UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
Form 11-K
(Mark One)
| x | ANNUAL REPORT PURSUANT TO SECTION 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934 [NO FEE REQUIRED] |
For the fiscal year ended December 31, 2005
or
| ¨ | TRANSITION REPORT PURSUANT TO SECTION 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934 [NO FEE REQUIRED] |
For the transition period from to
Commission file number:
| A. | Full title of the plan and the address of the plan, if different from that of the issuer named below: |
American Community Bancshares, Inc. 401(k) Plan
| B. | Name of issuer of the securities held pursuant to the plan and the address of its principal executive office: |
American Community Bancshares, Inc.,
4500 Cameron Valley Parkway, Suite 150,
Charlotte, North Carolina 28211
The following financial statements and reports, which have been prepared pursuant to the requirements of the Employee Retirement Income Security Act of 1974, are filed as part of this Annual Report on Form 11-K:
Statement of Plan Assets as of December 31, 2005 and 2004
Statement of Income, Expenses and Transfers for 2005 and 2004
SIGNATURES
Pursuant to the requirements of the Securities Exchange Act of 1934, the Plan Administrator has duly caused this annual report to be signed on its behalf by the undersigned hereunto duly authorized.
AMERICAN COMMUNITY BANCSHARES, INC. 401 (K) PLAN
(Name of Plan)
| Date: June 30, 2006 | /s/ Dan R. Ellis, Jr | |||
| (Signature) |
Form 5500 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation
Annual Return/Report of Employee Benefit Plan This form is required to be filed under sections 104 and 4065 of the Employee Retirement Income Security Act of 1974 (ERISA) and sections 6047(e), 6057(b), and 6058(a) of the Internal Revenue Code (the Code). Complete all entries in accordance with the instructions to the Form 5500.
Official Use Only OMB Nos. 1210 – 0110 1210 – 0089 2005 This Form is Open to Public Inspection.
Part I Annual Report Identification Information
For the calendar plan year 2005 or fiscal plan year beginning , and ending ,
A This return/report is for: (1) a multiemployer plan; (2) a single-employer plan (other than a multiple-employer plan); (3) a multiple-employer plan; or (4) a DFE (specify)
B 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; (4) a short plan year return/report (less than 12 months).
C If the plan is a collectively-bargained plan, check here
D If filing under an extension of time or the DFVC program, check box and attach required information. (see instructions)
Part II Basic Plan Information — enter all requested information.
1a Name of plan
AMERICAN COMMUNITY BANK 401(K) PSP
1b Three-digit plan number (PN) 001
1c Effective date of plan (mo., day, yr.) 07/01/1999
2a Plan sponsor’s name and address (employer, if for a single-employer plan) (Address should include room or suite no.)
AMERICAN COMMUNITY BANK
2593 WEST ROOSEVELT BLVD.
MONROE NC 28111-0000
2b Employer Identification Number (EIN) 56-2073258
2c Sponsor’s telephone number 704-225-8444
2d Business code (see instructions) 522110
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, statements and attachments, as well as the electronic version of this return/report if it is being filed electronically, and to the best of my knowledge and belief, it is true, correct and complete.
SIGN HERE Signature of plan administrator Date
DAN R. ELLIS JR. Type or print name of individual signing as plan administrator
SIGN HERE Signature of employer/plan sponsor/DFE Date
DAN R. ELLIS JR. Type or print name of individual signing as employer, plan sponsor or DFE
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. v8.2 Form 5500 (2005)
Form 5500 (2005) Page 2 Official Use Only
3a Plan administrator’s name and address (If same as plan sponsor, enter “Same”)
AMERICAN COMMUNITY BANK
2593 WEST ROOSEVELT BLVD.
MONROE NC 28111-0000
3b Administrator’s EIN 56-2073258
3c Administrator’s telephone number 704–225–8444
4 If the name and/or EIN of the plan sponsor has changed since the last return/report filed for this plan, enter the name, EIN and the plan number from the last return/report below:
a Sponsor’s name
b EIN
c PN
5 Preparer information (optional) a Name (including firm name, if applicable) and address
b EIN
c Telephone number
6 Total number of participants at the beginning of the plan year
6 103 7a 118 7b 0 7c 15 7d 133 7e 0 7f 133 7g 116 7h 2 7i 9
7 Number of participants as of the end of the plan year (welfare plans complete only lines 7a, 7b, 7c, and 7d)
a Active participants
b Retired or separated participants receiving benefits
C Other retired or separated participants entitled to future benefits
d Subtotal. Add lines 7a, 7b, and 7c
e Deceased participants whose beneficiaries are receiving or are entitled to receive benefits
f Total. Add lines 7d and 7e
g Number of participants with account balances as of the end of the plan year (only defined contribution plans complete this item)
h Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested
i If any participant(s) separated from service with a deferred vested benefit, enter the number of separated participants required to be reported on a Schedule SSA (Form 5500)
8 Benefits provided under the plan (complete 8a and 8b, as applicable)
a Pension benefits (check this box if the plan provides pension benefits and enter the applicable pension feature codes from the List of Plan Characteristics Codes printed in the instructions): 2E 2F 2G 2J 2K 3E
b Welfare benefits (check this box if the plan provides welfare benefits and enter the applicable welfare feature codes from the List of Plan Characteristics Codes printed in the instructions):
9a Plan funding arrangement (check all that apply)
(1) Insurance (2) Code section 412(i) insurance contracts (3) Trust (4) General assets of the sponsor
9b Plan benefit arrangement (check all that apply)
(1) Insurance (2) Code section 412(i) insurance contracts (3) Trust (4) General assets of the sponsor
Form 5500 (2005) Page 3
Official Use Only
10 Schedules attached (Check all applicable boxes and, where indicated, enter the number attached. See instructions.)
a Pension Benefit Schedules
(1) R (Retirement Plan Information)
(2) B (Actuarial Information)
(3) E (ESOP Annual Information)
(4) SSA (Separated Vested Participant Information)
b Financial Schedules
(1) H (Financial Information)
(2) I (Financial Information — Small Plan)
(3) 1 A (Insurance Information)
(4) C (Service Provider Information)
(5) D (DFE/Participating Plan Information)
(6) G (Financial Transaction Schedules)
(7) 1 P (Trust Fiduciary Information)
SCHEDULE A (Form 5500) Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation
Insurance Information This schedule is required to be filed under section 104 of the Employee Retirement Income Security Act of 1974. File as an attachment to Form 5500. Insurance companies are required to provide this information pursuant to ERISA section 103(a)(2).
Official Use Only OMB No. 1210-0110 2005 This Form is Open to Public Inspection.
For calendar plan year 2005 or fiscal plan year beginning , and ending ,
A Name of plan
AMERICAN COMMUNITY BANK 401 (K) PSP
B Three-digit plan number 001
C Plan sponsor’s name as shown on line 2a of Form 5500
AMERICAN COMMUNITY BANK
D Employer Identification Number 56-2073258
Part I Information Concerning Insurance Contract Coverage, Fees, and Commissions
Provide information for each contract on a separate Schedule A. Individual contracts grouped as a unit in Parts II and III can be reported on a single Schedule A.
