rom 9330 Return of Excise Taxes

(Rev. February 1989) Related to Employee Benefit Plans OMB No, 1545-0575
Department of the Treasury (Under sections 4971, 4972, 4973(a)(2), 4975, 4976, 4977, 4978, Expires: 12-31-91
Internal Revenue Service 4978A, 4979, 4979A, and 4980 of the Internal Revenue Code)

For tax year beginning 19 and ending 119

Name (see general instructions)

Address (number and street)

City or town, state, and ZIP code

Check applicable box and enter number:
C1 Employer identification number OR
CO. Social security number

(see general instructions)

Name and address of employer whose plan was involved in the prohibited transaction, if applicable Employer identification number

Plan year ending

Name of plan Plan number

Tax on Failure To Meet Minimum Funding Standards (Section 4971)

1 Accumulated funding deficiency in the plan's minimum funding standard account (see specific instructions) .

2 Accumulated funding deficiency in the plan's alternative minimum funding standard account (see specific instructions)

3 Tax due—10% of line 1 or 10% of line 2 for plan years beginning after 12-31-88 (5% of line 1 or line 2 for
multiemployer plans or for plan years beginning before 1-1-89) (See instructions.) Enter here and online 21>

Tax on Excess Contributions to Section 403(b)(7)(A) Custodial Accounts (Section 4973)

4 Total amount contributed for current year, less rollovers identified in section 4973(c)(1)

Amount excludable from gross income under section 403(b) (see instructions)

Current year excess contributions (line 4 less line 5, but not less than zero) . .

Prior year excess contributions not previously eliminated—if zero, proceed to line 11

Contribution credit (if line 5 exceeds line 4, enter the excess; otherwise, enter zero) .

Total of all prior years’ distributions out of the account included in your gross income under section 720)
and not previously used to reduce excess contributions . Soe

10 Adjusted prior years’ excess contributions (line 7 less the total of lines 8 and 9).

11 Taxable excess contributions (line 6 plus line 10) an

12 Excess contributions tax—Enter the lesser of 6% of line 11 or 6% of the value of your account as of the last

oaorvnan

day of the year. Enterhereandonline22.. we
Tax on Prohibited Transactions (Section 4975)
13a (a) Date () Amount involved (@) Initial tax on
of in prohibited prohibited transaction
Transaction} transaction (b) Description of prohibited transaction Hoel (5% of column (e))
number | (see instructions) (see instructions) (See instructions)

@

(ii)

(iii)

b Tax due—Add amounts in column (d). Enterhere andonline23_. . red

Under penalties of perjury, | declare that | have examined this return, including accompanying schedules and statements, and to the best of my knowledge and
Please | belief itis true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Sign
Here |» »
Your signature Date

. Preparer's »
Paid | signature » Date
Preparer’s Firms name (or
Use Only | yours if setf-employed) »

and address

For Paperwork Reduction Act Notice, see page 1 of the instructions.

Form 5330 (Rev. 2-89)


Form 5330 (Rev. 2-89) Page 2
Tax on Disqualified Benefits (Section 4976)

14 If your welfare benefit fund has provided a disqualified benefit during your taxable year, enter the amount Mh
of the disqualified benefit here and on line 24 (see instructions) . .

Tax on Excess Fringe Benefits (Section 4977)

15a_Did you make an election to be taxed under section 4977? . . .. .OYes ONo tN
b If “Yes,” enter the calendar year in which the excess fringe benefits were paid sone > 19 YYW Y

¢ ({fline ais “Yes,” enter the excess fringe benefits on this line (see instructions) soe
d_ Enter 30% of line c on this line and online 25... Ferrera
iziaaus Taxon Certain ESOP Dispositions (Section 4978 and 978A) _

2057 applied
Taxon Nondeductible Employer Contributions to ‘Qualified Plans ‘Geetion 4972)
17a Total contributions for your taxable year to your qualified (under section 401(a), 403(b), or 408(k)) plan
b Amount allowable as a deduction under section 404 Fo oe
¢ Subtract line b from linea .
d Enter amount of any prior year nondeductible contributions made for years
beginning after 12/31/86 . we So
Amount of any prior year nondeductible contributions for years beginning after
12/31/86 returned to you in this taxable year or any prior taxable year
Subtract linee from lined . . :
Amount of line f carried forward and deductible i in this taxable year .
Subtract line g from line f
Taxable excess contributions—add line ¢ c and line h

TAX—Enter 10% of line ihere and online 27 below...

Tax on Excess Contributions to Certain Plans (Section 4979) _
18a_ Enter the amount of any excess contributions under a cash or deferred arrangement that is part of a plan ]/ 7 ],
ZG

qualified under section 401(a), 403(a), 403(b), 408(k), 5ONCK18) or excess S aggregate ¢ contributions
described insection401(m) . .

b Enter 10% of the amount entered on line 18a here and on line 28.
Tax on Certain Prohibited Allocations of Qualified ESOP Securities ‘(Gection 49798)
19 If you owe any tax under section 4979A, enter the amount of the tax here and on line 29 below (see

-sm

instructions) .
Taxon Reversion of Qualified Plan Assets toari n Employer (Section 4980)
20a Date reversion occurred ® month___day___year_ Mh

b_ If you owe any tax under section 4980, enter the amount here and on line 30 below (see instructions)
age Summary of Taxes Due-

21 Taxon failure to meet minimum funding standard (from line 3) :
22 Taxon excess contributions to section 403(b)(7)(A) custodial accounts (from line 12)
23 Taxon prohibited transactions (from line 13b)
24 = Tax on disqualified benefits (from line 14)
25 Taxon excess fringe benefits (from line 15d) .
26a Tax on certain ESOP dispositions from line 16a .
b Taxon certain ESOP dispositions from line 16b . .
27 Taxon nondeductible contributions to qualified plans (from line W).
28 Taxon excess contributions to certain plans (fromline18b). . . . . eee ee Pe
29 Tax on certain prohibited allocations of qualified ESOP securities (from line 19)
30 Taxon reversion of qualified plan assets to an employer (from line 20b)
31a Total tax (add lines 21 through 30) .
b Enter amount of tax paid upon filing of Form 5558, if applicable :
¢ Total tax due (subtract line 31b from line 32). Pay in full with return. (Make checks ¢ or money J orders

payable to Internal Revenue Service.) _ . . . . oe a
32 Are you electing to be taxed on a prohibited transaction which occurred prior toJanuary 1, 1975, sothat your

planand trust will retainitsexemptstatus? . . . . . . OYes ONo
33 Have you corrected any of the prohibited transactions ‘which you a are reporting on this return? | ..... .O Yes OCNo

If 'Yes,”’ complete Part XIll.



Form 5330 (Rev. 2-89) Page 3

Schedule of Other Participating Disqualified Persons

34 Tranter Employer etiiat
(a) Name and address of disqualified person mrrarsection, ree mer orsocal
Part It security number

aes Description of Correction (See line 33 instructions.)

35 (a)

Transaction (b) Nature of correction OR
number from
Part Ill

¥U.S. Government Printing Office: 1989-242-473/80079