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UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
WASHINGTON, D.C. 20549
FORM 11-K
(Mark one)
[X] ANNUAL REPORT PURSUANT TO SECTION 15(d) OF THE SECURITIES EXCHANGE ACT
OF 1934 FOR THE FISCAL YEAR ENDED JUNE 30, 1998
OR
[ ] TRANSITION REPORT PURSUANT TO SECTION 15(d) OF THE SECURITIES
EXCHANGE ACT OF 1934 FOR THE TRANSITION PERIOD FROM TO .
COMMISSION FILE NUMBER
333-69053
HIGH COUNTRY BANCORP, INC.
SALIDA BUILDING AND LOAN ASSOCIATION 401(k) PROFIT SHARING PLAN & TRUST
(Name of Issuer of the securities held pursuant to the Plan)
130 WEST 2ND, P.O. BOX 309
SALIDA, COLORADO 81201
(Address of principal executive offices)
(719) 539-2516
(Registrant's telephone number, including area code)
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REQUIRED INFORMATION
ITEM 1. Not applicable
ITEM 2. Not applicable
ITEM 3. Not applicable
ITEM 4. 1997 Return-Report of Employee Benefit Plan (with fewer than 100
participants) prepared in accordance with Section 104(a) (2) (A)
of ERISA has been included as Exhibit 1 hereto.
EXHIBITS
1 -- 1997 Return-Report of Employee Benefit Plan (with fewer than 100
participants)
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SIGNATURES
THE PLAN Pursuant to the requirements of the Securities Exchange Act of
1934, the Salida Building and Loan 401(k) Profit Sharing Plan &
Trust has duly caused this annual report to be signed on its
behalf by the undersigned thereunto duly authorized, in the City
of Salida, State of Colorado, on the 23rd day of December, 1998
SALIDA BUILDING AND LOAN 401(k) PROFIT SHARING PLAN & TRUST
By: /s/ Larry D. Smith
------------------------------
Name: Larry D. Smith
Title: Administrator
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SCHEDULE P ANNUAL REPORT OF FIDUCIARY
(FORM 5500) OF EMPLOYEE BENEFIT TRUST 1997
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Department of the Treasury File as an attachment to Form 5500, 5500-C/R, or 5500-EZ This Form is Open to
Internal Revenue Service For the Paperwork Reduction Notice, see Form 5500 instructions Public Inspection
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For trust calendar year 1997 or fiscal year beginning July 1, 1997, and ending June 30, 1998.
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1a Name of trustee or custodian
ROBERT MITCHELL, LORIN SMITH, RICHARD YOUNG, TIM GLENN, AND PHIL HARSH
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b Number, street, and room or suite no. (If a P.O. box, see the instructions for Form 5500, 5500-C/R, or 5500-EZ.)
P.O. BOX 309
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c City or town, state, and ZIP code
SALIDA, CO 81201
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2a Name of trust b Trust's employer identification number
SALIDA BUILDING & LOAN ASSOCIATION 84-0982365
401(k) PROFIT SHARING PLAN & TRUST
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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,
5500-C/R, or 5500-EZ.................................................................. 84-0311998
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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/ Lorin Smith Date 12/23/98
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INSTRUCTIONS
Section references are to the Internal Revenue Code
PURPOSE OF FORM
You may use this schedule to satisfy the requirements under section 6033(a) for
an annual information return from every section 401(a) organization exempt from
under section 501(a).
Filing this form will start the running of the statute of limitations under
section 6501(a) for any trust described in section 401(a), which is exempt from
tax under section 501(a).
WHO MAY FILE
1. Every trustee of a trust created as part of an employee benefit plan as
described in section 401(a)
2. Every custodian of a custodial account described in
section 401(f).
HOW TO FILE
File Schedule P (Form 5500) for the trust year ending with or within any
participating plan's year. Attach it to the Form 5500, 5500-C/R, or 5500-EZ
filed by the plan for that plan year. A separately filed Schedule P (Form 5500)
will not be accepted.
