Looking for a U.s. Department Of The Treasury Forms And Templates? Download it for free!

Form 5500-Sf - Short Form Annual Return/report Of Small Employee Benefit Plan - 2014 Page 3

3 -

1 x

Form 5500-SF 2014

Page

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

12b

-123456789012345

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

12c

-123456789012345

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

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) .........................................................................................................................................................

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 control

Yes

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 (optional)

14a

14b