Form 5500-Ez - Annual Return Of One-Participant (Owners And Their Spouses) Retirement Plan - 2015

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5500-EZ
Annual Return of One-Participant
OMB No. 1545-0956
Form
(Owners and Their Spouses) Retirement Plan
2015
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).
Department of the Treasury
Complete all entries in accordance with the instructions to the Form 5500-EZ.
This Form is Open
▶
Internal Revenue Service
to Public Inspection.
Information about Form 5500-EZ and its instructions is at
▶
Part I
Annual Return Identification Information
For the calendar plan year 2015 or fiscal plan year beginning (MM/DD/YYYY)
and ending
A
This return is:
(1)
(3)
the first return filed for the plan;
the final return filed for the plan;
(2)
(4)
an amended return;
a short plan year return (less than 12 months).
B
If filing under an extension of time, check this box (see instructions) .
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C
If this return is for a foreign plan, check this box (see instructions) .
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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 or town, state or province, country, and ZIP or foreign postal 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 or town, state or province, country, and ZIP or foreign postal code (if foreign, see instructions)
4a Name of trust (answering 4a, 4b, 4c, and 4d is optional)
4b Trust's EIN
4c Name of trustee or custodian
4d Trustee or custodian's telephone number
5
If the name and/or EIN of the employer has changed since the last return filed for this plan,
5b
EIN
enter the name, EIN, and plan number for the last return in the appropriate space provided:
a Employer’s name
5c
PN
6a(1) Total number of participants at the beginning of the plan year .
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6a(1)
a(2) Total number of active participants at the beginning of the plan year
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6a(2)
b(1) Total number of participants at the end of the plan year .
6b(1)
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b(2) Total number of active participants at the end of the plan year
6b(2)
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c Number of participants that terminated employment during the plan year with accrued
benefits that were less than 100% vested .
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6c
Part III
Financial Information
(1) Beginning of year
(2) End of year
7a Total plan assets
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7a
b Total plan liabilities .
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7b
c Net plan assets (subtract line 7b from 7a)
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7c
5500-EZ
For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 5500-EZ.
Form
(2015)
Cat. No. 63263R

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