Attention

:
This form or schedule is provided for information purposes and should not be
reproduced on personal computer printers by individual taxpayers for filing.
The Form 5500-series of forms and schedules is printed on special paper with
dropout ink so it can be processed by the computerized processing system
"EFAST." The Forms 5500 and 5500-EZ (and related schedules) may be
obtained by calling 1-800-TAX-FORM (1-800-829-3676). Be sure to order using
the IRS form number.
Check the Department of Labor's website at www.efast.dol.gov for
additional information concerning the processing system, electronic filing,
software, and "non-standard" filings.

SCHEDULE D
(Form 5500)

MM / D D / Y Y Y Y

and ending

Name of plan or DFE

Plan or DFE sponsor's name as shown on line 2a of Form 5500

NO
T

Information on interests in MTIAs, CCTs, PSAs, and 103-12 IEs (to be completed by plans and DFEs)

Name of MTIA, CCT, PSA, or 103-12IE

Name of MTIA, CCT, PSA, or 103-12IE

EIN

IN
FO
RM
AT
IO
N

(b) Name of sponsor of entity listed in (a)

(c)

(d) Entity
code

PN

PU
RP
OS
ES

(a)

EIN

ON
LY
,

(b) Name of sponsor of entity listed in (a)

(c)

Employer Identification Number

DO

(a)

D

Three-digit
plan number

US
E

B

Part I

FI
LI
NG

MM / D D / Y Y Y Y

For calendar plan year 2004
or fiscal plan year beginning

C

2004

This Form is Open to
Public Inspection.

File as an attachment to Form 5500.

FO
R

Department of Labor
Employee Benefits Security Administration

A

OMB No. 1210-0110

This schedule is required to be filed under section 104 of the Employee
Retirement Income Security Act of 1974 (ERISA).

Department of the Treasury
Internal Revenue Service

Official Use Only

DFE/Participating Plan Information

.00

(e) Dollar value of interest in MTIA, CCT, PSA, or
103-12IE at end of year (see instructions)

(d) Entity
code

PN

(e) Dollar value of interest in MTIA, CCT, PSA, or
103-12IE at end of year (see instructions)

.00

FO
R

For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Cat. No. 22774J Schedule D (Form 5500) 2004

1

1

0

4

0

0

0

1

0

7
v7.1

Schedule D (Form 5500) 2004

Page

2
Official Use Only

Name of MTIA, CCT, PSA, or 103-12IE

FI
LI
NG

(a)

(b) Name of sponsor of entity listed in (a)

EIN

(e) Dollar value of interest in MTIA, CCT, PSA, or
103-12IE at end of year (see instructions)

(d) Entity
code

PN

Name of MTIA, CCT, PSA, or 103-12IE

(b) Name of sponsor of entity listed in (a)

Name of MTIA, CCT, PSA, or 103-12IE

(b) Name of sponsor of entity listed in (a)

(a)

EIN

.00

DO

(e) Dollar value of interest in MTIA, CCT, PSA, or
103-12IE at end of year (see instructions)

(d) Entity
code

PN

.00

(e) Dollar value of interest in MTIA, CCT, PSA, or
103-12IE at end of year (see instructions)

.00

Name of MTIA, CCT, PSA, or 103-12IE

IN
FO
RM
AT
IO
N

(c)

(d) Entity
code

PN

ON
LY
,

(a)

EIN

PU
RP
OS
ES

(c)

NO
T

(a)

US
E

FO
R

(c)

(b) Name of sponsor of entity listed in (a)

EIN

(d) Entity
code

PN

(e) Dollar value of interest in MTIA, CCT, PSA, or
103-12IE at end of year (see instructions)

FO
R

(c)

1

1

0

4

0

0

0

2

0

8

.00

Schedule D (Form 5500) 2004

Page

3
Official Use Only

(a)

Information on Participating Plans (to be completed by DFEs)

FI
LI
NG

Part II

Plan name

EIN

(a)

Plan name

PN

US
E

(c)

FO
R

(b) Name of plan sponsor

(a)

Plan name

PN

EIN

(a)

Plan name

PN

EIN

(a)

Plan name

PN

IN
FO
RM
AT
IO
N

(b) Name of plan sponsor

(c)

PU
RP
OS
ES

(b) Name of plan sponsor

(c)

DO

EIN

ON
LY
,

(c)

NO
T

(b) Name of plan sponsor

(b) Name of plan sponsor

EIN

PN

FO
R

(c)

1

1

0

4

0

0

0

3

0

9

Schedule D (Form 5500) 2004

Page

4
Official Use Only

Plan name

FI
LI
NG

(a)

EIN

(a)

Plan name

PN

US
E

(c)

FO
R

(b) Name of plan sponsor

(a)

Plan name

PN

DO

EIN

(b) Name of plan sponsor

EIN

(a)

Plan name

PN

(b) Name of plan sponsor

EIN

(a)

Plan name

PN

IN
FO
RM
AT
IO
N

(c)

PU
RP
OS
ES

(c)

ON
LY
,

(c)

NO
T

(b) Name of plan sponsor

(b) Name of plan sponsor

EIN

PN

FO
R

(c)

1

1

0

4

0

0

0

4

0

A