Return of Excise Taxes 

Related to Employee Benefit Plans Form 5330

OMB No. 1545-0575 (Rev. April 2009)

Department of the Treasury

Internal Revenue Service

(Under sections 4965, 4971, 4972, 4973(a)(3), 4975, 4976, 4977, 4978, 4979,

4979A, 4980, and 4980F of the Internal Revenue Code)

Filer tax year beginning , and ending ,

Name of filer (see instructions)

Number, street, and room or suite no. (If a P.O. box or foreign address, see instructions)

City or town, state, and ZIP code

Taxes. You can only complete one section of Part I for each Form 5330 filed (see instructions).

8a Section 4971(a) tax on failure to meet minimum funding standards (from Schedule D, line 2) 

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

(from Schedule B, line 12) 

2

3a Section 4975(a) tax on prohibited transactions (from Schedule C, line 3)

4 Section 4976 tax on disqualified benefits for funded welfare plans

9a Section 4971(f)(1) tax on failure to pay liquidity shortfall (from Schedule E, line 4)

5a Section 4978 tax on ESOP dispositions

b The tax on line 5a is a result of the application of:

Section 4972 tax on nondeductible contributions to qualified plans (from Schedule A,

line 12)

1

b Section 4971(f)(2) tax for failure to correct liquidity shortfall

6 Section 4979A tax on certain prohibited allocations of qualified ESOP securities

11 Section 4977 tax on excess fringe benefits (from Schedule G, line 4)

Part I

8a

2

3a

4

9a

5a

5b

1

9b

6

11

161

164

200

209

203

159

163

226

227

201

A

C

D

H

Name of plan

Name and address of plan sponsor

If this is an amended return, check here ©

FOR

IRS

USE

ONLY

For Privacy Act and Paperwork Reduction Act Notice, see instructions.

Total Section B taxes. Add lines 8a through 11. Enter here and on Part II, line 17 © 12

Sec. 664(g) Sec. 1042

b Section 4975(b) tax on failure to correct prohibited transactions 3b

b Section 4971(b) tax for failure to correct minimum funding standards 8b

12

Section A. Taxes that are reported by the last day of the 7th month after the end of the

tax year of the employer (or other person who must file the return)

7 Total Section A taxes. Add lines 1 through 6. Enter here and on Part II, line 17 © 7

Section B. Taxes that are reported by the last day of the 7th month after the end of the employer’s tax year or 8 1⁄2

months after the last day of the plan year that ends within the filer’s tax year

Section C. Tax that is reported by the last day of the 15th month after the end of the plan year

13 Section 4979 tax on excess contributions to certain plans (from Schedule H, line 2).

Enter here and on Part II, line 17 © 205 13

224

225

Cat. No. 11870M Form 5330 (Rev. 4-2009)

Section 4971(g)(2) tax on failure to comply with a funding improvement or rehabilitation

plan (see instructions)

10a

Section 4971(g)(3) tax on failure to meet requirements for plans in endangered or critical

status (from Schedule F, line 1c)

b

c Section 4971(g)(4) tax on failure to adopt rehabilitation plan (from Schedule F, line 2d) 

10a

10b

10c

450

451

452

Section B1. Tax that is reported by the last day of the 7th month after the end of the calendar year in which the excess

fringe benefits were paid to the employer’s employees

B Filer’s identifying number (see instructions)

E

F

G

Plan sponsor’s EIN

Plan year ending (MM/DD/YYYY)

Plan number

Social security number (SSN)

Employer identification number (EIN)
19 Tax due. Subtract line 18 from line 17. If the result is greater than zero, enter here, and attach

check or money order payable to “United States Treasury.” Write your name, identifying number, 

plan number, and “Form 5330, Section(s) ” on your payment © 19

Part II Tax Due

17 Enter the amount from Part I, line 7, 12, 13, 14, 15, or 16 (whichever is applicable) 17

18 Enter amount of tax paid with Form 5558 or any other tax paid prior to filing this return 18

Form 5330 (Rev. 4-2009) Page 2

Form 5330 (Rev. 4-2009)

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 © Telephone number © Date

Section E. Tax that is reported by the last day of the month following the month in which the failure occurred

Section D. Tax that is reported by the last day of the month following the month in which the reversion occurred

Section 4980F tax on failure to provide notice of significant reduction in future accruals

