Return of Excise Taxes 

Related to Employee Benefit Plans Form 5330

(Rev. October 2003) OMB No. 1545-0575

Department of the Treasury

Internal Revenue Service

(Under sections 4971, 4972, 4973(a)(3), 4975, 4976, 4977, 4978, 4978A,

4978B, 4979, 4979A, 4980, and 4980F of the Internal Revenue Code)

Filer tax year beginning , and ending ,

Name of filer (see page 2 of the instructions) Check applicable box and see instructions.

Employer identification number (EIN)

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

Filer’s identifying number City or town, state, and ZIP code



Summary of Taxes Due

7 Section 4971 tax on failure to meet minimum funding standards (from line 31)

2 Section 4973(a)(3) tax on excess contributions to section 403(b)(7)(A) custodial accounts (from line 22)

6 Section 4975 tax on prohibited transactions (from line 26c)

3 Section 4976 tax on disqualified benefits (from line 23)

8 Section 4977 tax on excess fringe benefits (from line 32d)

4a Section 4978 and 4978A tax on certain ESOP dispositions (from line 24a)

b Section 4978B tax on certain ESOP dispositions (from line 24b)

1 Section 4972 tax on nondeductible contributions to qualified plans (from line 13l)

9 Section 4979 tax on excess contributions to certain plans (from line 33b)

5 Section 4979A tax on certain prohibited allocations of qualified ESOP securities (from line 25)

10a Section 4980 tax on reversion of qualified plan assets to an employer (from line 36)

12a Total tax. Add lines 1 through 11 (see page 3 of the instructions)

b Enter amount of tax paid with Form 5558 or any other tax paid prior to filing this return

c Total tax due. Subtract line 12b from line 12a. Attach check or money order payable to

“United States Treasury.” Write your name, identifying number, and “Form 5330,

Section(s) ” on your payment 

Part I

7

2

6

3

8

4a

4b

1

9

5

10a

12a

12b

12c

161

164

200

209

202

203

159

163

201

205

204

11 Section 4971(f) tax on failure to pay liquidity shortfall (from line 47) 226 11

A B

C

D

E

F

G

H

Name and address of plan sponsor

Name of plan

Plan sponsor’s EIN

Plan year ending

Plan number

Check here if this is an amended return 

FOR

IRS

USE

ONLY

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge

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

Your signature Date

Preparer’s

Paid signature

Preparer’s

Use Only

Date

Firm’s name (or yours

if self-employed) and

address

For Privacy Act and Paperwork Reduction Act Notice, see page 9 of the instructions. Cat. No. 11870M Form 5330 (Rev. 10-2003)









 Telephone number  ( )

b Section 4980F tax on failure to provide notice of significant reduction in future accruals (from line 43) 228 10b
Form 5330 (Rev. 10-2003) Page 2

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 3 

22

Tax on Certain ESOP Dispositions (Sections 4978, 4978A, and 4978B)

Enter your section 4978 or 4978A tax on dispositions of employer securities by employee stock

ownership plans and certain worker-owned cooperatives here and on line 4a (see page 4 of the

instructions) 

24a

Section 664(g) Section 4978A

b Enter your section 4978B tax on dispositions of employer securities to which section 133 applied

here and on line 4b 

Part VI

Part V

Part IV

Tax on Nondeductible Employer Contributions to Qualified Plans (Section 4972)

Total contributions for your tax year to your qualified (under section 401(a), 403(a), or 408(k), or

408(p)) plan

13a

b Amount allowable as a deduction under section 404

c Subtract line 13b from line 13a

Enter amount of any prior year nondeductible contributions made for years

beginning after 12/31/86

d

Amount of any prior year nondeductible contributions for years beginning

after 12/31/86 returned to you in this tax year or any prior tax year

e

f Subtract line 13e from line 13d

g Amount of line 13f carried forward and deductible in this tax year

h Subtract line 13g from line 13f

k Taxable excess contributions. Subtract line 13j from line 13i

l Multiply line 13k by 10%. Enter here and on line 1 

Tax on Excess Contributions to Section 403(b)(7)(A) Custodial Accounts (Section 4973(a)(3))

Total amount contributed for current year less rollovers (see page 3 of the instructions)

Amount excludable from gross income under section 403(b) (see page 3 of the instructions)

14

Current year excess contributions. Subtract line 15 from line 14; but not less than zero

15

Prior year excess contributions not previously eliminated. If zero, go to line 21

16

Contribution credit. If line 15 is more than line 14, enter the excess; otherwise, enter -0-

17

Total 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

18

Adjusted prior years’ excess contributions. Subtract the total of lines 18 and 19 from line 17 

19

Taxable excess contributions. Add lines 16 and 20

20

Excess contributions tax. Enter the lesser of 6% of line 21 or 6% of the value of your account as

of the last day of the year. Enter here and on line 2 

21

Tax on Certain Prohibited Allocations of Qualified ESOP Securities (Section 4979A) (See page 5 of instructions)

25 Enter 50% of the prohibited allocation or the allocation described in section 664(g)(5)(A), here and

on line 5 

Part III

Part II

DUE DATE: The taxes listed on this page are due by the last day of the 7th month after the end of the tax year of the filer.

