Form 5500 - Annual Return/report Of Employee Benefit Plan - 2016 Page 2
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Form 5500 (2016)
Page
X
3b
Administrator’s EIN
3a
Plan administrator’s name and address
Same as Plan Sponsor
012345678
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
3c
Administrator’s telephone
c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
number
0123456789
123456789 ABCDEFGHI ABCDEFGHI ABCDE
123456789 ABCDEFGHI ABCDEFGHI ABCDE
CITYEFGHI ABCDEFGHI AB, ST 012345678901
UK
4
4b
If the name and/or EIN of the plan sponsor has changed since the last return/report filed for this plan, enter the name,
EIN
012345678
EIN and the plan number from the last return/report:
a
Sponsor’s name
4c
PN
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
012
5
123456789012
Total number of participants at the beginning of the plan year
5
6
Number of participants as of the end of the plan year unless otherwise stated (welfare plans complete only lines 6a(1),
6a(2), 6b, 6c, and 6d).
a(1)
6a(1)
Total number of active participants at the beginning of the plan year................................................................................
a(2)
6a(2)
Total number of active participants at the end of the plan year .......................................................................................
123456789012
b
6b
Retired or separated participants receiving benefits .............................................................................................................
123456789012
c
6c
Other retired or separated participants entitled to future benefits .........................................................................................
123456789012
d
6d
Subtotal. Add lines 6a(2), 6b, and 6c. ..................................................................................................................................
123456789012
e
6e
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits. ...............................................
123456789012
f
6f
Total. Add lines 6d and 6e. .................................................................................................................................................
g
Number of participants with account balances as of the end of the plan year (only defined contribution plans
123456789012
6g
complete this item) ..............................................................................................................................................................
h
Number of participants that terminated employment during the plan year with accrued benefits that were
123456789012
6h
less than 100% vested ........................................................................................................................................................
7
Enter the total number of employers obligated to contribute to the plan (only multiemployer plans complete this item) ........
7
8a
If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristics Codes in the instructions:
b
If the plan provides welfare benefits, enter the applicable welfare feature codes from the List of Plan Characteristics Codes in the instructions:
9a
9b
Plan funding arrangement (check all that apply)
Plan benefit arrangement (check all that apply)
X
X
(1)
Insurance
(1)
Insurance
X
X
(2)
Code section 412(e)(3) insurance contracts
(2)
Code section 412(e)(3) insurance contracts
X
X
(3)
Trust
(3)
Trust
X
X
(4)
General assets of the sponsor
(4)
General assets of the sponsor
10
Check all applicable boxes in 10a and 10b to indicate which schedules are attached, and, where indicated, enter the number attached. (See instructions)
a
b
Pension Schedules
General Schedules
X
(1)
R (Retirement Plan Information)
X
(1)
H (Financial Information)
X
X
I (Financial Information – Small Plan)
(2)
MB (Multiemployer Defined Benefit Plan and Certain Money
(2)
Purchase Plan Actuarial Information) - signed by the plan
X
(3)
___ A (Insurance Information)
actuary
X
(4)
C (Service Provider Information)
X
X
(5)
D (DFE/Participating Plan Information)
(3)
SB (Single-Employer Defined Benefit Plan Actuarial
X
Information) - signed by the plan actuary
(6)
G (Financial Transaction Schedules)
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