Form 5500-C/R Return/Report of Employee Benefit Plan OMB Nos. 1210-0016
Department of the Treasury (with Fewer than 100 Participants) 1210-0089
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Internal Revenue Service This form is required to be filed under sections 104 and 4065 of the 1997
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_________ Employee Retirement Income Security Act of 1974 and sections 6039D, This Form is Open
Department of Labor 6047(e), 6057(b), and 6058(a) of the Internal Revenue Code. to Public Inspection.
Pension and Welfare Benefits Administration * See separate instructions
_________
Pension Benefit Guaranty Corporation
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For the calendar plan year 1997 or fiscal plan year beginning , 1997, and ending DECEMBER , 1997
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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 OL-560185960-001-199712
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You must check either box A(5), or A(6) whichever is applicable. See instructions.
A This return/report is: (5) Form 5500-C filer check here . . . . . [X]
(1) [_] the first return/report filed for the plan; (Complete only pages 1 and 3 through 6.)
(2) [_] an amended return/report; (Code section 6039D filers see instructions
(3) [_] the final return/report filed for the plan; or on page 5.)
(4) [_] a short plan year return/report (less than 12 months). (6) Form 5500-R filer check here . . . . . [_]
(Complete only pages 1 and 2. Detach pages 3
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 . . . . . . *[X]
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 plan) 1b Employer identification number (EIN
(Address should include room or suite no.) 56-0185960
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1c Sponsor's telephone number
(336) 227-3631
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COMMUNITY SAVINGS BANK SSB 1d Business code (see instructions, page 17
PO BOX 1837 6120
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BURLINGTON, NC 27216-1837 1e CUSIP issuer number
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2a Name and address of plan administrator (if same as plan sponsor, enter "Same" 2b Administrator's EIN
COMMUNITY SAVINGS BANK SSB 56-0185960
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PO BOX 1837 2c Administrator's telephone number
BURLINGTON, NC 27216-1837
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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 line 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 from page 8 of the instructions.) * A-SINGLE-EMPLOYER PLAN
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5a Name of plan * COMMUNITY SAVINGS BANK SSB PROFIT 5b Effective date of plan (mo., day, yr.
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SHARING AND SAVINGS PLAN AND TRUST 07/01/1956
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5c Three-digit
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All filers must complete 6a through 6d, as applicable. plan number > 001
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6a [_] Welfare benefit plan 6b [X] Pension benefit plan
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(If the correct codes are not preprinted below, enter the applicable codes from
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page 8 of the instructions in the boxes.)
2-DEF.CON.-PROFIT SHARING
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.)
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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 * ________________________________________________________________ Date * _______________________
Type or print name of individual signing above William R. Gilliam -- President
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Signature of plan administrator * ___________________________________________________________________ Date * _______________________
Type or print name of individual signing above William R. Gilliam -- President
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For Paperwork Reduction Act Notice, see the instructions for Form 5500-C/R. Cat. No. 10957K Form 5500-C/R (1997
Page 2
Form 5500-C-R (1997) Form 5500-R filers, complete pages 1 and 2 only. Form 5500-C filers, complete page 1 skip page 2,
and complete pages 3 through 6.
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6e Check investment arrangement(s): (1)[_] Master trust (2)[_] Common/Collective trust
(3) [_] Pooled separate account Yes No
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7a Total participants; (1) At the beginning of plan year * ............ (2) At the end
of plan year * ............................................................................................
b Enter number of participants with account balances at the end of the plan year (defined benefit
plans do not complete this item)*..........................................................................
c (1) Were any participants in the pension benefit plan separated from service with a deferred vested
benefit for which a Schedule SSA (Form 5500) is required to be attached? (See instructions.) .............. 7c(1)
(2) If "Yes", enter the number of separated participants required to be reported *
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8a Was this plan terminated during this plan year or any prior plan year? If "Yes" enter the
year * .................................................................................................... 8a
b Were all the plan assets either distributed to participants or beneficiaries, transferred to another
plan, or brought under the control of PBGC? 8b
c If line 8a is "Yes" and the plan is covered by PBGC, is the plan continuing to file 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? ............................................................................................ 8c
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9 Is this plan a established or maintained pursuant to one or more collective bargaining
agreements? ................................................................................................ 9
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10 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-. *
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11a (1) Were any plan amendments adopted during this plan year? ................................................ 11a(1)
(2) Enter the date the most recent amendment was adopted * Month ............ Day .............