If the trust or custodial account is used by more than one plan, file one
Schedule P (Form 5500). If a plan uses more than one custodial account for its
funds, file one Schedule P (Form 5500) for each trust or custodial account.
TRUST'S EMPLOYER IDENTIFICATION NUMBER
Enter the trust employer identification number (EIN) assigned to the employee
benefit trust or custodial account, if one has been issued to you. The trust EIN
should be used for transactions conducted for the trust, If you do not have a
trust EIN, enter the EIN you would use on Form 1099-R to report distributions
from employee benefit plans and on Form 945 to report withheld amounts of income
tax form those payments.
NOTE: Trustees who do not have an EIN may apply for one on Form SS-4,
Application for Employer Identification Number. You must be consistent and use
the same EIN for all trust reporting purposes.
SIGNATURE
The fiduciary (trustee or custodian must sign this schedule. If there is more
than one fiduciary, the fiduciary authorized by the others may sign.
OTHER RETURNS AND FORMS THAT MAY BE REQUIRED
* Form 990-T For trusts described in section 401(a), a tax is imposed on income
derived from business that is unrelated to the purpose for which the trust
received a tax exemption. Report this income and tax on Form 990-T, Exempt
Organization Business Income Tax Return. (See sections 511 through 514 and the
related regulations.)
* Form 1099-R--If you made payments or distributions to
individual beneficiaries of a plan, report those payments on Form 1099-R. (See
the instructions for Forms 1099, 1098, 5498, and W-2G.)
* Form 945--If you made payments or distributions to individual beneficiaries
of a plan, you may be required to withhold income tax from those payments. Use
Form 945 Annual Return of Withheld Federal Income Tax, to report taxes withheld
from nonpayroll items. (See Circular E, Employer's Tax Guide (Pub. 15), for more
information.)
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D111 Cat. No. 13504X Schedule P (Form 5500) 1997
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Form 5500-C/R RETURN/REPORT OF EMPLOYEE BENEFIT PLAN
Department of Treasury (WITH FEWER THAN 100 PARTICIPANTS)
Internal Revenue Service THIS FORM IS REQUIRED TO BE FILED UNDER SECTIONS 1997
------------------- 104 AND 4065 OF THE EMPLOYEE RETIREMENT
Department of Labor INCOME SECURITY ACT OF 1974 AND SECTIONS 6039D THIS FORM IS OPEN
Pension and Welfare Benefits Administration 6047(e), 6057(b), AND 6058(a) OF THE TO PUBLIC INSPECTION
------------------- INTERNAL REVENUE CODE
Pension Benefit Guaranty Corporation See Separate Instructions
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FOR THE CALENDAR PLAN YEAR 1997 OR FISCAL PLAN YEAR BEGINNING JULY 1, 1997 AND ENDING JUNE 30, 1998
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If A(1) through A(4), B, C, and/or D do not apply to this year's | FOR IRS USE ONLY
return/report, leave the boxes unmarked. |EP-ID_________________
You must check either box A(5) or A(6), whichever is applicable. See
instructions. (5) FORM 5500-C FILER CHECK HERE................/ X /
(Complete only pages 1 and 3 through 6.)
A This return/report is: (Code section 6039D filers see instructions on
(1) / / the first return/report filed for the plan page 5.)
(2) / / an amended return/report (6) FORM 5500-R FILER CHECK HERE................./ /
(3) / / the final return/report filed for the plan; or (Complete only pages 1 and 2. Detach pages 3
(4) / / a short plan year return/report (less than 12 months). through 6 before filing.) If you checked
box (1) or (3), you must file a Form 5500-C.
(See page 6 of the instructions.)
IF ANY INFORMATION ON A PREPRINTED PAGE 1 IS INCORRECT, CORRECT IT. IF ANY INFORMATION IS MISSING, ADD IT. PLEASE USE RED INK
WHEN MAKING THESE CHANGES AND INCLUDE THE PREPRINTED PAGE 1 WITH YOUR COMPLETED RETURN/REPORT.
