Department of Labor: 1995-5500inst

8/14/2019 Department of Labor: 1995-5500inst

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Cat. No. 13502B

Pension BenefitGuaranty Corporation

Department of LaborPension and WelfareBenefits Administration

Department of the TreasuryInternal Revenue Service

Instructions for Form 5500Annual Return/ Report of Employee BenefitPlan (With 100 or more participants)Code references are to the Internal Revenue Code. ERISA

refers to the Employee Retirement Income Security Act of 1974.

Paperwork Reduction Act Notice

The time needed to complete and file the forms listed below reflects the combinedrequirements of the Internal Revenue Service, Department of Labor, Pension BenefitGuaranty Corporation, and the Social Security Administration. These times will varydepending on individual circumstances. The estimated average times are:

Copying,assembling, andsending the form

to the IRS

Learning aboutthe law or the

form Preparing the formRecordkeeping

87 hr., 46 min. 48 min.14 hr., 11 min.9 hr., 32 min.Form 5500 (initial filers)

82 hr., 16 min. 48 min.14 hr., 6 min.9 hr., 32 min.Form 5500 (all other filers) 1 hr., 42 min.28 min.17 hr., 28 min. 16 min.Schedule A (Form 5500)

1 hr., 45 min.1 hr., 23 min.8 hr., 39 min.Schedule B (Form 5500) Part 2

23 min.18 min.5 hr., 16 min.Schedule C (Form 5500)

Schedule E (Form 5500)(nonleveraged ESOP) 13 min.12 min.1 hr., 12 min.

Schedule E (Form 5500)(leveraged ESOP) 1 hr., 56 min.1 hr., 41 min.10 hr., 2 min.

1 hr., 55 min.Schedule P (Form 5500) 33 min.30 min.

5 hr., 30 min.Schedule SSA (Form 5500) 11 min.6 min.

If you have comments concerning the accuracy of these time estimates or suggestionsfor making these forms simpler, we would be happy to hear from you. You can write tothe Tax Forms Committee, Western Area Distribution Center, Rancho Cordova, CA95743-0001. DO NOT send any of these forms or schedules to this address. Instead, see

Where To File on page 2.

How To Use This InstructionBookletThe instructions are divided into four mainsections.

Section 1 Page

Who Must File 2

When To File 2

Extension of Time To File 2Where To File 2

Section 2

Kinds of Plans 2

Pension Benefit 2

Fringe Benefit 3

Welfare Benefit 3

Plans Excluded From Filing 3

Kinds of Filers 3

Investment Arrangements FilingDirectly With DOL 4

What To File 5

Forms 5

Lines To Complete on Form 5500 5

Schedules 6Other Filings 6

Section 3

Section 4

Plan Year 1

Schedule F (Form 5500)

Schedule G (Form 5500)

Final Return/Report 7

Signature and Date 7

Reproductions 7

Change in Plan Year 8

Amended Return/Report 8

How the Annual Return/Report InformationMay Be Used 8

Informat ion at the Top of the Form 8

Line-By-Line Instructions 8

Codes for Principal Business Activity and

Princ ipal Product or Service 23, 24

2 hr., 52 min. 28 min.24 min.

15 hr., 4 min. 21 min.6 min.

Electronic Filing of Form 5500 1

Penalties 2

We ask for the information on this form to carry out the law as specified in ERISA andCode sections 6039D, 6047(e), 6057(b), and 6058(a). You are required to give us theinformation. We need it to determine whether the plan is operating according to the law.

Avoid Common Mistakes 1

3 hr., 23 min.2 hr., 47 min.29 hr., 39 min.Schedule B (Form 5500) Part 1

A Change to Note for 1995When the Schedule F (Form 5500) wasprinted, the provisions of Code section 127had expired. Congress, however, wasconsidering legislation that would extendthese provisions beyond December 31,1994. Get Pub. 553, Highlights of 1995Tax Changes, for more information.

Section 1

Plan Year

File 1995 forms for plan years that startedin 1995. If the plan year differs from thecalendar year, fill in the fiscal year spacejust under the form title. For a short planyear, see When To File on page 2.

Electronic Filing of Form 5500

Form 5500 and the related schedules canbe filed by magnetic media (magnetictapes, floppy diskettes) or electronically. Ifthe plan administrator files thereturn/report electronically or on magneticmedia, he or she must also file Form8453-E, Employee Benefit Plan Declaration

and Signature for Electronic/MagneticMedia Filing. This is the declaration andsignature form for the electronic/magneticmedia return. For more information, seePub. 1507, Procedures forElectronic/Magnetic Media Filing of Forms5500, 5500-C/R, and 5500-EZ for PlanYear 1995.

Reminder

Many filers receive rejection notices bymaking several common mistakes that canbe avoided as discussed in AvoidCommon Mistakes below. Thereturn/report will also be consideredincomplete and penalties may be assessedif information required on a schedule is nottyped or printed on the appropriateschedule, such as the Schedule A (Form5500). See the instructions for Scheduleson page 6. An annual return/report mustbe filed for employee welfare benefit planswhich provide benefits wholly or partiallythrough a Multiple Employer WelfareArrangement (MEWA) as defined in ERISAsection 3(40), unless otherwise exempt(see page 3).

In addition to filing this form with theIRS, plans covered by the Pension BenefitGuaranty Corporation (PBGC) terminationinsurance program must file their AnnualPremium Payment, PBGC Form 1, directlywith that agency.

Avoid Common Mistakes

Filers make several common mistakes. Toreduce the possibility of correspondenceand penalties, we remind filers to:

Enter only one code on line 4.

Attach the required accountants

opinion. The instructions for line 26 explainwhich plans are not required to attach theopinion.

If you must complete lines 25, 27, and/or29:

1. You must check Yes or No on line25c.

2. You must attach and properly identifyany schedules required by the line 27instructions.

3. You must report the amount of anyloss to the plan caused by fraud or


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dishonesty on line 29b(2) if you checkedYes on line 29b(1).

Penalties

ERISA and the Code provide for theassessment or imposition of penalties fornot giving complete information and for notfiling statements and returns/reports.Certain penalties are administrative (i.e.,they may be imposed or assessed by oneof the governmental agencies delegated toadminister the collection of the Form 5500series data). Others require a legal

conviction.

Administrative Penalties

Listed below are various penalties for notmeeting the Form 5500 series filingrequirements. One or more of the followingfive penalties may be assessed or imposedin the event of incomplete filings or filingsreceived after the due date unless it isdetermined that your explanation for failureto file properly is for reasonable cause:

1. A penalty of up to $1,000 a day foreach day a plan administrator fails orrefuses to file a complete return/report.See ERISA section 502(c)(2) and 29 CFR2560.502c-2.

2. A penalty of $25 a day (up to $15,000)for not filing returns for certain plans ofdeferred compensation, certain trusts andannuities, and bond purchase plans by thedue date(s). See Code section 6652(e).This penalty also applies to returnsrequired to be filed under Code section6039D.

3. A penalty of $1 a day (up to $5,000)for each participant for whom a registrationstatement (Schedule SSA (Form 5500)) isrequired but not filed. See Code section6652(d)(1).

4. A penalty of $1 a day (up to $1,000)for not filing a notification of change ofstatus of a plan. See Code section6652(d)(2).

5. A penalty of $1,000 for not filing anactuarial statement. See Code section6692.

Other Penalties

1. Any individual who willfully violatesany provision of Part 1 of Title I of ERISAshall be fined not more than $5,000 orimprisoned not more than 1 year, or both.See ERISA section 501.

2. A penalty of up to $10,000, 5 yearsimprisonment, or both, may be imposed formaking any false statement orrepresentation of fact, knowing it to befalse, or for knowingly concealing or notdisclosing any fact required by ERISA. Seesection 1027, Title 18, U.S. Code, asamended by section 111 of ERISA.

Who Must File

Any administrator or sponsor of anemployee benefit plan subject to ERISAmust file information about each planevery year (Code section 6058 and ERISAsections 104 and 4065). Every employermaintaining a specified fringe benefit planas described in Code section 6039D(except Code sections 79, 105, 106, 120,

and 129 plans) is also required to file eachyear. The Internal Revenue Service (IRS),Department of Labor (DOL), and PensionBenefit Guaranty Corporation (PBGC) haveconsolidated their returns and report formsto minimize the filing burden for planadministrators and employers. The charton page 5 gives a brief guide to the typeof return/report to be filed.

When To File

File all required forms and schedules bythe last day of the 7th month after the plan

year ends. For a short plan year, file theform and applicable schedules by the lastday of the 7th month after the short planyear ends. For purposes of thisreturn/report, the short plan year ends onthe date of the change in accountingperiod or upon the complete distribution ofthe assets of the plan. (Also see Section3.) If the current year Form 5500 is notavailable before the due date of your shortplan year return/report, use the latest yearform available and change the date printedon the return/report to the current year.Also show the dates your short plan yearbegan and ended.

Extension of Time To File

A one-time extension of time to file (up to212 months) may be granted for filingreturns/reports if Form 5558, Applicationfor Extension of Time To File CertainEmployee Plan Returns, is filed before thenormal due date (not including anyextensions) of the return/report.

