IRS Form 5500-SF "Short Form Annual Return/Report of Small Employee Benefit Plan"

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Download IRS Form 5500-SF "Short Form Annual Return/Report of Small Employee Benefit Plan"

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OMB Nos. 1210-0110
Form 5500-SF
Short Form Annual Return/Report of Small Employee
1210-0089
Benefit Plan
Department of the Treasury
2019
Internal Revenue Service
This form is required to be filed under sections 104 and 4065 of the Employee Retirement
Income Security Act of 1974 (ERISA), and sections 6057(b) and 6058(a) of the Internal
Department of Labor
This Form is Open to
Revenue Code (the Code).
Employee Benefits Security Administration
Public Inspection
Pension Benefit Guaranty Corporation
 Complete all entries in accordance with the instructions to the Form 5500-SF.
Part I
Annual Report Identification Information
For calendar plan year 2019 or fiscal plan year beginning
and ending
X
a multiple-employer plan (not multiemployer) (Filers checking this box must attach a
X
a single-employer plan
A
list of participating employer information in accordance with the form instructions.)
This return/report is for:
X
a foreign plan
X
a one-participant plan
B
This return/report is
X
X
the first return/report
the final return/report
X
an amended return/report
X
a short plan year return/report (less than 12 months)
C
Check box if filing under:
X
X
X
Form 5558
automatic extension
DFVC program
X
special extension (enter description)
Part II
Basic Plan Information
—enter all requested information
1a
1b
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
Three-digit
Name of plan
plan number
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
001
(PN)
ABCDEFGHI ABCDEFGHI ABCDEFGHI
1c
Effective date of plan
YYYY-MM-DD
2a
Plan sponsor’s name (employer, if for a single-employer plan)
2b
Employer Identification Number
Mailing address (include room, apt., suite no. and street, or P.O. Box)
(EIN)
012345678
City or town, state or province, country, and ZIP or foreign postal code (if foreign, see instructions)
2c S
ponsor’s telephone number
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
1234567890
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
2d
Business code (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
123456
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGH ABCDEFGHI ABCDEFGHI ABCDEFGHI I
3a
3b
X
ABCDEFGHI ABCDEFGHI
Administrator’s EIN
Plan administrator’s name and address
Same as Plan Sponsor.
012345678
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
3c
Administrator’s telephone number
c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
1234567890
ABCDEFGHI
123456789 ABCDEFGHI ABCDEFGHI ABCDE
123456789 ABCDEFGHI ABCDEFGHI ABCDE
CITYEFGHI ABCDEFGHI AB
ST 012345678901I A
4
4b
If the name and/or EIN of the plan sponsor or the plan name has changed since the last return/report filed for
EIN
012345678
this plan, enter the plan sponsor’s name, EIN, the plan name and the plan number from the last return/report.
a
4d
012
Sponsor’s name
PN
c
D
Plan Name
ABCDEFGHI ABCDEFGHI ABCDEFGHI CDEFGHI
EFGHI
5a
5a
12345678
Total number of participants at the beginning of the plan year ................................................................................
5b
b
12345678
Total number of participants at the end of the plan year .........................................................................................
c
Number of participants with account balances as of the end of the plan year (only defined contribution plans
5c
complete this item) .................................................................................................................................................
5d(1)
d(1)
Total number of active participants at the beginning of the plan year ..................................................................
5d(2)
d(2)
Total number of active participants at the end of the plan year ...........................................................................
e
Number of participants who terminated employment during the plan year with accrued benefits that were less
5e
than 100% vested .................................................................................................................................................
Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established.
Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return/report, including, if applicable, a Schedule
SB or Schedule MB completed and signed by an enrolled actuary, as well as the electronic version of this return/report, and to the best of my knowledge and
belief, it is true, correct, and complete.
SIGN
HERE
Signature of plan administrator
Date
Enter name of individual signing as plan administrator
SIGN
HERE
Signature of employer/plan sponsor
Date
Enter name of individual signing as employer or plan sponsor
For Paperwork Reduction Act Notice, see the Instructions for Form 5500-SF.
Form 5500-SF (2019)
v.190130
OMB Nos. 1210-0110
Form 5500-SF
Short Form Annual Return/Report of Small Employee
1210-0089
Benefit Plan
Department of the Treasury
2019
Internal Revenue Service
This form is required to be filed under sections 104 and 4065 of the Employee Retirement
Income Security Act of 1974 (ERISA), and sections 6057(b) and 6058(a) of the Internal
Department of Labor
This Form is Open to
Revenue Code (the Code).
Employee Benefits Security Administration
Public Inspection
Pension Benefit Guaranty Corporation
 Complete all entries in accordance with the instructions to the Form 5500-SF.
Part I
Annual Report Identification Information
For calendar plan year 2019 or fiscal plan year beginning
and ending
X
a multiple-employer plan (not multiemployer) (Filers checking this box must attach a
X
a single-employer plan
A
list of participating employer information in accordance with the form instructions.)
