US Internal Revenue Service: i5500--1990

8/14/2019 US Internal Revenue Service: i5500--1990

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Annual Return/Report of Employee Benefit Plan(With 100 or more participants)

(Code references are to the Internal Revenue Code. ERISArefers to the Employee Retirement Income Security Act of 1974.)

Section 1 Page11A. Who Must File

1B. When To File

1Due date

1Extension of Time To File

2C. Where To File

Section 2

2A. Kinds of Plans

2Pension benefit

2Welfare benefit

Preparing the formRecordkeeping 2Fringe benefit

2B. Plans Excluded From FilingForm 5500 (initial filers)

Form 5500 (all other filers)Schedule A (Form 5500)

Schedule B (Form 5500)

Schedule C (Form 5500)

3C. Kinds of FilersD. Investment Arrangements Filing

3Directly With DOL

4E. What To File

4Schedule E (Form 5500) Forms14 min.(non leveraged ESOP) 1 hr., 26 min.

5SchedulesSchedule E (Form 5500)

5Other Filings(leveraged ESOP)Section 3Schedule P (Form 5500)

Schedule SSA (Form 5500)

6

Section 4

7

Department ofthe TreasuryInternalRevenue Service

Department ofLabor

Pension and WelfareBenefits Administration

PensionBenefit

GuarantyCorporation

86 hrs., 34 min.

80 hrs., 50 min.17 hrs., 28 min.

34 hrs., 12 min.

5 hrs., 16 min.

9 hrs., 49 min.

1 hr., 40 min.

6 hrs., 42 min.

8 hrs., 51 min.

8 hrs., 51 min.28 min.

2 hrs., 23 min.

18 min.

13 hrs., 26 min.

13 hrs., 21 min.1 hr., 42 min.

3 hrs., 3 min.

23 min.

12 min.

1 hr., 55 min.

32 min.

19 min.

1 hr., 41 min.

30 min.

12 min.

48 min.

48 min.16 min.

Learning aboutthe law or the

form

Copyingassembling, and

sendingthe form

to IRS

. . . .

The instructions are divided into four mainsections.

How To Use This InstructionBooklet

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A. Who Must File.Any administrator orsponsor of an employee benefit plansubject to ERISA must file informationabout each such plan every year(Codesection 6058 and ERISA sections 104 and4065). Also required to file, for each year, isevery employer maintaining a specifiedfringe benefit plan as described in Codesection 6039D. The Internal RevenueService (IRS), Department of Labor (DOL),and Pension Benefit Guaranty Corporation(PBGC) have consolidated their returns andreport forms to minimize the filing burden forplan administrators and employers. Thechart on page 4 gives a brief guide to thetype of return/report to be filed.

Page one of Form 5500 has a new formatthat allows us to preprint repetitive planinformation on the form we mail you eachyear after the initial plan year.

File 1990 forms for plan years thatstarted in 1990. If the plan year differs fromthe calendar year, fill in the fiscal yearspace just under the form title. For a shortplan year, see Section 1, instruction B.

New Format for Page One

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

Penalties.ERISA and the Code providefor the assessment or imposition ofpenalties for not giving completeinformation and not filing statements andreturns/reports. Certain penalties areadministrative; that is, they may be imposedor assessed by one of the governmentalagencies delegated to administer thecollection of Form 5500 series data. Othersrequire a legal conviction.A. Administrative Penalties.Listedbelow are various penalties for not meetingthe Form 5500 series filing requirements.One or more of the following five penaltiesmay be imposed or assessed in the eventof incomplete filings or filings received after

the date they are due unless it is determinedthat your explanation for failure to fileproperly is for reasonable cause:

1. A penalty of up to $1,000 a day for eachday a plan administrator fails or refuses to filea complete return/report. See ERISA section502(c)(2) and 29 CFR 2560.502c-2.

2. A penalty of $25 a day (up to $15,000) fornot filing returns for certain plans of deferredcompensation, certain trusts and annuities,and bond purchase plans by the due date(s).See Code section 6652(e). This penalty alsoapplies to returns required to be filed underCode section 6039D.

3. A penalty of $1 a day (up to $5,000) foreach 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 notfiling a notification of change of status of aplan. See Code section 6652(d)(2).

5. A penalty of $1,000 for not filing anactuarial statement. See Code section 6692.

B. Other Penalties.

1. Any individual who willfully violates anyprovision of Part 1 of Title I of ERISA shall befined not more than $5,000 or imprisoned notmore than 1 year, or both. See ERISA section501.

B. When To File.File all required forms

and schedules by the last day of the 7thmonth after the plan year ends. For a shortplan year, file the form and applicableschedules by the last day of the 7th monthafter the short plan year ends. For purposesof this return/report, the short plan yearends upon the date of the change inaccounting period or upon the completedistribution of the assets of the plan. (Alsosee Section 3.) If the current year Form5500 is not available before the due date ofyour short plan year return/report, use thelatest year form available and change thedate printed on the return/report to thecurrent year. Also show the dates yourshort plan year began and ended.

2. A penalty of up to $10,000, 5 yearsimprisonment, or both, for making any falsestatement or representation of fact, knowingit to be false, or for knowingly concealing ornot disclosing any fact required by ERISA.See section 1027, Title 18, U.S. Code, asamended by section 111 of ERISA.

Section 1

Paperwork Reduction Act Notice.We ask for the information on this form to carry out thelaw as specified in ERISA and Code section 6039D. You are required to give us thisinformation. We need it to determine whether the plan is operating according to the law.

The time needed to complete and file the forms listed below reflects the combinedrequirements of the Internal Revenue Service, Department of Labor, Pension Benefit GuarantyCorporation, and the Social Security Administration. These times will vary depending onindividual circumstances. The estimated average times are:

If you have comments concerning the accuracy of these time estimates or suggestions formaking these forms more simple, we would be happy to hear from you. You can write to boththe Internal Revenue Service, Washington, DC 20224, Attention: IRS Reports ClearanceOfficer, T:FP; and the Office of Management and Budget, Paperwork Reduction Project(1210-0016), Washington, DC 20503. DO NOT send this form to either of these offices.Instead, see the instructions on page 2 for information on where to file.

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. . . . General InformationFinal return/report;signature and date; reproductions; change in

plan year; and amended return/report

Specific Instructions for Form 5500 listed

in numerical sequence

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Holtsville, NY 00501

Atlanta, GA 39901

Memphis, TN 37501

All Form 5500EZ filers Andover, MA 05501

If the principal office ofthe plan sponsor or the

plan administrator islocated in

Use the folloviringInternal RevenueService Center

address

Connecticut, Delaware, District ofColumbia, Foreign Address,Maine, Maryland,Massachusetts, New Hampshire,New Jersey, New York,Pennsylvania, PuertoRico, Rhode Island, Vermont,Virginia

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

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

Request for Extension of Time To File. Aone time extension of time up to 2 monthsmay be granted for filing returns/reports ifForm 5558, Application for Extension of TimeTo File Certain Employee Plan Returns, is filedbefore the normal due date (not includingany extensions thereof) of the return/report.

Exception:Single-employer plans andplans of a controlled group of corporationswhich file consolidated Federal income taxreturns are automatically granted an extensionof time to file Form 5500, 5500-C/R, or 5500EZ

to the due date of the Federal income taxreturn of the single employer or controlledgroup of corporations if all the followingconditions are met:

1. The plan year and the tax year coincide.

2. The single employer or the controlledgroup has been granted an extension of time tofile its Federal income tax return to a date laterthan the normal due date (not including anyextensions thereof) for filing the Form 5500,5500-C/R, or 5500EZ.

3. A copy of the IRS extension of time to filethe Federal income tax return is attached toeach Form 5500, 5500-C/R, or 5500EZ filedwith IRS.

Note:An extension of time to file thereturn/report does not operate as an extensionof time to file the PBGC Form 1.

C. Where To File.Please file thereturn/report with the Internal Revenue ServiceCenter indicated below. No street address isneeded.

See page 5 for the filing address forinvestment arrangements filing directly withDOL.

Section 2

B. Plans Excluded From Filing (this doesnot apply if you are a fringe benefit planrequired to file by Code section6039D).Do not file a return/report for anemployee benefit plan that is any of thefollowing:

(a) Pension benefit plan.This is anemployee pension benefit plan covered byERISA. The return/report is due whether or notthe plan is qualified and even if benefits nolonger accrue, contributions were not madethis plan year, or contributions are no

longer made (frozen plan or wasting trust).See Section 3 Final Return/Report on page 6.

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Pension benefit plans required to file includedefined benefit plans and defined contributionplans (e.g., profit-sharing, stock bonus, moneypurchase plans, etc.). The following are amongthe pension benefit plans for which areturn/report must be filed:

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

(ii) Custodial account established underCode section 403(b)(7) for regulatedinvestment company stock.