1 Coverage:
(a) Name of insurance carrier
PRINCIPAL FINANCIAL GROUP
(b) EIN (c) NAIC code (d) Contract or identification number (e) Approximate number of persons covered at end of policy or contract year Policy or contract year (f) From (g) To
42-0127290 61271 445676 0 01/01/2005 10/24/2005
2 Insurance fees and commissions paid to agents, brokers and other persons. Enter the total fees and total commissions below and list agents, brokers and other persons individually in descending order of the amount paid in the items on the following page(s) in Part I.
Totals
Total amount of commissions paid Total fees paid / amount
3278 0
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. v8.2 Schedule A (Form 5500) 2005
Schedule A (Form 5500) 2005 Page 2 Official Use Only
(a) Name and address of the agents, brokers or other persons to whom commissions or fees were paid
SHELIA C. HINSON POST OFFICE BOX 27 INDIAN TRAIL NC 28079-0000
(b) Amount of commissions paid Fees paid
(c) Amount (d) Purpose (e) Organization code
3278 SERVICE FEE 3
(a) Name and address of the agents, brokers or other persons to whom commissions or fees were paid
(b) Amount of commissions paid Fees paid
(c) Amount (d) Purpose (e) Organization code
(a) Name and address of the agents, brokers or other persons to whom commissions or fees were paid
(b) Amount of commissions paid Fees paid
(e) Organization code (c) Amount (d) Purpose
Schedule A (Form 5500) 2005 Page 3 Official Use Only
Part I Investment and Annuity Contract Information
Where individual contracts are provided, the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report.
3 Current value of plan’s interest under this contract in the general account at year end
4 Current value of plan’s interest under this contract in separate accounts at year end
5 Contracts With Allocated Funds
a State the basis of premium rates b Premiums paid to carrier c Premiums due but unpaid at the end of the year
d If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or retention of the contract or policy, enter amount Specify nature of costs
e Type of contract (1) individual policies (2) group deferred annuity (3) other (specify)
f If contract purchased, in whole or in part, to distribute benefits from a terminating plan check here
6 Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts)
a Type of contract (1) deposit administration (2) immediate participation guarantee (3) guaranteed investment (4) other (specify below) FLEXIBLE INVESTMENT ANNUITY
b Balance at the end of the previous year 13742
c Additions: (1) Contributions deposited during the year 6991
(2) Dividends and credits
(3) Interest credited during the year 282
(4) Transferred from separate account
(5) Other (specify below) 489
LOAN PAYMENTS, MKT VALUE CHANGE
(6) Total additions 7762
d Total of balance and additions (add b and c(6)) 21504
e Deductions:
(1) Disbursed from fund to pay benefits or purchase annuities during year
(2) Administration charge made by carrier 673
(3) Transferred to separate account 1206
(4) Other (specify below) 19625
CONTRACT TERMINATION
(5) Total deductions 21504
f Balance at the end of the current year (subtract e(5) from d) 0
Schedule A (Form 5500) 2005 Page 4 Official Use Only
Part II Welfare Benefit Contract Information
If more than one contract covers the same group of employees of the same employer(s) or members of the same employee organization(s), the information may be combined for reporting purposes if such contracts are experience-rated as a unit. Where individual contracts are provided, the entire group of such individual contracts with each carrier may be treated as a unit for purposes on this report.
7 Benefit and contract type (check all applicable boxes)
a Health (other than dental or vision) b Dental c Vision d Life Insurance e Temporary disability (accident and sickness) f Long-term disability g Supplemental unemployment h Prescription drug i Stop loss (large deductible) j HMO contract k PPO contract l Indemnity contract m Other (specify)
8 Experience-rated contracts
a Premiums: (1) Amount received (2) Increase (decrease) in amount due but unpaid (3) Increase (decrease) in unearned premium reserve (4) Earned ((1) + (2) - (3))
b Benefit charges: (1) Claims paid (2) Increase (decrease) in claim reserves (3) Incurred claims (add (1) and (2)) (4) Claims charged
c Remainder of premium: (1) Retention charges (on an accrual basis) —
(A) Commissions (B) Administrative service or other fees (C) Other specific acquisition costs (D) Other expenses (E) Taxes (F) Charges for risks or other contingencies (G) Other retention charges (H) Total retention
(2) Dividends or retroactive rate refunds. (These amounts were paid in cash, or credited.)
d Status of policyholder reserves at end of year: (1) Amount held to provide benefits after retirement
(2) Claim reserves (3) Other reserves
e Dividends or retroactive rate refunds due. (Do not include amount entered in c(2).)
9 Nonexperience-rated contracts:
a Total premiums or subscription charges paid to carrier
b If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or retention of the contract or policy, other than reported in Part I, item 2 above, report amount
Specify nature of costs
SCHEDULE D (Form 5500) Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration
DFE/Participating Plan Information This schedule is required to be filed under section 104 of the Employee Retirement Income Security Act of 1974 (ERISA). File as an attachment to Form 5500.
Official Use Only OMB No. 1210-0110 2005 This Form is Open to Public Inspection.
For calendar plan year 2005 or fiscal plan year beginning , and ending
A Name of plan or DFE
AMERICAN COMMUNITY BANK 401(K) PSP
B Three-digit plan number 001
C Plan or DFE sponsor’s name as shown on line 2a of Form 5500
AMERICAN COMMUNITY BANK
D Employer Identification Number 56-2073258
Part 1 Information on interests in MTIAs, CCTs, PSAs, and 103–12 IEs (to be completed by plans and DFEs)
(a) Name of MTIA, CCT, PSA, or l03-12IE PRIN PTR SM-CAP BLEND SEP ACCT
(b) Name of sponsor of entity listed in (a) PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN-PN 42-0127290-093 (d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 0
(a) Name of MTIA, CCT, PSA, or 103-12IE PRINCIPAL MONEY MKT SEP ACCT
(b) Name of sponsor of entity listed in (a) PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN-PN 42-0127290-024 (d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 0
(a) Name of MTlA, CCT, PSA, or l03-l2IE PRINCIPAL BOND AND MTG SEP ACCT
(b) Name of sponsor of entity listed in (a) PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN-PN 42-0127290-005 (d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 0
(a) Name of MTIA, CCT, PSA, or 103-12IE PRIN PTR MD-CP GR I SEP ACCT
(b) Name of sponsor of entity listed in (a) PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN-PN 42-0127290-056 (d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 0
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. v8.2 Schedule D (Form 5500) 2005
Schedule D (Form 5500) 2005 Page 2 Official Use Only
(a) Name of MTIA, CCT, PSA, or 103-12IE PRIN PTR SM-CAP GR III SEP ACCT
(b) Name of sponsor of entity listed in (a) PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN-PN 42-0127290-097
