesany provision of Part 1 of Title I of ERISAshall be fined not more than $5,000 orimprisoned not more than 1 year, or both.See ERISA section 501.

2. A penalty of up to $10,000, 5 yearsimprisonment, or both, may be imposed formaking any false statement or

representation of fact, knowing it to befalse, or for knowingly concealing or notdisclosing any fact required by ERISA. Seesection 1027, Title 18, U.S. Code, asamended by section 111 of ERISA.

Who Must File

Any administrator or sponsor of anemployee benefit plan subject to ERISAmust file information about each planevery year (Code section 6058 and ERISAsections 104 and 4065). Every employermaintaining a specified fringe benefit planas described in Code section 6039D(except Code sections 79, 105, 106, 120,and 129 plans) is also required to file each

year. The Internal Revenue Service (IRS),Department of Labor (DOL), and PensionBenefit Guaranty Corporation (PBGC) haveconsolidated their returns and report formsto minimize the filing burden for planadministrators and employers. The charton page 5 gives a brief guide to the typeof return/report to be filed.

When To File

File all required forms and schedules bythe last day of the 7th month after the planyear ends. For a short plan year, file theform and applicable schedules by the last

day of the 7th month after the short planyear ends. For purposes of thisreturn/report, the short plan year ends onthe date of the change in accountingperiod or upon the complete distribution ofthe assets of the plan. (Also see Section3.) If the current year Form 5500 is notavailable before the due date of your shortplan year return/report, use the latest yearform available and change the date printedon the return/report to the current year.Also show the dates your short plan yearbegan and ended.

Extension of Time To File

A one time extension of time to file (up to212 months) may be granted for filingreturns/reports if Form 5558, Applicationfor Extension of Time To File CertainEmployee Plan Returns, is filed before thenormal due date (not including anyextensions) of the return/report.

Exception: Plans are automatically grantedextensions of time to file Form 5500 untilthe due date of the Federal income taxreturn of the employer if all the followingconditions are met: (1) The plan year andthe employers tax year are the same. (2)The employer has been granted an

extension of time to file its Federal incometax return to a date later than the normaldue date for filing the Form 5500. (3) Acopy of the IRS extension of time to filethe Federal income tax return is attachedto the Form 5500 filed with the IRS. Anextension granted by using this exceptionCANNOT be extended further by filing aForm 5558.

Note: An extension of time to file thereturn/report does not operate as anextension of time to file the PBGCForm 1.

Where To File

Please file the return/report with the

Internal Revenue Service Center indicatedbelow. No street address is necessary.

See pages 6 and 7 for the filing addressfor investment arrangements filing directlywith DOL.

If the principal office ofthe plan sponsor or the

plan administrator islocated in

Use the followingInternal RevenueService Center

address

Connecticut, Delaware,District of Columbia,Foreign Address, Maine,Maryland, Massachusetts,New Hampshire, NewJersey, New York,Pennsylvania, Puerto Rico,

Rhode Island, Vermont,Virginia

Holtsville, NY 00501

Alabama, Alaska, Arkansas,California, Florida, Georgia,Hawaii, Idaho, Louisiana,Mississippi, Nevada, NorthCarolina, Oregon, SouthCarolina, Tennessee,Washington

Atlanta, GA 39901

Arizona, Colorado, Illinois,Indiana, Iowa, Kansas,Kentucky, Michigan,Minnesota, Missouri,Montana, Nebraska, NewMexico, North Dakota,Ohio, Oklahoma, SouthDakota, Texas, Utah, WestVirginia, Wisconsin,Wyoming

Memphis, TN 37501

All Form 5500-EZ filers And over, MA 05501

Section 2Kinds of Plans

Employee benefit plans include pensionbenefit plans and welfare benefit plans. Filethe applicable return/report for any of thefollowing plans.

Pension Benefit Plan

This is an employee pension benefit plancovered by ERISA. The return/report is duewhether or not the plan is qualified andeven if benefits no longer accrue,contributions were not made this plan year,or contributions are no longer made(frozen plan or wasting trust ). See FinalReturn/Report on page 7.

Pension benefit plans required to fileinclude defined benefit plans and definedcontribution plans (e.g., profit-sharing,stock bonus, money purchase plans, etc.).The following are among the pensionbenefit plans for which a return/reportmust be filed:

1. Annuity arrangements under Codesection 403(b)(1).

2. Custodial account established underCode section 403(b)(7) for regulatedinvestment company stock.

3. Individual retirement accountestablished by an employer under Codesection 408(c).

4. Pension benefit plan maintainedoutside the United States primarily fornonresident aliens if the employer whomaintains the plan is:

a. A domestic employer, or

b. A foreign employer with incomederived from sources within the UnitedStates (including foreign subsidiaries ofdomestic employers) and deductscontributions to the plan on its U.S.income tax return. See Plans ExcludedFrom Filing on page 3.

5. Church plans electing coverage underCode section 410(d).

6. A plan that covers residents of Puerto

Rico, the Virgin Islands, Guam, WakeIsland, or American Samoa. This includes aplan that elects to have the provisions ofsection 1022(i)(2) of ERISA apply.

See Items To Complete on Form 5500on page 5 for more information about whatquestions must be completed by pensionplans.

Welfare Benefit Plan

This is an employee welfare benefit plancovered by Part 1 of Title I of ERISA.Welfare plans provide benefits such asmedical, dental, life insurance,


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apprenticeship and training, scholarshipfunds, severance pay, disability, etc.

See Items To Complete on Form 5500on page 5 for more information about whatquestions must be completed for welfarebenefit plans.

Fringe Benefit Plan

Cafeteria plans described in Code section125 and educational assistance programsdescribed in Code section 127 areconsidered fringe benefit plans andgenerally are required to file the annual

information specified by Code section6039D. However, Code section 127educational assistance programs, whichprovide only job-related training that isdeductible under Code section 162, do notneed to file Form 5500.

Note: A fringe benefit plan may beassociated with one or more welfare plansas described above for which a Form 5500may be required to be filed.

See Items To Complete on Form 5500on page 5 for more information about howto complete this form for a fringe benefitplan.

Plans Excluded From Filing

These exemptions do not apply to a fringebenefit plan required to file to satisfy therequirements of Code section 6039D.

Do not file a return/report for anemployee benefit plan that is any of thefollowing:

1. A welfare benefit plan which coveredfewer than 100 participants as of thebeginning of the plan year and is:unfunded, fully insured, or a combinationof insured and unfunded.

a. An unfunded welfare benefit plan hasits benefits paid as needed directly fromthe general assets of the employer or theemployee organization that sponsors the

plan.Note: Plans that are NOT unfunded includethose plans that received employee (orformer employee) contributions during theplan year and/or used a trust or separatelymaintained fund (including a Code section501(c)(9) trust) to hold plan assets or act asa conduit for the transfer of plan assetsduring the plan year.

b. A fully insured welfare benefit planhas its benefits provided exclusivelythrough insurance contracts or policies, thepremiums of which must be paid directlyby the employer or employee organizationfrom its general assets or partly from itsgeneral assets and partly from

contributions by its employees or members(which the employer or organizationforwards within 3 months of receipt).

The insurance contracts or policiesdiscussed above must be issued by aninsurance company or similar organization(such as Blue Cross, Blue Shield or ahealth maintenance organization) which isqualified to do business in any state.

c. A combination unfunded/insuredwelfare plan has its benefits providedpartially as an unfunded plan and partiallyas a fully insured plan. An example of such

a plan is a welfare plan which providesmedical benefits as in a above and lifeinsurance benefits as in b above.

See 29 CFR 2520.104-20 and the DOLTechnical Release 92-01.

Note: An employees beneficiaryassociation as used in Code section501(c)(9) should not be confused with theemployee organization or employer thatestablishes and maintains (i.e., sponsors)the welfare benefit plan.

2. An unfunded pension benefit plan or

an unfunded or insured welfare benefitplan: (a) whose benefits go only to a selectgroup of management or highlycompensated employees, and(b) which meets the terms of Departmentof Labor Regulations 29 CFR 2520.104-23(including the requirement that anotification statement be filed with DOL) or29 CFR 2520.104-24.

3. Plans maintained only to comply withworkers compensation, unemploymentcompensation, or disability insurance laws.

4. An unfunded excess benefit plan.

5. A welfare benefit plan maintainedoutside the United States primarily forpersons substantially all of whom are

nonresident aliens.6. A pension benefit plan maintained

outside the United States if it is a qualifiedforeign plan within the meaning of Codesection 404A(e) that does not qualify forthe treatment provided in Code section402(e)(5).

