-----BEGIN PRIVACY-ENHANCED MESSAGE----- Proc-Type: 2001,MIC-CLEAR Originator-Name: webmaster@www.sec.gov Originator-Key-Asymmetric: MFgwCgYEVQgBAQICAf8DSgAwRwJAW2sNKK9AVtBzYZmr6aGjlWyK3XmZv3dTINen TWSM7vrzLADbmYQaionwg5sDW3P6oaM5D3tdezXMm7z1T+B+twIDAQAB MIC-Info: RSA-MD5,RSA, A7kyM7r3PkpgAXMBjzW7noxs6p4PPM6rANdhaucANQm9vvHVeCrTMGoy4GtmI5lH 5++GpatOVdKvjU3iyhuT+w== 0001015402-02-003043.txt : 20020830 0001015402-02-003043.hdr.sgml : 20020830 20020830141044 ACCESSION NUMBER: 0001015402-02-003043 CONFORMED SUBMISSION TYPE: S-8 PUBLIC DOCUMENT COUNT: 6 FILED AS OF DATE: 20020830 EFFECTIVENESS DATE: 20020830 FILER: COMPANY DATA: COMPANY CONFORMED NAME: SAFEGUARD HEALTH ENTERPRISES INC CENTRAL INDEX KEY: 0000727303 STANDARD INDUSTRIAL CLASSIFICATION: HOSPITAL & MEDICAL SERVICE PLANS [6324] IRS NUMBER: 521528581 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: S-8 SEC ACT: 1933 Act SEC FILE NUMBER: 333-98989 FILM NUMBER: 02754034 BUSINESS ADDRESS: STREET 1: 95 ENTERPRISE T CITY: ALISO VIEJO STATE: CA ZIP: 92656-2601 BUSINESS PHONE: 9494254110 S-8 1 doc1.txt AS FILED WITH THE SECURITIES AND EXCHANGE COMMISSION ON AUGUST 30, 2002 ================================================================================ SECURITIES AND EXCHANGE COMMISSION WASHINGTON, D.C. 20549 ________ FORM S-8 REGISTRATION STATEMENT UNDER THE SECURITIES ACT OF 1933 ________ SAFEGUARD HEALTH ENTERPRISES, INC. (Exact name of registrant as specified in its charter) DELAWARE 52-1528581 (State or other jurisdiction of (I.R.S. Employer incorporation or organization) Identification No.) 95 ENTERPRISE, SUITE 100 ALISO VIEJO, CALIFORNIA 92656-2605 (Address of principal executive offices) SAFEGUARD HEALTH ENTERPRISES, INC. 401(K) PLAN (Full title of the plan) RONALD I. BRENDZEL, ESQ. SENIOR VICE PRESIDENT, GENERAL COUNSEL AND SECRETARY SAFEGUARD HEALTH ENTERPRISES, INC. 95 ENTERPRISE, SUITE 100 ALISO VIEJO, CALIFORNIA 92656-2605 TEL: (949) 425-4110 FAX: (949) 425-4586 (Name, address and telephone number of agent for service) COPIES TO: STRASBURGER & PRICE, L.L.P. 901 MAIN STREET, SUITE 4300 DALLAS, TEXAS 75202 (214) 651-4300 ATTN: DAVID K. MEYERCORD, ESQ.
CALCULATION OF REGISTRATION FEE ======================================================================================================================= PROPOSED PROPOSED MAXIMUM AMOUNT TO BE MAXIMUM OFFERING AGGREGATE OFFERING AMOUNT OF TITLE OF SECURITIES TO BE REGISTERED REGISTERED (1) (2) PRICE PER SHARE (3) PRICE (3) REGISTRATION FEE - ------------------------------------ ------------------ -------------------- -------------------- ----------------- Common Stock, $.01 par value 500,000 shares $ 1.275 $ 637,500 $ 58.65 ======================================================================================================================= (1) Represents the maximum aggregate number of shares of Common Stock that can be purchased by the employee benefit plan described herein. (2) In addition, pursuant to Rule 416(c) under the Securities Act of 1933, as amended, this Registration Statement also includes an indeterminate amount of interests to be offered or sold pursuant to the employee benefit plan described herein. (3) Estimated solely for purposes of computing the amount of the registration fee in accordance with Rule 457(h) under the Securities Act of 1933, as amended, based on the average of the bid and asked prices for the Common Stock on the OTC Bulletin Board on August 27, 2002.
PART II INFORMATION REQUIRED IN THE REGISTRATION STATEMENT ITEM 3. INCORPORATION OF DOCUMENTS BY REFERENCE. The following documents are incorporated by reference in this Registration Statement by SafeGuard Health Enterprises, Inc., a Delaware corporation (the "Company", the "Registrant" or "SafeGuard"), and SafeGuard Health Enterprises, Inc. 401(k) Plan (the "Plan"): (a) the Annual Report on Form 10-K of SafeGuard for the fiscal year ended December 31, 2001, filed by SafeGuard with the Securities and Exchange Commission (the "SEC"); (b) the Quarterly Report on Form 10-Q of SafeGuard for the quarter ended March 31, 2002, filed with the SEC; (c) the Quarterly Report on Form 10-Q of SafeGuard for the quarter ended June 30, 2002, filed with the SEC; (d) the Current Report on Form 8-K of SafeGuard dated as of April 24, 2002 filed with the SEC; (e) the description of the Common Stock, $.01 par value per share (the "Common Stock"), of the Company contained in Item 1 of the Registration Statement on Form 8-A filed pursuant to Section 12 of the Securities Exchange Act of 1934, as amended (the "Exchange Act"), relating to the Common Stock, as declared effective on November 17, 1983 (File No. 2-86472); and (f) the description of the Rights to Purchase Preferred Stock of the Company contained in Item 1 of our Registration Statement on Form 8-A/12G filed under Section 12 of the Exchange Act, relating to the Rights to Purchase Preferred Stock, filed with the SEC on April 1, 1996, including all amendments or reports filed for purposes of updating such description. All documents subsequently filed by the Company or the Plan pursuant to Sections 13(a), 13(c), 14 and 15(d) of the Exchange Act, prior to the filing of a post-effective amendment to the Registration Statement which indicates that all securities offered hereby have been sold or which deregisters all such securities then remaining unsold, shall be deemed to be incorporated by reference in the Registration Statement and to be a part hereof from the date of filing of such documents. Any statement contained in a document incorporated or deemed to be incorporated by reference herein shall be deemed to be modified or superseded for purposes of this Registration Statement to the extent that a statement contained herein or in any other subsequently filed document which also is or is deemed to be incorporated by reference herein modifies or replaces such statement. Any statement so modified shall not be deemed in its unmodified form to constitute a part of this Registration Statement. Any statement so superseded shall not be deemed to constitute a part of this Registration Statement. ITEM 4. DESCRIPTION OF SECURITIES. Not applicable. ITEM 5. INTERESTS OF NAMED EXPERTS AND COUNSEL. Not applicable. ITEM 6. INDEMNIFICATION OF DIRECTORS AND OFFICERS. Under Section 145 of the Delaware General Corporation Law ("Delaware Law"), the Company has broad powers to indemnify its directors, officers, employees and agents against liabilities they may incur in such capacities, including liabilities under the Securities Act. The Company's Certificate of Incorporation and Bylaws provide that the Company shall indemnify its directors and officers to the fullest extent permitted by law, and allow the Company to advance litigation expenses in the case of stockholder derivative actions or other actions, against an undertaking by the director or officer to repay such advances if it is ultimately determined that the director or officer is not entitled to indemnification. The Bylaws also provide that rights conferred Bylaws shall not be deemed to be exclusive of any other right such persons may have or acquire under the Bylaws, agreement, vote of stockholders or disinterested directors, or otherwise. The Certificate of Incorporation further provides that, pursuant to Delaware Law, no director of the Company shall be personally liable to the Company or its stockholders for monetary damages for breach of the director's fiduciary duty as a director. This provision in the Certificate of Incorporation does not eliminate the duty of care, and in appropriate circumstances equitable remedies such as injunctive or other forms of non-monetary relief will remain available under Delaware Law. In addition, each director will continue to be subject to liability for breach of the director's duty of loyalty to the Company or its stockholders, for acts or omissions not in good faith or involving intentional misconduct, for knowing violations of law, for actions leading to improper personal benefit to the director, and for payment of dividends or approval of stock repurchases or redemptions that are unlawful under Delaware Law. The provision also does not affect a director's responsibilities under any other law, such as the federal securities laws or state or federal environmental laws. ITEM 7. EXEMPTION FROM REGISTRATION CLAIMED. Not applicable. ITEM 8. EXHIBITS. EXHIBIT NO. DESCRIPTION - ----- ----------- 4.1 Amended and Restated Certificate of Incorporation of the Company, as amended (incorporated herein by reference to Exhibit 4.4 to the Company's Report on Form 8-K dated as of March 6, 2001). 