Form 5330 - Return Of Excise Taxes Related To Employee Benefit Plans Page 6

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6
Form 5330 (Rev. 4-2009)
Page
Name of Filer:
Filer’s identifying number:
Schedule E. Tax on Failure to Pay Liquidity Shortfall (Section 4971(f)(1)) Reported by the last day of the 7th month after
the end of the employer’s tax year or 8
1
months after the last day of the plan year that ends within the filer’s tax year
2
(e) Total
(d) 4th Quarter
(a) 1st Quarter
(b) 2nd Quarter
(c) 3rd Quarter
Add cols. a-d for line 3
1
1
Amount of shortfall
2
2
Shortfall paid by the due date
3
3
Net shortfall amount
4
Multiply line 3 column (e) by 10% (5% for multiemployer plans). Enter here and on Part I,
line 9a
4
Schedule F. Tax on Multiemployer Plans in Endangered or Critical Status (Section 4971(g)(3), 4971(g)(4)) Reported by the
last day of the 7th month after the end of the employer’s tax year or 8
1
months after the last day of the plan year that
2
ends within the filer’s tax year
1
1
Section 4971(g)(3) tax on failure to meet requirements for plans in endangered or critical status
1a
a
Enter the amount of contributions necessary to meet the applicable benchmarks or requirements
1b
b
Enter the amount of the accumulated funding deficiency
1c
c
Enter the greater of line 1a or line 1b, here and on Part I, line 10b
2
2
Section 4971(g)(4) tax on failure to adopt rehabilitation plan
a
Enter the amount of the excise tax on the accumulated funding deficiency under section
2a
4971(a)(2) from Schedule D, line 2
b
Enter the number of days during the tax year which are included in the period beginning on the first day
2b
of the 240 day period and ending on the day the rehabilitation plan is adopted
2c
c
Multiply line 2b by $1,100
d
Enter the greater of line 2a or line 2c, here and on Part I, line 10c
2d
Schedule G. Tax on Excess Fringe Benefits (Section 4977) 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
1
Did you make an election to be taxed under section 4977?
Yes
No
2
If “Yes,” enter the calendar year (YYYY) in which the excess fringe benefits were paid
3
3
If line 1 is “Yes,” enter the excess fringe benefits on this line (see instructions)
4
Enter 30% of line 3 here and on Part I, line 11
4
Schedule H. Tax on Excess Contributions to Certain Plans (Section 4979) Reported by the last day of the 15th month after the
end of the plan year
1
Enter the amount of an excess contribution under a cash or deferred arrangement that is part of a plan
1
qualified under section 401(a), 403(a), 403(b), 408(k), or 501(c)(18) or excess aggregate contributions
2
Multiply line 1 by 10% and enter here and on Part I, line 13
2
Schedule I. Tax on Reversion of Qualified Plan Assets to an Employer (Section 4980) Reported by the last day of the
month following the month in which the reversion occurred
MM
DD
YY
1
Date reversion occurred
2a
Employer reversion amount
b
Excise tax rate
3
3
Multiply line 2a by line 2b and enter the amount here and on Part I, line 14
4
Explain below why you qualify for a rate other than 50%:
Schedule J. Tax on Failure to Provide Notice of Significant Reduction in Future Accruals (Section 4980F) Reported by the
last day of the month following the month in which the failure occurred
1
1
Enter the number of applicable individuals who were not provided ERISA section 204(h) notice
2
2
Enter the effective date of the amendment
MM
DD
YY
3
3
Enter the number of days in the noncompliance period
4
4
Enter the total number of failures to provide ERISA section 204(h) notice (see instructions)
5
5
Multiply line 4 by $100. Enter here and on Part I, line 15
6
Provide a brief description of the failure, and of the correction, if any
Schedule K. Tax on Prohibited Tax Shelter Transactions (Section 4965) Reported on or before the 15th day of the 5th month
following the close of the entity manager’s tax year during which the plan became a party to a prohibited tax shelter transaction
1
Enter the number of prohibited tax shelter transactions you caused the same plan to be a
1
party to
2
Multiply line 1 by $20,000. Enter the result here and on Part I, line 16
2
5330
Form
(Rev. 4-2009)

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