(from Schedule J, line 5). Enter here and on Part II, line 17 ©

15

228 15

14 Section 4980 tax on reversion of qualified plan assets to an employer (from Schedule I,

line 3). Enter here and on Part II, line 17 © 204 14

Section F. Taxes reported on or before the 15th day of the 5th month following the close of the entity manager’s taxable

year during which the plan became a party to a prohibited tax shelter transaction

Section 4965 tax on prohibited tax shelter transactions for entity managers (from Schedule 

K, line 2). Enter here and on Part II, line 17 ©

16

16

Name of Filer: Filer’s identifying number:

237

Preparer’s Date Preparer’s SSN or PTIN

signature Check if

self-employed Paid

Preparer’s

Use Only Firm’s name (or

yours if self-employed),

address, and ZIP code

EIN

©

© Phone no. ( )
Form 5330 (Rev. 4-2009) Page 3

Total contributions for your tax year to your qualified employer plan (under section 401(a),

403(a), 408(k), or 408(p))

1

2 Amount allowable as a deduction under section 404

3 Subtract line 2 from line 1

Enter amount of any prior year nondeductible contributions made for

years beginning after 12/31/86

4

Amount of any prior year nondeductible contributions for years beginning 

after 12/31/86 returned to you in this tax year for any prior tax year

5

6 Subtract line 5 from line 4

7 Amount of line 6 carried forward and deductible in this tax year

8 Subtract line 7 from line 6

11 Taxable excess contributions. Subtract line 10 from line 9

12 Multiply line 11 by 10%. Enter here and on Part I, line 1 ©

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

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

Current year excess contributions. Subtract line 2 from line 1. If zero or less, enter -0-

Prior year excess contributions not previously eliminated. If zero, go to line 8

Contribution credit. If line 2 is more than line 1, 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

Adjusted prior years’ excess contributions. Subtract the total of lines 5 and 6 from line 4

Taxable excess contributions. Add lines 3 and 7

Excess contributions tax. Enter the lesser of line 9 or line 11 here and on Part I, line 2 ©

Schedule A. Tax on Nondeductible Employer Contributions to Qualified Employer Plans (Section 4972)

Reported by the last day of the 7th month after the end of the tax year of the employer (or other person who must file

the return)

Tentative taxable excess contributions. Add lines 3 and 8

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

9

10

Multiply line 8 by 6%

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

Multiply line 10 by 6%

Form 5330 (Rev. 4-2009)

Name of Filer: Filer’s identifying number:

1

2

3

8

9

4

5

6

7

11

12

10

Schedule B. Tax on Excess Contributions to Section 403(b)(7)(A) Custodial Accounts (Section 4973(a)(3))

Reported by the last day of the 7th month after the end of the tax year of the employer (or other person who must file 

the return)

1

2

3

4

5

6

7

8

11

12

9

10

1

2

3

4

5

6

7

8

9

11

12

10
Form 5330 (Rev. 4-2009) Page 4

(e) Initial tax on prohibited

transaction (multiply each

transaction in column (d) by

the appropriate rate (see

instructions))

(d) Amount involved

in prohibited

transaction

(see instructions)

(b) Date

of transaction

(see instructions)

(c) Description of prohibited transaction

(a)

Transaction

number

(i)

(ii)

(iii)

3 Add amounts in column (e); enter here and on Part I, line 3a ©

Yes No Have you corrected all of the prohibited transactions that you are reporting on this return? If “Yes,” 

complete Schedule C, line 5, on the next page. If “No,” attach statement (see instructions) ©

4

1 Is the excise tax a result of a prohibited transaction that was (box “a” or box “b” must be checked):

discrete other than discrete (a lease or a loan)

(iv)

Form 5330 (Rev. 4-2009)

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

(v)

(vi)

(vii)

(viii)

(ix)

(x)

Name of Filer: Filer’s identifying number:

a b

Schedule C. Tax on Prohibited Transactions (Section 4975) (see instructions) Reported by the last day of the 7th month

after the end of the tax year of the employer (or other person who must file the return) (continued)

(xi)

(xii)
(e)

Description of correction

(d) (b)

Name and address of

disqualified person

(c)

EIN or SSN

(a)

Item no.

from line 2

Form 5330 (Rev. 4-2009)

5 Complete the table below, if applicable, of other participating disqualified persons and description of correction 

(see instructions).