Exception: Plans are automatically grantedextensions of time to file Form 5500 untilthe due date of the Federal income taxreturn of the employer if all the followingconditions are met: (1) The plan year andthe employers tax year are the same. (2)The employer has been granted anextension of time to file its Federal incometax return to a date later than the normaldue date for filing the Form 5500. (3) Acopy of the IRS extension of time to filethe Federal income tax return is attachedto the Form 5500 filed with the IRS. Anextension granted by using this exceptionCANNOT be extended further by filing aForm 5558.

Note: An extension of time to file thereturn/report does not operate as anextension of time to file the PBGCForm 1.

Where To File

File the return/report with the InternalRevenue Service Center indicated below.No street address is necessary.

See pages 6 and 7 for the filing addressfor investment arrangements filing directlywith DOL.

If the principal office ofthe plan sponsor or the

plan administrator islocated in

Use the followingInternal RevenueService Center

address

Connecticut, Delaware,District of Columbia,Foreign Address, Maine,Maryland, Massachusetts,New Hampshire, NewJersey, New York,Pennsylvania, Puerto Rico,Rhode Island, Vermont,Virginia

Holtsville, NY00501-0044

Alabama, Alaska, Arkansas,California, Florida, Georgia,Hawaii, Idaho, Louisiana,Mississippi, Nevada, NorthCarolina, Oregon, SouthCarolina, Tennessee,Washington

Atlanta, GA39901-0044

Arizona, Colorado, Illinois,Indiana, Iowa, Kansas,Kentucky, Michigan,Minnesota, Missouri,Montana, Nebraska, NewMexico, North Dakota,Ohio, Oklahoma, SouthDakota, Texas, Utah, WestVirginia, Wisconsin,Wyoming

Memphis, TN37501-0044

Section 2

Kinds of Plans

Employee benefit plans include pensionbenefit plans and welfare benefit plans. Filethe applicable return/report for any of thefollowing plans.

Pension Benefit Plan

This is an employee pension benefit plancovered by ERISA. The return/report is duewhether or not the plan is qualified andeven if benefits no longer accrue,contributions were not made this plan year,

or contributions are no longer made(frozen plan or wasting trust). See FinalReturn/Report on page 7.

Pension benefit plans required to fileinclude defined benefit plans and definedcontribution plans (e.g., profit-sharing,stock bonus, money purchase plans, etc.).The following are among the pensionbenefit plans for which a return/reportmust be filed:

1. Annuity arrangements under Codesection 403(b)(1).

2. Custodial accounts established underCode section 403(b)(7) for regulatedinvestment company stock.

3. Individual retirement accounts (IRAs)established by an employer under Codesection 408(c).

4. Pension benefit plans maintainedoutside the United States primarily fornonresident aliens if the employer whomaintains the plan is:

a. A domestic employer, or

b. A foreign employer with incomederived from sources within the UnitedStates (including foreign subsidiaries ofdomestic employers) if contributions to theplan are deducted on its U.S. income taxreturn. For this type of plan, enter code D


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on line 6c. See Plans Excluded FromFiling below.

5. Church plans electing coverage underCode section 410(d).

6. A plan that covers residents of PuertoRico, the U.S. Virgin Islands, Guam, WakeIsland, or American Samoa. This includes aplan that elects to have the provisions ofsection 1022(i)(2) of ERISA apply.

See Lines To Complete on Form 5500on page 5 for more information about whatquestions must be completed by pension

plans.Fringe Benefit Plan

Cafeteria plans described in Code section125 and educational assistance programsdescribed in Code section 127 areconsidered fringe benefit plans andgenerally are required to file the annualinformation specified by Code section6039D. However, Code section 127educational assistance programs, whichprovide only job-related training that isdeductible under Code section 162, do notneed to file Form 5500. Also see AChange to Note for 1995 on page 1.

Note: A fringe benefit plan may be

associated with one or more welfare plansas described above for which a Form 5500may be required to be filed.

See Lines To Complete on Form 5500on page 5 for more information about howto complete this form for a fringe benefitplan.

Welfare Benefit Plan

This is an employee welfare benefit plancovered by Part 1 of Title I of ERISA.Welfare plans provide benefits such asmedical, dental, life insurance,apprenticeship and training, scholarshipfunds, severance pay, disability, etc.

See Lines To Complete on Form 5500

on page 5 for more information about whatquestions must be completed for welfarebenefit plans.

Plans Excluded From Filing

These exemptions do not apply to a fringebenefit plan required to file to satisfy therequirements of Code section 6039D.

Do not file a return/report for anemployee benefit plan that is any of thefollowing:

1. A welfare benefit plan which coveredfewer than 100 participants as of thebeginning of the plan year and is:unfunded, fully insured, or a combinationof insured and unfunded.

a. An unfunded welfare benefit plan hasits benefits paid as needed directly fromthe general assets of the employer or theemployee organization that sponsors theplan.

Note: Plans which are NOT unfundedinclude those plans that received employee(or former employee) contributions duringthe plan year and/or used a trust orseparately maintained fund (including aCode section 501(c)(9) trust) to hold planassets or act as a conduit for the transferof plan assets during the plan year.

b. A fully insured welfare benefit planhas its benefits provided exclusivelythrough insurance contracts or policies, thepremiums of which must be paid directlyby the employer or employee organizationfrom its general assets or partly from itsgeneral assets and partly fromcontributions by its employees or members(which the employer or organizationforwards within 3 months of receipt).

The insurance contracts or policiesdiscussed above must be issued by aninsurance company or similar organization

(such as Blue Cross, Blue Shield or ahealth maintenance organization) that isqualified to do business in any state.

c. A combination unfunded/insuredwelfare plan has its benefits providedpartially as an unfunded plan and partiallyas a fully insured plan. An example of sucha plan is a welfare plan which providesmedical benefits as in a above and lifeinsurance benefits as in b above.

See 29 CFR 2520.104-20 and the DOLTechnical Release 92-01.

Note: An employees beneficiaryassociation as used in Code section501(c)(9) should not be confused with theemployee organization or employer thatestablishes and maintains (i.e., sponsors)the welfare benefit plan.

2. An unfunded pension benefit plan oran unfunded or insured welfare benefitplan: (a) whose benefits go only to a selectgroup of management or highlycompensated employees, and(b) which meets the terms of Departmentof Labor Regulations 29 CFR 2520.104-23(including the requirement that anotification statement be filed with DOL) or29 CFR 2520.104-24.

3. Plans maintained only to comply withworkers compensation, unemploymentcompensation, or disability insurance laws.

4. An unfunded excess benefit plan.5. A welfare benefit plan maintained

outside the United States primarily forpersons substantially all of whom arenonresident aliens.

6. A pension benefit plan maintainedoutside the United States if it is a qualifiedforeign plan within the meaning of Codesection 404A(e) that does not qualify forthe treatment provided in Code section402(e)(5).

7. An annuity arrangement described in29 CFR 2510.3-2(f).

8. A simplified employee pension (SEP)described in Code section 408(k) thatconforms to the alternative method of

compliance described in 29 CFR2520.104-48 or 29 CFR 2520.104-49. ASEP is a pension plan that meets certainminimum qualifications regarding eligibilityand employer contributions.

9. A church plan not electing coverageunder Code section 410(d).

10. A governmental plan.

11. A welfare benefit plan thatparticipates in a group insurancearrangement that files a return/report Form5500 on behalf of the welfare benefit plan.See 29 CFR 2520.104-43.

12. An apprenticeship or training planmeeting all of the conditions specified in29 CFR 2520.104-22.

Kinds of Filers

The different types of plan entities that filethe forms are described below. (Also seeinstructions for line 4 on page 9.)

Single-Employer Plan

If one employer or one employeeorganization maintains a plan, file aseparate return/report for the plan. If theemployer or employee organizationmaintains more than one such plan, file aseparate return/report for each plan.

If a member of a controlled group ofcorporations, a group of trades orbusinesses under common control, or anaffiliated service group maintains a planthat does not involve other groupmembers, file a separate return/report as asingle-employer plan.

If several employers participate in aprogram of benefits in which the fundsattributable to each employer are availableonly to pay benefits to that employersemployees, each employer must file aseparate return/report.

Plan for Controlled Group ofCorporations, Group of Trades orBusinesses Under Common Control, oran Affiliated Service Group

These groups are defined in Code sections414(b), (c), and (m), and are referred to ascontrolled groups.

File one return/report for the plan.Complete line 21 once for all of thegroups employees.

If the funds under the plan attributable toeach employer are available only to paybenefits to that employers employees,each employer in the group must file a

separate return/report as a single-employerplan.

Note: If there are employers thatparticipate in a plan of one of the groupslisted above but those employers are notmembers of the group, the plan isconsidered a multiple-employer plan(other). SeeMultiple-Employer Plan(Other)on page 4 for more information.

Multiemployer Plan

A multiemployer plan is a plan (1) to whichmore than one employer is required tocontribute, (2) that is maintained pursuantto one or more collective-bargainingagreements, and (3) has not made the

election under Code section 414(f)(5) andERISA section 3(37)(E). File onereturn/report for each plan. Contributingemployers do not file individually for theseplans. See Code section 414 for moreinformation.

Multiple-Employer-CollectivelyBargained Plan

A multiple-employer-collectively bargainedplan involves more than one employer; iscollectively bargained and collectivelyfunded; and, if covered by PBGCtermination insurance, had properly elected


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before September 27, 1981, not to betreated as a multiemployer plan underCode section 414(f)(5) or ERISA sections3(37)(E) and 4001(a)(3). File onereturn/report for each such plan.Participating employers do not fileindividually for these plans.

