2
Form 5330 (Rev. 12-2013)
Page
Name of Filer:
Filer’s identifying number:
Section D. Tax that is reported by the last day of the month following the month in which the reversion occurred
14
Section 4980 tax on reversion of qualified plan assets to an employer (from Schedule I,
line 3). Enter here and on Part II, line 17 .
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14
204
Section E. Tax that is reported by the last day of the month following the month in which the failure occurred
15
Section 4980F tax on failure to provide notice of significant reduction in future accruals
(from Schedule J, line 5). Enter here and on Part II, line 17 .
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15
228
Section F. Taxes reported on or before the 15th day of the 5th month following the close of the entity manager’s taxable
year during which the plan became a party to a prohibited tax shelter transaction
16
Section 4965 tax on prohibited tax shelter transactions for entity managers (from Schedule
K, line 2). Enter here and on Part II, line 17 .
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16
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237
Part II
Tax Due
17
17
Enter the amount from Part I, line 7, 12, 13, 14, 15, or 16 (whichever is applicable) .
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18
Enter amount of tax paid with Form 5558 or any other tax paid prior to filing this return .
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18
19
Tax due. Subtract line 18 from line 17. If the result is greater than zero, enter here, and attach
check or money order payable to “United States Treasury.” Write your name, identifying number,
plan number, and “Form 5330, Section(s)
” on your payment
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Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Sign
Here
Your Signature
Telephone number
Date
Print/Type preparer’s name
Preparer's signature
Date
PTIN
Paid
Check
if
self-employed
Preparer
Firm’s name
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Firm's EIN
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Use Only
Firm's address
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Phone no.
5330
Form
(Rev. 12-2013)