Official Use Only

This Form is Open to

Public Inspection.

2004

Form 5500-EZ OMB No. 1545-0956

Part I Annual Return Identification Information

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Part II Basic Plan Information -- enter all requested information.

1a Name of plan

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.

Complete all entries in accordance with

the instructions to the Form 5500-EZ.

A This return is: (1) the first return filed for the plan; (3) the final return filed for the plan;

(2) an amended return; (4) a short plan year return

(less than 12 months).

B If filing under an extension of time, check box and attach required information. (see instructions) ..............................................................

For Paperwork Reduction Act Notice, see the instructions for Form 5500-EZ. Form 5500-EZ (2004)

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Department of the Treasury

Internal Revenue Service

1b Three-digit plan number (PN) ▼

MM / DD / Y Y Y Y 1c Date plan first

became effective

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

Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return, including accompanying schedules, statements and

attachments, as well as the electronic version of this return if it is being filed electronically, and to the best of my knowledge and belief, it is true, correct and complete.

Date

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

MM / DD / Y Y Y Y

For the calendar plan year 2004

or fiscal plan year beginning and ending MM / DD / Y Y Y Y MM / DD / Y Y Y Y

Cat. No. 63263R

v7.1

Signature of employer or plan administrator

SIGN HERE ▼

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Form 5500-EZ (2004) Page 2

3a Plan administrator's name and address (If same as employer, enter "Same")

3b Administrator's EIN

3c Administrator's telephone number

b EIN c PN

2a Employer's name and address (Address should include room or suite no.)

Name

Name Continued

City

State Zip Code

Name

Name Continued

Street

City

1)

2)

c/o

1)

3)

4)

5)

6)

7)

3)

4)

5)

9)

8)

c/o

Street

D/B/A

Employer Identification Number (EIN)

(Do not enter your Social Security Number)

2)

State Zip Code

Foreign Country

Foreign Routing Code

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

 last return below:

a Employer's name

Location Address if different than 4) or 5)

6)

2d Business code

(see instructions)

2c Employer's telephone

Foreign Routing Code number

Foreign Country

Location Address if different than Street

2b

7)

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5 Preparer information (optional)

a Name (including firm name, if applicable) and address

b EIN

c Telephone number

Name

Name Continued

Street

City

State Zip Code

Foreign Routing Code

Foreign Country

6 Type of plan: (a)

(b) Stock bonus plan

(c) Money purchase pension plan (see instructions) (f) ESOP plan (attach Schedule E (Form 5500))

7a If this is a master/prototype, or regional prototype plan, enter the opinion/notification letter number ..........

b Check if this plan covers:

(1) Self-employed individuals, (2) Partner(s) in a partnership, or (3) 100% owner of corporation

8a Enter the number of qualified pension benefit plans maintained by the employer (including this plan) .......................................

b Check here if you have more than one plan and the total assets of all plans are more than $100,000 (see instructions) ......... ▼

9 Enter the number of participants in each category listed below:

a Under age 59 1/2 at the end of the plan year ....................................................................................................................................

b Age 59 1/2 or older at the end of the plan year, but under age 70 1/2 at the beginning of the plan year ......................................

c Age 70 1/2 or older at the beginning of the plan year .......................................................................................................................

Number

Form 5500-EZ (2004) Page 3

1)

2)

3)

4)

5)

6)

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Defined benefit pension plan (other than a plan

described in Code section 412(i))

Defined benefit pension plan described in

Code section 412(i)

 (d) Profit-sharing plan

(e)

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Form 5500-EZ (2004) Page 4

b Cash contributions received by the plan for this plan year ........................................

c Noncash contributions received by the plan for this plan year ..................................

d Total plan distributions to participants or beneficiaries (see instructions) ..................

e Total nontaxable plan distributions to participants or beneficiaries ............................

f Transfers to other plans ...............................................................................................

g Amounts received by the plan other than from contributions .....................................

h Plan expenses other than distributions .......................................................................

11a Total plan assets ........

b Total plan liabilities .....

(a) Beginning of Year (b) End of Year

12 Specific Assets: If the plan held assets at any time during the plan year in any of the following categories, check "Yes" and enter the

current value of any assets remaining in the plan as of the end of the plan year. Otherwise, check "No."

Yes No Amount

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a Partnership/joint venture interests ..................................................

b Employer real property ....................................................................

c Real estate (other than employer real property) ............................

10a (1) Is this a fully insured pension plan which is funded entirely by insurance or annuity contracts?

If "Yes," complete lines 10a(2) through 10f and skip lines 10g through 13d.

(2) If 10a(1) is "Yes," are the insurance contracts held: ...................................................................

Yes No

under a with no

trust trust

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▼(1) (2)

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Form 5500-EZ (2004) Page 5

13 Check "Yes" and enter amount involved if any of the following

transactions took place between the plan and a disqualified

person during this plan year. Otherwise, check "No."

a Sale, exchange, or lease of property .............................................

b Payment by the plan for services ...................................................

c Acquisition or holding of employer securities .................................

d Loan or extension of credit .............................................................

Yes No

14a Does your business have any employees other than you and your spouse (and your partners and

their spouses)? ...................................................................................................................................................................

b Total number of employees (including you and your spouse and your partners and their spouses) .............................

c Does this plan meet the coverage requirements of Code section 410(b)? .....................................................................

15a Did the plan distribute any annuity contracts this plan year? ...........................................................................................

b During this plan year, did the plan make distributions to a married participant in a form other than a qualified

joint and survivor annuity or were any distributions on account of the death of a married participant made to

beneficiaries other than the spouse of that participant? ...................................................................................................

c During this plan year, did the plan make loans to married participants? .........................................................................

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Yes No Amount

d Employer securities .........................................................................

e Participant loans (see instructions).................................................

f Loans (other than to participants) ...................................................

g Tangible personal property ..............................................................

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00

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00

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00

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00

Yes No Amount

If 14a is "No," do not complete line 14b or line 14c. See the specific instructions for line 14b and line 14c.

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