Multiple-Employer Plan (Other)

A multiple-employer plan (other) involvesmore than one employer and is not one ofthe plans already described. File onereturn/report for each plan.

Note: Each employer participating in aqualified defined contribution or definedbenefit plan, which is considered amultiple-employer plan (other), must file aForm 5500-C/R regardless of the numberof participants. For the years you arerequired to file pages 1 and 3 through 6 asForm 5500-C, complete only lines 1through 7a, 9, and 21. For the years youfile pages 1 and 2 as Form 5500-R,complete only lines 1 through 7a, 8a, and8b. Each participating employer filing theForm 5500-C/Rmustenter code F on line4 and use an appropriate number (001,002, etc.) on line 5c.

Note: If a participating employer is also the

sponsor of the multiple-employer plan(other), the plan number on thereturn/report filed for the plan should be333 and, if more than one plan, theyshould be consecutively numbered startingwith 333.

If more than one employer participates inthe plan and the plan provides that eachemployers contributions are available topay benefits only for that employersemployees who are covered by the plan,one annual return/report must be filed foreach participating employer. These filerswill be considered single employers andshould complete the entire form.

Group Insurance Arrangement

This arrangement provides benefits to theemployees of two or more unaffiliatedemployers (not in connection with amultiemployer plan or a multiple-employer-collectively bargained plan), fully insuresone or more welfare plans of eachparticipating employer, and uses a trust (orother entity such as a trade association) asthe holder of the insurance contracts andthe conduit for payment of premiums tothe insurance company.

Do not file a separate return/report for awelfare benefit plan that is part of a groupinsurance arrangement if a consolidatedreturn/report for all the plans in the

arrangement was filed by the trust or otherentity according to 29 CFR 2520.104-43.Form 5500 is required by 29 CFR2520.103-2 to be part of the consolidatedreport.

Investment Arrangements FilingDirectly With DOL

Some plans invest in certain trusts,accounts, and other investmentarrangements which may file informationconcerning themselves and theirrelationship with employee benefit plansdirectly with DOL (as specified on pages 6

and 7). Plans participating in an investmentarrangement as described inCommon/Collective Trust and PooledSeparate Account, Master Trust, and103-12 Investment Entities below arerequired to attach certain additionalinformation to the return/report filed withthe IRS as specified below.

Common/Collective Trust and PooledSeparate Account

Definition.For reporting purposes, acommon/collective trust is a trust

maintained by a bank, trust company, orsimilar institution which is regulated,supervised, and subject to periodicexamination by a state or Federal agencyfor the collective investment andreinvestment of assets contributed theretofrom employee benefit plans maintained bymore than one employer or a controlledgroup of corporations, as the term is usedin Code section 1563. For reportingpurposes, a pooled separate account isan account maintained by an insurancecarrier which is regulated, supervised, andsubject to periodic examination by a stateagency for the collective investment andreinvestment of assets contributed theretofrom employee benefit plans maintained bymore than one employer or controlledgroup of corporations, as the term is usedin Code section 1563. See 29 CFRsections 2520.103-3, 2520.103-4,2520.103-5, and 2520.103-9.

Note: For reporting purposes, a separateaccount which is not considered to beholding plan assets pursuant to 29 CFR2510.3-101(h)(1)(iii) shall not constitute apooled separate account.

Additional information required to beattached to the Form 5500 for plansparticipating in common/collective trustsand pooled separate accounts.A planparticipating in a common/collective trustor pooled separate account must completethe annual return/report and attach either:(1) the most recent statement of the assetsand liabilities of any common/collectivetrust or pooled separate account, or (2) acertification that: (a) the statement of theassets and liabilities of thecommon/collective trust or pooled separateaccount has been submitted directly toDOL by the financial institution orinsurance carrier; (b) the plan has receiveda copy of the statement; and (c) includesthe EIN and other numbers used by thefinancial institution or insurance carrier toidentify the trusts or accounts, and thename and address provided in the directfiling made with DOL.

Master Trust

Definition.For reporting purposes, amaster trust is a trust for which a regulatedfinancial institution (as defined below)serves as trustee or custodian (regardlessof whether such institution exercisesdiscretionary authority or control withrespect to the management of assets heldin the trust), and in which assets of morethan one plan sponsored by a singleemployer or by a group of employers undercommon control are held.

A regulated financial institution meansa bank, trust company, or similar financialinstitution which is regulated, supervised,and subject to periodic examination by astate or Federal agency. Common controlis determined on the basis of all relevantfacts and circumstances (whether or notsuch employers are incorporated). See 29CFR 2520.103-1(e).

For reporting purposes, the assets of amaster trust are considered to be held inone or more investment accounts. Amaster trust investment account may

consist of a pool of assets or a singleasset.

Each pool of assets held in a mastertrust must be treated as a separate mastertrust investment account if each planwhich has an interest in the pool has thesame fractional interest in each asset inthe pool as its fractional interest in thepool, and if each such plan may notdispose of its interest in any asset in thepool without disposing of its interest in thepool. A master trust may also containassets which are not held in such a pool.Each such asset must be treated as aseparate master trust investment account.

Financial information must generally be

provided for each master trust investmentaccount as specified on pages 6 and 7.

Additional information required to beattached to the Form 5500 for plansparticipating in master trusts.A planparticipating in a master trust mustcomplete the annual return/report andattach a schedule listing each master trustinvestment account in which the plan hasan interest, indicating the plans name,EIN, and plan number and the name of themaster trust used in the master trustinformation filed with DOL (see page 6). Intabular format, show the net value of theplans interest in each investment accountat the beginning and end of the plan year,

and the net investment gain (or loss)allocated to the plan for the plan year fromthe investment account (see instructionsfor lines 31c(11) through (15) on page 20).

Note: If a master trust investment accountconsists solely of one plans asset(s) duringthe reporting period, the plan may reportthe(se) asset(s) either as an investmentaccount to be reported as part of themaster trust report filed directly with DOLor as a plan asset(s), which is not part ofthe master trust (and therefore subject toall instructions pertaining to assets not heldin a master trust).

103-12 Investment Entities

29 CFR 2520.103-12 provides analternative method of reporting for planswhich invest in an entity (other than aninvestment arrangement filing with DOL asdescribed on this page inCommon/Collective Trust and PooledSeparate Accounts or Master Trust), theunderlying assets of which include p lanassets (within the meaning of 29 CFR2510.3-101) of two or more plans whichare not members of a related group ofemployee benefit plans. For reportingpurposes, a related group consists ofeach group of two or more employee


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(described on page 3 underPlansExcluded From Filing), which must file theForm 5500 because it has 100 or moreparticipants, need not complete lines 31and 32.

Note: If one Form 5500 is filed for both awelfare plan and a fringe benefit plan,check box 6d and complete Schedule F(Form 5500) in addition to the items listedabove for welfare benefit plans.

Pension plans.In general, most pensionplans (defined benefit and definedcontribution) are required to complete allline items on the form. However, some lineitems do not have to be completed bycertain types of pension plans, asdescribed below.

1. Plans exclusively using a tax deferredannuity arrangement under Code section403(b)(1).These plans (see Who MustFile on page 2) need only complete lines 1through 5, 6b (enter pension code 8),and 9.

2. Plans exclusively using a custodialaccount for regulated investmentcompany stock under Code section403(b)(7).These plans need onlycomplete lines 1 through 5, 6b (enterpension code 9), and 9.

3. Individual retirement account plan.Apension plan utilizing individual retirementaccounts or annuities (as described inCode section 408) as the sole fundingvehicle for providing benefits need onlycomplete lines 1 through 5, 6b (enterpension code 0), and 9.

4. Fully insured pension plan.A pensionbenefit plan providing benefits exclusivelythrough an insurance contract, or contractswhich are fully guaranteed and that meetsall of the conditions of 29 CFR2520.104-44 must complete lines 1through 26, 29, and 30.

A pension plan including both insurance

contracts of the type described in 29 CFR2520.104-44 as well as other assetsshould limit its reporting in lines 31 and 32to those other assets.

Note: For purposes of the annual return/report and the alternative method ofcompliance set forth in 29 CFR2520.104-44, a contract is considered tobe allocated only if the insurancecompany or organization that issued thecontract unconditionally guarantees, uponreceipt of the required premium orconsideration, to provide a retirementbenefit of a specified amount. This amountmust be provided without adjustment forfluctuations in the market value of theunderlying assets of the company ororganization, to each participant, and eachparticipant has a legal right to suchbenefits, which is legally enforceabledirectly against the insurance company ororganization.

5. Nonqualified pension benefit plansmaintained outside the United States.Nonqualified pension benefit plansmaintained outside the United Statesprimarily for nonresident aliens required tofile a return/report (see Who Must File onpage 2) must complete lines 1 through 8c

(enter code D in the box on line 6c), 9through 12, 15, and 16.

Plans of more than one employer.Allplans of more than one employer (plans ofa controlled group, multiemployer plans,multiple-employer-collectively bargainedplans, and multiple-employer plan (other))generally must complete all applicable(welfare or pension) items on the formexcept for line 6f. Only single-employerpension plans must complete line 6f.Multiemployer plans and multiple-employer-collectively bargained plans do

not have to complete line 7h.