Year ....................
b If line 11a is "Yes", did any amendment result in a retroactive reduction of accrued benefits for
any participant? ....................................................................................... 11b
c If line 11a is "Yes", did any amendment change the information contained in the latest summary plan
description or summary description of modifications available at the time of the amendment? ............. 11c
d If line 11c is "Yes", has a summary plan description or summary description of modifications that
reflects the plan amendments referred to on line 11c been furnished to participants? (see instructions) . 11d
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12a If this is a pension benefit plan subject to the minimum funding standards, has the plan experienced
a funding deficiency for this plan year? (See instructions.) ........................................... 12a
b If line 12a is "Yes", have you filed Form 5330 to pay the excise tax? .................................. 12b
c 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.) ........................................................... 12c
d 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 . . . . ..................................................................................... 12d
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13a Total plan assets as of the beginning ................... and end ......................... of the plan year
b Total liabilities as of the beginning ................... and end ......................... of the plan year
c Net assets as of the beginning * and end * of the plan year
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14 For this plan year, enter: a Plan income ........................ d Plan contributions ..................
b Expenses ........................... e Total benefits paid .................
c Net income (loss) (subtract 14b from 14a) ........
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15 You may NOT use N/A in response to lines 15a through 15o. If you check "Yes", you must enter a Yes No Amount
dollar amount in the amount column. During this plan year:
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a Was this plan covered by a fidelity bond? . . . . . . . . . . . . . . . . . . . . . . . . . . 15a
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b If line 15a is "Yes", enter the name of the surety company * ..............................
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c Was there any loss to the plan, whether or not reimbursed, caused by fraud or dishonesty? . . . 15c
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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%
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or more interest in the employer, or relatives of any such persons? 15d
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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? 15e
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f Did the plan acquire or hold any employer security or employer real property? . . . . . . . . 15f
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g Has the plan granted an extension on any delinquent loan owned to the plan? . . . . . . . . . . 15g
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h Were any participant contributions transmitted to the plan more than 31 days after receipt or
withholding by the employer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15h
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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? . . . . . . . . . . . . . . . . . . . . . . . . 15i
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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? . . . . . . . . . . . . . . . . . 15j
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k Did the plan at any time hold 20% or more of its assets in any single security, debt,
mortgage, parcel or real estate, or partnership/joint venture interests? . . . . . . . . . . . . 15k
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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? . . . . . . . . . . . . . . . . . . . 15l
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m Were there any noncash contributions made to the plan the value of which was set without an
appraisal by an independent third party? 15m
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n Were there any purchases of nonpublicly traded securities by the plan the value of which was
set without an appraisal by an independent third party? . . . . . . . . . . . . . . . . . . . . 15n
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o Has the plan reduced or failed to provide any benefit when due under the plan because of
insufficient assets? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15o
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16a Is the plan covered under the Pension Benefit Guaranty Corporation termination insurance program [_] Yes [_] No
[_] Not determined
b If line 16a is "Yes" or "Not determined," enter the employer identification number and the plan number used to identify it.
Employer identification number * Plan number *
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Complete page 1, and pages 3 through 6 only, if you are filing Form 5500-C. (See instruction on page 13.) 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 12 Day 31 Year 97
g Is any part of this plan funded by an insurance contract described in Code section 417(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?........ N/A................................................................................. [_] Yes [_] No
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7a Total participants: (1) At the beginning of plan year * 48 (2) At the end of plan year * 44
b Enter number of participants with account balances at the end of the plan year. (Defined benefits plans
do not complete this item.) * 39
c Number of participants that terminated employment during the plan year with accrued benefits that were
less than 100% vested * 1
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Yes No
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d (1) Were any participants in the pension benefit plan separated from service with a deferred vested
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 * 3
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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 1 Day 1 Year 97
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
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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 all plan assets either distributed to participants or beneficiaries, transferred to another plan,
or brought under the control of PBGC?.................................................................... 9b N/A
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 or
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 X
i If line 9h is "Yes," enter the amount of tax paid with Form 5330 * $ N/A
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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
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If "Yes," identify the other plan(s): c Employer identification number(s) d Plan number(s)
b Name of plan(s) * N/A ------------------------------------- ---------------------
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e If required, has a Form 5310-A been filed?............................................. N/A [_] Yes [_] No
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11 Enter the plan funding arrangement code 12 Enter the plan benefit arrangement code from Yes No
from page 13 of the instructions * 1 page 13 of the instructions * 1
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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-
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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 Yes No
Schedule B (Form 5500) required to be attached? (If this is a defined contribution plan,
leave blank.)...................................................................................... 15a X
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 X
If "Yes," complete (1), (2), and (3) below:
(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 date of last payment by employer * Month ----- Day
----- Year ------
(3) If (1) is greater than (2), subtract (2) from (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 than 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?.................................................. 17 (b) 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?.............................................................. 17 (c) 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(1)(1)1?............ 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 21o (see instructions)................................................ [X]
If you checked the box, enter the first day of the plan year for which data is being
submitted * Month .1.Day 1-- Year 97
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)?.............................................................................. 21(a) X
b If line 21a is "Yes," enter the total number of separate lines of business claimed by the
employer * N/A 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..