(iii) Individual retirement accountestablished by an employer under Codesection 408(c).

(iv) Pension benefit plan maintained outsidethe United States primarily for nonresidentaliens if the employer who maintains the planis:

a domestic employer, or

a foreign employer with income derivedfrom sources within the U.S. (includingforeign subsidiaries of domesticemployers) and deducts contributions tothe plan on its U.S. income tax return.See Plans Excluded From Filing below.

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

(vi) A plan that covers residents of PuertoRico, the Virgin Islands, Guam, Wake Island,or American Samoa. This includes a plan thatelects to have the provisions of section1022(i)(2) of ERISA apply.

See Items To Be Completed on Form5500 on page 4 for more information aboutwhat questions need to be completed bypension plans.

(A)

(B)

(b) Welfare benefit plan.This is anemployee welfare benefit plan covered by Part1 of Title I of ERISA. Welfare plans wouldprovide benefits such as medical, dental, lifeinsurance, apprenticeship and training,scholarship funds, severance pay, disability,etc.

See Items To Be Completed on Form5500 on page 4 far more information abouthow to complete this form for a fringe benefitplan.

(a) A welfare benefit plan which coveredfewer than 100 participants as of the beginningof the plan year and is: (i) fully

See Items To Be Completed on Form5500 on page 4 for more information aboutwhat questions need to be completed forwelfare benefit plans.

(c) Fringe benefit plan.Group legalservices plans described in Code section 120,cafeteria plans described in Code section 125,and educational assistance programsdescribed in Code section 127 are consideredfringe benefit plans and generally are requiredto file the annual information specified by Codesection 6039D. However, Code section 127educational assistance programs whichprovide only job-related training which is

deductible under Code section 162 do notneed to file Form 5500.

insured, (ii) unfunded, or (iii) a combinationof insured and unfunded.

(1) An unfunded welfare benefit plan hasits benefits paid as needed directly from thegeneral assets of the employer or theemployee organization that sponsors theplan.

(2) A fully insured welfare benefit plan hasits benefits provided exclusively throughinsurance contracts or policies, thepremiums of which must be paid directly bythe employer or employee organization from

its general assets or partly from its generalassets and partly from contributions by itsemployees or members (which the employeror organization forwards within 3 months ofreceipt).

(3) A combination unfunded/insuredwelfare plan has its benefits providedpartially as an unfunded plan and partially asa fully insured plan. An example of such aplan is a welfare plan which providesmedical benefits as in (1) above and lifeinsurance benefits as in (2) above.

The insurance contracts or policiesdiscussed above must be issued by aninsurance company or similar organization(such as Blue Cross, Blue Shield or a healthmaintenance organization) that can legallydo business in any state. A plan meeting (1)above cannot have any assets at any timeduring the plan year.

Directly, as used in (1) above, meansthat the plan cannot use a trust or separatelymaintained fund (including a Code section501(c)(9) trust) to hold plan assets or to actas a conduit for the transfer of plan assets.

See 29 CFR 2520.104-20.

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

(b) An unfunded pension benefit plan oran unfunded or insured welfare benefit plan:(1) whose benefits go only to a select groupof management or highly compensatedemployees, and (2) which meets the terms ofDepartment of Labor Regulations 29 CFR2520.104-23 (including the requirement thata notification statement be filed with DOL) or29 CFR 2520.104-24.

(c) Plans maintained only to comply withworkers' compensation, unemploymentcompensation, or disability insurance laws.

(d) An unfunded excess benefit plan.

(e) A welfare benefit plan maintainedoutside the United States primarily forpersons substantially all of whom arenonresident aliens.

(f) 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 for thetreatment provided in Code section 402(c).

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

(h) A simplified employee pension (SEP)described in Code section 408(k) whichconforms to the alternative method ofcompliance described-in 29 CFR2520.104-48 or 29 CFR 2520.104-49. A SEPis a pension plan which meets certainminimum qualifications regarding eligibilityand employer contributions.

A. Kinds of Plans.Employee benefit plansinclude pension benefit plans and welfarebenefit plans. File the applicable return/reportfor any of the following plans.


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(i) A church plan not electing coverageunder Code section 410(d) or a governmentalplan.

(j) A welfare plan (other than a fringe benefitplan) that participates in a group insurancearrangement that files a return/report Form5500 on behalf of the welfare plan. See 29CFR 2520.104-43.

(k) An apprenticeship or training planmeeting all of the conditions specified in 29CFR 2520.104-22.

C. Kinds of Filers.The different types ofentities which file the forms are describedbelow. (Also see instructions for item 4 onpage 7.)

(a) Single-employer plan.If one employeror one employee organization maintains aplan, file a separate return/report for the plan. Ifthe employer or employee organizationmaintains more than one such plan, file aseparate return/report for each plan.

If a member of either a controlled group ofcorporations or a group of trades orbusinesses under common control maintains aplan that does not involve other group

members, file a separate return/report as asingle-employer plan.

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

(b) Plan for controlled group of corporationsor group of trades or businesses undercommon control.These groups are defined inCode sections 414(b) and (c), and are referredto as controlled groups.

If the benefits are payable to participantsfrom the plan's total assets without regard to

contributions by each participant's employer,file one return/report for the plan. On thereturn/report for the plan, complete item 22only for the controlled group's employees.

Exception: Employers who participate in apension plan of one of the groups listed abovebut who are not members of the group mustfile a separate return/report. The return/reportshould be filed on Form 5500-C/R regardlessof the number of participants. The years youare required to file pages 1 and 3 through 6 asForm 5500-C complete only items 1 through 6,9, and 22. The years you file pages 1 and 2 asForm 5500-R complete only items 1 through8c. These participating employers must entercode F in item 4 of the Form 5500-C/R.

If several employers participate in aprogram of benefits wherein the fundsattributable to each employer are availableonly to pay benefits to that employer'semployees, each employer must file aseparate return/report as a single employerplan.

(c) Multiemployer plan. Multiemployerplans are plans: (1) to which more than oneemployer is required to contribute, (2) whichare maintained pursuant to one or morecollective bargaining agreements, and (3) havenot made the election under Code section414(f)(5) and ERISA section 3(37)(E). File onereturn/report for each such plan.

D. Investment Arrangements FilingDirectly With DOL.Same plans invest incertain trusts, accounts, and otherinvestment arrangements which may fileinformation concerning themselves and theirrelationship with employee benefit plansdirectly with DOL (as specified on page 5).Plans participating in an investmentarrangement as described in paragraphs athrough c below are required to attachcertain additional information to the return/report filed with IRS as specified below.

(d) Multiple-employer-collectively-bargainedplan.A multiple-employer-collectively-bargained plan involves more than oneemployer, is collectively bargained andcollectively funded, and, if covered by PBGCtermination insurance, had properly electedbefore 9-27-81 not to be treated as amultiemployer plan under Code section414(f)(5) or ERISA sections 3(37)(E) and

4001(a)(3). File one return/report for each suchplan. Participating employers do not fileindividually for these plans.

Note: Filers described in (c) or (d) above doNOT complete item 22.

The Form 5500-C or Form 5500-R filed bythe participating employer should list his or her

appropriate plan number.

a. Common/Collective Trust andPooled Separate Account

Note: If a participating employer is also thesponsor of the multiple-employer plan (other),the plan number on the return/ report filed forthe plan should be 333 and if more than one

plan they should be consecutively numberedstarting with 333.

If more than one employer participates inthe plan and the plan provides that eachemployer's contributions are available to paybenefits only for that employer's employeeswho are covered by the plan, one annualreturn/report must be filed for eachparticipating employer. These filers will beconsidered single employers and shouldcomplete the entire form.

You do not need to file a separatereturn/report for a welfare benefit plan that ispart of a group insurance arrangement if aconsolidated return/report for all the plans inthe arrangement was filed by the trust or otherentity according to 29 CFR 2520.104-43. Form5500 is required by 29 CFR 2520.103-2 to bepart of the consolidated report.

Exception: Each employer participating in amultiple-employer plan (other) which providespension benefits must file a Form 5500-C/Rregardless of the number of participants. For theyears you are required to file pages 1 and 3through 6 as Form 5500-C, complete only items1 through 6, 9, and 22. For the years you filepages 1 and 2 as Form 5500-R, complete onlyitems 1 through 8c. Each participating employerfiling the Form 5500-C/R must enter code F initem 4.

(f) Group insurance arrangement. Agroup insurance arrangement is anarrangement which provides benefits to theemployees of two or more unaffiliatedemployers (not in connection with amulti-employer plan or a multiple-employer-

collectively-bargained plan), fully insures oneor more welfare plans of each participatingemployer, and uses a trust (or other entity suchas a trade association) as the holder of theinsurance contracts and the conduit forpayment of premiums to the insurancecompany.

