Part I – Annual Return Identification Information
Check box A(1) if this is the first filing for this plan. Do not check this box if you have ever filed for this plan, even if it was a different
form (for example, Form 5500).
Check box A(2) if you are filing an amended Form 5500-EZ to correct errors and/or omissions in a previously filed annual return for the
2012 plan year. The amended Form 5500-EZ must conform to the requirements under the How To File section earlier.
If you are filing an amendment for a “one-participant plan” that filed a Form 5500-SF electronically, you may submit the amendment either electronically using the Form 5500-SF with
EFAST2 or on paper using the Form 5500-EZ with the IRS. If you are filing an amended return for a one-participant plan that
previously filed on a paper Form 5500-EZ, you must submit the amended return using the paper Form 5500-EZ with the IRS.
Check box A(4) if this form is filed for a period of less than 12 months. Show the dates at the top of the form.
For a short plan year, file a return by the last day of the 7th month following the end of the short plan year. Modify the
heading of the form to show the beginning and ending dates of your short plan year and check box A(4) for a short plan year.
If this is also the first or final return filed for the plan, check the appropriate box (box A(1) or A(3)).
All one-participant plans should file a return for their final plan year indicating that all assets have been distributed.
Check box A(3) if all assets under the plan(s) (including insurance/annuity contracts) have been distributed to the participants and beneficiaries
or distributed or transferred to another plan. The final plan year is the year in which distribution of all plan assets is
completed.
Extension of Time To File
Check box B if either of the following applies:
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You are filing a Form 5558, Application for Extension of Time To File Certain Employee Plan Returns. (Do not attach Form 5558 to your Form 5500-EZ. See below for more information.)
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You are using an extension based on the extended due date of your federal income tax return. (See the Note below.)
A one-time extension of time to file Form 5500-EZ (up to 2½ months) may be obtained by filing Form 5558 on or before the normal
due date (not including any extensions) of the return. You must file Form 5558 with the IRS.
Approved copies of the Form 5558 will not be returned to the filer. A copy of the completed extension request must be retained
with the plan's records.
See the instructions for Form 5558 and file it with the Department of the Treasury, Internal Revenue Service Center, Ogden,
UT 84201-0045.
Note.
Line A of the Form 5558 asks for “Name of filer, plan administrator, or plan sponsor”. The name of the plan sponsor is generally the same as the employer name for a one-participant plan.
Note.
Filers are automatically granted an extension of time to file Form 5500-EZ until the extended due date of the federal income
tax return of the employer (and are not required to file Form 5558) if all the following conditions are met: (1) the plan
year and the employer's tax year are the same, (2) the employer has been granted an extension of time to file its federal
income tax return to a date later than the normal due date for filing the Form 5500-EZ, and (3) a copy of the application
for extension of time to file the federal income tax return is retained with the plan's records. Be sure to check box B at the top of the form. An extension granted by using this exception cannot be extended further by filing a Form 5558 after
the normal due date (without extension) of Form 5500-EZ.
Check box C if the return is filed by a foreign plan. See Who Must File Form 5500-EZ earlier.
Part II – Basic Plan Information
Line 1a.
Enter the formal name of the plan.
Line 1b.
Enter the three-digit plan number (PN) that the employer assigned to the plan. Plans should be numbered consecutively
starting with 001.
Once a plan number is used for a plan, it must be used as the plan number for all future filings of returns for the
plan, and this number may not be used for any other plan even after the plan is terminated.
Line 1c.
Enter the date the plan first became effective.
Line 2a.
Each row is designed to contain specific information regarding the employer. Please limit your response to the information
required in each row as specified below:
-
Enter in the first row the name of the employer.
-
Enter in the second row the trade name if different from the name entered in the first row.
-
Enter in the third row the in care of (“C/O”) name.
-
Enter in the fourth row the street address. A post office box number may be entered if the Post Office does not deliver mail
to the employer's street address.
-
Enter in the fifth row the name of the city, the two character abbreviation of the U.S. state or possession and ZIP code.
Note.
You can use Form 8822-B, Change of Address — Business, to notify the IRS if you changed your business mailing address or your
business location.
For foreign addresses, enter the information in the order of the city, province or state, and the name of the country. Follow
the country's practice in placing the postal code in the address. Do not abbreviate the country name.
Line 2b.
Enter the employer's nine-digit employer identification number (EIN). For example, 00-1234567. Do not enter a social
security number (SSN).
Employers without an EIN must apply for one as soon as possible. EINs are issued by the IRS. To apply for an EIN:
-
Mail or fax Form SS-4, Application for Employer Identification Number, obtained by calling 1-800-TAX-FORM (1-800-829-3676)
or at the IRS website at IRS.gov.
-
Call 1-800-829-4933 to receive your EIN by telephone.
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Select the Online EIN Application link at IRS.gov. The EIN is issued immediately once the application information is validated.
The online application process is not yet available for corporations with addresses in foreign countries.
Note.
Although EINs for a plan's trust or custodial account are generally not required to be furnished on the Form 5500 and its
schedules or Form 5500-EZ, the IRS will issue EINs for other reporting purposes. EINs for trusts or custodial accounts associated
with plans may be obtained as explained above.
Line 2c.
Enter the employer's telephone number including the area code.
Line 2d.
Enter the six-digit applicable code that best describes the nature of the plan sponsor's business from the list of
principal business activity codes later in these instructions.
Line 3a.
Each row is designed to contain specific information regarding the plan administrator. Please limit your response
to the information required in each row of boxes as specified below:
-
Enter in the first row the name of the plan administrator unless the administrator is the employer identified in line 2a.
