Form 1120-ND (Rev. 10-2013)
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Schedule L Balance Sheets
(a) Beginning of year (b) End of year
Assets
1 Cash . . . . . . . . . . . . . . . . . . . 1
2 Certificates of deposit . . . . . . . . . . . . . . 2
3 U.S. government obligations . . . . . . . . . . . 3
4 State and local government obligations . . . . . . . . 4
5 Other assets (attach schedule) . . . . . . . . . . . 5
6 Total assets. Add lines 1 through 5 . . . . . . . . . 6
Liabilities and Fund Balance
7 Liabilities . . . . . . . . . . . . . . . . . . 7
8 Fund balance . . . . . . . . . . . . . . . . 8
9 Total liabilities and fund balance. Add lines 7 and 8 . . . . 9
Schedule M Other Information
Yes No
1a Enter name of the electing taxpayer
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b Enter the employer identification number of the electing taxpayer
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2 a
Enter the amount of contributions the fund received during the year under section 468A(a) .
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$
b Enter the ruling amount for the tax year under section 468A(d)(2) . . . . . . .
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$
c
Enter the amount of distributions includible in income by the electing taxpayer under section 468A(c)(1)
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$
d Enter the amount of tax-exempt interest received or accrued for the year . . . . .
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$
3
During the year were any contributions received other than cash payments deductible by the electing taxpayer under section 468A?
4
During the year were fund assets used for any purpose other than paying the fund’s administrative or incidental
expenses (including taxes), for making investments, or for direct or indirect payment of decommissioning costs of
a nuclear power plant owned or leased by the electing taxpayer? If “Yes,” attach an explanation . . . . . .
5 Self-dealing (see instructions):
a
Has the fund engaged in any of the following acts during the year, either directly or indirectly, with one or more
disqualified persons?
(i) Sale, exchange, or leasing of property . . . . . . . . . . . . . . . . . . . . . . .
(ii) Borrowing or lending of money or other extension of credit . . . . . . . . . . . . . . . . .
(iii) Furnishing of goods, services, or facilities . . . . . . . . . . . . . . . . . . . . . .
(iv) Payment of compensation (or payment or reimbursement of expenses) . . . . . . . . . . . .
(v) Transfer to, or use by or for the benefit of, a disqualified person of any part of the fund’s income or assets .
b If any of lines 5a(i) through 5a(v) are answered “Yes,” were all of the acts self-dealing exceptions? (see inst.) . .
c
If the answer to line 5b is “No,” attach a schedule listing the act; the date of the act; and the name, address, and
identifying number of each trustee and/or disqualified person who engaged in the act.
d
Has any self-dealer or trustee taken any action to “correct” any act of self-dealing? See instructions for the
definition of “correct.” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If “Yes,” attach complete details of the corrective action. Also explain any uncorrected acts.
Part II—Initial Taxes on Self-Dealing (Section 4951)
Section A.—Acts of Self-Dealing and Tax Computation
(a) Act number (b) Date of act (c) Description of act
1
2
(d) Names of disqualified persons liable for tax (e) Names of trustees liable for tax
(f) Amount involved in act (g) Initial tax on self-dealing disqualified person (10% of column (f))
(h) Tax on trustee (if applicable) (2
1
/2% of column (f))
Total . . . . . . . .
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Section B.—Summary of Initial Taxes
1 Enter section 4951 tax on disqualified person (Section A, column (g)) . . . . . . . . . . 1
2 Enter section 4951 tax on trustee (Section A, column (h)) . . . . . . . . . . . . . . 2
3 Total section 4951 taxes (add lines 1 and 2) . . . . . . . . . . . . . . . . . . 3
4 Tax paid with Form 7004 . . . . . . . . . . . . . . . . . . . . . . . . . 4
5
Tax due. Enter the excess, if any, of line 3 over line 4. (Do not enter this amount in Part I.) Pay in
full with return. (Make check or money order payable to “United States Treasury.”) . . . . .
5
6 Overpayment. Enter the excess, if any, of line 4 over line 3 . . . . . . . . . . . . .
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Form 1120-ND (Rev. 10-2013)
