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

5500-C/R

OMB Nos. 1210-0016

Return/Report of Employee Benefit Plan

Form

1210-0089

(With fewer than 100 participants)

Department of the Treasury

1998

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.

EP–ID

You must check either box A(5) or A(6), whichever is applicable. See instructions.

(5)

Form 5500-C filer check here

This return/report is:

(Complete only pages 1 and 3 through 6.) (Code section

(1)

the first return/report filed for the plan;

6039D filers see instructions on page 5.)

(2)

an amended return/report;

(6)

Form 5500-R filer check here

(Complete only pages 1 and 2. Detach pages 3 through 6

(3)

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.)

(4)

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

EIN

Plan number

b Administrator

EIN

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

Three-digit

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

Date

Type or print name of individual signing above

Signature of plan administrator

Date

Type or print name of individual signing above

5500-C/R

For Paperwork Reduction Act Notice, see the instructions for Form 5500-C/R.

Cat. No. 10957K

Form

(1998)

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

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