Return of Excise Taxes Related to Employee Benefit Plans
                                         (under sections 4965, 4971, 4972, 4973(a)(3), 4975, 4976, 4977, 4978, 4979,                    OMB No. 1545-0575 
Form  (Rev. December 2021)5330                   4979A, 4980, and 4980F of the Internal Revenue Code) 
Department of the Treasury               ▶ Go to www.irs.gov/Form5330 for instructions and the latest information.
Internal Revenue Service 
Filer tax year beginning                                                       ,       and ending                                                    , 
A     Name of filer (see instructions)                                                                            B  Filer’s identifying number (Enter either the 
                                                                                                                        EIN or SSN, but not both. See instructions.) 
      Number, street, and room or suite no. (If a P.O. box or foreign address, see instructions.)                       Employer identification number (EIN) 

      City or town, state or province, country, and ZIP or foreign postal code                                          Social security number (SSN) 

C     Name of plan                                                                                                E  Plan sponsor’s EIN 

D     Name and address of plan sponsor                                                                            F     Plan year ending (MM/DD/YYYY) 

H     If this is an amended return, check here     . . . . . .                 . . . .            . . . . .  ▶    G  Plan number

Part I Taxes. You can only complete one section of Part I for each Form 5330 filed. See instructions. 
Section A. Taxes that are reported by the last day of the 7th month after the end of the tax                                 FOR   
                                                                                                                             IRS   
year of the employer (or other person who must file the return)                                                              USE 
                                                                                                                             ONLY

1     Section 4972 tax on nondeductible contributions to qualified plans (from Schedule A, line 12)  .                       161   1 

2     Section 4973(a)(3) tax on excess contributions to section 403(b)(7)(A) custodial accounts (from
      Schedule B, line 12)  .            . . .   . . . . . . .                 . . . . .            . . . .  . .  .     . .  164   2 

3 a   Section 4975(a) tax on prohibited transactions (from Schedule C, line 3)  .                       . .  . .  .     . .  159   3a 
b     Section 4975(b) tax on failure to correct prohibited transactions  .                        . . . . .  . .  .     . .  224   3b 

4     Section 4976 tax on disqualified benefits for funded welfare plans  .                         . . . .  . .  .     . .  200   4 

5 a   Section 4978 tax on ESOP dispositions  .         . . . .                 . . . .            . . . . .  . .  .     . .  209   5a 
b     The tax on line 5a is a result of the application of:                      Sec. 664(g)            Sec. 1042                  5b

6     Section 4979A tax on certain prohibited allocations of qualified ESOP securities or ownership of
      synthetic equity .         .     . . . .   . . . . . . .                 . . . . .            . . . .  . .  .     . .  203   6 

7     Total Section A taxes. Add lines 1 through 6. Enter here and on Part II, line 17 .                     . .  .     .  ▶       7 
Section B. Taxes that are reported by the 15th day of the 10th month after the last day of the plan year
8 a   Section 4971(a) tax on failure to meet minimum funding standards (from Schedule D, line 2)  .                     . .  163   8a 
b     Section 4971(b) tax for failure to correct minimum funding standards  .                         . . .  . .  .     . .  225   8b 

9 a   Section 4971(f)(1) tax on failure to pay liquidity shortfall (from Schedule E, line 4)  .                .  .     . .  226   9a 
b     Section 4971(f)(2) tax for failure to correct liquidity shortfall            . .            . . . . .  . .  .     . .  227   9b 

10 a  Section 4971(g)(2) tax on failure to comply with a funding improvement or rehabilitation plan (see 
      instructions)  .         . .     . . . .   . . . . . . .                 . . . . .            . . . .  . .  .     . .  450   10a 
b     Section 4971(g)(3) tax on failure to meet requirements for plans in endangered or critical status
      (from Schedule F, line 1c)           . .   . . . . . . .                 . . . . .            . . . .  . .  .     . .  451   10b 
c     Section 4971(g)(4) tax on failure to adopt rehabilitation plan (from Schedule F, line 2d)                   .     . .  452   10c 
Section B1. Tax that is reported by the last day of the 7th month after the end of the calendar year in which the excess 
fringe benefits were paid to the employer’s employees 
11    Section 4977 tax on excess fringe benefits (from Schedule G, line 4)  .                         . . .  . .  .     . .  201   11 