4.2 Amendment to Restated Certificate of Incorporation of the Company (filed herewith). 4.3 Amended and Restated Bylaws of the Company (incorporated herein by reference to Exhibit 3.2 to the Company's Quarterly Report on Form 10-Q for the quarter ended March 31, 2001). 4.4 Specimen Common Stock Certificate (filed herewith). 4.5 Amended and Restated SafeGuard Health Enterprises, Inc. 401(k) Plan (incorporated herein by reference to Exhibit 10.28 to the Company's Annual Report on Form 10-K for the year ended December 31, 2001). 4.6 First Amendment to Amended and Restated SafeGuard Health Enterprises, Inc. 401 (k) Plan (incorporated herein by reference to Exhibit 10.29 to the Company's Annual Report on Form 10-K for the year ended December 31, 2001). 23.1 Independent Auditors' Consent (filed herewith). 24.1 Power of Attorney (contained on signature page of this Registration Statement). 25.1 Annual Report for the Plan for the year ended December 31, 2000 filed with Internal Revenue Service on September 19, 2001 (filed herewith). 99.1 Certification Pursuant to 18 U.S.C., Section 1350 (filed herewith). The undersigned Registrant hereby undertakes that it will submit in a timely manner to the Internal Revenue Service ("IRS"), the Plan and all amendments thereto made since the date of its most recent determination letter from the IRS, that it will make all changes required by the IRS in order to qualify the Plan as so amended, and that when it receives a favorable determination letter, it will file a copy of such determination letter as an exhibit to a future filing with the SEC. ITEM 9. UNDERTAKINGS. (a) The undersigned Registrant hereby undertakes: (1) To file, during any period in which offers or sales are being made, a post-effective amendment to this Registration Statement: (i) To include any prospectus required by Section 10(a)(3) of the Securities Act of 1933; (ii) To reflect in the prospectus any facts or events arising after the effective date of the Registration Statement (or the most recent post-effective amendment thereof) which, individually or in the aggregate, represent a fundamental change in the information set forth in the Registration Statement; and (iii) To include any material information with respect to the plan of distribution not previously disclosed in the Registration Statement or any material change to such information in the Registration Statement; Provided, however, that paragraphs (a)(1)(i) and (a)(1)(ii) above do not apply if the information required to be included in a post-effective amendment by those paragraphs is contained in periodic reports filed with or furnished to the Commission by the Company pursuant to Section 13 or Section 15(d) of the Securities Exchange Act of 1934 that are incorporated by reference in the Registration Statement. (2) That, for the purpose of determining any liability under the Securities Act of 1933, each such post-effective amendment shall be deemed to be a new registration statement relating to the securities offered therein, and the offering of such securities at that time shall be deemed to be the initial bona fide offering thereof. (3) To remove from registration by means of a post-effective amendment any of the securities being registered which remain unsold at the termination of the offering. (b) The undersigned Registrant hereby undertakes that, for purposes of determining any liability under the Securities Act of 1933, each filing of the Company's annual report pursuant to Section 13(a) or Section 15(d) of the Securities Exchange Act of 1934 (and, where applicable, each filing of an employee benefit plan's annual report pursuant to Section 15(d) of the Securities Exchange Act of 1934) that is incorporated by reference in the Registration Statement shall be deemed to be a new registration statement relating to the securities offered therein, and the offering of such securities at that time shall be deemed to be the initial bona fide offering thereof. (c) Insofar as indemnification for liabilities arising under the Securities Act of 1933 may be permitted to directors, officers and controlling persons of the Company pursuant to the foregoing provisions or otherwise, the Company has been advised that in the opinion of the Commission such indemnification is against public policy as expressed in the Act and is, therefore, unenforceable. In the event that a claim for indemnification against such liabilities (other than the payment by the Company of expenses incurred or paid by a director, officer or controlling person of the Company in the successful defense of any action, suit or proceeding) is asserted by such director, officer or controlling person in connection with the securities being registered, the Company will, unless in the opinion of its counsel the matter has been settled by controlling precedent, submit to a court of appropriate jurisdiction the question whether such indemnification by it is against public policy as expressed in the Act and will be governed by the final adjudication of such issue. SIGNATURES THE COMPANY. Pursuant to the requirements of the Securities Act of 1933, the Company certifies that it has reasonable grounds to believe that it meets all of the requirements for filing on Form S-8 and has duly caused this Registration Statement on Form S-8 to be signed on its behalf by the undersigned, thereunto duly authorized, in the City of Aliso Viejo, State of California, on August 27, 2002. SAFEGUARD HEALTH ENTERPRISES, INC. By: /s/ James E. Buncher ------------------------------------- James E. Buncher President and Chief Executive Officer By: /s/ Ronald I. Brendzel ------------------------------------- Ronald I. Brendzel Senior Vice President and Secretary POWER OF ATTORNEY Each person whose signature appears below constitutes and appoints James E. Buncher and/or Ronald I. Brendzel, his true and lawful attorneys-in-fact and agents, each acting alone, with full powers of substitution and resubstitution, for him and in his name, place and stead, in any and all capacities, to sign any and all amendments (including post-effective amendments) to this Registration Statement and to file the same, with all exhibits thereto, and other documents in connection therewith, with the Securities and Exchange Commission, granting unto said attorneys-in-fact and agents, each acting alone, full power and authority to do and perform each and every act and thing requisite and necessary to be done in and about the premises, as fully to all intents and purposes as he might or could do in person, hereby ratifying and confirming all that said attorneys-in-fact and agents, each acting alone, or his substitute or substitutes, may lawfully do or cause to be done by virtue hereof. Pursuant to the requirements of the Securities Act of 1933, this Registration Statement has been signed by the following persons in the capacities and on the dates indicated.
