room 5GOO Return of Initial Excise Taxes OMB No, 1545-0575
fev. December 1981) | Related to Pension and Profit-Sharing Plans

Department of the Treasury Expires 9-30-83,

Internal Revenue Service (Under sections 4971, 4972, 4973(a)(2) and 4975 of the Internal Revenue Code)

For tax year beginning 19 and ending 119

Name (see general instructions) Check applicable box and enter number:
[CJ Employer identification number OR

Address (number and street) [FJ Social security number

(see general instructions)

City or town, State and ZIP code

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

Plan year ending

Name of plan Plan number

ETA Taxes on Failure to Meet Minimum Funding Standards

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—5% of line 1 or 5% of line 2 (see instructions). Enter here andonline14. . . |.

Part Il Tax on Excess Contributions to 403(b)(7)(A) Custodial Accounts

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

5 Amount excludable from gross income under section 403(b) (see instructions). . 2 2 2. ewe
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)

9 Total of all prior years’ distributions out of the account included in your gross income under section 72(e)

i |

and not previously used to reduce excess contributions . . . coe
10 Adjusted prior years’ excess contributions (line 7 less the total of lines 8and9) . 2...
11 Taxable excess contributions (line 6 plus line10). . . . . : : :

12 Excess contributions tax—Enter the lesser of 6% of line 11 or °% of the value of your account as of the
last day of the year. Enter here and on line 15 . oa . . wee ee

[2tsSl[Mm@ Tax on Prohibited Transactions

13 (a) 2. Date 6: Amount involved d. Initial tax on
° i In prohibite prohibited transaction
Teans- transaction b. Description of prohibited transaction transaction (5% of column ©)
action | (see instructions) (see instructions) (Gee instructions)
(i)
(ii)
(iii)
(b) Tax due—Add amounts in column d. Enter here and online16. . . . . - . . . )
Part IV Summary of Taxes Due
14 Tax on failure to meet minimum funding standard (from line3). . . . « So ee
15 Tax on excess contributions to 403(b)(7)(A) custodial accounts (from line 12) Do eee

16 Tax on prohibited transactions (from line 13(b)). . . - . ee

17 _Tax on excess contributions for self-employed individuals (from ‘ine 27) :

Under penalties of periury, | declare that | have examined this return, ncloding accompanying schedules and statements, and to the best

Please | of my knowledge and belief, it 1s true, correct, and complete. Declaration of preparer (other than taxpayer) 1s based on all information of
which preparer has any knowledge.

Sign

Here | Dycirsanaare ax
. Preparer’s:

Paid | Pome D ac
Preparer's |~Fimrs name (or

Use Only | yours, if self-employed)
and address

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


Form 5330 (Rev. 12-81) Page 2
MET Summary of Taxes Due (Continued)

18 (a) Total tax (add lines 14,15, 16 and 17). 6. ww
(b) Enter amount of tax paid upon filing of Form 5558, if applicable So
(c) Total tax due (subtract line 18(b) from line 18(a)). Pay in full with return. (Make checks or money
orders payable to Internal Revenue Service)... . : re
19 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?. . 2... ee ee ee ee ee ee ee Yes [NO
20 Have you corrected any of the prohibited transactions which you are reporting on this return? . . . . . .[] Yes [] No

If “Yes,” complete Part VI.
Schedule of Other Participating Disqualified Persons
21

b.
a. Name and address of disqualified person Transaction | Employer identinication

number from number or social
Part Ill security number

iZta1mm Description and Documentation of Correction

22

Transaction b. Nature of correction c. Date of

number from correction
Part II

BEET Tax on Excess Contributions to Self-employed Plans

Voluntary Contributions
23 (a) Enter total contributions by owner-employee as an employee for current tax year less qualified dis-
tributions for tax years beginning after 12-31-81, and plus prior years excess contribution(s) not
previously corrected, if any. . .
Enter the smallest of: (i) 10% of owner-employee's earned income, (ii) $2,500, or (iii) the amount
of owner-employee’s voluntary contributions computed using the rate allowable under the plan
for employees other than owner-employees (if there are no employees in the plan other than owner-
employees, this amount is zero). . . ra
(©) Current year excess contributions (subtract (b) from @, but not less than zero). . . . se

Defined Benefit Plan Contributions
24 (a) You have excess contributions if: (i) as of the close of the tax year, the full funding limitation, deter-
mined under section 412(c)(7) is zero, and (ii) some or all of the contributions made in this tax
year are not deductible in this tax year. If the above two requirements are met, enter the nonde-
ductible contributions less qualified distributions for tax years beginning after 12-31-81 here .

(b) Prior years’ excess contributions; if previously corrected, enter zero... . 1. ee ee
(©) Add (@) and (b) we ee
Defined Contribution Plan Contributions
25 (a) Enter the total employer contributions for the current tax year which were not deductible for such

tax year less qualified distributions for tax years beginning after 12-31-81. . . . woe
(b) Prior years’ employer excess contributions; if previously corrected, enter zero—See specific instruc:

(b)

tion for PartVIE we
(e)_ Add (a) and (b) se ee ee

26 Total excess contributions (enter total of lines 23(c), 24(c), and 25(c)). 6 ee ee ee ee

27 Excess contributions tax—6% of line 26. Enter here andonline 17. . . . . . . . wl

% U.S. GOVERNMENT PRINTING OFFICH: 1982-343-537