Free Form 5330 (Rev. April 2009) - Federal

Form

5330
Name of filer (see instructions)

(Rev. April 2009)
Department of the Treasury Internal Revenue Service

Return of Excise Taxes Related to Employee Benefit Plans
(Under sections 4965, 4971, 4972, 4973(a)(3), 4975, 4976, 4977, 4978, 4979, 4979A, 4980, and 4980F of the Internal Revenue Code)

OMB No. 1545-0575

Filer tax year beginning
A

,

and ending

,
B Filer's identifying number (see instructions) Employer identification number (EIN)

Number, street, and room or suite no. (If a P.O. box or foreign address, see instructions) Social security number (SSN) City or town, state, and ZIP code E Plan sponsor's EIN

C

Name of plan

D

Name and address of plan sponsor

F

Plan year ending (MM/DD/YYYY)

H

If this is an amended return, check here

G Plan number

Part I

Taxes. You can only complete one section of Part I for each Form 5330 filed (see instructions).
FOR IRS USE ONLY

Section A. Taxes that are reported by the last day of the 7th month after the end of the tax year of the employer (or other person who must file the return) 1 Section 4972 tax on nondeductible contributions to qualified plans (from Schedule A, line 12) Section 4973(a)(3) tax on excess contributions to section 403(b)(7)(A) custodial accounts (from Schedule B, line 12)

161

1

2

164

2 3a 3b 4 5a 5b 6

3a Section 4975(a) tax on prohibited transactions (from Schedule C, line 3) b Section 4975(b) tax on failure to correct prohibited transactions 4 Section 4976 tax on disqualified benefits for funded welfare plans

159 224

200

5a Section 4978 tax on ESOP dispositions b The tax on line 5a is a result of the application of: 6 7

209

Sec. 664(g)

Sec. 1042
203

Section 4979A tax on certain prohibited allocations of qualified ESOP securities

Total Section A taxes. Add lines 1 through 6. Enter here and on Part II, line 17 7 Section B. Taxes that are reported by the last day of the 7th month after the end of the employer's tax year or 8 1/ 2 months after the last day of the plan year that ends within the filer's tax year 163 8a 8a Section 4971(a) tax on failure to meet minimum funding standards (from Schedule D, line 2) 225 8b b Section 4971(b) tax for failure to correct minimum funding standards 9a Section 4971(f)(1) tax on failure to pay liquidity shortfall (from Schedule E, line 4) b Section 4971(f)(2) tax for failure to correct liquidity shortfall
226 227

9a 9b

10a Section 4971(g)(2) tax on failure to comply with a funding improvement or rehabilitation 450 10a plan (see instructions) b Section 4971(g)(3) tax on failure to meet requirements for plans in endangered or critical status (from Schedule F, line 1c) 451 10b c Section 4971(g)(4) tax on failure to adopt rehabilitation plan (from Schedule F, line 2d) 452 10c Section B1. Tax that is reported by the last day of the 7th month after the end of the calendar year in which the excess fringe benefits were paid to the employer's employees 11 12 13 Section 4977 tax on excess fringe benefits (from Schedule G, line 4)
201

11

Total Section B taxes. Add lines 8a through 11. Enter here and on Part II, line 17 12 Section C. Tax that is reported by the last day of the 15th month after the end of the plan year Section 4979 tax on excess contributions to certain plans (from Schedule H, line 2). Enter here and on Part II, line 17
Cat. No. 11870M
205

13
Form

For Privacy Act and Paperwork Reduction Act Notice, see instructions.

5330

(Rev. 4-2009)

Form 5330 (Rev. 4-2009)

Page

2

Name of Filer: Filer's identifying number: Section D. Tax that is reported by the last day of the month following the month in which the reversion occurred 14 Section 4980 tax on reversion of qualified plan assets to an employer (from Schedule I, line 3). Enter here and on Part II, line 17 204 14 Section E. Tax that is reported by the last day of the month following the month in which the failure occurred 15 Section 4980F tax on failure to provide notice of significant reduction in future accruals (from Schedule J, line 5). Enter here and on Part II, line 17 228 15 Section F. Taxes reported on or before the 15th day of the 5th month following the close of the entity manager's taxable year during which the plan became a party to a prohibited tax shelter transaction 16 Section 4965 tax on prohibited tax shelter transactions for entity managers (from Schedule K, line 2). Enter here and on Part II, line 17 237 16