This return/report is for:
X
a foreign plan
X
a one-participant plan
B
This return/report is
X
X
the first return/report
the final return/report
X
an amended return/report
X
a short plan year return/report (less than 12 months)
C
Check box if filing under:
X
X
X
Form 5558
automatic extension
DFVC program
X
special extension (enter description)
Part II
Basic Plan Information
—enter all requested information
1a
1b
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
Three-digit
Name of plan
plan number
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
001
(PN)
ABCDEFGHI ABCDEFGHI ABCDEFGHI
1c
Effective date of plan
YYYY-MM-DD
2a
Plan sponsor’s name (employer, if for a single-employer plan)
2b
Employer Identification Number
Mailing address (include room, apt., suite no. and street, or P.O. Box)
(EIN)
012345678
City or town, state or province, country, and ZIP or foreign postal code (if foreign, see instructions)
2c S
ponsor’s telephone number
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
1234567890
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
2d
Business code (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
123456
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGH ABCDEFGHI ABCDEFGHI ABCDEFGHI I
3a
3b
X
ABCDEFGHI ABCDEFGHI
Administrator’s EIN
Plan administrator’s name and address
Same as Plan Sponsor.
012345678
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
3c
Administrator’s telephone number
c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
1234567890
ABCDEFGHI
123456789 ABCDEFGHI ABCDEFGHI ABCDE
123456789 ABCDEFGHI ABCDEFGHI ABCDE
CITYEFGHI ABCDEFGHI AB
ST 012345678901I A
4
4b
If the name and/or EIN of the plan sponsor or the plan name has changed since the last return/report filed for
EIN
012345678
this plan, enter the plan sponsor’s name, EIN, the plan name and the plan number from the last return/report.
a
4d
012
Sponsor’s name
PN
c
D
Plan Name
ABCDEFGHI ABCDEFGHI ABCDEFGHI CDEFGHI
EFGHI
5a
5a
12345678
Total number of participants at the beginning of the plan year ................................................................................
5b
b
12345678
Total number of participants at the end of the plan year .........................................................................................
c
Number of participants with account balances as of the end of the plan year (only defined contribution plans
5c
complete this item) .................................................................................................................................................
5d(1)
d(1)
Total number of active participants at the beginning of the plan year ..................................................................
5d(2)
d(2)
Total number of active participants at the end of the plan year ...........................................................................
e
Number of participants who terminated employment during the plan year with accrued benefits that were less
5e
than 100% vested .................................................................................................................................................
Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established.
Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return/report, including, if applicable, a Schedule
SB or Schedule MB completed and signed by an enrolled actuary, as well as the electronic version of this return/report, and to the best of my knowledge and
belief, it is true, correct, and complete.
SIGN
HERE
Signature of plan administrator
Date
Enter name of individual signing as plan administrator
SIGN
HERE
Signature of employer/plan sponsor
Date
Enter name of individual signing as employer or plan sponsor
For Paperwork Reduction Act Notice, see the Instructions for Form 5500-SF.
Form 5500-SF (2019)
v.190130
2
Form 5500-SF (2019)
Page
X
X
6a
Yes
No
Were all of the plan’s assets during the plan year invested in eligible assets? (See instructions.) .........................................................
b
Are you claiming a waiver of the annual examination and report of an independent qualified public accountant (IQPA)
X
X
Yes
No
under 29 CFR 2520.104-46? (See instructions on waiver eligibility and conditions.) .............................................................................
If you answered “No” to either line 6a or line 6b, the plan cannot use Form 5500-SF and must instead use Form 5500.
c
If the plan is a defined benefit plan, is it covered under the PBGC insurance program (see ERISA section 4021)? ......
X
Yes
X
No
X
Not determined
If “Yes” is checked, enter the My PAA confirmation number from the PBGC premium filing for this plan year_____________________. (See instructions.)
Part III
Financial Information
7
Plan Assets and Liabilities
(a) Beginning of Year
(b) End of Year
a
-123456789012345
-123456789012345
Total plan assets .............................................................................
7a
b
-123456789012345
123456789012345
Total plan liabilities ..........................................................................
7b
c
-123456789012345
-123456789012345
Net plan assets (subtract line 7b from line 7a) .................................
7c
8
Income, Expenses, and Transfers for this Plan Year
(a) Amount
(b) Total
a
Contributions received or receivable from:
-123456789012345
(1) Employers ................................................................................ 8a(1)
-123456789012345
(2) Participants ............................................................................... 8a(2)
-123456789012345
(3) Others (including rollovers) ........................................................ 8a(3)
b
-123456789012345
Other income (loss) .........................................................................
8b
c
-123456789012345
Total income (add lines 8a(1), 8a(2), 8a(3), and 8b) ........................
8c
d
Benefits paid (including direct rollovers and insurance premiums
-123456789012345
to provide benefits) ..........................................................................
8d
e
-123456789012345
Certain deemed and/or corrective distributions (see instructions) ....
8e
f
-123456789012345
Administrative service providers (salaries, fees, commissions) ........
8f
g
-123456789012345
Other expenses ...............................................................................
