Form 5500-Ez - Annual Return Of One-Participant (Owners And Their Spouses) Retirement Plan - 2009

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5500-EZ
Annual Return of One-Participant
OMB No. 1545-0956
Form
(Owners and Their Spouses) Retirement Plan
2009
This form is required to be filed under section 6058(a) of the Internal Revenue Code.
Certain foreign retirement plans are also required to file this form (see instructions).
This Form is Open
Department of the Treasury
Complete all entries in accordance with the instructions to the Form 5500-EZ
to Public Inspection.
Internal Revenue Service
Part I
Annual Return Identification Information
For the calendar plan year 2009 or fiscal plan year beginning
,
and ending
,
A
This return is:
(1)
the first return filed for the plan;
(3)
the final return filed for the plan;
(2)
an amended return;
(4)
a short plan year return (less than 12 months).
B
If filing under an extension of time, check this box (see instructions)
C
If this return is for a foreign plan, check this box (see instructions)
Part II
Basic Plan Information — enter all requested information.
1a
Name of plan
1b
Three-digit
plan number (PN)
1c
Date plan first became effective
(MM,DD,YYYY)
2a
Employer’s name
2b
Employer Identification Number (EIN)
(Do not enter your Social Security Number)
Trade name of business (if different from name of employer)
2c
Employer’s telephone number
In care of name
2d
Business code (see instructions)
Mailing address (room, apt., suite no. and street, or P.O. Box)
City, state, and ZIP code (if foreign, see instructions)
3a
Plan administrator’s name (If same as employer, enter “Same”)
3b
Administrator’s EIN
In care of name
3c
Administrator’s telephone number
Mailing address (room, apt., suite no. and street, or P.O. Box)
City, state, and ZIP code (if foreign, see instructions)
4b
EIN
4
If the name and/or EIN of the employer has changed since the last return filed for this plan,
enter the name, EIN, and plan number for the last return in the appropriate space provided:
4c
PN
a
Employer’s name
5a
5
a
Total number of participants at the beginning of the plan year
b
Total number of participants at the end of the plan year
5b
Part III
Financial Information
(1) Beginning of year
(2) End of year
6a
6
a
Total plan assets
6b
b
Total plan liabilities
6c
c
Net plan assets (subtract line 6b from 6a)
5500-EZ
For Paperwork Reduction Act Notice, see the instructions for Form 5500-EZ.
Cat. No. 63263R
Form
(2009)

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