Form 5330 - Return Of Excise Taxes Related To Employee Benefit Plans
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65330
Return of Excise Taxes
Form
Related to Employee Benefit Plans
OMB No. 1545-0575
(Rev. April 2009)
(Under sections 4965, 4971, 4972, 4973(a)(3), 4975, 4976, 4977, 4978, 4979,
Department of the Treasury
4979A, 4980, and 4980F of the Internal Revenue Code)
Internal Revenue Service
Filer tax year beginning
,
and ending
,
B
Filer’s identifying number (see instructions)
A
Name of filer (see instructions)
Employer identification number (EIN)
Number, street, and room or suite no. (If a P.O. box or foreign address, see instructions)
Social security number (SSN)
City or town, state, and ZIP code
E
Plan sponsor’s EIN
C
Name of plan
F
Plan year ending (MM/DD/YYYY)
D
Name and address of plan sponsor
G
Plan number
If this is an amended return, check here
H
Part I
Taxes. You can only complete one section of Part I for each Form 5330 filed (see instructions).
FOR
Section A. Taxes that are reported by the last day of the 7th month after the end of the
IRS
USE
tax year of the employer (or other person who must file the return)
ONLY
1
Section 4972 tax on nondeductible contributions to qualified plans (from Schedule A,
1
line 12)
161
2
Section 4973(a)(3) tax on excess contributions to section 403(b)(7)(A) custodial accounts
2
(from Schedule B, line 12)
164
3a
3a
Section 4975(a) tax on prohibited transactions (from Schedule C, line 3)
159
3b
224
b
Section 4975(b) tax on failure to correct prohibited transactions
4
4
Section 4976 tax on disqualified benefits for funded welfare plans
200
5a
5a
Section 4978 tax on ESOP dispositions
209
5b
b
The tax on line 5a is a result of the application of:
Sec. 664(g)
Sec. 1042
6
6
Section 4979A tax on certain prohibited allocations of qualified ESOP securities
203
7
Total Section A taxes. Add lines 1 through 6. Enter here and on Part II, line 17
7
Section B. Taxes that are reported by the last day of the 7th month after the end of the employer’s tax year or 8
1
⁄
2
months after the last day of the plan year that ends within the filer’s tax year
8a
8a Section 4971(a) tax on failure to meet minimum funding standards (from Schedule D, line 2)
163
8b
b
Section 4971(b) tax for failure to correct minimum funding standards
225
9a
9a
Section 4971(f)(1) tax on failure to pay liquidity shortfall (from Schedule E, line 4)
226
9b
b
Section 4971(f)(2) tax for failure to correct liquidity shortfall
227
10a
Section 4971(g)(2) tax on failure to comply with a funding improvement or rehabilitation
plan (see instructions)
10a
450
Section 4971(g)(3) tax on failure to meet requirements for plans in endangered or critical
b
status (from Schedule F, line 1c)
10b
451
c
Section 4971(g)(4) tax on failure to adopt rehabilitation plan (from Schedule F, line 2d)
10c
452
Section B1. Tax that is reported by the last day of the 7th month after the end of the calendar year in which the excess
fringe benefits were paid to the employer’s employees
11
11
Section 4977 tax on excess fringe benefits (from Schedule G, line 4)
201
12
Total Section B taxes. Add lines 8a through 11. Enter here and on Part II, line 17
12
Section C. Tax that is reported by the last day of the 15th month after the end of the plan year
13
Section 4979 tax on excess contributions to certain plans (from Schedule H, line 2).
13
Enter here and on Part II, line 17
205
5330
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Cat. No. 11870M
Form
(Rev. 4-2009)
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