Form 5500-Sf - Short Form Annual Return/report Of Small Employee Benefit Plan - 2015 Page 3

ADVERTISEMENT

3 -
1 x
Form 5500-SF 2015
Page
(If "Yes," complete line 12a or lines 12b, 12c, 12d, and 12e below, as applicable.)
a
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.
Enter the minimum required contribution for this plan year ................................................................................................ 12b
123456789012345
b
Enter the amount contributed by the employer to the plan for this plan year ...................................................................... 12c
-123456789012345
c
d
Subtract the amount in line 12c from the amount in line 12b. Enter the result (enter a minus sign to the left of a
12d
YYYY-MM-DD
negative amount) ...............................................................................................................................................................
e
X
X
X
Yes
No
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
X
X
Yes
No
Has a resolution to terminate the plan been adopted in any plan year? ....................................................................................
X
If “Yes,” enter the amount of any plan assets that reverted to the employer this year ....................................................... 13a
b
Were all the plan assets distributed to participants or beneficiaries, transferred to another plan, or brought under the control
X
X
Yes
No
X
of the PBGC? ..................................................................................................................................................................................
c
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
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
Part VIII
Trust Information
14a
14b
Name of trust
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
Trust’s EIN
ORTHOPAEDIC & SPORTS ASSOCIATES OF LONG ISLAND PC 401K PROFIT SHARING PLAN
11-3469628
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
14c
14d
Name of trustee or custodian
Trustee’s or custodian’s
JOHN LEPPARD
telephone number
(516)364-0070
Part IX
IRS Compliance Questions
Yes
X
15a
No
Is the plan a 401(k) plan? ....................................................................................................................................................
Design-
15b
X
X
based safe
ADP/ACP
If “Yes,” how does the 401(k) plan satisfy the nondiscrimination requirements for employee deferrals and employer
harbor
matching contributions (as applicable) under sections 401(k)(3) and 401(m)(2)? ...............................................................
test
method
15c
If the ADP/ACP test is used, did the 401(k) plan perform ADP/ACP testing for the plan year using the "current year
Yes
X
No
testing method" for nonhighly compensated employees (Treas. Reg sections 1.401(k)-2(a)(2)(ii) and 1.401(m)-
2(a)(2)(ii))? ...........................................................................................................................................................................
Ratio
X
X
Average
16a
percentage
Check the box to indicate the method used by the plan to satisfy the coverage requirements under section 410(b): ........
benefit test
test
16b
Does the plan satisfy the coverage and nondiscrimination tests of sections 410(b) and 401(a)(4) by combining
X
X
Yes
No
this plan with any other plans under the permissive aggregation rules? .............................................................................
17a
X
X
X
Yes
No
N/A
Has the plan been timely amended for all required tax law changes? .................................................................................
17b
Date the last plan amendment/restatement for the required tax law changes was adopted____/____/____. Enter the applicable code ____ (See instructions
for tax law changes and codes).
17c
If the plan sponsor is an adopter of a pre-approved master and prototype (M&P) or volume submitter plan that is subject to a favorable IRS opinion or
advisory letter, enter the date of that favorable letter _______/_______/_______ and the letter’s serial number ________________.
17d
If the plan is an individually-designed plan and received a favorable determination letter from the IRS, enter the date of the plan’s last favorable
determination letter ______/_______/_______.
18
Is the Plan maintained in a U.S. territory (i.e., Puerto Rico (if no election under ERISA section 1022(i)(2) has been
X
X
Yes
No
made), American Samoa, Guam, the Commonwealth of the Northern Mariana Islands or the U.S. Virgin Islands)? .........
19
X
X
Yes
No
Were in-service distributions made during the plan year? ...................................................................................................
If “Yes,” enter amount .......................................................................................................................................................... 19
20
Were required minimum distributions made to 5% owners who have attained age 70 ½ (regardless of whether or not
X
X
X
Yes
No
N/A
retired), as required under section 401(a)(9)? .....................................................................................................................

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Financial
Go
Page of 3