(e) Multiple-employer plan (other).Amultiple-employer plan (other) involves morethan one employer and is not one of the plansalready described. A multiple-employer plan(other) includes only plans whose contributionsfrom individual employers are available to paybenefits to all participants. File one return/report for each such plan.

(i) Definition. For reporting purposes, a"common/collective trust" is a trustmaintained by a bank, trust company, orsimilar institution which is regulated,supervised, and subject to periodicexamination by a state or Federal agency forthe collective investment and reinvestment ofassets contributed thereto from employeebenefit plans maintained by more than oneemployer or controlled group of corporations,as the term is used in Code section 1563.For reporting purposes, a "pooled separateaccount" is an account maintained by aninsurance carrier which is regulated,supervised, and subject to periodic

examination by a state agency for thecollective investment and reinvestment ofassets contributed thereto from employeebenefit plans maintained by more than oneemployer or controlled group of corporations,as the term is used in Code section 1563.See 29 CFR sections 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 a

pooled separate account.

(ii) Additional Information Required To BeAttached to the Form 5500 for PlansParticipating in Common/Collective Trusts

and Pooled Separate Accounts.A planparticipating in a common/collective trust orpooled separate account must complete theannual return/report and attach either (1) themost recent statement of the assets andliabilities of any common/collective trust orpooled separate account, or (2) acertification that: (A) the statement of theassets and liabilities of the common/collective trust or pooled separate accounthas been submitted directly to DOL by thefinancial institution or insurance carrier; (B)the plan has received a copy of thestatement; and (C) includes the EIN andother numbers used by the financialinstitution or insurance carrier to identify thetrusts or accounts in the direct filing made

with DOL.

Contributing employers do not file individuallywith respect to such plans. See Code section414 for more information.

b. Master Trust

(i) Definition. For reporting purposes, amaster trust is a trust for which a regulatedfinancial institution (as defined below) servesas trustee or custodian (regardless ofwhether such institution exercisesdiscretionary authority or control with respectto the management of assets held in thetrust), and in which assets of more than oneplan sponsored by a single employer or by agroup of employers under common controlare held.

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Summary of Filing Requirements for Employers and Plan Administrators(File forms ONLY with IRS)

When to fileWhat to fileType of plan

Most pension plans with only one participant or one participant and that participant's spouse Form 5500EZ

Pension plan with fewer than 100 participants Form 5500-C/R

Pension plan with 100 or more participants Form 5500

Annuity under Code section 403(b)(1) or trust under Code section 408(c) Form 5500 or 5500-C/R

Custodial account under Code section 403(b)(7) Form 5500 or 5500-C/RWelfare benefit plan with 100 or more participants* Form 5500

Welfare benefit plan with fewer than 100 participants (see exception on page 1 of these instructions)* Form 5500-C/R

Pension or welfare plan with 100 or more participants (see instructions for item 29)Financial statements, schedules,

and accountant's opinion

Pension or welfare plan with benefits provided by an insurance company Schedule A (Form 5500)

Pension plan that requires actuarial information Schedule B (Form 5500)

Pension or welfare plan with 100 or more participants Schedule C (Form 5500)

Pension plan with ESOP benefits Schedule E (Form 5500)

Pension plan filing a registration statement identifying separated participants with deferred vestedbenefits from a pension plan

Schedule SSA(Form 5500)

*This includes Code section 6039D filers.Page 4

File all

required

forms and

schedules

for eachplan by the

last day of

the 7th

month after

the plan

year ends.

A regulated financial institution means abank, trust company, or similar financialinstitution which is regulated, supervised, andsubject to periodic examination by a state orFederal agency. Common control isdetermined on the basis of all relevant factsand circumstances (whether or not suchemployers are incorporated). See 29 CFR2520.103-1(e).

For reporting purposes, the assets of amaster trust are considered to be held in oneor more investment accounts. A master trust

investment account may consist of a pool ofassets or a single asset.

Each pool of assets held in a master trustmust be treated as a separate master trustinvestment account if each plan which has aninterest in the pool has the same fractionalinterest in each asset in the pool as itsfractional interest in the pool, and if each suchplan may not dispose of its interest in anyasset in the pool without disposing of itsinterest in the pool. A master trust may alsocontain assets which are not held in such apool. Each such asset must be treated as aseparate master trust investment account.

Financial information must generally beprovided with respect to each master trust

investment account as specified on page 5.(ii) Additional Information Required To Be

Attached to the Form 5500 for PlansParticipating in Master Trusts. A planparticipating in a master trust must completethe annual return/report and attach a schedulelisting each master trust investment account inwhich the plan has an interest indicating theplan's name, EIN, and plan number and thename of the master trust used in the mastertrust information filed with DOL (see page 5).In tabular format, show the net value of theplan's interest in each investment account atthe beginning and end of the plan year, andthe net investment gain (or loss) allocated tothe plan for the plan year from the investmentaccount (see instructions for items 34c(11)

through (15) on page 16).

is not part of the master trust (and thereforesubject to all instructions pertaining to assetsnot held in a master trust).

Definition. 29 CFR 2520.103-12 provides analternative method of reporting for plans whichinvest in an entity (other than an investmentarrangement filing with DOL described in a or babove), the underlying assets of which includeplan assets (within the meaning of 29 CFR2510.3-101) of two or more plans which arenot members of a related group of employeebenefit plans. For reporting purposes, arelated group consists of each group of twoor more employee benefit plans (1) each ofwhich receives 10% or more of its aggregatecontributions from the same employer or froma member of the same controlled group ofcorporations (as determined under Codesection 1563(a), without regard to Codesection 1563(a)(4) thereof); or (2) each ofwhich is either maintained by, or maintainedpursuant to a collective bargaining agreementnegotiated by, the same employeeorganization or affiliated employeeorganizations. For purposes of this paragraph,an affiliate of an employee organizationmeans any person controlling, controlled by, orunder common control with such organization.See 29 CFR 2520.103-12.

For reporting purposes, the investmententities described above with respect to whichthe required information is filed directly withDOL constitute 103-12 investment entities(103-12 IEs).

Note:If a master trust investment accountconsists solely of one plan's asset(s) during thereporting period, the plan may report the(se)asset(s) either as an investment account to bereported as part of the master trust report fileddirectly with DOL or as a plan assets(s) which

E. What To File.This section describes thedifferent categories of the 5500 series of formsand schedules. In addition, this section also listsitems to be completed by different types of Form5500 filers. This section also contains adescription of the special filing requirements forplans that invest in certain investmentarrangements. For a brief guide illustratingwhich forms and schedules are required bydifferent types of plans and filers, see chartbelow.

Form 5500.File Form 5500, AnnualReturn/Report of Employee Benefit Plan,annually for each plan with 100 or moreparticipants at the beginning of the plan year.

Forms

c. 103-12 Investment Entities

Form 5500-C/R.File Form 5500-C/R,Return/Report of Employee Benefit Plan, foreach pension benefit plan, welfare benefitplan, and fringe benefit plan (unlessotherwise exempted) with fewer than 100participants (one-participant plans see Form5500EZ below) at the beginning of the planyear.Note: Generally, under the filingrequirements explained above, if the numberof plan participants increases from under 100to 100 or more, or decreases from 100 or

more to under 100, from one year to thenext, you would have to file a different formfrom that filed the previous year. However,there is an exception to this rule. You maycontinue to file the same form you filed lastyear, provided that at the beginning of this

plan year the plan had at least 80participants, but not more than 120.

Form 5500EZ.Form 5500EZ,AnnualReturn of One-Participant Pension BenefitPlan, should be filed by most one participantplans.

A one-participant plan is: (1) a pensionbenefit plan that covers only an individual oran individual and his or her spouse whowholly own a trade or business, whetherincorporated or unincorporated; or (2) a

pension benefit plan for a partnership thatcovers only the partners or the partners andthe partners' spouses.

See Form 5500EZ and its instructions tosee if the plan meets the requirements forfiling the form.

1. Welfare Benefit PlansWelfare benefitplans generally must complete the followingitems on the Form 5500: 1 through 6a; 6c,7a(4), b, c, and d; 8a, b, e, and f; 9a, b, c,and f; 10a through d; 11 through 14; 28through 32; and 34 through 36.

Certain kinds of plans and certain kinds offilers that are required to submit an annualForm 5500 are not required to complete theentire form. These are described below, bytype of plan. Check the list of headings to

see if your plan is affected.

Items To Be Completed on Form5500

Form 8822.Form 8822, Change ofAddress, may be used to notify the IRS if theplan's mailing address changes.


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The various schedules to be attached to thereturn/report are listed below.

3. Pension PlansIn general, most pensionplans (defined benefit and defined contribution)are required to complete all items on the form.However, some items need not be completedby certain types of pension plans, as describedbelow.