See Attachment..................................................................................... 21c X
d In testing whether this plan satisfies the coverage and discrimination tests of Code sections
410(b) and 410(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 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?.............................................................................. 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 49
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 14
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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
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j Enter the number of nonexcludable employees. Subtract line 21i from line 21h............................... 21j 35
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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 N/A
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m Enter the number of nonexcludable employees who benefit under the plan..................................... 21m N/A
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n Enter the number of employees entered on line 21m who are highly compensated employees..................... 21n N/A
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o This plan satisfies the coverage requirements on the basis of (check one):
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(1) [_] The average benefits test (2) [_] The ratio percentage test-enter percentage N/A %
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Yes No
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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
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b Enter the date of the most recent IRS determination letter.......................... Month 5 Year 97
--- ----
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
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b Were all the assets referred to on line 23a valued for the 1997 plan year by an independent third-party
appraiser?............................................................................................... 23b X
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
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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 _______ N/A
(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
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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. N/A
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 must enter a dollar Yes No Amount
amount in the amount column.
During this plan year:
a Was this plan covered by a fidelity bond?...................................................... 26a X 2,000,000
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b If line 26a is "Yes," enter the name of the surety company The St. Paul
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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
-----------------------------
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? See attached statement......... 26k X 1,692,236
-----------------------------
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?............................................... 26l X
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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
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0 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 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
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a Cash........................................................... 27a 74,105 128,908
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b Receivables.................................................... 27b
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c Investments:
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(1) U.S. Government Securities................................. 27c(1)
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(2) Corporate debt and equity instruments...................... 27c(2)
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(3) Real estate and mortgages (other than to participants)..... 27c(3)
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(4) Loans to participants:
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A Mortgages................................................ (4)A
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B Other.................................................... (4)B
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(5) Other................. Certificates of Deposit............. 27c(5) 2,770,991 2,948,465
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(6) Total investments. Add lines 27c (1) through 27c (5)....... * 27c(6) 2,845,096 3,077,373
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d Buildings and other property used in plan operations........... 27d
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e Other assets................................................... 27e
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f Total assets, Add lines 27a, 27b, 27c(6), 27d, and 27e......... * 27f 2,845,096 3,077,373
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Liabilities
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g Payables....................................................... 27g
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h Acquisition Indebtedness....................................... 27h
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i Other liabilities.............................................. 27i 6,351 9,740
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j Total liabilities, Add lines 27g through 27i................... * 27j 6,351 9,740
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k Net assets. Subtract line 27j from line 27f.................... * 27k 2,838,745 3,067,633
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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 funds(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
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a Contributions received or receivable in cash from:
---------------------
(1) Employer(s) including contributions on behalf of self-
employed individuals)................................... 28a(1) 85,329
------------------------------------
(2) Employees................................................. 28a(2) 47,534
------------------------------------
(3) Others.................................................... 28a(3)
------------------------------------
(4) Add lines 28a(1) through 28a(3)........................... 28a(4) 132,863
------------------------------------
b Noncash contributions. Enter the total of lines 28a(4) and
lines 28b in column (b)....................................... 28b 132,863
------------------------------------
c Earnings from investments (interest, dividends, rents,
royalties).................................................... 28c 179,415
------------------------------------
d Net realized gain (loss) on sale or exchange of assets......... 28d
------------------------------------