SIGNATURE CAPACITY DATE ====================== ======================================= =============== /s/ James E. Buncher President, Chief Executive Officer and August 27, 2002 - ---------------------- Director James E. Buncher /s/ Steven J. Baileys Chairman of the Board of Directors August 27, 2002 - ---------------------- Steven J. Baileys /s/ Ronald I. Brendzel Senior Vice President, General Counsel, August 27, 2002 - ---------------------- Secretary and Director Ronald I. Brendzel /s/ Dennis L. Gates Senior Vice President, Chief Financial August 27, 2002 - ---------------------- Officer and Director Dennis L. Gates /s/ Jack R. Anderson Director August 27, 2002 - ---------------------- Jack R. Anderson /s/ Stephen J. Blewitt Director August 27, 2002 - ---------------------- Steven J. Blewitt /s/ Leslie B. Daniels Director August 27, 2002 - ---------------------- Leslie B. Daniels
THE PLAN. Pursuant to the requirements of the Securities Act of 1933, the Plan Administrator has duly caused this Registration Statement to be signed on its behalf by the undersigned, thereunto duly authorized, in the City of Aliso Viejo, State of California, on August 27, 2002. SAFEGUARD HEALTH ENTERPRISES, INC. By: /s/ James E. Buncher ------------------------------------- James E. Buncher President and Chief Executive Officer By: /s/ Ronald I. Brendzel ------------------------------------- Ronald I. Brendzel Senior Vice President and Secretary INDEX TO EXHIBITS ----------------- EXHIBIT NO. DESCRIPTION - ----- ----------- 4.1 Amended and Restated Certificate of Incorporation of the Company, as amended (incorporated herein by reference to Exhibit 4.4 to the Company's Report on Form 8-K dated as of March 6, 2001). 4.2 Amendment to Restated Certificate of Incorporation of the Company (filed herewith). 4.3 Amended and Restated Bylaws of the Company (incorporated herein by reference to Exhibit 3.2 to the Company's Quarterly Report on Form 10-Q for the quarter ended March 31, 2001). 4.4 Specimen Common Stock Certificate (filed herewith). 4.5 Amended and Restated SafeGuard Health Enterprises, Inc. 401(k) Plan (incorporated herein by reference to Exhibit 10.28 to the Company's Annual Report on Form 10-K for the year ended December 31, 2001). 4.6 First Amendment to Amended and Restated SafeGuard Health Enterprises, Inc. 401 (k) Plan (incorporated herein by reference to Exhibit 10.29 to the Company's Annual Report on Form 10-K for the year ended December 31, 2001). 23.1 Independent Auditors' Consent (filed herewith). 24.1 Power of Attorney (contained on signature page of this Registration Statement). 25.1 Annual Report for the Plan for the year ended December 31, 2000 filed with Internal Revenue Service on September 19, 2001 (filed herewith). 99.1 Certification Pursuant to 18 U.S.C., Section 1350 (filed herewith). EX-4.2 3 doc2.txt AMENDMENT TO RESTATED CERTIFICATE OF INCORPORATION OF SAFEGUARD HEALTH ENTERPRISES, INC. The Corporation was originally incorporated in Delaware under the name "SFGD Reincorporation Company" on April 27, 1987, and the Restated Certificate of Incorporation was duly adopted in accordance with Section 245 and 242 of the General Corporation Law of Delaware on October 25, 2000. The Corporation hereby amends the first paragraph of Article Fourth of the Restated Certificate of Incorporation so that the first paragraph of Article Fourth reads as follow: "FOURTH. The total number of shares of stock that the corporation shall have authority to issue is Seventy-Three Million Five Hundred Thousand (73,500,000), of which Forty-Two Million Five Hundred Thousand (42,500,000) shares are Common Stock, one cent ($.01) par value per share, and Thirty-One Million (31,000,000) shares are Preferred Stock, one cent ($.01) par value per share." All other terms of the Company's Restated Certificate of Incorporation dated as of October 25, 2000, shall remain the same. We the undersigned do hereby certify that the forgoing is a true and correct Amendment to the Restated Certificate of Incorporation of SafeGuard Health Enterprises, Inc. a Delaware Corporation. Executed as of the 30th day of May 2002 at Aliso Viejo, California. SafeGuard Health Enterprises, Inc. /s/ James E. Buncher --------------------------- By: JAMES E. BUNCHER President and Chief Executive Officer /s/Ronald I. Brendzel --------------------------- By: RONALD I. BRENDZEL Senior Vice President and Secretary EX-4.4 4 doc3.txt INCORPORATED UNDER THE LAWS OF THE STATE OF DELAWARE NUMBER SHARES SFS6979 SAFEGUARD SAFEGUARD HEALTH ENTERPRISES, INC. SEE REVERSE FOR CERTAIN DEFINITIONS CUSIP 786444 10 9 ================================================================================ This Certifies that Is the record holder of ================================================================================ FULLY PAID AND NONASSESSABLE SHARES OF THE PAR VALUE OF $0.01 EACH OF THE COMMONS STOCK OF SAFEGUARD HEALTH ENTERPRISES, INC. transferable only on the books of the Corporation by the holder hereof in person or by Attorney upon surrender of this Certification properly endorsed. This Certificate is not valid until countersigned by the Transfer Agent and registered by the Registrar: Witness the facsimile seal of the Corporation and the facsimile signatures of its duly authorized officers. See Reverse for abbreviations and statement of Rights Granted To each class of shares Dated: /s/ /s/ Secretary President [Seal] EX-23.1 5 doc4.txt Exhibit 23.1 - ------------- INDEPENDENT AUDITORS' CONSENT We consent to the incorporation by reference in this Registration Statement of SafeGuard Health Enterprises, Inc. on Form S-8 of our report dated March 7, 2002, appearing in the Annual Report on Form 10-K of SafeGuard Health Enterprises, Inc. for the year ended December 31, 2001. /s/ Deloitte & Touche, L.L.P. DELOITTE & TOUCHE, L.L.P. Costa Mesa, California August 27, 2002 EX-25.1 6 doc5.txt EMPLOYER Form 5558 APPLICATION FOR EXTENSION OF TIME OMB No. 1545-0212 (Rev. May 200) TO FILE CERTAIN EMPLOYEE PLAN RETURNS Department of the Treasury Internal Revenue Service -For Paperwork Reduction Act Notice, File With IRS Only. see instructions on back - --------------------------------------------------------------------------------
File before the Name of filer, plan administrator, or plan sponsor (see instructions) Filer's Identifying Number Normal due - Check applicable box and enter date of the SAFEGUARD HEALTH, INC. number (see instructions) Form 5500, ----------------------------------------------------------------------- [X] Employer Identification 5500-EZ, or number (EIN) 1a must enter an EIN. 5330 (see Number, street, and room or suite no. (If a P.O. box, see instructions) All other filers, see specific instructions) instructions. 95 ENTERPRISE - 52-1528581 ----------------------------------------------------------------------- ------------------------------- OR City or town, state and zip code [ ] Social security number (see Specific Instructions) ALISO VIEJO, CA 92656 - - ---------------- ----------------------------------------------------------------------- -------------------------------
1 I request an extension of time until 10 / 15 / 2001 to file (check ------------------ month day year appropriate box(es)). a [X] Form 5500 or 5500-EZ (no more that 2 1/2 months). The application IS automatically approved to the date shown on line 1 (above) if: (1) box 1a is checked, (2), the Form 5558 is signed and filed on or before the normal due date of Form 5500 or 5500-EZ for which this extension is requested, and (3) the date on line 1 is no more than 2 1/2 months after the normal due date. YOU MUST ATTACH A COPY OF THIS FORM 5558 TO EACH FORM 5500 AND 5500-EZ FILED AFTER THE DUE DATE FOR THE PLANS LISTED BELOW. b [ ] Form 5330 (NO MORE THAN 6 MONTHS). Payment amount attached is $ (see instructions) ----------- 2 Complete the following for the plan(s) covered by this application (see HOW TO FILE): - --------------------------------------------------------------------------------
Plan name/filer Type of plan (check) Plan Plan Year Ending - ---------------------------------- ------------------------- ------------------- Pension Welfare Fringe number Month Day Year ------- ------- ------- ------ ----- ---- ------ SAFEGUARD HEALTH ENTERPRISES, INC. 401(K) PLAN X 002 12 31 2000 - ---------------------------------- ------- ------- ------- ------ ----- ---- ------ - ---------------------------------- ------- ------- ------- ------ ----- ---- ------ - ---------------------------------- ------- ------- ------- ------ ----- ---- ------
