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Form 5500 Annual Return/Report of Employee Benefit Plan Official Use Only
Department of the Treasury This form is required to be filed under sections 104 and 4065 of the Employee OMB Nos. 1210-0110
Internal Revenue Service Retirement Income Security Act of 1974 (ERISA) and sections 6039D, 6047(e), 1210-0089
6057(b), and 6058(a) of the Internal Revenue Code (the Code).
Department of Labor
Pension and Welfare Benefits 1999
Administration Complete all entries in accordance with
the instructions to the Form 5500
Pension Benefit Guaranty The Form is Open to
Corporation Public Inspection
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Part I Annual Report Identification Information
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For the calendar plan year 1999 or fiscal plan year beginning 10/01/1999, and ending 09/30/2000
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A. This return/report is for: (1) [ ] a multiemployer plan; (3) [ ] a multiple-employer plan;
(2) [X] a single-employer plan (other (4) [ ] a DFE (specify) ____________
than a multiple-employer plan)
B. This return/report is (1) the first return/report filed for the (3) the final return/report filed for the
plan; plan;
(2) an amended return/report; (4) a short plan year return/report (less
than 12 months).
C. If the plan is a collectively-bargained plan, check here
D. If you filed for an extension of time to file, check the box and attach a copy of the extension application
Part II Basic Plan Information -- enter all requested information.
1a Name of plan 1b three-digit plan number (PN) 002
The Xxxxxx Savings & Loan Company 1c effective date of plan (mo.day.yr.)
401 (k) Profit Sharing Plan 10/01/1994
2a Plan sponsor's name and address (employer, if for a single-employer plan) 2b Employer Identification Number (EIN)
(Address should include room or suite no.) 00-0000000
Xxxxxx Savings & Loan Company 2c Sponsor's telephone number
0000 Xxxxxxx Xxxx 000-000-0000
Xxxxxxxxxx, Xxxx 00000
2d Business code (see instruction)
522120
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 instruction, I declare that I have examined this
return/report, including accompanying schedules, statements and attachments, and to the best of my knowledge and belief, it is true,
correct and complete.
/s/ Xxxxx X. Xxxxxx 05/02/2001 Xxxxx X. Xxxxxx
Signature of plan administrator Date Typed or printed name of individual signing as plan
administrator
/s/ Xxxxx X. Xxxxxx 05/02/2001 Xxxxx X. Xxxxxx
Signature of employer/plan sponsor/DFE Date Typed or printed name of individual signing as employer, plan
sponsor or DFE as applicable
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500
(Form 5500 (1999) Page 2
3a Plan administrator's name and address (if same as plan sponsor, enter "Same") 3b Administrator's EIN
Same
3c Administrator's telephone number
4 If the name and/or EIN of the plan sponsor has changed since the last return/report filed b EIN
for this plan, enter the name, EIN and the plan umber from the last return/report below:
c PN
a Sponsor's name
5 Preparer information (optional) a Name (including firm name, if applicable) and b EIN
address
c Telephone no.
6 Total number of participants at the beginning of the plan year 6 76
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 72
b Retired or separated participants receiving benefits 7b 0
c Other retired or separated participants entitled to future benefits 7c 0
d Subtotal. Add lines 7a, 7b, and 7c 7d 72
e Deceased participants whose beneficiaries are receiving or are entitled to receive 7e 0
benefits
f Total. Add lines 7d and 7e 7f 72
g Number of participants with account balances as of the end of the plan year (only 7g
defined contribution plans complete this item) 84
h Number of participants that terminated employment during the plan year with accrued 7h
benefits that were less than 100% vested 0
i If any participant(s) separated from service with a deferred vested benefit, enter 7i
the number of separated participants required to be reported on a Schedule SSA (Form 4
5500)
8 Benefits provided under the plan (complete 8a through 8c, as applicable)
a X Pension benefits (check this box if the plan provides pension benefits and enter the applicable pension feature codes
from the List of Plan Characteristics Codes (printed in the instructions)): 2G 2K 2C
b Welfare benefits (check this box if the plan provides welfare benefits and enter the applicable welfare feature codes
from the List of Plan Characteristics Codes (printed in the instructions)):
c Fringe benefits (check this box if the plan provides fringe benefits)
9a Plan funding arrangement (check all that apply) 9b Plan benefit arrangement (check all that apply)
