<PAGE> 1
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 10-KSB/A
(Mark One)
[x] Annual Report under Section 13 or 15(d) of the Securities Exchange Act of
1934
For the fiscal year ended November 30, 1999
-----------------
[_] Transition Report under Section 13 or 15(d) of the Securities Exchange Act
of 1934 (No fee required)
For the transition period from ______________ to ______________
Commission file number: 1-13484
COHESANT TECHNOLOGIES INC.
(Exact name of Small Business Issuer in Its Charter)
Delaware 34-1775913
(State or Other Jurisdiction (I.R.S. Employer
of Incorporation or Organization) Identification No.)
5845 West 82nd Street, Suite 102, Indianapolis, Indiana 46278
(Address of Principal Executive Offices) (Zip Code)
Issuer's Telephone Number, Including Area Code: (317) 875-5592
Securities registered under Section 12(b) of the Exchange Act: Common Stock,
$.001 Par Value, registered on the Boston Stock Exchange
Securities registered under Section 12(g) of the Exchange Act: Common Stock,
$.001 Par Value.
Check whether the issuer: (1) filed all reports required to be filed by
Section 13 or 15(d) of the Exchange Act during the past 12 months (or for such
shorter period that the registrant was required to file such reports), and (2)
has been subject to such filing requirements for past 90 days. Yes X No ____
Check if there is no disclosure of delinquent filers in response to Item
405 of Regulation S-B contained in this form, and no disclosure will be
contained, to the best of registrant's knowledge, in definitive proxy or
information statements incorporated by reference in Part III of this Form
10-KSB/A or any amendment to this Form 10-KSB/A. [X]
State issuer's revenues for its most recent fiscal year. $14,191,450
<PAGE> 2
State the aggregate market value of the voting stock held by non-affiliates
computed by reference to the average bid and asked prices of such stock, as of
January 26, 2000. $5,623,348.
As of January 26, 2000, the issuer had 2,336,733 shares of Common Stock,
$.001 par value, outstanding.
ITEM 13. EXHIBITS, LIST AND REPORTS ON FORM 8-K
(a) Exhibits
99.1 Form 11-K Annual Report for the Company's 401(K) Profit Sharing
Plan.
(b) Reports on Form 8-K. - none.
SIGNATURES
Pursuant to the requirements of Section 13 or 15(d) of the Securities
Exchange Act of 1934, as amended, the Registrant has duly caused this amendment
to its form 10-KSB to be signed on its behalf by the undersigned, thereunto duly
authorized.
Dated: April 27, 2000
COHESANT TECHNOLOGIES INC.
By: /s/ Dwight D. Goodman
-----------------------------------
Dwight D. Goodman
President
2
<PAGE> 1
EXHIBIT 99.1
FORM 11-K
ANNUAL REPORT
Pursuant to Section 15(d) of the
Securities Exchange Act of 1934
For the Fiscal Year Ended November 30, 1999
COHESANT TECHNOLOGIES INC. (and Subsidiaries)
EMPLOYEE 401(K) PROFIT SHARING PLAN
------------------------------------------------------------
(Full title of the plan)
COHESANT TECHNOLOGIES INC.
-------------------------------------
(Name of issuer of the securities held pursuant to the plan)
5845 West 82nd Street, Suite 102, Indianapolis, Indiana 46278
-------------------------------------
(Address of principal executive office)
<PAGE> 2
INDEX OF FINANCIAL STATEMENTS
PAGES
-----
Financial Statements:
1. Form 5500 for the Plan's fiscal year ended November 30, 1999 3
2. Form 5500 for the Plan's fiscal year ended November 30, 1998 5
SIGNATURES
The Plan. Pursuant to the requirements of the Securities Exchange Act of 1934,
the trustees (or other persons who administer the employee benefit plan) have
duly caused this annual report to be signed on its behalf by the undersigned
hereunto duly authorized.
Date: April 27, 2000 COHESANT TECHNOLOGIES INC.
