OMB No. 1545-0956 Form 5500-EZ

Department of the Treasury

Internal Revenue Service

For the calendar plan year 1996 or fiscal plan year beginning , 1996, and ending , 19

This Form Is Open

Please type or print to Public Inspection

This return is: (i) the first return filed (ii) an amended return (iii) the final return

1a Name of employer 1b

Use IRS

label.

Otherwise,

please

type or

print.

Number, street, and room or suite no. (If a P.O. box, see instructions for line 1a.) 1c Telephone number of employer

City or town, state, and ZIP code

1d

If plan year has changed since last

return, check here ©

2c Date plan first became effective

2b (i) Name of plan © Month Day Year

2d Enter three-digit

Check if name of plan has changed since last return plan number ©

(ii)

3

4a

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

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

b

Type of plan: Defined benefit pension plan (attach Schedule B (Form 5500))

5a

a b Money purchase plan (see instructions)

c Profit-sharing plan d Stock bonus plan e ESOP plan (attach Schedule E (Form 5500))

6 Number Enter the number of participants in each category listed below:

Under age 591 a ⁄2 at the end of the plan year 6a

b

6c

Age 591⁄2 or older at the end of the plan year, but under age 701⁄2 at the beginning of the plan year

7a Is this a fully insured pension plan which is funded entirely by insurance or annuity contracts? ©

b Cash contributions received by the plan for this plan year 7b

7c

Total nontaxable plan distributions to participants or beneficiaries

c

7d

Amounts received by the plan other than from contributions

d

Plan expenses other than distributions

e 7e

8a Total plan assets at the end of the year 8a

b Total plan liabilities at the end of the year 8b

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.”

9

Yes No Amount

a Sale, exchange, or lease of property 9a

b Payment by the plan for services 9b

c Acquisition or holding of employer securities 9c

d Loan or extension of credit 9d

Yes No

10a 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)? ©

If 10a is “No,” do not complete line 10b and line 10c. See the specific instructions for line 10b and line 10c.

11a Did the plan distribute any annuity contracts this plan year? ©

b

c

Under penalties of perjury and other penalties set forth in the instructions, 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.

Signature of employer (owner) or plan administrator ©

For Paperwork Reduction Act Notice, see page 1 of the instructions. Cat. No. 63263R Form 5500-EZ (1996)

Employer identification number

Date ©

2a Is the employer also the plan administrator? Yes No (If “No,” see instructions.)

Annual Return of One-Participant

(Owners and Their Spouses) Retirement Plan

(iv) a short plan year (less than 12 mos.)

© See separate instructions.

This form is required to be filed under

section 6058(a) of the Internal Revenue Code.

1e

Business activity code

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

Check if this plan covers: (i) Self-employed individuals, (ii) Partner(s) in a partnership, or

b

Noncash contributions received by the plan for this plan year

g 7g

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? ©

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

(iii) 100% owner of corporation

Yes

Total plan distributions to participants or beneficiaries

h 7h

No

If “Yes,” complete lines 7a(ii) through 7f and skip lines 7g through 9d.

(i)

under a

trust

with no

trust

(ii)

If 7a(i) is “Yes,” are the insurance contracts held: ©

c Age 701⁄2 or older at the beginning of the plan year

6b

Check here if you filed an extension of time to file and attach a copy of the approved extension ©

Transfers to other plans 7f f

10a

10c

11a

11b

11c

96