Schedules

Note: All schedules and attachments toForms 5500 and 5500-C/R must includethe name of the plan, the plan sponsorsEIN, and plan number (PN) as found inlines 5a, 1b, and 5c, respectively.

The various schedules to attach to thereturn/report are listed below:

Schedule A (Form 5500), InsuranceInformation, must be attached to Form5500 or 5500-C/R, if any benefits underthe plan are provided by an insurancecompany, insurance service, or othersimilar organization (such as Blue Cross,

Blue Shield, or a health maintenanceorganization). (This includes investmentswith insurance companies such asguaranteed investment contracts (GICs).)

Caution: Your return/report is subject torejection if you submit a privately designedand printed substitute Federal form thathas not been approved by the IRS.

Exceptions. (1) Do not file Schedule A(Form 5500) if the plan covers only: (a) anindividual, or an individual and his or herspouse, who wholly owns a trade orbusiness, whether incorporated orunincorporated; or (b) a partner(s) in apartnership, or a partner(s) and his or herspouse.

(2) Do not file Schedule A (Form 5500)with the Form 5500 or Form 5500-C/R if aSchedule A (Form 5500) is filed for thecontract as part of the master trust or103-12 IE information filed directly withDOL.

Do not file a Schedule A (Form 5500)with a Form 5500-EZ.

Schedule B (Form 5500), ActuarialInformation, must be attached to Form5500, 5500-C/R, or 5500-EZ for mostdefined benefit pension plans. See theinstructions for Schedule B.

Schedule C (Form 5500), ServiceProvider and Trustee Information, must be

attached to Form 5500. See line 25 andthe instructions for Schedule C.

Schedule E (Form 5500), ESOP AnnualInformation, must be attached to Form5500, 5500-C/R, or 5500-EZ for all pensionbenefit plans with ESOP benefits. See theinstructions for Schedule E.

Schedule F (Form 5500), Fringe BenefitPlan Annual Information Return, must beattached to page 1 of Form 5500 or5500-C/R for all fringe benefit plans. Alsosee A Change to Note for 1995 onpage 1.

Schedule G (Form 5500), FinancialSchedules, may be attached to Form 5500when a Yes is checked for any line in27a through 27f. The Schedule G isoptional for 1995 (you may use theschedules specified in the instructions forline 27 instead).

Schedule SSA (Form 5500), AnnualRegistration Statement IdentifyingSeparated Participants With DeferredVested Benefits, may be needed forseparated participants. See When ToReport a Separated Participant in the

instructions for Schedule SSA. Schedule P (Form 5500), Annual Returnof Fiduciary of Employee Benefit Trust,may be filed by any fiduciary (trustee orcustodian) of an organization that isqualified under Code section 401(a) andexempt from tax under Code section501(a) who wants to protect theorganization under the statute of limitationsprovided in Code section 6501(a).

File the Schedule P (Form 5500) as anattachment to Form 5500, 5500-C/R, or5500-EZ for the plan year in which thetrust year ends.

Other Filings

Certain investment arrangements foremployee benefit plans file financialinformation directly with DOL. Thesearrangements include common/collectivetrusts, pooled separate accounts, mastertrusts, and 103-12 IEs. Definitions of theseinvestment arrangements may be found onpage 4. Their DOL filing requirements aredescribed below.

Common/collective trust and pooledseparate account information to be fileddirectly with DOL.Financial institutionsand insurance carriers filing the statementof the assets and liabilities of acommon/collective trust or pooled separateaccount should identify the trust or

account by providing the EIN of the trustor account, or (if more than one trust oraccount is covered by the same EIN) boththe EIN and any additional numberassigned by the financial institution orinsurance carrier (such as: 99-1234567Trust No. 1); and a list of all plansparticipating in the trust or account,identified by the plan number, EIN, andname of the plan sponsor. The direct filingshould be addressed to:

Common/Collective Trust (OR)Pooled Separate AccountPension and Welfare BenefitsAdministration

U.S. Department of Labor, Room N5638

200 Constitution Avenue, NWWashington, DC 20210

Master trust information to be fileddirectly with DOL.The followinginformation with respect to a master trustmust be filed with DOL by the planadministrator or by a designee, such as theadministrator of another plan participatingin the master trust or the financialinstitution serving as trustee of the mastertrust, no later than the date on which theplans return/report is due. While only onecopy of the required information should befiled for all plans participating in the master


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trust, the information is an integral part ofthe return/report of each participating plan,and the plans return/report will not bedeemed complete unless all theinformation is filed within the prescribedtime.

Note: If a master trust investment accountconsists solely of one plans asset(s) duringthe reporting period, the plan may reportthe(se) asset(s) either as an investmentaccount to be reported as part of themaster trust report filed directly with DOLoras a plan asset(s) that is not part of the

master trust (and therefore subject to allinstructions pertaining to assets not held ina master trust).

Each of the following statements andschedules must indicate the name of themaster trust and the name of the mastertrust investment account. The informationshall be filed with DOL by mailing it to:

Master TrustPension and Welfare BenefitsAdministration

U.S. Department of Labor, Room N5638200 Constitution Avenue, NWWashington, DC 20210

1. The name and fiscal year of themaster trust and the name and address ofthe master trustee.

2. A list of all plans participating in themaster trust, showing each plans name,EIN, PN, and its percentage interest ineach master trust investment account asof the beginning and end of the fiscal yearof the master trust ending with or withinthe plan year.

3. A Schedule A (Form 5500) for eachinsurance or annuity contract held in themaster trust.

4. A statement, in the same format asPart I of Schedule C (Form 5500), for eachmaster trust investment account showingamounts of compensation paid during the

fiscal year of the master trust ending withor within the plan year to personsproviding services with respect to theinvestment account and subtracted fromthe gross income of the investmentaccount in determining the net increase(decrease) in net assets of the investmentaccount.

5. A statement for each master trustinvestment account showing the assetsand liabilities of the investment account atthe beginning and end of the fiscal year ofthe master trust ending with or within theplan year, grouped in the same categoriesas those specified on lines 31a through 31lof Form 5500.

6. A statement for each master trustinvestment account showing the incomeand expenses, changes in net assets, andnet increase (decrease) in net assets ofeach such investment account during thefiscal year of the master trust ending withor within the plan year, in the categoriesspecified on line 32 of Form 5500. In placeof line 32a, show the total of all transfersof assets into the investment account byparticipating plans. In place of line 32j,show the total of all transfers of assets outof the investment account by participatingplans.

7. Schedules, in the format set forth inthe instructions for lines 27a through 27fon Form 5500, of the following items withrespect to each master trust investmentaccount for the fiscal year of the mastertrust ending with or within the plan year:assets held for investment, nonexemptparty-in-interest transactions, defaulted oruncollectible loans and leases, and 5%transactions involving assets in theinvestment account. The 5% figure shallbe determined by comparing the currentvalue of the transaction at the transaction

date with the current value of theinvestment account assets at thebeginning of the applicable fiscal year ofthe master trust.

103-12 IE information to be filed directlywith DOL.The information describedbelow must be filed with DOL by thesponsor of the 103-12 IE no later than thedate on which the plans return/report isdue before the plan administrator can electthe alternative method of reporting. Whileonly one copy of the required informationshould be filed for the 103-12 IE, theinformation is an integral part of thereturn/report of each plan electing thealternative method of compliance. Thefiling address is:

103-12 Investment EntityPension and Welfare BenefitsAdministration

U.S. Department of Labor, Room N5638200 Constitution Avenue, NWWashington, DC 20210

1. The name, fiscal year, and EIN of the103-12 IE and the name and address ofthe sponsor of the 103-12 IE. If more thanone 103-12 IE is covered by the same EIN,they shall be sequentially numbered asfollows: 99-1234567 Entity No. 1.

2. A list of all plans participating in the103-12 IE, showing each plans name, EIN,PN, and its percentage interest in the

103-12 IE as of the beginning and end ofthe fiscal year of the 103-12 IE ending withor within the plan year.

3. A Schedule A (Form 5500) for eachinsurance or annuity contract held in the103-12 IE.

4. A statement, in the same format asPart I of Schedule C (Form 5500), for the103-12 IE showing amounts ofcompensation paid during the fiscal year ofthe 103-12 IE ending with or within theplan year to persons providing services tothe 103-12 IE.

5. A statement showing the assets andliabilities at the beginning and end of thefiscal year of the 103-12 IE ending with or

within the plan year, grouped in the samecategories as those specified on line 31 ofForm 5500.

6. A statement showing the income andexpenses, changes in net assets, and netincrease (decrease) in net assets duringthe fiscal year of the 103-12 IE ending withor within the plan year, grouped in thesame categories as those specified in line32 of Form 5500. In place of line 32a,show the total of all transfers of assets intothe 103-12 IE by participating plans. Inplace of line 32j, show the total of all

transfers of assets out of the 103-12 IE byparticipating plans.

7. Schedules, in the format set forth inthe instructions for line 27 of Form 5500(except line 27d) with respect to the103-12 IE for the fiscal year of the 103-12IE ending with or within the plan year.Substitute the term 103-12 IE in place ofthe word plan when completing theschedules.

8. A report of an independent qualifiedpublic accountant regarding the aboveitems and other books and records of the103-12 IE that meets the requirements of29 CFR 2520.103-1(b)(5).