7. An annuity arrangement described in29 CFR 2510.3-2(f).

8. A simplified employee pension (SEP)described in Code section 408(k) whichconforms to the alternative method ofcompliance described in 29 CFR2520.104-48 or 29 CFR 2520.104-49. ASEP is a pension plan that meets certainminimum qualifications regarding eligibility

and employer contributions.9. A church plan not electing coverage

under Code section 410(d) or agovernmental plan.

10. A welfare benefit plan thatparticipates in a group insurancearrangement that files a return/report Form5500 on behalf of the welfare benefit plan.See 29 CFR 2520.104-43.

11. An apprenticeship or training planmeeting all of the conditions specified in29 CFR 2520.104-22.

Kinds of Filers

The different types of plan entities that file

the forms are described below. (Also seeinstructions for item 4 on page 9.)

Single-Employer Plan

If one employer or one employeeorganization maintains a plan, file aseparate return/report for the plan. If theemployer or employee organizationmaintains more than one such plan, file aseparate return/report for each plan.

If a member of a controlled group ofcorporations, a group of trades orbusinesses under common control, or anaffiliated service group maintains a plan

that does not involve other groupmembers, file a separate return/report as asingle-employer plan.

If several employers participate in aprogram of benefits in which the fundsattributable to each employer are availableonly to pay benefits to that employersemployees, each employer must file aseparate return/report.

Plan for Controlled Group ofCorporations, Group of Trades orBusinesses Under Common Control, or

an Affiliated Service GroupThese groups are defined in Code sections414(b), (c), and (m), and are referred to ascontrolled groups.

If the benefits are payable to participantsfrom the plans total assets without regardto contributions by each participantsemployer, file one return/report for theplan. On the return/report for the plan,complete item 21 only for the controlledgroups employees.

Note: Employers who participate in apension plan of one of the groups listedabove but who are not members of thegroup must file a separate return/report.The return/report should be filed on Form5500-C/R regardless of the number ofparticipants. The years you are required tofile pages 1 and 3 through 6 as Form5500-C, complete only items 1 through 7a,9, and 21. The years you file pages 1 and 2as Form 5500-R complete only items 1through 7a, 8a, and 8b. These participatingemployers must enter code F in item 4 ofthe Form 5500-C/R.

If several employers participate in aprogram of benefits in which the fundsattributable to each employer are availableonly to pay benefits to that employersemployees, each employer must file aseparate return/report as a single employerplan.

Multiemployer Plan

A multiemployer plan is a plan (1) to whichmore than one employer is required tocontribute, (2) that is maintained pursuantto one or more collective-bargainingagreements, and (3) has not made theelection under Code section 414(f)(5) andERISA section 3(37)(E). File onereturn/report for each plan. Contributingemployers do not file individually for theseplans. See Code section 414 for moreinformation.

Multiple-Employer-CollectivelyBargained Plan

A multiple-employer-collectively bargainedplan involves more than one employer; iscollectively bargained and collectivelyfunded; and, if covered by PBGCtermination insurance, had properly electedbefore September 27, 1981, not to betreated as a multiemployer plan underCode section 414(f)(5) or ERISA sections3(37)(E) and 4001(a)(3). File onereturn/report for each such plan.Participating employers do not fileindividually for these plans.


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Multiple-Employer Plan (Other)

A multiple-employer plan (other) involvesmore than one employer and is not one ofthe plans already described. File onereturn/report for each plan.

Note: Each employer participating in aqualified defined contribution or definedbenefit plan, which is considered amultiple-employer plan (other), must file aForm 5500-C/R regardless of the numberof participants. For the years you arerequired to file pages 1 and 3 through 6 as

Form 5500-C, complete only items 1through 7a, 9, and 21. For the years youfile pages 1 and 2 as Form 5500-R,complete only items 1 through 7a, 8a, and8b. Each participating employer filing theForm 5500-C/Rmustenter code F in item4 and use an appropriate number (001,002, etc.) in item 5c.

Note: If a participating employer is also thesponsor of the multiple-employer plan(other), the plan number on thereturn/report filed for the plan should be333 and, if more than one plan, theyshould be consecutively numbered startingwith 333.

If more than one employer participates in

the plan and the plan provides that eachemployers contributions are available topay benefits only for that employersemployees who are covered by the plan,one annual return/report must be filed foreach participating employer. These filerswill be considered single employers andshould complete the entire form.

Group Insurance Arrangement

This arrangement provides benefits to theemployees of two or more unaffiliatedemployers (not in connection with amultiemployer plan or a multiple-employer-collectively bargained plan), fully insuresone or more welfare plans of eachparticipating employer, and uses a trust (or

other entity such as a trade association) asthe holder of the insurance contracts andthe conduit for payment of premiums tothe insurance company.

Do not file a separate return/report for awelfare benefit plan that is part of a groupinsurance arrangement if a consolidatedreturn/report for all the plans in thearrangement was filed by the trust or otherentity according to 29 CFR 2520.104-43.Form 5500 is required by 29 CFR2520.103-2 to be part of the consolidatedreport.

Investment Arrangements FilingDirectly With DOL

Some plans invest in certain trusts,accounts, and other investmentarrangements which may file informationconcerning themselves and theirrelationship with employee benefit plansdirectly with DOL (as specified on pages 6and 7). Plans participating in an investmentarrangement as described inCommon/Collective Trust and PooledSeparate Account, Master Trust, and103-12 Investment Entities below arerequired to attach certain additional

information to the return/report filed withthe IRS as specified below.

Common/Collective Trust and PooledSeparate Account

Definition.For reporting purposes, acommon/collective trust is a trustmaintained by a bank, trust company, orsimilar institution which is regulated,supervised, and subject to periodicexamination by a state or Federal agencyfor the collective investment andreinvestment of assets contributed thereto

from employee benefit plans maintained bymore than one employer or a controlledgroup of corporations, as the term is usedin Code section 1563. For reportingpurposes, a pooled separate account isan account maintained by an insurancecarrier which is regulated, supervised, andsubject to periodic examination by a stateagency for the collective investment andreinvestment of assets contributed theretofrom employee benefit plans maintained bymore than one employer or controlledgroup of corporations, as the term is usedin Code section 1563. See 29 CFRsections 2520.103-3, 2520.103-4,2520.103-5, and 2520.103-9.

Note: For reporting purposes, a separateaccount which is not considered to beholding plan assets pursuant to 29 CFR2510.3-101(h)(1)(iii) shall not constitute apooled separate account.

Additional information required to beattached to the Form 5500 for plansparticipating in common/collective trustsand pooled separate accounts.A planparticipating in a common/collective trustor pooled separate account must completethe annual return/report and attach either:(1) the most recent statement of the assetsand liabilities of any common/collectivetrust or pooled separate account, or (2) acertification that: (a) the statement of theassets and liabilities of thecommon/collective trust or pooled separateaccount has been submitted directly toDOL by the financial institution orinsurance carrier; (b) the plan has receiveda copy of the statement; and (c) includesthe EIN and other numbers used by thefinancial institution or insurance carrier toidentify the trusts or accounts, and thename and address provided in the directfiling made with DOL.

Master Trust

Definition.For reporting purposes, amaster trust is a trust for which a regulatedfinancial institution (as defined below)serves as trustee or custodian (regardless

of whether such institution exercisesdiscretionary authority or control withrespect to the management of assets heldin the trust), and in which assets of morethan one plan sponsored by a singleemployer or by a group of employers undercommon control are held.

A regulated financial institution meansa bank, trust company, or similar financialinstitution which is regulated, supervised,and subject to periodic examination by astate or Federal agency. Common controlis determined on the basis of all relevantfacts and circumstances (whether or not

such employers are incorporated). See 29CFR 2520.103-1(e).

For reporting purposes, the assets of amaster trust are considered to be held inone or more investment accounts. Amaster trust investment account mayconsist of a pool of assets or a singleasset.

Each pool of assets held in a mastertrust must be treated as a separate mastertrust investment account if each planwhich has an interest in the pool has thesame fractional interest in each asset inthe pool as its fractional interest in thepool, and if each such plan may notdispose of its interest in any asset in thepool without disposing of its interest in thepool. A master trust may also containassets which are not held in such a pool.Each such asset must be treated as aseparate master trust investment account.