(1) Insurance (1) Insurance
(2) Section 412(i) insurance contracts (2) Section 412(i) insurance contracts
(3) X Trust (3) X Trust
(4) General assets of the sponsor (4) General assets of the sponsor
10 Schedules attached (Check all applicable boxes and, where indicated, enter the number attached. See instructions.)
a Pension Benefit Schedules b Financial Schedules
(1) R (Retirement Plan Information) (1) H (Financial Information
(2) X 1 T (Qualified Pension Plan Coverage Information) (2) X I (Financial Information - Small Plan)
If a Schedule T is not attached because the plan is (3) ___ A (Insurance Information)
relying on coverage testing information for a prior (4) C (Service Provider Information)
year, enter the year ____ (5) D (DFE/Participating Plan Information)
(4) E (ESOP Annual Information) (6) G (Financial Transaction Schedules)
(5) X SSA (Separated Vested Participant Information) (7) X 1 P (Trust Fiduciary Information)
c Fringe Benefit Schedule
F (Fringe Benefit Plan Annual Information)
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SCHEDULE I Annual Return/Report of Employee Benefit Plan Official Use Only
Form 5500 OMB No. 1210-0110
Department of the Treasury This schedule is required to be filed under sections 104 and 4065 of the
Internal Revenue Service Employee Retirement Income Security Act of 1974 (ERISA) and section 6058(a)
of the Internal Revenue Code (the Code).
Department of Labor 1999
Pension and Welfare Benefits
Administration
Pension Benefit Guaranty The Form is Open to
Corporation File as an attachment to Form 5500 Public Inspection
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For the Calendar plan year 1999 or fiscal plan year beginning 10/01/1999, and ending 09/30/2000
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A Name of Plan B Three-digit
The Xxxxxx Savings & Loan Company 401(k) Profit Sharing Plan plan number 002
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C Plan sponsor's name as shown on line 2a of Form 5500 D Employer Identification Number
Xxxxxx Savings & Loan 00-0000000
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Complete Schedule I if the plan covered fewer than 100 participants as of the beginning of the plan year. You may also complete
Schedule I if you are filing as a small plan under the 80-120 participant rule (see instructions). Complete Schedule H if reporting
as a large plan or DFE.
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Part I Small Plan Financial Information
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Report below the current value of assets and liabilities, income, expenses, transfers and changes in net assets during the plan
year. Combine the value of plan assets held in more than one trust. Do not enter the value of the portion of an insurance contract
that guarantees during this plan year to pay a specific dollar benefit at a future date. 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.
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1 Plan Assets and Liabilities: (a) Beginning of Year (b) End of Year
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a Total plan assets 1a 3,842,923 3,369,354
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b Total plan liabilities 1b
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c Net plan assets (subtract line 1b from line 1a) 1c 3,842,923 3,369,354
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2 Income, expenses, and Transfers for this Plan Year: (a) Amount (b) Total
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a Contributions received or receivable
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(1) Employers 2a(1) 19,897
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(2) Participants 2a(2) 100,551
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(3) Others (including rollovers) 2a(3) 8,507
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b Noncash contributions 2b
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c Other Income 2c -537,227
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d Total income (add lines 2a(1), 2a(2), 2a(3), 2b and 2c) 2d -408,272
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e Benefits paid (including direct rollovers) 2e 65,297
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f Corrective distributions (see instructions) 2f
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g Certain deemed distributions of participant loans (see instructions) 2g
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h Other expenses 2h
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i Total expenses (add lines 2e, 2f, 2g and 2h) 2i 65,297
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j Net income (loss) (subtract line 2i from line 2d) 2j -473,569
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k Net transfers 2k
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3 Specific Assets: If the plan held any assets in one or more of the following specific categories, check, yes and enter the
current value as of the end of the plan year. Allocate the value of the plan's interest in a commingled trust containing the assets
of more than one plan on a line-by-line basis unless the trust meets one of the specific exceptions described in the instructions.
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Yes No Amount
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a partnership/joint venture interests 3a X
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b Employer real property 3b X
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For Paperwork Reduction Act Notice and OMB Control Numbers, see the Instructions for Form 5500. Schedule 1(Form 5500) 1999
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Schedule I (Form 5500 (1999) Page 2
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Yes No Amount
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3c Real estate (other than employer real property) 3c X
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d Employer securities 3d X
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e Participant loans 3e X 142,799
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f Loans (other than to participants) 3f X
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g Tangible personal property 3g X
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Part II Transactions During Plan Year
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4 During the plan year Yes No Amount
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a Did the employer fail to transmit to the plan any participant
contributions within the maximum time period described in 29 4a X
CFR2510.3-102? (See Instructions)
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b Were any loans by the plan or fixed income obligations due the plan
in default as of the close of the plan year to classified during 4b X
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c Were any leases to which the plan was a party in default or
classified during the year as uncollectible? 4c X
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d Did the plan engage in any nonexempt transaction with any 4d X
party-in-interest?