Section 3

Final Return/Report

If all assets under the plan (includinginsurance/annuity contracts) have beendistributed to the participants andbeneficiaries or distributed to another plan(and when all liabilities for which benefitsmay be paid under a welfare benefit planhave been satisfied), check the finalreturn/report box at the top of the formfiled for such plan. The year of completedistribution is the last year a return/reportmust be filed for the plan. For purposes ofthis paragraph, a complete distribution willoccur in the year in which the assets of aterminated plan are brought under thecontrol of PBGC.

For a defined benefit plan covered byPBGC, a PBGC Form 1 must be filed anda premium must be paid until the end ofthe plan year in which the assets aredistributed or brought under the control ofPBGC.

Filing the return/report marked Finalreturn and indicating that the planterminated satisfies the notificationrequirement of Code section 6057(b)(3).

Signature and DateThe plan administrator must sign and dateall returns/reports filed. The name of theindividual who signed as plan administratormust be typed or printed clearly on the lineunder the signature line. In addition, theemployer must sign a return/report filed fora single-employer plan or a plan requiredto file only because of Code section 6039D(i.e., for a fringe benefit plan).

When a joint employer-union board oftrustees or committee is the plan sponsoror plan administrator, at least oneemployer representative and one unionrepresentative must sign and date the

return/report.Participating employers in amultiple-employer plan (other), who arerequired to file Form 5500-C/R, arerequired to sign the return/report. The planadministrator need not sign the Form5500-C/R filed by the participatingemployer.

Reproductions

Original forms are preferable, but a clearreproduction of the completed form isacceptable. Sign the return/report after it isreproduced. All signatures must be original.


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Change in Plan Year

Generally only defined benefit pensionplans need prior approval for a change inplan year. (See Code section 412(c)(5).)Rev. Proc. 87-27, 1987-1 C.B. 769,explains the procedure for automaticapproval of a change in plan year. Apension benefit plan that would ordinarilyhave to obtain approval for a change inplan year under Code section 412(c)(5) isgranted an automatic approval for achange in plan year if all the followingcriteria are met:

1. No plan year exceeds 12 months.

2. The change will not delay the timewhen the plan would otherwise have beenrequired to conform to the requirements ofany statute, regulation, or publishedposition of the IRS.

3. The trust, if any, retains its exemptstatus for the short period required toeffect the change, as well as for thetaxable year immediately preceding theshort period.

4. All actions necessary to implementthe change in plan year, including planamendment and a resolution of the boardof directors (if applicable), have been taken

on or before the last day of the shortperiod.

5. No change in plan year has beenmade for any of the preceding plan years.

6. In the case of a defined benefit plan,deductions are taken in accordance withsection 5 of Rev. Proc. 87-27.

For the first return/report that is filedfollowing the change in plan year, checkthe box on line C at the top of the form.

Amended Return/Report

If you file an amended return/report, checkbox A(2) an amended return/report at thetop of the form. When filing an amended

return, answer all questions and circle theamended line numbers.

How The Annual Return/ReportInformation May Be Used

All Form 5500 series return/reports will besubjected to a computerized review. It is,therefore, in the filers best interest that theresponses accurately reflect thecircumstances they were designed toreport. Annual reports filed under Title I ofERISA must be made available by planadministrators to plan participants and bythe Department of Labor to the publicpursuant to ERISA section 104.

Section 4Important: Answer all questions on theForm 5500 with respect to the plan year,unless otherwise explicitly stated in theline-by-line instructions or on the formitself. Therefore, your responses usuallyapply to the year entered or printed at thetop of the first page of the form. Yes orNo questions must be marked eitherYes or No, but not both. N/Acannot be used to respond to a Yes orNo question that is required to beanswered by the filer as specified on

page 5 under Lines To Complete OnForm 5500.

Information at the Top of the Form

On the first line at the top of the formcomplete the space for dates when (1) the12-month plan year is not a calendar year,or (2) the plan year is less than 12 months(a short plan year).

Line A.Check box (1) if this is the initialfiling for this plan. Do not check this box ifyou have ever filed for this plan even if itwas on a different form (Form 5500 vs.Form 5500-C or Form 5500-R).

Check box (2) if you have already filedfor the 1995 plan year and are nowsubmitting an amended return/report tocorrect errors and/or omissions on thepreviously filed return/report.

Check box (3) if the plan no longer existsto provide benefits. See Section 3 on page7 for instructions concerning therequirement to file a final return/report.

Check box (4) if this form is being filedfor a period of less than 12 months andshow the dates at the top.

Line B.Check box B if you reportinformation in 1a, 2a, 2b, or 5a that is

different from that reported on the lastreturn/report filed. Be certain to provide allinformation in lines 1 through 6d. Pleaseenter changes in red ink and/or circle theline numbers if the information has beenchanged since the last return/report.

Line C.Check this box if the plan yearhas been changed since the lastreturn/report was filed.

Line D.Check this box if you filed for anextension of time to file this form. Attach acopy of the approved Form 5558 or a copyof the employers extension of time to filethe income tax return if you are using theexception in the instructions for Extensionof Time To File on page 2.

Line-By-Line Instructions

Page 1

If a return/report was filed last year, aForm 5500 with information from thatreturn/report printed on page 1 shouldhave been mailed to the filer. Check anypreprinted information in lines 1 through 6dfor accuracy and completeness. Provideany additional information to completelyanswer the questions and cross out anyincorrect information. Enter thesecorrections on page 1. Please use red inkto enter this information and/or circle linenumbers. This will help us process theforms more efficiently and reduce our needto contact you. The return/report must becompleted in accordance with thefollowing specific instructions.

Line 1a.Enter the name and address ofthe plan sponsor. If the plan covers onlythe employees of one employer, enter theemployers name. If the Post Office doesnot deliver mail to the street address andthe sponsor has a P.O. box, show the boxnumber instead of the street address.

The term plan sponsor means

The employer, for an employee benefitplan that a single employer established ormaintains;

The employee organization in the case ofa plan of an employee organization; or

The association, committee, joint boardof trustees, or other similar group ofrepresentatives of the parties whoestablish or maintain the plan, if the plan isestablished or maintained jointly by one ormore employers and one or moreemployee organizations, or by two or moreemployers.

Include enough information on line 1a todescribe the sponsor adequately. Forexample, Joint Board of Trustees of Local187 Machinists rather than just JointBoard of Trustees.

For group insurance arrangements, enterthe name of the trust or other entity thatholds the insurance contracts. In addition,attach a list of all participating employersand their EINs.

A group insurance arrangement is anarrangement which provides benefits to theemployees of two or more unaffiliatedemployers (not in connection with amultiemployer plan or a multiple-employer

collectively bargained plan), fully insuresone or more welfare plans of eachparticipating employer, and uses a trust (orother entity such as a trade association) asthe holder of the insurance contracts andthe conduit for payment of premiums tothe insurance company.

Line 1b.Enter the nine-digit employeridentification number (EIN) assigned to theplan sponsor/employer. For example,00-1234567.

Employers and plan administrators whodo not have an EIN should apply for oneon Form SS-4, Application for EmployerIdentification Number. Form SS-4 can beobtained at most IRS or Social Security

Administration (SSA) offices. Send FormSS-4 to the Internal Revenue ServiceCenter where you will file this Form 5500.

A plan of a controlled group ofcorporations should use the EIN of one ofthe sponsoring members. This EIN must beused in all subsequent filings of the annualreturns/reports for the controlled group.

If the plan sponsor is a group ofindividuals, get a single EIN for the group.When you apply for a number, enter online 1 of Form SS-4 the name of the group,such as Joint Board of Trustees of theLocal 187 Machinists Retirement Plan.

Note: Although EINs for funds (trusts orcustodial accounts) associated with plans

are generally not required to be furnishedon the Form 5500 series returns/reports,the IRS will issue EINs for such funds forother trust reporting purposes. EINs maybe obtained by filing Form SS-4 asexplained above.

Plan sponsors should use the trust EINdescribed in the Note above when openinga bank account or conducting othertransactions for a trust that require an EIN.

Line 1d.From the list of business codeson pages 23 and 24, enter the one thatbest describes the nature of the


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employers business. If more than oneemployer is involved, enter the businesscode for the main business activity.

Line 1e. Plans entering entity code A orB on line 4 must enter the first six digits ofthe CUSIP (Committee on UniformSecurities Identification Procedures)number, issuer number, if one has beenassigned to the plan sponsor for purposesof issuing corporate securities. CUSIPissuer numbers are assigned tocorporations and other entities that issuepublic securities listed on stock exchanges

or traded over the counter. The CUSIPissuer number is the first six digits of thenumber assigned to the individualsecurities that are traded. If the plansponsor has no CUSIP issuer number,enter N/A.

Line 2a.If the document constituting theplan appoints or designates a planadministrator other than the sponsor, enterthe administrators name and address. Ifthe plan administrator is also the sponsor,enter Same. If filing as a group insurancearrangement, enter Same. If Same isentered on line 2a, leave lines 2b and 2cblank.

The term administrator means

The person or group of personsspecified as the administrator by theinstrument under which the plan isoperated;

The plan sponsor/employer if anadministrator is not so designated; or

Any other person prescribed byregulations of the Secretary of Labor if anadministrator is not designated and a plansponsor cannot be identified.

Line 2b.A plan administrator must havean EIN for reporting purposes. Enter theplan administrators nine-digit EIN here. Ifthe plan administrator does not have anEIN, apply for one as explained in the

instructions for line 1b on page 8.Employees of an employer are not plan

administrators unless so designated in theplan document, even though they engagein administrative functions of the plan. If anemployee of the employer is designated asthe plan administrator, that employee mustget an EIN.

