Form 5500 - Annual Return/report Of Employee Benefit Plan

Annual Return/Report of Employee Benefit Plan

OMB Nos. 1210-0110

Form 5500

1210-0089

Department of the Treasury

This form is required to be filed for employee benefit plans under sections 104

Internal Revenue Service

and 4065 of the Employee Retirement Income Security Act of 1974 (ERISA) and

Department of Labor

sections 6047(e), 6057(b), and 6058(a) of the Internal Revenue Code (the Code).

2015

Employee Benefits Security

Administration

 Complete all entries in accordance with

the instructions to the Form 5500.

Pension Benefit Guaranty Corporation

This Form is Open to Public

Inspection

Part I

Annual Report Identification Information

For calendar plan year 2015 or fiscal plan year beginning

and ending

a multiemployer plan;

a multiple-employer plan (Filers checking this box must attach a list of

This return/report is for:

participating employer information in accordance with the form instructions); or

_C_

a single-employer plan;

a DFE (specify)

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).

If the plan is a collectively-bargained plan, check here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Form 5558;

automatic extension;

the DFVC program;

Check box if filing under:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

special extension (enter description)

Part II

Basic Plan Information

—enter all requested information

Name of plan

Three-digit plan

001

number (PN) 

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

Effective date of plan

YYYY-MM-DD

Plan sponsor’s name (employer, if for a single-employer plan)

Employer Identification

Mailing address (include room, apt., suite no. and street, or P.O. Box)

Number (EIN)

City or town, state or province, country, and ZIP or foreign postal code (if foreign, see instructions)

012345678

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

Plan Sponsor’s telephone

D/B/A ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

number

0123456789

ABCDEFGHI

c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

Business code (see

instructions)

123456789 ABCDEFGHI ABCDEFGHI ABCDE

012345

123456789 ABCDEFGHI ABCDEFGHI ABCDE

CITYEFGHI ABCDEFGHI AB, ST 012345678901

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 accompanying schedules,

statements and attachments, 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

YYYY-MM-DD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

HERE

Signature of plan administrator

Date

Enter name of individual signing as plan administrator

SIGN

YYYY-MM-DD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

HERE

Signature of employer/plan sponsor