8g
h
-123456789012345
Total expenses (add lines 8d, 8e, 8f, and 8g) ..................................
8h
i
-123456789012345
Net income (loss) (subtract line 8h from line 8c) ..............................
8i
j
Transfers to (from) the plan (see instructions)..................................
-123456789012345
8j
Part IV Plan Characteristics
9a
If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristic Codes in the instructions:
b
If the plan provides welfare benefits, enter the applicable welfare feature codes from the List of Plan Characteristic Codes in the instructions:
Part V
Compliance Questions
10
Yes
No
During the plan year:
Amount
a
Was there a failure to transmit to the plan any participant contributions within the time period
described in 29 CFR 2510.3-102? (See instructions and DOL’s Voluntary Fiduciary Correction
-123456789012345
Program) ....................................................................................................................................... 10a
b
Were there any nonexempt transactions with any party-in-interest? (Do not include transactions
-123456789012345
reported on line 10a.) ..................................................................................................................... 10b
c
Was the plan covered by a fidelity bond? ....................................................................................... 10c
-123456789012345
d
Did the plan have a loss, whether or not reimbursed by the plan’s fidelity bond, that was caused
-123456789012345
by fraud or dishonesty? .................................................................................................................. 10d
e
Were any fees or commissions paid to any brokers, agents, or other persons by an insurance
carrier, insurance service, or other organization that provides some or all of the benefits under
-123456789012345
the plan? (See instructions.) ........................................................................................................... 10e
f
Has the plan failed to provide any benefit when due under the plan? ............................................
-123456789012345
10f
g
Did the plan have any participant loans? (If “Yes,” enter amount as of year-end.) .......................... 10g
h
If this is an individual account plan, was there a blackout period? (See instructions and 29 CFR
2520.101-3.) .................................................................................................................................. 10h
i
If 10h was answered “Yes,” check the box if you either provided the required notice or one of the
exceptions to providing the notice applied under 29 CFR 2520.101-3 ............................................
10i
3-
1
x
Form 5500-SF (2019)
Page
Part VI
Pension Funding Compliance
11
Is this a defined benefit plan subject to minimum funding requirements? (If "Yes," see instructions and complete Schedule SB
(Form 5500) and lines 11a and b below.) If this is a defined contribution pension plan, leave line 11 blank and complete line 12
X
X
Yes
No
below. ....................................................................................................................................................................................................
a
Enter the unpaid minimum required contributions for all years from Schedule SB (Form 5500) line 40 ........................ 11a
b
PBGC missed contribution reporting requirements. If the plan is covered by PBGC and the amount reported on line 11a is greater than $0, has PBGC
been notified as required by ERISA sections 4043(c)(5) and/or 303(k)(4)? Check the applicable box:
_
Yes.
_
No. Reporting was waived under 29 CFR 4043.25(c)(2) because contributions equal to or exceeding the unpaid minimum required contribution were made
by the 30th day after the due date.
_
No. The 30-day period referenced in 29 CFR 4043.25(c)(2) has not yet ended, and the sponsor intends to make a contribution equal to or exceeding the
unpaid minimum required contribution by the 30th day after the due date.
_
No. Other. Provide explanation ______________________________________________________________________________________________
12
Is this a defined contribution plan subject to the minimum funding requirements of section 412 of the Code or section 302 of
ERISA? .................................................................................................................................................................................................
X
X
Yes
No
(If "Yes," complete line 12a or lines 12b, 12c, 12d, and 12e below, as applicable.) If this is a defined benefit pension plan, leave line
12 blank and complete line 11 above.
a
If a waiver of the minimum funding standard for a prior year is being amortized in this plan year, see instructions, and enter the date of the letter ruling
granting the waiver. ............................................................................................................................. Month _______
Day _______
Year ________
If you completed line 12a, complete lines 3, 9, and 10 of Schedule MB (Form 5500), and skip to line 13.
Enter the minimum required contribution for this plan year ........................................................................................ 12b
123456789012345
b
12c
-123456789012345
c
Enter the amount contributed by the employer to the plan for this plan year ..............................................................
d
Subtract the amount in line 12c from the amount in line 12b. Enter the result (enter a minus sign to the left of a
12d
YYYY-MM-DD
negative amount) .......................................................................................................................................................
X
X
X
Yes
No
N/A
e
Will the minimum funding amount reported on line 12d be met by the funding deadline? ............................................
Part VII
Plan Terminations and Transfers of Assets
13a
X
X
Yes
No
Has a resolution to terminate the plan been adopted in any plan year? .............................................................................
If “Yes,” enter the amount of any plan assets that reverted to the employer this year .................................................. 13a
b
Were all the plan assets distributed to participants or beneficiaries, transferred to another plan, or brought under the
X
X
Yes
No
control of the PBGC? ..............................................................................................................................................................
c
If, during this plan year, any assets or liabilities were transferred from this plan to another plan(s), identify the plan(s) to
which assets or liabilities were transferred. (See instructions.)
13c(1) Name of plan(s):
13c(2) EIN(s)
13c(3) PN(s)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
123456789
012
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
Page of 3