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ASSETS

VIEWS: 4 PAGES: 3

  • pg 1
									PLAN NAME:
INFORMATION REQUEST FOR THE PLAN YEAR ENDING:

                                                    ASSETS & LIABILITES

Enter only the assets and liabilities of the Plan. Do not include any assets or liabilities of the Employer.


                                                                     Value First Day               Value Last Day
                                                                       of the Plan                   of the Plan
A.      ASSETS                                                             Year                          Year
        1)          CASH
                    a.  Checking
                    b.  Money Market
                    c.  Savings
                    d.  Certificates of Deposit

        2)          RECEIVABLE
                    a.  Contributions
                    b.  Accrued Interest

        3)          INVESTMENTS
                    (enter market value not book value)
                    a.     Mutual Funds
                    b.     Corporate Debt (Bonds)
                    c.     Corporate Equity (Stocks)
                    d.     Government Securities
                    e.     Real Estate
                    f.     Loans (Participant)
                    g.     Annuity Cash Surrender Value(s)
                    h.     Common/ Collective Trusts
                    i.     Pooled Separate Accounts
                    j.     Insurance Company General Account
                    k.     Partnerships/ Joint Venture Interests
                    l.     Insurance Cash Surrender Value(s)
                    m.     Other (Specify)

                    TOTAL ASSETS                                 $                             $

B.      LIABILITIES

                    a.     Beneifit Claims Payable
                    b.     Administrative/ Operating Payables

                    NET ASSETS                                   $                             $
Is the Plan insured by a Fidelity Bond? [ ] Yes   [ ] No

If yes, enter the name of the surety company: Amount of Bond Coverage: ______________

Jantzen Associates, Inc. 3717 N. Ravenswood Ave, Suite 241, Chicago, IL 60613 p 773.472.7000 f 773.472.1147
                                  INCOME STATEMENT (ASSET RECONCILIATION)

                                                                Net Asset Value First Day of Plan Year $
A.    INCOME DURING PLAN YEAR

      1)    Employer Contributions (For employee deferrals please provide itemized breakdown on separate sheet)
            Date                 Amount                        Date                 Amount
      a)                                              d)
      b)                                              e)
      c)                                              f)


      Please identify (circle) if any represent a contribution for the prior plan year.                      $

      2)    Earnings from investments (interest/ dividends):                                                 $
      3)    Net Realized Gain (Loss) on sale or exchange of Assets:                                          $
      4)    Unrealized Appreciation (Depreciation) of Assets:                                                $
      5)    Other (Increase/Decrease in value of Insurance, Rental Income etc.)                              $
                                                                                             TOTAL INCOME $
B.    EXPENSES DURING THE PLAN YEAR

      1)    Insurance Premiums Paid (Provide breakdown per policy) :                                         $
      2)    Disbursements to Participants or Beneficiaries (Provide date) :                                  $
      3)    Service Charges :                                                                                $
      4)    Other (Specify) :                                                                                $

                                                                                          TOTAL EXPENSES $


                                                                Net Asset Value Last Day of Plan Year $


CONTRIBUTION (Budget parameters) Please indicate amount in addition to any advance funding.
      a)    Maximum                                   b)       Minimum

      c)    Specify other objectives_____________________________________________________________

      These objectives will be considered to the extent legally feasible.

EMPLOYER STATUS

      a)    [ ] Subchapter S [ ] C Corporation [ ] Partnership [ ] Sole Proprietor [ ] Limited Liability Corporation
      b)    Member of a Controlled Group of Corporations? [ ] Yes [ ] No
      c)    Affliated with other service organizations? [ ] Yes [ ] No
      d)    Did any leased employee perform services for the employer at any time during the plan year? [ ] Yes [ ] No


The information supplied in this form is,to the best of my knowledge, true and correct.

By: _____________________________                 Title: ________________________                Date: ________________
CENSUS OF ALL EMPLOYEES
                                                                                                                                           Hours Worked During Year
                                      Social Security     Date of    Date of       Date of   Ownership      Total                           Under Over      Over
        Name of Employee                                                                                                Deferral   Match
                                         Number            Birth      Hire       Termination    %        Compensation                      500 hrs 500 hrs 1000 hrs




* If the Plan excludes Union Employees, indicate total number excluded: ______

JANTZEN ASSOCIATES, INC. 3717 N. RAVENSWOOD AVE, SUITE 241, CHICAGO, IL 60613 (773) 472-7000 OR FAX (773) 472-1147

								
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