If the annual return/report is also for awelfare benefit plan (see Who Must File onpage 1), complete the above items and thosespecified for welfare benefit plans in 1 above.

a. Plans exclusively using a tax deferredannuity arrangement under Code section403(b)(1). These plans (see Who Must Fileon page 1) need only complete items 1 through5, 6b (enter code 4), and 9.

b. Plans exclusively using a custodial accountfor regulated investment company stock underCode section 403(b)(1).These plans need onlycomplete items 1 through 5, 6b (enter code 5),and 9.

c. Individual Retirement Account Plan.Apension plan utilizing individual retirement

accounts or annuities (as described in Codesection 408) as the sole funding vehicle forproviding benefits need only complete items 1through 5, 6b (enter code 6), and 9.

d. Fully Insured Pension Plan.A pensionbenefit plan providing benefits exclusivelythrough an insurance contract, or contractsthat are fully guaranteed and which meet all ofthe conditions of 29 CFR 2520.104-44 needonly complete items 1 through 29, 32, and 33.

A pension plan which includes bothinsurance contracts of the type described in 29CFR 2520.104-44 as well as other assetsshould limit its reporting in items 34 and 35 tothose other assets.

Note:For purposes of the annual return/ reportand the alternative method of compliance setforth in 29 CFR 2520.104-44, a contract isconsidered to be allocated only if theinsurance company or organization that issuedthe contract unconditionally guarantees, uponreceipt of the required premium orconsideration, to provide a retirement benefit ofa specified amount, without adjustment forfluctuations in the market value of theunderlying assets of the company ororganization, to each participant, and each

participant has a legal right to such benefitswhich is legally enforceable directly against theinsurance company or organization.

e. Nonqualified pension benefit plans

maintained outside the U.S.Nonqualifiedpension benefit plans maintained outside theUnited States primarily for nonresident aliensrequired to file a return/report (see Who MustFile on page 1) need only complete items 1through 8c, 9 through 12, and 15 through 17.

4. Plans of More Than One EmployerAllplans of more than one employer (plans of acontrolled group, multiemployer plans,multiple-employer-collectively-bargained plans,and multiple-employer plan (other)) generallyshould complete all applicable (welfare orpension) items on the form except for item 6d.Only single-employer pension plans mustcomplete this item.

Schedules2. Fringe Benefit PlansFor a Form 5500filed only because of Code section 6039D (i.e.,for a fringe benefit plan), complete only items 1through 6a, 7a(4), 7b, 9a and b, 22h, 22m, 35gand 35h. Note:All attachments to the Forms 5500, and

5500-C/R, must include the name of the planand the plan sponsor's EIN and plan number(PN) as found in items 5a, 1b, and 5c,respectively.

Attach Schedule A (Form 5500), InsuranceInformation, to Form 5500, or 5500-C/R, ifany benefits under the plan are provided by an

insurance company, insurance service, orother similar organization (such as Blue Cross.Blue Shield, or a health maintenanceorganization).

Exceptions:(1) Schedule A (Form 5500) isnot needed if the plan covers only: (a) anindividual, or an individual and his or herspouse, who wholly owns a trade or business,whether incorporated or unincorporated, or (b)a partner in a partnership, or a partner and hisor her spouse.

(2) A Schedule A (Form 5500) is notrequired to be filed with the Form 5500 or Form5500-C/R if a Schedule A (Form 5500) is filedfor the contract as part of the master trust or103-12 IE information filed directly with DOL.

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

Attach Schedule B (Form 5500), ActuarialInformation, to Form 5500, 5500-C/R, or5500EZ for most defined benefit pensionplans. See the instructions for Schedule B.

Attach Schedule C (Form 5500), ServiceProvider and Trustee Information, to Form5500. See item 28 and the instructions toSchedule C.

Attach Schedule E (Form 5500), ESOPAnnual Information, to Form 5500, 5500-C/R,or 5500EZ for all pension benefit plans withESOP benefits. See the instructions forSchedule E.

Schedule SSA (Form 5500), AnnualRegistration Statement IdentifyingSeparated Participants With DeferredVested Benefits, may be needed forseparated participants. See When To ReportSeparated Participants in the instructions forSchedule SSA.

Schedule P (Form 5500), Annual Return ofFiduciary of Employee Benefit Trust.Anyfiduciary (trustee or custodian) of anorganization that is qualified under Codesection 401(a) and exempt from tax underCode section 501(a) who wants to protect theorganization under the statute of limitationsprovided in Code section 6501(a) must file aSchedule P (Form 5500).

File the Schedule P (Form 5500) as anattachment to Form 5500, 5500-C/R, or5500EZ for the plan year in which the trustyear ends.

Other Filings

Reporting Requirements for InvestmentArrangements Filing Directly with DOL

Certain investment arrangements for employeebenefit plans file financial information directlywith DOL. These arrangements includecommon/collective trusts, pooled separateaccounts, master trusts, and 103-121Es.Definitions of these investment arrangements

may be found on pages 3 and 4. Their DOLfiling requirements are described below.

1. Common/Collective Trust and PooledSeparate Account Information To Be FiledDirectly With DOL

Financial institutions and insurance carriersfiling the statement of the assets andliabilities of a common/collective trust orpooled separate account should identify thetrust or account by providing the EIN of thetrust or account, or (if more than one trust oraccount is covered by the same EIN) both

the EIN and any additional number assignedby the financial institution or insurancecarrier (such as: 99-1234567 Trust No. 1);and a list of all plans participating in the trustor account, identified by the plan number,EIN, and name of the plan sponsor. Thedirect filing should be addressed to:

Common/Collective Trust (OR)Pooled Separate AccountPension and Welfare Benefits AdministrationU.S. Department of Labor, Room N5644200 Constitution Avenue, NWWashington, DC 20210

2. Master Trust Information To Be FiledDirectly With DOL

The following information with respect to amaster trust must be filed with DOL by theplan administrator or by a designee, such asthe administrator of another planparticipating in the master trust or thefinancial institution serving as trustee of themaster trust, no later than the date on whichthe plan's return/report is due. While onlyone copy of the required information shouldbe filed for all plans participating in themaster trust, the information is an integralpart of the return/report of each participatingplan, and the plan's return/report will not bedeemed complete unless all the informationis filed within the prescribed time.

Note: if a master trust investment accountconsists solely of one plan's asset(s) during

the reporting period; the plan may reportthe(se) asset(s) either as an investmentaccount to be reported as part of the mastertrust report filed directly with DOL or as a

plan asset(s) which is not part of the mastertrust (and therefore subject to all instructions

pertaining to assets not held in a mastertrust).

Each of the following statements andschedules must indicate the name of themaster trust and the name of the master trustinvestment account: The information shall befiled with DOL by mailing it to:

Master TrustPension and Welfare Benefits AdministrationU.S. Department of Labor, Room N5644200 Constitution Avenue, NWWashington, DC 20210

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

b. A list of all plans participating in themaster trust, showing each plan's name,EIN, PN, and its percentage interest in eachmaster trust investment account as of thebeginning and end of the fiscal year of themaster trust ending with or within the planyear.

Page 5


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

d. A statement, in the same format as Part Iof Schedule C (Form 5500), for each mastertrust investment account showing amounts ofcompensation paid during the fiscal year of themaster trust ending with or within the plan yearto persons providing services with respect tothe investment account and subtracted fromthe gross income of the investment account indetermining the net increase (decrease) in net

assets of the investment account.e. A statement for each master trust

investment account showing the assets andliabilities of the investment account at thebeginning and end of the fiscal year of themaster trust ending with or within the planyear, grouped in the same categories as thosespecified in item 34 of Form 5500.

f. A statement for each master trustinvestment account showing the income andexpenses, changes in net assets, and netincrease (decrease) in net assets of each suchinvestment account during the fiscal year ofthe master trust ending with or within the planyear, in the categories specified in item 35 ofForm 5500. In place of item 35a, show the total

of all transfers of assets into the investmentaccount by participating plans. In place of item35j, show the total of all transfers of assets outof the investment account by participatingplans.

g. Schedules, in the format set forth in theinstructions for item 30 of Form 5500, of thefollowing items with respect to each mastertrust investment account for the fiscal year ofthe master trust ending with or within the planyear: assets held for investment, nonexemptparty-in-interest transactions, defaulted oruncollectible loans and leases, and 5%transactions involving assets in the investmentaccount. The 5% figure shall be determined bycomparing the current value of the transactionat the transaction date with the current value of

the investment account assets at the beginningof the applicable fiscal year of the master trust.

3. 103-12 IE Information To Be Filed DirectlyWith DOL

The information described below must befiled with the DOL by the sponsor of the103-12 IE no later than the date on which theplan's return/report is due before the planadministrator can elect the alternative methodof reporting. While only one copy of therequired information should be filed for the103-12 IE, the information is an integral part ofthe return/report of each plan electing thealternative method of compliance.

