Form 5500-Sf Sample - Short Form Annual Return/report Of Small Employee Benefit Plan - 2016

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OMB Nos. 1210-0110

Form 5500-SF

Short Form Annual Return/Report of Small Employee

1210-0089

Benefit Plan

Department of the Treasury

2016

Internal Revenue Service

This form is required to be filed under sections 104 and 4065 of the Employee Retirement

Income Security Act of 1974 (ERISA), and sections 6057(b) and 6058(a) of the Internal

Department of Labor

This Form is Open to

Employee Benefits Security Administration

Revenue Code (the Code).

Public Inspection

Pension Benefit Guaranty Corporation

 Complete all entries in accordance with the instructions to the Form 5500-SF.

Part I

Annual Report Identification Information

For calendar plan year 2016 or fiscal plan year beginning

and ending

a single-employer plan

a multiple-employer plan (not multiemployer) (Filers checking this box must attach a

list of participating employer information in accordance with the form instructions.)

This return/report is for:

a one-participant plan

a foreign plan

the first return/report

the final return/report

This return/report is

an amended return/report

a short plan year return/report (less than 12 months)

Check box if filing under:

Form 5558

automatic extension

DFVC program

special extension (enter description)

Part II

Basic Plan Information

—enter all requested information

Name of plan

Three-digit

plan number



(PN)

Effective date of plan

Plan sponsor’s name (employer, if for a single-employer plan)

Employer Identification Number

Mailing address (include room, apt., suite no. and street, or P.O. Box)

(EIN)

City or town, state or province, country, and ZIP or foreign postal code (if foreign, see instructions)

2c S

ponsor’s telephone number

Business code (see instructions)

Plan administrator’s name and address

Administrator’s EIN

Same as Plan Sponsor.

Administrator’s telephone number

If the name and/or EIN of the plan sponsor has changed since the last return/report filed for this plan, enter the

EIN

name, EIN, and the plan number from the last return/report.

Sponsor’s name

Total number of participants at the beginning of the plan year ................................................................................

Total number of participants at the end of the plan year .........................................................................................

Number of participants with account balances as of the end of the plan year (only defined contribution plans

complete this item) .................................................................................................................................................

5d(1)

d(1)

Total number of active participants at the beginning of the plan year ..................................................................

5d(2)

d(2)

Total number of active participants at the end of the plan year ...........................................................................

Number of participants that terminated employment during the plan year with accrued benefits that were less

than 100% vested .................................................................................................................................................

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, if applicable, a Schedule

SB or Schedule MB completed and signed by an enrolled actuary, 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

HERE

Signature of plan administrator

Date

Enter name of individual signing as plan administrator

SIGN

HERE

Signature of employer/plan sponsor

Date

Enter name of individual signing as employer or plan sponsor

Preparer’s name (including firm name, if applicable) and address (include room or suite number )