Form 5500-Sf - Short Form Annual Return/report Of Small Employee Benefit Plan - 2014 Page 2
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1
2
32
Form 5500-SF 2014
Page
6a
X
X
Yes
No
Were all of the plan’s assets during the plan year invested in eligible assets? (See instructions.) ..........................................................
b
Are you claiming a waiver of the annual examination and report of an independent qualified public accountant (IQPA)
X
X
Yes
No
under 29 CFR 2520.104-46? (See instructions on waiver eligibility and conditions.) ................................................................................
If you answered “No” to either line 6a or line 6b, the plan cannot use Form 5500-SF and must instead use Form 5500.
c
X
X
X
If the plan is a defined benefit plan, is it covered under the PBGC insurance program (see ERISA section 4021)? ......
Yes
No
Not determined
Part III
Financial Information
7
Plan Assets and Liabilities
(a) Beginning of Year
(b) End of Year
a
-123456789012345
-123456789012345
Total plan assets ...............................................................................
7a
b
-123456789012345
123456789012345
Total plan liabilities ............................................................................
7b
c
-123456789012345
-123456789012345
Net plan assets (subtract line 7b from line 7a) ..................................
7c
8
Income, Expenses, and Transfers for this Plan Year
(a) Amount
(b) Total
a
Contributions received or receivable from:
-123456789012345
(1) Employers ..................................................................................
8a(1)
-123456789012345
(2) Participants.................................................................................
8a(2)
-123456789012345
(3) Others (including rollovers) .........................................................
8a(3)
b
-123456789012345
Other income (loss) ...........................................................................
8b
c
-123456789012345
Total income (add lines 8a(1), 8a(2), 8a(3), and 8b) .........................
8c
d
Benefits paid (including direct rollovers and insurance premiums
-123456789012345
to provide benefits) ............................................................................
8d
e
-123456789012345
Certain deemed and/or corrective distributions (see instructions) ....
8e
f
-123456789012345
Administrative service providers (salaries, fees, commissions) ........
8f
g
-123456789012345
Other expenses .................................................................................
8g
h
-123456789012345
Total expenses (add lines 8d, 8e, 8f, and 8g) ...................................
8h
i
-123456789012345
Net income (loss) (subtract line 8h from line 8c) ...............................
8i
j
Transfers to (from) the plan (see instructions) ..................................
-123456789012345
8j
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:
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
-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
-123456789012345
on line 10a.) .............................................................................................................................................
10b
c
Was the plan covered by a fidelity bond? ...............................................................................................
-123456789012345
10c
d
Did the plan have a loss, whether or not reimbursed by the plan’s fidelity bond, that was caused by fraud
-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
-123456789012345
instructions.) ............................................................................................................................................
10e
f
Has the plan failed to provide any benefit when due under the plan? ....................................................
-123456789012345
10f
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
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) and line 11a below) ............................................................................................................................................................................
11a
Enter the unpaid minimum required contribution for current year from Schedule SB (Form 5500) line 39 .................... 11a
12
X
X
Yes
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 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 ________
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