Financial information must generally beprovided for each master trust investmentaccount as specified on pages 6 and 7.

Additional information required to beattached to the Form 5500 for plansparticipating in master trusts.A planparticipating in a master trust mustcomplete the annual return/report andattach a schedule listing each master trustinvestment account in which the plan hasan interest indicating the plans name, EIN,and plan number and the name of themaster trust used in the master trustinformation filed with DOL (see page 6). Intabular format, show the net value of theplans interest in each investment accountat the beginning and end of the plan year,and the net investment gain (or loss)allocated to the plan for the plan year fromthe investment account (see instructionsfor items 31c(11) through (15) on page 20).

Note: If a master trust investment accountconsists solely of one plans asset(s) duringthe reporting period, the plan may report

the(se) asset(s) either as an investmentaccount to be reported as part of themaster trust report filed directly with DOLor as a plan asset(s) which is not part ofthe master trust (and therefore subject toall instructions pertaining to assets not heldin a master trust).

103-12 Investment Entities

29 CFR 2520.103-12 provides analternative method of reporting for planswhich invest in an entity (other than aninvestment arrangement filing with DOL asdescribed on this page inCommon/Collective Trust and PooledSeparate Accounts or Master Trust), the

underlying assets of which include planassets (within the meaning of 29 CFR2510.3-101) of two or more plans whichare not members of a related group ofemployee benefit plans. For reportingpurposes, a related group consists ofeach group of two or more employeebenefit plans (1) each of which receives10% or more of its aggregate contributionsfrom the same employer or from a memberof the same controlled group ofcorporations (as determined under Codesection 1563(a), without regard to Codesection 1563(a)(4)); or (2) each of which is


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either maintained by, or maintainedpursuant to a collective-bargaining

agreement negotiated by, the sameemployee organization or affiliatedemployee organizations. For purposes ofthis paragraph, an affiliate of anemployee organization means any personcontrolling, controlled by, or undercommon control with such organization.See 29 CFR 2520.103-12.

For reporting purposes, the investmententities described above with respect towhich the required information is fileddirectly with DOL constitute 103-12investment entities (103-12 IEs).

What To File

This section describes the different

categories of the Form 5500 series and therelated schedules and also lists items to becompleted by different types of Form 5500filers. In addition, this section contains adescription of the special filingrequirements for plans which invest incertain investment arrangements. For abrief guide illustrating which forms andschedules are required by different typesof plans and filers, see the summaryabove.

Forms

The following are the different forms in the5500 series.

Form 5500, Annual Return/Report of

Employee Benefit Plan, must be filedannually for each plan with 100 or moreparticipants at the beginning of the planyear.

Form 5500-C/R, Return/Report ofEmployee Benefit Plan, must be filed foreach pension benefit plan, welfare benefitplan, and fringe benefit plan (unlessotherwise exempted) with fewer than 100participants at the beginning of the planyear (one-participant plans see Form5500-EZ below).

Note: To determine whether to file Form5500 or Form 5500-C/R for an employee

benefit plan, calculate the number ofparticipants in the same manner as item 7

of the Form 5500 or 5500-C/R but thecalculation should be as of thebeginningof the plan year. Also, under the filingrequirements explained above, if thenumber of plan participants increases to100 or more, or decreases below 100, fromone year to the next, you would generallyhave to file a different form from that filedthe previous year. However, there is anexception to this rule. The filer maycontinue to file the same form filed lastyear (i.e., Form 5500 or 5500-C/R), even ifthe number of participants changed,provided that at the beginning of this planyear the plan had at least 80 participants,but not more than 120.

Form 5500-EZ, Annual Return of

One-Participant (Owners and TheirSpouses) Pension Benefit Plan, should befiled by most one-participant plans.

A one-participant plan is: (1) a pensionbenefit plan that covers only an individualor an individual and his or her spouse whowholly own a trade or business, whetherincorporated or unincorporated; or (2) apension benefit plan for a partnership thatcovers only the partners or the partnersand the partners spouses.

See Form 5500-EZ and its instructions tosee if the plan meets the requirements forfiling the form.

Form 8822, Change of Address, may be

used to notify the IRS if the plans mailingaddress changes after the return/reporthas been filed.

Items To Complete on Form 5500

Certain kinds of plans and certain kinds offilers that must file an annual Form 5500are not required to complete the entireform. These are described below, by typeof plan. Check the list of headings to see ifyour plan is affected.

Welfare benefit plans.Welfare benefitplans generally must complete thefollowing items on the Form 5500: 1

through 6a, 6e, 7a(4), 7b, 7c, and 7d; 8a,8b, 8d, and 8e; 9a, 9b, 9c, and 9f; 10athrough 10d; 11 through 14; 25 through29; and 31 through 33.

Exception: An unfunded, fully insured, or acombination unfunded/insured welfare plan(described on page 3 underPlansExcluded from Filing), which must file theForm 5500 because it has 100 or moreparticipants, need not complete items 31and 32.

Note: If one Form 5500 is filed for both awelfare plan and a fringe benefit plan,check item 6d and complete Schedule F(Form 5500) in addition to the items listedabove for welfare plans.

Fringe benefit plans.For a Form 5500filed only for a fringe benefit plan

described in Code sections 125 and 127,complete only items 1 through 5, 6d, andSchedule F (Form 5500). DO NOT file anyother schedules.

If Form 5500 is filed for both a welfarebenefit plan and a fringe benefit plan,complete the above items, all applicableschedules, and the items specified forWelfare benefit plans above.

Pension plans.In general, most pensionplans (defined benefit and definedcontribution) are required to complete allitems on the form. However, some itemsdo not have to be completed by certaintypes of pension plans, as describedbelow.

1. Plans exclusively using a tax deferredannuity arrangement under Code section403(b)(1).These plans (see Who MustFile on page 2) need only complete items1 through 5, 6b (enter pension code 8),and 9.

2. Plans exclusively using a custodialaccount for regulated investmentcompany stock under Code section403(b)(7).These plans need onlycomplete items 1 through 5, 6b (enterpension code 9), and 9.

Summary of Filing Requirements for Employers and Plan Administrators(File forms ONLY with IRS)

Type of plan What to file When to file

File allrequired

forms andschedules

for eachplan by thelast day of

the 7thmonth after

the planyear ends.

Most pension plans with only one participant or one participant and that participants spouse

Pension plan with fewer than 100 participants

Pension plan with 100 or more participants

Annuity under Code section 403(b)(1) or trust under Code section 408(c)

Custodial account under Code section 403(b)(7)

Welfare benefit plan with 100 or more participants

Welfare benefit plan with fewer than 100 participants (see exceptions on page 3 of these instructions)

Pension or welfare plan with 100 or more participants (see instructions for item 26)

Pension or welfare plan with benefits provided by an insurance company

Pension plan that requires actuarial information

Pension or welfare plan with 100 or more participants

Pension plan with ESOP benefits

Pension plan filing a registration statement identifying separated participants with deferredvested benefits from a pension plan

Form 5500-EZ

Form 5500-C/R

Form 5500

Form 5500 or Form 5500-C/R

Financial statements, schedules,and accountants opinion

Schedule A (Form 5500)

Schedule B (Form 5500)

Schedule C (Form 5500)

Schedule E (Form 5500)

Schedule SSA(Form 5500)

Form 5500 or Form 5500-C/R

Form 5500

Form 5500-C/R

Fringe benefit plan under Code section 6039D Schedule F (Form 5500)

Financial Schedules for item 27 Schedule G (Form 5500)


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3. Individual retirement account plan.Apension plan utilizing individual retirementaccounts or annuities (as described inCode section 408) as the sole fundingvehicle for providing benefits need onlycomplete items 1 through 5, 6b (enterpension code 0), and 9.

4. Fully insured pension plan.A pensionbenefit plan providing benefits exclusivelythrough an insurance contract, or contractswhich are fully guaranteed and that meetsall of the conditions of 29 CFR2520.104-44 need only complete items 1

through 26, 29, and 30.A pension plan including both insurance

contracts of the type described in 29 CFR2520.104-44 as well as other assetsshould limit its reporting in items 31 and 32to those other assets.

Note: For purposes of the annual return/report and the alternative method ofcompliance set forth in 29 CFR2520.104-44, a contract is considered tobe allocated only if the insurancecompany or organization that issued thecontract unconditionally guarantees, uponreceipt of the required premium orconsideration, to provide a retirementbenefit of a specified amount. This amount

must be provided without adjustment forfluctuations in the market value of theunderlying assets of the company ororganization, to each participant, and eachparticipant has a legal right to suchbenefits, which is legally enforceabledirectly against the insurance company ororganization.