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 0
(a) Name of MTIA, CCT, PSA, or l03-12IE PRIN PTNRS LG-CAP VALUE II SA
(b) Name of sponsor of entity listed in (a) PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN-PN 42-0127290-100
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 0
(a) Name of MTIA, CCT, PSA, or l03-12IE PRIN LG CP STK IDX SEP ACCT
(b) Name of sponsor of entity listed in (a) PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN-PN 42-0127290-016
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 0
(a) Name of MTIA, CCT, PSA, or 103-12IE PRIN PTR LG-CAP GR SEP ACCT
(b) Name of sponsor of entity listed in (a) PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN-PN 42-0127290-025
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 0
(a) Name of MTIA, CCT, PSA, or 103-12IE PRIN MID CAP STK IDX SEP ACCT
(b) Name of sponsor of entity listed in (a) PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN-PN 42-0127290-023
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 0
(a) Name of MTIA, CCT, PSA, or 103-12IE PRIN PTR MD-CAP GROWTH SEP ACCT
(b) Name of sponsor of entity listed in (a) PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN-PN 42-0127290-026
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 0
Schedule D (Form 5500) 2005 Page 2 Official Use Only
(a) Name of MTIA, CCT, PSA, or 103-12IE PRIN SM CAP STK IDX SEP ACCT
(b) Name of sponsor of entity listed in (a) PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN-PN 41-2012720-028
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 0
(a) Name of MTIA, CCT, PSA, or 103-12IE PRINCIPAL INTL SM CO SEP ACCT
(b) Name of sponsor of entity listed in (a) PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN-PN 41-2012720-014
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 0
(a) Name of MTIA, CCT, PSA, or 103-12IE PRINCIPAL DIVERS INTL SEP ACCT
(b) Name of sponsor of entity listed in (a) PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN-PN 41-2012720-015
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 0
(a) Name of MTlA, CCT, PSA, or 103-12IE AMER CT INC & GRO (ADV) SP ACCT
(b) Name of sponsor of entity listed in (a) PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN-PN 41-2012720-044
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 0
(a) Name of MTIA, CCT, PSA, or 103-12IE PRIN PTNR MD-CP GR II SEP ACCT
(b) Name of sponsor of entity listed in (a) PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN-PN 41-2012720-047
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 0
(a) Name of MTIA, CCT, PSA, or 103-12IE INVESCO SMM CO GR SEP ACCT
(b) Name of sponsor of entity listed in (a) PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN-PN 41-2 012720-058
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 0
Schedule D (Form 5500) 2005 Page 2 Official Use Only
(a) Name of MTIA, CCT, PSA, or 103-12IE INVESCO SMALL CO GR SEP ACCT
(b) Name of sponsor of entity listed in (a) PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN-PN 42-0127290-058
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 0
(a) Name of MTIA, CCT, PSA, or 103-12IE INVESCO LEISURE SEP ACCT
(b) Name of sponsor of entity listed in (a) PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN-PN 42-0127290-059
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 0
(a) Name of MTIA, CCT, PSA, or 103-12IE
(b) Name of sponsor of entity listed in (a)
(c) EIN-PN
(d) Entity code
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions)
(a) Name of MTIA, CCT, PSA, or 103-12IE
(b) Name of sponsor of entity listed in (a)
(c) EIN-PN
(d) Entity code
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-l2IE at end of year (see instructions)
(a) Name of MTIA, CCT, PSA, or 103-12IE
(b) Name of sponsor of entity listed in (a)
(c) EIN-PN
(d) Entity code
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions)
(a) Name of MTIA, CCT, PSA, or 103-12IE
(b) Name of sponsor of entity listed in (a)
(c) EIN-PN
(d) Entity code
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-l2IE at end of year (see instructions)
Schedule D (Form 5500) 2005 Page 3
Official Use Only
Part I Information on Participating Plans (to be completed by DFEs)
(a) Plan name
(b) Name of plan sponsor
(c) EIN-PN
(a) Plan name
(b) Name of plan sponsor
(c) EIN-PN
(a) Plan name
(b) Name of plan sponsor
(c) EIN-PN
(a) Plan name
(b) Name of plan sponsor
(c) EIN-PN
(a) Plan name
(b) Name of plan sponsor
(c) EIN-PN
(a) Plan name
(b) Name of plan sponsor
(c) EIN-PN
(a) Plan name
(b) Name of plan sponsor
(c) EIN-PN
(a) Plan name
(b) Name of plan sponsor
(c) EIN-PN
SCHEDULE I
(Form 5500)
Department of the Treasury Internal Revenue Service
Department of Labor
Employee Benefits Security
Administration
Pension Benefit Guaranty Corporation
Financial Information — Small Plan
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).
File as an attachment to Form 5500.
Official Use Only OMB No. 1210-0110
2005
This Form is Open to Public Inspection.
For calendar year 2005 or fiscal plan year beginning , and ending
| A Name of plan B Three-digit AMERICAN COMMUNITY BANK 401 (K) PSP plan number 001 C Plan sponsor's name as shown on line 2a of Form 5500 D Employer Identification Number AMERICAN COMMUNITY BANK 56-2073258 |
Complete Schedule I if the plan covered fewer than 100 participants as of the beginning of the plan year. You may also complete Schedule I if you are filing as a small plan under the 80-120 participant rule (see instructions). Complete Schedule H if reporting as a large plan or DFE.
Part I Small Plan Financial Information
Report below the current value of assets and liabilities, income, expenses, transfers and changes in net assets during the plan year. Combine the value of plan assets held in more than one trust. 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. Include all income and expenses of the plan including any trust(s) or separately maintained fund(s) and any payments/receipts to/from insurance carriers. Round off amounts to the nearest dollar.
| 1 Plan Assets and Liabilities: (a) Beginning of Year (b) End of Year a Total plan assets 1a 866781 1588232 b Total plan liabilities 1b 0 0 c Net plan assets (subtract line 1b from line 1a) 1c 866781 1588232 2 Income, Expenses, and Transfers for this Plan Year: (a) Amount (b) Total a Contributions received or receivable (1) Employers 2a(1) 85738 (2) Participants 2a(2) 250686 (3) Others (including rollovers) 2a(3) b Noncash contributions 2b c Other income 2c 77456 d Total income (add lines 2a(1), 2a(2), 2a(3), 2b, and 2c) 2d 413880 e Benefits paid (including direct rollovers) 2e 21171 f Corrective distributions (see instructions) 2f g Certain deemed distributions of participant loans (see instructions) 2g h Other expenses 2h i Total expenses (add lines 2e, 2f, 2g, and 2h) 2i 21171 j Net income (loss) (subtract line 2i from line 2d) 2j 392709 k Transfers to (from) the plan (see instructions) 2k 328742 |
3 Specific Assets: If the plan held assets at anytime during the plan year in any of the following categories, check “Yes” and enter the current value of any assets remaining in the plan as of the end of the plan year. 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.