The filing address is:

103-12 Investment EntityPension and Welfare Benefits AdministrationU. S. Department of Labor, Room N5644200 Constitution Avenue, NWWashington, DC 20210

a. The name, fiscal year, and EIN of the103-12 IE and the name and address of thesponsor of the 103-12 IE. If more than one103-12 IE is covered by the same EIN. theyshall be sequentially numbered as follows:99-1234567 Entity No. 1.

Page 6

b. A list of all plans participating in the103-12 IE, showing each pian's name, EIN,PN, and its percentage interest in the 103-12IE as of the beginning and end of the fiscalyear of the 103-12 IE ending with or within theplan year.

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

d. A statement, in the same format as Part Iof Schedule C (Form 5500), for the 103-12 IEshowing amounts of compensation paid duringthe fiscal year of the 103-12 IE ending with orwithin the plan year to persons providingservices to the 103-12 IE.

e. A statement shelving the assets andliabilities at the beginning and end of the fiscalyear of the 103-12 IE ending with or within theplan year, grouped in the same categories asthose specified in item 34 of Form 5500.

f. A statement showing the income andexpenses, changes in net assets, and netincrease (decrease) in net assets during thefiscal year of the 103-12 IE ending with orwithin the plan year, grouped in the samecategories as those specified in item 35 ofForm 5500. In place of item 35a, show the totalof all transfers of assets into the 103-12 IE byparticipating plans. In place of item 35j, showthe total of all transfers of assets out of the103-12 IE by participating plans.

g. Schedules, in the format set forth in theinstructions for item 30 of Form 5500 (exceptitem 30c) with respect to the 103-12 IE for thefiscal year of the 103-12 IE ending with orwithin the plan year. Substitute the term103-121E in place of the word plan whencompleting the schedules.

h. A report of an independent qualifiedpublic accountant regarding the above itemsand other books and records of the 103-12 IEthat meets the requirements of 29 CFR2520.103-1(b)(5).

Section 3

General Information

Final Return/Report.If all assets under theplan (including insurance/annuity contracts)have been distributed to the participants andbeneficiaries or distributed to another plan (andwhen all liabilities for which benefits may bepaid under a welfare plan have been satisfied),check the final return/report box at the top ofthe form filed for such plan. The year ofcomplete distribution is the last year areturn/report must be filed for the plan. Forpurposes of this paragraph, a completedistribution will occur in the year in which theassets of a terminated plan are brought underthe control of PBGC.

For a defined benefit plan covered byPBGC, a PBGC Form 1 must be filed and apremium must be paid until the end of the planyear in which the assets are distributed orbrought under the control of PBGC.

Filing the return/report marked Final returnand indicating that the plan terminated satisfiesthe notification requirement of Code section6057(b)(3).

Signature and Date.The plan administratormust sign and date all returns/reports filed. Thename of the individual who signed as planadministrator must be typed or printed clearlyon the line under the signature line.

In addition, the employer must sign areturn/report filed for a single-employer plan,or a plan required to file only because ofCode section 6039D.

When a joint employer-union board oftrustees or committee is the plan sponsor orplan administrator, at least one employerrepresentative and one union representativemust sign and date the return/report.

Participating employers in amultiple-employer plan (other), who arerequired to file Form 5500-C/R, are required

to sign the return/report. The planadministrator need not sign the Form5500-C/R filed by the participating employer.

Reproductions.Original forms arepreferable, but a clear reproduction of thecompleted form is acceptable. Sign thereturn/report after it is reproduced. Allsignatures must be original.

Change in Plan Year.Generally onlydefined contribution pension benefit plansneed to get prior approval for a change inplan year. (See Code section 412(c)(5).)Rev. Proc. 87-27, 1987-1 C.B. 769 explainsthe procedure for automatic approval of achange in plan year. A pension benefit planthat would ordinarily need to obtain approval

for a change in plan year under Code section412(c)(5) is granted an automatic approvalfor a change in plan year if all the followingcriteria are met:

1. No plan year is more than 12 monthslong.

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

3. The trust, if any, retains its exemptstatus for the short period required to effectthe change, as well as for the taxable yearimmediately preceding the short period.

4. All actions necessary to implement thechange in plan year, including planamendment and a resolution of the board ofdirectors (if applicable), have been taken onor before the last day of the short period.

5. No change in plan year has been madefor 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, check thebox on line C at the top of the form.

Amended Return/Report.If you file anamended return/report, check box A(2) anamended return/report at the top of theform: When filing an amended return, besure to answer all questions and put a circlearound the numbers of the items that havebeen amended.

How The Annual Return/ReportInformation May Be Used.All Form 5500series return/reports will be subjected to acomputerized review. It is, therefore, in thefiler's best interest that the responsesaccurately reflect the circumstances theywere designed to report. Annual reports filedunder Title I of ERISA must be madeavailable by plan administrators to planparticipants and by the Department of Laborto the public pursuant to ERISA section 104.


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Section 4Specific Instructions forForm 5500Important: Answer all items on the Form 5500with respect to the plan year, unless otherwiseexplicitly stated in the item-by-item instructionsor on the form itself. Therefore, your responsesusually apply to the year entered or printed atthe top of the first page of the form. Yes andNo questions are to be marked either Yesor No but not both. N/A cannot be used torespond to a Yes or No question whichis required to be answered by the filer asspecified on page 4 under Items To BeCompleted On Form 5500.

Information To Be Completed at the Top ofthe Form

A. Check box (1) if this is the initial filing forthis plan. Do not check this box if you haveever filed for this plan even if it was on adifferent form (Form 5500 vs. Form 5500-C orForm 5500-R).

First Line at the top of the formCompletethe space for dates when: (1) the 12-monthplan year is not a calendar year, or (2) the planyear is less than 12 months (a short plan year).

Check box (2) if you have already filed forthe 1990 plan year and are now submitting anamended return/report to reflect errors and/oromissions on the previously filed return/report.

Check box (3) if the plan no longer exists toprovide benefits. See section 3 for instructionsconcerning the requirement to file a finalreturn/report.

Check box (4) if this form is being filed for aperiod of less than 12 months.

B. Check the box if you made any changes tothe preprinted information on page 1.

The numbers of the following instructionsare the same as the item numbers on the

return/report.

C. Check the box if the plan year has beenchanged since the last return/report was filed.

If you did not receive a Form 5500 with thepage one information filled in, complete items1 through 6b as follows:

1a. Enter the name and address of the plansponsor. If the plan covers only the employeesof one employer, enter the employer's name. Ifthe Post Office does not deliver mail to thestreet address and the sponsor has a P.O.box, show the P.O. box number instead of thestreet address.

The term plan sponsor means

(i) the employer, for an employee benefitplan that a single employer established ormaintains;

(ii) the employee organization in the case ofa plan of an employee organization; or

(iii) the association, committee, joint boardof trustees, or other similar group ofrepresentatives of the parties who establish ormaintain the plan, if the plan is established ormaintained jointly by one or more employersand one or more employee organizations, orby two or more employers.

Include enough information in 1(a) todescribe the sponsor adequately. For example,Joint Board of Trustees of Local 187Machinists rather than just Joint Board ofTrustees.

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 insures oneor more welfare plans of each participating

employer, and uses a trust (or other entitysuch as a trade association) as the holder ofthe insurance contracts and the conduit forpayment of premiums to the insurancecompany.

For group insurance arrangements, enterthe name of the trust or other entity that holdsthe insurance contracts. In addition, attach alist of all participating employers and theirEINs.

1b. Enter the 9-digit employer identificationnumber (EIN) assigned to the plansponsor/employer. For example, 00-1234567.

Employers and plan administrators who donot have an EIN should apply for one on FormSS-4, available from most IRS or SocialSecurity Administration offices. Send FormSS-4 to the same Internal Revenue ServiceCenter to which this form will be sent.

Plan sponsors are reminded that theyshould use the trust EIN when opening a bank

account or conducting other transactions for aplan that requires an employer identificationnumber. The trust may apply for an EIN asexplained in the preceding paragraph.

A plan of a controlled group of corporationswhose sponsor is more than one of themembers of the controlled group should insertonly the EIN of one of the sponsoringmembers. This EIN must be used in allsubsequent filings of the annual returns/reportsfor the controlled group unless there is achange in the sponsor.

If the plan sponsor is a group of individuals,get a single EIN for the group. When you applyfor a number, enter on line 1 of Form SS-4 thename of the group, such as Joint Board of

Trustees of the Local 187 Machinists'Retirement Plan.

Note:Although Employer IdentificationNumbers (EINs) for funds (trusts or custodialaccounts) associated with plans are notrequired to be furnished on the Form 5500series returns/reports, the IRS will issue EINsfor such funds for other reporting purposes.EINs maybe obtained by filing Form SS-4 asexplained above.