12    Total Section B taxes. Add lines 8a through 11. Enter here and on Part II, line 17  .                    .  .     .  ▶       12 
Section C. Tax that is reported by the last day of the 15th month after the end of the plan year 
13    Section 4979 tax on excess contributions to certain plans (from Schedule H, line 2). Enter here 
      and on Part II, line 17  .         . . .   . . . . . . .                 . . . . .            . . . .  . .  .     .  ▶ 205   13 
For Privacy Act and Paperwork Reduction Act Notice, see instructions.                                   Cat. No. 11870M            Form 5330 (Rev. 12-2021) 

Form 5330 (Rev. 12-2021)                                                                                                      Page  2 
Name of filer:                                                                                Filer’s identifying number: 
Section D. Tax that is reported by the last day of the month following the month in which the reversion occurred 
14   Section 4980 tax on reversion of qualified plan assets to an employer (from Schedule I, line 3). 
     Enter here and on Part II, line 17  . . .      . .     .  . .      . . . . . . . .   .   . .    .  ▶   204     14 
Section E. Tax that is reported by the last day of the month following the month in which the failure occurred 
15   Section 4980F tax on failure to provide notice of significant reduction in future accruals (from 
     Schedule J, line 5). Enter here and on Part II, line 17 .   .      . . . . . . . .   .   . .    .    ▶ 228     15 
Section F. Taxes reported on or before the 15th day of the 5th month following the close of the entity manager’s taxable  
year during which the plan became a party to a prohibited tax shelter transaction 
16   Section 4965 tax on prohibited tax shelter transactions for entity managers (from Schedule K, 
     line 2). Enter here and on Part II, line 17  . . .     .  . .      . . . . . . . .   .   . .    .  ▶   237     16 
Part II  Tax Due 

17   Enter the amount from Part I, line 7, 12, 13, 14, 15, or 16 (whichever is applicable)  . . .    . . .  .       17 

18   Enter the amount of tax paid with Form 5558 or any other tax paid prior to filing this return  .  . .  .       18 

19   Tax due. Subtract line 18 from line 17. If the result is greater than zero, enter here . . .    . . .  ▶       19 
        Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge  
        and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
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                                                                                                                    Form 5330 (Rev. 12-2021) 

Form 5330 (Rev. 12-2021)                                                                                                       Page  3 
Name of filer:                                                                                Filer’s identifying number: 
Schedule A. Tax on Nondeductible Employer Contributions to Qualified Employer Plans (Section 4972) 
Reported by the last day of the 7th month after the end of the tax year of the employer (or other person who must file   
the return) 
1  Total  contributions  for  your  tax  year  to  your  qualified  employer  plan  (under  section  401(a),  403(a), 
   408(k), or 408(p))    . . . . . . . . . . .        . .    .   .   . .     . . .  .  . .      . . . .  .            1 

2  Amount allowable as a deduction under section 404    .    .   .   . .     . . .  .  . .      . . . .  .            2 

3  Subtract line 2 from line 1 . . . . . . . .        . .    .   .   . .     . . .  .  . .      . . . .  .            3 
4  Enter  amount  of  any  prior  year  nondeductible  contributions  made  for  years 
   beginning after 12/31/86  . . . . . . . . .        . .    .   .   . .     . . .     4 
5  Amount  of  any  prior  year  nondeductible  contributions  for  years  beginning 
   after 12/31/86 returned to you in this tax year for any prior tax year  . . . .     5 

6  Subtract line 5 from line 4 . . . . . . . .        . .    .   .   . .     . . .     6 

7  Amount of line 6 carried forward and deductible in this tax year  . .     . . .     7 

8  Subtract line 7 from line 6 . . . . . . . .        . .    .   .   . .     . . .  .  . .      . . . .  .            8 

9  Tentative taxable excess contributions. Add lines 3 and 8  .  .   . .     . . .  .  . .      . . . .  .            9 

10 Nondeductible section 4972(c)(6) or (7) contributions exempt from excise tax     .  . .      . . . .  .            10 

11 Taxable excess contributions. Subtract line 10 from line 9  . .   . .     . . .  .  . .      . . . .  .            11 

12 Multiply line 11 by 10%. Enter here and on Part I, line 1 .   .   . .     . . .  .  . .      . . . .  ▶            12 
Schedule B. Tax on Excess Contributions to Section 403(b)(7)(A) Custodial Accounts (Section 4973(a)(3)) 
Reported by the last day of the 7th month after the end of the tax year of the employer (or other person who must file   
the return) 

