Form 5500-Sf Sample - Short Form Annual Return/report Of Small Employee Benefit Plan - 2016 Page 3

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Form 5500-SF 2016

Page

Part VI

Pension Funding Compliance

Is this a defined benefit plan subject to minimum funding requirements? (If "Yes," see instructions and complete Schedule SB

Yes

(Form 5500) and line 11a below) .............................................................................................................................................................

11a

Enter the unpaid minimum required contributions for all years from Schedule SB (Form 5500) line 40 ..........................................

11a

Is this a defined contribution plan subject to the minimum funding requirements of section 412 of the Code or section 302 of

Yes

ERISA? ...................................................................................................................................................................................................

(If "Yes," complete line 12a or lines 12b, 12c, 12d, and 12e below, as applicable.)

If a waiver of the minimum funding standard for a prior year is being amortized in this plan year, see instructions, and enter the date of the letter ruling

granting the waiver. ............................................................................................................................. Month _______

Day _______

Year ________

If you completed line 12a, complete lines 3, 9, and 10 of Schedule MB (Form 5500), and skip to line 13.

123456789012345

Enter the minimum required contribution for this plan year ............................................................................................. 12b

-123456789012345

Enter the amount contributed by the employer to the plan for this plan year ................................................................... 12c

Subtract the amount in line 12c from the amount in line 12b. Enter the result (enter a minus sign to the left of a

YYYY-MM-DD

12d

negative amount) ..........................................................................................................................................................

Yes

N/A

Will the minimum funding amount reported on line 12d be met by the funding deadline? ......................................................

Part VII

Plan Terminations and Transfers of Assets

13a

Yes

Has a resolution to terminate the plan been adopted in any plan year? ......................................................................................................................................

If “Yes,” enter the amount of any plan assets that reverted to the employer this year ..........................................................................................................

13a

Were all the plan assets distributed to participants or beneficiaries, transferred to another plan, or brought under the

Yes

control of the PBGC? .................................................................................................................................................................

If, during this plan year, any assets or liabilities were transferred from this plan to another plan(s), identify the plan(s) to

which assets or liabilities were transferred. (See instructions.)

13c(1) Name of plan(s):

13c(2) EIN(s)

13c(3) PN(s)

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

123456789

012

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

Part VIII

Trust Information

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

14b

Trust’s EIN

14a

Name of trust

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

14c

14d

Trustee’s or custodian’s

Name of trustee or custodian

telephone number

Part IX

IRS Compliance Questions

Yes

15a

Is the plan a 401(k) plan? If “No,” skip b.......................................................................................................................................................

“Prior year” ADP

Design-based

15b

How did the plan satisfy the nondiscrimination requirements for employee deferrals under section

safe harbor

test

401(k)(3) for the plan year? Check all that apply: .......................................................................................................................................

“Current year”

N/A

ADP test

16a

What testing method was used to satisfy the coverage requirements under section 410(b) for the plan

Ratio

Average

year? Check all that apply: .........................................................................................................................................................................

percentage

N/A

benefit test

test

16b

Did the plan satisfy the coverage and nondiscrimination requirements of sections 410(b) and 401(a)(4)

Yes

for the plan year by combining this plan with any other plan under the permissive aggregation rules? ............................................

17a

If the plan is a master and prototype plan (M&P) or volume submitter plan that received a favorable IRS opinion letter or advisory letter, enter the date of

the letter _______/_______/_______ and the serial number ________________.

17b

If the plan is an individually-designed plan that received a favorable determination letter from the IRS, enter the date of the most recent determination

letter ______/_______/_______.

Defined Benefit Plan or Money Purchase Pension Plan Only:

Yes

Were any distributions made during the plan year to an employee who attained age 62 and had not separated from

service? ………………………………………………………………………………………………….....................

Yes

Was any plan participant a 5% owner who had attained at least age 70 ½ during the prior plan year? ........................................................