5. Nonqualified pension benefit plansmaintained outside the United States.Nonqualified pension benefit plansmaintained outside the United Statesprimarily for nonresident aliens required tofile a return/report (see Who Must File onpage 2) must only complete items 1through 8c (enter code D in item 6c), 9

through 12, 15 and 16.Plans of more than one employer.Allplans of more than one employer (plans ofa controlled group, multiemployer plans,multiple-employer-collectively bargainedplans, and multiple-employer plan (other))generally must complete all applicable(welfare or pension) items on the formexcept for item 6f. Only single-employerpension plans must complete item 6f.Multiemployer plans and multiple-employer-collectively bargained plans neednot complete item 7h.

Schedules

Note: All attachments to Forms 5500 and

5500-C/R must include the name of theplan, the plan sponsors EIN, and plannumber (PN) as found in items 5a, 1b, and5c, respectively.

The various schedules to attach to thereturn/report are listed below:

Schedule A (Form 5500), InsuranceInformation, must be attached to Form5500 or 5500-C/R, if any benefits underthe plan are provided by an insurancecompany, insurance service, or othersimilar organization (such as Blue Cross,Blue Shield, or a health maintenanceorganization). (This includes investments

with insurance companies such asguaranteed investment contracts (GICs).)

Exceptions. (1)Schedule A (Form 5500) isnot needed if the plan covers only: (a) anindividual, or an individual and his or herspouse, who wholly owns a trade orbusiness, whether incorporated orunincorporated; or (b) a partner(s) in apartnership, or a partner(s) and his or herspouse.

(2)A Schedule A (Form 5500) is notrequired to be filed with the Form 5500 orForm 5500-C/R if a Schedule A (Form5500) is filed for the contract as part of themaster trust or 103-12 IE information fileddirectly with DOL.

Do not file a Schedule A (Form 5500)with a Form 5500-EZ.

Schedule B (Form 5500), ActuarialInformation, must be attached to Form5500, 5500-C/R, or 5500-EZ for mostdefined benefit pension plans. See theinstructions for Schedule B.

Schedule C (Form 5500), ServiceProvider and Trustee Information, must beattached to Form 5500. See item 25 andthe instructions for Schedule C.

Schedule E (Form 5500), ESOP Annual

Information, must be attached to Form5500, 5500-C/R, or 5500-EZ for all pensionbenefit plans with ESOP benefits. See theinstructions for Schedule E.

Schedule F (Form 5500), Fringe BenefitPlan Annual Information Return, must beattached to page 1 of Form 5500 or5500-C/R for all fringe benefit plans.

Schedule G (Form 5500), FinancialSchedules, may be attached to Form 5500when a Yes is checked for any item in27a through 27f. The Schedule G isoptional for 1993 (you may use theschedules specified in the instructions foritem 27 instead).

Schedule SSA (Form 5500), Annual

Registration Statement IdentifyingSeparated Participants With DeferredVested Benefits, may be needed forseparated participants. See When ToReport a Separated Participant in theinstructions for Schedule SSA.

Schedule P (Form 5500), Annual Returnof Fiduciary of Employee Benefit Trust,may be filed by any fiduciary (trustee orcustodian) of an organization that isqualified under Code section 401(a) andexempt from tax under Code section501(a) who wants to protect theorganization under the statute of limitationsprovided in Code section 6501(a).

File the Schedule P (Form 5500) as an

attachment to Form 5500, 5500-C/R, or5500-EZ for the plan year in which thetrust year ends.

Other Filings

Certain investment arrangements foremployee benefit plans file financialinformation directly with DOL. Thesearrangements include common/collectivetrusts, pooled separate accounts, mastertrusts, and 103-12 IEs. Definitions of theseinvestment arrangements may be found onpage 4. Their DOL filing requirements aredescribed below.

Common/collective trust and pooledseparate account information to be fileddirectly with DOL.Financial institutionsand insurance carriers filing the statementof the assets and liabilities of acommon/collective trust or pooled separateaccount should identify the trust oraccount by providing the EIN of the trustor account, or (if more than one trust oraccount is covered by the same EIN) boththe EIN and any additional numberassigned by the financial institution orinsurance carrier (such as: 99-1234567

Trust No. 1); and a list of all plansparticipating in the trust or account,identified by the plan number, EIN, andname of the plan sponsor. The direct filingshould be addressed to:

Common/Collective Trust (OR)Pooled Separate AccountPension and Welfare BenefitsAdministration

U.S. Department of Labor, Room N5644200 Constitution Avenue, NWWashington, DC 20210

Master trust information to be fileddirectly with DOL.The followinginformation with respect to a master trustmust be filed with DOL by the plan

administrator or by a designee, such as theadministrator of another plan participatingin the master trust or the financialinstitution serving as trustee of the mastertrust, no later than the date on which theplans return/report is due. While only onecopy of the required information should befiled for all plans participating in the mastertrust, the information is an integral part ofthe return/report of each participating plan,and the plans return/report will not bedeemed complete unless all theinformation is filed within the prescribedtime.

Note: If a master trust investment accountconsists solely of one plans asset(s) duringthe reporting period, the plan may reportthe(se) asset(s) either as an investmentaccount to be reported as part of themaster trust report filed directly with DOLoras a plan asset(s) that is not part of themaster trust (and therefore subject to allinstructions pertaining to assets not held ina master trust).

Each of the following statements andschedules must indicate the name of themaster trust and the name of the mastertrust investment account. The informationshall be filed with DOL by mailing it to:

Master TrustPension and Welfare BenefitsAdministration


1. The name and fiscal year of themaster trust and the name and address ofthe master trustee.

2. A list of all plans participating in themaster trust, showing each plans name,EIN, PN, and its percentage interest ineach master trust investment account asof the beginning and end of the fiscal yearof the master trust ending with or withinthe plan year.


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3. A Schedule A (Form 5500) for eachinsurance or annuity contract held in themaster trust.

4. A statement, in the same format asPart I of Schedule C (Form 5500), for eachmaster trust investment account showingamounts of compensation paid during thefiscal year of the master trust ending withor within the plan year to personsproviding services with respect to theinvestment account and subtracted fromthe gross income of the investmentaccount in determining the net increase

(decrease) in net assets of the investmentaccount.

5. A statement for each master trustinvestment account showing the assetsand liabilities of the investment account atthe beginning and end of the fiscal year ofthe master trust ending with or within theplan year, grouped in the same categoriesas those specified in item 31 of Form5500.

6. A statement for each master trustinvestment account showing the incomeand expenses, changes in net assets, andnet increase (decrease) in net assets ofeach such investment account during thefiscal year of the master trust ending with

or within the plan year, in the categoriesspecified in item 32 of Form 5500. In placeof item 32a, show the total of all transfersof assets into the investment account byparticipating plans. In place of item 32j,show the total of all transfers of assets outof the investment account by participatingplans.

7. Schedules, in the format set forth inthe instructions for item 27 of Form 5500,of the following items with respect to eachmaster trust investment account for thefiscal year of the master trust ending withor within the plan year: assets held forinvestment, nonexempt party-in-interesttransactions, defaulted or uncollectible

loans and leases, and 5% transactionsinvolving assets in the investment account.The 5% figure shall be determined bycomparing the current value of thetransaction at the transaction date with thecurrent value of the investment accountassets at the beginning of the applicablefiscal year of the master trust.

103-12 IE information to be filed directlywith DOL.The information describedbelow must be filed with DOL by thesponsor of the 103-12 IE no later than thedate on which the plans return/report isdue before the plan administrator can electthe alternative method of reporting. Whileonly one copy of the required informationshould be filed for the 103-12 IE, theinformation is an integral part of thereturn/report of each plan electing thealternative method of compliance. Thefiling address is:

103-12 Investment EntityPension and Welfare BenefitsAdministration


1. The name, fiscal year, and EIN of the103-12 IE and the name and address ofthe sponsor of the 103-12 IE. If more than

one 103-12 IE is covered by the same EIN,they shall be sequentially numbered asfollows: 99-1234567 Entity No. 1.

2. A list of all plans participating in the103-12 IE, showing each plans name, EIN,PN, and its percentage interest in the103-12 IE as of the beginning and end ofthe fiscal year of the 103-12 IE ending withor within the plan year.