1d. From the list of business codes onpages 19 and 20, enter the one that bestdescribes the nature of the employer'sbusiness. If more than one employer isinvolved, enter the business code for the mainbusiness activity.

1e. Plans entering code A or B in item 4must enter the first six digits of the CUSIP(Committee on Uniform SecuritiesIdentification Procedures) number, issuernumber, if one has been assigned to the plansponsor for purposes of issuing corporatesecurities. CUSIP issuer numbers areassigned to corporations and other entitieswhich issue public securities listed on stockexchanges or traded over the counter. TheCUSIP issuer number is the first six digits ofthe number assigned to the individualsecurities which are traded. If the plan sponsorhas no CUSIP issuer number, enter N/A.

2a. If the document constituting the planappoints or designates a plan administratorother than the sponsor, enter theadministrator's name and address. If the planadministrator is also the sponsor, enterSame. If filing as a group insurancearrangement, enter Same. If Same isentered on 2a, then items 2b and 2c shouldbe left blank.

The term administrator means(i) the person or group of persons

specified as the administrator by the

instrument under which the plan is operated;(ii) the plan sponsor/employer if an

administrator is not so designated; or

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

2b. A plan administrator must have anElN for reporting purposes. Enter the planadministrator's 9-digit EIN here. If the planadministrator has no EIN, apply for one asexplained in 1b above.

Employees of an employer are not planadministrators unless so designated in theplan document, even though they engage inadministrative functions of the plan. If an

employee of the employer is designated asthe plan administrator, that employee mustget an EIN.

3. If the plan sponsor's/administrator'sname and EIN are different than whatappears on the last return/report filed for thisplan, enter the plan sponsor's/administrator's name and EIN as it appearson the last return/report filed for this plan.

3c. Indicate if the change in 3a is only achange in sponsorship. Change insponsorship means the plan's sponsor hasbeen changed but no assets or liabilitieshave been transferred to another plan(s), theplan has not terminated or merged with anyother plan, and so forth. Therefore, the plan

is now the responsibility of the new sponsorwhose name is entered in item 1a of thisreturn/report.

4. From the following list of plan entitieschoose the one that describes your planentity and enter the code for it in item 4.

CodeEntity

Single-employer plan A. . . . . . . .

Plan of controlled group of corporationsBor common control employers

Multiemployer plan CMultiple-employer-collectively-bargained plan D

Multiple-employer plan (other) E

Group insurance arrangement(of welfare plans) F

5a(1). Enter the formal name of the plan,group insurance arrangement, or enoughinformation to identify the plan.

5b. Enter the date the plan first becameeffective.

5c. Enter the 3-digit number the employeror plan administrator assigned to the plan. Allwelfare plan numbers and Code section6039D plan numbers start at 501. All otherplans start at 001

. . . .

. . . . . . . . .

. . . . . . . . . .

. . . .

. . . . . . . . . .

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Type of Pension Benefit Plan Code

Defined benefit 1

Defined Contribution

Profit-sharing 2A

Stock bonus 2B

2CTarget Benefit

2DOther money purchase

Other defined contribution (specify2Eon page 1)

Other

Defined benefit plan with benefitsbased partly on balance of separateaccount of participant (Code section414(k)) 3

Annuity arrangement of certainexempt organizations (Code section403(b)(1)) 4

Custodial account for regulatedinvestment company stock (Codesection 403(b)(7)) 5

Pension plan utilizing individualretirement accounts or annuities(described in Code section 408) as thesole funding vehicle forproviding benefits 6

Other (Describe what type of plan you

7are filing for.)

Type of Welfare or Fringe Benefit Code

Health (other than dental and vision)

Life insurance B

Supplemental unemployment CDental D

Vision E

Temporary disability (accident andFsickness)

Prepaid legal services G

Long-term disability H

ISeverance pay

Apprenticeship and training J

KScholarship (funded)

Death benefits (other than life ins.)

Code section 120 group legal services

L

Mplan

NCode section 125 cafeteria plan

Code section 127 educationalassistance program O

Taft-Hartley Financial Assistancefor Employee Housing Expenses P

Other (specify on page 1) Q

Once you use a plan number, continue touse it for that plan on all future filings with IRS,DOL, and PBGC reports. Do not use it for anyother plan even if you terminated the first plan.

Group Insurance Arrangement. Forentities filing as a group insurancearrangement, enter the name of thearrangement and enter the next 3-digit plannumber available to the plan sponsor in the500 series (i.e., 501, 502, etc.).

If you entered code M, N, or O, you mustcheck No in 6a(2) if the plan is:

A fringe benefit plan filing because of thereporting requirement under Code section6039D should enter either code M, N, or O. Aplan that is required to file under Title I ofERISA as a welfare plan and under Codesection 6039D as a fringe benefit plan shouldenter the applicable welfare benefit code(s)and the applicable fringe benefit code.

(1) unfunded, (2) fully insured, or (3) acombination of unfunded/insured as defined onpage 2, Section 2B(a).

Exception: Employers sponsoring welfarebenefit plans participating in group insurancearrangements which file an annual report ontheir behalf should enter No if theseemployers are filing Form 5500 only becausethey are part of a Code section 125 cafeteriaplan.

6b. Pension benefit plans must enter thecodes from the list below that describe the typeof pension benefit for which the Form 5500 isbeing filed. If none of the codes in the listdescribe the type of pension plan, enter code7 and describe the type of pension plan youare filing for.

6c(2). Check for an ESOP (Employee StockOwnership Plan) which acquires employersecurities with borrowed money or otherdebt-financing techniques.

6c(3). Check if the plan is a pension planthat provides for individual accounts andpermits a participant or beneficiary to exerciseindependent control over the assets in his orher account (see ERISA section 404(c)).

6c(4). Check this box for pension benefitplans maintained outside the United Statesprimarily for nonresident aliens. See Kinds ofFilers on page 3 for more information.

6c(5). In the space provided following 6c(8),

enter name of the trust and financial institution.Also enter city and state where the trust ismaintained. (See page 3 for master trustinstructions.)

6c(6). In the space provided following 6c(8),enter name and address of the 103-12 IE.(See page 4.)

6d. For single-employer pension plans,enter the date the employer's tax year ends.For example, if the tax year is a calendar year,enter 12-31-90. For all plans with more thanone employer, enter N/A.

6e. Definition of Affiliated ServiceGroup.In general, Code section 414(m)(2)defines an affiliated service group as a first

service organization (FSO) that has:(1) a service organization (A-ORG) that is a

shareholder or partner in the FSO and thatregularly performs services for the FSO, or isregularly associated with the FSO inperforming services for third persons, and/or

6a. Enter every code from the list below thatdescribes the welfare benefit plan for which

this return/report is being filed.

An affiliated service group also includes agroup consisting of an organization whoseprincipal 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 by

the organization. For a plan maintained bymore than one employer, check "Yes" if anysuch employer is a member of an affiliatedservice group.

6f. A cash or deferred arrangementdescribed in Code section 401(k) is a part ofa qualified defined contribution plan whichprovides for an election by employees todefer part of their compensation or receivethese amounts in cash.

7. The description of participant in theinstructions below is only for purposes ofitem 7 of this form.

For welfare plans, dependents areconsidered to be neither participants norbeneficiaries. For pension benefit plans,

alternate payees entitled to benefits undera qualified domestic relations order are not tobe counted as participants for this item.

Participant means any individual who isincluded in one of the categories below.

7a.Active participants include anyindividuals who are currently in employmentcovered by a plan and who are earning orretaining credited service under a plan. Thiscategory includes any individuals who are: (i)currently below the integration level in a planthat is integrated with social security, and/or(ii) eligible to elect to have the employermake payments to a Code section 401(k)qualified cash or deferred arrangement.

Active participants also include any

nonvested individuals who are earning orretaining credited service under a plan. Thiscategory does not include nonvested formeremployees who have incurred the break inservice period specified in the plan.

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

For purposes of Code section 6039D,participant means any individual who, for aplan year, has had at least one dollarexcluded from income by reason of Codesection 120, 125, or 127. If you are filingForm 5500 for a welfare plan that is requiredto file under Title I of ERISA and under Code

section 6039D as a fringe benefit plan, thepreceding sentence does not apply.

7b. Inactive participants receiving benefitsare any individuals who are retired orseparated from employment covered by theplan and who are receiving benefits underthe plan. This includes former employeeswho are receiving group health continuationcoverage benefits pursuant to Part 6 ofERISA who are covered by the employeewelfare benefit plan. This category does notinclude any individual to whom an insurancecompany has made an irrevocablecommitment to pay all the benefits to whichthe individual is entitled under the plan.

