Form 5500

Form 5500 (2005)
Page 2
Official Use Only
2a Plan sponsor's name and address (employer, if for single-employer plan) (Address should include room or suite no.)
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
2b Employer Identification Number (EIN)
2c Sponsor's telephone number
Format: (000) 000-0000.
2d Business code (see instructions)
3a Plan administrator's name and address (If same as plan sponsor, enter "Same")
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
3b Administrator's EIN
3c Administrator's telephone number
Format: (000) 000-0000.
4 If the name and/or EIN of the plan sponsor has changed since the last return/report filed for this plan, enter the name, EIN and the plan number from the last return/report below:
a Sponsor's name
First NameLast Name
b EIN
c PN

Form 5500 (2005)
Page 3
Official Use Only
5 Preparer information (optional)
a Name (including firm name, if applicable) and address
First NameLast Name
5 Preparer information (optional) Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
b EIN
c Telephone number
Format: (000) 000-0000.
6 Total number of participants at the beginning of the plan year
7 Number of participants as of the end of the plan year (welfare plans complete only lines 7a, 7b, 7c, and 7d)
a Active participants
b Retired or separated participants receiving benefits
c Other retired or separated participants entitled to future benefits
d Subtotal. Add lines 7a, 7b, and 7c
e Deceased participants whose beneficiaries are receiving or are entitled to receive benefits
f Total. Add lines 7d and 7e
g Number of participants with account balances as of the end of the plan year (only defined contribution plans complete this item)
h Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested
i If any participant(s) separated from service with a deferred vested benefit, enter the number of separated participants required to be reported on a Schedule SSA (Form 5500)

Form 5500 (2005)
Page 4
Official Use Only
8 Benefits provided under the plan (complete 8a and 8b, as applicable)
1
Other
Welfare benefits (check this box if the plan provides welfare benefits and enter below the applicable welfare feature codes from the Listof Plan Characteristics Codes printed in the instructions):
Pension benefits (check this box if the plan provides pension benefits and enter below the applicable pension feature codes from the Listof Plan Characteristics Codes printed in the instructions):
Rows 9a Plan funding arrangement (check all that apply) 9b Plan benefit arrangement (check all that apply)
(1)
(2)
(3)
(4)

10 Schedules attached (Check all applicable boxes and, where indicated, enter the number attached. See instructions.)

Rows	b Financial Benefit Schedules
1) H (Financial Information)
2) B (Actuarial Information)
3) E (ESOP Annual Information)
4) SSA (Separated Vested Participant Information)
4) SSA (Separated Vested Participant Information)

10 Schedules attached (Check all applicable boxes and, where indicated, enter the number attached. See instructions.)

Rows	b Financial Schedules
1) H (Financial Information)
2) I (Financial Information--Small Plan)
3) A (Insurance Information)
4) C (Service Provider Information)
6) G (Financial Transaction Schedules)
7) P (Trust Fiduciary Information)

Select theme:

Form 5500 (2005)

Rows	9a Plan funding arrangement (check all that apply)	9b Plan benefit arrangement (check all that apply)
(1)
(2)
(3)
(4)