Fillable Form 5500 - Annual Return/report Of Employee Benefit Plan

Form 5500 - Annual Return/report Of Employee Benefit Plan - 2005

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5500

Official Use Only

Annual Return/Report of Employee Benefit Plan

Form

OMB Nos. 1210-0110 / 1210-0089

Department of the Treasury

2005

This form is required to be filed under sections 104 and 4065 of the Employee

Internal Revenue Service

Retirement Income Security Act of 1974 (ERISA) and sections 6047(e),

Department of Labor

6057(b), and 6058(a) of the Internal Revenue Code (the Code).

Employee Benefits Security

Administration

Complete all entries in accordance with

This Form is Open to

Pension Benefit

the instructions to the Form 5500.

Public Inspection.

Guaranty Corporation

Annual Report Identification Information

Part I

For the calendar plan year 2005

M M / D D / Y Y Y Y

or fiscal plan year beginning

and ending

This return/report is for:

(1)

a multiemployer plan;

(3)

a multiple-employer plan; or

(2)

a single-employer plan (other than

(4)

a DFE (specify) .....................

a multiple-employer plan);

This return/report is:

(1)

the first return/report filed for the plan;

(3)

the final return/report filed for the plan;

(2)

an amended return/report;

(4)

a short plan year return/report

(less than 12 months).

If the plan is a collectively-bargained plan, check here ...............................................................................................................................

If filing under an extension of time or the DFVC program, check box and attach required information. (see instructions) ......................

Part II

Basic Plan Information -- enter all requested information.

Name of plan

M M / D D / Y Y Y Y

Three-digit plan number (PN)

1 c

Effective date of plan

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

Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return/report, including accompanying

schedules, statements and attachments, as well as the electronic version of this return/report if it is being filed electronically, and to the best of my

knowledge and belief, it is true, correct and complete.

Signature of plan administrator

M M / D D / Y Y Y Y

SIGN HERE

Date

Type or print name of individual signing as plan administrator

Signature of employer/plan sponsor/DFE

M M / D D / Y Y Y Y

SIGN HERE

Date

Type or print name of individual signing as employer, plan sponsor or DFE

Cat. No. 13500F