Cat. No. 63263R 2 End of year Form 5500-EZ 2018 Page Amount Contributions received or receivable from 7a b Participants. 6b Net plan assets subtract line 6b from 6a 6c c Total plan assets For Privacy Act and Paperwork Reduction Act Notice see the Instructions for Form 5500-EZ. Certain foreign retirement plans are also required to file this form see instructions. Complete all entries in accordance with the instructions to the Form 5500-EZ. See instructions. Enter the unpaid minimum required contributions for all years from Schedule SB Form 5500 line 40. Form 5500-EZ Annual Return of A One-Participant Owners/Partners and Their Spouses Retirement Plan or A Foreign Plan This form is required to be filed under section 6058 a of the Internal Revenue Code. Is this a defined benefit plan that is subject to minimum funding requirements If Yes complete Schedule SB Form 5500 and line 10a below. 11e Caution A penalty for the late or incomplete filing of this return will be assessed unless reasonable cause is established. e Under penalties of perjury I declare that I have examined this return including if applicable any related Schedule MB Form 5500 or Schedule SB Form 5500 signed by an enrolled actuary and to the best of my knowledge and belief it is true correct and complete. Go to www*irs*gov/Form5500EZ for instructions and the latest information* Department of the Treasury Internal Revenue Service Part I OMB No* 1545-0956 This Form is Open to Public Inspection* Annual Return Identification Information For the calendar plan year 2018 or fiscal plan year beginning MM/DD/YYYY and ending A This return is 1 the first return filed for the plan 3 the final return filed for the plan 2 an amended return 4 a short plan year return less than 12 months. B If filing under an extension of time check this box see instructions. C If this return is for a foreign plan check this box see instructions. D 1a. Basic Plan Information enter all requested information* 1b Three-digit plan number PN Name of plan 1c Date plan first became effective MM/DD/YYYY 2a 2b Employer Identification Number EIN Employer s name Do not enter your Social Security Number Trade name of business if different from name of employer 2c Employer s telephone number In care of name 2d Business code see instructions Mailing address room apt. suite no. and street or P. O. box City or town state or province country and ZIP or foreign postal code if foreign see instructions 3a Plan administrator s name If same as employer enter Same 3b Administrator s EIN If the employer s name the employer s EIN and/or the plan name has changed since the last return filed for this plan enter the employer s name and EIN the plan name and the plan number for the last return in the appropriate space provided* a 4c 4b EIN Plan name 4d PN 5a 1 Total number of participants at the beginning of the plan year. b 2 Total number of active participants at the end of the plan year. c Number of participants who terminated employment during the plan benefits that were less than 100 vested.
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