| Yes No Amount a Partnership/joint venture interests 3a X b Employer real property 3b X For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. v8.2 Schedule I (Form 5500) 2005 |
Schedule I (Form 5500) 2005 Page 2 Official Use Only
| Yes No Amount 3c Real estate (other than employer real property) 3c X d Employer securities 3d X 162589 e Participant loans 3e X 46943 f Loans (other than to participants) 3f X g Tangible personal property 3g X Part I Transactions During Plan Year 4 During the plan year: Yes No Amount a Did the employer fail to transmit to the plan any participant contributions within the time period described in 29 CFR 2510.3-102? (See instructions and DOL’s Voluntary Fiduciary Correction Program.) 4a X b Were any loans by the plan or fixed income obligations due the plan in default as of the close of the plan year or classified during the year as uncollectible? Disregard participant loans secured by the participant’s account balance 4b X c Were any leases to which the plan was a party in default or classified during the year as uncollectible? 4c X d Were there any nonexempt transactions with any party-in-interest? (Do not include transactions reported on line 4a.) 4d X e Was the plan covered by a fidelity bond? 4e X 5000000 f Did the plan have a loss, whether or not reimbursed by the plan's fidelity bond, that was caused by fraud or dishonesty? 4f X g Did the plan hold any assets whose current value was neither readily determinable on an established market nor set by an independent third party appraiser? 4g X h Did the plan receive any noncash contributions whose value was neither readily determinable on an established market nor set by an independent third party appraiser? 4h X i 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 interest? 4i X j Were all the plan assets either distributed to participants or beneficiaries, transferred to another plan, or brought under the control of the PBGC? 4j X k Are you claiming a waiver of the annual examination and report of an independent qualified public accountant (IQPA) under 29 CFR 2520.104-46? If no, attach an IQPA’s report or 2520.104-50 statement. (See instructions on waiver eligibility and conditions.) 4k X |
5a Has a resolution to terminate the plan been adopted during the plan year or any prior plan year? If yes, enter the amount of any plan assets that reverted to the employer this year ` Yes x No Amount
5b If during this plan year, any assets or liabilities were transferred from this plan to another plan(s), identify the plan(s) to which assets or liabilities were transferred. (See instructions.)
5b(1) Name of plan(s) 5b(2) ElN(s) 5b[3) PN(s)
SCHEDULE P (FORM 5500)
Department of the Treasury Internal Revenue Service
Annual Return of Fiduciary of Employee Benefit Trust
This schedule may be filed 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) that is exempt from tax under section 501(a). File as an attachment to Form 5500 or 5500-EZ.
Official Use Only OMB No. 1210-0110
2005
This Form is Open to Public Inspection.
For trust calendar year 2005 or fiscal year beginning , and ending,
1a Name of trustee or custodian
FISEBV TRUST COMPANY
b Number, street, and room or suite no. (If a P.O. box, see the instructions for Form 5500 or 5500-EZ.)
717 17TH STREET, SUITE 2600
c City or town, state, and ZIP code
DENVER CO 80202-0000
2a Name of trust
AMERICAN COMMUNITY BANK 401 (K) PSP
b Trust’s employer identification number 84-1567636
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
5 Enter the plan sponsor’s employer identification number as shown on Form 5500 or 5500-EZ 56-2073258
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.
SIGN HERE
Signature of
fiduciary Date
For Paperwork Reduction Act Notice and OMB Control Numbers, v8.2 Schedule P (Form 5500) 2005
see the instructions for Form 5500 or 5500-EZ.
SCHEDULE SSA (Form 5500) Department of the Treasury Internal Revenue Service
Annual Registration Statement Identifying Separated Participants With Deferred Vested Benefits Under Section 6057(a) of the Internal Revenue Code File as an attachment to Form 5500 unless box 1 is checked.
Official Use Only OMB No. 1210-0110 2005 This Form is NOT Open to Public Inspection.
| For calendar plan year 2005 or fiscal plan year beginning , and ending , A Name of plan B Three-digit AMERICAN COMMUNITY BANK 401 (K) PSP plan number 001 C Plat sponsor’s name as shown on line 2a of Form 5500 D Employer Identification Number AMERICAN COMMUNITY BANK 56-2073258 |
1 Check here if plan is a government, church or other plan that elects to voluntarily file Schedule SSA. If so, complete lines 2 through 3c, and the signature area.
2 Plan sponsor’s address (number, street, and room or suite no.) (If a P.O. box, see the instructions for line 2.) City or town, state, and ZIP code
3a Name of plan administrator (if other than sponsor)
3b Administrator’s EIN
3c Number, street, and room or suite no. (If a P.O. box, see the instructions for line 2.) 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.
SIGN HERE Signature of plan administrator
Phone number of plan administrator 704-225-8444 Date
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500, v8.2 Schedule SSA (Form 5500) 2005
Schedule SSA (Form 5500) 2005 Page 2 Official Use Only
4 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 “A”, “B”, “C”, or “D” Use with entry code “A” or “B” |
| (a) Entry Code (b) Social Security Number (c) Name of Participant Enter code for nature and form of benefit Amount of vested benefit (First) (M.I.) (Last) (d) Type of annuity (e) Payment frequency (f) Defined benefit plan — periodic payment A 2 33191506 ANGELIA D HUDSON A A A 240269567 JAMES M MCRORIE A A A 243662944 ELIZABETH C MARTIN A A A 216365489 CANDACE M COOPER A A |
| Use with entry code “A” or “B” Use with entry code “C” Amount of vested benefit (a) Defined contributior plan (i) Entry Code (g) Units or shares Share indicator (h) Total value of account Previous sponsor’s employer identification number (j) Previous plan number A 542.17 A 9034.96 A 442.90 A 320.41 |
Schedule SSA (Form 5500) 2005 Page 2
Official Use Only
4 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 “A”, “B”, “C”, or “D” Use with entry code “A” or “B”
(a) Entry Code A A A A
(b) Social Security Number 249804387 296602538 343529006 413769123
(c) Name of Participant
(First) ROY JANET ELEANOR GEORGE
(M.I.) E S M M
(Last) WATKINS BROWN MCINTIRE GRAY
Enter code for nature and form of benefit (d) Type of annuity
A A A A (e) Payment frequency A A A A
Amount of vested benefit (f) Defined benefit plan — periodic payment
Use with entry code “A” or “B” (a) Entry Code A A A A
Amount of vested benefit Defined contribution plan
(g) Units of shares Share indicator (h) Total value of account
6708.92 1617.75 1212.14 11824.78
Use with entry code “C” (i) Previous sponsor’s employer identification number (j) Previous plan number
Schedule SSA (Form 5500) 2005 Page 2
Official Use Only
4 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 “A”, “B”, “C”, or “D”
Use with entry code “A” or “B”
(a) Entry Code
(b) Social Security Number
(c) Name of Participant
(First)
(M.I.)
(Last)
Enter code for nature and form of benefit
(d) Type of annuity
(e) Payment frequency
Amount of vested benefit
(f) Defined benefit plan — periodic payment
A 489613540 JENNIFER L LOCKWOOD A A
Use with entry code “A” or “B”
Use with entry code “C”
Amount of vested benefit Defined contribution plan
(a) Entry Code
(g) Units or shares
Share indicator
(h) Total value of account
(i) Previous sponsor’s employer identification number
(j) Previous plan number
A 177.23
Form 6500 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation
Annual Return/Report of Employee Benefit Plan This form is required to be filed under sections 104 and 4065 of the Employee Retirement Income Security Act of 1974 (ERISA) and sections 6047(e), 6057(b), and 6058(a) of the Internal Revenue Code (the Code). Complete all entries in accordance with the instructions to the Form 5500.
Official Use Only OMB Nos. 1210-0110/1201-0089 2004 This Form is Open to Public Inspection.
