Form 5330 - Return Of Excise Taxes Related To Employee Benefit Plans Page 4

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4
Form 5330 (Rev. 10-2003)
Page
DUE DATE: See When To File on page 1 of the instructions for taxes due under sections 4971, 4977, 4979, 4980, 4971(f), and 4980F.
Tax on Failure To Meet Minimum Funding Standards (Section 4971)
Part X
30
Accumulated funding deficiency in the plan’s minimum funding standard account (see page 6 of the
instructions)
31
Multiply line 30 by tax rate (see instructions on page 6 for applicable tax rates). Enter here and on
line 7
Part XI
Tax on Excess Fringe Benefits (Section 4977)
Yes
No
32a
Did you make an election to be taxed under section 4977?
b
If “Yes,” enter the calendar year in which the excess fringe benefits were paid
c
If line 32a is “Yes,” enter the excess fringe benefits on this line (see page 7 of the instructions)
d
Enter 30% of line 32c on this line and on line 8
Tax on Excess Contributions to Certain Plans (Section 4979)
Part XII
33a Enter the amount of any excess contributions under a cash or deferred arrangement that is part of
a plan qualified under section 401(a), 403(a), 403(b), 408(k), 501(c)(18) or excess aggregate
contributions described in section 401(m)
b
Multiply line 33a by 10%. Enter here and on line 9
Part XIII
Tax on Reversion of Qualified Plan Assets to an Employer (Section 4980) (See page 8 of instructions)
34
Date reversion occurred
month
day
year
35a
Employer reversion amount
b
Excise tax rate
%
36
Multiply line 35a by line 35b and enter the amount here and on line 10a
37
Explain below why you qualify for a rate other than 50%:
Tax on Failure to Provide Notice of Significant Reduction in Future Accruals (Section 4980F)
Part XIV
38
Enter the number of applicable individuals who were not provided ERISA section 204(h) notice
39
Enter the effective date of the amendment
40
Enter the number of days in the noncompliance period
41
Enter the total number of failures to provide ERISA section 204(h) notice (see page 7 of the
instructions)
42
Provide a brief description of the failure, and of the correction made, if any
43
Multiply line 41 by $100. Enter here and on line 10b
Part XV
Tax on Failure to Correct Liquidity Shortfall (Section 4971(f))
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
Total
44
Amount of shortfall
45
Amount corrected
46
Net shortfall amount
47
Multiply line 46 (total column) by 10%. Enter here and on line 11

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