Form 5500-EZ Annual Return of One-Participant (Owners and Their Spous

Attention:
• Telephone requests for the 2005 Form 5500-series
forms, schedules and instructions will not be filled
until December 1, 2005.
• Requests for the 2005 Form 5500-series products
can be made on the Internet (see below) beginning
December 1, 2005. Requests made prior to that
date will be filled with the 2004 version of the
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purposes and should not be reproduced on personal computer
printers by individual taxpayers for filing.
The Forms 5500 and 5500-EZ (and related schedules) are
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processed by the computerized processing system “EFAST.”
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This form is required to be filed under
section 6058(a) of the Internal Revenue Code.

2005

Complete all entries in accordance with
the instructions to the Form 5500-EZ.

This Form is Open to
Public Inspection.

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Annual Return Identification Information

For the calendar plan year 2005
or fiscal plan year beginning

MM / D D / Y Y Y Y

MM / D D / Y Y Y Y

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and ending

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Part I

OMB No. 1545-0956

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Department of the Treasury
Internal Revenue Service

Official Use Only

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5500-EZ

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Form

Annual Return of One-Participant
(Owners and Their Spouses) Retirement Plan

(1)

the first return filed for the plan;

(3)

(2)

an amended return;

(4)

the final return filed for the plan;

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This return is:

a short plan year return
(less than 12 months).

Part II

Basic Plan Information -- enter all requested information.

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If filing under an extension of time, check box and attach required information. (see instructions) ..............................................................

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1a Name of plan

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1c Date plan first
became effective

MM / D D / Y Y Y Y

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1b Three-digit plan number (PN)

Caution: A penalty for the late or incomplete filing of this return will be assessed unless reasonable cause is established.
Under penalties of perjury, I declare that I have examined this return (including, if applicable, any related Schedule B signed by an enrolled actuary and Schedule P
signed by the plan Trustee, which I will retain) and to the best of my knowledge and belief, it is true, correct, and complete.

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SIGN HERE

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Signature of employer or plan administrator

Date

MM / D D / Y Y Y Y

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Type or print name of individual signing as employer or plan administrator

For Paperwork Reduction Act Notice, see the instructions for Form 5500-EZ.

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Cat. No. 63263R

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Form 5500-EZ (2005)

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Form 5500-EZ (2005)

Page

2
Official Use Only

1)

Employer's name and address (Address should include room or suite no.)

Name

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2a

Name Continued

c / o

3)

Street

4)

City

5)

State

6)

Foreign Routing Code

7)

Foreign Country

8)

D/B/A

9)

Location Address if different than Street

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2)

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2b Employer Identification Number (EIN)
(Do not enter your Social Security Number)

2c Employer's telephone
number

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NO

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2d Business code
(see instructions)

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Plan administrator's name and address (If same as employer, enter "Same")

Name

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1)

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Name Continued

c / o

3)

Street

4)

City

5)

State

6)

Foreign Routing Code

7)

Foreign Country

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RP

2)

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3c Administrator's telephone number

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Zip Code

3b Administrator's EIN

a

If the name and/or EIN of the employer has changed since the last return filed for this plan, enter the name, EIN and the plan number from the
last return below:
Employer's name

b

EIN

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Location Address if different than 4) or 5)
3a

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Zip Code

c PN

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Form 5500-EZ (2005)

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Official Use Only

Preparer information (optional)
a

Name (including firm name, if applicable) and address

Name

1)

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5

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Name Continued
Street

3)

City

4)

State

5)

Foreign Routing Code

6)

Foreign Country

EIN

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b

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2)

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Zip Code

Telephone number

(c)

Money purchase pension plan

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(e)

Stock bonus plan

(f)

ESOP plan

(2)

Partner(s) in a partnership, or

(3)

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Self-employed individuals,

100% owner of corporation

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(1)

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7a If this is a master/prototype, or regional prototype plan, enter the opinion/notification letter number ..........
b Check if this plan covers:

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8a Enter the number of qualified pension benefit plans maintained by the employer (including this plan) .......................................

Number

Enter the number of participants in each category listed below:

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a Under age 59 1/2 at the end of the plan year ....................................................................................................................................

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b Age 59 1/2 or older at the end of the plan year, but under age 70 1/2 at the beginning of the plan year ......................................

c Age 70 1/2 or older at the beginning of the plan year .......................................................................................................................

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b Check here if you have more than one plan and the total assets of all plans are more than $100,000 (see instructions) .........

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Defined benefit pension plan described in
Code section 412(i)

Profit-sharing plan

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(b)

(d)

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Defined benefit pension plan (other than a plan
described in Code section 412(i))

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Type of plan:

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c

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Form 5500-EZ (2005)

Page

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Yes

No
(2)

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under a
trust

(1)

with no
trust

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10a (1) Is this a fully insured pension plan which is funded entirely by insurance or annuity contracts?
If "Yes," complete lines 10a(2) through 10f and skip lines 10g through 13d.
(2) If 10a(1) is "Yes," are the insurance contracts held: ...................................................................

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Official Use Only

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c Noncash contributions received by the plan for this plan year ..................................

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d Total plan distributions to participants or beneficiaries (see instructions) ..................

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b Cash contributions received by the plan for this plan year ........................................

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e Total nontaxable plan distributions to participants or beneficiaries ............................

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f Transfers to other plans ...............................................................................................

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g Amounts received by the plan other than from contributions .....................................

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h Plan expenses other than distributions .......................................................................

b Total plan liabilities .....

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Specific Assets: If the plan held assets at any time during the plan year in any of the following categories, check "Yes" and enter the
current value of any assets remaining in the plan as of the end of the plan year. Otherwise, check "No."
Yes

Amount

No

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12

(b) End of Year

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11a Total plan assets ........

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(a) Beginning of Year

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a Partnership/joint venture interests ..................................................

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b Employer real property ....................................................................

c Real estate (other than employer real property) ............................

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Form 5500-EZ (2005)

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Official Use Only

No

Amount

12d Employer securities .........................................................................

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e Participant loans (see instructions) .................................................

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f Loans (other than to participants) ...................................................

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g Tangible personal property ..............................................................

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.00

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.00

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No

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Amount

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Yes

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Check "Yes" and enter amount involved if any of the following
transactions took place between the plan and a disqualified
person during this plan year. Otherwise, check "No."

NO

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Yes

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a Sale, exchange, or lease of property .............................................

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c Acquisition or holding of employer securities .................................

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b Payment by the plan for services ...................................................

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d Loan or extension of credit .............................................................

No

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Yes

14a Does your business have any employees other than you and your spouse (and your partners and
their spouses)? ...................................................................................................................................................................

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c Does this plan meet the coverage requirements of Code section 410(b)? .....................................................................

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c During this plan year, did the plan make loans to married participants? .........................................................................

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b During this plan year, did the plan make distributions to a married participant in a form other than a qualified
joint and survivor annuity or were any distributions on account of the death of a married participant made to
beneficiaries other than the spouse of that participant? ...................................................................................................

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15a Did the plan distribute any annuity contracts this plan year? ...........................................................................................

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

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If 14a is "No," do not complete line 14b or line 14c. See the specific instructions for line 14b and line 14c.

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