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e Was the plan covered by a fidelity bond? 4e X 5,000,000
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f Did the plan have a loss, whether or not reimbursed by the plans'
fidelity bond, that was caused by fraud or dishonesty? 4f X
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g Did the plan hold any assets whose current value was neither readily
determinable on an established market nor set by an independent third 4g X
party appraiser?
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h Did the plan receive any noncash contributions whose value was
neither readily determinable on an established market nor set by an 4h X
independent third party appraiser?
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i Did the plan at any time hold 20% or more of its assets in any single
security, debt, mortgage, parcel of real estate, or partnership, joint 4i X
venture interest?
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j Were all the plan assets either distributed to participants or
beneficiaries, transferred to another plan or brought under the control 4j X
of the PBGC?
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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 Yes X No Amount
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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.)
5b(1) Name of plan(s) 5b(2) EIN(s) 5b(3) PN(s)
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SCHEDULE P Annual Return of Fiduciary Official Use Only
(FORM 5500) of Employee Benefit Trust OMB No. 1210-0110
This schedule may be filed to satisfy the requirements under section 6033(a)
for an annual information return from every section 401(a) organization
exempt from tax under section 501(a). 1999
Filing this form will start the running of the statute of limitations under
Department of the Treasury section 6501(a) for any trust described in section 401(a) that is exempt
Internal Revenue Service from tax under section 501(a). The Form is Open to
File as an attachment to Form 5500 or 5500-EZ. Public Inspection
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For trust calendar year 1999 or fiscal year beginning 10/01/1999 and ending 09/30/2000
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1a Name of trustee or custodian
The Xxxxxx Savings & Loan Company
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b Number, street, and room or suite no. (if a P.O. box, see the instructions for Form 5500 or 5500 EZ.)
0000 Xxxxxxx Xxxx
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c City or town, state, and ZIP code
Xxxxxxxxxx, Xxxx 00000
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2a Name of trust
The Xxxxxx Savings & Loan Company 401(k) Profit Sharing Plan
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b Trust's employer identification number 00-0000000
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3 Name of plan if different from name of trust
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4 Have you furnished the participating employee benefit plan(s) with the trust financial information required to be reported by the
plan(s)? X Yes No
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5 Enter the plan sponsor's employer identification number as shown on Form 5500 or 5500 EZ 00-0000000
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Under penalties of perjury, I declare that I have examined this schedule, and to the best of my knowledge and belief it is true,
correct, and complete
Signature of fiduciary /s/ Xxxxx X. Xxxxxx Date 05/02/2001
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For the Paperwork Reduction Notice and OMB Control Numbers,
see the instructions for Form 5500 or 5500-EZ
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SCHEDULE SSA Annual Registration Statement Identifying Separated Official Use Only
(Form 5500) Participants With Deferred Vested Benefits OMB No. 1210-0110
Under Section 6057(a) of the Internal Revenue Code
1999
Department of the Treasury
Internal Revenue Service File as an attachment to Form 5500 This Form is NOT Open
to Public Inspection
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For the Calendar plan year 1999 or fiscal plan year beginning 10/01/1999, and ending 09/30/2000
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A Name of Plan B Three-digit
The Xxxxxx Savings & Loan Company 401(k) Profit Sharing Plan plan number 002
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C Plan sponsor's name as shown on line 2a of Form 5500 D Employer Identification Number
Xxxxxx Savings & Loan 00-0000000
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1 Check here if additional participants are shown on attachments. All attachments must include the sponsor's name, EIN, name of
plan, plan number, and column identification letter for each column completed for line 4.
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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. Otherwise, complete the signature area only.
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2 Plan sponsor's address (number, street, and room or suite no.) (If a P.O. box, see the instructions for line 2.)
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City, or town, state, and Zip code
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3a Name of plan administrator (if other than sponsor)
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3b Administrator's EIN
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0x Xxxxxx, xxxxxx, and room or suite no. (If a P.O. box, see the instructions for line 2.)
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City, or town, state, and Zip code
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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.
Signature of plan administrator /s/ Xxxxx X. Xxxxxx
Phone number of plan administrator Date 05/02/2001
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For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500.
Schedule SSA (Form 5500) 1999 Page 2
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4 Enter one of the following Entry Codes in column (a) for each separated participant with deferred vested:
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.
