Form 5330 - Return Of Excise Taxes Related To Employee Benefit Plans Page 3

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Form 5330 (Rev. 10-2003)
Page
DUE DATE: Section 4975 taxes are due by the last day of the 7th month after the end of the tax year of the filer.
Part VII
Tax on Prohibited Transactions (Section 4975)
26a Is the excise tax a result of a prohibited transaction that was (check one or more):
discrete
other than discrete (a lease or a loan)
b
(c) Amount involved
(d) Initial tax on prohibited
(a) Date
in prohibited
transaction (multiply each
Transaction
of transaction
(b) Description of prohibited transaction
transaction
transaction in column (c) by
number
(see page 6 of
(see page 6 of the
the appropriate rate (see
the instructions)
instructions)
page 6 of the instructions))
(i)
(ii)
(iii)
(iv)
26c Add amounts in column (d). Enter here and on line 6
27
Have you corrected all of the prohibited transactions that you are reporting on this return? (See page 6
of the instructions)
Yes
No
If “Yes,” complete Part IX. If “No,” complete Part IX and see page 6 of the instructions.
Part VIII
Schedule of Other Participating Disqualified Persons (see instructions on page 6)
(b)
(c)
28
(a)
Transaction
Employer identification
Name and address of disqualified person
number from
number or social
Part VII
security number
(i)
(ii)
(iii)
(iv)
Part IX
Description of Correction (see line 27 instructions on page 6)
29
(a)
(c)
Transaction
(b)
Date of
number from
Nature of correction
correction
Part VII
(i)
(ii)
(iii)
(iv)

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