5500EZ XML Generation Form

Part I: Annual Return Identification Information

Part II: Basic Plan Information — enter all requested information.

Sponsor Information

2aSponsor Name

Sponsor D/B/A Name (if any)

Sponsor Address

Address Line 1

City

State

Zip Code

Sponsor EIN (9-digit)

Sponsor Phone Number

BusinessCode

4If 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.

4aLastRptEmplrName

4bLastRptEmplrEIN

4cLastRptPlanName

4dLastRptPlanNum

Participant Counts

5a(1)Total number of participants at the beginning of the plan year

5a(2)Total number of active participants at the beginning of the plan year

5b(1) Total number of participants at the end of the plan year

5b(2)Total number of active participants at the end of the plan year

5c Number of participants who terminated employment during the plan year with accrued benefits that were less than 100% vested

Part III: Financial Information.

Assets and Liabilities

(1)Beginning of year

(2)End of year

6aTotal plan assets

bTotal plan liabilities

cNet plan assets (subtract line 6b from 6a)

7Contributions received or receivable from

aEmployers

bParticipants

cOthers (including rollovers)

Part IV: Plan Characteristics.

Pension Code Table (TypePensionBnftCode)

8Enter up to 20 Pension Benefit Codes

TypePensionBnftCode #1

Add Pension Code

Part V: Compliance and Funding Questions.

Additional Funding and Contribution Fields

9PartcpLoansInd (Yes/No) Choose... Yes No

PartcpLoansEoyAmt

10DbPlanFundingReqdInd (Yes/No) Choose... Yes No

UnpaidMinContribCurrYrTotAmt

11DcPlanFundingReqdInd (Yes/No) Choose... Yes No

11aRulingLetterGrantDate

11bSec412ReqContribAmt

11cEmplrContribPaidAmt

11dFundingDeficiencyAmt

11eFundingDeadlineInd (Yes/No/NA) Choose... Yes No NA

12If the plan sponsor is an adopter of a pre-approved plan that received a favorable IRS Opinion Letter, enter the date of the Opinion Letter

OpinLtrDate

OpinSerialNum

Employer Signature

SignedDate (Timestamp)

ManualSignedDate

SignedName

ManualSignedName