Form 5500 - Annual Return/report Of Employee Benefit Plan - 2013 Page 2
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1
2Form 5500 (2013)
Page
2
Administrator’s EIN
Plan administrator’s name and address
Same as Plan Sponsor Name
Same as Plan Sponsor Address
3a
3b
X
X
012345678
Administrator’s telephone
3c
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
number
c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
0123456789
123456789 ABCDEFGHI ABCDEFGHI ABCDE
123456789 ABCDEFGHI ABCDEFGHI ABCDE
CITYEFGHI ABCDEFGHI AB, ST 012345678901
UK
If the name and/or EIN of the plan sponsor has changed since the last return/report filed for this plan, enter the name,
EIN
4
4b
EIN and the plan number from the last return/report:
012345678
Sponsor’s name
PN
a
4c
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
012
Total number of participants at the beginning of the plan year
5
5
123456789012
Number of participants as of the end of the plan year (welfare plans complete only lines 6a, 6b, 6c, and 6d).
6
Active participants ................................................................................................................................................................
a
6a
123456789012
Retired or separated participants receiving benefits .............................................................................................................
b
6b
123456789012
Other retired or separated participants entitled to future benefits ..........................................................................................
c
6c
123456789012
Subtotal. Add lines 6a, 6b, and 6c.......................................................................................................................................
d
6d
123456789012
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits. ................................................
e
6e
123456789012
Total. Add lines 6d and 6e. .................................................................................................................................................
f
6f
123456789012
Number of participants with account balances as of the end of the plan year (only defined contribution plans
g
complete this item) ...............................................................................................................................................................
6g
123456789012
Number of participants that terminated employment during the plan year with accrued benefits that were
h
less than 100% vested .........................................................................................................................................................
6h
123456789012
Enter the total number of employers obligated to contribute to the plan (only multiemployer plans complete this item).........
7
7
If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristics Codes in the instructions:
8a
If the plan provides welfare benefits, enter the applicable welfare feature codes from the List of Plan Characteristics Codes in the instructions:
b
Plan funding arrangement (check all that apply)
Plan benefit arrangement (check all that apply)
9a
9b
Insurance
Insurance
X
X
(1)
(1)
Code section 412(e)(3) insurance contracts
Code section 412(e)(3) insurance contracts
X
X
(2)
(2)
Trust
Trust
X
X
(3)
(3)
General assets of the sponsor
General assets of the sponsor
X
X
(4)
(4)
Check all applicable boxes in 10a and 10b to indicate which schedules are attached, and, where indicated, enter the number attached. (See instructions)
10
a
b
Pension Schedules
General Schedules
R (Retirement Plan Information)
X
(1)
H (Financial Information)
(1)
X
MB (Multiemployer Defined Benefit Plan and Certain Money
I (Financial Information – Small Plan)
X
X
(2)
(2)
Purchase Plan Actuarial Information) - signed by the plan
___ A (Insurance Information)
X
(3)
actuary
C (Service Provider Information)
X
(4)
D (DFE/Participating Plan Information)
SB (Single-Employer Defined Benefit Plan Actuarial
X
(5)
X
(3)
Information) - signed by the plan actuary
G (Financial Transaction Schedules)
X
(6)
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