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

Complete page 1, and pages 3 through 6 only, if you are filing Form 5500-C.

Form 5500-C/R (1998)

Page

Number

21j

Enter the number of nonexcludable employees. Subtract line 21i from line 21h

Do 100% of the nonexcludable employees entered on line 21j benefit under the plan?

Yes

If line 21k is “Yes,” DO NOT complete lines 21l through 21o.

21l

Enter the number of nonexcludable employees (line 21j) who are highly compensated employees

21m

Enter the number of nonexcludable employees who benefit under the plan

21n

Enter the number of employees entered on line 21m who are highly compensated employees

This plan satisfies the coverage requirements on the basis of (check one):

(1)

The average benefits test

(2)

The ratio percentage test—enter percentage

Yes

22a

Is it or was it ever intended that this plan qualify under Code section 401(a)? If “Yes,” complete lines 22b and 22c

b Enter the date of the most recent IRS determination letter

Month

Year

Is a determination letter request pending with the IRS?

22c

23a

Does the plan hold any assets that have a fair market value that is not readily determinable on an established market?

23a

(If “Yes,” complete line 23b.) (See instructions.)

23b

Were all the assets referred to on line 23a valued for the 1998 plan year by an independent third-party appraiser?

If line 23b is “No,” enter the value of the assets that were not valued by an independent

23c

third-party appraiser for the 1998 plan year

Enter the most recent date the assets on line 23c were valued by an independent third-party appraiser. (If more than

one asset, see instructions.)

Month

Day

Year

(If this plan has NO ESOP features, leave line 23e blank and go to line 24.)

e If dividends paid on employer securities held by the ESOP were used to make payments

23e

on ESOP loans, enter the amount of the dividends used to make the payments

Does the employer/sponsor listed in 1a of this form maintain other qualified pension benefit plans?

If “Yes,” enter the total number of plans, including this plan

25a Is the plan covered under the Pension Benefit Guaranty Corporation termination insurance

program?

Yes

Not determined

b If line 25a is “Yes” or “Not determined,” enter the EIN and the plan number used to identify it.

EIN

Plan number

Yes

Amount

You may NOT use N/A in response to any line 26 item. If you check “Yes,” you must enter a dollar

amount in the amount column.

During this plan year:

26a

Was this plan covered by a fidelity bond?

If line 26a is “Yes,” enter the name of the surety company

26c

c 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 highly paid employees of the employer, any owner of a 10% or more

26d

interest in the employer, or relatives of any such persons?

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

most highly paid employees of the employer, any owner of a 10% or more interest in the employer,

26e

or relatives of any such persons?

26f

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

26g

g 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

26h

withholding by the employer?

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

26i

in default as of the close of the plan year?

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

26j

the 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

26k

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%

26l

or more of the current value of plan assets?

Were there any noncash contributions made to the plan whose value was set without an appraisal

26m

by an independent third party?

Were there any purchases of nonpublicly traded securities by the plan whose value was set without

26n

an appraisal by an independent third party?

o Has the plan reduced or failed to provide any benefit when due under the terms of the plan because

of insufficient assets?

26o

Form 5500-C/r - Return/report Of Employee Benefit Plan - 1998 Page 5

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