B Check here if any information reported in 1a, 2a, 2b, or 5a changed since the last return/report for
this plan............................................................................................................. / /
C If your plan year changed since the last return/report, check here..................................................../ /
D If you filed for an extension of time to file this return/report, check here and attach a copy of the approved
extension............................................................................................................./ /
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1a Name and address of plan sponsor (employer, if for a single-employer 1b Employer identification number (EIN)
plan) 84-0311998
(Address should include room or suite no.) 1c Sponsor's telephone number
SALIDA BUILDING & LOAN ASSOCIATION 719-539-2516
1d Business code (see instructions, page 17)
P.O. BOX 309 6120
1e CUSIP issuer number
SALIDA, COLORADO 81201
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2a Name and address of plan administrator (if same as plan 2b Administrator's EIN
sponsor,enter "Same")
SAME 2c Administrator's telephone number
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3 If you are filing this page without the preprinted historical plan information and the name, address and EIN of the plan
sponsor or plan Administrator has changed since the last return/report filed for this plan, enter the information from the
last return/report on lines 3a and/or 3b and complete line 3c.
a Sponsor--------------------------------------------------------------- EIN ---------------- Plan Number -------------
b Administrator--------------------------------------------------------- EIN -------------------------------------------
c If line 3a indicates a change in the sponsor's name, address, and EIN, is this a change in sponsorship only? (See lne 3c on
page 8 of the instructions for the definition of sponsorship.) Enter "Yes" or "No."
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4 ENTITY CODE. (If not shown, enter applicable code form page 8 of the instructions.) A
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5a Name of Plan > SALIDA BUILDING & LOAN ASSOCIATION 5b Effective date of plan (mo., day, yr.)
401(k) PROFIT SHARING PLAN & TRUST July 1, 1979
5c Three-digit plan number 001
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ALL FILERS MUST COMPLETE 6a THROUGH 6d, AS APPLICABLE.
6a / / Welfare benefit 6b / X / Pension benefit plan / 2 / / / / / / / /
(If the correct codes are not preprinted below,
enter the applicable codes from page 8 of the
instructions in the boxes.) / / / / / / / / /
6c Pension plan features. (If the correct codes are not
preprinted below enter the applicable pension plan feature
codes from page 9 of the instructions in the
boxes.) / C / G / L / / / / / /
6d / / Fringe benefit plan. Attach Schedule F (Form 5500). See
instructions.
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CAUTION: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is
established.
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Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this
return/report, including
Accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete.
Signature of employer/plan sponsor /s / LORIN SMITH, PRESIDENT Date 12/23/98
Type or print name of individual signing above LORIN SMITH, PRESIDENT
Signature of plan administrator / s / LORIN SMITH Date 12/23/98
Type or print name of individual signing above LORIN SMITH
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FOR PAPERWORK REDUCTION ACT NOTICE, SEE INSTRUCTIONS FOR FORM 5500-C/R. Cat. No. 10957K Form 5500-C/R (1997)
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Form 5500-C/R (1997) COMPLETE PAGE 1, AND PAGES 3 THROUGH 6 ONLY, IF YOU ARE FILING FORM 5500-C PAGE 3
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6e Check all applicable investment arrangements below. (See instructions on page 12.):
(1) / / Master Trust (2) / / 103-12 investment entity
(3) / / common/collective trust (4) / / Pooled separate account
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f Single-employer plans enter the tax year end of the employer in which this plan year ends Month 06 Day 30 Year 1998
g Is any part of this plan funded by an insurance contract described in Code section 412(I)?..........
/ / Yes / X / No
h If line 6g is "Yes," was the part subject to the minimum funding standards for either of the
prior 2 plan years?.................................................................................
