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 G
(Form 5500)

2004

For calendar plan year 2004
or fiscal plan year beginning
A

This Form is Open to
Public Inspection.

File as an attachment to Form 5500.

MM / D D / Y Y Y Y

MM / D D / Y Y Y Y

and ending

Name of plan

Schedule of Loans or Fixed Income Obligations in Default or Classified as Uncollectible

Party-in-interest

ON
LY
,

(b) Identity and address of obligor

Name
Street

Original amount of loan

Amount
received during
reporting year

State

PU
RP
OS
ES

City
(c)

Employer Identification Number

NO
T

Part I

(a)

D

Name of plan sponsor as shown on line 2a of Form 5500

DO

C

Three-digit
plan number

US
E

B

Department of Labor
Employee Benefits Security
Administration

FI
LI
NG

OMB No. 1210-0110

This schedule is required to be filed under section 104 of the Employee
Retirement Income Security Act of 1974 (ERISA) and section 6058(a) of the
Internal Revenue Code (the Code).

FO
R

Department of the Treasury
Internal Revenue Service

Official Use Only

Financial Transaction Schedules

Zip Code

.00

(d) Principal

.00

(f) Unpaid balance at end of year

(e) Interest

.00

.00

Amt. overdue
(h) Principal

IN
FO
RM
AT
IO
N

(g) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan
and the terms of the renegotiation, and other material items

.00

Amt. overdue
(i) Interest

.00

FO
R

For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Cat. No. 14739A Schedule G (Form 5500) 2004

2

3

0

4

0

0

0

1

0

A
v7.1

Schedule G (Form 5500) 2004

Page

2

(a)

FI
LI
NG

Official Use Only

Party-in-interest

(b) Identity and address of obligor

FO
R

Name
Street

.00

(d) Principal

.00

(e) Interest

.00

Original amount of loan

Amount
received during
reporting year

Zip Code

(f) Unpaid balance at end of year

NO
T

(c)

State

US
E

City

.00

(a)

Party-in-interest

(b) Identity and address of obligor

Name
Street

IN
FO
RM
AT
IO
N

City
(c)

Original amount of loan

Amount
received during
reporting year

.00

Amt. overdue
(i) Interest

PU
RP
OS
ES

Amt. overdue
(h) Principal

ON
LY
,

DO

(g) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan
and the terms of the renegotiation, and other material items

State

.00

.00

Zip Code

.00

(d) Principal

.00

(f) Unpaid balance at end of year

(e) Interest

.00

FO
R

(g) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan
and the terms of the renegotiation, and other material items

Amt. overdue
(h) Principal

.00


2

3

0

4

0

Amt. overdue
(i) Interest

0

0

2


0

B

.00

Schedule G (Form 5500) 2004

Page

3
Official Use Only

Schedule of Leases in Default or Classified as Uncollectible

FI
LI
NG

Part II

(c)

FO
R

(a) Party-in-interest
(b) Identity of lessor/lessee

Relationship to plan, employer, employee organization or other party-in-interest

Original cost

(h) Expenses paid during the plan year

(f)

.00

Current value at time of lease

(i)

.00

(g) Gross rental receipts during the plan year

.00

(a) Party-in-interest
(b) Identity of lessor/lessee

(c)

(j)

.00

.00

.00

Net receipts

Amount in arrears

PU
RP
OS
ES

DO

ON
LY
,

(e)

NO
T

US
E

(d) Terms and description (type of property, location and date it was purchased, terms regarding rent, taxes, insurance, repairs, expenses, renewal
options, date property was leased)

Relationship to plan, employer, employee organization or other party-in-interest

(e)

Original cost

IN
FO
RM
AT
IO
N

(d) Terms and description (type of property, location and date it was purchased, terms regarding rent, taxes, insurance, repairs, expenses, renewal
options, date property was leased)

(f)

(h) Expenses paid during the plan year

.00

Current value at time of lease

(i)

FO
R

(g) Gross rental receipts during the plan year

(j)

2

3

0

.00

.00

.00

Amount in arrears

.00

Net receipts

.00


4

0

0

0

3

0

C

Schedule G (Form 5500) 2004

Page

4
Official Use Only

Nonexempt Transactions

FI
LI
NG

Part III

If a nonexempt prohibited transaction occured with respect to a disqualified person, file Form 5330 with the IRS to pay
the excise tax on the transaction.
(a)

Identity of party involved

Description of transactions including maturity date, rate of interest, collateral, par or maturity value

US
E

(c)

FO
R

(b) Relationship to plan, employer, or other party-in-interest

(i)

Selling price


(f)

.00

.00

(j)

Lease rental

.00

(g) Expenses incurred in connection with transaction

(a)

.00

.00

.00

.00

.00

.00

.00

Net gain or (loss) on each transaction

PU
RP
OS
ES

Current value of asset

ON
LY
,

(e)

DO

NO
T

(h) Cost of asset

(d) Purchase price

Identity of party involved

(b) Relationship to plan, employer, or other party-in-interest

Description of transactions including maturity date, rate of interest, collateral, par or maturity value

IN
FO
RM
AT
IO
N

(c)

(h) Cost of asset

(d) Purchase price

(e)

Selling price

(f)

Lease rental



.00


(i)

Current value of asset

.00


(j)

Net gain or (loss) on each transaction

.00

FO
R

(g) Expenses incurred in connection with transaction

.00


2

3

0

4

0

0

0

4

0

D