Part I Annual Report Identification Information
For the calendar plan year 2004 or fiscal plan year beginning and ending
A This return/report is for: (1) a multiemployer plan; (2) X a single-employer plan (other than a multiple-employer plan); (3) a multiple-employer plan; or (4) a DFE (specify)
B 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; (4) a short plan year return/report (less than 12 months).
C If the plan is a collectively-bargained plan, check here
D If filing under an extension of time or the DFVC program, check box and attach required information, (see instructions)
Part II Basic Plan Information — enter all requested information.
1a Name of plan
AMERICAN COMMUNITY BANK 401(K) PROF
IT SHARING PLAN
1b Three-digit plan number (PN) 001 1c Effective date of plan 07011999
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, statements, and attachments, as well as the electronic version of this return/report if it is being filed electronically, and to the best of my knowledge and belief, it is true, correct, and complete.
Signature of plan administrator
SIGN HERE
Date 7/20/05
Type or print name of individual signing as plan administrator a
Signature of employer plan sponsor/DFE
SIGN HERE
Date
Type or print name of individual signing as employer, plan sponsor or DFE
b
For Paperwork Reduction Act Notice and OMB control Numbers, see the instructions for Form 5500. Cat. No. 13500F Form 5500 (2004)
Form 5500 (2004) Page 2 Official use Only
2a Plan sponsor’s name and address (employer, if for single-employer plan) (Address should include room or suite no.)
1) AMERICAN COMMUNITY BANK
2) C/O
3) 2593 W ROOSEVELT BLVD
4) MONROE 2b Employer Identification Number (EIN)
5) NC 281100418 562073258
6) 2c Sponsor’s telephone number 7042258444
7) 2d Business code (see instructions) 52211 0
8)
9)
3a Plan administrator’s name and address (if same as plan sponsor, enter “Same”)
1) SAME
2) C/O
3)
4) 3b Administrator’s EIN
5)
6) 3c Administrator’s telephone number
7)
4 If the name and/or EIN of the plan sponsor has changed since the last return/report filed for this plan, enter the name, EIN and the plan number from the last return/report below:
a Sponsor’s name
b EIN c PN
Form 5500 (2004) Page 3 Official Use Only
5 Preparer information (optional)
a Name (including firm name, if applicable) and address
1)
2)
3) b EIN
4)
5) c Telephone number
6)
6 Total number of participants at the beginning of the plan year 79
7 Number of participants as of the end of the plan year (welfare plans complete only lines 7a, 7b, 7c, and 7d)
a Active participants 77
b Retired or separated participants receiving benefits
c Other retired or separated participants entitled to future benefits 2
d Subtotal. Add lines 7a, 7b, and 7c 79
e Deceased participants whose beneficiaries are receiving or are entitled to receive benefits
f Total. Add lines 7d and 7e 79
g Number of participants with account balances as of the end of the plan year (only defined contribution plans complete this item) 65
h Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 11
i If any participant(s) separated from service with a deferred vested benefit, enter the number of separated participants required to be reported on a Schedule SSA (Form 5500) 1
Form 5500 (2004) Page 4
Official Use Only
8 Benefits provided under the plan (complete 8a and 8b, as applicable)
a X Pension benefits (check this box if the plan provides pension benefits and enter below the applicable pension feature codes from the List of Plan Characteristics Codes (printed in the instructions):
2E 2F 2G 2J 2K 3E
b Welfare benefits (check this box if the plan provides welfare benefits and enter below the applicable welfare feature codes from the List of Plan Characteristics Codes printed in the instructions):
9a Plan funding arrangement (check all that apply)
(1) X Insurance
(2) Code Section 412(i) insurance contracts
(3) X Trust
(4) General assets of the sponsor
9b Plan benefit arrangement (check all that apply)
(1) X Insurance
(2) Code Section 412(i) insurance contracts
(3) X Trust
(4) General assets of the sponsor
10 Schedules attached (Check all applicable boxes and, where indicated, enter the number attached. See instructions.)
a Pension Benefit Schedules
1) X R (Retirement Plan Information)
2) X 1 T (Qualified Pension Plan Coverage Information)
If a Schedule T is not attached because the plan is relying on coverage testing information for a prior year, enter the year
3) B (Actuarial Information)
4) E (ESOP Annual Information)
5) X SSA (Separated Vested Participant Information)
b Financial Schedules
1) H (Financial Information)
2) X I (Financial Information—Small Plan)
3) X 1 A (Insurance Information)
4) C (Service Provider Information)
5) X D (DFE/Participating Plan Information)
6) G (Financial Transaction Schedules)
7) X 1 P (Trust Fiduciary Information)
Official Use Only
SCHEDULE A
(Form 5500)
Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security
Administration
Pension Benefit Guaranty Corporation
Insurance Information
This schedule is required to be filed under section 104 of the Employee Retirement Income Security Act of 1974
File as an attachment to Form 5500.
Insurance companies are required to provide this information pursuant to ERISA section 103(a)(2).
OMB Nos. 1210-0110
2004
This Form is Open to Public Inspection.
For calendar plan year 2004 or fiscal plan year beginning and ending
A Name of plan
AMERICAN COMMUNITY BANK 401(K) PROFIT SHARING PLAN
B Three-digit plan number
001
C Plan sponsor’s name as shown on line 2a of Form
5500 AMERICAN COMMUNITY BANK
D Employer Identification Number
562073258
Part I Information Concerning Insurance Contract Coverage, Fees, and Commissions
Provide information for each contract on a separate Schedule A. Individual contracts grouped as a unit in Parts II and III can be reported on a single Schedule A.
1 Coverage:
(a) Name of insurance carrier
PRINCIPAL LIFE INSURANCE COMPANY
(b) EIN 420127290
(c) NAIC code 61271
(d) Contract or identification number 4 - 45676
(e) Approximate number of persons covered at end of policy or contract year 79
Policy or contract year (f) From 01012004
(g) To 12312004
2 Insurance fees and commissions paid to agents, brokers, and other persons. Enter the total fees and total commissions below and list agents, brokers and other persons individually in descending order of the amount paid in the items on the following page(s) in Part I.