Check the box to indicate whether the tax applies as a result of the application of

Tax on Disqualified Benefits for Funded Welfare Plan (Section 4976) (See page 4 of instructions)

23

Tentative taxable excess contributions. Add lines 13c and 13h

Nondeductible section 4972(c)(6) or (7) contributions exempt from excise tax

i

j

Section 1042
Form 5330 (Rev. 10-2003) Page 3

(b)

Transaction

number from

Part VII

28

(a)

Name and address of disqualified person

(i)

(ii)

(iii)

Description of Correction (see line 27 instructions on page 6)

29 (a)

Transaction

number from

Part VII

(c)

Date of

correction

(b)

Nature of correction

(c)

Employer identification

number or social

security number

Tax on Prohibited Transactions (Section 4975)

(d) Initial tax on prohibited

transaction (multiply each

transaction in column (c) by

the appropriate rate (see

page 6 of the instructions))

(c) Amount involved

in prohibited

transaction

(see page 6 of the

instructions)

(a) Date

of transaction

(see page 6 of

the instructions)

b

(b) Description of prohibited transaction Transaction

number

(i)

(ii)

(iii)

26c Add amounts in column (d). Enter here and on line 6 

Yes No

Have you corrected all of the prohibited transactions that you are reporting on this return? (See page 6

of the instructions)

27

If “Yes,” complete Part IX. If “No,” complete Part IX and see page 6 of the instructions.

Part IX

Part VII

Part VIII

DUE DATE: Section 4975 taxes are due by the last day of the 7th month after the end of the tax year of the filer.

Schedule of Other Participating Disqualified Persons (see instructions on page 6)

26a Is the excise tax a result of a prohibited transaction that was (check one or more):

discrete other than discrete (a lease or a loan)

(iv)

(iv)

(i)

(ii)

(iii)

(iv)
Form 5330 (Rev. 10-2003) Page 4

Tax on Failure To Meet Minimum Funding Standards (Section 4971)

Accumulated funding deficiency in the plan’s minimum funding standard account (see page 6 of the

instructions)

30

31 Multiply line 30 by tax rate (see instructions on page 6 for applicable tax rates). Enter here and on

line 7 

Tax on Excess Contributions to Certain Plans (Section 4979)

33a 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 Multiply line 33a by 10%. Enter here and on line 9 

Tax on Reversion of Qualified Plan Assets to an Employer (Section 4980) (See page 8 of instructions)

34 Date reversion occurred  month day year

35a Employer reversion amount

36 Multiply line 35a by line 35b and enter the amount here and on line 10a 

37 Explain below why you qualify for a rate other than 50%:

Part XII

Part X

Part XIII

Tax on Excess Fringe Benefits (Section 4977)

32a Did you make an election to be taxed under section 4977? Yes No

b If “Yes,” enter the calendar year in which the excess fringe benefits were paid 

c If line 32a is “Yes,” enter the excess fringe benefits on this line (see page 7 of the instructions)

d Enter 30% of line 32c on this line and on line 8 

Part XI

DUE DATE: See When To File on page 1 of the instructions for taxes due under sections 4971, 4977, 4979, 4980, 4971(f), and 4980F.

Part XV Tax on Failure to Correct Liquidity Shortfall (Section 4971(f))

44 Amount of shortfall

45 Amount corrected

46 Net shortfall amount

47 Multiply line 46 (total column) by 10%. Enter here and on line 11 

1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Total

b

Tax on Failure to Provide Notice of Significant Reduction in Future Accruals (Section 4980F)

38 Enter the number of applicable individuals who were not provided ERISA section 204(h) notice 

39 Enter the effective date of the amendment 

40 Enter the number of days in the noncompliance period 

41 Enter the total number of failures to provide ERISA section 204(h) notice (see page 7 of the

instructions) 

42 Provide a brief description of the failure, and of the correction made, if any

43 Multiply line 41 by $100. Enter here and on line 10b

Part XIV

Excise tax rate %