Form 5500-Sf - Short Form Annual Return/report Of Small Employee Benefit Plan - 2011 Page 2
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22 -
1 x
Form 5500-SF 2011
Page
1
Part IV
Plan Characteristics
9a
If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristic Codes in the instructions:
2A
2E
2F
2G
2J
2K
2T
3B
3D
b
If the plan provides welfare benefits, enter the applicable welfare feature codes from the List of Plan Characteristic Codes in the instructions:
Part V
Compliance Questions
10
Yes
No
During the plan year:
Amount
a
Was there a failure to transmit to the plan any participant contributions within the time period described in
X
-123456789012345
29 CFR 2510.3-102? (See instructions and DOL’s Voluntary Fiduciary Correction Program) ..............
10a
b
Were there any nonexempt transactions with any party-in-interest? (Do not include transactions reported
X
-123456789012345
on line 10a.) .............................................................................................................................................
10b
X
c
10c
Was the plan covered by a fidelity bond? ...............................................................................................
400000
-123456789012345
d
Did the plan have a loss, whether or not reimbursed by the plan’s fidelity bond, that was caused by fraud
X
-123456789012345
or dishonesty? .........................................................................................................................................
10d
e
Were any fees or commissions paid to any brokers, agents, or other persons by an insurance carrier,
insurance service or other organization that provides some or all of the benefits under the plan? (See
X
-123456789012345
instructions.) ............................................................................................................................................
10e
X
f
Has the plan failed to provide any benefit when due under the plan? ....................................................
-123456789012345
10f
X
g
Did the plan have any participant loans? (If “Yes,” enter amount as of year end.) ..................................
-123456789012345
10g
h
If this is an individual account plan, was there a blackout period? (See instructions and 29 CFR
X
2520.101-3.) ............................................................................................................................................
10h
i
If 10h was answered “Yes,” check the box if you either provided the required notice or one of the
exceptions to providing the notice applied under 29 CFR 2520.101-3 ....................................................
10i
Part VI
Pension Funding Compliance
11
Is this a defined benefit plan subject to minimum funding requirements? (If "Yes," see instructions and complete Schedule SB (Form
X
X
Yes
No
5500)) ...........................................................................................................................................................................................................
X
X
12
Yes
X
No
Is this a defined contribution plan subject to the minimum funding requirements of section 412 of the Code or section 302 of ERISA? ..
(If "Yes," complete 12a or 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.
12b
-123456789012345
b
Enter the minimum required contribution for this plan year..........................................................................................
12c
-123456789012345
c
Enter the amount contributed by the employer to the plan for this plan year ...............................................................
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
Yes
X
No
X
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
X
13a
X
X
Yes
No
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
b
Were all the plan assets distributed to participants or beneficiaries, transferred to another plan, or brought under the control
X
X
X
Yes
No
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
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.
Filed with authorized/valid electronic signature.
07/19/2012
SHERI ELIAS O'GORMAN
YYYY-MM-DD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
SIGN
HERE
Signature of plan administrator
Date
Enter name of individual signing as plan administrator
YYYY-MM-DD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
SIGN
HERE
Signature of employer/plan sponsor
Date
Enter name of individual signing as employer or plan sponsor
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