Totals Total amount of commissions paid Total fees paid / amount
3085 26
For Paperwork Reduction Act Notice and OMB Control Numbers, see the Instructions for Form 5500. Cat. No. 135051 Schedule A (Form 5500) 2004
Schedule A (Form 5500) 2004 Page 2 Official use Only
(a) Name and address of the agents, brokers or other persons to whom commissions or fees were paid
SHELIA C HINSON
PO BOX 27
INDIAN TRAIL NC 280790027
(b) Amount of commissions paid (c) Fees paid / Amount (e) Organization code
3085 26 3
(d) Fees paid / Purpose
SERVICE FEE
(a) Name and address of the agents, brokers or other persons to whom commissions or fees were paid
(b) Amount of commissions paid (c) Fees paid / Amount (e) Organization code
(d) Fees paid / Purpose
(a) Name and address of the agents, brokers or other persons to whom commissions or fees were paid
(b) Amount of commissions paid (C) Fees paid / Amount (e) Organization code
(d) Fees paid / Purpose
Schedule A (Form 5500) 2004 Page 3
Official Use Only
Part II Investment and Annuity Contract Information
Where individual contracts are provided, the entire group of such individual contracts with each carrier may be treated as a Unit for purposes of this report
3 Current value of plan’s interest under this contract in the general account at year end 13742
4 Current value of plan’s interest under this contract in separate accounts at year end 804666
5 Contracts With Allocated Funds
a State the basis of premium rates
b Premiums paid to carrier
c Premiums due but unpaid at the end of the year
d If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or retention of the contract or policy, enter amount Specify nature of costs
e Type of contract (1) individual policies (2) group deferred annuity (3) other (specify below)
f If contract purchased, in whole or in part, to distribute benefits from a terminating plan check here
Schedule A (Form 5500) 2004 Page 4 Official Use Only
6 Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts)
a Type of contract
(1) deposit administration (2) immediate participation guarantee (3) guaranteed investment (4) X other (specify below)
FLEXIBLE INVESTMENT ANNUITY
b Balance at the end of the previous year 13715 c Additions:
(1) Contributions deposited during the year 4684
(2) Dividends and credits
(3) Interest credited during the year 226
(4) Transferred from separate account 8
(5) Other (specify below) 105
LOAN PAYMENT
(6) Total additions 5023
d Total of balance and additions (add b and c(6)) 18738
e Deductions:
(1) Disbursed from fund to pay benefits or purchase annuities during year 2505
(2) Administration charge made by carrier 348
(3) Transferred to separate account 1053
(4) Other (specify below) 1090
LOAN WITHDRAWAL , MKT VALUE CHANGE
(5) Total deductions 4996
f Balance at the end of the current year (subtract e(5) from d) 13742
SCHEDULE D (Form 5500) Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration
DFE/Participating Plan Information This schedule is required to be filed under section 104 of the Employee Retirement Income Security Act of 1974 (ERISA). File as an attachment to Form 5500.
Official use Only OMB No. 1210-0110
2004 This Form is Open to Public Inspection.
For calendar plan year 2004 or fiscal plan year beginning
A Name of plan or DFE AMERICAN COMMUNITY BANK 401(K) PROFIT SHARING PLAN
and ending
B Three-digit plan number 001
C Plan or DFE sponsor’s name as shown on line 2a of Form 5500 AMERICAN COMMUNITY BANK
D Employer Identification Number 562073258
Part I Information on interests in MTIAs, CCTs, PSAs, and 103-12 IEs (to be completed by plans and DFEs)
(a) Name of MTIA, CCT, PSA, or 103-12IE
PRIN PTR SM–CAP BLEND SEP ACCT (b) Name of sponsor of entity listed in (a)
PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN 420127290 PN 093 (d) Entity code P (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 36127
(a) Name of MTIA, CCT, PSA, or 103-121E PRINCIPAL MONEY MKT SEP ACCT (b) Name of sponsor of entity listed in (a) PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN 420127290 PN 024 (d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 96502
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Cat. No. 22774J Schedule D (Form 5500) 2004
Schedule D (Form 5500) 2004 Page 2
Official Use Only
(a) Name of MTIA, CCT, PSA, or 103-12IE
PRINCIPAL BOND AND MTG SEP ACC
(b) Name of sponsor of entity listed in (a)
PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN 420127290 PN 005 (d) Entity code P (e) Dollar value of interest in MTIA, CCT, PSA, or 103-l2IE at end of year (see instructions) 57714
(a) Name of MTIA, CCT, PSA, or 103-12IE PRIN LG CP STK IDX SEP ACCT
(b) Name of sponsor of entity listed in (a) PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN 420127290 PN 016 (d) Entity code P (a) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 132736
(a) Name of MTIA, CCT, PSA, or 103-12IE
PRIN PTR LG–CAP GR SEP ACCT
(b) Name of sponsor of entity listed in (a)
PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN 420127290 PN 025 (d) Entity code P (e) Dollar value of interest in MTIA, CCT, PSA, or 103-l2IE at end of year (see instructions) 52143
(a) Name of MTIA, CCT, PSA, or 103-12IE PRIN MID CAP STK IDX SEP ACCT
(b) Name of sponsor of entity listed in (a) PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN 420127290 PN 023 (d) Entity code P (e) Dollar value of interest in MTIA, CCT, PSA, or 103-l2IE at end of year (see instructions) 69710
Schedule D (Form 5500) 2004 Page 2
Official Use Only
(a) Name of MTIA, CCT, PSA, or 103-12IE
PRIN PTR MD – CP GROWTH SEP ACCT
(b) Name of sponsor of entity listed in (a)
PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN 420127290
PN 026
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 23410
(a) Name of MTIA, CCT, PSA, or 103-12IE
PRIN SM CAP STK IDX SEP ACCT
(b) Name of sponsor of entity listed in (a)
PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN 420127290
PN 028
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 55083
(a) Name of MTIA, CCT, PSA, or 103-l2IE
PRINCIPAL INTL SM CO SEP ACCT
(b) Name of sponsor of entity listed in (a)
PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN 420127290
PN 014
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-l2IE at end of year (see instructions) 38514
(a) Name of MTIA, CCT, PSA, or 103-12IE
PRINCIPAL DIVERS INTL SEP ACCT
(b) Name of sponsor of entity listed in (a)
PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN 420127290
PN 015
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 53727
Schedule D (Form 5500) 2004 Page 2
Official Use Only
(a) Name of MTIA, CCT, PSA, or 103-12IE
PUTNAM VOYAGER (M) SEP ACCT
(b) Name of sponsor of entity listed in (a)
PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN 420127290
PN 037
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 0
(a) Name of MTIA, CCT, PSA, or 103-12IE
AMER CT INC & GR (ADV) SP ACCT
(b) Name of sponsor of entity listed in (a)
PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN 420127290
PN 044
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-l2IE at end of year (see instructions) 76242
(a) Name of MTIA, CCT, PSA, or 103-12IE
PRIN PTNR MD–CP GR II SEP ACCT
(b) Name of sponsor of entity listed in (a)
PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN 420127290
PN 047
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-l2IE at end of year (see instructions) 99106
(a) Name of MTIA, CCT, PSA, or 103-l2IE
F1D ADV VAL STRAT SEP ACCT
(b) Name of sponsor of entity listed in (a)
PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN 420127290
PN 054
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 0
Schedule D (Form 5500) 2004 Page 2
Official Use Only
(a) Name of MTIA, CCT, PSA, or 103-12IE
INVESCO SMALL CO GR SEP ACCT
(b) Name of sponsor of entity listed in (a)
PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN 420127290
PN 058
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 9820
(a) Name of MTIA, CCT, PSA, or 103-12IE
INVESCO LEISURE SEP ACCT
(b) Name of sponsor of entity listed in (a)
PRINCIPAL LIFE INSURANCE COMPANY
(c) EIN 420127290
PN 059
(d) Entity code P
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 3831
(a) Name of MTIA, CCT, PSA, or 103-12IE
(b) Name of sponsor of entity listed in (a)
(c) EIN
PN
(d) Entity code
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions)
(a) Name of MTIA, CCT, PSA, or 103-l2IE
(b) Name of sponsor of entity listed in (a)
(c) EIN
PN
(d) Entity code
(e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions)
SCHEDULE I (Form 5500) Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits security Administration Pension Benefit Guaranty corporation
Financial Information — Small Plan
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).