3 State in detail why you need the extension (if line 1b is checked) - -------------------------------------------------------------------------------- - -------------------------------------------------------------------------------- - -------------------------------------------------------------------------------- Under penalties of perjury, I declare that to the best of my knowledge and belief the statements made on this form are true, correct, and complete, and that I am authorized to prepare this application. Signature - /s/ Date - 7-10-01 - -------------------------------------------------------------------------------- NOTICE TO To Be Completed by the IRS if line 1b is checked APPLICANT [ ] This application for extensions to file Form 5330 IS approved to the date shown on line 1, if line b is checked. (You MUST attach an approved copy of this form to each Form 5330 that was granted an extension.) TO BE [ ] The date entered on line 1 is more than the 6-month COMPLETED maximum time allowed for Form 5330. This application is BY THE IRS approved to (You MUST attach an approved --------------------- IF LINE 1b copy of this form to each Form 5330 that was granted an IS CHECKED extension.) [ ] The application for an extension for Form 5330 IS NOT approved, because it was filed after the normal due date of the return. (A 10-day grace period IS NOT granted.) [ ] This application for an extension for Form 5330 IS NOT approved because [ ] The application was not signed. [ ] No reason was given on this application or the reason was not acceptable. [ ] No payment was attached for the tax due on Form 5330 [ ] Other - ------------------------------------------------- A 10-day grace period is granted from the date shown below or the due date of the return, whichever is later. (YOU MUST ATTACH A COPY OF THIS FORM TO EACH RETURN YOU FILE THAT IS GRANTED A GRACE PERIOD.) By: ---------- ------------------------------------ ------------ (Date) (Director) - -------------------------------------------------------------------------------- APPLICATIONS FOR EXTENSION OF FORM 5330: COMPLETE IF YOU WANT THIS FORM 5558 RETURNED TO AN ADDRESS OTHER THAN THE ADDRESS SHOWN ABOVE. - -------------------------------------------------------------------------------- Name ---------------------------------------------------------------------- Please Print Number, street and room or suite no. (If a P.O. box, see instructions) or Type ---------------------------------------------------------------------- City or town, state, and zip code - -------- ---------------------------------------------------------------------- MGA Form 5558 (Rev. 5-2000)
==================== Form 5500 Annual Return/Report of Employee Benefit Plan Official Use Only Department of Treasury OMB Nos. 1210-0110 Internal Revenue Service This form is required to be filed under sections 104 and 4065 of the Employee 1210-0089 ---------- -------------------- Department of Labor Retirement Income Security Act of 1974 (ERISA) and sections 6039D, 6047(e), Pension and Welfare Benefits 6057(b), and 6058 (a) of the Internal Revenue Code (the Code). 2000 Administration Complete all entries in accordance with ---------- The instructions to the Form 5500. -------------------- Pension Benefit This Form is Open to Guaranty Corporation Public Inspection =================================================================================================================================
PART I ANNUAL REPORT IDENTIFICATION INFORMATION - -------------------------------------------------------------------------------- FOR THE CALENDAR YEAR 2000 OR FISCAL PLAN YEAR BEGINNING , AND ENDING , - --------------------------------------------------------------------------------
A This return/report is for: (1) [ ] a multiemployer plan; (3) [ ] a multiple-employer (2) [X] a single-employer plan plan; or (other than a multiple (4) [ ] a DFE (specify) -employer plan); ------- B This return/report is: (1) [ ] the first return/report (3) [ ] the final return/report filed for the plan; filed for the plan; (2) [ ] an amended return/report; (4) [ ] a short plan year return/report (less than 12 months)
C If the plan is a collectively-bargained plan, check here . . . . . . . . - [X] D If you filed for an extension of time to file, check the box And attach a copy of the extension application . . . . . . . . . . . . . . - [X] - -------------------------------------------------------------------------------- PART II BASIC PLAN INFORMATION - enter all requested information. - --------------------------------------------------------------------------------
1a Name of plan 1b Three-digit SAFEGUARD HEALTH ENTERPRISES, INC. plan number - 002 401 (K) PLAN -------------------------------------- 1c effective date of plan (mo.,day,yr.) 10/01/1993 - ---------------------------------------------------------------------------- ----------------------------------------- 2a Plan sponsor's name and address (employer, if for a single-employer plan) 2b Employer Identification Number (EIN) (Address should include room or suite no.) 52-1528581 ----------------------------------------- 2c Sponsor's telephone number SAFEGUARD ENTERPRISES, INC. 949-425-4178 ----------------------------------------- 2d Business code (see instructions) 95 ENTERPRISE 524150 ----------------------------------------- ALISO VIEJO CA 92656 - -----------------------------------------------------------------------------------------------------------------------
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 and to the best of my knowledge and belief, it is true, correct, and complete. /s/ RONALD I. BRENDZEL RONALD I. BRENDZEL SR. VP & SECRETARY 9/19/01 SR. VP & SECRETARY - ------------------------------ ----------- ----------------------------------- Signature of plan administrator Date Typed or printed name of individual signing as plan administrator /s/ RONALD I. BRENDZEL RONALD I. BRENDZEL SR. VP & SECRETARY 9/19/01 SR. VP & SECRETARY - ------------------------------ ----------- ----------------------------------- Signature of employer/plan Date Typed or printed name of individual Sponsor/DFE signing as employer, plan sponsor or DFE as applicable ================================================================================ FOR PAPERWORK REDUCTION ACT NOTICE AND FORM 5500 (2000) OMB CONTROL NUMBERS, SEE THE INSTRUCTIONS FOR FORM 5500 Form 5500 Page 2 -------------------------------------------------- ================= Official Use Only ================================================================================ 3a Plan administrator's name and address 3b Administrator's EIN SAME --------------------------- 3c Administrator's telephone number ---------------------------
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: b EIN ------------------ a Sponsor's Name c PIN - ---------------------------------------------------------------------- ------------------ 5 Preparer Information (optional) a Name (including firm name, b EIN if applicable) and address - ---------------------------------------------------------------------- ------------------ c Telephone Number ------------------ 6 Total number of participants at the beginning of the plan year 6 226 - ---------------------------------------------------------------------- -- ------------------ 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 . . . . . . . . . . . . . . . . . . . . . . . . 7a 218 - ---------------------------------------------------------------------- -- ------------------ b Retired or separated participants receiving benefits . . . . . . . . 7b 0 - ---------------------------------------------------------------------- -- ------------------ c Other retired or separated participants entitled to future benefits 7c 28 - ---------------------------------------------------------------------- -- ------------------ d Subtotal, Add lines 7a, 7b and 7c. . . . . . . . . . . . . . . . . . 7d 246 - ---------------------------------------------------------------------- -- ------------------ e Deceased participants whose beneficiaries are receiving or are entitled to receive benefits . . . . . . . . . . . . . . . . . . . . 7e 0 - ---------------------------------------------------------------------- -- ------------------ f Total Add lines 7d and 7e . . . . . . . . . . . . . . . . . . . . . 7f 246 - ---------------------------------------------------------------------- -- ------------------ g Number of participants with account balances as of the end of the plan year (only defined contribution plans complete this item) . . . 7g 128 - ---------------------------------------------------------------------- -- ------------------ h Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested . . . . . 7h 0 - ---------------------------------------------------------------------- -- ------------------ 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) . . . . . . . . . . . . . . . 7i 2 - ---------------------------------------------------------------------- -- ------------------
8 Benefits provided under the plan (complete 8a through 8c, as applicable) a [X] 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): [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] c [ ] Fringe benefits (check this box id the plan provides fringe benefits) - --------------------------------------------------------------------------------
9a Plan finding arrangement (check all that apply) 9b Plan benefit arrangement (check all that apply) (1) [X] Insurance (1) [X] Insurance (2) [ ] Section 412(i) insurance contracts (2) [ ] Section 412(i) insurance contracts (3) [X] Trust (3) [X] Trust (4) [ ] General assets of the sponsor (4) [ ] General assets of the sponsor ========================================================================================================
Form 5500 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 b FINANCIAL SCHEDULES - ------------------------------------------------------------ ------------------------------------------------------------- (1) [X] R (Retired Plan Information) (1) [X] H (Financial Information) (2) [X] 1 T (Qualified Pension Plan Coverage Information) (2) [ ] I (Financial Information - Small Plan) ---- If a Schedule T is not attached because the plan (3) [X] 1 A (Insurance Information) ---- is relying on coverage testing information for a (4) [X] C (Service Provider Information) prior year, enter the year - (5) [X] D (DFE/Participating Plan Information) (3) [ ] B (Actuarial Information) (6) [ ] G (Financial Transaction Schedules) (4) [ ] E (ESOP Annual Information) (7) [X] 1 P (Trust Fiduciary Information) ---- (5) [X] SSA (Separated Vested Participant Information) c Fringe Benefit Schedule [ ] F (Fringe Benefit Plan Annual Information) ==========================================================================================================================