3. A Schedule A (Form 5500) for eachinsurance or annuity contract held in the103-12 IE.

4. A statement, in the same format asPart I of Schedule C (Form 5500), for the103-12 IE showing amounts ofcompensation paid during the fiscal year ofthe 103-12 IE ending with or within theplan year to persons providing services tothe 103-12 IE.

5. A statement showing the assets andliabilities at the beginning and end of thefiscal year of the 103-12 IE ending with orwithin the plan year, grouped in the samecategories as those specified in item 31 ofForm 5500.

6. A statement showing the income andexpenses, changes in net assets, and netincrease (decrease) in net assets during

the fiscal year of the 103-12 IE ending withor within the plan year, grouped in thesame categories as those specified in item32 of Form 5500. In place of item 32a,show the total of all transfers of assets intothe 103-12 IE by participating plans. Inplace of item 32j, show the total of alltransfers of assets out of the 103-12 IE byparticipating plans.

7. Schedules, in the format set forth inthe instructions for item 27 of Form 5500(except item 27d) with respect to the103-12 IE for the fiscal year of the 103-12IE ending with or within the plan year.Substitute the term 103-12 IE in place ofthe word plan when completing theschedules.

8. A report of an independent qualifiedpublic accountant regarding the aboveitems and other books and records of the103-12 IE that meets the requirements of29 CFR 2520.103-1(b)(5).

Section 3

Final Return/Report

If all assets under the plan (includinginsurance/annuity contracts) have beendistributed to the participants andbeneficiaries or distributed to another plan(and when all liabilities for which benefitsmay be paid under a welfare benefit plan

have been satisfied), check the finalreturn/report box at the top of the formfiled for such plan. The year of completedistribution is the last year a return/reportmust be filed for the plan. For purposes ofthis paragraph, a complete distribution willoccur in the year in which the assets of aterminated plan are brought under thecontrol of PBGC.

For a defined benefit plan covered byPBGC, a PBGC Form 1 must be filed anda premium must be paid until the end ofthe plan year in which the assets are

distributed or brought under the control ofPBGC.

Filing the return/report marked Finalreturn and indicating that the planterminated satisfies the notificationrequirement of Code section 6057(b)(3).

Signature and Date

The plan administrator must sign and dateall returns/reports filed. The name of theindividual who signed as plan administratormust be typed or printed clearly on the lineunder the signature line. In addition, theemployer must sign a return/report filed fora single-employer plan or a plan requiredto file only because of Code section 6039D(i.e., for a fringe benefit plan).

When a joint employer-union board oftrustees or committee is the plan sponsoror plan administrator, at least oneemployer representative and one unionrepresentative must sign and date thereturn/report.

Participating employers in amultiple-employer plan (other), who arerequired to file Form 5500-C/R, arerequired to sign the return/report. The planadministrator need not sign the Form5500-C/R filed by the participatingemployer.

Reproductions

Original forms are preferable, but a clearreproduction of the completed form isacceptable. Sign the return/report after it isreproduced. All signatures must be original.

Change in Plan Year

Generally only defined benefit pensionplans need to get prior approval for achange in plan year. (See Code section412(c)(5).) Rev. Proc. 87-27, 1987-1 C.B.769 explains the procedure for automaticapproval of a change in plan year. Apension benefit plan that would ordinarilyneed to obtain approval for a change inplan year under Code section 412(c)(5) isgranted an automatic approval for achange in plan year if all the followingcriteria are met:

1. No plan year exceeds 12 months.

2. The change will not delay the timewhen the plan would otherwise have beenrequired to conform to the requirements ofany statute, regulation, or publishedposition of the IRS.

3. The trust, if any, retains its exemptstatus for the short period required toeffect the change, as well as for thetaxable year immediately preceding the

short period.4. All actions necessary to implement

the change in plan year, including planamendment and a resolution of the boardof directors (if applicable), have been takenon or before the last day of the shortperiod.

5. No change in plan year has beenmade for any of the preceding plan years.

6. In the case of a defined benefit plan,deductions are taken in accordance withsection 5 of Rev. Proc. 87-27.


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For the first return/report that is filedfollowing the change in plan year, checkthe box on line C at the top of the form.

Amended Return/Report

If you file an amended return/report, checkbox A(2) an amended return/report at thetop of the form. When filing an amendedreturn, answer all questions and circle theamended item numbers.

How The Annual Return/ReportInformation May Be Used

All Form 5500 series return/reports will besubjected to a computerized review. It is,therefore, in the filers best interest that theresponses accurately reflect thecircumstances they were designed toreport. Annual reports filed under Title I ofERISA must be made available by planadministrators to plan participants and bythe Department of Labor to the publicpursuant to ERISA section 104.

Section 4Important: Answer all items on the Form5500 with respect to the plan year, unlessotherwise explicitly stated in the

item-by-item instructions or on the formitself. Therefore, your responses usuallyapply to the year entered or printed at thetop of the first page of the form. Yes orNo questions must be marked eitherYes or No, but not both. N/Acannot be used to respond to a Yes orNo question that is required to beanswered by the filer as specified onpage 5 under Items To Complete OnForm 5500.

Information at the Top of the Form

On the first line at the top of the formcomplete the space for dates when (1) the12-month plan year is not a calendar year,

or (2) the plan year is less than 12 months(a short plan year).

A. Check box (1) if this is the initial filingfor this plan. Do not check this box if youhave ever filed for this plan even if it wason a different form (Form 5500 vs. Form5500-C or Form 5500-R).

Check box (2) if you have already filedfor the 1993 plan year and are nowsubmitting an amended return/report tocorrect errors and/or omissions on thepreviously filed return/report.

Check box (3) if the plan no longer existsto provide benefits. See Section 3 on page7 for instructions concerning therequirement to file a final return/report.

Check box (4) if this form is being filedfor a period of less than 12 months andshow the dates at the top.

B. Check this box if you make anychanges to the preprinted information onpage 1. Changes should be highlighted orentered in red ink if possible.

C. Check this box if the plan year hasbeen changed since the last return/reportwas filed.

D. Check this box if you filed for anextension of time to file this form. Attach acopy of the approved Form 5558 or a copy

of the employers extension of time to filethe income tax return if you are using theexception in Extension of Time To File onpage 2 of these instructions.

Line-By-Line Instructions

Page 1

Check the preprinted information for 1athrough 6d for accuracy andcompleteness. Cross out any incorrectinformation and enter the correctinformation. Add any incomplete

information in red ink if possible.If you did not receive a Form 5500 with

a preprinted page 1, complete items 1through 6d as follows:

1a. Enter the name and address of theplan sponsor. If the plan covers only theemployees of one employer, enter theemployers name. If the Post Office doesnot deliver mail to the street address andthe sponsor has a P.O. box, show the boxnumber instead of the street address.

The term plan sponsor means

The employer, for an employee benefitplan that a single employer established ormaintains;

The employee organization in the case ofa plan of an employee organization; or

The association, committee, joint boardof trustees, or other similar group ofrepresentatives of the parties whoestablish or maintain the plan, if the plan isestablished or maintained jointly by one ormore employers and one or moreemployee organizations, or by two or moreemployers.

Include enough information in item 1(a)to describe the sponsor adequately. Forexample, Joint Board of Trustees of Local187 Machinists rather than just JointBoard of Trustees.

For group insurance arrangements, enter

the name of the trust or other entity thatholds the insurance contracts. In addition,attach a list of all participating employersand their EINs.

A group insurance arrangement is anarrangement which provides benefits to theemployees of two or more unaffiliatedemployers (not in connection with amultiemployer plan or a multiple-employercollectively bargained plan), fully insuresone or more welfare plans of eachparticipating employer, and uses a trust (orother entity such as a trade association) asthe holder of the insurance contracts andthe conduit for payment of premiums tothe insurance company.

1b. Enter the nine-digit employeridentification number (EIN) assigned to theplan sponsor/employer. For example,00-1234567.

Employers and plan administrators whodo not have an EIN should apply for oneon Form SS-4, Application for EmployerIdentification Number. Form SS-4 can beobtained at most IRS or Social SecurityAdministration (SSA) offices. Send FormSS-4 to the Internal Revenue ServiceCenter where you will file this Form 5500.

A plan of a controlled group ofcorporations should use the EIN of one ofthe sponsoring members. This EIN must beused in all subsequent filings of the annualreturns/reports for the controlled group.

