Fillable Form 5500: (Department of Labor)

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Form 5500: (Department of Labor)

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an amended return/report a short plan year return/report (less than 12
a collectively-bargained plan, check here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Form 5558 automatic extension
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Form 5500
Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security
Administration
Pension Benefit Guaranty Corporation
Annual Return/Report of Employee Benefit Plan
This form is required to be filed for employee benefit plans under sections 104
and 4065 of the Employee Retirement Income Security Act of 1974 (ERISA) and
sections 6057(b) and 6058(a) of the Internal Revenue Code (the Code).
Complete all entries in accordance with
the instructions to the Form 5500.
OMB Nos. 1210-0110
1210-0089
2019
This Form is Open to Public
Inspection
Part I
Annual Report Identification Information
For calendar plan year 2019 or fiscal plan year beginning and ending
a multiemployer plan a multiple-employer plan (Filers checking this box must attach a list of
A This return/report is for:
participating employer information in accordance with the form instructions.)
a DFE (specify)
a single-employer plan
the first return/report the final return/report
B This return/report is:
months)
C
If the plan is . .
D Check box if filing under:
the DFVC program
special extension (enter description)
Part II
Basic Plan Information—enter all requested information
1a
Name of plan
2a Plan sponsor’s name (employer, if for a single-employer plan)
Mailing address (include room, apt., suite no. and street, or P.O. Box)
City or town, state or province, country, and ZIP or foreign postal code (if foreign, see instructions)
Three-digit plan
1c
Effective date of plan
2b Employer Identification
Number (EIN)
2c
Plan Sponsor’s telephone
number
2d Business code (see
instructions)
Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established.
Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return/report, including accompanying schedules,
statements and attachments, as well as the electronic version of this return/report, and to the best of my knowledge and belief, it is true, correct, and complete.
SIGN
HERE
Signature of plan administrator
Date
Enter name of individual signing as plan administrator
SIGN
HERE
Signature of employer/plan sponsor
Date
Enter name of individual signing as employer or plan sponsor
SIGN
HERE
Signature of DFE
Date
Enter name of individual signing as DFE
For Paperwork Reduction Act Notice, see the Instructions for Form 5500.
Form 5500 (2019)
v. 190130
participants at the beginning of the plan year ...............................................................................
active participants at the end of the plan year .......................................................................................
separated participants receiving benefits..............................................................................................................
participants entitled to future benefits ..........................................................................................
and 6c.................................................................................................................................
whose beneficiaries are receiving or are entitled to receive benefits. ................................................
..................................................................................................................................................
account balances as of the end of the plan year (only defined contribution plans
.............................................................................................................................................................
terminated employment during the plan year with accrued benefits that were
.........................................................................................................................................................
employers obligated to contribute to the plan (only multiemployer plans complete this item).........
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123456789 ABCDEFGHI ABCDEFGHI ABCDE
CITYEFGHI ABCDEFGHI AB, ST 012345678901
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Form 5500 (2019) Page 2
3a
Plan administrator’s name and address Same as Plan Sponsor
3b
Administrator’s EIN
3c
Administrator’s telephone
number
4 If the name and/or EIN of the plan sponsor or the plan name has changed since the last return/report filed for this plan,
enter the plan sponsor’s name, EIN, the plan name and the plan number from the last return/report:
4b
EIN
a
Sponsor’s name
c Plan Name
4d
PN
5
Total number of participants at the beginning of the plan year
5
6
Number of participants as of the end of the plan year unless otherwise stated (welfare plans complete only lines 6a(1),
6a(2), 6b, 6c, and 6d).
a(1) Total number of active
6a(1)
a(2) Total number of
6a(2)
b Retired or
6b
c Other retired or separated
6c
d Subtotal. Add lines 6a(2), 6b, ...
6d
e Deceased participants
6e
f Total. Add lines 6d and 6e.
6f
g Number of participants with
complete this item)
6g
h Number of participants who
less than 100% vested
6h
7
Enter the total number of
7
8a
If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristics Codes in the instructions:
b
If the plan provides welfare benefits, enter the applicable welfare feature codes from the List of Plan Characteristics Codes in the instructions:
9a Plan funding arrangement (check all that apply)
(1) Insurance
(2) Code section 412(e)(3) insurance contracts
(3) Trust
(4) General assets of the sponsor
9b Plan benefit arrangement (check all that apply)
(1) Insurance
(2) Code section 412(e)(3) insurance contracts
(3) Trust
(4) General assets of the sponsor
10
Check all applicable boxes in 10a and 10b to indicate which schedules are attached, and, where indicated, enter the number attached. (See instructions)
a Pension Schedules
b General Schedules
(1) R (Retirement Plan Information) (1) H (Financial Information)
(2) MB (Multiemployer Defined Benefit Plan and Certain Money
Purchase Plan Actuarial Information) - signed by the plan
(2)
(3)
___
I (Financial Information – Small Plan)
A (Insurance Information)
actuary
(4) C (Service Provider Information)
(3) SB (Single-Employer Defined Benefit Plan Actuarial
(5) D (DFE/Participating Plan Information)
Information) - signed by the plan actuary
(6) G (Financial Transaction Schedules)
X X
X X
Form 5500 (2019) Page 3
Part III
Form M-1 Compliance Information (to be completed by welfare benefit plans)
11a
If the plan provides welfare benefits, was the plan subject to the Form M-1 filing requirements during the plan year? (See instructions and 29 CFR
2520.101-2.) ........................………..….
Yes No
If “Yes” is checked, complete lines 11b and 11c.
11b Is the plan currently in compliance with the Form M-1 filing requirements? (See instructions and 29 CFR 2520.101-2.) ……..... Yes No
11c
Enter the Receipt Confirmation Code for the 2019 Form M-1 annual report. If the plan was not required to file the 2019 Form M-1 annual report, enter the
Receipt Confirmation Code for the most recent Form M-1 that was required to be filed under the Form M-1 filing requirements. (Failure to enter a valid
Receipt Confirmation Code will subject the Form 5500 filing to rejection as incomplete.)
Receipt Confirmation Code______________________
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Form 5500: (Department of Labor)

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Completed 20 July 2020

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