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

Form 5500-R filers, complete pages 1 and 2 only. Form 5500-C filers, complete page 1, skip page 2, and complete pages 3 through 6.

Form 5500-C/R (1998)

Page

Check investment arrangement(s):

(1)

Master trust

(2)

Common/Collective trust

(3)

Pooled separate account

Yes

Total participants: (1) At the beginning of plan year

(2) At the end of plan year

Enter number of participants with account balances at the end of the plan year (defined benefit plans do not complete this item)

(1)

Were any participants in the pension benefit plan separated from service with a deferred vested benefit for which

7c(1)

a Schedule SSA (Form 5500) is required to be attached? (See instructions.)

(2)

If “Yes,” enter the number of separated participants required to be reported

Was this plan terminated during this plan year or any prior plan year? If “Yes,” enter the year

Were all the plan assets either distributed to participants or beneficiaries, transferred to another plan, or brought under the control of PBGC?

If line 8a is “Yes” and the plan is covered by PBGC, is the plan continuing to file PBGC Form 1 and pay

premiums until the end of the plan year in which assets are distributed or brought under the control of PBGC?

Is this a plan established or maintained pursuant to one or more collective bargaining agreements?

If any benefits are provided by an insurance company, insurance service, or similar organization, enter the number of

Schedules A (Form 5500), Insurance Information, that are attached. If none, enter -0-.

11a(1)

11a

(1)

Were any plan amendments adopted during this plan year?

(2)

Enter the date the most recent amendment was adopted

Month

Day

Year

11b

If line 11a is “Yes,” did any amendment result in a retroactive reduction of accrued benefits for any participant?

If line 11a is “Yes,” did any amendment change the information contained in the latest summary plan description or

11c

summary description of modifications available at the time of the amendment?

If line 11c is “Yes,” has a summary plan description or summary description of modifications that reflects the plan

amendments referred to on line 11c been furnished to participants? (see instructions)

11d

12a

If this is a pension benefit plan subject to the minimum funding standards, has the plan experienced a funding deficiency

12a

for this plan year? (See instructions.)

12b

If line 12a is “Yes,” have you filed Form 5330 to pay the excise tax?

12c

Is the plan administrator making an election under section 412(c)(8) for an amendment adopted after the end of the plan year? (See instructions.)

If a change in the actuarial funding method was made for the plan year pursuant to a Revenue Procedure providing

automatic approval for the change, indicate whether the plan sponsor/administrator agrees to the change

12d

13a

Total plan assets as of the beginning

and end

of the plan year

Total liabilities as of the beginning

and end

of the plan year

Net assets as of the beginning

and end

of the plan year

For this plan year, enter:

Plan income

Plan contributions

Expenses

Total benefits paid

Net income (loss) (subtract 14b from 14a)

You may NOT use N/A in response to lines 15a through 15o. If you check “Yes,” you must enter a

Yes

Amount

dollar amount in the amount column. During this plan year:

15a

Was this plan covered by a fidelity bond?

If line 15a is “Yes,” enter the name of the surety company

15c

Was there any loss to the plan, whether or not reimbursed, caused by fraud or dishonesty?

Was there any sale, exchange, or lease of any property between the plan and the employer, any fiduciary, any of the five most

15d

highly paid employees of the employer, any owner of a 10% or more interest in the employer, or relatives of any such persons?

Was there any loan or extension of credit by the plan to the employer, any fiduciary, any of the five most highly paid

15e

employees of the employer, any owner of a 10% or more interest in the employer, or relatives of any such persons?

15f

Did the plan acquire or hold any employer security or employer real property?

15g

Has the plan granted an extension on any delinquent loan owed to the plan?

Were any participant contributions transmitted to the plan more than 31 days after receipt or

15h

withholding by the employer?

Were any loans by the plan or fixed income obligations due the plan classified as uncollectible or in

15i

default as of the close of the plan year?

Has any plan fiduciary had a financial interest in excess of 10% in any party providing services to the

15j

plan or received anything of value from any such party?

Did the plan at any time hold 20% or more of its assets in any single security, debt, mortgage, parcel

15k

of real estate, or partnership/joint venture interests?

Did the plan at any time engage in any transaction or series of related transactions involving 20% or

15l

more of the current value of plan assets?

15m

Were there any noncash contributions made to the plan the value of which was set without an appraisal by an independent third party?

Were there any purchases of nonpublicly traded securities by the plan the value of which was set

15n

without an appraisal by an independent third party?

Has the plan reduced or failed to provide any benefit when due under the plan because of insufficient assets?

15o

16a

Is the plan covered under the Pension Benefit Guaranty Corporation termination insurance program?

Yes

Not determined

If line 16a is “Yes” or “Not determined,” enter the employer identification number and the plan number used to identify it.

Employer identification number

Plan number

Form 5500-C/r - Return/report Of Employee Benefit Plan - 1998 Page 2

Related Articles

Related forms

Related Categories