Line 3.If the plan sponsors/administrators name, address, and EINhave changed since the last return/reportwas filed for this plan, enter the plansponsors/administrators name, address,and EIN as it appeared on the lastreturn/report filed for this plan.

Line 3c.Indicate if the change on line 3a

is only a change in sponsorship. Changein sponsorship means the plans sponsorhas been changed but no assets orliabilities have been transferred to anotherplan(s), the plan has not terminated, ormerged with any other plan. Therefore, theplan is now the responsibility of the newsponsor whose name is entered in item 1aof this return/report.

Line 4.Entity Code.From the followinglist of entities choose the one thatdescribes your entity and enter that codeon line 4.

Entity Code

Single-employer plan A

Plan of controlled group of corporationsor common control employers B

Multiemployer plan C

Multiple-employer-collectivelybargained plan D

Multiple-employer plan (other) E

Group insurance arrangement(of welfare plans) F

Line 5a.Enter the formal name of theplan, group insurance arrangement, orenough information to identify the plan.

This name should not exceed 70characters. If the present plan nameexceeds 70 characters and spaces, try toabbreviate it.

Line 5b.Enter the date the plan firstbecame effective.

Line 5c.Enter the three-digit number theemployer or plan administrator assigned tothe plan. All welfare benefit plan numbersand Code section 6039D plan numbersstart at 501. All other plans start at 001.

Once you use a plan number, continueto use it for that plan on all future filingswith the IRS, DOL, and PBGC. Do not useit for any other plan even if you terminatedthe first plan.

Line 6a.Welfare Benefit Plan Codes.Check this box and enter every code fromthe list below that describes the welfarebenefit p lan for which this return/report isfiled.

Example. If your plan provides healthinsurance, life insurance, dental insurance,and eye examinations, enter the codes A,B, D, and E. If your plan has a benefit notdescribed by one of the codes, enter Zand write in a description of this benefit inthe space provided.

Type of Welfare Plan Code

Health (other than dental or vision) A

Life insurance B

Supplemental unemployment CDental D

Vision E

Temporary disability (accident and sickness) F

Prepaid legal G

Long-term disability H

Severance pay I

Apprenticeship and training J

Scholarship (funded) K

Death benefits (other than life ins.) L

Taft-Hartley Financial Assistancefor Employee Housing Expenses P

Other (specify on page 1) Z

Line 6b.Pension Benefit Plan Codes.Check this box and enter the codes fromthe list below that describe the type ofbenefits for which the Form 5500 is being

filed.Note: A pension plan must be either adefined benefit or a defined contributionplan.

Type of Pension Benefit Plan Code

Defined benefit 1

Defined Contribution

Profit-sharing 2

Stock bonus 3

Target benefit 4

Other money purchase 5

Other (specify on page 1) 6

Other

Defined benefit plan with benefitsbased partly on balance of separateaccount of participant (Code section414(k)) 7

Annuity arrangement of certainexempt organizations (Code section403(b)(1)) 8

Custodial account for regulatedinvestment company stock (Codesection 403(b)(7)) 9

Pension plan utilizing individualretirement accounts (IRAs) or annuities(described in Code section 408) asthe sole funding vehicle forproviding benefits 0

Line 6c.Pension Plan Feature Codes.If the plan includes pension benefits, enterthe code(s) from the list of pension planfeature codes below.

Type of Pension Plan Feature Code(see descriptions and codes below)

Employee stock ownership plan (ESOP) A

Leveraged ESOP B

Participant-directed account plan C

Pension plan maintained outsid e the USA D

Plan covering self- employed individuals E

Affiliated service group (Code section 414(m)(2)) F

401(k) plan(plan containing a cash or deferredarrangement) G

Top-heavy plan (in 1984 or subsequent plan year) HPlan with permitted disparity provisions(SeeCode sections 401(a)(5) and 401(l)) I

Master plan J

Prototype plan K

Regional prototype plan L

One-participant plan M

If you enter code A or B, you mustcomplete Schedule E (Form 5500) andattach it to the Form 5500 you file for thisplan.

Enter code B for a leveraged ESOP ifthe plan acquires employer securities withborrowed money or other debt-financingtechniques.

Enter code C for a pension plan that

provides for individual accounts andpermits a participant or beneficiary toexercise independent control over theassets in his or her account (see ERISAsection 404(c)).

Enter Code D for a pension benefit planmaintained outside the United Statesprimarily for nonresident aliens. See Kindsof Filers on page 3 for more information.

Enter code F for a plan of an affiliatedservice group. In general, Code section414(m)(2) defines an affiliated service groupas a first service organization (FSO) thathas:

1. A service organization (A-ORG) that isa shareholder or partner in the FSO and

that regularly performs services for theFSO, or is regularly associated with theFSO in performing services for thirdpersons, and/or

2. Any other organization (B-ORG) if:

a. A significant portion of the business ofthat organization consists of performingservices for the FSO or A-ORG of a typehistorically performed by employees in theservice field of the FSO or A-ORG, and

b. 10% or more of the interest of theB-ORG is held by persons who are highly


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compensated employees of the FSO orA-ORG.

An affiliated service group also includesa group consisting of an organizationwhose principal business is performingmanagement functions for anotherorganization (or one organization and otherrelated organizations) on a regular andcontinuing basis, and the organization forwhich such functions are so performed bythe organization.

Enter Code G for a cash or deferredarrangement described under Code section401(k) that is part of a qualified definedcontribution plan that provides for anelection by employees to defer part of theircompensation or receive these amounts incash.

Enter Code H if the plan is top heavy. Atop-heavy plan is a plan that during anyplan year is:

1. Any defined benefit plan if, as of thedetermination date, the present value ofthe cumulative accrued benefits under theplan for key employees exceeds 60% ofthe present value of the cumulativeaccrued benefits under the plan for allemployees; and

2. Any defined contribution plan if, as ofthe determination date, the aggregate ofthe accounts of key employees under theplan exceeds 60% of the aggregate of theaccounts of all employees under the plan.

Each plan of an employer included in arequired aggregation group must betreated as a top-heavy plan if such groupis a top-heavy group. See definitions ofrequired aggregation group and top-heavygroup below.

A key employee is any participant inan employer plan who at any time duringthe plan year, or any of the 4 precedingyears, is:

1. An officer of the employer having an

annual compensation greater than 50% of$120,000, the defined benefit dollarlimitation for 1995 under Code section415(b)(1)(A),

2. One of the 10 employees havingannual compensation from the employergreater than $30,000, the definedcontribution dollar limitation for 1995 underCode section 415(c)(1)(A) and owning (orconsidered as owning within the meaningof Code section 318) the largest interestsin the employer,

3. A 5% owner of the employer, or

4. A 1% owner of the employer havingan annual compensation from the employerof more than $150,000.

In determining whether an individual isan officer of the employer, no more than50 employees, or, if less, the greater of 3employees or 10% of the employees, areto be treated as officers. See Code section416(i) and T-12 of Regulations section1.416-1. A key employee will not includeany officer or employee of a governmentalplan under Code section 414(d).

A required aggregation group consistsof:

1. Each plan of the employer in which akey employee is or was a participant, and

2. Each other plan of the employer thatenables a plan to meet the requirementsfor nondiscrimination in contributions orbenefits under Code section 401(a)(4), orthe participation requirements under Codesection 410.

A top-heavy group is an aggregationgroup if, as of the determination date, thesum of the present value of the cumulativeaccrued benefits for key employees underall defined benefit plans included in suchgroup and the aggregate of the accountsof key employees under all defined

contribution plans in such group exceeds60% of a similar sum determined for allemployees. To determine if a plan istop-heavy, include distributions made inthe 5-year period ending on thedetermination date. However, do not takeinto account accrued benefits for anindividual who has not performed servicesfor the employer during the 5-year periodending on the determination date.

Enter code M for a one-participant planfiling Form 5500 or Form 5500-C/R. Seethe instructions for Plans Excluded FromFiling on page 3 and Form 5500-EZ underOther Forms on page 5.

Line 6d.Fringe Benefit Plan.Complete

only page 1 (lines 1 through 5 and 6d) andSchedule F (Form 5500) for a Form 5500filed only because of Code section 6039D.Check this box and see page 5 foradditional instructions on Lines ToComplete on Form 5500 for a fringebenefit plan.

Line 6e.Line 6e must be answered if theplan used any of these investmentarrangements at any time during the planyear. See pages 4 through 7 for definitions,additional information to attach to Form5500, and other information pertaining tomaster trusts, 103-12 investment entities,common/collective trusts and pooledseparate accounts. Also see the

instructions for lines 25 through 32 forspecific reporting requirements for planswhich utilize these entities.

Line 6e(1).In the space provided in line6e, enter the name of the trust andfinancial institution. Also enter the city andstate where the trust is maintained. (SeeMaster Trust on page 4 for moreinformation.)

Line 6e(2).In the space provided in line6e, enter the name and address of the103-12 IE. (See page 7 for 103-12 IEinstructions.)

Line 6f.For single-employer pensionplans, enter the date the employers taxyear ends. For example, if the tax year is a

calendar year, enter 12-31-95. Do notcomplete line 6f for plans with more thanone employer.