(and Subsidiaries) Employee 401(k)
Profit Sharing Plan
By: /s/ Dwight D. Goodman
-------------------------------
Dwight D. Goodman, President
-2-
<PAGE> 3
Form 5500-C/R
Department of the Treasury
Internal Revenue Service
----------
Department of Labor
Pension and Welfare Benefits Administration
----------
Pension Benefit Guaranty Corporation
RETURN/REPORT OF EMPLOYEE BENEFIT PLAN
(With fewer than 100 participants)
This form is required to be filed under sections 104 and 4065 of the Employee
Retirement Income Security Act of 1974 and sections 6039D, 6047(e),
6057(b), and 6058(a) of the Internal Revenue Code.
See separate instructions.
OMB Nos. 1210-0016
1210-0089
- --------------------------------------------------------------------------------
1998
- --------------------------------------------------------------------------------
This Form Is Open
to Public Inspection.
<TABLE>
- ------------------------------------------------------------------------------------------------------------------------------------
For the calendar plan year 1998 or fiscal plan year beginning December 1, 1998, and ending November 30, 1999
- ------------------------------------------------------------------------------------------------------------------------------------
<S> <C>
If A(1) through A(4), B, C, and/or D, do not apply to this year's return/report, FOR IRS USE ONLY
leave the boxes unmarked. EP-ID
YOU MUST CHECK EITHER BOX A(5) OR A(6), WHICHEVER IS APPLICABLE. SEE INSTRUCTIONS.
</TABLE>
A This return/report is:
(1) [_] the first return/report filed for the plan;
(2) [_] an amended return/report;
(3) [_] the final return/report filed for the plan; or
(4) [_] a short plan year return/report (less than 12 months).
(5) FORM 5500-C FILER CHECK HERE ......................................[_]
(Complete only pages 1 and 3 through 6.) (Code section
6039 D files see instructions on page 5.)
(6) FORM 5500-R FILER CHECK HERE ......................................[X]
(Complete only pages 1 and 2. Detatch pages 3 through 6
before filing.) If you checked box (1) or (3), you must file a
Form 5500-C. (See page 5 of the instructions.)
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 extension ................................[_]
- --------------------------------------------------------------------------------
<TABLE>
<S> <C>
1a Name and address of plan sponsor (employer, if for a single-employer plan) 1b Employer identification number (EIN)
(Address should include room or suite no.) 34 | 1775913
--------------------------------------------
COHESANT TECHNOLOGIES, INC. 1c Sponsor's telephone number
5845 WEST 82ND STREET, SUITE 102 (317) 875-5592
INDIANAPOLIS, IN 46278 --------------------------------------------
1d Business code (see instructions, page 18)
339900
--------------------------------------------
1e CUSIP issuer number
N/A
--------------------------------------------
2a Name and address of plan administrator (if same as plan sponsor, enter "Same ") 2b Administrator's EIN
SAME |
--------------------------------------------
2c Administrator's telephone number
- ------------------------------------------------------------------------------------------------------------------------------------
3 If 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 in line 3a and/or line 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 line 3c on
page 8 of the instructions for the definition of sponsorship.) Enter"Yes"or"No."
- -------------------------------------------------------------------------------------
4 ENTITY CODE. (If not shown, enter the
applicable code from page 8 of the instructions.) B
- -------------------------------------------------------------------------------------
5a Name of plan COHESANT TECHNOLOGIES, INC. (AND SUBSIDIARIES) EMPLOYEE 401(k) 5b Effective date of plan (mo., day, yr.)
------------------------------------------------------------------- 1/01/1997
PROFIT SHARING PLAN --------------------------------------------
--------------------------------------------------------------------------------- 5c Three-digit
plan number 003
- ------------------------------------------------------------------------------------------------------------------------------------
ALL FILERS MUST COMPLETE 6a THROUGH 6d, AS APPLICABLE.
6a [_] Welfare benefit plan 6b [X] Pension benefit plan 2
(Enter the applicable codes from page 9 of the instructions in the boxes.) --------------------------------------------
6c Pension plan features. (Enter the applicable pension plan feature codes from
page 9 of the instructions in the boxes.) C G K
-------------------------------------------
6d [_] Fringe benefit plan. Attach Schedule F (Form 5500). See instructions.
