Form 5500-C/r - Return/report Of Employee Benefit Plan - 1998

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OMB Nos. 1210-0016
Return/Report of Employee Benefit Plan
(With fewer than 100 participants)
Department of the Treasury
Internal Revenue Service
This form is required to be filed under sections 104 and 4065 of the Employee
Retirement Income Security Act of 1974 and sections 6039D, 6047(e),
Department of Labor
6057(b), and 6058(a) of the Internal Revenue Code.
Pension and Welfare Benefits Administration
This Form Is Open
See separate instructions.
to Public Inspection.
Pension Benefit Guaranty Corporation
For the calendar plan year 1998 or fiscal plan year beginning
, 1998, and ending
, 19
If A(1) through A(4), B, C, and/or D do not apply to this year’s return/report,
For IRS Use Only
leave the boxes unmarked.
You must check either box A(5) or A(6), whichever is applicable. See instructions.
Form 5500-C filer check here
This return/report is:
(Complete only pages 1 and 3 through 6.) (Code section
the first return/report filed for the plan;
6039D filers see instructions on page 5.)
an amended return/report;
Form 5500-R filer check here
(Complete only pages 1 and 2. Detach pages 3 through 6
the final return/report filed for the plan; or
before filing.) If you checked box (1) or (3), you must file a
Form 5500-C. (See page 5 of the instructions.)
a short plan year return/report (less than 12 months).
Check here if any information reported in 1a, 2a, 2b, or 5a changed since the last return/report for this plan
If your plan year changed since the last return/report, check here
If you filed for an extension of time to file this return/report, check here and attach a copy of the extension
1a Name and address of plan sponsor (employer, if for a single-employer plan)
1b Employer identification number (EIN)
(Address should include room or suite no.)
Sponsor’s telephone number
Business code (see instructions, page 18)
CUSIP issuer number
Name and address of plan administrator (if same as plan sponsor, enter ‘‘Same’’)
Administrator’s EIN
Administrator’s telephone number
If the name, address, and EIN of the plan sponsor or plan administrator has changed since the last return/report filed for this plan, enter the
information from the last return/report on lines 3a and/or 3b and complete line 3c.
a Sponsor
Plan number
b Administrator
c If line 3a indicates a change in the sponsor’s name, address, and EIN, is this a change in sponsorship only? (See line 3c on page 8 of the
instructions for the definition of sponsorship.) Enter “Yes” or “No.”
ENTITY CODE. (If not shown, enter applicable code from page 8 of the instructions.)
Effective date of plan (mo., day, yr.)
Name of plan
plan number
All filers must complete 6a through 6d, as applicable.
Welfare benefit plan
Pension benefit plan
(Enter the applicable codes from page 9 of the instructions in the boxes.)
Pension plan features. (Enter the applicable pension plan feature codes from page 9 of the
instructions in the boxes.)
Fringe benefit plan. Attach Schedule F (Form 5500). See instructions.
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 and
statements, and to the best of my knowledge and belief, it is true, correct, and complete.
Signature of employer/plan sponsor
Type or print name of individual signing above
Signature of plan administrator
Type or print name of individual signing above
For Paperwork Reduction Act Notice, see the instructions for Form 5500-C/R.
Cat. No. 10957K


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