Form 5500-Ez - Annual Return Of One-Participant (Owners And Their Spouses) Retirement Plan - 2011 Page 2

Download a blank fillable Form 5500-Ez - Annual Return Of One-Participant (Owners And Their Spouses) Retirement Plan - 2011 in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 5500-Ez - Annual Return Of One-Participant (Owners And Their Spouses) Retirement Plan - 2011 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Form 5500-EZ (2011)

Page

(Continued)

Part III

Amount

Contributions received or receivable from:

a Employers.

b Participants .

c Others (including rollovers) .

Plan Characteristics

Part IV

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

Compliance and Funding Questions

Part V

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). (See instructions.) .

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

of section 412 of the Code? .

If “Yes,” complete lines 11a or 11b, 11c, 11d, and 11e 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

(see instructions)

11a

b Enter the minimum required contribution for this plan year .

11b

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

11c

d Subtract the amount in line 11c from the amount in line 11b. Enter the result (enter a minus sign

to the left of a negative amount)

11d

Yes No

N/A

e Will the minimum funding amount reported on line 11d be met by the funding

deadline? .

11e

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

5500-EZ

Form

(2011)