2
Form 5330 (Rev. 4-2009)
Page
Name of Filer:
Filer’s identifying number:
Section D. Tax that is reported by the last day of the month following the month in which the reversion occurred
14
Section 4980 tax on reversion of qualified plan assets to an employer (from Schedule I,
line 3). Enter here and on Part II, line 17
14
204
Section E. Tax that is reported by the last day of the month following the month in which the failure occurred
15
Section 4980F tax on failure to provide notice of significant reduction in future accruals
(from Schedule J, line 5). Enter here and on Part II, line 17
15
228
Section F. Taxes reported on or before the 15th day of the 5th month following the close of the entity manager’s taxable
year during which the plan became a party to a prohibited tax shelter transaction
16
Section 4965 tax on prohibited tax shelter transactions for entity managers (from Schedule
K, line 2). Enter here and on Part II, line 17
16
237
Part II
Tax Due
17
17
Enter the amount from Part I, line 7, 12, 13, 14, 15, or 16 (whichever is applicable)
18
18
Enter amount of tax paid with Form 5558 or any other tax paid prior to filing this return
19
Tax due. Subtract line 18 from line 17. If the result is greater than zero, enter here, and attach
check or money order payable to “United States Treasury.” Write your name, identifying number,
plan number, and “Form 5330, Section(s)
” on your payment
19
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Sign
Here
Your signature
Telephone number
Date
Date
Preparer’s SSN or PTIN
Preparer’s
Paid
Check if
signature
self-employed
Preparer’s
Firm’s name (or
EIN
Use Only
yours if self-employed),
(
)
address, and ZIP code
Phone no.
5330
Form
(Rev. 4-2009)