Return of Excise Taxes 

Related to Employee Benefit Plans

Form 5330

OMB No. 1545-0575

Expires 5-31-96

(Rev. May 1993)

Department of the Treasury

Internal Revenue Service

(Under sections 4971, 4972, 4973(a)(2), 4975, 4976, 4977, 4978,

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

Filer tax year beginning , 19 and ending , 19

Name of filer (see instructions on page 3) Check applicable box and see instructions.

Employer identification number

Number, street, and room or suite no. (If a P.O. box, see page 3 of the instructions) Social security number

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

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

Please 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 Paperwork Reduction Act Notice, see page 1 of the instructions. Form 5330 (Rev. 5-93)

©

Cat. No. 11870M

©

©

©

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Summary of Taxes Due

7 Section 4971 tax on failure to meet minimum funding standards (from line 32)

Section 4973 tax on excess contributions to section 403(b)(7)(A) custodial accounts (from

line 21)

2

6 Section 4975 tax on prohibited transactions (from line 25b)

3 Section 4976 tax on disqualified benefits (from line 22)

8 Section 4977 tax on excess fringe benefits (from line 33d)

4a Section 4978 and 4978A tax on certain ESOP dispositions (from line 23a)

b Section 4978B tax on certain ESOP dispositions (from line 23b)

1 Section 4972 tax on nondeductible contributions to qualified plans (from line 12j)

9 Section 4979 tax on excess contributions to certain plans (from line 34b)

5 Section 4979A tax on certain prohibited allocations of qualified ESOP securities (from line 24)

10 Section 4980 tax on reversion of qualified plan assets to an employer (from line 37)

11a Total tax. Add lines 1 through 10 (see 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 11b from line 11a. Attach check or money order for full amount

payable to “Internal Revenue Service.” Write your name, identifying number, and “Form 5330,

Section(s) ” on it ©

Part I

7

2

6

3

8

4a

4b

1

9

5

10

11a

11b

11c
Form 5330 (Rev. 5-93) Page 2

Tax on Disqualified Benefits (Section 4976)

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 (see instructions) ©

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 instructions) ©

23a

Section 4978 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)

12a Total contributions for your tax year to your qualified (under section 401(a), 403(b), or 408(k)) plan

b Amount allowable as a deduction under section 404

c Subtract line 12b from line 12a

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 12e from line 12d

g Amount of line 12f carried forward and deductible in this tax year

h Subtract line 12g from line 12f

i Taxable excess contributions. Add line 12c and line 12h

j Tax. Enter 10% of line 12i here and on line 1 ©

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

13 Total amount contributed for current year less rollovers (see instructions)

14 Amount excludable from gross income under section 403(b) (see instructions)

15 Current year excess contributions (line 13 less line 14, but not less than zero)

16 Prior year excess contributions not previously eliminated. If zero, go to line 20

17 Contribution credit (if line 14 is more than line 13, enter the excess; otherwise, enter -0-)

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

19 Adjusted prior years’ excess contributions (line 16 less the total of lines 17 and 18)

20 Taxable excess contributions (line 15 plus line 19)

Excess contributions tax. Enter the lesser of 6% of line 20 or 6% of the value of your account as

of the last day of the year here and on line 2 ©

21

Tax on Certain Prohibited Allocations of Qualified ESOP Securities (Section 4979A)

24 Enter 50% of the prohibited allocation here and on line 5 (see instructions) ©

Employer identification number of plan sponsor Plan Number

Plan Number

Plan Number

Plan Number

Plan Number

Part III

Part II

Employer identification number of plan sponsor

Employer identification number of plan sponsor

Employer identification number of plan sponsor

Employer identification number of plan sponsor

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

Check the box(es) to indicate which tax you are filing for
Form 5330 (Rev. 5-93) Page 3

Schedule of Other Participating Disqualified Persons (See instructions)

(b)

Transaction

number from

Part VII

28 (a)

Name and address of disqualified person

(i)

(ii)

(iii)

Description of Correction (See line 27 instructions.)

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

(5% of column (c)) 

(see instructions)

(c) Amount involved

in prohibited

transaction

(see instructions)

(a) Date 

of transaction 

(see instructions)

25a

(b) Description of prohibited transaction Transaction

number

(i)

(ii)

(iii)

25b Tax due. Add amounts in column (d). Enter here and on line 6 ©

Are you electing to be taxed on a prohibited transaction which occurred prior to January 1, 1975, so that

your plan and trust will retain its exempt status? (See Specific Instructions and When To File for different

due date.) 

26

Yes No

Yes No

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

instructions)

27

If “Yes,” you must complete Part IX.

Employee identification number of plan sponsor Plan Number

Part IX

Part VII

Part VIII

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

However, see number 6 under When To File if the box on line 26 is checked “Yes.”
Form 5330 (Rev. 5-93) Page 4

Plan Number

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

30 Accumulated funding deficiency in the plan’s minimum funding standard account (see instructions)

Accumulated funding deficiency in the plan’s alternative minimum funding standard account (see

instructions)

31

32 Tax due. See instructions for applicable tax rates. Enter the tax here and on line 7 ©

Tax on Excess Contributions to Certain Plans (Section 4979)

34a 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 Enter 10% of line 34a here and on line 9 ©

Tax on Reversion of Qualified Plan Assets to an Employer (Section 4980)

35 Date reversion occurred © month day year

Employer reversion amount Tax percentage %

Plan Number

Plan Number

36

37 If you owe any tax under section 4980, enter the amount here and on line 10 (see instructions) ©

38 Explain below why you qualify for the 20% rate:

Part XII

Part X

Part XIII

Tax on Excess Fringe Benefits (Section 4977)

33a 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 © 19

c If line 33a is “Yes,” enter the excess fringe benefits on this line (see instructions)

d Enter 30% of line 33c on this line and on line 8 ©

Employer identification number of plan sponsor Plan Number

Employer identification number of plan sponsor

Part XI

Employer identification number of plan sponsor

Employer identification number of plan sponsor

DUE DATE: See When To File for taxes due under sections 4971, 4977, 4979, and 4980.