If the plan sponsor is a group ofindividuals, get a single EIN for the group.When you apply for a number, enter online 1 of Form SS-4 the name of the group,such as Joint Board of Trustees of theLocal 187 Machinists Retirement Plan.

Note: Although EINs for funds (trusts orcustodial accounts) associated with plansare generally not required to be furnishedon the Form 5500 series returns/reports,the IRS will issue EINs for such funds forother trust reporting purposes. EINs maybe obtained by filing Form SS-4 asexplained above.

Plan sponsors should use the trust EINdescribed in the Note above when openinga bank account or conducting othertransactions for a trust that requires anEIN.

1d. From the list of business codes onpages 22 and 23, enter the one that bestdescribes the nature of the employersbusiness. If more than one employer isinvolved, enter the business code for themain business activity.

1e. Plans entering entity code A or B initem 4 must enter the first six digits of theCUSIP (Committee on Uniform SecuritiesIdentification Procedures) number, issuernumber, if one has been assigned to theplan sponsor for purposes of issuingcorporate securities. CUSIP issuernumbers are assigned to corporations andother entities that issue public securitieslisted on stock exchanges or traded overthe counter. The CUSIP issuer number isthe first six digits of the number assignedto the individual securities that are traded.If the plan sponsor has no CUSIP issuernumber, enter N/A.

2a. If the document constituting the planappoints or designates a plan administratorother than the sponsor, enter theadministrators name and address. If theplan administrator is also the sponsor,enter Same. If filing as a group insurancearrangement, enter Same. If Same isentered on 2a, leave items 2b and 2cblank.

The term administrator means

The person or group of personsspecified as the administrator by theinstrument under which the plan isoperated;

The plan sponsor/employer if an

administrator is not so designated; or Any other person prescribed byregulations of the Secretary of Labor if anadministrator is not designated and a plansponsor cannot be identified.

2b. A plan administrator must have anEIN for reporting purposes. Enter the planadministrators nine-digit EIN here. If theplan administrator does not have an EIN,apply for one as explained in 1b above.

Employees of an employer are not planadministrators unless so designated in theplan document, even though they engage


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in administrative functions of the plan. If anemployee of the employer is designated asthe plan administrator, that employee mustget an EIN.

3. If the p lan sponsors/administratorsname, address, and EIN have changedsince the last return/report was filed forthis plan, enter the plansponsors/administrators name, address,and EIN as it appeared on the lastreturn/report filed for this plan.

3c. Indicate if the change in 3a is only achange in sponsorship. Change insponsorship means the p lans sponsorhas been changed but no assets orliabilities have been transferred to anotherplan(s), the plan has not terminated ormerged with any other plan. Therefore, theplan is now the responsibility of the newsponsor whose name is entered in item 1aof this return/report.

4. Plan Entity Code.From thefollowing list of plan entities choose theone that describes your plan entity andenter that code in item 4.

Entity Code

Single-employer plan A

Plan of controlled group of corporations

or common control employers BMultiemployer plan C

Multiple-employer-collectivelybargained plan D

Multiple-employer plan (other) E

Group insurance arrangement(of welfare plans) F

5a. Enter the formal name of the plan,group insurance arrangement, or enoughinformation to identify the plan. This nameshould not exceed 70 characters. If thepresent plan name exceeds 70 charactersand spaces, try to abbreviate it.

5b. Enter the date the plan first becameeffective.

5c. Enter the three-digit number the

employer or plan administrator assigned tothe plan. All welfare benefit plan numbersand Code section 6039D plan numbersstart at 501. All other plans start at 001.

Once you use a plan number, continueto use it for that plan on all future filingswith the IRS, DOL, and PBGC. Do not useit for any other plan even if you terminatedthe first plan.

6a. Welfare Benefit Plan Codes.Check this box and enter every code fromthe list below that describes the welfarebenefit plan for which this return/report isbeing filed.

Example. If your plan provides healthinsurance, life insurance, dental insurance,

and eye examinations, the four codes A, B,D, and E should be entered. If your planhas a benefit not described by one of thecodes, enter Z and write in a descriptionof this benefit in the space provided.

Type of Welfare Plan Code

Health (other than dental or vision) A

Life insurance B

Supplemental unemployment C

Dental D

Vision E

Temporary disability (accident and sickness) F

Prepaid legal G

Long-term disability H

Severance pay I

Apprenticeship and training J

Scholarship (funded) K

Death benefits (other than life ins.) L

Taft-Hartley Financial Assistancefor Employee Housing Expenses P

Other (specify on page 1) Z

6b. Pension Benefit Plan Codes.Check this box and enter the codes fromthe list below that describe the type ofbenefits for which the Form 5500 is beingfiled.

Note: A pension plan must be either adefined benefit or a defined contributionplan.

Type of Pension Benefit Plan Code

Defined benefit 1

Defined Contribution

Profit-sharing 2

Stock bonus 3

Target Benefit 4

Other money purchase 5

Other (specify on page 1) 6

Other

Defined benefit plan with benefitsbased partly on balance of separateaccount of participant (Code section

414(k)) 7Annuity arrangement of certain

exempt organizations (Code section403(b)(1)) 8

Custodial account for regulatedinvestment company stock (Codesection 403(b)(7)) 9

Pension plan utilizing individualretirement accounts or annuities(described in Code section 408) asthe sole funding vehicle forproviding benefits 0

6c. Pension Plan Feature Codes.Enter the code(s) from the list below thatdescribes the pension plan features.

Type of Pension Plan Feature Code(see descriptions and codes below)

Employee Stock Ownership Plan (ESOP) ALeveraged ESOP B

Participant-Directed Account Plan C

Pension Plan maintained outside the USA D

Plan covering self- employed individuals E

Affiliated Service Group (Code section 414(m)(2)) F

401(k) Plan(Plan containing a cash or deferredarrangement) G

Top-Heavy plan (in 1984 or subsequent planyear) H

Plan with Permitted Disparity Provisions(SeeCode sections 401(a)(5) and 401(l) I

Master plan J

Prototype plan K

Regional Prototype plan L

If you enter code A or B, you mustcomplete Schedule E (Form 5500) and

attach it to the Form 5500 you file for thisplan.

Enter code B for a leveraged ESOP ifthe plan acquires employer securities withborrowed money or other debt-financingtechniques.

Enter code C for a pension plan thatprovides for individual accounts andpermits a participant or beneficiary toexercise independent control over theassets in his or her account (see ERISAsection 404(c)).

Enter Code D for a pension benefit planmaintained outside the United Statesprimarily for nonresident aliens. See Kindsof Filers on page 3 for more information.

Enter code F for a plan of an AffiliatedService Group. In general, Code section414(m)(2) defines an affiliated service groupas a first service organization (FSO) thathas:

1. A service organization (A-ORG) that isa shareholder or partner in the FSO andthat regularly performs services for theFSO, or is regularly associated with theFSO in performing services for thirdpersons, and/or

2. Any other organization (B-ORG) if:

a. A significant portion of the business ofthat organization consists of performingservices for the FSO or A-ORG of a typehistorically performed by employees in theservice field of the FSO or A-ORG, and

b. 10% or more of the interest of theB-ORG is held by persons who are highlycompensated employees of the FSO orA-ORG.

An affiliated service group also includesa group consisting of an organizationwhose principal business is performing

management functions for anotherorganization (or one organization and otherrelated organizations) on a regular andcontinuing basis, and the organization forwhich such functions are so performed bythe organization.

Enter Code G for a cash or deferredarrangement described under Code section401(k) that is part of a qualified definedcontribution plan that provides for anelection by employees to defer part of theircompensation or receive these amounts incash.

Enter Code H if the plan is top heavy. Atop-heavy plan is a plan that during anyplan year is:

1. Any defined benefit plan if, as of thedetermination date, the present value ofthe cumulative accrued benefits under theplan for key employees exceeds 60% ofthe present value of the cumulativeaccrued benefits under the plan for allemployees; and

2. Any defined contribution plan if, as ofthe determination date, the aggregate ofthe accounts of key employees under theplan exceeds 60% of the aggregate of theaccounts of all employees under the plan.

Each plan of an employer included in arequired aggregation group must betreated as a top-heavy plan if such groupis a top-heavy group. See definitions of

required aggregation group and top-heavygroup, below.

