Form 5500-EZ

Department of the Treasury 

Internal Revenue Service

Annual Return of One-Participant 

(Owners and Their Spouses) Retirement Plan

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

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

▶ Complete all entries in accordance with the instructions to the Form 5500-EZ.

OMB No. 1545-0956

2012

This Form is Open 

to Public Inspection.

Part I Annual Return Identification Information

For the calendar plan year 2012 or fiscal plan year beginning , and ending ,

A This return is: (1) the first return filed for the plan;

(2) an amended return;

(3) the final return filed for the plan;

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

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

C If this return is for a foreign plan, check this box (see instructions) . . . . . . . . . . . . . . . . . . ▶

Part II Basic Plan Information — enter all requested information.

1a Name of plan 1b Three-digit 

plan number (PN) ▶

1c Date plan first became effective 

(MM,DD,YYYY)

2a Employer’s name

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)

2b Employer Identification Number (EIN) 

(Do not enter your Social Security Number)

2c Employer’s telephone number

2d Business code (see instructions)

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

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)

3b Administrator’s EIN

3c Administrator’s telephone number

4a Name of trust (optional) 4b Trust's EIN (optional)

5 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:

a Employer’s name

5b EIN

5c PN

6a Total number of participants at the beginning of the plan year. . . . . . . . . . 6a

b Total number of participants at the end of the plan year . . . . . . . . . . . . 6b

Part III Financial Information

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

7a Total plan assets . . . . . . . . . . . . . . . . . . . 7a

b Total plan liabilities . . . . . . . . . . . . . . . . . . . 7b

c Net plan assets (subtract line 7b from 7a) . . . . . . . . . . . 7c

For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 5500-EZ. Cat. No. 63263R Form 5500-EZ (2012)
Form 5500-EZ (2012) Page 2

Part III (Continued)

8 Contributions received or receivable from:

a Employers. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Amount

8a

b Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8b

c Others (including rollovers) . . . . . . . . . . . . . . . . . . . . . . . 8c

Part IV Plan Characteristics

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

Part V Compliance and Funding Questions

Yes No Amount

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

If “Yes,” enter amount as of year end . . . . . . . . . . . . . . . . . 10

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

If “Yes,” complete Schedule SB (Form 5500) and line 11a below. (See instructions.) . 11

a Enter the amount from Schedule SB (Form 5500), line 39 . . . . . . . . . . . . . 11a

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

of section 412 of the Code? . . . . . . . . . . . . . . . . . . . . 12

If “Yes,” complete lines 12a or 12b, 12c, 12d, and 12e below, as applicable:

a 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) . . . . . . . . . . . . . . . . . . . . . . . . . . 12a

b Enter the minimum required contribution for this plan year . . . . . . . . . . . . . 12b

c Enter the amount contributed by the employer to the plan for this plan year . . . . . . . 12c

d Subtract the amount in line 12c from the amount in line 12b. Enter the result (enter a minus sign 

to the left of a negative amount) . . . . . . . . . . . . . . . . . . . . . 12d

Yes No N/A

e Will the minimum funding amount reported on line 12d be met by the funding 

deadline? . . . . . . . . . . . . . . . . . . . . . . . . . 12e

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

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.

Sign 

Here ▲

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

plan administrator

Preparer's name (including firm name, if applicable) and address, including room or suite number (optional) Preparer's telephone number (optional)

Form 5500-EZ (2012)