1  Total amount contributed for current year less rollovers. See instructions  . .  .  . .      . . . .  .            1 

2  Amount excludable from gross income under section 403(b). See instructions  .       . .      . . . .  .            2 

3  Current year excess contributions. Subtract line 2 from line 1. If zero or less, enter -0-   . . . .  .            3 

4  Prior year excess contributions not previously eliminated. If zero, go to line 8 .  . .      . . . .  .            4 

5  Contribution credit. If line 2 is more than line 1, enter the excess; otherwise, enter -0- . . . . .  .            5 

6  Total of all prior years’ distributions out of the account included in your gross income under section
   72(e) and not previously used to reduce excess contributions      . .     . . .  .  . .      . . . .  .            6 

7  Adjusted prior years’ excess contributions. Subtract the total of lines 5 and 6 from line 4    . . .  .            7 

8  Taxable excess contributions. Add lines 3 and 7  . . .    .   .   . .     . . .  .  . .      . . . .  .            8 

9  Multiply line 8 by 6%  .  . . . . . . . . .        . .    .   .   . .     . . .  .  . .      . . . .  .            9 

10 Enter the value of your account as of the last day of the year  . . .     . . .  .  . .      . . . .  .            10 

11 Multiply line 10 by 6%    . . . . . . . . .        . .    .   .   . .     . . .  .  . .      . . . .  .            11 

12 Excess contributions tax. Enter the lesser of line 9 or line 11 here and on Part I, line 2  .  . . .  ▶            12 
                                                                                                                      Form 5330 (Rev. 12-2021) 

Form 5330 (Rev. 12-2021)                                                                                                               Page  4 
Name of filer:                                                                          Filer’s identifying number: 
Schedule C. Tax on Prohibited Transactions (Section 4975) (see instructions) Reported by the last day of the 7th month after the 
end of the tax year of the employer (or other person who must file the return)
1      Is the excise tax a result of a prohibited transaction that was (box “a” or box “b” must be checked): 
       a       discrete             b other than discrete (a lease or a loan) 
2      Complete the table below to disclose the prohibited transactions and figure the initial tax. See instructions.
  (a)          (b) Date                                                             (d) Amount involved         (e) Initial tax on prohibited  
Transaction    of transaction   (c) Description of prohibited transaction               in prohibited           transaction (multiply each  
number       (see instructions)                                                         transaction            transaction in column (d) by  
                                                                                      (see instructions)                      the appropriate rate 
                                                                                                                              (see instructions)) 

  (i) 

  (ii) 

(iii) 

(iv) 

  (v) 

(vi) 

(vii) 

(viii) 

(ix) 

  (x) 

(xi) 

(xii) 

3      Add amounts in column (e); enter here and on Part I, line 3a  . .  . . . . . . . . .          .  ▶
4      Have  you  corrected  all  of  the  prohibited  transactions  that  you  are  reporting  on  this  return?  If  “Yes,” 
       complete Schedule C, line 5, on the next page. If “No,” attach statement. See instructions  . . .     .  ▶                  Yes             No
                                                                                                                Form 5330 (Rev. 12-2021) 

Form 5330 (Rev. 12-2021)                                                                                                     Page  5 
Name of filer:                                                                            Filer’s identifying number: 
Schedule C. Tax on Prohibited Transactions (Section 4975) Reported by the last day of the 7th month after the end of the tax 
year of the employer (or other person who must file the return) (continued) 
5 Complete the table below, if applicable, of other participating disqualified persons and description of correction. See instructions.
  (a)                        (b)                             (c)                 (d)                         (e) 
Item no.                 Name and address of             EIN or SSN             Date of            Description of correction 
from line 2              disqualified person                                  correction  

Schedule D. Tax on Failure To Meet Minimum Funding Standards (Section 4971(a)) Reported by the 15th day of the 10th month 
after the last day of the plan year 
1 Aggregate  unpaid  required  contributions  (accumulated  funding  deficiency  for  multiemployer  plans). 
  See instructions .     . . .      . .      . . . . . . . . .     . . . .  . . .   .    .  . . . .  .       1 
2 Multiply line 1 by 10% (5% for multiemployer plans). Enter here and on Part I, line 8a  . . . . .  ▶       2 
                                                                                                             Form 5330 (Rev. 12-2021) 