A key employee is any participant inan employer plan who at any time duringthe plan year, or any of the 4 precedingyears, is:

1. An officer of the employer having anannual compensation greater than 50% of$115,641, the defined benefit dollarlimitation for 1993 under Code section415(b)(1)(A),

2. One of the 10 employees havingannual compensation from the employer


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greater than $30,000, the definedcontribution dollar limitation for 1993 underCode section 415(c)(1)(A) and owning (orconsidered as owning within the meaningof Code section 318) the largest interestsin the employer,

3. A 5% owner of the employer, or

4. A 1% owner of the employer havingan annual compensation from the employerof more than $150,000.

In determining whether an individual isan officer of the employer, no more than

50 employees, or, if less, the greater of 3employees or 10% of the employees, areto be treated as officers. See Code section416(i) and T-12 of Regulations section1.416-1. A key employee will not includeany officer or employee of a governmentalplan under Code section 414(d).

A required aggregation group consistsof:

1. Each plan of the employer in which akey employee is or was a participant, and

2. Each other plan of the employer thatenables a plan to meet the requirementsfor nondiscrimination in contributions orbenefits under Code section 401(a)(4), orthe participation requirements under Code

section 410.A top-heavy group is an aggregation

group if, as of the determination date, thesum of the present value of the cumulativeaccrued benefits for key employees underall defined benefit plans included in suchgroup and the aggregate of the accountsof key employees under all definedcontribution plans in such group exceeds60% of a similar sum determined for allemployees. To determine if a plan istop-heavy, include distributions made inthe 5-year period ending on thedetermination date. However, do not takeinto account accrued benefits for anindividual who has not performed services

for the employer during the 5-year periodending on the determination date.

A qualified plan must limit the annualcompensation of each employee taken intoaccount for this year to $235,840, adjustedannually for the cost of living. The familymembers (spouse and lineal descendentsunder age 19) of 5% owners or one of the10 most highly compensated employeesare treated as a single employee. Qualifiedplans may comply with this requirement inoperation even if the plan has not yet beenamended to comply with the Tax ReformAct of 1986.

6d. Fringe Benefit Plan.Complete onlypage 1 (items 1 through 5 and 6d) and

Schedule F (Form 5500) for a Form 5500filed only because of Code section 6039D.Check this box and see page 5 foradditional instructions on Items ToComplete on Form 5500 for a fringebenefit plan.

6e. See pages 4 through 7 for definitionsand other information pertaining to mastertrusts, 103-12 investment entities,common/collective trusts and pooledseparate accounts. Also see theinstructions for items 25 through 32 forspecific reporting requirements for planswhich utilize these entities.

6e(1). In the space provided in line 6e,enter the name of the trust and financialinstitution. Also enter the city and statewhere the trust is maintained. (See MasterTrust on page 4 for more information.)

6e(2). In the space provided in line 6e,enter the name and address of the 103-12IE. (See page 7 for 103-12 IE instructions.)

6f. For single-employer pension plans,enter the date the employers tax yearends. For example, if the tax year is acalendar year, enter 12-31-93. Do notcomplete 6f for plans with more than oneemployer.

6g and 6h. A defined benefit plan isgenerally subject to the minimum fundingrequirements under section 412 unless it isa fully insured plan that is exempt from theminimum funding requirements undersection 412(i). A plan is considered a 412(i)plan whether or not all or part of the planis trusteed or a noninsured top-heavy sidefund is maintained. All such plans mustcheck their 412(i) status in item 6g. Checkbox 6h if any part of the plan that wasformerly subject to the minimum fundingrequirements under section 412 for eitherof the prior two plan years has becomeexempt under section 412(i).

Note: All defined benefit plans subject tothe minimum funding requirements underSection 412 must complete item 15a andattach Schedule B (Form 5500). Alsocomplete item 15a and attach Schedule B(Form 5500) for all 412(i) plans where allpremiums for the plan year required undersection 412(i) have not been paid beforethe lapse of any insurance contract underthe plan and/or where a noninsuredtop-heavy side fund is maintained.

7. The description of participant in theinstructions below is only for purposes ofitem 7 of this form.

For welfare plans, the number ofparticipants should be determined byreference to 29 CFR 2510.3-3(d).Dependents are considered to be neitherparticipants nor beneficiaries. For pensionbenefit plans, alternate payees entitled tobenefits under a qualified domesticrelations order are not to be counted asparticipants for this item.

Participant means any individual whois included in one of the categories below.

7a. Active participants include anyindividuals who are currently inemployment covered by a plan and whoare earning or retaining credited serviceunder a plan. This category includes anyindividuals who are: (1) currently below thepermitted disparity level in a plan that isintegrated with social security, and/or(2) eligible to elect to have the employermake payments to a Code section 401(k)qualified cash or deferred arrangement.Active participants also include anynonvested individuals who are earning orretaining credited service under a plan.This category does not include nonvestedformer employees who have incurred thebreak in service period specified in theplan.

For determining if active participants arefully vested, partially vested, or nonvested,

consider vesting in employer contributionsonly.

7b. Inactive participants receivingbenefits are any individuals who are retiredor separated from employment covered bythe plan and who are receiving benefitsunder the plan. This includes formeremployees who are receiving group healthcontinuation coverage benefits pursuant toPart 6 of ERISA who are covered by theemployee welfare benefit plan. Thiscategory does not include any individual towhom an insurance company has made an

irrevocable commitment to pay all thebenefits to which the individual is entitledunder the plan.

7c. Inactive participants entitled to futurebenefits are individuals who are retired orseparated from employment covered bythe plan and who are entitled to beginreceiving benefits under the plan in thefuture. This category does not include anyindividual to whom an insurance companyhas made an irrevocable commitment topay all the benefits to which the individualis entitled under the plan.

7e. Deceased participants are anydeceased individuals who had one or morebeneficiaries who are receiving or are

entitled to receive benefits under the plan.This category does not include anindividual if an insurance company hasmade an irrevocable commitment to pay allthe benefits to which the beneficiaries ofthat individual are entitled under the plan.

7g. Enter the number of participantsincluded in line 7f who have accountbalances at the end of the plan year. Forexample, for a Code section 401(k) plan,the number entered on line 7g should bethe number of participants counted in line7f who have made a contribution to theplan during this plan year or any prior planyear.

7h. Include any participant who

terminated employment during this planyear, whether or not the participantincurred a break in service. Multiemployerplans and multiple-employer-collectivelybargained plans need not complete 7h.

7i(1). If Yes, file Schedule SSA (Form5500) as an attachment to Form 5500.Plan administrators: Code section 6057(e)provides that the plan administrator mustgive each participant a statement showingthe same information reported on ScheduleSSA for that participant.

8a. Check Yes if an amendment to theplan was adopted regardless of theeffective date of the amendment.

8b. Enter the date the most recentamendment was adopted regardless of thedate of the amendment or the effectivedate of the amendment.

8c. Check Yes only if the accruedbenefits were retroactively reduced. Forexample, a plan provides a benefit of 2%for each year of service, but the plan isamended to change the benefit to 112% ayear for all years of service under the plan.Do not check Yes if accrued benefitswere retroactively reduced solely to theextent permitted under a model


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amendment provided in IRS Notice 88-131,1988-2 C.B. 546.

8d. Check Yes only if an amendmentchanged the information previouslyprovided to participants by the summaryplan description or summary description ofmodifications.

8e. A revised summary plan descriptionor summary description of modificationsmust be filed with the DOL and distributedto all participants and pension planbeneficiaries no later than 210 days afterthe close of the plan year in which theamendment(s) was adopted. If the materialwas distributed and filed since theamendments were adopted (even if afterthe end of the plan year), check Yes toitem 8e.

9a. Check Yes if the plan wasterminated and enter the year oftermination if applicable.

9b. If the plan was terminated but allplan assets were not distributed, areturn/report must be filed for each yearthe plan has assets. In that case, thereturn/report must be filed by the planadministrator, if designated, or by theperson or persons who actually control theplans property.

If all plan assets were used to buyindividual annuity contracts and thecontracts were distributed to theparticipants, check Yes.

If all the plan assets were legallytransferred to the control of another planor brought under the control of PBGC,check Yes.

Do not check Yes for a welfare benefitplan that is still liable to pay benefits forclaims that were incurred prior to thetermination date, but not yet paid. See 29CFR 2520.104b-2(g)(2)(ii).

9h. The Code provides for anondeductible excise tax on a reversion of

assets from a qualified plan.9i. The employer must report the

reversion by filing Form 5330 and pay anyapplicable tax. The tax will not be imposedon employers who are tax-exempt entitiesunder Code section 501(a). See theinstructions for Form 5330.