Page 8

any other organization (B-ORG) if:

a significant portion of the business ofthat organization consists of performingservices for the FSO or A-ORG of atype historically performed byemployees in the service field of theFSO or A-ORG, and

(2)

(a)

10% or more of the interest of theB-ORG is held by persons who arehighly compensated employees of theFSO or A-ORG.

(b)

Example: If your plan provides healthinsurance, life insurance, dental insurance, eyeexaminations, the four codes A, B, D, and Eshould be entered. If your plan has a benefitnot described by one of the codes, enter Qand write in a description of this benefit in thespace provided.

A

. . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . .

. .

. . .

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. . . . . .

. . . . . . . .

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. . . .

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. . .

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. . . . . . . . . . .

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. . . . . . . . . . .

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. . . . .


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FundingArrangement

Codes

Trust 1Trust and insurance 2Insurance 3

Exclusively from general assets ofsponsor (unfunded)Partially insured and partially fromgeneral assets of sponsor

Other

4

56

7c. Inactive participants entitled to futurebenefits are individuals who are retired orseparated from employment covered by theplan and who are entitled to begin receivingbenefits under the plan in the future. Thiscategory does not include any individual towhom an insurance company has made anirrevocable commitment to pay all the benefitsto which the individual is entitled under theplan.

7e. Deceased participants are anydeceased individuals who have one or more

beneficiaries who are receiving or are entitledto receive benefits under the plan. Thiscategory does not include an individual if aninsurance company has made an irrevocablecommitment to pay all the benefits to which thebeneficiaries of that individual are entitledunder the plan.

7g. Enter the number of participantsincluded in line 7fwho have account balances.For example, for a Code section 401(k) plan,the number entered on line 7g should be thenumber of participants counted in line 7fwhohave made a contribution to the plan duringthis plan year or any prior plan year.

7h(1). If Yes, file Schedule SSA (Form5500) as an attachment to Form 5500. Plan

administrators: Code section 6057(e)provides that the plan administrator must giveeach participant a statement showing the sameinformation for that participant as is reportedon Schedule SSA.

8a. Check Yes if an amendment to theplan was adopted regardless of the effectivedate of the amendment.

8b. Enter the date the most recentamendment was adopted regardless of thedate of the amendent or the effective date ofthe amendment.

8c. Check Yes only if the accrued benefitswere retroactively reduced. For example, aplan provides a benefit of 2% for each year ofservice, but the plan is amended to change the

benefit to 1% a year for all years of serviceunder the plan. Do not check Yes if accruedbenefits were retroactively reduced solely tothe extent permitted under a modelamendment provided in IRS Notice 88-131,1988-2 C.B. 546.

8e. Check Yes only if an amendmentchanged the information previously provided toparticipants by the summary plan descriptionor summary description of modifications.

8f. A revised summary plan description orsummary description of modifications must befiled with DOL and distributed to all participantsand pension plan beneficiaries no later than210 days after the close of the plan year inwhich the amendment(s) was adopted. If thematerial was distributed and filed since theamendments were adopted (even if after theend of the plan year), check Yes to item 8f.

9a. Check Yes if the plan was terminatedor if the plan was merged or consolidated intoanother plan. Enter year of termination ifapplicable. If you entered a code M, N, or O in6a(1) and indicated that this is an unfundedplan and you also checked 9a Yes, you mustalso check 9b Yes.

9b. If the plan was terminated and all planassets were not distributed, file a return/reportfor each year the plan has assets. In that case,the return/report must be filed by the plan

administrator, if designated, or by the personor persons who actually control the plan'sproperty.

If all plan assets were used to buy individualannuity contracts and the contracts weredistributed to the participants, check Yes.

If all the trust assets were transferred toanother plan or brought under the control ofPBGC, check Yes.

Do not check Yes for a welfare plan whichis still liable to pay benefits for claims which

were incurred prior to the termination date, butnot yet paid. See 29 CFR 2520.104b-2(g)(2)(ii).

9h. The Code provides for a nondeductibleexcise tax on a reversion of assets from aqualified plan.

9i. The employer must report the reversionby filing Form 5330 and pay any applicable tax.The tax will not be imposed upon employerswho are tax-exempt entities under Codesection 501(a). See instructions for Form 5330.

10a. If this plan was merged or consolidatedinto another plan(s), or plan assets or liabilitieswere transferred to another plan(s), indicatewhich other plan or plans were involved.

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

other plan.

10e. Pension, benefit plans must file Form5310 at least 30 days before any plan mergeror consolidation or any transfer of plan assetsor liabilities to another plan.

11. Enter the code for the fundingarrangement used by the plan for the planyear from the list below.

The funding arrangement is the methodused during the plan year for the receipt,holding, investment, and transmittal of planassets prior to the time the plan actuallyprovides the benefits promised under the plan.

For purposes of items 11 and 12, the termtrust includes any fund or account whichreceives, holds, transmits, or invests planassets other than an account or policy of aninsurance company.

Note: An employee benefit plan whichattaches Schedule A (Form 5500), InsuranceInformation, must enter a code 2, 3, or 5 initem 11 and/or 12 in accordance with theinstructions for items 11 and 12.

12. Enter the code for the benefitarrangement used by the plan for the planyear from the list below.

The benefit arrangement is the method bywhich benefits were actually provided duringthe plan year to participants by the plan. Forexample, if all participants received theirbenefits from a trust (as defined in 11 above)the plan's benefit arrangement code would

be 1. If some benefits come from a trustand some come from an insurance company,the code would be 2. If all benefits werepaid from an account or policy of aninsurance company, the code would be 3.

13a. Enter Yes if either the contributionsto the plan or the benefits paid by the planare subject to the collective bargainingprocess, even if the plan is not establishedand administered by a joint board oftrustees. Enter Yes even if only some ofthose covered by the plan are members of acollective bargaining unit which negotiatesbenefit levels on its own behalf. The benefitschedules need not be identical for allemployees under the plan.

13b. All plans entering code C or D on

line 4 must enter the 6-digit LM number toidentify each sponsoring labor organizationwhich is a party to the collective bargainingagreement. Other plans which aremaintained pursuant to collective bargainingagreements should enter the appropriate LMnumber, if available. The LM number is thesix-digit Labor-Management file numberentered by the sponsoring labor organizationin item 1 of 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' LM numberscannot be entered in the spaces provided initem 13b on the form, enter the additional LM

numbers on a supplemental sheet toaccompany the Form 5500.

14. If either the funding arrangement code(item 11) and/or the benefit arrangementcode (item 12) is 2, 3, or 5, at least oneSchedule A (Form 5500) must be attached tothe Form 5500 filed for pension and welfareplans. The insurance company (or similarorganization) which provides benefits isrequired to provide the plan administratorwith the information needed to complete thereturn/report, pursuant to ERISA section 103(a)(2). If you do not receive this informationin a timely manner, contact the insurancecompany (or similar organization). Ifinformation is missing on Schedule A (Form

5500) due to a refusal to provide thisinformation, note this on the Schedule A. Ifthere are no Schedule(s) A attached, enter0.

15b. If a waived funding deficiency isbeing amortized in the current plan year, donot complete (1), (2), and (3), but complete1, 2, 3, 7, and 9 of Schedule B (Form 5500).

An enrolled actuary need not sign ScheduleB under these circumstances.

15b(3). File Form 5330 with IRS to paythe excise tax on any funding deficiency.

Caution:There is a penalty for not filingForm 5330 on time.

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

. . . . . . . . . . .

. . . . . . . . . . . . .

. . . . . . . . . . . . .

. . . . . . . .

. . . . . . .

. . . . .

FundingArrangement

Codes

Trust 1Trust and insurance 2Insurance 3Exclusively from general assets ofsponsor (unfunded)

Partially insured and partially fromgeneral assets of sponsor

Other

4

56

. . . . . . . . . . .

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Page 9


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16. A top-heavy plan is a plan whichduring any plan year is:

(1) any defined benefit plan if, as of thedetermination date, the present value of thecumulative accrued benefits under the plan forkey employees exceeds 60% of the presentvalue of the cumulative accrued benefits underthe plan for all employees; and

(2) any defined contribution plan if, as of thedetermination date, the aggregate of theaccounts of key employees under the planexceeds 60% of the aggregate of the accounts

of all employees under the plan.

Each plan of an employer included in arequired aggregation group is to be treated asa top-heavy plan if such group is a top-heavygroup. See definitions of required aggregationgroup and top-heavy group, below.

Key Employee A key employee is anyparticipant in an employer plan who at any timeduring the plan year, or any of the 4 precedingyears, is:

(1) an officer of the employer having anannual compensation greater than 150% of theamount in effect under Code section415(c)(1)(A),

(2) one of the 10 employees having annual

compensation from the employer of more thanthe limitation in effect under Code section415(c)(1)(A) and owning (or considered asowning within the meaning of Code section318) both more than % interest and thelargest interests in the employer,

(3) a 5% owner of the employer, or

an annual compensation from the employer ofmore than $150,000.