File as an attachment to Form 5500.
Official Use Only OMB No. 1210-0110 2004 This Form is Open to Public Inspection.
For the calendar plan year 2004 or fiscal plan year beginning and ending
A Name of plan AMERICAN COMMUNITY BANK 401(K) PROFIT SHARING PLAN
B Three-digit plan number 001
C Plan sponsor’s name as shown on line 2a of Form 5500 AMERICAN COMMUNITY BANK
D Employer Identification Number 562073258
Complete Schedule I if the plan covered fewer than 100 participants as of the beginning of the plan year. You may also complete Schedule I if you are filing as a small plan under the 80-120 participant rule (see instructions). Complete Schedule H if reporting as a large plan or DFE.
Part I Small Plan Financial Information
Report below the current value of assets and liabilities, income, expenses, transfers and changes in net assets during the plan year. Combine the value of plan assets held in more than one trust. 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. Include all income and expenses of the plan including any trust(s) or separately maintained fund(s) and any payments/receipts to/from insurance carriers. Round off amounts to the nearest dollar.
1 Plan Assets and Liabilities: (a) Beginning of Year (b) End of Year
a Total plan assets: 621069 866781 b Total plan liabilities c Net plan assets (subtract line 1b from line 1a) 621069 866781
2 Income, Expenses, and Transfers for this Plan Year: (a) Amount
a Contributions received or receivable (1) Employers 58097 (2) Participants 164094 (3) Others (including rollovers) b Noncash Contributions c Other income 84133 (b) Total
d Total income (add lines 2a(1), 2a(2), 2a(3), 2b, and 2c) 306324 For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Cat. No. 244l4Y schedule I (Form 5500) 2004
Schedule I (Form 5500) 2004 Page 2 Official Use Only
(a) Amount 2e Benefits paid (including direct rollovers) 49019 f Corrective distributions (see instructions) g Certain deemed distributions of participant loans (see instructions) h Other expenses 11593 (b) Total i Total expenses (add lines 2e, 2f, 2g, and 2h) 60612 j Net income (loss) (subtract line 2i from line 2d) 245712 k Transfers to (from) the plan (see instructions)
3 Specific Assets: If the plan held assets at any time during the plan year in any of the following categories, check “Yes” and enter the current value of any assets remaining in the plan as of the end of the plan year. 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. Yes No Amount
a Partnership/joint venture interests X b Employer real property X c Real estate (other than employer real property) X d Employer securities X e Participant loans X 39860 f Loans (other than to participants) X g Tangible personal property X
Part II Transactions During Plan Year 4 During the plan year: Yes No Amount a Did the employer fail to transmit to the plan any participant contributions within the time period described in 29 CFR 2510-3-102? (See instructions and DOL’s Voluntary Fiduciary Correction Program.) X b Were any loans by the plan or fixed income obligations due the plan in default as of the close of the plan year or classified during the year as uncollectible? Disregard participant loans secured by the participant’s account balance X c Were any leases to which the plan was a party in default or classified during the year as uncollectible? X
Schedule I (Form 5500) 2004 Page 3 Official Use Only
Yes No Amount
4d Were there any nonexempt transactions with any party-in-interest? (Do not include transactions reported on line 4a.) X
e Was the plan covered by a fidelity bond? X 1000000
f Did the plan have a loss, whether or not reimbursed by the plan’s fidelity bond, that was caused by fraud or dishonesty? X
g Did the plan hold any assets whose current value was neither readily determinable on an established market nor set by an independent third party appraiser? X
h Did the plan receive any noncash contributions whose value was neither readily determinable on an established market nor set by an independent third party appraiser? X
i 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 interest? X
j Were all the plan assets either distributed to participants or beneficiaries, transferred to another plan, or brought under the control of the PBGC? X
k Are you claiming a waiver of the annual examination and report of an independent qualified public accountant (IQPA) under 29 CFR 2520.104-46? If no, attach the IQPA’s report or 2520.104-50 statement. (See instructions on waiver eligibility and conditions.) X
5a Has a resolution to terminate the plan been adopted during the plan year or any prior plan year? If yes, enter the amount of any plan assets that reverted to the employer this year Yes No X Amount
5b If during the plan year, any assets or liabilities were transferred from this plan to another plan(s), identify the plan(s) to which assets or liabilities were transferred. (See instructions.)
5b(1) Name of plan 5b(2) EIN 5b(3) PN
5b(1) Name of plan 5b(2) EIN 5b(3) PN
5b(1) Name of plan 5b(2) EIN 5b(3) PN
SCHEDULE P (Form 5500)
Annual Return of Fiduciary of Employee Benefit Trust This schedule may be filed 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) that is exempt from tax under section 501(a). File as an attachment to Form 5500 or 5500-EZ.
Official Use Only OMB No. 1210-0110 2004 This Form is Open to Public Inspection.
Department of the Treasury Internal Revenue Service
For the trust calendar year 2004 or fiscal trust year beginning and ending
Please type or print 1a Name of trustee or custodian DAN ELLIS
b Number, street, and room or suite no. (If a P.O. box, see the instructions for Form 5500 or 5500-EZ.) 2593 W ROOSEVELT BLVD P.O. BOX 5035
c City or town State ZIP code MONROE NC 281115035
2a Name of trust AMERICAN COMMUNITY BANK 401(K) PROFIT SHARING PLAN
b Trust’s employer identification number 420127290
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
5 Enter the plan sponsor’s employer identification number as shown on Form 5500 or 5500-EZ 562073258
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
SIGN HERE
Date 7/20/05
For Paperwork Reduction Act Notice and OMB Control Nos., see the inst. for Form 5500 or 5500-EZ. Cat. No. 13504X Schedule P (Form 5500) 2004
SCHEDULE R (Form 5500) Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation
Retirement Plan Information This schedule is required to be filed under section 104 and 4065 of the Employee Retirement Security Act of 1974 (ERISA) and section 6058(a) of the Internal Revenue Code (the Code). File as an Attachment to Form 5500.
Official Use only OMB No. 1210-0110 2004 This Form is Open to Public Inspection.
For the calendar plan year 2004 or fiscal plan year beginning and ending
A Name of plan-AMERICAN COMMUNITY BANK 401(K) PROFIT SHARING PLAN B Three-digit plan number 001
C Plan sponsor’s name as shown on line 2a of Form 5500 AMERICAN COMMUNITY BANK
D Employer Identification Number 562073258
Part I Distributions
All references to distributions relate only to payments of benefits during the plan year.
1 Total value of distributions paid in property other than in cash or the forms of property specified in the instructions
2 Enter the EIN(s) of payor(s) who paid benefits on behalf of the plan to participants or beneficiaries during the year (if more than two, enter EINs of the two payors who paid the greatest dollar amounts of benefits). } Profit-sharing plans, ESOPs, and stock bonus plans, skip line 3. 420127290
3 Number of participants (living or deceased) whose benefits were distributed in a single sum, during the plan year
Part II Funding Information (If the plan is not subject to the minimum funding requirements of section 412 of the Internal Revenue Code or ERISA section 302, skip this Part)
4 Is the plan administrator making an election under Code section 412(c)(8) or ERISA section 302(c)(8)? Yes No N/A If the plan is a defined benefit plan, go to line 7.