e Other income (specify)......................................... 28e
------------------------------------
f Total income. Add lines 28b through 28e........................ * 28f 312,278
------------------------------------
Expenses
g Distributions of benefits and payments to provide benefits:
------------------------------------
(1) Directly to participants or their beneficiaries........... 28g(1) 83,393
------------------------------------
(2) Other..................................................... 28g(2)
------------------------------------
(3) Total distribution of benefits and payments to provide
benefits................................................. 28g(3) 83,393
------------------------------------
h Administrative expenses (salaries, fees, commissions,
insurance premiums).......................................... 28h
------------------------------------
i Other expenses (specify)....................................... 28i
------------------------------------
j Total expenses. Add lines 28g through 28i...................... * 28j 83,393
------------------------------------
k Net income (loss). Subtract line 28j from line 28f..............* 28k 228,885
- --------------------------------------------------------------------------------------------------------------
SCHEDULE SSA Annual Registration Statement Identifying Separated OMB No. 1210-0016
(Form 5500) Participants with Deferred Vested Benefits -----------------
1997
Under Section 8057(a) of the Internal Revenue Code -----------------
* File as an attachment to Form 5500-C/R This Form is Not
Department of the Treasury Open to Public
Internal Revenue Service * For Paperwork Reduction Act Notice, see the Instructions for Form 5500 or 5500-C/R Inspection
- ------------------------------------------------------------------------------------------------------------------------------------
For the calendar year 1997 or fiscal Plan year begining 1997,and ending ,19
- ------------------------------------------------------------------------------------------------------------------------------------
1a Name of plan sponsor (employer if for a single employer plan) 1b Sponsor's employer identification number (EIN)
Community Savings Bank, SSB 56 0185960
- ------------------------------------------------------------------------------------------------------------------------------------
2a Name of plan Community Savings Bank, SSB Profit Sharing and 2b Three digit
Savings Plan and Trust Plan number* 0 0 1
- ------------------------------------------------------------------------------------------------------------------------------------
3 Enter one of the following Entry Codes in column (a) for each separated
participant with deferred vested benefits that:
Code A- has not previously been reported.
Code B- has previously been reported under the above plan number but
requires revisions to the information previously reported.
Code C- has previously been reported under another plan number but will be
receiving their benefits from the plan listed above Instead.
Code D- has previously been reported under the above plan number but is no
longer entitled to those deferred vested benefits.
- ------------------------------------------------------------------------------
Use with entry code Use with entry code Use with entry code
"A","B","C", or"D" "A" or "B" "C"
- -----------------------------------------------------------------------------------------------------------------------------------
(a) (b) (c) Enter code for Amount of vested benefit
Entry Social security Name of participant nature and --------------------------
code number from of Defined (i) (j)
benefit (f) contribution plan Previous sponsor's Previous
--------------- ----------------- employer plan
(d) (e) Defined benefit (g) (h) identification number
Type of Payment plan-periodic Units or Total number
annuity frequency payment shares value of
account
- -----------------------------------------------------------------------------------------------------------------------------------
A ###-##-#### Betty R. King a a 13,286.28
A ###-##-#### Debra Matthews a a 21,566.93
A ###-##-#### Holly Sims a a 7,882.92
- ------------------------------------------------------------------------------------------------------------------------------------
[_] Check here if additional participants are shown on attachments. All attachments must include the sponsor's name,EIN,
name of plan, plan number and column identification letter for each column completed for line 3
- ------------------------------------------------------------------------------------------------------------------------------------
[_] Check here if plan is a government, church or other plan that elects to voluntarily file Schedule SSA. If so, complete lines 4
through 5c, and the signature area. Otherwise, complete the signature area only.
- ------------------------------------------------------------------------------------------------------------------------------------
4 Plan sponsor's address (number, street, and room or suite no.) (if a P.O. box, see the instructions for line 4,)
P. O. Box 1837
- ------------------------------------------------------------------------------------------------------------------------------------
City or town, state, and Zip code
Burlington, NC 27216
- -----------------------------------------------------------------------------------------------------------------------------------
5a Name of plan administrator (if other than sponsor) 5b Administrator's EIN
Same
- -----------------------------------------------------------------------------------------------------------------------------------
5c Number, street, and room or suite no, (If a P.O. box, see the instructions for line 4.)
- -----------------------------------------------------------------------------------------------------------------------------------
City or town, state, and ZIP code
- ----------------------------------------------------------------------------------------------------------------------------------
Under penalties of perjury, I declare that I have examined this report, and to the best of my knowledge and belief, it is true
correct, and complete.
Signature of plan administrator *----------------------------------------------------------------------------------------------
Phone number of plan administrator * (336) 227-3631 Date *
- -----------------------------------------------------------------------------------------------------------------------------------
Cat. No. 13506T Schedule SSA (form 5500) (1997)
MANDATORY DISAGGREGATION - DEMO 4
COMMUNITY SAVINGS BANK, SSB
EIN: 56-0185960
The plan consists of employee and matching contributions under Section
401(m) of the Code (the "401(m) plan"), discretionary Employer contributions
(the "Discretionary Contribution Plan"), and qualified nonelective contributions
(the "Qualified Non-Elective Plan"). See ARTICLE IV of the Plan. Accordingly,
---
pursuant to Regulation Section 1.410(b)-7(c)(l), the plan is treated as three
separate plans for purposes of Section 410(b) of the Code - the 401(m) Plan, the
Discretionary Contribution Plan and the Qualified Non-Elective Plan.
