Form 5500-Ez - Annual Return Of One-Participant (Owners And Their Spouses) Retirement Plan - 2014 Page 2

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Form 5500-EZ (2014)

Page

Part III

(Continued)

Amount

Contributions received or receivable from:

a Employers.

b Participants .

c Others (including rollovers) .

Part IV

Plan Characteristics

Enter the applicable two-character feature codes from the List of Plan Characteristics Codes in the instructions:

Part V

Compliance and Funding Questions

Yes No

Amount

During the plan year, did the plan have any participant loans?

If “Yes,” enter amount as of year end .

Is this a defined benefit plan that is subject to minimum funding requirements?

If “Yes,” complete Schedule SB (Form 5500) and line 11a below. (See instructions.)

a Enter the unpaid minimum required contribution for current year from Schedule SB (Form 5500),

line 39 .

11a

Is this a defined contribution plan subject to the minimum funding requirements

of section 412 of the Code? .

If “Yes,” complete lines 12a or 12b, 12c, 12d, and 12e below, as applicable:

a If a waiver of the minimum funding standard for a prior year is being amortized in this plan

year, enter the month, day, and year (MM/DD/YYYY) of the letter ruling granting the waiver

12a

(see instructions)

b Enter the minimum required contribution for this plan year .

12b

c Enter the amount contributed by the employer to the plan for this plan year .

12c

d Subtract the amount in line 12c from the amount in line 12b. Enter the result (enter a minus sign

to the left of a negative amount)

12d

Yes No

N/A

e Will the minimum funding amount reported on line 12d be met by the funding

deadline? .

12e

Caution. A penalty for the late or incomplete filing of this return will be assessed unless reasonable cause is established.

Under penalties of perjury, I declare that I have examined this return including, if applicable, any related Schedule MB (Form 5500) or Schedule SB (Form 5500)

signed by an enrolled actuary, and to the best of my knowledge and belief, it is true, correct, and complete.

Sign

Here

Signature of employer or plan administrator

Date

Type or print name of individual signing as employer or

plan administrator

Preparer's telephone number (optional)

Preparer's name (including firm name, if applicable) and address, including room or suite number (optional)

5500-EZ

Form

(2014)