Form 5330 - Return Of Excise Taxes Related To Employee Benefit Plans Page 4

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4
Form 5330 (Rev. 4-2009)
Page
Name of Filer:
Filer’s identifying number:
Schedule C. Tax on Prohibited Transactions (Section 4975) (see instructions) Reported by the last day of the 7th month
after the end of the tax year of the employer (or other person who must file the return) (continued)
1
Is the excise tax a result of a prohibited transaction that was (box “a” or box “b” must be checked):
discrete
other than discrete (a lease or a loan)
a
b
2
Complete the table below to disclose the prohibited transactions and figure the initial tax (see instructions)
(e) Initial tax on prohibited
(d) Amount involved
(a)
(b) Date
transaction (multiply each
in prohibited
Transaction
of transaction
(c) Description of prohibited transaction
transaction in column (d) by
transaction
number
(see instructions)
the appropriate rate (see
(see instructions)
instructions))
(i)
(ii)
(iii)
(iv)
(v)
(vi)
(vii)
(viii)
(ix)
(x)
(xi)
(xii)
3
Add amounts in column (e); enter here and on Part I, line 3a
4
Have you corrected all of the prohibited transactions that you are reporting on this return? If “Yes,”
Yes
No
complete Schedule C, line 5, on the next page. If “No,” attach statement (see instructions)
5330
Form
(Rev. 4-2009)

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