rom G453-E Return/Report of Employee Benefit Plan |_ ome No. 1546-1033 _
(With Fewer Than 100 Participants)

Department of the Treasury Electronic/Magnetic Media 1991

Internal Revenue Service For the calendar plan year 1991 or the fiscal plan year beginning .19 __, and ending 19

If you are filing this form for an amended Form 5500EZ or 5500-C/R, check box... . . . sO oO

1a Name and address of plan sponsor (employer if for a single-employer plan) 1b 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_. . ww ss I l ]

5 Total assets at the end of the plan year poe
6 Schedule B (Form 5500) is attached... . 2... . LE Yes O No (_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 1991
Return/Report of Employee Benefit Plan. | have also examined a copy of the return being filed electronically or on magnetic
media with the Internal Revenue Service, including the 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 Date
Please ; —
. Signature of plan administrator Date
Sign
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 multiempioyer 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 P

Address

For Paperwork Reduction Act Notice, see page 2 of this form. Cat. No. 10331Y Form 8453-E (1991)


Form 8453-E (1991)

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 . 20 min.
Copying, assembling,

and sending the form

toIRS ...... . 20 min.

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 below.

Purpose of Form

Form 8453-E is used by qualified
filers who file Form 5500-C/R,
5500EZ, and the 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 who wants to file a Form
5500-C/R or 5500EZ for the 1991
plan year 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 4050,

Attention: EFU (EPMF),
Stop 983

Woburn, MA 01888-4050.

*U.S, GPO: 191-285-396