Form 8453-E - Employee Benefit Plan Declaration And Signature For Electronic/magnetic Media Filing - 1998

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8453-E
Employee Benefit Plan Declaration and Signature for
OMB No. 1545-1033
Form
Electronic/Magnetic Media Filing
1998
See instructions on back.
Department of the Treasury
For the calendar plan year 1998 or the fiscal plan year beginning
, 19
, and ending
, 19
Internal Revenue Service
If you are filing this form for an amended Form 5500, 5500-C/R, or 5500-EZ, check this box
1a
Name and address of plan sponsor (employer if for a single-employer plan)
1b Employer identification number
2a
Name and address of plan administrator (if same as plan sponsor, enter “same”)
2b Administrator’s employer identification no.
Return/Report Information
3
Name of plan
4
Enter the three-digit plan number
$
5 Total assets at the end of the plan year
6a
Is Schedule B (Form 5500) required?
Yes
No
b If the actuary wants to receive a printed copy of the Schedule B, check this box
Declaration of Employer/Plan Sponsor, Administrator, Fiduciary, Actuary, and Accountant
Under penalties of perjury, I declare that the above information agrees with the corresponding information on my 1998 employee benefit plan information return/report.
I have also examined a copy of the return/report being filed electronically or on magnetic media with the Internal Revenue Service, including the accompanying schedules
and statements. To the best of my knowledge and belief, the return/report is true, correct, and complete.
If I am not the transmitter, I consent that my return/report, including this declaration and accompanying schedules and statements, be sent to the Internal Revenue
Service by our return transmitter. I also consent to the IRS sending my Electronic Return Originator (ERO) and/or transmitter an acknowledgment of receipt of transmission
and an indication of whether or not my return is accepted, and, if rejected, the reason(s) for the rejection. If the processing of my return is delayed, I authorize the IRS
to disclose to my ERO and/or transmitter the reason(s) for the delay.
Signature of employer/plan sponsor
Date
Please
Sign
Signature of plan administrator
Date
Here
Signature of fiduciary
Date
To the best of my knowledge, the information supplied in this schedule and on the accompanying statements, if any, is complete and
accurate, and in my opinion each assumption used in combination, represents my best estimate of anticipated experience under the plan.
Furthermore, in the case of a plan other than a multiemployer plan, each assumption used (a) is reasonable (taking into account the experience
of the plan and reasonable expectations), or (b) would, in the aggregate, result in a total contribution equivalent to that which would be
determined if each such assumption were reasonable. In the case of a multiemployer plan, the assumptions used, in the aggregate, are
reasonable (taking into account the experience of the plan and reasonable expectations).
Signature of actuary
Date
I have reviewed the audit report, and related statements and schedules, included as part of this Annual Return/Report Form 5500 being
filed electronically or on magnetic media with the Internal Revenue Service, and, as preparer of the audit report, consent to its inclusion as
part of this filing.
Signature of independent qualified public accountant
Date
Declaration of Transmitter
If the transmitter also prepared the return/report, check this box
I declare that the employee benefit plan information return is based on all information of which I have knowledge. A copy of all
forms and information to be filed with the Internal Revenue Service has been (or will be) provided to the taxpayer.
Transmitter’s signature
Date
Address
ZIP Code
8453-E
For Paperwork Reduction Act Notice, see back of form.
Cat. No. 10331Y
Form
(1998)

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