Free 2008 Form 5500 Schedule H - Federal


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Date: November 25, 2008
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Category: Tax Forms
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URL

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Attention:
Telephone requests for the forms, schedules, and instructions for the 2008 Form 5500-series will not be filled until December 10, 2008. Requests for the 2008 Form 5500-series products can be made on the Internet (see below) beginning December 10, 2008. Requests made prior to that date will be filled with the 2007 version of the products. The product you are about to view is provided for information 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 printed on special paper with dropout ink so they can be processed by the computerized processing system "EFAST." These forms and schedules may be obtained by calling 1-800-TAX-FORM (1-800-829-3676). Be sure to order using the IRS form number. Note: You can also use the Internet link Forms and Publications by U.S. Mail to request a limited number of these forms and schedules. Check the Department of Labor's website at www.efast.dol.gov for additional information concerning the processing system, electronic filing, software, and "non-standard" filings. Note: There is no Schedule B (Form 5500) for filing 2008 plan year actuarial information. Instead, file the 2008 Schedule MB (Form 5500), Multiemployer Defined Benefit Plan and Certain Money Purchase Plan Actuarial Information, or the Schedule SB (Form 5500), Single-Employer Defined Benefit Plan Actuarial Information, as applicable. For only plan year 2008 filings, paper Schedules MB and SB are provided in the format presented for completion by pen or typewriter. ________________________________________________

SCHEDULE H (Form 5500)
Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation

Financial Information
This schedule is required to be filed under Section 104 of the Employee Retirement Income Security Act of 1974 (ERISA) and section 6058(a) of the Internal Revenue Code (the Code).


Official Use Only

OMB No. 1210-0110

2008
This Form is Open to Public Inspection.

File as an attachment to Form 5500.

For the calendar plan year 2008 or fiscal plan year beginning
A Name of plan

MM / D D / Y Y Y Y

and ending
B

MM / D D / Y Y Y Y
Three-digit plan number

Part I

Asset and Liability Statement

NL

a Total noninterestbearing cash ............... b Receivables (less allowance for doubtful accounts): (1) Employer contributions ....... (2) Participant contributions .......

Y,

Assets

(a) Beginning of Year

D

O

1 Current value of plan assets and liabilities at the beginning and end of the plan year. Combine the value of plan assets held in more than one trust. Report the value of the plan's interest in a commingled fund containing the assets of more than one plan on a line-by-line basis unless the value is reportable on lines 1c(9) through 1c(14). Do not enter the value of that portion of an insurance contract which guarantees, during this plan year, to pay a specific dollar benefit at a future date. Round off amounts to the nearest dollar. MTIAs, CCTs, PSAs, and 103-12 IEs do not complete lines 1b(1), 1b(2), 1c(8), 1g, 1h, and 1i. CCTs, PSAs, and 103-12 IEs also do not complete lines 1d and 1e. See instructions.

NO

T

US E
(b) End of Year







.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00

FO

R

C

Plan sponsor's name as shown on line 2a of Form 5500

D

Employer Identification Number

FI LI NG







.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00

AT

(2) (3)

U.S. Government securities ............

IO

(3) Other ................... c General investments: (1) Interest-bearing cash (including money market accounts and certificates of deposit) ..........

NA

L

PU



RP



O



SE

S


O









(B) All other ....... (4)

(A) Preferred ...... (B) Common ...... (5) Partnership/joint venture interests.

For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Cat. No. 24420C Schedule H (Form 5500) 2008

FO

Corporate stocks (other than employer securities):

R

IN

FO

(A) Preferred ......

RM

Corporate debt instruments (other than employer securities):

1

7

0

8

0

0

0

1

0

H
v11.3

Schedule H (Form 5500) 2008 (a) Beginning of Year 1c (6) Real estate (other than employer real property) ...... Loans (other than to participants) ...

Page

2
Official Use Only

(b) End of Year







.00 .00 .00 .00 .00 .00 .00 .00







.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00

(7)

(8) (9)

S

O

(14) Value of funds held in insurance company general account (unallocated contracts) . (15) Other ................... d Employer-related investments: (1) Employer securities ............ Employer real property .............. e Buildings and other property used in plan operation ............ f Total assets (add all amounts in lines 1a through 1e) ... (2)

NL







Y,

.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00

D

(13) Value of interest in registered investment companies (e.g., mutual funds) .....







