For

Department of the Treasury

Internal Revenue Service| For the calendar year 1991 or fiscal plan year beginning | ,19 CJ ,

PI
mi

m 95900EZ Annual Return of One-Participant (Owners and Their |_ovs no. 1545-0956

lease type or

Spouses) Pension Benefit Plan 1991

This Form ts Open
achine print and ending | 119 LJ : ito Public Inspection

This return is: (i) J the first return filed (i) [] an amended return (iii) L) the final return

Use IRS | 1a Name of employer 1b Employer identification number
label.
her-
wise, Number, street, and room or suite no. (If a P.O. box, see instructions for line 1a.) 1c Telephone number of employer
please
type or
machine City or town, state, and ZIP code 1d If plan year has changed since
print. last return, check here . >O
2a (i) Name of plan > 2b Date plan first became effective
Month Day Year
(ii) (1 Check if name of plan has changed since last return 2c¢ Enter three-digit
_ plan number > CL] LJ CJ
3a Enter the date the most recent plan amendment was adopted. . . . . Month Year Yes J No
b Enter the date of the most recent IRS determination letter . . . . . . Month Year Yh.
¢ Is a determination letter request pending with IRS? ee Y

4a Enter the number of other qualified pension benefit plans maintained ‘by the 1e employer >

b If you have more than one pension plan and the total assets of all plans are more than $100,000, check this
box

5 Type of plan: a oa Defined ‘benefit pension plan (attach Schedule B (Form 5500)) bO Money purchase plan

c (OProfit-sharing plan d C1 Stock bonus plan e CL] ESOP plan (attach Schedule E ‘(Form 5500)

Va
Z

6 Were there any noncash contributions made to the plan during the plan year? .
7 Enter the number of participants in each category listed below: Number
a Under age 59% at the end of the plan year . . 7a
b Age 59% or older at the end of the plan year, but under age 70Y%s ‘at the beginning of the Plan y year 7b
c Age 70% or older at the beginning of the plan year... Tce
8a_A fully insured plan with no trust and which is funded entirely by allocated insurance contracts that fully guarantee the
amount of benefit payments should check the box at the right and not complete 8b through 10d . : >
b Contributions received for this planyear 2 2. 8b
c Net plan income other than from contributions . 2 2... ee 8c
d Plan distributions . Ce ee ee ee. LB
e Plan expenses other than distributions . 8e
9a Total plan assets at the end of the year 9a
b Total plan liabilities at the end of the year. 9b
10 During the plan year, if any of the following transactions “took place between ‘the plan and a Y ZY
party-in-interest (see instructions), check “Yes” and enter amount. Otherwise, check “No.” Yes ZY Amount 7% No
a Sale, exchange, or lease of property. . 2 2... we ee ee. [Oa ZA Y,
b Loan or extension of credit... ee Y Y
¢ Acquisition or holding of employer secutities . Co ee ee ee ee [106 Y Y
d Payment by the plan for services... ss sw CCC C«d Od ZA Y
Yes J No
11a Does your business have any employees other than you and your spouse (and your partners and their spouses)? Y

\f “No,” do NOT complete the rest of this question; go to question 12.
b Total number of employees (including you and your spouse and your partners and their spouses) >

c Does this plan meet the coverage test of Code section 410(b)?
See the specific instructions for line 11c.

12

Answer these questions only if there was a benefit payment, loan, or distribution of an annuity contract made
during the plan year and the plan is subject to the spousal consent requirements (see instructions).
a Was there consent of the participant's spouse to any benefit payment or loan within the 90-day period prior to such payment or loan?
b If “No,” check the reason for no consent: (i) Ci the participant was not married
(i) C1 the benefit payment made was part of a qualified joint and survivor annuity (iii) OD other
c Were any annuity contracts purchased by the plan and distributed to the participants? .

‘Under penalties of perjury and other penalties set forth in the instructions, | declare that | have examined this return, Tneluaing accompanying schedules and statements,
and to the best of my knowledge and belief, it is true, correct, and complete.

Sigt

nature of employer/plan sponsor > Date >

For Paperwork Reduction Act Notice, see page 1 of the instructions. Cat. No. 63263R. Form 5500EZ (1991)