/ / Yes / / No
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7a Total participants: (1) At the beginning of the plan year 28 (2) At the end of the plan year 31
b Enter number of participants with account balances at the end of the plan year. (Defined benefits plans do not complete
this item.) 31
c Number of participants that terminated employment during the plan year with accrued benefits that were less than 100%
vested 4
d (1) Were any participants in the pension benefit plan separated from service with a deferred vested | Yes | No |
benefit for which a Schedule SSA (Form 5500) is required to be attached?....................... 7d(1) | | X |
(2) If "Yes," enter the number of separated participants required to be reported N/A
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8a Was this plan ever amended since its effective date? If "Yes," complete line 8b and, if the amendment was adopted in
this plan year, complete lines 8c through 8e........................................................ 8a | X | |
b If line 8a is "Yes," enter the date the most recent amendment was adopted
Month 11 Day 01 year 95
c Did any amendment during the current plan year result in the retroactive reduction of accrued
benefits for any participant? 8c | N/A |
d During this plan year, did any amendment change the information contained in the latest summary
plan description or summary description of modifications available at the time of
amendment?....................................................... 8d | N/A |
e If line 8d is "Yes," has a summary plan description or summary description of modifications
that reflects the plan amendments referred to on line 8d been furnished to participants? (see
instructions)............................................. 8e | N/A |
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9a Was this plan terminated during this plan year or any prior plan year? If "Yes,"
enter year ______________________ 9a | | X |
b Were plan assets either distributed to participants or beneficiaries, transferred to another
plan, or brought under the Control of PBGC?..................................................... 9b | | X |
c Was a resolution to terminate this plan adopted during this plan year or any prior plan year?.. 9c | | X |
d If line 9a or line 9c is "Yes," have you received a favorable determination letter from the
IRS for the termination?........................................................................ 9d | N/A |
e If line 9d is "No," has a determination letter been requested from the IRS?..................... 9e | N/A |
f If line 9a or line 9c is "Yes," have participants and beneficiaries been notified of the
termination of the proposed termination?........................................................ 9f | N/A |
g If line 9a is "Yes" and the plan is covered by PBGC, is the plan continuing to file a PBGC
Form 1 and pay premiums until the end of the plan year in which assets are distributed or
brought under the control of PBGC?.............................................................. 9g | N/A |
h During this plan year, did any trust assets revert to the employer for which the Code
Section 4980 excise tax is due?................................................................. 9h | N/A |
i If line 9h is "Yes," enter the amount of tax paid with Form 5330 $0
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10a Was this plan merged or consolidated into another plan(s), or were assets or liabilities
transferred to another plan(s) since the end of the plan year covered by the last return/report
Form 5500 or 5500-C that was filed for this plan (or during this plan year if this is the first
return/report)? If "Yes," complete lines 10b through 10e........................................ 10a | | X |
If "Yes," identify the other plan(s): c Employer identification number(s) d Plan number(s)
b Name of plan(s) ------------------------------ --------------------------------------- ------------------
----------------------------------------------- --------------------------------------- ------------------
e If required, has a Form 5310-A been filed?...................................................... / / Yes / / No
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11 Enter the plan funding arrangement code 12 Enter the plan benefit arrangement code from
from page 13 of the instructions 1 page 13 of the instructions 1 | Yes | No |
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13 Is this a plan established of maintained pursuant to one or more collective bargaining agreements?..13 | | X |
14 If any benefits are provided by an insurance company, insurance service, or similar organization,
enter the number of Schedules A (Form 5500), Insurance Information, that are attached. If none, enter-0-. 0
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Form 5500-C/R (1997) COMPLETE PAGE 1, AND PAGES 3 THROUGH 6 ONLY, IF YOU ARE FILING FORM 5500-C Page 4
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WELFARE PLANS DO NOT COMPLETE LINES 15 THROUGH 25. SKIP TO LINE 26 ON PAGE 5.
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15a If this is a defined benefit plan subject to the minimum
funding standards for this plan year, is Schedule B (Form 5500) | Yes | No |
required to be attached? (If this is a defined contribution plan, leave blank.)................. 15a | | |
If "Yes," attach Schedule B (Form 5500).
b If this is a defined contribution plan (i.e., money purchase or target
benefit), is it subject to the minimum funding standards
(if a waiver was granted, see instructions)?