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Use with entry code Use with entry code
"A," "B," "C," or "D" "A" or "B"
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(a) (b) (c) Enter code for Amount of vested benefit
Entry Social Name of Participant nature and
Code Security form of
Number benefit
------ ----------- ----------------------------- ----------------- ----------------------
(f)
(d) (e) Defined benefit
Type of Payment plan - periodic
annuity frequency payment
------------------------------------------------
A ###-##-#### XXXXX XXXXXXX A A
------------------------------------------------
A ###-##-#### XXXXX XXXXX A A
------------------------------------------------
A ###-##-#### XXXXXXXXX XXXXX A A
------------------------------------------------
A ###-##-#### XXXXXX XXXXXXX A A
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Use with entry code Use with entry code
"A" or "B" "C"
Amount of vested benefit --------------------------------------------------------------
Defined contribution plan
(i) (j)
(a) (g) (h) Previous sponsor's Previous
Entry Units or Share Total value employer plan number
Code Shares indicator of account identification number
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308,234.00
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18,573.18
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1,300.60
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67,187.81
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SCHEDULE T Qualified Pension Plan Coverage Information Official Use Only
(Form 5500) OMB Nos. 1210-0110
This form is required to be filed under section 6058(a) of the
Internal Revenue Code (the Code). 1999
Department of the Treasury
Internal Revenue Service File as an attachment to Form 5500 This Form is Open to
Public Inspection
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For the Calendar plan year 1999 or fiscal plan year beginning 10/01/1999, and ending 09/30/2000
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A Name of Plan B Three-digit
The Xxxxxx Savings & Loan Company 401(k) Profit Sharing Plan plan number 002
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C Plan sponsor's name as shown on line 2a of Form 5500 D Employer Identification Number
Xxxxxx Savings & Loan 00-0000000
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Note: If the plan is maintained by:
More than one employer and benefits employees who are not collectively-bargained employees, a separate Schedule T may be
required for each employer (see the instruction for line 1).
An employer that operates qualified separate lines of business (QSLOBs) under Code section 414(r), a separate Schedule T
may be required for each QSLOB (see the instruction for line 2).
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1 If this schedule is being filed to provide coverage information regarding the noncollectively bargained employees of an employer
participating in a plan maintained by more than one employer, enter the name and EIN of the participating employer:
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1a Name of participating employer 1b Employer identification number
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2 If the employer maintaining the plan operates QSLOBs, enter the following information:
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a The number of QSLOBs that the employer operates is
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b The number of such QSLOBs that have employees benefiting under this plan is
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c Does the employer apply the minimum coverage requirements to this plan on an employer-wide rather than a QSLOB
basis? Yes No
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d If the entry on line 2b is two or more and line 2c is "No," identify the QSLOB to which the coverage information given on
line 3 or 4 relates.
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3 Exceptions - Check the box before each statement that describes the plan or the employer.
If you check any box, do not complete the rest of this Schedule.
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a The employer employs only highly compensated employees (HCEs).
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b No HCEs benefited under the plan at anytime during the plan year.
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c The plan benefits only collectively bargained employees.
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d The plan benefits all nonexcludable nonhighly compensated employees of the employer (as defined in Code sections
414(b), (c), and (m)), including leased employees and self-employed individuals.
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e The plan is treated as satisfying the minimum coverage requirements under Code section 410(b)(6)(C).
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For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500
Schedule T (Form 5500) 1999 Page 2
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3 Enter the date the plan year began for which coverage data is being submitted. Month 09 Day 30 Year 2000
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a Did any leased employees perform services for the employer at any time during the plan year? Yes X No
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b In testing whether the plan satisfies the coverage and nondiscrimination tests of Code sections 410(b) and 401(a)(4),
does the employer aggregate plans? Yes X No
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c Complete the following:
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(1) Total number of employees of the employer (as defined in Code section 414(b), c(1) 122
(c), and (m)), including leased employees and self-employed individuals
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(2) Number of excludable employees as defined in IRS regulations (see instructions) c(2) 15
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(3) Number of nonexcludable employees. (Subtract line 4c(2) from line 4c(1)) c(3) 107
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(4) Number of nonexcludable employees (line 4c(3)) who are HCEs c(4) 11
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(5) Number of nonexcludable employees (line 4c(3)) who benefit under the plan c(5) 107
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(6) Number of benefiting nonexcludable employees (line 4c(5)) who are HCEs c(6) 11
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d Enter the plan's ratio percentage and, if applicable, identify the disaggregated d 100.0%
part of the plan to which the information on lines 4c and 4d pertains
(see instructions 401(k)
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e Identify any disaggregated part of the plan and enter its ratio percentage:
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(1) Disaggregated part: 401(m) Ratio Percentage: e(1) 100.0%
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(2) Disaggregated part: Ratio Percentage: e(2)
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(3) Disaggregated part: Ratio Percentage: e(3)
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f This plan satisfies the coverage requirements on the basis of (check one):
X the ratio percentage test average benefit test
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