Part II
17 18 19

Tax Due
17 18

Enter the amount from Part I, line 7, 12, 13, 14, 15, or 16 (whichever is applicable) Enter amount of tax paid with Form 5558 or any other tax paid prior to filing this return Tax due. Subtract line 18 from line 17. If the result is greater than zero, enter here, and attach check or money order payable to "United States Treasury." Write your name, identifying number, plan number, and "Form 5330, Section(s) " on your payment

19

Sign Here
Paid Preparer's Use Only

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Your signature Preparer's signature Firm's name (or yours if self-employed), address, and ZIP code Date

Telephone number Check if self-employed EIN Phone no. (

Date Preparer's SSN or PTIN

)

Form

5330

(Rev. 4-2009)

Form 5330 (Rev. 4-2009)

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Name of Filer: Filer's identifying number: Schedule A. Tax on Nondeductible Employer Contributions to Qualified Employer Plans (Section 4972) Reported by the last day of the 7th month after the end of the tax year of the employer (or other person who must file the return) 1 Total contributions for your tax year to your qualified employer plan (under section 401(a), 403(a), 408(k), or 408(p)) Amount allowable as a deduction under section 404 Subtract line 2 from line 1 Enter amount of any prior year nondeductible contributions made for years beginning after 12/31/86 Amount of any prior year nondeductible contributions for years beginning after 12/31/86 returned to you in this tax year for any prior tax year Subtract line 5 from line 4 Amount of line 6 carried forward and deductible in this tax year Subtract line 7 from line 6 Tentative taxable excess contributions. Add lines 3 and 8 Nondeductible section 4972(c)(6) or (7) contributions exempt from excise tax Taxable excess contributions. Subtract line 10 from line 9 1 2 3 4 5 6 7 8 9 10 11

2 3 4 5

6 7 8 9 10 11

12 Multiply line 11 by 10%. Enter here and on Part I, line 1 12 Schedule B. Tax on Excess Contributions to Section 403(b)(7)(A) Custodial Accounts (Section 4973(a)(3)) Reported by the last day of the 7th month after the end of the tax year of the employer (or other person who must file the return) 1 2 3 4 5 6 Total amount contributed for current year less rollovers (see instructions) Amount excludable from gross income under section 403(b) (see instructions) Current year excess contributions. Subtract line 2 from line 1. If zero or less, enter -0Prior year excess contributions not previously eliminated. If zero, go to line 8 Contribution credit. If line 2 is more than line 1, enter the excess; otherwise, enter -0Total of all prior years' distributions out of the account included in your gross income under section 72(e) and not previously used to reduce excess contributions Adjusted prior years' excess contributions. Subtract the total of lines 5 and 6 from line 4 Taxable excess contributions. Add lines 3 and 7 Multiply line 8 by 6% Enter the value of your account as of the last day of the year Multiply line 10 by 6% Excess contributions tax. Enter the lesser of line 9 or line 11 here and on Part I, line 2 1 2 3 4 5

6 7 8 9 10 11 12
Form

7 8 9 10 11 12

5330

(Rev. 4-2009)

Form 5330 (Rev. 4-2009)

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Name of Filer:

Filer's identifying number:

Schedule C. Tax on Prohibited Transactions (Section 4975) (see instructions) Reported by the last day of the 7th month after the end of the tax year of the employer (or other person who must file the return) (continued) 1 2 Is the excise tax a result of a prohibited transaction that was (box "a" or box "b" must be checked): discrete other than discrete (a lease or a loan) a b Complete the table below to disclose the prohibited transactions and figure the initial tax (see instructions)
(b) Date of transaction (see instructions) (c) Description of prohibited transaction (d) Amount involved in prohibited transaction (see instructions) (e) Initial tax on prohibited transaction (multiply each transaction in column (d) by the appropriate rate (see instructions))

(a) Transaction number

(i)

(ii)

(iii)

(iv)

(v)

(vi)

(vii)

(viii)

(ix)

(x)

(xi)

(xii) 3 4 Add amounts in column (e); enter here and on Part I, line 3a Have you corrected all of the prohibited transactions that you are reporting on this return? If "Yes," complete Schedule C, line 5, on the next page. If "No," attach statement (see instructions)
Form

Yes

No

5330

(Rev. 4-2009)

Form 5330 (Rev. 4-2009)

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Name of Filer: Filer's identifying number: Schedule C. Tax on Prohibited Transactions (Section 4975) Reported by the last day of the 7th month after the end of the tax year of the employer (or other person who must file the return) (continued) 5 Complete the table below, if applicable, of other participating disqualified persons and description of correction (see instructions).
(a) Item no. from line 2 (b) Name and address of disqualified person (c) EIN or SSN (d) Date of correction (e) Description of correction

