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OMB Nos. 1210-0110

Form 5500-SF

Short Form Annual Return/Report of Small Employee

1210-0089

Benefit Plan

Department of the Treasury

2013

Internal Revenue Service

This form is required to be filed under sections 104 and 4065 of the Employee

Retirement Income Security Act of 1974 (ERISA), and sections 6057(b) and 6058(a) of

Department of Labor

This Form is Open to Public

the Internal Revenue Code (the Code).

Employee Benefits Security Administration

Inspection

Pension Benefit Guaranty Corporation

Complete all entries in accordance with the instructions to the Form 5500-SF.

Part I

Annual Report Identification Information

For calendar plan year 2013 or fiscal plan year beginning

and ending

a single-employer plan

a multiple-employer plan (not multiemployer)

a one-participant plan

This return/report is for:

the first return/report

the final return/report

This return/report is:

an amended return/report

a short plan year return/report (less than 12 months)

Form 5558

automatic extension

DFVC program

Check box if filing under:

special extension (enter description)

Part II

Basic Plan Information

—enter all requested information

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

Name of plan

Three-digit

plan number

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

001

(PN)

ABCDEFGHI ABCDEFGHI ABCDEFGHI

Effective date of plan

YYYY-MM-DD

Plan sponsor’s name and address; include room or suite number (employer, if for a single-employer plan)

Employer Identification Number

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

012345678

(EIN)

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

2c S

ponsor’s telephone number

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

1234567890

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

Business code (see instructions)

ABCDEFGHI ABCDEFGH ABCDEFGHI ABCDEFGHI ABCDEFGHI I

123456

Plan administrator’s name and address

Same as Plan Sponsor Name

Same as Plan Sponsor Address

Administrator’s EIN

012345678

EFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

Administrator’s telephone number

ABCDEFGHI

1234567890

c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

ABCDEFGHI

123456789 ABCDEFGHI ABCDEFGHI ABCDE

If the name and/or EIN of the plan sponsor has changed since the last return/report filed for this plan, enter the

012345678

EIN

name, EIN, and the plan number from the last return/report.

DEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI CDEFGHI

012

Sponsor’s name

Total number of participants at the beginning of the plan year ..................................................................................

12345678

Total number of participants at the end of the plan year ............................................................................................

12345678

Number of participants with account balances as of the end of the plan year (defined benefit plans do not

12345678

complete this item) .....................................................................................................................................................

Yes

Were all of the plan’s assets during the plan year invested in eligible assets? (See instructions.) ..........................................................

Are you claiming a waiver of the annual examination and report of an independent qualified public accountant (IQPA)

Yes

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.

If the plan is a defined benefit plan, is it covered under the PBGC insurance program (see ERISA section 4021)? ......

Yes

Not determined

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.

SIGN

HERE

Signature of plan administrator

Date

Enter name of individual signing as plan administrator

SIGN

HERE

Signature of employer/plan sponsor

Date

Enter name of individual signing as employer or plan sponsor

Preparer’s name (including firm name, if applicable) and address; include room or suite number (optional)