====================== SCHEDULE A INSURANCE INFORMATION Official Use Only (FORM 5500) Department of Treasury This schedule is required to be filed under sections 104 of the OMB No. 1210-0110 Internal Revenue Service Employee Retirement Income Security Act of 1974 ---------------------- --------------- Department of Labor 2000 Pension and Welfare Benefits - FILE AS AN ATTACHMENT TO FORM 5500. --------------- ---------------------- Administration - Insurance companies are required to provide this information This Form is Open to Pension Benefit Pursuant to ERISA section 103(a)(2) Public Inspection Guaranty Corporation ========================================================================================================================
For the calendar year 2000 or fiscal plan year beginning , and ending , - -------------------------------------------------------------------------------- A Name of Plan B Three-digit SAFEGUARD HEALTH ENTERPRISES, INC. 401(K) PLAN plan number 002 - -------------------------------------------------------------------------------- C Plan sponsor's name as shown on line 2a D Employer Identification Number of Form 5500 SAFEGUARD HEALTH ENTERPRISES, INC. 52-1528581 - -------------------------------------------------------------------------------- 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 Part II and III can be reported on a single Schedule A. - -------------------------------------------------------------------------------- 1 Coverage: - -------------------------------------------------------------------------------- (a) Name of Insurance carrier - -------------------------------------------------------------------------------- MANULIFE FINANCIAL - --------------------------------------------------------------------------------
(b) EIN (c) NAIC (d) Contract or (e) Approxiamte number of persons Policy or contract year ------------------------- code identification number covered at end of policy or contract year (f) Form (g) To - ---------- -------- --------------------- ----------------------------------------- ---------- ------------- 01-0233346 65838 71086 158 01/01/2000 12/31/2000 =================================================================================================================
2 Insurance fees and commissions paid to agents, brokers, and other persons: - -------------------------------------------------------------------------------- TOTALS - -------------------------------------------------------------------------------- Amount of commissions paid Fees paid/Amount - -------------------------------------------------------------------------------- 5445 5467 ================================================================================ FOR PAPERWORK REDUCTION ACT NOTICE AND v3.2 SCHEDULE A (FORM 5500)(2000) OMB CONTROL NUMBERS, SEE THE INSTRUCTIONS FOR FORM 5500 SCHEDULE A (Form 5500) 2000 Page 2 -------------------------------------------------- ================= Official Use Only ================================================================================ (a) Name and address of the agents, brokers or other persons to whom commissions or fees were paid - -------------------------------------------------------------------------------- MARSH USA INC P O BOX 504434 THE LAKES NV 88905-4434 - -------------------------------------------------------------------------------- (b) Amount of Fees paid (e) commissions paid Organization ------------------------------------------- code (c) Amount (d) Purpose - -------------------------------------------------------------------------------- 5445 3 ================================================================================ ================================================================================ (a) Name and address of the agents, brokers or other persons to whom commissions or fees were paid - -------------------------------------------------------------------------------- COMPENSATION CONSULTANTS 17748 SKYPARK CIRCLE, SUITE 240 IRVINE CA 92614 - -------------------------------------------------------------------------------- (b) Amount of Fees paid (e) commissions paid Organization ------------------------------------------- code (c) Amount (d) Purpose - -------------------------------------------------------------------------------- MARKETING ALLOWANCE 5467 5 ================================================================================ (a) Name and address of the agents, brokers or other persons to whom commissions or fees were paid - -------------------------------------------------------------------------------- - -------------------------------------------------------------------------------- (b) Amount of Fees paid (e) commissions paid Organization ------------------------------------------- code (c) Amount (d) Purpose - -------------------------------------------------------------------------------- ================================================================================ SCHEDULE A (Form 5500) 2000 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. . . . . . . . . . . . . . . . . . . . 1627 - ------------------------------------------------------------------------------ ---------- 4 Current value of plan's interest under this contract in separate accounts at year end . . . . . . . . . . . . . . . . . . . . 1,083,805 - ------------------------------------------------------------------------------ ---------- 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 account(s). a Type of contract (1) [ ] deposit (2) [ ] immediate administration participation guarantee (3) [ ] guaranteed (4) [X] other (specify below) investments - GUARANTEED INTEREST ---------------------
b Balance at the end of the previous year . . . . . . . . . . . . . . . . . . . 0 ---- c Additions: (1) Contributions deposited during the year. . . . . . . . . 1637 ---- ---- (2) Dividends and credits . . . . . . . . . . . . . . . . . . . . . . . ---- ---- (3) Interest credited during the year. . . . . . . . . . . . . . . . . . 92 ---- ---- (4) Transferred from separate account. . . . . . . . . . . . . . . . . . ---- ---- (5) Other (specify below) . . . . . . . . . . . . . . . . . . . . . . . ---- ---- - ----------------------------------------------------------------------- ---- (6) Total additions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1729 ---- d Total of balance and additions (add b and c (6)) . . . . . . . . . . . . . . . 1729 ---- e Deductions: (1) Disbursed from fund to pay benefits or purchase annuities during year 91 ---- (2) Administration change made by carrier. . . . . . . . . . . . . . . . 11 ---- (3) Transferred to separate account. . . . . . . . . . . . . . . . . . . ---- (4) Other (specify below) . . . . . . . . . . . . . . . . . . . . . . . ---- - ------------------------------------------------------------------------ ---- (5) Total deductions . . . . . . . . . . . . . . . . . . . . . . . . . . 102 - -------------------------------------------------------------------------- ---- f Balance at the end of current year (subtract e(5) from d) . . . . . . . 1627 ======================================================================================
SCHEDULE A (Form 5500) 2000 Page 4 -------------------------------------------------- ================= Official Use Only ================================================================================ PART III WELFARE BENEFIT CONTRACT INFORMATION - -------- If more than one contract covers the same group of employees of the same employer(s) or members if the same employee organizations(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 contract with each carrier may be treated as a unit for purposes of this report. - --------------------------------------------------------------------------------
7 Benefit and contract type (check all applicable boxes) a [ ] Health b [ ] Dental c [ ] Vision d [ ] Life Insurance e [ ] Temporary disability f [ ] Long-term disability g [ ] Supplemental h [ ] Prescription drug (accident and sickness) unemployment i [ ] Stop loss j [ ] HMO contract k [ ] PPO contract l [ ] Indemnity contract (large deductible) 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) Increase (decrease) (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 C Official Use Only (FORM 5500) SERVICE PROVIDER INFORMATION OMB No. 1210-0110 Department of the Treasury Internal Revenue Service This schedule is required to ------------------ be filed under section 104 of 2000 Department of Labor Pension the Employee Retirement Income and Welfare Benefits Security Act of 1974. Administration ------------------ THIS FORM IS OPEN Pension Benefit FILE AS AN ATTACHMENT TO PUBLIC Guaranty Corporation TO FORM 5500. INSPECTION. - -------------------------------------------------------------------------------- For the calendar year 2000 or fiscal plan year beginning , , and ending - -------------------------------------------------------------------------------- A Name of plan B Three-digit SAFEGUARD HEALTH ENTERPRISES, INC. 401(K) PLAN plan number 002 - -------------------------------------------------------------------------------- C Plan sponsor's name as shown on line 2a of Form 5500 SAFEGUARD HEALTH ENTERPRISES, INC. - -------------------------------------------------------------------------------- D EMPLOYER IDENTIFICATION NUMBER 52-1528581 - -------------------------------------------------------------------------------- PART I SERVICE PROVIDER INFORMATION (SEE INSTRUCTIONS) - -------------------------------------------------------------------------------- 1 Enter the total dollar amount of compensation paid by the plan to all persons, other than those listed below, who received compensation during the plan year: . . . . . . . . 