Schedule D. Tax on Failure to Meet Minimum Funding Standards (Section 4971(a)) Reported by the last day of the 7th month after the end of the employer's tax year or 8 1/ 2 months after the last day of the plan year that ends within the filer's tax year 1 2 Aggregate unpaid required contributions (accumulated funding deficiency for multiemployer plans) (see instructions) Multiply line 1 by 10% (5% for multiemployer plans). Enter here and on Part I, line 8a 1 2
Form

5330

(Rev. 4-2009)

Form 5330 (Rev. 4-2009)

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6

Name of Filer: Filer's identifying number: Schedule E. Tax on Failure to Pay Liquidity Shortfall (Section 4971(f)(1)) Reported by the last day of the 7th month after the end of the employer's tax year or 8 1/ 2 months after the last day of the plan year that ends within the filer's tax year
(a) 1st Quarter (b) 2nd Quarter (c) 3rd Quarter (d) 4th Quarter (e) Total Add cols. a-d for line 3

1 Amount of shortfall 2 Shortfall paid by the due date 3 Net shortfall amount Multiply line 3 column (e) by 10% (5% for multiemployer plans). Enter here and on Part I, 4 line 9a Schedule F. Tax on Multiemployer Plans in Endangered or Critical Status (Section 4971(g)(3), 4971(g)(4)) Reported by the last day of the 7th month after the end of the employer's tax year or 8 1/ 2 months after the last day of the plan year that ends within the filer's tax year 1 2 3 4 Section 4971(g)(3) tax on failure to meet requirements for plans in endangered or critical status a Enter the amount of contributions necessary to meet the applicable benchmarks or requirements b Enter the amount of the accumulated funding deficiency c Enter the greater of line 1a or line 1b, here and on Part I, line 10b 2 Section 4971(g)(4) tax on failure to adopt rehabilitation plan a Enter the amount of the excise tax on the accumulated funding deficiency under section 4971(a)(2) from Schedule D, line 2 1 1 1a 1b 1c 2 2a

b Enter the number of days during the tax year which are included in the period beginning on the first day 2b of the 240 day period and ending on the day the rehabilitation plan is adopted 2c c Multiply line 2b by $1,100 d Enter the greater of line 2a or line 2c, here and on Part I, line 10c 2d Schedule G. Tax on Excess Fringe Benefits (Section 4977) Reported by the last day of the 7th month after the end of the calendar year in which the excess fringe benefits were paid to the employer's employees Yes No 1 Did you make an election to be taxed under section 4977? 2 If "Yes," enter the calendar year (YYYY) in which the excess fringe benefits were paid 3 3 If line 1 is "Yes," enter the excess fringe benefits on this line (see instructions) 4 Enter 30% of line 3 here and on Part I, line 11 4 Schedule H. Tax on Excess Contributions to Certain Plans (Section 4979) Reported by the last day of the 15th month after the end of the plan year Enter the amount of an excess contribution under a cash or deferred arrangement that is part of a plan 1 qualified under section 401(a), 403(a), 403(b), 408(k), or 501(c)(18) or excess aggregate contributions 2 Multiply line 1 by 10% and enter here and on Part I, line 13 2 Schedule I. Tax on Reversion of Qualified Plan Assets to an Employer (Section 4980) Reported by the last day of the month following the month in which the reversion occurred 1 2a 3 4 MM DD Date reversion occurred Employer reversion amount b Excise tax rate Multiply line 2a by line 2b and enter the amount here and on Part I, line 14 Explain below why you qualify for a rate other than 50%: YY 3 1

Schedule J. Tax on Failure to Provide Notice of Significant Reduction in Future Accruals (Section 4980F) Reported by the last day of the month following the month in which the failure occurred 1 1 Enter the number of applicable individuals who were not provided ERISA section 204(h) notice 2 MM DD YY 2 Enter the effective date of the amendment 3 3 Enter the number of days in the noncompliance period 4 4 Enter the total number of failures to provide ERISA section 204(h) notice (see instructions) 5 5 Multiply line 4 by $100. Enter here and on Part I, line 15 6 Provide a brief description of the failure, and of the correction, if any

Schedule K. Tax on Prohibited Tax Shelter Transactions (Section 4965) Reported on or before the 15th day of the 5th month following the close of the entity manager's tax year during which the plan became a party to a prohibited tax shelter transaction 1 2 Enter the number of prohibited tax shelter transactions you caused the same plan to be a party to Multiply line 1 by $20,000. Enter the result here and on Part I, line 16 1 2
Form

5330

(Rev. 4-2009)