(If this is a defined benefit plan, leave blank.)................................................ 15b | | |
(1) Amount of employer contribution required for the plan year under Code section 412 15b(1) $ N/A
(2) Amount of contribution paid by the employer for the plan year.............................. 15b(2) $ N/A
Enter the date of last payment by employer > Month N/A Day Year
(3) If (1) is greater than (2), subtract (2) form (1) and enter the funding deficiency
here. Otherwise, enter-0-. (If you have a funding deficiency, file Form 5330.)........... 15b(3) $ N/A
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16 Has the annual compensation of each participant taken into account under the current plan year
been limited as required by section 401(a)(17)? (See instructions),............................ 16 | X | |
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17a (1) Did the plan distribute any annuity contracts this year? (See instructions).............. 17a(1) | X | |
(2) If (1) is "Yes," did these contracts contain a requirement that the spouse
consent before any distributions under
The contract are made in a form other that a qualified joint and survivor annuity?........ 17a(2) | N/A |
b Did the plan make distributions or loans to married participants and beneficiaries
without the required consent of the participant's spouse?................................. 17b | | X |
c Upon plan amendment or termination, do the accrued benefits of every participant include
the subsidized benefits that the participant may become entitled to receive subsequent
to the plan amendment or termination?..................................................... 17c | X | |
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18 Is the plan administrator making an election under section 412(c)(8) for an amendment adopted
after the end of the plan year? (See instructions.)............................................ 18 | | X |
19 If a change in the actuarial funding method was made for the plan year pursuant to a Revenue
Procedure providing Automatic approval for the change, indicate whether the plan
sponsor/administrator agrees to the change...................................................... 19 | N/A |
20 Is the employer electing to compute minimum funding for this plan year or either of the two
immediately preceeding Plan years using the transition rule of Code section 412(l)(11)?......... 20 | N/A |
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21 Check if you are applying the substantiation guidelines from Revenue Procedure 93-42, in
completing lines 21a through (see instructions)........................................... / /
If you checked the box, enter the first day of the plan year for which date is being submitted Month____Day___Year__
a Does the employer apply the separate line of business rules of Code section 414(R) when testing
this plan for the coverage and discrimination tests requirements of Code sections 410(b) and
401(a)(4)?...................................................................................... 21a | | X |
b If line 21a is "Yes," enter the total number of separate lines of business claimed by the employer ______
If more than one separate line of business, see instructions for additional information to attach.
c Does the employer apply the mandatory disaggregation rules under Income Tax Regulations
section 1.410(b)-7(c)? If "Yes," see instructions for additional information to attach........ 21c | | X |
d In testing whether this plan satisfies the coverage and discrimination tests of Code
sections 410(b) and 401(a), does the employer aggregate plans?.................................. 21d | | X |
e Does the employer restructure the plan into component plans to satisfy the coverage and
discrimination tests of Code sections 410(b) and 401(a)(4)?..................................... 21e | | X |
f If you meet either one of the following exceptions, check the applicable box to tell us which
exception you meed and DO NOT complete the rest of question 21:
(1) / / No highly compensateded employee benefited under the plan at any time duringng
the plan year;
(2) / / This is a collectively bargained plan that benefits only collectively bargained
employees, no more than 2% of whom are professional employees.
g Did any leased employee perform services for services for the employer at any time during
the plan year?................................................................................... 21g | | X |
Number
h Enter the total number of employees of the employer. Employer includes entities aggregated with
the employer under Code section 414(b), (c), or (m). Include leased employees and self-employed
individuals...................................................................................... 21h | 50 |
i Enter the total number of employees excludable under the plan because of: (1) failure to meet
requirements for minimum age and years of service; (2) collectively bargained employees;
(3) nonresident aliens who receive no earned income
From U.S. sources; and (4) 500 hours of service/last day rule.................................... 21i | 19 |
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Form 5500-C/R (1997) COMPLETE PAGE 1, AND PAGES 3 THROUGH 6 ONLY, IF YOU ARE FILING FORM 5500-C Page 5
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Number
j Enter the number of nonexcludable employees. Subtract line 21i from line 21h.................... 21j | 31 |
k Do 100% of the nonexcludable employees entered on line 21j benefit under the plan?.............. / X / Yes / /No
If line 21k is "Yes," DO NOT complete lines 21l through 21o.