1 287 - -------------------------------------------------------------------------------- 2 On the first item below list the contract administrator, if any, as defined in the instructions. On the other items, list service providers in descending order of the compensation they received for the services rendered during the plan year. List only the top 40. 103-12 IEs should enter N/A in (c) and (d). - -------------------------------------------------------------------------------- (a) Name - -------------------------------------------------------------------------------- (b) Employer identification number (see instructions) - -------------------------------------------------------------------------------- (c) Official plan position Contract administrator - -------------------------------------------------------------------------------- (d) Relationship to employer, employee organization, or person known to be a party-in-interest - -------------------------------------------------------------------------------- (e) Gross salary or allowances paid by plan - -------------------------------------------------------------------------------- (f) Fees and commissions paid by plan - -------------------------------------------------------------------------------- (g) Nature of service code(s) (see instructions) 12 ================================================================================ (a) Name MANULIFE FINANCIAL - -------------------------------------------------------------------------------- (b) Employer identification number (see instructions) 01-0233346 - -------------------------------------------------------------------------------- (c) Official plan position INVESTMENT MGMT - -------------------------------------------------------------------------------- (d) Relationship to employer, employee organization, or person known to be a party-in-interest NONE - -------------------------------------------------------------------------------- (e) Gross salary or allowances paid by plan - -------------------------------------------------------------------------------- (f) Fees and commissions paid by plan 10385 - -------------------------------------------------------------------------------- (g) Nature of service code(s) (see instructions) 21 - -------------------------------------------------------------------------------- FOR PAPERWORK REDUCTION ACT NOTICE AND OMB CONTROL NUMBERS, SEE THE INSTRUCTIONS FOR FORM 5500. V3.2 SCHEDULE C (FORM 5500) 2000 Schedule C (Form 5500) 2000 Page 2 - -------------------------------------------------------------------------------- Official Use Only ================================================================================ (a) Name - -------------------------------------------------------------------------------- (b) Employer identification number (see instructions) - -------------------------------------------------------------------------------- (c) Official plan position - -------------------------------------------------------------------------------- (d) Relationship to employer, employee organization, or person known to be a party-in-interest - -------------------------------------------------------------------------------- (e) Gross salary or allowances paid by plan - -------------------------------------------------------------------------------- (f) Fees and commissions paid by plan - -------------------------------------------------------------------------------- (g) Nature of service code(s) (see instructions) ================================================================================ ================================================================================ (a) Name - -------------------------------------------------------------------------------- (b) Employer identification number (see instructions) - -------------------------------------------------------------------------------- (c) Official plan position - -------------------------------------------------------------------------------- (d) Relationship to employer, employee organization, or person known to be a party-in-interest - -------------------------------------------------------------------------------- (e) Gross salary or allowances paid by plan - -------------------------------------------------------------------------------- (f) Fees and commissions paid by plan - -------------------------------------------------------------------------------- (g) Nature of service code(s) (see instructions) ================================================================================ ================================================================================ (a) Name - -------------------------------------------------------------------------------- (b) Employer identification number (see instructions) - -------------------------------------------------------------------------------- (c) Official plan position - -------------------------------------------------------------------------------- (d) Relationship to employer, employee organization, or person known to be a party-in-interest - -------------------------------------------------------------------------------- (e) Gross salary or allowances paid by plan - -------------------------------------------------------------------------------- (f) Fees and commissions paid by plan - -------------------------------------------------------------------------------- (g) Nature of service code(s) (see instructions) Schedule C (Form 5500) 2000 Page 3 - -------------------------------------------------------------------------------- Official Use Only ================================================================================ (a) Name________________________________________________ (b) EIN_______________ (c) Position____________________________________________________________________ (d) Address_____________________________________________________________________ (e) Telephone No._______________________________________________________________ Explanation:____________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ================================================================================ (a) Name________________________________________________ (b) EIN_______________ (c) Position____________________________________________________________________ (d) Address_____________________________________________________________________ (e) Telephone No._______________________________________________________________ Explanation:____________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ================================================================================ (a) Name________________________________________________ (b) EIN_______________ (c) Position____________________________________________________________________ (d) Address_____________________________________________________________________ (e) Telephone No._______________________________________________________________ Explanation:____________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ================================================================================ SCHEDULE D DFE/PARTICIPATING PLAN Official Use Only (FORM 5500) INFORMATION OMB No. 1210-0110 Department of the Treasury This schedule is required to Internal Revenue Service be filed under section 104 of 2000 the Employee Retirement Income ------------------ Security Act of 1974 (ERISA). Department of Labor Pension THIS FORM IS OPEN and Welfare Benefits FILE AS AN ATTACHMENT TO PUBLIC Administration TO FORM 5500. INSPECTION. - -------------------------------------------------------------------------------- For the calendar year 2000 or fiscal plan year beginning , , and ending - -------------------------------------------------------------------------------- A Name of plan SAFEGUARD HEALTH ENTERPRISES, INC. 401(K) PLAN - -------------------------------------------------------------------------------- B Three-digit plan number 002 - -------------------------------------------------------------------------------- C Plan sponsor's name as shown on line 2a of Form 5500 SAFEGUARD HEALTH ENTERPRISES, INC. - -------------------------------------------------------------------------------- D EMPLOYER IDENTIFICATION NUMBER 52-1528581 ================================================================================ 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 MANUAL FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) LIFESTYLE - CONSERVATIVE ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 5406 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANUAL FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) LIFESTYLE - MODERATE ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 12664 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANUAL FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) LIFESTYLE - BALANCED ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 72059 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANUAL FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) LIFESTYLE - GROWTH ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 202238 ------------------------------------------------------------- ================================================================================ FOR PAPERWORK REDUCTION ACT NOTICE AND OMB CONTROL NUMBERS, SEE THE INSTRUCTIONS FOR FORM 5500. V3.2 SCHEDULE D (FORM 5500) 2000 Schedule D (Form 5500) 2000 Page 2 - -------------------------------------------------------------------------------- Official Use Only ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) LIFESTYLE - AGGRESSIVE ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 177747 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) MONEY MARKET FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 151315 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) SHORT TERM GOVERNMENT FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 7071 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) TOTAL RETURN FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 667 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) HIGH QUALITY BOND FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 1261 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) INCOME FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 944 ------------------------------------------------------------- ================================================================================ Schedule D (Form 5500) 2000 Page 2 - -------------------------------------------------------------------------------- Official Use Only ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) HIGH YIELD FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 2598 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) BALANCED SELECT FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 560 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) DIVERSIFIED CAPITAL FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 8989 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) BALANCED FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 18638 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) EQUITY INCOME FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 7496 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) GROWTH & INCOME FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 25661 ------------------------------------------------------------- ================================================================================ Schedule D (Form 5500) 2000 Page 2 - -------------------------------------------------------------------------------- Official Use Only ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) DIVIDEND & GROWTH FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 38460 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) MID CAP VALUE FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 10370 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) MID CAP EQUITY FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 36449 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) VALUE FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 2750 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) SMALL CAP VALUE FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 2896 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) DISCOVERY FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 1116 ------------------------------------------------------------- ================================================================================ Schedule D (Form 5500) 2000 Page 2 - -------------------------------------------------------------------------------- Official Use Only ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) SOCIALLY RESPONSIBLE FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 1711 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) CAPITAL GROWTH STOCK FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 23339 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) GROWTH PLUS STOCK FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 3658 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) SELECTIVE GROWTH STOCK FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 977 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) GROWTH OPPORTUNITIES FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 18038 ------------------------------------------------------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-12IE MANULIFE FINANCIAL -------------------------------------- (b) Name of sponsor of entity listed in (a) LARGE CAP EQUITY FUND ----------------------------------- (c) EIN PN 01-0233346-000 -------------------------------------------------------------------- (d) Entity code P --------------------------------------------------------------- (e) Dollar value of interest in MTIA, CCT, PSA, or 103-12IE at end of year (see instructions) 37281 ------------------------------------------------------------- ================================================================================ SCHEDULE D (FORM 5500) 2000 Page 2 | - ----------------------------------------------------- ------------------ Official Use Only ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-121E MANULIFE FINANCIAL -------------------------------- (b) Name of sponsor of entity listed in (a) VALUE & RESTRUCTURING FUND ----------------------------- (c) EIN-PN 01-0233346-000 (d) Entity code P (e) Dollar value of interest in -------------- -- MTIA, CCT, PSA, or 103-121E at end of year (see instructions) 11293 ------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-121E MANULIFE FINANCIAL -------------------------------- (b) Name of sponsor of entity listed in (a) GROWTH FUND ----------------------------- (c) EIN-PN 01-0233346-000 (d) Entity code P (e) Dollar value of interest in -------------- -- MTIA, CCT, PSA, or 103-121E at end of year (see instructions) 22752 ------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-454E MANULIFE FINANCIAL -------------------------------- (b) Name of sponsor of entity listed in (a) FOREIGN FUND ----------------------------- (c) EIN-PN 01-0233346-000 (d) Entity code P (e) Dollar value of interest in -------------- -- MTIA, CCT, PSA, or 103-121E at end of year (see instructions) 108 ------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-454E MANULIFE FINANCIAL -------------------------------- (b) Name of sponsor of entity listed in (a) INTERNATIONAL STOCK FUND ----------------------------- (c) EIN-PN 01-0233346-000 (d) Entity code P (e) Dollar value of interest in -------------- -- MTIA, CCT, PSA, or 103-121E at end of year (see instructions) 1741 ------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-454E MANULIFE FINANCIAL -------------------------------- (b) Name of sponsor of entity listed in (a) OVERSEES FUND ----------------------------- (c) EIN-PN 01-0233346-000 (d) Entity code P (e) Dollar value of interest in -------------- -- MTIA, CCT, PSA, or 103-121E at end of year (see instructions) 1481 ------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-454E MANULIFE FINANCIAL -------------------------------- (b) Name of sponsor of entity listed in (a) ALL CAP GROWTH FUND ----------------------------- (c) EIN-PN 01-0233346-000 (d) Entity code P (e) Dollar value of interest in -------------- -- MTIA, CCT, PSA, or 103-121E at end of year (see instructions) 6304 ------------- ================================================================================ SCHEDULE D (FORM 5500) 2000 Page 2 | - ----------------------------------------------------- ------------------ Official Use Only ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-454E MANULIFE FINANCIAL -------------------------------- (b) Name of sponsor of entity listed in (a) SELECT TWENTY FUND ----------------------------- (c) EIN-PN 01-0233346-000 (d) Entity code P (e) Dollar value of interest in -------------- -- MTIA, CCT, PSA, or 103-121E at end of year (see instructions) 48659 ------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-454E MANULIFE FINANCIAL -------------------------------- (b) Name of sponsor of entity listed in (a) ENTERPRISE FUND ----------------------------- (c) EIN-PN 01-0233346-000 (d) Entity code P (e) Dollar value of interest in -------------- -- MTIA, CCT, PSA, or 103-121E at end of year (see instructions) 27648 ------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-454E MANULIFE FINANCIAL -------------------------------- (b) Name of sponsor of entity listed in (a) SMALL COMPANY STOCK FUND ----------------------------- (c) EIN-PN 01-0233346-000 (d) Entity code P (e) Dollar value of interest in -------------- -- MTIA, CCT, PSA, or 103-121E at end of year (see instructions) 555 ------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-454E MANULIFE FINANCIAL -------------------------------- (b) Name of sponsor of entity listed in (a) SMALL CAP GROWTH FUND ----------------------------- (c) EIN-PN 01-0233346-000 (d) Entity code P (e) Dollar value of interest in -------------- -- MTIA, CCT, PSA, or 103-121E at end of year (see instructions) 2346 ------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-454E MANULIFE FINANCIAL -------------------------------- (b) Name of sponsor of entity listed in (a) AGRESSIVE GROWTH FUND ----------------------------- (c) EIN-PN 01-0233346-000 (d) Entity code P (e) Dollar value of interest in -------------- -- MTIA, CCT, PSA, or 103-121E at end of year (see instructions) 6295 ------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-454E MANULIFE FINANCIAL -------------------------------- (b) Name of sponsor of entity listed in (a) EMERGING GROWTH STOCK FUND ----------------------------- (c) EIN-PN 