Date of

correction

Form 5330 (Rev. 4-2009) Page 5

Name of Filer: Filer’s identifying number:

Schedule C. Tax on Prohibited Transactions (Section 4975) Reported by the last day of the 7th month after the end of

the tax year of the employer (or other person who must file the return) (continued)

Aggregate unpaid required contributions (accumulated funding deficiency for multiemployer

plans) (see instructions)

1

2 Multiply line 1 by 10% (5% for multiemployer plans). Enter here and on Part I, line 8a ©

1

2

Schedule D. Tax on Failure to Meet Minimum Funding Standards (Section 4971(a)) Reported by the last day of the 

7th month after the end of the employer’s tax year or 8 1⁄2 months after the last day of the plan year that ends within

the filer’s tax year
Date reversion occurred ©

Employer reversion amount

Multiply line 2a by line 2b and enter the amount here and on Part I, line 14 ©

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

1 Did you make an election to be taxed under section 4977? Yes No

2 If “Yes,” enter the calendar year (YYYY) in which the excess fringe benefits were paid ©

3 If line 1 is “Yes,” enter the excess fringe benefits on this line (see instructions)

4 Enter 30% of line 3 here and on Part I, line 11 ©

b Excise tax rate

Form 5330 (Rev. 4-2009)

Schedule G. Tax on Excess Fringe Benefits (Section 4977) Reported by the last day of the 7th month after the end of the

calendar year in which the excess fringe benefits were paid to the employer’s employees

3

4

Schedule E. Tax on Failure to Pay Liquidity Shortfall (Section 4971(f)(1)) Reported by the last day of the 7th month after

the end of the employer’s tax year or 8 1⁄2 months after the last day of the plan year that ends within the filer’s tax year

1 Amount of shortfall

2 Shortfall paid by the due date

3 Net shortfall amount

Multiply line 3 column (e) by 10% (5% for multiemployer plans). Enter here and on Part I, 

line 9a ©

4

4

1

2

3

(a) 1st Quarter (b) 2nd Quarter (c) 3rd Quarter (d) 4th Quarter (e) Total

Schedule H. Tax on Excess Contributions to Certain Plans (Section 4979) Reported by the last day of the 15th month after the

end of the plan year

Enter the amount of an excess contribution under a cash or deferred arrangement that is part of a plan

qualified under section 401(a), 403(a), 403(b), 408(k), or 501(c)(18) or excess aggregate contributions

Multiply line 1 by 10% and enter here and on Part I, line 13 ©

1

2

1

2

Schedule I. Tax on Reversion of Qualified Plan Assets to an Employer (Section 4980) Reported by the last day of the

month following the month in which the reversion occurred

1

2a

3

4

3

Schedule J. Tax on Failure to Provide Notice of Significant Reduction in Future Accruals (Section 4980F) Reported by the

last day of the month following the month in which the failure occurred

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

Enter the effective date of the amendment ©

Enter the number of days in the noncompliance period ©

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

Multiply line 4 by $100. Enter here and on Part I, line 15 ©

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

1

2

3

4

5

6

1

2

3

4

5

Form 5330 (Rev. 4-2009) Page 6

Name of Filer: Filer’s identifying number:

Add cols. a-d for line 3

Schedule K. Tax on Prohibited Tax Shelter Transactions (Section 4965) Reported on or before the 15th day of the 5th month

following the close of the entity manager’s tax year during which the plan became a party to a prohibited tax shelter transaction

Enter the number of prohibited tax shelter transactions you caused the same plan to be a

party to ©

Multiply line 1 by $20,000. Enter the result here and on Part I, line 16 ©

1

2

1

2

Schedule F. Tax on Multiemployer Plans in Endangered or Critical Status (Section 4971(g)(3), 4971(g)(4)) Reported by the

last day of the 7th month after the end of the employer’s tax year or 8 1⁄2 months after the last day of the plan year that

ends within the filer’s tax year

1 Section 4971(g)(3) tax on failure to meet requirements for plans in endangered or critical status

a Enter the amount of contributions necessary to meet the applicable benchmarks or requirements

1

1a

b Enter the amount of the accumulated funding deficiency

c Enter the greater of line 1a or line 1b, here and on Part I, line 10b ©

1b

1c

2 Section 4971(g)(4) tax on failure to adopt rehabilitation plan

Enter the amount of the excise tax on the accumulated funding deficiency under section

4971(a)(2) from Schedule D, line 2

a

Enter the number of days during the tax year which are included in the period beginning on the first day

of the 240 day period and ending on the day the rehabilitation plan is adopted ©

b

c Multiply line 2b by $1,100

d Enter the greater of line 2a or line 2c, here and on Part I, line 10c ©

2

2a

2b

2c

2d

MM DD YY

MM DD YY