- ------------------------------------------------------------------------------------------------------------------------------------
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 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/ Robert W Pawlak Date 3-17-00
----------------------------------------------------------------- --------------------------
Type or print name of individual signing above Robert W Pawlak
--------------------------------------------------------------------------------------
Signature of plan administrator /s/ Robert W Pawlak Date 3-17-00
--------------------------------------------------------------------- --------------------------
Type or print name of individual signing above Robert W Pawlak
- ------------------------------------------------------------------------------------------------------------------------------------
FOR PAPERWORK REDUCTION ACT NOTICE, SEE THE INSTRUCTIONS FOR FORM 5500-C/R. MGA. Form 5500-C/R (1998)
</TABLE>
<PAGE> 4
SCHEDULE P
(Form 5500)
Department of the Treasury
Internal Revenue Service
ANNUAL RETURN OF FIDUCIARY
OF EMPLOYEE BENEFIT TRUST
- File as an attachment to Form 5500, 5500-C/R, or 5500-EZ.
- For the Paperwork Reduction Notice, see the Form 5500 instructions.
OMB No. 1210-0016
- --------------------------------------------------------------------------------
1998
- --------------------------------------------------------------------------------
This Form Is Open to
Public Inspection.
<TABLE>
<S> <C>
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For trust calendar year 1998 or fiscal year beginning December 1, 1998, and ending November 30, 1999
PLEASE TYPE OR PRINT
- ------------------------------------------------------------------------------------------------------------------------------------
1a Name of trustee or custodian
- ------------------------------------------------------------------------------------------------------------------------------------
National City Bank
- ------------------------------------------------------------------------------------------------------------------------------------
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.)
101 West Washington Street
- ------------------------------------------------------------------------------------------------------------------------------------
c City or town, state, and ZIP code
Indianapolis, IN 46255
- ------------------------------------------------------------------------------------------------------------------------------------
2a Name of trust b Trust's employer identification number
Cohesant Technologies, Inc. (and Subsidiaries)
Employee 401(k) Profit Sharing Plan 34|0420310
- ------------------------------------------------------------------------------------------------------------------------------------
3 Name of plan if different from name of trust
- ------------------------------------------------------------------------------------------------------------------------------------
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.............................................. 34|1775913
- ------------------------------------------------------------------------------------------------------------------------------------
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/ Lee Clark Date 2/29/2000
- ------------------------------------------------------------------------------------------------------------------------------------
</TABLE>
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 tax 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 plan 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 trust or 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 from 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.)
- --------------------------------------------------------------------------------
MGA Schedule P (Form 5500) 1998
<PAGE> 5
Form 5500-C/R
Department of the Treasury
Internal Revenue Service
----------
Department of Labor
Pension and Welfare Benefits Administration
----------
Pension Benefit Guaranty Corporation
RETURN/REPORT OF EMPLOYEE BENEFIT PLAN
(With fewer than 100 participants)
This form is required to be filed under sections 104 and 4065 of the Employee
Retirement Income Security Act of 1974 and sections 6039D, 6047(e),
6057(b), and 6058(a) of the Internal Revenue Code.
See separate instructions.
OMB Nos. 1210-0016
1210-0089
- --------------------------------------------------------------------------------
1997
- --------------------------------------------------------------------------------
This Form Is Open
to Public Inspection.
<TABLE>
- ------------------------------------------------------------------------------------------------------------------------------------
For the calendar plan year 1997 or fiscal plan year beginning December 1, 1997, and ending November 30, 1998
- ------------------------------------------------------------------------------------------------------------------------------------
<S> <C>
If A(1) through A(4), B, C, and/or D, do not apply to this year's return/report, FOR IRS USE ONLY
leave the boxes unmarked. EP-ID
YOU MUST CHECK EITHER BOX A(5) OR A(6), WHICHEVER IS APPLICABLE. SEE INSTRUCTIONS.
</TABLE>
A This return/report is:
(1) [X] the first return/report filed for the plan;
(2) [_] an amended return/report;
(3) [_] the final return/report filed for the plan; or
(4) [_] a short plan year return/report (less than 12 months).