In determining whether an individual is anofficer of the employer, no more than 50employees, or, if less, the greater of 3employees or 10% of the employees, are to betreated as officers. See Code section 416(i)and T-12 of Regulations section 1.416. A key

employee will not include any officer oremployee of a governmental plan under Codesection 414(d).

Required Aggregation GroupA requiredaggregation group consists of:

(2) each other plan of the employer whichenables a plan to meet the requirements fornondiscrimination in contributions or benefitsunder Code section 401(a)(4), or theparticipation requirements under Code section410.

(1) each plan of the employer in which a keyemployee is or was a participant, and

Top-Heavy GroupA top-heavy group is anaggregation group if, as of the determination

date, the sum of the present value of thecumulative accrued benefits for key employeesunder all defined benefit plans included in suchgroup and the aggregate of the accounts ofkey employees under all defined contributionplans in such group exceeds 60% of a similarsum determined for all employees. Todetermine if a plan is top-heavy, includedistributions made in the 5-year period endingon the determination date. However, do nottake into account accrued benefits for anindividual who hasn't performed services forthe employer during the 5-year period endingon the determination date.

A qualified plan must limit the annualcompensation of each employee taken intoaccount for any year (including plan yearsbeginning before 1989) to $200,000. Thefamily members (spouse and linealdescendants under age 19) of 5% owners orone of the 10 most highly compensatedemployees are treated as a single employee.Qualified plans must comply with thisrequirement in operation even if the plan hasnot yet been amended to comply with the TaxReform Act of 1986.

18a. If the plan distributes an annuitycontract, whether or not deferred and whetheror not upon termination, that contract mustprovide that all distributions from it will meetthe participant and spousal consentrequirements of Code section 417. Consent isnot needed for the distribution of the contractitself. Check No if the plan did not distributeany annuity contracts.

18b. In general, distributions must be madein the form of a qualified joint and survivorannuity for life or a qualified preretirementsurvivor annuity. An annuity distribution to asingle individual (see 18c(1) below), is aqualified joint and survivor annuity. CheckYes if distributions in other forms were made,

even if such distributions were permissible,e.g., because consent was obtained or was notneeded.

18c. Generally, within the 90 days prior tothe date of any benefit payment or the makingof a loan to a participant, you must get thespouse's consent to the payment of the benefitor the use of the accrued benefit for themaking of the loan. However, there are somecircumstances where obtaining this spousalconsent is not required. The following is apartial listing of circumstances where spousalconsent is not required:

(5) The participant had no service under theplan after August 22, 1984.

(1) The participant is not married and noformer spouse is required to be treated as acurrent spouse under a qualified domesticrelations order issued by a court.

(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 spouse whichis not less than 50% of (and is not greater than100% of) the amount of the annuity which ispayable during the joint lives of the participantand the spouse. See Code section 417(b).

18d. A plan may not eliminate a subsidizedbenefit or a retirement option by planamendment or plan termination.

19. For purposes of determining the presentvalue of a participant's accrued benefits andthe amount of any distribution (other than

a. The interest rate(s) used by PBGC tovalue a participant's (or beneficiary's) vestedbenefit upon termination of an insufficienttrusteed single-employer plan, if the presentvalue of such benefit does not exceed

$25,000.

The Code section 417 interest rate is:

b. 120% of the interest rate in a above ifthe present value of the vested accruedbenefit exceeds $25,000 (using the rate in aabove). In this case the value of the benefitmay not be less than $25,000.

20. The maximum annual benefit thatmay be provided under a defined benefitplan may not exceed the lesser of $90,000or 100% of compensation. However, ifbenefits begin before the social securityretirement age, the $90,000 limit must bereduced as described in IRS Notice 87-21,1987-1 C.B. 458.

In addition, the dollar limitations will bereduced for participants with fewer than 10

years of participation in a defined benefitplan, i.e., a 10% reduction for each yearunder 10 years of participation.

For defined contribution plans, Codesection 415 now provides that the dollar limiton annual additions to a qualified plan maynot exceed the greater of $30,000 or 25% ofthe defined benefit dollar limit for suchlimitation year. The defined contributiondollar limit will not be increased until thedefined benefit dollar limit, as increased bycost of living adjustments, equals or exceeds$120,000. (For years beginning afterDecember 31, 1987, the $90,000 definedbenefit limit will be adjusted to reflectpost-1986 cost of living increases.) The

defined contribution dollar limit will then beincreased to an amount equal to 25% of thedefined benefit limit.

Annual additions to a defined contributionplan will, for years beginning after December31, 1986, include 100% of all after-taxemployee contributions. For participantsparticipating in plans of tax-exemptorganizations, the pre-Tax Reform Act limitsremain in effect.

The Tax Reform Act of 1986 provides thata participant's previously accrued benefitwon't be reduced merely because of thereduction in dollar limits or increases inrequired periods of participation. Thetransitional rule applies to an individual who

was a participant prior to January 1, 1987, ina plan in existence on May 5, 1986. If thisparticipant's current accrued benefit exceedsthe dollar limit under the Tax Reform Act of1986, but complies with prior law, then theapplicable dollar limit for the participant isequal to the current accrued benefit. Theterm current accrued benefit is defined asthe participant's accrued benefit as of theclose of the last limitation year beginningbefore January 1, 1987, and expressed asan annual benefit. To compute the definedbenefit fraction, the current accrued benefitwould replace the dollar limit otherwise usedin the denominator of the fraction. Thecurrent accrued benefit is also reflected inthe numerator of the defined benefit fraction.Page 10

(4) a 1% owner of the employer having

(2) The participant's nonforfeitable accruedbenefit in the plan does not have at the time ofdistribution a present value of more than$3,500.

(4) The payout is from a profit-sharing orstock bonus plan that pays the spouse theparticipant's full account balance upon the

participant's death, an annuity payment is notelected by the participant, and theprofit-sharing or stock bonus plan is not atransferee plan with respect to the participant(i.e., had not received a transfer from a planthat was subject to the consent requirementswith respect to the participant).

certain nondecreasing life annuities), aqualified plan must use the Code section 417interest rate or any other interest rate(s)provided in the plan for the purposes ofactuarial equivalence, whichever producesthe greatest benefit.


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21. Employees must begin to receiveminimum distributions pursuant to Codesection 401(a)(9) by April 1 of the calendaryear following the calendar year in which theemployee attains age 70. Once begun,minimum distributions must continue eachcalendar year.

22. In general, a plan must satisfy ore of thecoverage tests on each day of the year beingtested. However, if the plan satisfies one of thetests on at least one day in each quarter of theyear being tested, the plan will be deemed to

pass the coverage tests for the entire yearprovided that the quarterly testing datesreasonably represent the coverage of the planover the entire plan year. Complete item 22 forthe testing date selected by the employer(typically the last day of the plan year).

If Form 5500 is being filed solely because ofCode section 6039D, for item 22, completeonly h and m.

Multiemployer plan (code C in item 4),multiple-employer-collectively-bargained plan(code D in item 4), and multipleemployer plan(other) filers (Code E in item 4) are notrequired to complete item 22. However, theparticipating employers in multiple-employerplan (other) pension benefit plans are required

to complete the applicable questions in item 22on the Form 5500-C/R that they file.

22a. In general, if the employer operatedseparate lines of business within the meaningof Code section 414(r) for a year, the employermay apply the coverage and discriminationrequirements separately with respect toemployees in each separate line of business. If22a is Yes, complete 22c through 22o for theseparate line of business covered by the planas if the employees of the separate line ofbusiness were the sole employees of theemployer. If this plan benefits employees inmore than one separate line of business,complete 22 for one of the lines of businessand for each additional line of businesscovered by the plan submit an attachmentcompleted in the same format as 22.

22c. Section 1.410(b)-7(c) of the ProposedIncome Tax Regulations requires that certainplans be disaggregated into parts that mustseparately satisfy the coverage requirementsas if they were separate plans. The followingplans must be disaggregated and the partsmust be tested separately for coverage: (i) thepart of a plan that benefits collectivelybargained employees and the part of a planthat benefits noncollectively bargainedemployees, (ii) the part of a plan that is anemployee stock ownership plan described insections 4975(e)(7) or 409 (an ESOP) and thepart of a plan that is not an ESOP, (iii) the partof a plan that consists of contributions under a

qualified cash or deferred arrangement(CODA) and the part of a plan that is not aCODA, and (iv) the part of a plan that consistsof matching contributions and employeecontributions (Code section 401(m)) and thepart of a plan that does not consist of Codesection 401( m) contributions. If this plancontains parts that must be disag

Documents

US Internal Revenue Service: i5500--1990