Return of Excise Taxes 

Related to Employee Benefit Plans Form 5330

OMB No. 1545-0575 (Rev. August 2004)

Department of the Treasury

Internal Revenue Service

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

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)

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

Filer’s identifying number—EIN or

SSN (see instructions)

City or town, state, and ZIP code



Summary of Taxes Due

7a Section 4971(a) tax on failure to meet minimum funding standards (see instructions)

2 Section 4973(a)(3) tax on excess contributions to section 403(b)(7)(A) custodial accounts (from line 24)

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

3 Section 4976 tax on disqualified benefits for funded welfare plans (see instructions)

8 Section 4977 tax on excess fringe benefits (from line 30d)

4a Section 4978 and 4978A tax on certain ESOP dispositions (see instructions)

b The tax on line 4a is a result of the application of:

1 Section 4972 tax on nondeductible contributions to qualified plans (from line 14l)

9 Section 4979 tax on excess contributions to certain plans (see instructions)

5 Section 4979A tax on certain prohibited allocations of qualified ESOP securities (see instructions)

10 Section 4980 tax on reversion of qualified plan assets to an employer (from line 34)

13a Total tax. Add lines 1 through 12b (see page 4 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 13b from line 13a. 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

7a

2

6a

3

8

4a

4b

1

9

5

10

13a

13b

13c

161

164

200

209

203

159

163

201

205

204

12a Section 4971(f)(1) tax on failure to pay liquidity shortfall (from line 45) 226 12a

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. 8-2004)









 Telephone number  ( )

Section 4980F tax on failure to provide notice of significant reduction in future accruals (from line 41) 228 11

Sec. 664(g) Sec. 1042 Sec. 4978A

b Section 4975(b) tax on failure to correct prohibited transactions (see Part IV instructions) 6b

b Section 4971(b) tax on failure to correct minimum funding standards (see Part VI instructions) 7b

11

b Section 4971(f)(2) additional tax on failure to correct liquidity shortfall (see Part XI instructions) 12b

224

225

227
Form 5330 (Rev. 8-2004) Page 2

24

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

14a

b Amount allowable as a deduction under section 404

c Subtract line 14b from line 14a

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 14e from line 14d

g Amount of line 14f carried forward and deductible in this tax year

h Subtract line 14g from line 14f

k Taxable excess contributions. Subtract line 14j from line 14i

l Multiply line 14k 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 5 of the instructions)

Amount excludable from gross income under section 403(b) (see page 5 of the instructions)

15

Current year excess contributions. Subtract line 16 from line 15; but not less than zero

16

Prior year excess contributions not previously eliminated. If zero, go to line 22a

17

Contribution credit. If line 16 is more than line 15, enter the excess; otherwise, enter -0-

18

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

19

Adjusted prior years’ excess contributions. Subtract the total of lines 19 and 20 from line 18 

20

Taxable excess contributions. Add lines 17 and 21

21

Excess contributions tax. Enter the lesser of line 22b or line 23b. Enter here and on line 2 

22a

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.

Tentative taxable excess contributions. Add lines 14c and 14h

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

i

j

Multiply line 22a by 6%

Enter the value of your account as of the last day of the year

Multiply line 23a by 6%

b

b

Form 5330 (Rev. 8-2004)

23a
Form 5330 (Rev. 8-2004) Page 3

Tax on Prohibited Transactions (Section 4975) (see instructions)

(e) Initial tax on prohibited

transaction (multiply each

transaction in column (c) by

the appropriate rate (see

page 6 of the instructions))

(d) Amount involved

in prohibited

transaction

(see page 6 of the

instructions)

(b) Date

of transaction

(see page 6 of

the instructions)

(c) Description of prohibited transaction

(a)

Transaction

number

(i)

(ii)

(iii)

25c Add amounts in column (e). Enter here and on line 6a 

Yes No

Have you corrected all of the prohibited transactions that you are reporting on this return? (See page 7

of the instructions)

26

If “Yes,” complete Part V. If “No,” complete Part V and see page 7 of the instructions.

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.

25a 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)

Part IV

Form 5330 (Rev. 8-2004)

b Complete the table below to disclose the prohibited transactions and figure the initial tax (see instructions).

(v)

(vi)

(vii)

(viii)

(ix)

(x)
Form 5330 (Rev. 8-2004) Page 4

Schedule of Other Participating Disqualified Persons and Description of Correction (see instructions)

(e)

Description of correction

(d)

Date of correction

(b)

Name and address of

disqualified person

(c)

EIN or SSN

(a)

Item no.

from Part IV

Part V

Form 5330 (Rev. 8-2004)

27 Complete the schedule of other participating disqualified persons and description of correction (see instructions)
Form 5330 (Rev. 8-2004) Page 5

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

Accumulated funding deficiency in the plan’s minimum funding standard account (see page 7 of the

instructions)

28

29 Multiply line 28 by tax rate (see instructions on page 7 for applicable tax rates). Enter here and on

line 7a 

Tax on Excess Contributions to Certain Plans (Section 4979)

31a 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 31a 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)

32 Date reversion occurred  month day year

33a Employer reversion amount

34 Multiply line 33a by line 33b and enter the amount here and on line 10 

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

Tax on Excess Fringe Benefits (Section 4977)

30a 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 30a is “Yes,” enter the excess fringe benefits on this line (see page 8 of the instructions)

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

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.

Tax on Failure to Pay Liquidity Shortfall (Section 4971(f)(1))

42 Amount of shortfall

Shortfall paid by the due

date

43

44 Net shortfall amount

45 Multiply line 44 (total column) by 10% (5% for multiemployer plans). Enter here and on line 12a 

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

b Excise tax rate %

Printed on recycled paper

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

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

37 Enter the effective date of the amendment 

38 Enter the number of days in the noncompliance period 

39 Enter the total number of failures to provide ERISA section 204(h) notice (see page 8 of

the instructions) 

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

41 Multiply line 39 by $100. Enter here and on line 11.

Form 5330 (Rev. 8-2004)

Part X

Part VII

Part XI

Part IX

Part VI

Part VIII