(5) FORM 5500-C FILER CHECK HERE ......................................[X]
(Complete only pages 1 and 3 through 6.) (Code section
6039 D files see instructions on page 5.)
(6) FORM 5500-R FILER CHECK HERE ......................................[_]
(Complete only pages 1 and 2. Detatch pages 3 through 6
before filing.) If you checked box (1) or (3), you must file a
Form 5500-C. (See page 5 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 extension ................................[X]
- --------------------------------------------------------------------------------
<TABLE>
<S> <C>
1a Name and address of plan sponsor (employer, if for a single-employer plan) 1b Employer identification number (EIN)
(Address should include room or suite no.) 34 | 1775913
--------------------------------------------
COHESANT TECHNOLOGIES, INC. 1c Sponsor's telephone number
5845 WEST 82ND STREET, SUITE 102 (317) 875-5592
INDIANAPOLIS, IN 46278 --------------------------------------------
1d Business code (see instructions, page 17)
3998
--------------------------------------------
1e CUSIP issuer number
N/A
--------------------------------------------
2a Name and address of plan administrator (if same as plan sponsor, enter "Same ") 2b Administrator's EIN
SAME |
--------------------------------------------
2c Administrator's telephone number
- ------------------------------------------------------------------------------------------------------------------------------------
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 in line 3a and/or lines 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 line 3c on
page 8 of the instructions for the definition of sponsorship.) Enter"Yes"or"No."
- -------------------------------------------------------------------------------------
4 ENTITY CODE. (If not shown, enter the
applicable code from page 8 of the instructions.) B
- -------------------------------------------------------------------------------------
5a Name of plan COHESANT TECHNOLOGIES, INC. (AND SUBSIDIARIES) EMPLOYEE 401(k) 5b Effective date of plan (mo., day, yr.)
------------------------------------------------------------------- 1/01/97
PROFIT --------------------------------------------
--------------------------------------------------------------------------------- 5c Three-digit
plan number 003
- ------------------------------------------------------------------------------------------------------------------------------------
ALL FILERS MUST COMPLETE 6a THROUGH 6d, AS APPLICABLE.
6a [_] Welfare benefit plan 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 K
-------------------------------------------
6d [_] Fringe benefit plan. Attach Schedule F (Form 5500). See instructions.
- ------------------------------------------------------------------------------------------------------------------------------------
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 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/ Robert W Pawlak Date 9-2-99
----------------------------------------------------------------- --------------------------
Type or print name of individual signing above Robert W Pawlak
--------------------------------------------------------------------------------------
Signature of plan administrator /s/ Robert W Pawlak Date 9-2-99
--------------------------------------------------------------------- --------------------------
Type or print name of individual signing above Robert W Pawlak
- ------------------------------------------------------------------------------------------------------------------------------------
FOR PAPERWORK REDUCTION ACT NOTICE, SEE THE INSTRUCTIONS FOR FORM 5500-C/R. MGA. Form 5500-C/R (1997)
</TABLE>
<PAGE> 6
EIN 34-1775913 / PN 003
<TABLE>
<S> <C> <C>
Form 5500-C/R (1997) COMPLETE PAGE 1, AND PAGES 3 THROUGH 6 ONLY, IF YOU ARE FILING FORM 5500-C
(SEE INSTRUCTIONS ON PAGE 13.) Page 3
- ------------------------------------------------------------------------------------------------------------------------------------
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
-------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------
f Single-employer plans enter the tax year end of the employer in which this plan year ends Month __________ Day ___ Year _____
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
7a Total participants: (1) At the beginning of plan year 0 (2) At the end of plan year 75
------- -------------------------------------
b Enter number of participants with account balances at the end of the plan year. (Defined benefits plans do not complete this
item.) 75
------------
c Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 1
--
d (1) Were any participants in the pension benefit plan separated from service with a deferred vested benefit Yes No
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
- ------------------------------------------------------------------------------------------------------------------------------------
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 11 Year 98
c Did any amendment during the current plan year result in the retroactive reduction of accrued benefits for
any participant? ........................................................................................... 8c X
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 X
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
- ------------------------------------------------------------------------------------------------------------------------------------
9a Was this plan terminated during this plan year or any prior plan year? If "Yes," enter the year 9a X
----------
b Were all 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
e If line 9d is "No," has a determination letter been requested from the IRS? ................................ 9e
f If line 9a or line 9c is "Yes," have participants and beneficiaries been notified of the termination or
the proposed termination? .................................................................................. 9f
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
h During this plan year, did any trust assets revert to the employer for which the Code section 4980 excise
tax is due? ................................................................................................ 9h X
i If line 9h is "Yes," enter the amount of tax paid with Form 5330 $
- ------------------------------------------------------------------------------------------------------------------------------------
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