Form 5330 (Rev. 12-2021)                                                                                                    Page  6 
Name of filer:                                                                               Filer’s identifying number: 
Schedule E. Tax on Failure To Pay Liquidity Shortfall (Section 4971(f)(1)) Reported by the 15th day of the 10th month after the 
last day of the plan year 
                                                                                                                         (e) Total   
                                                 (a) 1st Quarter   (b) 2nd Quarter   (c) 3rd Quarter (d) 4th Quarter    (add cols. a–d  
                                                                                                                         for line 3)
1   Amount of shortfall . . .  . .    . . 1 
2   Shortfall paid by the due date  . . . 2 
3   Net shortfall amount  . .  . .    . . 3 
4   Multiply line 3, column (e), by 10%. Enter here and on Part I, line 9a    . .  . .     . . . .   . .    ▶      4 
Schedule F. Tax on Multiemployer Plans in Endangered or Critical Status (Sections 4971(g)(3) and 4971(g)(4)) Reported by the 
15th day of the 10th month after the last day of the plan year
1   Section 4971(g)(3) tax on failure to meet requirements for plans in endangered or critical status.
a   Enter the amount of contributions necessary to meet the applicable benchmarks or requirements .       .        1a 
b   Enter the amount of the accumulated funding deficiency  .      . .     .  . .  . .     . . . .   . .  .        1b 
c   Enter the greater of line 1a or line 1b here and on Part I, line 10b   .  . .  . .     . . . .   . .  ▶        1c 
2   Section 4971(g)(4) tax on failure to adopt rehabilitation plan.
a   Enter the amount of the excise tax on the accumulated funding deficiency under section 4971(a)(2) from 
    Schedule D, line 2  . . .  . .    . . . .    .     . . .   .   . .     .  . .  . .     . . . .   . .  .        2a 
b   Enter the number of days during the tax year which are included in the period beginning on the first 
    day  following  the  close  of  the  240-day  period  and  ending  on  the  day  the  rehabilitation  plan  is 
    adopted ▶
c   Multiply line 2b by $1,100 . .    . . . .    .     . . .   .   . .     .  . .  . .     . . . .   . .  .        2c 
d   Enter the greater of line 2a or line 2c here and on Part I, line 10c . .  . .  . .     . . . .   . .    ▶      2d 
Schedule G. Tax on Excess Fringe Benefits (Section 4977) Reported by the last day of the 7th month after the end of the 
calendar year in which the excess fringe benefits were paid to the employer’s employees 
1   Did you make an election to be taxed under section 4977?       . .     .  . .  . .         Yes     No
2   If “Yes,” enter the calendar year (YYYY) in which the excess fringe benefits were paid ▶
3   If line 1 is “Yes,” enter the excess fringe benefits on this line. See instructions  . . . . .   . .  .        3 
4   Enter 30% of line 3 here and on Part I, line 11  . . . .   .   . .     .  . .  . .     . . . .   . .  ▶        4 
Schedule H. Tax on Excess Contributions to Certain Plans (Section 4979) Reported by the last day of the 15th month after  
the end of the plan year 
1   Enter the amount of an excess contribution under a cash or deferred arrangement that is part of a plan 
    qualified under section 401(a), 403(a), 403(b), 408(k), or 501(c)(18) or excess aggregate contributions .      1 
2   Multiply line 1 by 10% and enter here and on Part I, line 13   . .     .  . .  . .     . . . .   . .    ▶      2 
Schedule I. Tax on Reversion of Qualified Plan Assets to an Employer (Section 4980) Reported by the last day of the month 
following the month in which the reversion occurred 
1   Date reversion occurred  . . .    . . . .    .     . . .  ▶    MM              DD            YY 
2 a Employer reversion amount                                        b     Excise tax rate 
3   Multiply line 2a by line 2b and enter the amount here and on Part I, line 14  .  .     . . . .   . .  ▶        3 
4   Explain below why you qualify for a rate other than 50%: 

Schedule J. Tax on Failure To Provide Notice of Significant Reduction in Future Accruals (Section 4980F) Reported by the   
last day of the month following the month in which the failure occurred 
1   Enter the number of applicable individuals who were not provided ERISA section 204(h) notice ▶
2   Enter the effective date of the amendment  . .     . . .  ▶    MM              DD            YY 
3   Enter the number of days in the noncompliance period ▶
4   Enter the total number of failures to provide ERISA section 204(h) notice. See instructions  .   . .  .        4 
5   Multiply line 4 by $100. Enter here and on Part I, line 15 .   . .     .  . .  . .     . . . .   . .    ▶      5 
6   Provide a brief description of the failure, and of the correction, if any:

Schedule K. Tax on Prohibited Tax Shelter Transactions (Section 4965) Reported on or before the 15th day of the 5th month  
following the close of the entity manager’s tax year during which the plan became a party to a prohibited tax shelter transaction 
1   Enter  the  number  of  prohibited  tax  shelter  transactions  you  caused  the  same  plan  to  be  a 
    party to ▶
2   Multiply line 1 by $20,000. Enter the result here and on Part I, line 16  . .  . .     . . . .   . .  ▶        2 
                                                                                                                   Form 5330 (Rev. 12-2021)