5500 Annual Return/Report of Employee Benefit Plan

Form 5500 (2012) v. 111118 Page 3

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

Annual Return/Report of Employee Benefit Plan This form is required to be filed for employee benefit plans under sections 104 and 4065 of the Employee Retirement Income Security Act of 1974 (ERISA) and sections 6047(e), 6057(b), and 6058(a) of the Internal Revenue Code (the Code).  Complete all entries in accordance with the instructions to the Form 5500.

OMB Nos. 1210-0110 1210-0089 2012 This Form is Open to Public Inspection

Part I

Annual Report Identification Information

For calendar plan year 2012 or fiscal plan year beginning and ending

A This return/report is for:

X a multiemployer plan;

X a multiple-employer plan; or

X a single-employer plan;

X a DFE (specify) _C_

B This return/report is:

X the first return/report;

X the final return/report;

X an amended return/report;

X a short plan year return/report (less than 12 months).

C If the plan is a collectively-bargained plan, check here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X

D Check box if filing under:

X Form 5558;

X automatic extension;

X the DFVC program;

X special extension (enter description) ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Part II

Basic Plan Information—enter all requested information

1a Name of plan ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

1b Three-digit plan number (PN) 

001

1c Effective date of plan YYYY-MM-DD

2a Plan sponsor’s name and address; include room or suite number (employer, if for a single-employer plan)

2b Employer Identification Number (EIN) 012345678

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI D/B/A ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITYEFGHI ABCDEFGHI AB, ST 012345678901 UK

2c Sponsor’s telephone number 0123456789

2d Business code (see instructions) 012345

Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established.

Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return/report, including accompanying schedules, statements and attachments, as well as the electronic version of this return/report, and to the best of my knowledge and belief, it is true, correct, and complete.

SIGN HERE

YYYY-MM-DD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Signature of plan administrator

Date

Enter name of individual signing as plan administrator

SIGN HERE

YYYY-MM-DD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Signature of employer/plan sponsor

Date

Enter name of individual signing as employer or plan sponsor

SIGN HERE

YYYY-MM-DD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Signature of DFE

Date

Enter name of individual signing as DFE

Preparer’s name (including firm name, if applicable) and address; include room or suite number. (optional) ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

Preparer’s telephone number (optional)

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

Form 5500 (2012) v. 111118

3a Plan administrator’s name and address XSame as Plan Sponsor Name XSame as Plan Sponsor Address ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITYEFGHI ABCDEFGHI AB, ST 012345678901 UK			3b Administrator’s EIN 012345678
			3c Administrator’s telephone number 0123456789
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:			4b EIN 012345678
a Sponsor’s name ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI			4c PN 012
5a Name of trust (optional) ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI			5b Trust’s EIN (optional)ABCDEFGHI 555555555
6 Total number of participants at the beginning of the plan year				6		123456789012
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				7a	123456789012
b Retired or separated participants receiving benefits				7b	123456789012
c Other retired or separated participants entitled to future benefits				7c	123456789012
d Subtotal. Add lines 7a, 7b, and 7c.				7d	123456789012
e Deceased participants whose beneficiaries are receiving or are entitled to receive benefits.				7e	123456789012
f Total. Add lines 7d and 7e.				7f	123456789012
g Number of participants with account balances as of the end of the plan year (only defined contribution plans complete this item)				7g	123456789012
h Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested				7h	123456789012
8 Enter the total number of employers obligated to contribute to the plan (only multiemployer plans complete this item)				8
9a If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristic Codes in the instructions:
b If the plan provides welfare benefits, enter the applicable welfare feature codes from the List of Plan Characteristic Codes in the instructions:
10a Plan funding arrangement (check all that apply)	10b Plan benefit arrangement (check all that apply)
(1) X Insurance	(1) X Insurance
(2) X Code section 412(e)(3) insurance contracts	(2) X Code section 412(e)(3) insurance contracts
(3) X Trust	(3) X Trust
(4) X General assets of the sponsor	(4) X General assets of the sponsor
11 Check all applicable boxes in 11a and 11b to indicate which schedules are attached, and, where indicated, enter the number attached. (See instructions)
a Pension Schedules		b General Schedules
(1) X R (Retirement Plan Information)		(1) X H (Financial Information)
(2) X MB (Multiemployer Defined Benefit Plan and Certain Money Purchase Plan Actuarial Information) - signed by the plan actuary		(2) X I (Financial Information – Small Plan)
		(3) X ___ A (Insurance Information)
		(4) X C (Service Provider Information)
(3) X SB (Single-Employer Defined Benefit Plan Actuarial Information) - signed by the plan actuary		(5) X D (DFE/Participating Plan Information)
		(6) X G (Financial Transaction Schedules)