rom 5930 Return of Excise Taxes

(Rev. April 1991) Related to Employee Benefit Plans ome Ne. 1545.0575
Department of the Treasury (Under sections 4971, 4972, 4973(a)(2), 4975, 4976, 4977, 4978, Expires: 630-9
Internal Revenue Service 4978A, 4978B, 4979, 4979A, and 4980 of the Internal Revenue Code)

For tax year beginning ,19 and ending 19

Section A All Filers Complete This Section

Name (see general instructions) Check applicable box and enter number:

CO emptoyer identification number OR
Social security number
(see general instructions)

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

City or town, state, and ZIP code

Section B_ All Prohibited Transaction Filers Complete This Section

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

Pian 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... >
Gg Taxon Excess Contributions to Section ‘403(bN 7A) Custodial Accounts (Section 4973)
Total amount contributed for current year, less rollovers identified in section 4973(cX1).. 2 2...

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) . woe ee ee
Prior year excess contributions not previously eliminated. If zero, proceedtoline 11 . . . . . . Jo
Contribution credit (if line 5 exceeds line 4, enter the excess; otherwise, enter zero)

oaornaun

Tota! 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 . . . : frre

10 Adjusted prior years' excess contributions (line 7 less the total of lines 8 and 9).
11 Taxable excess contributions (tine 6 plus line 10) .

12 Excess contributions tax—Enter the lesser of 6% of line 11 or 6% of the value of your account as 5 of
the last day of the year. Enter here and on line 22 . rs rere

Pa Tax on Prohibited Transactions (Section 4975).
13a (a) Date (©) Amount invoived {d) Initial tax on
in prohibited prohibited transaction
Transaction} _of transaction (b) Description of prohibited transaction m prohibited ‘Be ot column Ce
number | (see instructions) (see instructions) (see instructions)
@
(i)
(iii)
b Tax due—Add amounts in column (d). Enter here andon line 23... . _.
Under penaities of perjury, | declare that | have examined this retum, inclading 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 Vio signature » Date
Preparer's
Paid signature » » Date
‘ -
Prepater's |Fivs name (oryous
Use Only | it self-employed) and

address

For Paperwork Reduction Act Notice, see page 1 of the instructions. Form 5330 (Rev, 4-91)


Form 5330 (Rev. 4-91)

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
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 49777, . . . . . . . oO Yes im) 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 4 4978, 4978A and 4978B)

16a 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 _L) Section 4978 [1 Section 4978A.

b Enter here and on line 26b your section 4978B tax on dispositions of employer securities to ‘whieh
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 .
Subtract line b from line a

d Enter amount of any prior year nondeductible contributions made for years

°

beginning after 12/31/86 . . . . rn

e Amount of any prior year nondeductible c contributions “for years beginning after
12/31/86 returned to you in this tax year or any prior tax year an

Subtract line e from line d

iil

Subtract line g from line f

f :
g Amount of line f carried forward and deductible in 1 this tax year .
h
i

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 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 8p Securities (Section 4979A)

19 If you owe any tax under section 49794, enter the amount of the tax here and on line 29 below (see
instructions) . . :

Tax on Reversion 0 of Qualified Plan Assets to: an | Employer “(Section 4980).

20a Date reversion occurred ® month day year

N

|

b if you owe any tax under section 4980, enter the amount here and on line 30 below (see instructions)
Part xi 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 cn 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 17}).
28 Tax on excess contributions to certain plans (from line 18b)
29 = Tax on certain prohibited allocations of qualified ESOP securities (from tine 19).
30 Tax on 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 31). Pay i in full with return. (Make checks or money orders
payable to Internal Revenue Service.). . rn

32 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) .

Tare

.O Yes [] No

33 Have you corrected any of the prohibited transactions which you are reporting on this return? (See ‘nstructions) (1 ves [] No

If ‘Yes,"' complete Part Xiil.



Form 5330 (Rev. 4-91)

Page 3

Schedule of Other Participating Disqualified Persons (See instructions)

(a)
Name and address of disqualified person

(b)
Transaction
number from
Part Ili

©)
Employer identification
‘number or social
security number

Description of Correction (See line 33 instructions.)

35 (a)
Transaction
number from
Part Il

(b)
Nature of correction

(c)
Date of
correction