l Enter the number of nonexcludable employees (line 21j) who are highly compensated employees..... 21l | |
m Enter the number of nonexcludable employees who benefit under the plan.......................... 21m | |
n Enter the number of employees entered on line 21m who are highly compensated employees.......... 21n | |
o This plan satisfies the coverage requirements on the basis of (check one):
(1) / / The average benefits test (2) / / The ratio percentage test-enter percentage . %
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| Yes | No |
22a Is it or was it ever intended that this plan qualify under Code section 401(a)? If "Yes,"
complete lines 22b and 22c...................................................................... 22a | X | |
b Enter the date of the most recent IRS determination letter........... Month 10 Year 1992
c Is a determination letter request pending with the IRS?......................................... 22c | | X |
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23a Does the plan hold any assets that have a fair market value that is not readily determinable
on an established market?
(If "Yes," complete line 23b.) (See instructions.).............................................. 23a | | X |
b Were all the assets referred to on line 23a valued for the 1997 plan year by an independent
third-party appraiser?.......................................................................... 23b | N/A |
c If line 23b is "No," enter the value of the assets that were not valued by an independent
third-party appraiser for the 1997 plan year.................................................... 23c | N/A |
d Enter the most recent date the assets on line 23c were valued by an independent third-party
appraiser. (If more than one asset, see instructions.) Month N/A Day Year
(If this plan has NO ESOP features, leave line 23e blank and go to line 24.)
e If dividends paid on employer securities held by the ESOP were used to make payments
on ESOP loans, enter the amount of the dividends used to make the payments...................... 23e | N/A |
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24 Does the employer/sponsor listed in 1a of this form maintain other qualified pension benefit
plans?.......................................................................................... 24 | X | |
If "Yes," enter the total number of plans, including this plan 2
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25a Is the plan covered under the Pension Benefit Guaranty Corporation termination insurance
program?..................................... / / Yes / X / No / / Not determined
b If line 25a is "Yes" or "Not determined," enter the EIN and the plan number used to identify it.
EIN Plan number
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26 You may NOT use N/A in response to any line 26 item. If you check "Yes," you | Yes | No | Amount
must enter a dollar amount in the amount column.
DURING THIS PLAN YEAR:
a Was this plan covered by a fidelity bond?.............................. 26a | X | | 1,000,000
b If line 26a is "Yes," enter the name of the surety company St. Paul Mercury Insurance
c Was there any loss to the plan, whether or not reimbursed, caused by
fraud or dishonesty?................................................... 26c | | X |
d Was there any sale, exchange, or lease of any property between the plan
and the employer, any fiduciary, any of the five most highly paid
employees of the employer, any owner of a 10% or more interest in the
employer, or relatives of any such persons?............................. 26d | | X |
e Was there any loan or extension of credit by the plan to the employer,
any fiduciary, any of the five most highly paid employees of the employer,
and owner of 10% or more interest in the employer, or relatives of any such
persons?................................................................ 26e | | X |
f Did the plan acquire or hold any employer security or employer real
property?............................................................... 26f | | X |
g Has the plan granted an extension on any delinquent loan owed to the
plan?................................................................... 26g | | X |
h Were any participant contributions transmitted to the plan more than 31
days after receipt or withholding by the employer?...................... 26h | | X |
i Were any loans by the plan or fixed income obligations due the plan
classified as uncollectible or in default as of the close of the plan
year?................................................................... 26i | | X |
j Has the plan fiduciary had a financial interest in excess of 10% in any
party providing services to The plan or received anything of value from
any such party?......................................................... 26j | | X |