O

NO

T

Participant loans. Value of interest in common/ collective trusts .. (10) Value of interest in pooled separate accounts ..... (11) Value of interest in master trust investment accounts ............. (12) Value of interest in 103-12 investment entities .......

US E

FO


R

FI LI NG





0 I





RP
8

O

0 0 0

NA

L

IO



RM

Liabilities
g Benefit claims payable h Operating payables .... i Acquisition indebtedness ..............

AT

FO

IN

FO

R

j Other liabilities ............ k Total liabilities (add all amounts in lines 1g through 1j) ....

Net Assets
l Net assets (subtract line 1k from line 1f) ....

1

7

PU
0



SE



2

Schedule H (Form 5500) 2008

Page

3
Official Use Only

Part II
2

Income and Expenses Statement

Plan income, expenses, and changes in net assets for the year. Include all income and expenses of the plan, including any trust(s) or separately maintained fund(s) and any payments/receipts to/from insurance carriers. Round off amounts to the nearest dollar. MTIAs, CCTs, PSAs, and 103-12 IEs do not complete lines 2a, 2b(1)(E), 2e, 2f, and 2g.

Income
a Contributions: (1) Received or receivable in cash from: (A) Employers .................................................. (B) Participants ................................................ (C) Others (including rollovers) ....................... (2) Noncash contributions .......................................

(a) Amount







.00

FO

US E

R

.00 .00

FI LI NG
(b) Total

.00

Y,

D

b Earnings on investments: (1) Interest: (A) Interest-bearing cash (including money market accounts and certificates of deposit) ....................... (B) U.S. Government securities ...................... (C) Corporate debt instruments ......................

O

NO

T

(3) Total contributions. Add lines 2a(1)(A), (B), (C), and line 2a(2) ..........................







.00







.00 .00 .00 .00 .00 .00


O RP PU

SE

(D) Loans (other than to participants) ............ (E) Participant loans ........................................ (F) Other ..........................................................

L

S

O




NL



(G) Total interest. Add lines 2b(1)(A) through (F) .............................................. (2) Dividends: (A) Preferred stock ..........................................

IO

NA

.00

AT







.00 .00


(B) Common stock ..........................................

FO

RM

(C) Total dividends. Add lines 2b(2)(A) and (B) ................................................

.00 .00

FO

(3) Rents ...................................................................................................................... (4) Net gain (loss) on sale of assets: (A) Aggregate proceeds ..................................

R

IN





.00 .00


(B) Aggregate carrying amount (see instructions) .............................................



(C) Subtract line 2b(4)(B) from line 2b(4)(A) and enter result .........................

.00

1

7

0

8

0

0

0

3

0

J

Schedule H (Form 5500) 2008 2b (5) Unrealized appreciation (depreciation) of assets: (A) Real estate ................................................ (B) Other ..........................................................

Page

4
Official Use Only

(a) Amount







.00 .00
(b) Total

FI LI NG

(C) Total unrealized appreciation of assets. Add lines 2b(5)(A) and (B) ......... (6) (7) (8) (9) Net investment gain (loss) from common/collective trusts ................................ Net investment gain (loss) from pooled separate accounts .............................. Net investment gain (loss) from master trust investment accounts .................. Net investment gain (loss) from 103-12 investment entities .............................





.00 .00 .00 .00 .00 .00 .00 .00

e Benefit payment and payments to provide benefits: (1) (2) Directly to participants or beneficiaries, including direct rollovers .................................. To insurance carriers for the provision of benefits .................................. Other .................................................................

O

NL

Expenses

Y,

d Total income. Add all income amounts in column (b) and enter total ......................

D

O

c Other income ................................................................................................................

NO

(10) Net investment gain (loss) from registered investment companies (e.g., mutual funds) ..............................................................................................

T

US E


FO
.00 .00 .00

4 0 K

SE

RP

O

(3) (4)

PU

S



R

Total benefit payments. Add lines 2e(1) through (3) ..........................................





.00 .00 .00 .00

f Corrective distributions (see instructions) ................................................................... g Certain deemed distributions of participant loans (see instructions) ........................ h Interest expense ........................................................................................................... i Administrative expenses: (1) Professional fees .............................................

RM

AT

IO

NA

L

FO

.00 .00 .00 .00


(2) (3) (4) (5)

Contract administrator fees .............................

R

IN



Other .................................................................

FO

Investment advisory and management fees ...