If this is the case, enter the word "same" on line 3a and leave the remainder of line 3a, and all of lines 3b and 3c blank.
-
Enter in the second row any in care of (“C/O”) name.
-
Enter in the third row the street address. A post office box number may be entered if the Post Office does not deliver mail
to the administrator's street address.
-
Enter in the fourth row the name of the city, the two character abbreviation of the U.S. state or possession and ZIP code.
For foreign addresses, enter the information in the order of the city, province or state, and the name of the country. Follow
the country's practice in placing the postal code in the address. Do not abbreviate the country name.
Line 3b.
Enter the plan administrator's nine-digit EIN. A plan administrator must have an EIN for Form 5500-EZ reporting purposes.
If the plan administrator does not have an EIN, apply for one as explained in the instructions for line 2b.
Line 3c.
Enter the plan administrator's telephone number including the area code.
Line 4a.
(Optional) You may use this line to enter the “Name of trust.” If a plan uses more than one trust or custodial account
for its fund, you should enter the primary trust or custodial account in which the greatest dollar amount or largest percentage
of the plan assets as of the end of the plan year is held on this line. For example, if a plan uses three different trusts,
X, Y, and Z, with the percentages of plan assets, 35%, 45%, and 20%, respectively, trust Y that held the 45% of plan assets
would be entered on line 6a.
Line 4b.
(Optional) You may use this line to enter the “Trust's Employer Identification Number (EIN)” assigned to the employee
benefit trust or custodial account, if one has been issued to you. The trust EIN should be used for transactions conducted
for the trust. If you do not have a trust EIN, enter the EIN you would use on Form 1099-R, Distributions From Pensions, Annuities,
Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc., to report distributions from employee benefit plans and
on Form 945, Annual Return of Withheld Federal Income Tax, to report withheld amounts of income tax from those payments.
Do not use a social security number in place of an EIN. Form 5500-EZ is open to public inspection. Because of privacy
concerns, the inclusion of a social security number may result in the rejection of the filing.
Trust EINs can be obtained from the IRS by applying for one on Form SS-4, Application for Employer Identification
Number. See instructions to line 2b (Form 5500-EZ) for applying for an EIN. Also see IRS EIN application link page for further
information.
Note.
Although lines 4a and 4b are optional, the IRS encourages filers to provide trust information on these lines.
Line 5.
If the employer's name and/or EIN have changed since the last return was filed for this plan, enter the employer's
name, EIN, and the plan number as it appeared on the last return filed for this plan.
Line 7a.
“
Total plan assets” include rollovers and transfers received from other plans, unrealized gains and losses such as appreciation/depreciation
in assets. It also includes specific assets held by the plan at any time during the plan year (for example, partnership/joint
venture interests, employer real property, real estate (other than employer real property), employer securities, loans (participants
and non-participant loans), and tangible personal property).
Enter the total amount of plan assets at the beginning of the plan year in column (1). Do not include contributions
designated for the 2012 plan year in column (1). Enter the total amount of plan assets at the end of the plan year in column
(2).
Line 7b.
Liabilities include but are not limited to benefit claims payable, operating payables, acquisition indebtedness, and
other liabilities. Do not include the value of future distributions that will be made to participants.
Part IV – Plan Characteristics
Line 9.
Enter the two-character plan characteristics from the List of Plan Characteristics Codes found later in these instructions.
Note.
In the case of an eligible combined plan under section 414(x) and ERISA section 210(e), the codes entered in line 9 must include
any codes applicable for either the defined benefit pension features or the defined contribution pension features of the plan.
New plan characteristics codes were added in the 2009 Instructions for Form 5500-EZ to identify foreign plans, one-participant
plans that satisfy the minimum coverage requirements of section 410(b) only when combined with another plan of the employer,
plans whose sponsors received services of leased employees (as defined in section 414(n)), and plans whose sponsors are members
of a controlled group under section 414(b) or (c), or an affiliated service group under section 414(m).
Part V – Compliance and Funding Questions
Line 10.
You must check “
Yes” if the plan had any participant loans outstanding at any time during the plan year and enter the amount outstanding as of
the end of the plan year.
Enter on this line all loans to participants including residential mortgage loans that are subject to section 72(p).
Include the sum of the value of the unpaid principal balances, plus accrued but unpaid interest, if any, for participant loans
made under an individual account plan with investment experience segregated for each account made in accordance with 29 CFR
2550.408b-1 and which are secured solely by a portion of the participant's vested accrued benefit. When applicable, combine
this amount with the current value of any other participant loans. Do not include a participant loan that has been deemed
distributed.
Line 11.
Check “
Yes” if this plan is a defined benefit plan subject to the minimum funding standard requirements of section 412.
Line 11a.
Enter the amount from line 39 of Schedule SB (Form 5500).
If the plan is a defined benefit plan, the enrolled actuary must complete and sign the 2012
Schedule SB (Form 5500) and forward it no later than the filing due date to the person responsible for filing Form 5500-EZ. The completed Schedule
SB is subject to the records retention provisions of the Code. See the 2012 Instructions for Form 5500 for more information
about Schedule SB.
Line 12a.
If a waiver of the minimum funding standard for a prior year is being amortized in the current plan year, enter the
month, day, and year (MM/DD/YYYY) the letter ruling was granted.
If a money purchase defined contribution plan (including a target benefit plan) has received a waiver of the minimum
funding standard, and the waiver is currently being amortized, complete lines 3, 9, and 10 of
Schedule MB (Form 5500). See the Instructions for Schedule MB in the Instructions for Form 5500. Do not attach Schedule MB to the Form 5500-EZ. Instead
keep the completed Schedule MB in accordance with the applicable records retention requirements.
