Return of Excise Taxes 

Related to Employee Benefit Plans

Form 5330

OMB No. 1545-0575

Expires: 6-30-93

(Rev. January 1992)

Department of the Treasury

Internal Revenue Service

(Under sections 4971, 4972, 4973(a)(2), 4975, 4976, 4977, 4978,

4978A, 4978B, 4979, 4979A, and 4980 of the Internal Revenue Code)

For tax year beginning , 19 and ending , 19

Name of filer (see instructions on page 2) Check applicable box and see instructions.

Employer identification number OR

Number, street and room or suite no. (If a P.O. box number (see page 2 of the instructions)) Social security number

Identification number

City or town, state, and ZIP code

Employer identification number of

plan sponsor

Name and address of the plan sponsor (see instructions on page 2)

Plan year ending

Name of plan Plan number

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

Accumulated funding deficiency in the plan’s minimum funding standard account (see specific

instructions)

1

Accumulated funding deficiency in the plan’s alternative minimum funding standard account (see

specific instructions)

2

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 on line 21 ©

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

4 Total amount contributed for current year, less rollovers (see instructions)

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

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

7 Prior year excess contributions not previously eliminated. If zero, proceed to line 11

8 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

72(e) and not previously used to reduce excess contributions

9

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)

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

of the last day of the year. Enter here and on line 22 ©

12

Tax on Prohibited Transactions (Section 4975)

(d) Initial tax on 

prohibited transaction

(5% of column (c)) 

(see instructions)

(c) Amount involved

in prohibited

transaction

(see instructions)

(a) Date 

of transaction 

(see instructions)

13a

(b) Description of prohibited transaction Transaction

number

(i)

(ii)

(iii)

13b Tax due—Add amounts in column (d). Enter here and on line 23 ©

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge

Please 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.

Sign

Here Your signature Date

Preparer’s

Paid signature

Preparer’s

Use Only

Date

Firm’s name (or yours

if self-employed) and

address

For Paperwork Reduction Act Notice, see page 1 of the instructions. Form 5330 (Rev. 1-92)

©

Cat. No. 11870M

Part III

Part I

Part II

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Form 5330 (Rev. 1-92) Page 2

Tax on Disqualified Benefits (Section 4976)

If your welfare benefit fund has provided a disqualified benefit during your taxable year, enter the

amount of the disqualified benefit here and on line 24 (see instructions)

14

Tax on Excess Fringe Benefits (Section 4977)

15a Did you make an election to be taxed under section 4977? Yes No

b If “Yes,” enter the calendar year in which the excess fringe benefits were paid © 19

c If line a is “Yes,” enter the excess fringe benefits on this line (see instructions)

d Enter 30% of line c on this line and on line 25

Tax on Certain ESOP Dispositions (Sections 4978, 4978A and 4978B)

Enter here and on line 26a your section 4978 or 4978A tax on dispositions of employer securities by

employee stock ownership plans and certain worker-owned cooperatives (see instructions). Check the

box to indicate which tax you are filing for

16a

Section 4978 Section 4978A

b Enter here and on line 26b your section 4978B tax on dispositions of employer securities to which

section 133 applied

Tax on Nondeductible Employer Contributions to Qualified Plans (Section 4972)

17a Total contributions for your tax year to your qualified (under section 401(a), 403(b), or 408(k)) plan

b Amount allowable as a deduction under section 404

c Subtract line b from line a

Enter amount of any prior year nondeductible contributions made for years

beginning after 12/31/86

d

Amount of any prior year nondeductible contributions for years beginning

after 12/31/86 returned to you in this tax year or any prior tax year

e

f Subtract line e from line d

g Amount of line f carried forward and deductible in this tax year

h Subtract line g from line f

i Taxable excess contributions—add line c and line h

j TAX—Enter 10% of line i here and on line 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 qualified under section 401(a), 403(a), 403(b), 408(k), 501(c)(18) or excess aggregate

contributions described in section 401(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 (Section 4979A)

19 If you owe any tax under section 4979A, enter the amount of the tax here and on line 29 below (see

instructions)

Tax on Reversion of Qualified Plan Assets to an Employer (Section 4980)

20a Date reversion occurred © month day year

b If you owe any tax under section 4980, enter the amount here and on line 30 below (see instructions)

Summary of Taxes Due

21 Tax on failure to meet minimum funding standard (from line 3)

22 Tax on excess contributions to section 403(b)(7)(A) custodial accounts (from line 12)

23 Tax on prohibited transactions (from line 13b)

24 Tax on disqualified benefits (from line 14)

25 Tax on excess fringe benefits (from line 15d)

26a Tax on certain ESOP dispositions (from line 16a)

b Tax on certain ESOP dispositions (from line 16b)

27 Tax on nondeductible contributions to qualified plans (from line 17j)

28 Tax on excess contributions to certain plans (from line 18b)

29 Tax on certain prohibited allocations of qualified ESOP securities (from line 19)

30 Tax on reversion of qualified plan assets to an employer (from line 20b)

31a Total tax (add lines 21 through 30) (see instructions)

b Enter amount of tax paid upon filing of Form 5558, if applicable

c

Are you electing to be taxed on a prohibited transaction which occurred prior to January 1, 1975, so that

your plan and trust will retain its exempt status? (See instructions)

32

Yes No

33 Have you corrected any of the prohibited transactions which you are reporting on this return? (See instructions) Yes No

If ‘‘Yes,’’ complete Part XIll.

Total tax due (subtract line 31b from line 31a). Pay in full with return. (Make checks or money orders

payable to Internal Revenue Service.) ©

Part XI

Part X

Part IX

Part VIII

Part VII

Part VI

Part V

Part IV
Form 5330 (Rev. 1-92) Page 3

Schedule of Other Participating Disqualified Persons (See instructions)

(b)

Transaction

number from

Part III

34 (a)

Name and address of disqualified person

(i)

(ii)

(iii)

Description of Correction (See line 33 instructions.)

35 (a)

Transaction

number from

Part III

(c)

Date of

correction

(b)

Nature of correction

(c)

Employer identification

number or social

security number

Part XII

Part XIII