Free 2007 Form 5500 Schedule SSA - Federal

Attention:
· Telephone requests for the 2007 Form 5500-series forms, schedules, and instructions will not be filled until October 16, 2007. · Requests for the 2007 Form 5500-series products can be made on the Internet (see below) beginning October 16, 2007. Requests made prior to that date will be filled with the 2006 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 1-800TAX-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. ________________________________________________

Official Use Only

SCHEDULE SSA (Form 5500)

Annual Registration Statement Identifying Separated Participants With Deferred Vested Benefits
Under Section 6057(a) of the Internal Revenue Code

OMB No. 1210-0110

2007
This Form is NOT Open to Public Inspection.

Department of the Treasury Internal Revenue Service



File as an attachment to Form 5500 unless box 1 is checked.

A

Name of plan

C

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

B

3a Name of plan administrator (if other than sponsor)

Under penalties of perjury, I declare that I have examined this report, and to the best of my knowledge and belief, it is true, correct, and complete. Phone number of Signature of plan administrator plan administrator

FO

R

City or town

IN

FO

3c Number, street, and room or suite no. (If a P.O. box, see the instructions for line 2.)

R

M

3b Administrator's EIN

A

T

IO

N

A

L

P

U

R

P

City or town

O

S

E S

2

Plan sponsor's address (number, street, and room or suite no.) (If a P.O. box, see the instructions for line 2.)

O N

LY

1

Check here if plan is a government, church or other plan that elects to voluntarily file Schedule SSA. If so, complete lines 2 through 3c, and the signature area.

,D

O

Three-digit plan number

D

Employer Identification Number



N

O

State

T

State

ZIP code





SIGN HERE

Date

MM / D D / Y Y Y Y
Cat. No. 13506T Schedule SSA (Form 5500) 2007

For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500.

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v10.1

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E

ZIP code

FO

R

FI LI N

For calendar plan year 2007 or fiscal plan year beginning

MM / D D / Y Y Y Y

and ending

MM / D D / Y Y Y Y

G

Schedule SSA (Form 5500) 2007 4

Page

2
Official Use Only

Enter one of the following Entry Codes in column (a) for each separated participant with deferred vested benefits that: Code A -- has not previously been reported. Code B -- has previously been reported under the above plan number but requires revisions to the information previously reported. Code C -- has previously been reported under another plan number but will be receiving their benefits from the plan listed above instead. Code D -- has previously been reported under the above plan number but is no longer entitled to those deferred vested benefits.

Use with entry code "A", "B", "C", or "D"
(a) Entry code (c) Name of participant (First)

(M. I.)

(Last)

(g) Units or shares (f) Defined benefit plan -- periodic payment

O

N

(d) Type of annuity

(e) Payment frequency

U S

Enter code for nature and form of benefit

E

Amount of vested benefit Defined contribution plan

FO

Use with entry code "A" or "B"

R

FI LI N
Share indicator

(b) Social security number









.

(h) Total value of account

O








(j) Previous plan number

.

T

Use with entry code "C"

IO

N

A

L

Use with entry code "A" or "B"
Amount of vested benefit Defined contribution plan (g) Units or shares Share indicator

FO

(d) Type of annuity

(e) Payment frequency

(f) Defined benefit plan -- periodic payment

M

A

Enter code for nature and form of benefit

T

P

U

(c) Name of participant

R

(a) Entry code (First)

P

O

Use with entry code "A", "B", "C", or "D"
(b) Social security number (M. I.) (Last)

S

E S

O N

LY

(i) Previous sponsor's employer identification number

,D

.







.








(j) Previous plan number

. .

R

(h) Total value of account

FO

R

IN

(i) Previous sponsor's employer identification number

Use with entry code "C"

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