Annual Return of One-Participant OMB No. 1545-0956

(Owners and Their Spouses) Retirement Plan

Form 5500-EZ

This form is required to be filed under section 6058(a) of the Internal Revenue Code.

Department of the Treasury

Internal Revenue Service

This Form is Open

© Complete all entries in accordance with the instructions to the Form 5500-EZ to Public Inspection.

B If filing under an extension of time, check this box (see instructions) ©

Annual Return Identification Information

Basic Plan Information — enter all requested information.

Form 5500-EZ (2009)

Part I

Part II

Cat. No. 63263R

2009

For the calendar plan year 2009 or fiscal plan year beginning , and ending ,

the first return filed for the plan;

an amended return;

the final return filed for the plan;

a short plan year return (less than 12 months).

1a Name of plan Three-digit

plan number (PN) ©

1b

Date plan first became effective

(MM,DD,YYYY)

1c

2a Employer’s name

3a Plan administrator’s name (If same as employer, enter “Same”)

If the name and/or EIN of the employer has changed since the last return filed for this plan,

enter the name, EIN, and plan number for the last return in the appropriate space provided:

4

2c Employer’s telephone number

Employer Identification Number (EIN)

(Do not enter your Social Security Number)

2b

3c Administrator’s telephone number

3b Administrator’s EIN

4c PN

4b EIN

a Employer’s name

5 Total number of participants at the beginning of the plan year 

Total number of participants at the end of the plan year 5b

a

b

6

Part III Financial Information

Total plan assets 

Total plan liabilities 

c Net plan assets (subtract line 6b from 6a) 

6a

6b

6c

(1) Beginning of year (2) End of year

For Paperwork Reduction Act Notice, see the instructions for Form 5500-EZ.

A This return is:

5a

a

b

(2) (4)

2d Business code (see instructions)

Certain foreign retirement plans are also required to file this form (see instructions).

(1) (3)

Trade name of business (if different from name of employer)

In care of name

Mailing address (room, apt., suite no. and street, or P.O. Box)

City, state, and ZIP code (if foreign, see instructions)

In care of name

Mailing address (room, apt., suite no. and street, or P.O. Box)

City, state, and ZIP code (if foreign, see instructions)

C If this return is for a foreign plan, check this box (see instructions) ©
Form 5500-EZ (2009)

7c

Part III (Continued)

7b

Form 5500-EZ (2009) Page 2

7 Contributions received or receivable from:

a

b

c

Employers 

Participants 

Others (including rollovers) 

7a

Amount

Part V Compliance and Funding Questions

9

Yes No

During the plan year, did the plan have any participant loans? 

If “Yes,” enter amount as of year end 

10

Amount

Is this a defined benefit plan that is subject to minimum funding requirements? 

If “Yes,” complete Schedule SB (Form 5500). (See instructions.)

11 Is this a defined contribution plan subject to the minimum funding requirements of

section 412 of the Code? 

a

b

c

If a waiver of the minimum funding standard for a prior year is being amortized in this plan

year, enter the month, day, and year (MM,DD,YYYY) of the letter ruling granting the waiver

(see instructions)

Enter the minimum required contribution for this plan year 

Enter the amount contributed by the employer to the plan for this plan year 

Subtract the amount in line 11c from the amount in line 11b. (Enter a minus sign to the left

of a negative amount.) 

d

e Will the minimum funding amount reported on line 11d be met by the funding

deadline? 

Yes No N/A

11b

11c

11d

If “Yes,” complete lines 11a or 11b, 11c, 11d, and 11e below, as applicable:

Part IV Plan Characteristics

8 Enter the applicable two-character feature codes from the List of Plan Characteristics Codes in the instructions:

Caution: A penalty for the late or incomplete filing of this return will be assessed unless reasonable cause is established.

Sign

Here

Under penalties of perjury, I declare that I have examined this return including, if applicable, any related Schedule MB (Form 5500) or Schedule SB (Form 5500) 

signed by an enrolled actuary, and to the best of my knowledge and belief, it is true, correct, and complete.

Signature of employer or plan administrator Date Type or print name of individual signing as employer or

plan administrator

©

9

10

11

11a

11e