- ------------------------------------------------------------------------------------------------------------------------------------
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
- ------------------------------------------------------------------------------------------------------------------------------------
13 Is this a plan established or 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
</TABLE>
<PAGE> 7
EIN 34-1775913 / PN 003
<TABLE>
<S> <C> <C>
Form 5500-C/R (1997) COMPLETE PAGE 1, AND PAGES 3 THROUGH 6 ONLY, IF YOU ARE FILING FORM 5500-C Page 5
- ------------------------------------------------------------------------------------------------------------------------------------
NUMBER
j Enter the number of nonexcludable employees. Subtract line 21i from line 21h ............................... 21j 80
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 %
- ------------------------------------------------------------------------------------------------------------------------------------
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 N/A Year N/A
c Is a determination letter request pending with the IRS? .................................................... 22c X
- ------------------------------------------------------------------------------------------------------------------------------------
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
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
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 _________ 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
- ------------------------------------------------------------------------------------------------------------------------------------
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
- ------------------------------------------------------------------------------------------------------------------------------------
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
- ------------------------------------------------------------------------------------------------------------------------------------
26 You may NOT use N/A in response to any line 26 item. If you check "Yes," you must enter a YES NO AMOUNT
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 CNA 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, any owner of a 10% or more interest
in the employer, or relatives of any such persons? .......................................... 26e X 5,394
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 any 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
l Did the plan at any time engage in any transaction or series of related transactions
involving 20% or more of the current value of plan assets? .................................. 261 X
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
- ------------------------------------------------------------------------------------------------------------------------------------
QUESTION 22: THE PLAN ADOPTED A STANDARDIZED PROTOTYPE SPONSORED BY NATIONAL CITY BANK, IRS OPINION LETTER DATED FEB. 28, 1995.
</TABLE>
<PAGE> 8
ATTACHMENT TO 1997 FORM 5500-C/R
FOR ITEM 21
PLAN NAME COHESANT TECHNOLOGIES, INC. (AND SUBSIDIARIES) EIN 34-1775913
EMPLOYEE 401(k) -----------
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PROFIT PN 003
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ATTACHMENT NUMBER 1 of 1 for:
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[X] Mandatory Disaggregation
[ ] Separate Line of Business (SLOB)
PLAN PART/SLOB EMPLOYER MATCHING CONTRIBUTIONS
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21b Enter the total number of separate lines of business claimed
by the employer - ______
c Does the employer apply the mandatory disaggregation rules
under Income Tax Regulations section 1.410(b)-7(c)? Yes [X] No [ ]
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?....................... Yes [ ] No [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)?...................... Yes [ ] No [X]
f If you meet either one of the following exceptions, check
the applicable box to tell us which exception you meet
and DO NOT complete the rest of question 21:
(1) [ ] No highly compensated employee benefited under the
plan at any time during 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 the employer
at any time during the plan year?........................ Yes [ ] No [X]
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.................. Number 86
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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.................................... 6
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j Enter the number of nonexcludable employees. Subtract line
21i from line 21h 80
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k Do 100% of the nonexcludable employees entered on line 21j
benefit under the plan? Yes [X] No [ ]
If line 21k is "Yes," DO NOT complete lines 21l through 21o.
l Enter the number of nonexcludable employees (line 21;) who
are highly compensated employees.........................
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m Enter the number of nonexcludable employees who benefit
under the plan...........................................
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n Enter the number of employees entered on line 21m who are
highly compensated employees.............................
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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 - ________ %
NOTES ________________________________________________________________________
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<PAGE> 9
SCHEDULE P
(Form 5500)
Department of the Treasury
Internal Revenue Service
ANNUAL RETURN OF FIDUCIARY
OF EMPLOYEE BENEFIT TRUST
- File as an attachment to Form 5500, 5500-C/R, or 5500-EZ.
- For the Paperwork Reduction Notice, see the Form 5500 instructions.
OMB No. 1210-0016
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1997
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This Form Is Open to
Public Inspection.
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For trust calendar year 1997 or fiscal year beginning DECEMBER 1, 1997, and ending NOVEMBER 30, 1998
PLEASE TYPE OR PRINT
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1a Name of trustee or custodian
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NATIONAL CITY BANK
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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.)