I. 401(m) Plan
-----------
A. Minimum Coverage Requirements.
1. Total number of employees on December 31, 1997 49
------
2. Number of employees excludable
a. Nonresident aliens = 0
------
b. Employees failing to meet minimum
age and service requirements = 14
------
c. Collectively bargained employees = 0
------
Total 14
------
3. Number of nonexcludable employees 35
------
4. Number of nonexcludable employees who are
highly compensated employees 1
------
5. Number of nonexcludable employees who are
nonhighly compensated employees 34
------
6. Number of nonexcludable, highly compensated
employees who are eligible to receive matching
contributions under the 401(m) Plan 1
------
7. Number of nonexcludable, nonhighly compensated
employees who are eligible to receive matching
contributions under the 401(m) Plan 34
------
8. Enter the percentage of nonexcludable, highly
compensated employees who are eligible to receive
matching contributions under the 401(m) Plan,
(i.e., divide 6. by 4.) 100%
---- ------
9. Enter the percentage of nonexcludable, nonhighly
compensated employees who are eligible to receive
matching contributions under the 401(m) Plan 100%
------
10. Divide the percentage of nonexcludable, nonhighly
compensated employees who are eligible to receive
matching contributions under the 401(m) Plan by the
percentage of nonexcludable, highly compensated
employees who are eligible to receive matching
contributions under the 401(m) Plan 1
------
The 401(m) Plan satisfies the ratio percentage test.
B. Nondiscrimination in Amount Requirement.
The 401(m) Plan satisfies the nondiscrimination in amount requirement
because it satisfies Regulation Sections 1.401(m)-1(b). See Regulation Section
---
1.401(a)(4)-1(b)(2)(ii)(B).
II. Discretionary Contribution Plan
-------------------------------
A. Minimum Coverage Requirements.
1. Total number of employees on December 31, 1997 49
------
2. Number of employees excludable
a. Nonresident aliens = 0
------
b. Employees failing to meet minimum
age and service requirements = 14
------
c. Collectively bargained employees = 0
------
Total 14
------
3. Number of nonexcludable employees 35
------
4. Number of nonexcludable employees who are
highly compensated employees 1
------
5. Number of nonexcludable employees who are
nonhighly compensated employees 34
------
6. Number of nonexcludable, highly compensated
employees who are eligible to receive discretionary
Employer contributions under the Discretionary
Contribution Plan 1
------
2
7. Number of nonexcludable, nonhighly compensated
employees who are eligible to receive discretionary
Employer contributions under the Discretionary
Contribution Plan 34
------
8. Enter the percentage of nonexcludable, highly
compensated employees who are eligible to receive
discretionary Employer contributions under the
Discretionary Contribution Plan (i.e., divide 6. by
----
4.)
100%
------
9. Enter the percentage of nonexcludable, nonhighly
compensated employees who are eligible to receive
discretionary Employer contributions under the
Discretionary Contribution Plan 100%
------
10. Divide the percentage of nonexcludable, nonhighly
compensated employees who are eligible to receive
discretionary Employer contributions under the
Discretionary Contribution Plan by the percentage
of nonexcludable, highly compensated employees
who are eligible to receive discretionary Employer
contributions under the Discretionary Contribution
Plan 1
------
The Discretionary Contribution Plan satisfies the ratio percentage
test.
B. Nondiscrimination in Amount Requirement.
The Discretionary Contribution Plan satisfies the safe harbor for
defined contributions plans found in Regulation Section 1.401(a)(4)-
1(b)(2)(ii)(A).
III. Qualified Non-Elective Plan
---------------------------
A. Minimum Coverage Requirements
The qualified Non-Elective Plan automatically satisfies the minimum
coverage requirements because it benefits no highly compensated employees
pursuant to Section 4.9(h) of the plan. See Regulation Section 1.410(b)-
---
2(b)(6).
B. Nondiscrimination in Amount Requirement.
The qualified nonelective contributions, if any, automatically satisfy
the nondiscrimination in amount requirement because they will only be made on
behalf of nonhighly compensated employees.
