Form 5500 - Annual Return/report Of Employee Benefit Plan - 2013
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1
2Annual Return/Report of Employee Benefit Plan
OMB Nos. 1210-0110
Form 5500
1210-0089
This form is required to be filed for employee benefit plans under sections 104
and 4065 of the Employee Retirement Income Security Act of 1974 (ERISA) and
Department of the Treasury
2013
Internal Revenue Service
sections 6047(e), 6057(b), and 6058(a) of the Internal Revenue Code (the Code).
Department of Labor
Complete all entries in accordance with
Employee Benefits Security
Administration
the instructions to the Form 5500.
This Form is Open to Public
Pension Benefit Guaranty Corporation
Inspection
Part I
Annual Report Identification Information
For calendar plan year 2013 or fiscal plan year beginning
and ending
a multiemployer plan;
a multiple-employer plan; or
This return/report is for:
X
X
A
a single-employer plan;
a DFE (specify)
X
X
_C_
the first return/report;
the final return/report;
This return/report is:
X
X
B
an amended return/report;
a short plan year return/report (less than 12 months).
X
X
If the plan is a collectively-bargained plan, check here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C
X
Form 5558;
automatic extension;
the DFVC program;
Check box if filing under:
D
X
X
X
special extension (enter description)
X
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
—enter all requested information
Part II
Basic Plan Information
Name of plan
Three-digit plan
1a
1b
number (PN)
001
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
Effective date of plan
1c
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
YYYY-MM-DD
Plan sponsor’s name and address; include room or suite number (employer, if for a single-employer plan)
Employer Identification
2a
2b
Number (EIN)
012345678
Sponsor’s telephone
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
2c
number
D/B/A ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
0123456789
ABCDEFGHI
Business code (see
2d
c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
instructions)
123456789 ABCDEFGHI ABCDEFGHI ABCDE
012345
123456789 ABCDEFGHI ABCDEFGHI ABCDE
CITYEFGHI ABCDEFGHI AB, ST 012345678901
UK
Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established.
Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return/report, including accompanying schedules,
statements and attachments, as well as the electronic version of this return/report, and to the best of my knowledge and belief, it is true, correct, and complete.
SIGN
YYYY-MM-DD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
HERE
Date
Enter name of individual signing as plan administrator
Signature of plan administrator
SIGN
YYYY-MM-DD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
HERE
Date
Enter name of individual signing as employer or plan sponsor
Signature of employer/plan sponsor
SIGN
YYYY-MM-DD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
HERE
Date
Enter name of individual signing as DFE
Signature of DFE
Preparer’s name (including firm name, if applicable) and address; include room or suite number. (optional)
Preparer’s telephone number
(optional)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500.
Form 5500 (2013)
v. 130118
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