101 WEST WASHINGTON STREET
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c City or town, state, and ZIP code
INDIANAPOLIS, IN 46255
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2a Name of trust b Trust's employer identification number
COHESANT TECHNOLOGIES, INC. (AND SUBSIDIARIES)
EMPLOYEES 401(K) PROFIT SHARING PLAN
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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.............................................. 34|1775913
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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/ Lee Clark Date 9/2/99
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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 tax 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 plan 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 trust or 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 from 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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MGA SCHEDULE P (FORM 5500) 1997
<PAGE> 10
Form 5558
(Rev. November 1997)
Department of the Treasury
Internal Revenue Service
APPLICATION FOR EXTENSION OF TIME
TO FILE CERTAIN EMPLOYEE PLAN RETURNS
FOR PAPERWORK REDUCTION ACT NOTICE, SEE INSTRUCTIONS ON BACK.
OMB No. 1545-0212
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FILE WITH IRS ONLY
File before the due date for filing the return (see instructions)
Name of filer or plan sponsor (see instructions)
COHESANT TECHNOLOGIES, INC.
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Number, street, and room or suite no. (If a P.O. box, see instructions.)
5845 WEST 82ND STREET, SUITE 102
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City or town, state, and ZIP code
INDIANAPOLIS, IN 46278
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Filer's Identifying Number--Check applicable box and enter number (see
instructions).
[X] Employer identification number (EIN). Filers checking box 1a must enter an
EIN. All other filers, see specific instructions.
34-1775913 OR
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[_] Social security number (see Specific Instructions)
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1 I request an extension of time until 9/ 15/ 99 to file (check appropriate box(es)).
month day year
a [X] Form 5500 series (no more than 2 1/2 months).
b [_] Form 5330 (no more than 6 months). Payment amount attached is $______
(see instructions)
2 Complete the following for the plan(s) covered by this application (see HOW TO FILE):
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PLAN YEAR ENDING
PLAN -------------------------------------
PLAN NAME/FILER NUMBER Month Day Year
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COHESANT TECHNOLOGIES, INC. EMPLOYEE 401(k) PROFIT SHARING PLAN 0 0 3 11 30 98
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3 STATE IN DETAIL WHY YOU NEED THE EXTENSION THIS EXTENSION IS NEED TO ALLOW THE PREPARER TO SECURE ADDITIONAL
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INFORMATION NECESSARY FOR THE PREPARATION OF A COMPLETE RETURN.
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Under penalties of perjury, I declare that to the best of my knowledge and belief the statements made on this form are true,
correct, and complete, and that I am authorized to prepare this application.
Signature /s/ Robert W. Pawlak Date 6-25-99
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Notice to Applicant
To Be Completed by the IRS
[_] This application IS approved to the date shown on line 1. (YOU MUST ATTACH AN APPROVED COPY OF THIS FORM TO EACH RETURN THAT
WAS GRANTED AN EXTENSION.)
[_] The date entered on line 1 is incorrect. The maximum time allowed is 2 1/2 months for Form 5500 series (6 months for Form
5330). This application is approved to ................................. (YOU MUST ATTACH AN APPROVED COPY OF THIS FORM TO EACH
FORM 5330 THAT WAS GRANTED AN EXTENSION.)
[_] The application IS NOT approved, because it was filed after the normal due date of the return. (A 10-DAY GRACE PERIOD IS NOT
GRANTED.)
[_] This application IS NOT approved, because
[_] The application was not signed.
[_] No reason was given on this application or the reason was not acceptable.
[_] No payment was attached for the tax due on Form 5330.
[_] Other
A 10-day grace period is granted from the date shown below or the due date of the return, whichever is later. (YOU MUST ATTACH
A COPY OF THIS FORM TO EACH RETURN YOU FILE THAT IS GRANTED A GRACE PERIOD.)
By:
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(Date) (Director)
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COMPLETE IF YOU WANT THIS FORM 5558 RETURNED TO AN ADDRESS OTHER THAN THE ADDRESS SHOWN ABOVE.
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Please Print or Type
Name
NATIONAL CITY BANK, ATTENTION: KAREN L. GAGNIER
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Number, street, and room or suite no. (If a P.O. box, see instructions.)
1001 S. WORTH
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City or town, state, and ZIP code
BIRMINGHAM, MI 48000-9694
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MGA Form 5558 (Rev. 11-97)
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