3
COMMUNITY SAVINGS BANK, SSB
BURLINGTON, NORTH CAROLINA
56-0185960
1997 FORM 5500-C/R
RE: QUESTION 26
The plan sponsor is a State chartered and supervised financial institution
which is Federally insured. The plan covers only employees of the sponsor.
The plan sponsor is empowered as fiduciary and expressly authorized to
invest all or part of the plan's assets in deposits which bear a reasonable
interest rate in a bank or similar financial institution. As such, the plan
invests all of its assets in certificates of deposit and savings accounts
of the plan sponsor. IRC Sec. 4975(d)(4) provides that such investments
are not prohibited transactions.
SCHEDULE P Annual Return of Fiduciary OMB No. 1210-0016
---------------------
(Form 5500) of Employee Benefit Trust 1997
---------------------
Department of the File as an attachment to Form 5500, This Form is Open to
Treasury 5500-C/R, or 5500-EZ. Public Inspection.
Internal Revenue For the Paperwork Reduction Notice, see
Service the Form 5500 instructions.
- --------------------------------------------------------------------------------
For trust calendar year 1997 or fiscal year beginning , 1997 and
ending , 19.
- --------------------------------------------------------------------------------
Please type 1a Name of trustee or custodian
or print
William R. Gilliam
- --------------------------------------------------------------------------------
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 1837
- --------------------------------------------------------------------------------
c City or town, state, and ZIP code
Burlington, NC 27216
- --------------------------------------------------------------------------------
2a Name of trust
Community Savings Bank, SSB Profit b Trust's employer identification
Sharing and Savings Plan and Trust number 56 0185960
- --------------------------------------------------------------------------------
3 Name of plan if different from name of trust
Same
- --------------------------------------------------------------------------------
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
- --------------------------------------------------------------------------------
5 Enter the plan sponsor's employer identification number as shown on
Form 5500,
5500-C/R, or 5500-EZ..................................* 56 0185960
- --------------------------------------------------------------------------------
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 Date
- --------------------------------------------------------------------------------
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 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
instruction 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.)
- --------------------------------------------------------------------------------
Cat. No. 13504X Schedule P (Form 5500) 1997
SUMMARY ANNUAL REPORT
For
COMMUNITY SAVINGS BANK, S.B.
PROFIT SHARING AND SAVINGS PLAN & TRUST
This is a summary of the annual report for Community Savings Bank, S.B.
Profit Sharing and Savings Plan & Trust, 56-0185960, for the plan year beginning
January 1, 1997 and ending December 31, 1997. The annual report has been filed
with the Internal Revenue Service, as required under the Employee Retirement
Income Security Act of 1974 (ERISA).
Basic Financial Statement
- -------------------------
Benefits under the plan are provided by trust.
Plan expenses were $83,393.
These expenses included -0- in administrative expenses and $83,393 in
benefits paid to participants and beneficiaries, and -0- in other expenses. A
total of 44 persons were participants in or beneficiaries of the plan at the end
of the plan year, although not all of these persons had yet earned the right to
receive benefits.
The value of plan assets, after subtracting liabilities of the plan, was
$3,067,633 as of December 31, 1997, compared to $2,838,745 as of January 1,
1997. During the plan year, the plan experienced an increase in its net assets
of $228,885. The plan had total income of $312,278 including employer
contributions of $85,329 and employee contributions of $47,534.
Your Rights to Additional Information
-------------------------------------
You have the right to receive a copy of the full annual report, or any part
thereof, on request.
To obtain a copy of the full annual report, or any part thereof, write or
call the office of Community Savings Bank, SSB, who is plan administrator, Post
Office Box 1837, Burlington, North Carolina 27216, (336) 227-3631. There is no
charge to cover copying costs.
You also have the right to receive from the plan administrator, on request
and at no charge, a statement of the assets and liabilities of the plan and
accompanying notes, or a statement of income and expenses of the plan and
accompanying notes, or both. If you request a copy of the full annual report
from the plan administrator, these two statements and accompanying notes will be
included as part of that report. There is no charge to cover copying costs.
You also have the legally protected right to examine the annual report at
the main office of the plan, Burlington, North Carolina and at the U.S.
Department of Labor in Washington, D.C. or to obtain a copy from the US
Department of Labor upon payment of copying costs. Requests to the Department
should be addressed to: Public Disclosure Room, N4677, Pension and Welfare
Benefit Programs, Department of Labor, 200 Constitution Avenue, NW, Washington,
D.C. 20216.