Lines 6g and 6h.A defined benefit planis generally subject to the minimumfunding requirements under section 412unless it is a fully insured plan that isexempt from the minimum fundingrequirements under section 412(i). A plan isconsidered a 412(i) plan whether or not allor part of the plan is trusteed or anoninsured top-heavy side fund ismaintained. All such plans must checktheir 412(i) status on line 6g. Check box 6h

if any part of the plan that was formerlysubject to the minimum fundingrequirements under section 412 for eitherof the prior 2 plan years has becomeexempt under section 412(i).

Note: All defined benefit plans subject tothe minimum funding requirements underSection 412 must complete line 15a andattach Schedule B (Form 5500). Alsocomplete line 15a and attach Schedule B(Form 5500) for all 412(i) plans where allpremiums for the plan year required undersection 412(i) have not been paid before

the lapse of any insurance contract underthe plan and/or where a noninsuredtop-heavy side fund is maintained.

Line 7.The description of participant inthe instructions below is only for purposesof line 7 of this form.

For welfare plans, the number ofparticipants should be determined byreference to 29 CFR 2510.3-3(d).Dependents are considered to be neitherparticipants nor beneficiaries. For pensionbenefit plans, alternate payees entitled tobenefits under a qualified domesticrelations order are not to be counted asparticipants for this line.

Participant means any individual whois included in one of the categories below.

Line 7a.Active participants include anyindividuals who are currently inemployment covered by a plan and whoare earning or retaining credited serviceunder a plan. This category includes anyindividuals who are: (1) currently below thepermitted disparity level in a plan that isintegrated with social security, and/or(2) eligible to elect to have the employermake payments to a Code section 401(k)qualified cash or deferred arrangement.Active participants also include anynonvested individuals who are earning orretaining credited service under a plan.This category does not include nonvested

former employees who have incurred thebreak in service period specified in theplan.

For determining if active participants arefully vested, partially vested, or nonvested,consider vesting in employer contributionsonly.

Line 7b.Inactive participants receivingbenefits are any individuals who are retiredor separated from employment covered bythe plan and who are receiving benefitsunder the plan. This includes formeremployees who are receiving group healthcontinuation coverage benefits pursuant toPart 6 of ERISA who are covered by theemployee welfare benefit plan. This

category does not include any individual towhom an insurance company has made anirrevocable commitment to pay all thebenefits to which the individual is entitledunder the plan.

Line 7c.Inactive participants entitled tofuture benefits are individuals who areretired or separated from employmentcovered by the plan and who are entitledto begin receiving benefits under the planin the future. This category does notinclude any individual to whom aninsurance company has made anirrevocable commitment to pay all the


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benefits to which the individual is entitledunder the plan.

Line 7e.Deceased participants are anydeceased individuals who had one or morebeneficiaries who are receiving or areentitled to receive benefits under the plan.This category does not include anindividual if an insurance company hasmade an irrevocable commitment to pay allthe benefits to which the beneficiaries ofthat individual are entitled under the plan.

Line 7g.Enter the number of participantsincluded in line 7f who have accountbalances at the end of the plan year. Forexample, for a Code section 401(k) plan,the number entered on line 7g should bethe number of participants counted in line7f who have made a contribution to theplan during this plan year or any prior planyear.

Line 7h.Include any participant whoterminated employment during this planyear, whether or not the participantincurred a break in service. Multiemployerplans and multiple-employer-collectivelybargained plans do not have to completeline 7h.

Line 7i(1).If Yes, file Schedule SSA(Form 5500) as an attachment to Form5500. Plan administrators: Code section6057(e) provides that the planadministrator must give each participant astatement showing the same informationreported on Schedule SSA for thatparticipant.

Line 8a.Check Yes if an amendment tothe plan was adopted regardless of theeffective date of the amendment.

Line 8b.Enter the date the most recentamendment was adopted regardless of thedate of the amendment or the effectivedate of the amendment.

Line 8c.Check Yes only if the accruedbenefits were retroactively reduced. For

example, a plan provides a benefit of 2%for each year of service, but the plan isamended to change the benefit to 112% ayear for all years of service under the plan.Do not check Yes if accrued benefitswere retroactively reduced solely to theextent permitted under a modelamendment provided in IRS Notice 88-131,1988-2 C.B. 546.

Line 8d.Check Yes only if anamendment changed the informationpreviously provided to participants by thesummary plan description or summarydescription of modifications.

Line 8e.A revised summary plandescription or summary description of

modifications must be filed with the DOLand distributed to all participants andpension plan beneficiaries no later than210 days after the close of the plan year inwhich the amendment(s) was adopted. Ifthe material was distributed and filed sincethe amendments were adopted (even ifafter the end of the plan year), check Yesfor question 8e.

Line 9a.Check Yes if the plan wasterminated and enter the year oftermination if applicable.

Line 9b.If the plan was terminated butall plan assets were not distributed, a

return/report must be filed for each yearthe plan has assets. In that case, thereturn/report must be filed by the planadministrator, if designated, or by theperson or persons who actually control theplans property.

If all plan assets were used to buyindividual annuity contracts and thecontracts were distributed to theparticipants, check Yes.

If all the plan assets were legallytransferred to the control of another planor brought under the control of PBGC,check Yes.

Check No for a welfare benefit planthat is still liable to pay benefits for claimsthat were incurred prior to the terminationdate, but not yet paid. See 29 CFR2520.104b-2(g)(2)(ii).

Line 9h.The Code provides for anondeductible excise tax on a reversion ofassets from a qualified plan.

Line 9i.The employer must report thereversion by filing Form 5330 and pay anyapplicable tax. The tax will not be imposedon employers who are tax-exempt entitiesunder Code section 501(a). See theinstructions for Form 5330.

Line 10a.If this plan was merged orconsolidated or spunoff into anotherplan(s), or plan assets or liabilities weretransferred to another plan(s), indicatewhich other plan or plans were involved.

Line 10c.Enter the EIN of the sponsor(employer, if for a single-employer plan) ofthe other plan(s).

Line 10d.Enter the plan number of theother plan(s).

Line 10e.Pension benefit plans must fileForm 5310-A, Notice of Plan Merger orConsolidation, Spinoff or Transfer of PlanAssets or Liabilities; Notice of QualifiedSeparate Lines of Business, at least 30days before any plan merger or

consolidation or any transfer of plan assetsor liabilities to another plan.

Caution: There is a penalty for not filingForm 5310-A on time.

Line 11.Funding Arrangement.Enterthe code for the funding arrangement usedby the plan for the plan year from the listbelow.

The funding arrangement is themethod used during the plan year for thereceipt, holding, investment, andtransmittal of plan assets prior to the t imethe plan actually provides the benefitspromised under the plan. For purposes oflines 11 and 12, the term trust includes

any fund or account which receives, holds,transmits, or invests plan assets other thanan account or policy of an insurancecompany.

Note: An employee benefit plan that enterscode 2, 3, or 5 on line(s) 11 and/or 12must attach aSchedule A (Form 5500),Insurance Information, to provideinformation pertaining to each contractyear ending with or within the plan year.See the instructions for Schedule A (Form5500). A plan attaching a Schedule A mayor may not be exempt from therequirement to engage an independent

qualified public accountant. See theinstructions for line 26 on page 15.

Plan FundingArrangement CodesTrust 1

Trust and insurance 2

Insurance 3

Exclusively from general assetsof sponsor (unfunded) 4

Partially insured and partiallyfrom general assets of sponsor 5

Other 6

Line 12.Benefit Arrangement.Enter

the code for the benefit arrangement usedby the plan for the plan year from the listbelow.

The benefit arrangement is the methodby which benefits were actually providedduring the plan year to participants by theplan. For example, if all participantsreceived their benefits from a trust (asdefined in the instructions for line 11above) the plans benefit arrangementcode would be 1. If some benefits comefrom a trust and some come from aninsurance company, the code would be2. If all benefits were paid from anaccount or policy of an insurancecompany, the code would be 3.

Plan BenefitArrangement CodesTrust 1

Trust and insurance 2

Insurance 3

Exclusively from general assetsof sponsor (unfunded) 4

Partially insured and partiallyfrom general assets of sponsor 5

Other 6

Line 13a.Check Yes if either thecontributions to the plan or the benefitspaid by the plan are subject to thecollective bargaining process, even if theplan is not established and administeredby a joint board of trustees. Check Yes

even if only some of those covered by theplan are members of a collectivebargaining unit that negotiates benefitlevels on its own behalf. The benefitschedules do not have to be identical forall employees under the plan.

Line 13b.All plans that entered code Cor D on line 4 must enter the six-digit LMnumber to identify each sponsoring labororganization that is a party to the collectivebargaining agreement. Other plans that aremaintained pursuant to collectivebargaining agreements should enter theappropriate LM number, if available. TheLM number is the six-digitLabor-Management file number entered by

the sponsoring labor organization in item 1of the Form LM-2 or LM-3 (LaborOrganization Annual Report) filed with theDepartment of Labor. Accordingly, the LMnumber(s) should be readily available fromthe sponsoring labor organization(s). If allsponsoring labor organizations LMnumbers cannot be entered in the spacesprovided on line 13b on the form, enter theadditional LM numbers on a supplementalsheet to accompany the Form 5500.