10a. If this plan was merged orconsolidated into another plan(s), or planassets or liabilities were transferred toanother plan(s), indicate which other planor plans were involved.

10c. Enter the EIN of the sponsor(employer, if for a single-employer plan) ofthe other plan.

10e. Pension benefit plans must fileForm 5310-A, Notice of Merger,Consolidation, or Transfer of Plan Assetsor Liabilities, at least 30 days before anyplan merger or consolidation or anytransfer of plan assets or liabilities toanother plan.

Caution: There is a penalty for not filingForm 5310-A on time.

11. Funding Arrangement.Enter thecode for the funding arrangement used bythe plan for the plan year from the listbelow.

The funding arrangement is themethod used during the plan year for thereceipt, holding, investment, andtransmittal of plan assets prior to the timethe plan actually provides the benefitspromised under the plan. For purposes ofitems 11 and 12, the term trust includesany fund or account which receives, holds,transmits, or invests plan assets other thanan account or policy of an insurancecompany.

Note: An employee benefit plan that enterscode 2, 3, or 5 in item 11 and/or 12 must

attach aSchedule A (Form 5500),Insurance Information, to provideinformation pertaining to each contractyear ending with or within the plan year.See the instructions for Schedule A (Form5500). A plan attaching a Schedule A mayor may not be exempt from therequirement to engage an independentqualified public accountant. See theinstructions for item 26 on page 15.

Plan FundingArrangement

Codes

Trust 1

Trust and insurance 2

Insurance 3

Exclusively from general assetsof sponsor (unfunded) 4

Partially insured and partiallyfrom general assets of sponsor 5

Other 6

12. Benefit Arrangement.Enter thecode for the benefit arrangement used bythe plan for the plan year from the listbelow.

The benefit arrangement is the methodby which benefits were actually providedduring the plan year to participants by theplan. For example, if all participantsreceived their benefits from a trust (asdefined in 11 above) the plans benefitarrangement code would be 1. If somebenefits come from a trust and some come

from an insurance company, the codewould be 2. If all benefits were paid froman account or policy of an insurancecompany, the code would be 3.

Plan BenefitArrangement

Codes

Trust 1

Trust and insurance 2

Insurance 3

Exclusively from general assetsof sponsor (unfunded) 4

Partially insured and partiallyfrom general assets of sponsor 5

Other 6

13a. Check Yes if either the

contributions to the plan or the benefitspaid by the plan are subject to thecollective bargaining process, even if theplan is not established and administeredby a joint board of trustees. Check Yeseven if only some of those covered by theplan are members of a collectivebargaining unit that negotiates benefitlevels on its own behalf. The benefitschedules do not have to be identical forall employees under the plan.

13b. All plans that entered code C or Don line 4 must enter the six-digit LMnumber to identify each sponsoring labor

organization that is a party to the collectivebargaining agreement. Other plans that aremaintained pursuant to collectivebargaining agreements should enter theappropriate LM number, if available. TheLM number is the six-digitLabor-Management file number entered bythe sponsoring labor organization in item 1of the Form LM-2 or LM-3 (LaborOrganization Annual Report) filed with theDepartment of Labor. Accordingly, the LMnumber(s) should be readily available fromthe sponsoring labor organization(s). If all

sponsoring labor organizations LMnumbers cannot be entered in the spacesprovided in item 13b on the form, enter theadditional LM numbers on a supplementalsheet to accompany the Form 5500.

14. If either the funding arrangementcode (item 11) and/or the benefitarrangement code (item 12) is 2, 3, or 5, atleast one Schedule A (Form 5500) must beattached to the Form 5500 filed forpension and welfare plans to provideinformation concerning the contract yearending with or within the plan year. Theinsurance company (or similar organization)that provides benefits is required toprovide the plan administrator with theinformation needed to complete thereturn/report, pursuant to ERISA section103(a)(2). If you do not receive thisinformation in a timely manner, contact theinsurance company (or similarorganization). If information is missing onSchedule A (Form 5500) due to a refusal toprovide this information, note this on theSchedule A. If there is no Schedule(s) Aattached, enter 0.

15a. If Yes is checked for line 15a,attach Schedule B (Form 5500) and theschedule on page 12 to the Form 5500.This schedule, prepared by the enrolledactuary who prepared the Schedule B,should show the distribution of activeparticipants by age and service groupings

with average compensation data. Theschedule must be clearly labeled Item15aSchedule of Active ParticipantData.

The schedule should be provided on thesame size paper as the Form 5500 anduse the above or a similar format. Expandthis schedule by adding columns after the5 to 9 column and before the 40 & upcolumn for active participants with totalyears of credited service in the followingranges: 10 to 14; 15 to 19; 20 to 24; 25 to29; 30 to 34; and 35 to 39. For eachcolumn, enter the number of activeparticipants with the specified number ofyears of credited service divided according

to age group. For participants with partialyears of credited service, round the totalnumber of years of credited service to thenext lower whole number.

For each grouping, enter the averagecompensation of the active participants inthat group. For this purpose, compensationis the compensation taken into account foreach participant under the plans benefitformula, limited to the amount definedunder section 401(a)(17) of the Code.Years of credited service are the yearscredited under the plans benefit formula.


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Exception: Do not enter the averagecompensation in any grouping thatcontains fewer than 20 participants. Forexample, if there are 19 participants thathave attained ages 30 to 34 and earned 5to 9 years of credited service, only enterthe number of participants in that groupingand do not enter the averagecompensation.

15b. If a waived funding deficiency isbeing amortized in the current plan year,do not complete (1), (2), and (3), butcomplete items 1, 2, 3, 7, and 9 ofSchedule B (Form 5500). An enrolledactuary does not have to sign Schedule Bunder these circumstances.

15b(3). File Form 5330 with the IRS topay the excise tax on any fundingdeficiency. Caution: There is a penalty fornot filing Form 5330 on time.

17a(1). Check Yes if the plandistributed any annuity contracts. Check

Yes even if the plan was terminated.17a(2). If Yes was checked for item

17a(1), the annuity contract must providethat all distributions from it will meet theparticipant and spousal consentrequirements of Code section 417.However, consent is not needed for thedistribution of the contract itself. If thecontracts contained the Code section 417requirements, check Yes.

17b. In general, distributions must bemade in the form of a qualified joint andsurvivor annuity for life or a qualifiedpreretirement survivor annuity. A qualifiedjoint and survivor annuity for a participantwho is not married is an annuity for the life

of the participant. Check Yes ifdistributions in other forms were made,even if those distributions were permissible(e.g., because consent was obtained orwas not required).

17c. Generally, within the 90 days priorto the date of any benefit payment or thedate a loan was made to a participant, youmust get the spouses consent to thepayment of the benefit or the use of theaccrued benefit to make the loan.However, there are some circumstanceswhere obtaining this spousal consent is notrequired. The following is a partial list of

circumstances when spousal consent isnot required:

1. The participant is not married and noformer spouse is required to be treated asa current spouse under a qualifieddomestic relations order issued by a court.

2. The participants nonforfeitableaccrued benefit in the plan does not havea present value of more than $3,500 at thetime of distribution.

3. The benefit is paid in the form of aqualified joint and survivor annuity (i.e., anannuity for the life of the participant with asurvivor annuity for the life of the spousethat is not less than 50% of, and is notgreater than 100% of, the amount of theannuity that is payable during the joint livesof the participant and the spouse). SeeCode section 417(b).

4. The payout is from a profit-sharing orstock bonus plan that pays the spouse theparticipants full account balance upon the

participants death, an annuity payment isnot elected by the participant, and theprofit-sharing or stock bonus plan is not atransferee plan with respect to theparticipant (i.e., had not received a transferfrom a plan that was subject to theconsent requirements with respect to theparticipant).

5. The participant had no service underthe plan after August 22, 1984.

17d. A plan may not eliminate asubsidized benefit or a retirement optionby plan amendment or plan termination.

18. If distributions were not made inaccordance with the joint and survivorannuity rules of Code sections 411(a)(11)

and 417(e), answer No. If distributionsdid comply with Code sections 411(a)(11)and 417(e), answer Yes. If nodistributions were made, enter N/A.

19. The maximum annual benefit thatmay be provided under a defined benefitplan may not exceed the lesser of$115,641 or 100% of average annualcompensation. However, if benefits beginbefore the social security retirement age,the $115,641 limit must be reduced asdescribed

us internal revenue service: i5500--1993

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