8 453 E Return/Report of Employee Benefit Plan OMB No. 1545-1033
Form a (With Fewer Than 100 Participants)

Departmentof the Teasury Electronic/Magnetic Media 1990
Internal Revenue Service _ | For the calendar plan year 1990 or the fiscal plan year beginning 119 _, and ending 19

Ja Name and address of plan sponsor (employer if fora single-employer plan) Ib Employer identification number

2a_Name and address of plan administrator (if same as plan sponsor, enter “same”) ‘2b Administrator's employer identification no.

Return/Report Information

3 Name of plan

4 Enter the three-digit plannumber . . toe foe re 7 | |

5  Totalassets atthe end ofthe planyear. . . toe bone so oe |

6 Schedule B(Form5500)isattached . . . 2... ... . . . . DD Yes (1) No C1 _Not applicable

Declaration of Employer/Plan Sponsor, Administrator, Fiduciary, and Actuary

Under penalties of perjury, | declare that the Return/Report information agrees with the corresponding information on my 1990
Return/Report of Employee Benefit Plan. | have also examined a copy of the return being filed electronically or on magnetic media with
the Internat Revenue Service, including accompanying schedules and statements. To the best of my knowledge and belief, the return is
true, correct, and complete.

If am not the transmitter, | have consented that the return, including this declaration and accompanying schedules and statements, be
sent to the Internal Revenue Service by our return transmitter.

» Signature of employer/plan sponsor a Date
Please >
H Signature of plan administrator Date
Sign 8 P
Here -
» Signature of fiduciary Date

To the best of my knowledge, the information supplied in this schedule and on the accompanying statements, if
any, is complete and accurate, and in my opinion each assumption used in combination, represents my best estimate
of anticipated experience under the plan. Furthermore, in the case of a plan other than a multiemployer plan, each
assumption used: (a) is reasonable (taking into account the experience of the plan and reasonable expectations), or
(b) would, in the aggregate, result in a total contribution equivalent to that which would be determined if each such
assumption were reasonable. In the case of a multiemployer plan, the assumptions used, in the aggregate, are
reasonable (taking into account the experience of the plan and reasonable expectations).

Signature of actuary Date

Declaration of Transmitter

If the transmitter also prepared the return, please check here » []

| declare that the Return/Report of Employee Benefit Plan is based on all information of which | have knowledge. A copy of all forms and
information to be filed with the Internal Revenue Service has been or will be provided to the taxpayer.

Transmitter's Signature

Address > ZIP Code D>
For Paperwork Reduction Act Notice, see page 2 of this form. Form 8453-E (1990)



Form 8453-E (1990)

Page 2

Instructions

Paperwork Reduction Act Notice

We ask for the information on this form
to carry out the law as specified in
ERISA and Internal Revenue Code
section 6039D. You are required to give
us this information. We need it to
determine whether the plan is
operating according to the law.

The time needed to complete and
file this form will vary depending on
individual circumstances. The
estimated average time is:

Recordkeeping . 7 min.
Learning about the

law or the form . . 2min.
Preparing the form . 18 min.
Copying, assembling,

and sending the form

toIRS 2... 1. 20 min.

U.S. GOVERNMENT PRINTING OFFICE: 1999 0864248

If you have comments concerning
the accuracy of these time estimates or
suggestions for making this form more
simple, we would be happy to hear from
you. You can write to both the Internal
Revenue Service, Washington, DC
20224,

Attention: IRS Reports Clearance
Officer, T:FP; and the

Office of Management and Budget,
Paperwork Reduction Project
(1545-1033),

Washington, DC 20503.

DO NOT send this form to either of
these offices. Instead see Where To
File at the end of these instructions.

Purpose of Form

Form 8453-E is used by qualified filers
who file Form 5500-C/R and related
schedules electronically or on magnetic
media. The form is used to transmit the
signature of the employer/plan

sponsor, plan administrator, fiduciary,
actuary and the return transmitter
signature(s) for the employee benefit
plan return. Form 8453-E and the
electronic/magnetic media information
comprises the Employee Benefit Plan’s
return/report for the plan year.

Who Must File.—Every participant in
the electronic/magnetic media program
wishing to file a Form 5500-C/R for
plan year 1990 via magnetic media,
must complete Form 8453-E.

Where To File

File Form 8453-E with the
Internal Revenue Service,
Andover Service Center,
P.O. Box 4099,

Attention: EFU (EPMF),
Stop 983

Woburn, MA 01889-9741.