Form 5500-Sf Draft - Short Form Annual Return/report Of Small Employee Benefit Plan - 2017

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OMB Nos. 1210-0110
Form 5500-SF
Short Form Annual Return/Report of Small Employee
1210-0089
Benefit Plan
Department of the Treasury
2017
Internal Revenue Service
This form is required to be filed under sections 104 and 4065 of the Employee Retirement
Income Security Act of 1974 (ERISA), and sections 6057(b) and 6058(a) of the Internal
Department of Labor
This Form is Open to
Revenue Code (the Code).
Employee Benefits Security Administration
Public Inspection
Pension Benefit Guaranty Corporation
 Complete all entries in accordance with the instructions to the Form 5500-SF.
Part I
Annual Report Identification Information
For calendar plan year 2017 or fiscal plan year beginning
and ending
X
a multiple-employer plan (not multiemployer) (Filers checking this box must attach a
X
a single-employer plan
A
list of participating employer information in accordance with the form instructions.)
This return/report is for:
X
X
a foreign plan
a one-participant plan
B
This return/report is
X
X
the first return/report
the final return/report
X
X
an amended return/report
a short plan year return/report (less than 12 months)
C
Check box if filing under:
X
X
X
Form 5558
automatic extension
DFVC program
X
special extension (enter description)
Part II
Basic Plan Information
—enter all requested information
1a
1b
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
Three-digit
Name of plan
plan number
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
001
(PN)
ABCDEFGHI ABCDEFGHI ABCDEFGHI
1c
Effective date of plan
YYYY-MM-DD
2a
2b
Plan sponsor’s name (employer, if for a single-employer plan)
Employer Identification Number
Mailing address (include room, apt., suite no. and street, or P.O. Box)
(EIN)
012345678
City or town, state or province, country, and ZIP or foreign postal code (if foreign, see instructions)
2c S
ponsor’s telephone number
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
1234567890
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
2d
Business code (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
123456
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGH ABCDEFGHI ABCDEFGHI ABCDEFGHI I
3a
3b
X
ABCDEFGHI ABCDEFGHI
Plan administrator’s name and address
Same as Plan Sponsor.
Administrator’s EIN
012345678
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
3c
Administrator’s telephone number
c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
1234567890
ABCDEFGHI
123456789 ABCDEFGHI ABCDEFGHI ABCDE
123456789 ABCDEFGHI ABCDEFGHI ABCDE
CITYEFGHI ABCDEFGHI AB
ST 012345678901I A
4
4b
If the name and/or EIN of the plan sponsor or the plan name has changed since the last return/report filed for
EIN
012345678
this plan, enter the plan sponsor’s name, EIN, the plan name and the plan number from the last return/report.
a
4d
012
Sponsor’s name
PN
c
Plan Name
D
ABCDEFGHI ABCDEFGHI ABCDEFGHI CDEFGHI
EFGHI
5a
5a
12345678
Total number of participants at the beginning of the plan year ..................................................................................
5b
b
12345678
Total number of participants at the end of the plan year ............................................................................................
c
Number of participants with account balances as of the end of the plan year (only defined contribution plans
5c
complete this item) .....................................................................................................................................................
5d(1)
d(1)
Total number of active participants at the beginning of the plan year ....................................................................
5d(2)
d(2)
Total number of active participants at the end of the plan year .............................................................................
e
Number of participants who terminated employment during the plan year with accrued benefits that were less
5e
than 100% vested .....................................................................................................................................................
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, if applicable, a Schedule
SB or Schedule MB completed and signed by an enrolled actuary, as well as the electronic version of this return/report, and to the best of my knowledge and
belief, it is true, correct, and complete.
SIGN
HERE
Signature of plan administrator
Date
Enter name of individual signing as plan administrator
SIGN
HERE
Signature of employer/plan sponsor
Date
Enter name of individual signing as employer or plan sponsor
For Paperwork Reduction Act Notice, see the Instructions for Form 5500-SF.
Form 5500-SF (2017)
v.170203

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