Form (Rev. December 2013) Department of the Treasury Internal Revenue Service A 5330 Return of Excise Taxes Related to Employee Benefit Plans (Under sections 4965, 4971, 4972, 4973(a)(3), 4975, 4976, 4977, 4978, 4979, 4979A, 4980, and 4980F of the Internal Revenue Code) Information about Form 5330 and its instructions is at www.irs.gov/form5330. OMB No. 1545-0575 Filer tax year beginning Name of filer (see instructions) , and ending , B Filer's identifying number (Enter either the EIN or SSN, but not both. See instructions.) Employer identification number (EIN) Number, street, and room or suite no. (If a P.O. box or foreign address, see instructions.) City or town, state or province, country, and ZIP or foreign postal code Social security number (SSN) C Name of plan E Plan sponsor's EIN D Name and address of plan sponsor F Plan year ending (MM/DD/YYYY) H If this is an amended return, check here . . . . . . . . . . . . . . . G Plan number Part I Taxes. You can only complete one section of Part I for each Form 5330 filed (see instructions). FOR IRS USE ONLY Section A. Taxes that are reported by the last day of the 7th month after the end of the tax year of the employer (or other person who must file the return) 1 Section 4972 tax on nondeductible contributions to qualified plans (from Schedule A, line 12) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Section 4973(a)(3) tax on excess contributions to section 403(b)(7)(A) custodial accounts (from Schedule B, line 12) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 1 164 2 3a 3b 4 5a 5b 3a Section 4975(a) tax on prohibited transactions (from Schedule C, line 3) . b Section 4975(b) tax on failure to correct prohibited transactions . . . . 4 Section 4976 tax on disqualified benefits for funded welfare plans . . ..... Sec. 664(g) . . . . 159 224 200 5a Section 4978 tax on ESOP dispositions . . . . b The tax on line 5a is a result of the application of: 6 ..... Sec. 1042 209 Section 4979A tax on certain prohibited allocations of qualified ESOP securities or ownership of synthetic equity . . . . . . . . . . . . . . . . . . . . . . . . . 203 6 7 Total Section A taxes. Add lines 1 through 6. Enter here and on Part II, line 17 . . . . 7 Section B. Taxes that are reported by the last day of the 7th month after the end of the employer's tax year or 81/2 months after the last day of the plan year that ends within the filer's tax year 8a Section 4971(a) tax on failure to meet minimum funding standards (from Schedule D, line 2) . b Section 4971(b) tax for failure to correct minimum funding standards . . . . . . . 9a Section 4971(f)(1) tax on failure to pay liquidity shortfall (from Schedule E, line 4) b Section 4971(f)(2) tax for failure to correct liquidity shortfall . . . . . . . 10a . . . . . . . . . . 163 225 8a 8b 9a 9b 226 227 Section 4971(g)(2) tax on failure to comply with a funding improvement or rehabilitation plan (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . 450 b Section 4971(g)(3) tax on failure to meet requirements for plans in endangered or critical status (from Schedule F, line 1c) . . . . . . . . . . . . . . . . . . . . 451 c Section 4971(g)(4) tax on failure to adopt rehabilitation plan (from Schedule F, line 2d) . . 452 Section B1. Tax that is reported by the last day of the 7th month after the end of the calendar fringe benefits were paid to the employer's employees Section 4977 tax on excess fringe benefits (from Schedule G, line 4) . . . . . . . . 201 10a 10b 10c year in which the excess 11 12 11 12 Total Section B taxes. Add lines 8a through 11. Enter here and on Part II, line 17 . . . Section C. Tax that is reported by the last day of the 15th month after the end of the plan year 13 Section 4979 tax on excess contributions to certain plans (from Schedule H, line 2). Enter here and on Part II, line 17 . . . . . . . . . . . . . . . . . . . . . For Privacy Act and Paperwork Reduction Act Notice, see instructions. Cat. No. 11870M 205 13 Form 5330 (Rev. 12-2013) Form 5330 (Rev. 12-2013) Page 2 Name of Filer: Filer's identifying number: Section D. Tax that is reported by the last day of the month following the month in which the reversion occurred 14 Section 4980 tax on reversion of qualified plan assets to an employer (from Schedule I, line 3). Enter here and on Part II, line 17 . . . . . . . . . . . . . . . . . 14 204 Section E. Tax that is reported by the last day of the month following the month in which the failure occurred 15 Section 4980F tax on failure to provide notice of significant reduction in future accruals (from Schedule J, line 5). Enter here and on Part II, line 17 . . . . . . . . . . . 15 228 Section F. Taxes reported on or before the 15th day of the 5th month following the close of the entity manager's taxable year during which the plan became a party to a prohibited tax shelter transaction 16 Section 4965 tax on prohibited tax shelter transactions for entity managers (from Schedule K, line 2). Enter here and on Part II, line 17 . . . . . . . . . . . . . . . . 16 237 Part II 17 18 19 Tax Due . . . . . . . . . 17 18 Enter the amount from Part I, line 7, 12, 13, 14, 15, or 16 (whichever is applicable) . Enter amount of tax paid with Form 5558 or any other tax paid prior to filing this return Tax due. Subtract line 18 from line 17. If the result is greater than zero, enter here, and attach check or money order payable to "United States Treasury." Write your name, identifying number, plan number, and "Form 5330, Section(s) " on your payment . . . . 19 Sign Here Paid Preparer Use Only Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. Your Signature Print/Type preparer's name Preparer's signature Telephone number Date Check if self-employed Firm's EIN Phone no. Form Date PTIN Firm's name Firm's address 5330 (Rev. 12-2013) Form 5330 (Rev. 12-2013) Page 3 Name of Filer: Filer's identifying number: Schedule A. Tax on Nondeductible Employer Contributions to Qualified Employer Plans (Section 4972) Reported by the last day of the 7th month after the end of the tax year of the employer (or other person who must file the return) 1 Total contributions for your tax year to your qualified empl