Total administrative expenses. Add lines 2i(1) through (4) ................................

.00 .00

j Total expenses. Add all expense amounts in column (b) and enter total ................

1

7

0

8

0

0

0

Schedule H (Form 5500) 2008

Page

5
Official Use Only

Net Income and Reconciliation
2k Net income (loss) (subtract line 2j from line 2d) ........................................................ l Transfers of assets (1) To this plan ........................................................................................................... (2) From this plan ......................................................................................................

(b) Total







.00 .00 .00

Part III
3

Accountant's Opinion

Complete lines 3a through 3c if the opinion of an independent qualified public accountant is attached to this Form 5500. Complete line 3d if an opinion is not attached.

(1)

Unqualified

(2)

Qualified

(3)

Disclaimer

(4)

Adverse

b Did the accountant perform a limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)? ................. c Enter the name and EIN of the accountant (or accounting firm):

US E

FO

R
Yes

a The attached opinion of an independent qualified public accountant for this plan is (see instructions):

FI LI NG

No



d The opinion of an independent qualified public accountant is not attached because: (1) this form is filed for a CCT, PSA or MTIA. (2) it will be attached to the next Form 5500 pursuant to 29 CFR 2520.104-50.

Part IV
4

Transactions During Plan Year

During the plan year:

PU

RP

CCTs and PSAs do not complete Part IV. 103-12 IEs also do not complete 4j.

MTIAs, 103-12 IEs, and GIAs do not complete 4a, 4e, 4f, 4g, 4h, 4k, or 5.

O

SE

S

O

Yes

NL

Y,
No

EIN

D

O

NO

Name

T

Amount

IO

a Did the employer fail to transmit to the plan any participant contributions within the time period described in 29 CFR 2510.3-102? (See instructions and DOL's Voluntary Fiduciary Correction Program.) ......................

NA

L







.00

FO

b Were any loans by the plan or fixed income obligations due the plan in default as of the close of the plan year or classified during the year as uncollectible? Disregard participant loans secured by the participant's account balance. (Attach Schedule G (Form 5500) Part I if "Yes" is checked.) ......................

RM

AT


0 0 5 0 L





.00 .00 .00 .00

c

d

Were there any nonexempt transactions with any party-in-interest? (Do not include transactions reported on line 4a. Attach Schedule G (Form 5500) Part III if "Yes" is checked.) ....................

e

Was this plan covered by a fidelity bond? ........................................

FO

Were any leases to which the plan was a party in default or classified during the year as uncollectible? (Attach Schedule G (Form 5500) Part II if "Yes" is checked.) ..........................................

R

IN

1

7

0

8

0

Schedule H (Form 5500) 2008

Page

6
Official Use Only

Yes 4 f Did the plan have a loss, whether or not reimbursed by the plan's fidelity bond, that was caused by fraud or dishonesty? ...... g Did the plan hold any assets whose current value was neither readily determinable on an established market nor set by an independent third party appraiser? ................................................. h Did the plan receive any noncash contributions whose value was neither readily determinable on an established market nor set by an independent third party appraiser? ............................................ i Did the plan have assets held for investment? (Attach schedule(s) of assets if "Yes" is checked, and see instructions for format requirements.) .................................................................................. j Were any plan transactions or series of transactions in excess of 5% of the current value of plan assets? (Attach schedule of transactions if "Yes" is checked and see instructions for format requirements.) .................................................................................. k Were all the plan assets either distributed to participants or beneficiaries, transferred to another plan, or brought under the control of the PBGC? ......................................................................

No

Amount







.00 .00 .00

NL

5a Has a resolution to terminate the plan been adopted during the plan year or any prior plan year? If yes, enter the amount of any plan assets that reverted to the employer this year ......................

Y,

D

O

NO

T

US E

FO

R

FI LI NG








.00

5b(1) Name of plan

5b(1) Name of plan

IN

FO

5b(2) EIN

RM

5b(2) EIN

AT

IO

NA

L

5b(2) EIN

PU

RP

5b(1) Name of plan

O

SE

5b If, during this plan year, any assets or liabilities were transferred from this plan to another plan(s), identify the plan(s) to which assets or liabilities were transferred. (See instructions).

S

O

5b(3) PN

5b(3) PN

5b(3) PN

FO
5b(2) EIN

5b(1) Name of plan

R

5b(3) PN

1

7

0

8

0

0

0

6

0

M