5 If a waiver of the minimum funding standard for a prior year is being amortized in this plan year, see instructions, and enter the date of the ruling letter granting the waiver. If you completed line 5, complete lines 3, 9, and 10 of Schedule B and do not complete the remainder of this schedule.
6a Enter the minimum required contribution for this plan year b Enter the amount contributed by the employer to the plan for this plan year
c Subtract the amount in line 6b from the amount in line 6a. Enter the result (enter a minus sign to the left of a negative amount.)
If you completed line 6c, do not complete the remainder of this schedule. For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Cat. No. 24419B Schedule R (Form 5500) 2004
Schedule R (Form 5500) 2004 Page 2
Official Use Only
7 If a change in actuarial cost method was made for this plan year pursuant to a revenue procedure providing automatic approval for the change, or a class ruling letter, does the plan sponsor or plan administrator agree with the change? Yes No N/A
Part III Amendments
8 If this is a defined benefit pension plan, were any amendments adopted during this plan year that increased the value of benefits? (see instructions) Yes No
Official Use Only
SCHEDULE SSA
(Form 5500)
Department of the Treasury Internal Revenue Service
Annual Registration Statement Identifying Separated Participants With Deferred Vested Benefits
Under Section 6057(a) of the Internal Revenue Code.
File as an attachment to Form 5500 unless box 1 is checked.
OMB No. 1210-0110
2004
This Form is NOT Open to Public Inspection.
For calendar plan year 2004 or fiscal plan year beginning and ending
A Name of Plan
AMERICAN COMMUNITY BANK 401(K) PROFIT SHARING PLAN
C Plan sponsor’s name as shown on line 2a of Form 5500
AMERICAN COMMUNITY BANK
B Three-digit plan number 001
D Employer Identification Number 562073258
1 Check here if plan is a government, church or other plan that elects to voluntarily file Schedule SSA. If so, complete lines 2 through 30, and the signature area.
2 Plan sponsor’s address (number, street, and room or suite no.) (If a P.O. box, see the instructions for line 2.)
City or town State ZIP code
3a Name of plan administrator (if other than sponsor)
3b Administrator’s EIN
3c Number, street, and room or suite no. (If a P.O. box, see the instructions for line 2.)
City or town State 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.
Phone number of plan administrator
Signature of plan administrator
SIGN HERE Date 7/20/05
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Cat. No. 13506T Schedule SSA (Form 5500) 2004
Schedule SSA (Form 5500) 2004 Page 2 Official Use Only
4 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 “A”, “B”, “C,” or “D”
(a) Entry code A (b) Social security number 251807591
(c) Name of participant (First) (M.I.) (Last)
MARY M NANCE
Use with entry code “A” or “B”
Enter code for nature and form of benefit
Amount of vested benefit Defined contribution plan
Share indicator
(f) Defined benefit plan — periodic payment
(g) Units or shares
(d) Type of annuity
(e) Payment frequency
(h) Total value of account
A A 21672 01
(i) Previous sponsor’s employer identification number
(j) Previous plan number
Use with entry code “C”
Use with entry code “A”, “B”, “C,” or “D”
(a) Entry code (b) Social security number
(c) Name of participant (First) (M.I.) (Last)
Use with entry code “A” or “B”
Enter code for nature and form of benefit
Amount of vested benefit Defined contribution plan
Share indicator
(g) Units or shares
(f) Defined benefit plan — periodic payment
(d) Type of annuity
(e) Payment frequency
(h) Total value of account
(i) Previous sponsor’s employer identification number
(j) Previous plan number
Use with entry code “C”
Qualified Pension Plan Coverage Information
Official Use Only
OMB No. 1210-0110
2004
This Form is Open to Public Inspection.
SCHEDULE T
(Form 5500)
This form is required to be filed under section 6058(a) of the
Internal Revenue Code (the Code).
File as an attachment to Form 5500.
Department of the Treasury Internal Revenue service
For the calendar plan year 2004 or fiscal plan year beginning and ending
A Name of plan
AMERICAN COMMUNITY BANK 401(K) PROFIT SHARING PLAN
B Three-digit plan number 001
C Plan sponsor’s name as shown on line 2a of Form 5500
D Employer Identification Number
AMERICAN COMMUNITY BANK 562073258
Note: If the plan is maintained by:
• More than one employer and benefits employees who are not collectively-bargained employees, a separate Schedule T may be required for each employer (see the instructions for line 1).
• An employer that operates qualified separate lines of business (QSLOBs) under Code section 414(r), a separate Schedule T may be required for each QSLOB (see the instructions for line 2).
1 If this schedule is being filed to provide coverage information regarding the noncollectively bargained employees of an employer participating in a plan maintained by more than one employer, enter the name and EIN of the participating employer:
1a Name of participating employer
1b Employer identification number
2 If the employer maintaining the plan operates QSLOBs, enter the following information:
a The number of QSLOBs that the employer operates is
b The number of such OSLOBs that have employees benefiting under this plan is
c Does the employer apply the minimum coverage requirements to this plan on an employer-wide rather than a QSLOB basis? Yes No
d If the entry on line 2b is two or more and line 2c is “No,” identify the QSLOB to which the coverage information given on line 3 or 4 relates.
3 Exceptions—Check the box before each statement that describes the plan or the employer. Also see instructions. If you check any box, do not complete the rest of this Schedule.
a The employer employs only highly compensated employees (HCEs).
b X No HCEs benefited under the plan at any time during the plan year.
c The plan benefits only collectively-bargained employees.
d X The plan benefits all nonexcludable nonhighly compensated employees of the employer (as defined in Code sections 414(b), (c), and (m)), including leased employees and self-employed individuals.
e The plan is treated as satisfying the minimum coverage requirements under Code section 410(b)(6)(C).
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Cat. No. 22770R Schedule T (Form 5500) 2004
Schedule T (Form 5500) 2004 Page 2
Official Use Only
4 Enter the date the plan year began for which coverage data is being submitted
a Did any leased employees perform services for the employer at any time during the plan year? Yes No
b In testing whether the plan satisfies the coverage and nondiscrimination tests of Code sections 410(b) and 401(a)(4), does the employer aggregate plans? Yes No
c Complete the following:
(1) Total number of employees of the employer (as defined in Code section 414(b), (c), and (m)), including leased employees and self-employed individuals
(2) Number of excludable employees as defined in IRS regulations (see instructions)
(3) Number of nonexcludable employees. (Subtract line 4c(2) from line 4c(1))
(4) Number of nonexcludable employees (line 4c(3)) who are HCEs
(5) Number of nonexcludable employees (line 4c(3)) who benefit under the plan
(6) Number of benefiting nonexcludable employees (line 4c(5)) who are HCEs
d Enter the plan’s ratio percentage and, if applicable, identify below the disaggregated part of the plan to which the information on lines 4c and 4d pertains (see instructions)
e Identify any disaggregated part of the plan and enter the ratio percentage or exception (see instructions).
Disaggregated Part: Ratio Percentage: Exception:
(1)
(2)
(3)
f This plan satisfies the coverage requirements on the basis of (check one):
(1) the ratio percentage test (2) average benefit test