k 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
venture interests?...................................................... 26k | X | | 679,671
l Did the plan at any time engage in any transactions or series of related
transactions involving 20% or more of the current value or plan
assets?................................................................. 26l | X | | 470,760
m Were there any noncash contributions made to the plan whose value was
set without an appraisal by an independent third party?................. 26m | | X |
n Were there any purchases of nonpublicly traded securities by the plan
whose value was set without an appraisal by an independent third
party?.................................................................. 26n | | X |
o Has the plan reduced or failed to provide any benefit when due under the
terms of the plan because of insufficient assets?....................... 26o | | X |
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Form 5500-C/R (1997) COMPLETE PAGE 1, AND PAGES 3 THROUGH 6 ONLY, IF YOU ARE FILING FORM 5500-C Page 6
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27 Current value of plan assets and liabilities at the beginning and end of the plan year. Combine the value of plan assets
held in more than one trust. Allocate the value of the plan's interest in a commingled trust containing the assets of more than
one plan on a on a line-by-line basis unless the trust meets one of the specific exceptions described in the instructions. 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. Round off amounts to the nearest dollar. Any other amounts are subject to rejection. Plans with no
assets at the beginning and end of the plan year enter-0- on line 27f.
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(a) Beginning (b) End of
Assets of year year
a Cash...................................................... 27a 245,997 4,466
b Receivables............................................... 27b 5,028 3,507
c Investments:
(1) U.S. Government securities........................... 27c(1) 0 0
(2) Corporate debt and equity instruments................ 27c(2) 422,267 844,906
(3) Real Estate and mortgages (other than to
participants)........................................ 27c(3) 0 0
(4) Loans to participants:
A Mortgages......................................... (4)A 0 0
B Other............................................. (4)B 0 0
(5) Other................................................ 27c(5) 0 0
(6) Total investments. Add lines 27c(1) through 27c(5).. 27c(6) 422,267 844,906
d Buildings and other property used in plan operations...... 27d 0 0
e Other assets.............................................. 27e 0 0
f Total assets. Add lines 27a, 27b, 27c(6), 27d, and 27e... 27f 673,292 852,879
Liabilities
g Payables.................................................. 27g 0 0
h Acquisition indebtedness.................................. 27h 0 0
i Other liabilities......................................... 27i 0 0
j Total liabilities. Add lines 27g through 27i............. 27j 0 0
k Net assets. Subtract line 27j from line 27f.............. 27k 673,292 852,879
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28 Plan income, expenses, and changes in net assets for the plan year. 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. Any other amounts are subject to rejection.
Income
(a) Amount (b) Total
a Contributions received or receivable in cash from:
(1) Employer(s) (including contributions on behalf of
self-employed individuals)........................... 28a(1) 66,332
(2) Employees............................................ 28a(2) 0
(3) Others............................................... 28a(3) 0
(4) Add lines 28a(1) through 28a(3)...................... 28a(4) 66,332
b Noncash contributions. Enter the total of lines 28a(4)
and lines 28b in column (b)............................... 28b 0 66,332
c Earnings from investments (interest, dividends, rents,
royalties)................................................ 28c 239,802
d Net realized gain (loss) on sale or exchange of assets.... 28d 0
e Other income (specify) 28e 0
f Total income. Add lines 28b through 28e................... 28f 306,134
Expenses
g Distribution of benefits and payments to provide benefits:
(1) Directly to participants or their beneficiaries...... 28g(1) 124,135
(2) Other................................................ 28g(2) 0
(3) Total distribution of benefits and payments to
provide benefits..................................... 28g(3) 124,135
h Administrative expenses (salaries, fees, commissions,
insurance premiums)....................................... 28h 2,412
i Other expenses (specify) 28i 0
j Total expenses. Add lines 28g through 28i................. 28j 126,547
k Net income (loss). Subtract line 28j from line 28f........ 28k 179,587
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