rom 95900EZ| Annual Return of One-Participant (Owners and Their — |_owsno. 1545-0956
Spouses) Pension Benefit Plan 1990

pepartinent ofthe mreasury For the calendar year 1990 or fiscal plan year beginning 19 -s

Please type or ~ and ending Lo, 19 This Form ts Open

machine print to Public Inspection

This return is: (i) [1] the first return filed (ii) (] an amended return (iii) (1 the final return

la Name of employer 1b Employer identification number
Number, street, and room or suite no. (If a P.O. box, see instructions for line 1a.) 1c Telephone number of employer
machine City or town, state, and ZIP code 1d If plan year has changed since last
print, return, check here . >O
2a (i) Name of plan > 2b Date plan first became fective
. Month Day Year
ii) (1 Check if name of plan has changed since last return 2c Enter three-digit
@ 8 plannumber. . » CJ im |
3a Enter the date the most recent plan amendment was adopted . . ., Month Year Yes
b Enter the date of the most recent IRS determination letter. . - . - . . . . Month Year Ms
c_lsa determination letter request pending with IRS? woe :
4a Enter the number of other qualified pension benefit plans maintained by the employer >

If you have more than one pension plan and the total assets of all plans are more than $100,000, check this box. . > []
5 Typeofplan: a CO Defined benefit pension plan (attach Schedule B (Form 5500)) 6 CL] Money purchase pian

c O Profit-sharing plan d@ C] Stock bonus plan e [] ESOP plan (attach Schedule E (Form 5500) Uh
6 _Were there any noncash contributions made to the plan during the plan year? :

os

7 Enter the number of participants in each category listed below: Number
a Under age 59% at the end of the plan year . . \7a\
b Age 59% or older at the end of the plan year, but under age 70/2 atthe beenning of the any year. . . . |7b
¢ Age 70% or older atthe beginning ofthe planyear_. . . 7c
8a_A fully insured plan with no trust and which is funded entirely byal allocated insurance contracts that fuly guarantee the amount of
benefit payments should check the box at the right and not complete 8b through 10d Foe ne
b Contributions received for this planyear . . oo Co e:):)
c Net plan income other than from contributions at . ca . , Be}
d Plan distributions foe coe : Fo ee 2 [8d
e Plan expenses other than distributions rere woe ~ ss + [Be
9a Totalplanassetsattheendoftheyear 2 7 | |. ww . , [9a
b Total pian liabilities atthe endoftheyear_ . . . _. . . |9b
10 During the plan year, if any of the following transactions took place between the plan and a
party-in-interest (see instructions), check “Yes" and enter amount. Otherwise, check “No." Yes | Amount [No
a Sale, exchange, orlease of property . . . . . . . Co 2. Oa!
b Loanorextensionofcredit . . . . . a co eee OI
¢ Acquisition or holding of employer securities. Soe 3
d Paymentbytheplanforservices . . . . . . . . . . OM

lla Does your business have any employees other than you and your spouse (and your partners and their spouses)? ,

If No," do NOT complete the rest of this question; go to question 12.

Total number of employees (including you and your spouse and your partners and their spouses) >

Does this plan meet the coverage test of Code section 410(b)? . oo

See the specific instructions for line Llc.

12 Answer these questions only if there was a benefit payment, loan, or distribution of an annuity contract made during the

plan year and the plan is subject to the spousal consent requirements (see instructions).

Was there consent of the participant's spouse to any benefit payment or loan within the 90-day period prior to such payment or loan?

b If“'No,”’ check the reason for no consent: (i) (] the participant was not married
(ii) C1 the benefit payment made was part of a qualified joint and survivor annuity (iii) [] other

S. Were any annuity contracts purchased by the plan and distributed tothe participants? . . st.
penalties of perjury and other penalties set forth in the instructions, ! declare that | hav mined this return, including accompanying schedules ana Tateert
and ele eis is true, correct, and complete.

og

ind to the bast of my knowledge

Signature of employer/plan sponsor D> Date
For Paperwork Reduction Act Notice, see page 1 of the instructions. *U.S. Government Printing Office: 1990— 265-358 Form SSOOEZ (1990)