Line 14.If either the funding arrangementcode (line 11) and/or the benefitarrangement code (line 12) is 2, 3, or 5, at


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least one Schedule A (Form 5500) must beattached to the Form 5500 filed forpension and welfare plans to provideinformation concerning the contract yearending with or within the plan year. Theinsurance company (or similar organization)that provides benefits is required toprovide the plan administrator with theinformation needed to complete thereturn/report, pursuant to ERISA section103(a)(2). If you do not receive thisinformation in a timely manner, contact theinsurance company (or similarorganization). If information is missing onSchedule A (Form 5500) due to a refusal toprovide this information, note this on theSchedule A. If there is no Schedule(s) Aattached, enter -0-.

Line 15a.If Yes is checked for line 15a,attach Schedule B (Form 5500) and theschedule shown above to the Form 5500instructions. This schedule, prepared bythe enrolled actuary who prepared the

Schedule B, must show the distribution ofactive participants by age and servicegroupings with average compensationdata. The schedule must be labeled Line15aSchedule of Active ParticipantData. Use the format shown above anduse the same size paper as the Form5500.

Expand this schedule by adding columnsafter the 5 to 9 column and before the40 & up column for active participantswith total years of credited service in thefollowing ranges: 10 to 14; 15 to 19; 20 to24; 25 to 29; 30 to 34; and 35 to 39. Foreach column, enter the number of activeparticipants with the specified number of

years of credited service divided accordingto age group. For participants with partialyears of credited service, round the totalnumber of years of credited service to thenext lower whole number.

For each grouping, enter the averagecompensation of the active participants inthat group. For this purpose, compensationis the compensation taken into account foreach participant under the plans benefitformula, limited to the amount definedunder section 401(a)(17) of the Code.Years of credited service are the yearscredited under the plans benefit formula.

Exception: Do not enter the averagecompensation in any grouping thatcontains fewer than 20 participants. Forexample, if there are 19 participants thathave attained ages 30 to 34 and earned 5to 9 years of credited service, only enterthe number of participants in that groupingand do not enter the averagecompensation.

If this plan is a multiple-employer plan(other), complete one or more schedules ofactive-participant data in a mannerconsistent with the computations for thefunding requirements reported on line 9 ofSchedule B (Form 5500). See the specificinstructions for Lines 9a through 9q ofSchedule B. For example, if the fundingrequirements are computed as if eachparticipating employer maintained aseparate plan, attach a separate schedulefor each participating employer in themultiple-employer plan (other).

Line 15b.If a waived funding deficiencyis being amortized in the current plan year,do not complete (1), (2), and (3), butcomplete lines 3, 8a, 9, and 10 ofSchedule B (Form 5500). An enrolledactuary does not have to sign Schedule Bunder these circumstances.

Line 15b(3).Subtract line 15b(2) from line15b(1). If zero or less, enter -0-. If greaterthan zero, enter the amount of the fundingdeficiency. File Form 5330 with the IRS topay the excise tax on any fundingdeficiency. Caution: There is a penalty fornot filing Form 5330 on time.

Line 16.The 1995 annual compensationlimit under Code section 401(a)(17) is$150,000. However, the 1995 annualcompensation limit for governmental plansand certain plans maintained under acollective bargaining agreement is$245,000.

Line 17a(1).Check Yes if the plandistributed any annuity contracts. CheckYes even if the plan was terminated.

Line 17a(2).If Yes was checked for line17a(1), the annuity contract must providethat all distributions from it will meet theparticipant and spousal consentrequirements of Code section 417.However, consent is not needed for the

distribution of the contract itself. If thecontracts contained the Code section 417requirements, check Yes.

Line 17b.Generally, within the 90 daysprior to the date of any benefit payment orthe date a loan was made to a participant,you must get the spouses consent to thepayment of the benefit or the use of theaccrued benefit to make the loan.However, there are some circumstanceswhere obtaining this spousal consent is notrequired. The following is a partial list ofcircumstances when spousal consent is

not required:1. The participant is not married and no

former spouse is required to be treated asa current spouse under a qualifieddomestic relations order issued by a court.

2. The participants nonforfeitableaccrued benefit in the plan does not havea present value of more than $3,500 at thetime of distribution.

3. The benefit is paid in the form of aqualified joint and survivor annuity (i.e., anannuity for the life of the participant with asurvivor annuity for the life of the spousethat is not less than 50% of, and is notgreater than 100% of, the amount of theannuity that is payable during the joint livesof the participant and the spouse). SeeCode section 417(b).

4. The payout is from a profit-sharing orstock bonus plan that pays the spouse theparticipants full account balance upon theparticipants death, an annuity payment isnot elected by the participant, and theprofit-sharing or stock bonus plan is not atransferee plan with respect to theparticipant (i.e., had not received a transferfrom a plan that was subject to theconsent requirements with respect to theparticipant).

5. The participant did not have serviceunder the plan after August 22, 1984.

Line 17c.A plan may not eliminate asubsidized benefit or a retirement optionby plan amendment or plan termination.

Line 18.Check Yes if, for purposes ofcomputing the minimum fundingrequirements for the plan year, the planadministrator is making an electionintended to satisfy the requirements ofCode section 412(c)(8).

Under Code section 412(c)(8), a planadministrator may elect to have anyamendment, which is adopted after theclose of the plan year to which it applies,treated as having been made on the firstday of that plan year if all the followingrequirements are met:

The amendment is adopted no later than212 months after the close of such planyear (2 years for a multiemployer plan);

The amendment does not reduce theaccrued benefit of any participantdetermined as of the beginning of suchplan year;

The amendment does not reduce theaccrued benefit of any participantdetermined as of the adoption of theamendment unless the plan administratornotified the Secretary of the Treasury ofthe amendment and the Secretary either

Line 15aSchedule of Active Participant Data

YEARS OF CREDITED SERVICE

Under 1 1 to 4 5 to 9AttainedAge

No. Comp.

Avg.

No. Comp.

Avg.

No. Comp.

Avg.

No. Comp.

Avg.

Under 25

25 to 29

30 to 34

60 to 64

65 to 69

70 & up

40 & up

35 to 39

40 to 4445 to 49

50 to 54

55 to 59


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approved the amendment or failed todisapprove the amendment within 90 daysafter the date the notice was filed.

See Temporary Regulations section11.412(c)-7(b) for details on when and howto make the election and the information toinclude on the statement of election, whichmust be filed with the appropriate Form5500 or Form 5500-C/R.

Line 19.Do not answer this question ifyou are filing for a defined contributionplan or for a defined benefit plan for whichthe funding method either has not beenchanged for the plan year or has beenchanged pursuant to an application underRev. Proc. 78-37, 1978-2 C.B. 540.

A revenue procedure that provides for anautomatic approval for a change in fundingmethod is not applicable for the currentplan year unless the plansponsor/administrator explicitly agrees withthe change. If such a change was madepursuant to a revenue procedure for thecurrent plan year and the plansponsor/administrator agrees with thechange, check Yes. Otherwise, checkNo. If No is checked, the change infunding method is not applicable for thisplan year.

Line 20.Defined contribution plans,defined benefit plans that are not subjectto the minimum funding requirements ofCode section 412, and defined benefitplans that are subject to the minimumfunding requirements of section 412 butare multiemployer plans or plans withfewer than 100 participants should notanswer questions 20a and 20b.

A plan has 100 or fewer participants onlyif there were 100 or fewer participants(both active and nonactive participants) oneach day of the preceding plan year takinginto account participants in all definedbenefit plans maintained by the sameemployer who are also employees of that

employer.Line 20a.If the employer is making aone-time irrevocable election to computeadditional unfunded old liability using theOptional rule under Code section412(l)(3)(E), line 15 of Schedule B is notcompleted and additional unfunded oldliability is computed in accordance withsection 412(l)(3)(E)(i). Check Yes if theemployer is making such an election.

Line 20b.The Transition rule of Codesection 412(l)(11) provides an alternativemethod of computing the additionalrequired funding charge under section412(l). For such an election to apply for thecurrent plan year, check Yes for this line.

Line 21.For plan years beginning on orafter January 1, 1995, certain employersmay complete item 21 based on areasonable, good-faith interpretation ofCode sections 410(b), 401(a)(4), and otherrelated Code sections, that differs from theregulations under such Code sections.Check the box in 21(i) if you are applying areasonable, good-faith interpretation thatdiffers from the regulations under suchCode sections. You may, but are notrequired to, attach an explanation of theareas in line item 21 for which you are

applying a reasonable, good-faithinterpretation.

Note: Most employers cannot comply withthe nondiscrimination rules for the 1995plan year on the basis of a reasonable,good-faith interpretation of the statute. SeeRegulations sections 1.401(a)(4)-13 and1.410(b)-10 to identify the employers thatmay rely on a reasonable, good-faithinterpretation of the statute for the 1995plan year (generally limited to plans oftax-exempt organizations).

Revenue Procedure 93-42, 1993-2 C.B.540, provides guidelines designed toreduce the burdens of substantiatingcompliance with the nondiscriminationprovisions. Generally, Rev. Proc. 93-42sets forth new guidelines for: (1) the qualityof data used in substantiating compliancewith the nondiscrimination rules, (2) thetiming of nondiscrimination testing, (3) theidentification of highly compensatedemployees, (4) the testing cycle of a plan,and (5) the qualified separate lines ofbusiness rules. The substantiationguidelines may be used in completing line21.

Check the box in

Department of Labor: 1995-5500inst

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