01-0233346-000 (d) Entity code P (e) Dollar value of interest in -------------- -- MTIA, CCT, PSA, or 103-121E at end of year (see instructions) 811 ------------- ================================================================================ SCHEDULE D (FORM 5500) 2000 Page 2 | - ----------------------------------------------------- ------------------ Official Use Only ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-454E MANULIFE FINANCIAL -------------------------------- (b) Name of sponsor of entity listed in (a) SCIENCE & TECHNOLOGY FUND ------------------------------ (c) EIN-PN 01-0233346-000 (d) Entity code P (e) Dollar value of interest in -------------- -- MTIA, CCT, PSA, or 103-121E at end of year (see instructions) 59582 ------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-454E MANULIFE FINANCIAL -------------------------------- (b) Name of sponsor of entity listed in (a) DEVELOPING MARKETS FUND ----------------------------- (c) EIN-PN 01-0233346-000 (d) Entity code P (e) Dollar value of interest in -------------- -- MTIA, CCT, PSA, or 103-121E at end of year (see instructions) 0 ------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-454E MANULIFE FINANCIAL -------------------------------- (b) Name of sponsor of entity listed in (a) 500 INDEX FUND ------------------------------ (c) EIN-PN 01-0233346-000 (d) Entity code P (e) Dollar value of interest in -------------- -- MTIA, CCT, PSA, or 103-121E at end of year (see instructions) 21871 ------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-454E -------------------------------- (b) Name of sponsor of entity listed in (a) ------------------------------ (c) EIN-PN 01-0233346-000 (d) Entity code P (e) Dollar value of interest in -------------- -- MTIA, CCT, PSA, or 103-121E at end of year (see instructions) ------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-454E -------------------------------- (b) Name of sponsor of entity listed in (a) ------------------------------ (c) EIN-PN 01-0233346-000 (d) Entity code P (e) Dollar value of interest in -------------- -- MTIA, CCT, PSA, or 103-121E at end of year (see instructions) ------------- ================================================================================ (a) Name of MTIA, CCT, PSA, or 103-454E -------------------------------- (b) Name of sponsor of entity listed in (a) ------------------------------ (c) EIN-PN 01-0233346-000 (d) Entity code P (e) Dollar value of interest in -------------- -- MTIA, CCT, PSA, or 103-121E at end of year (see instructions) ------------- =============================================================================== SCHEDULE D (FORM 5500) 2000 Page 3 | - ----------------------------------------------------- ------------------ Official Use Only ================================================================================ PART II INFORMATION ON PARTICIPATING PLANS (TO BE COMPLETED BY DFEs) - -------------------------------------------------------------------------------- (a) Plan name --------------------------------------------------------------- (b) Name of plan sponsor (c) EIN-PIN ----------------------------- --------- ================================================================================ (a) Plan name --------------------------------------------------------------- (b) Name of plan sponsor (c) EIN-PIN ----------------------------- --------- ================================================================================ (a) Plan name --------------------------------------------------------------- (b) Name of plan sponsor (c) EIN-PIN ----------------------------- --------- ================================================================================ (a) Plan name --------------------------------------------------------------- (b) Name of plan sponsor (c) EIN-PIN ----------------------------- --------- ================================================================================ (a) Plan name --------------------------------------------------------------- (b) Name of plan sponsor (c) EIN-PIN ----------------------------- --------- ================================================================================ (a) Plan name --------------------------------------------------------------- (b) Name of plan sponsor (c) EIN-PIN ----------------------------- --------- ================================================================================ (a) Plan name --------------------------------------------------------------- (b) Name of plan sponsor (c) EIN-PIN ----------------------------- --------- ================================================================================ (a) Plan name --------------------------------------------------------------- (b) Name of plan sponsor (c) EIN-PIN ----------------------------- --------- ================================================================================ SCHEDULE H FINANCIAL INFORMATION Official Use Only (FORM 5500) Department of | OMB No. 1210-110 the Treasury -------------------- Internal Revenue This schedule is required to be | ----------- filed under Section 104 of the | 2000 Department of 1974 (ERISA) and section 6058(a) | Labor Pension Employee Income Security Act of -------------------- and Welfare 1974 (ERISA) and section 6058(a) | THIS FORM IS OPEN Benefits of the Internal Revenue Service | TO PUBLIC Administration Internal Revenue Code (the Code). | INSPECTION ----------- -------------------- Pension Benefit Guaranty Corporation FILE AS AN ATTACHMENT TO FORM 5500. ================================================================================ For calendar year 2000 or fiscal plan year beginning , and ending - -------------------------------------------------------------------------------- A Name of Plan B Three-digit SAFEGUARD HEALTH ENTERPRISES, INC. 401(K) PLAN plan number 002 - -------------------------------------------------------------------------------- C Plan sponsor's name as shown on line 2a of Form 5500 D EMPLOYER IDENTIFICATION NUMBER SAFEGUARD HEALTH ENTERPRISES, INC. 52-1528581 - -------------------------------------------------------------------------------- PART I ASSET AND LIABILITY STATEMENT - -------------------------------------------------------------------------------- 1 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 onetrust. Report the value of the plan's interest in a commingled fund containing the assets of more than one plan on a line-by-line basis unlessthe value is reportable on lines 1c(9) through 1c(14). Do not enter the value of that portion of an insurance contract which guarantees, during thisplan year, to pay a specific dollar benefit at a future date. ROUND OFF AMOUNTS TO THE NEAREST DOLLAR. DFEs do not complete lines 1b(1), 1b(2),1c(8), 1g, 1h, 1i, and, except for master trust investment accounts, also do not complete lines 1d and 1e. See instructions.
ASSETS (a) Beginning (b) End of Year of Year -------- ------------- ------- A Total noninterest-bearing cash. . . . . . . . . . . . . . . a -------- ------------- ------- B Receivables (less allowance for doubtful accounts): -------- ------------- ------- (1) Employer contributions. . . . . . . . . . . . . . . . b(1) -------- ------------- ------- (2) Participant contributions . . . . . . . . . . . . . . b(2) 21183 9630 -------- ------------- ------- (3) Other . . . . . . . . . . . . . . . . . . . . . . . . b(3) 1373 0 -------- ------------- ------- C General investments: -------- ------------- ------- (1) Interest-bearing cash (including money market accounts and certificatesof deposit) . . . . . . . . c(1) 33465 5711 -------- ------------- ------- (2) U.S. Government securities. . . . . . . . . . . . . . c(2) 66384 -------- ------------- ------- (3) Corporate debt instruments (other than employer securities): -------- ------------- ------- (A) Preferred. . . . . . . . . . . . . . . . . . . . c(3)(A) -------- ------------- ------- (B) All other. . . . . . . . . . . . . . . . . . . . c(3)(B) 94092 -------- ------------- ------- (4) Corporate stocks (other than employer securities): -------- ------------- ------- (A) Preferred . . . . . . . . . . . . . . . . . . . . c(4)(A) -------- ------------- ------- (B) Common. . . . . . . . . . . . . . . . . . . . . . c(4)(B) 43387 -------- ------------- ------- (5) Partnership/joint venture interests c(5) -------- ------------- ------- (6) Real estate (other than employer real property). . . . c(6) -------- ------------- ------- (7) Loans (other than to participants) . . . . . . . . . . c(7) -------- ------------- ------- (8) Participant loans . c(8) 56080 61194 -------- ------------- ------- (9) Value of interest in common/collective trusts .. . . . c(9) -------- ------------- ------- (10) Value of interest in pooled separate accounts. . . . . c(10) -------- ------------- ------- (11) Value of interest in master trust investment accounts. c(11) -------- ------------- ------- (12) Value of interest in 103-12 investment entities. . . . c(12) -------- ------------- ------- (13) Value of interest in registered investment companies (e.g.,mutual funds) . . . . . . . . . . . . . . . . c(13) 1,347,199 876309 -------- ------------- ------- (14) Value of funds held in insurance company general account (unallocated contracts). . . . . . . c(14) -------- ------------- ------- (15) Other. . . . . . . . . . . . . . . . . . . . . . . . . c(15) 1627 -------- ------------- ------- - ----------------------------------------------------------------------------------------------- FOR PAPERWORK REDUCTION ACT NOTICE AND OMB CONTROL NUMBERS, SEE THE INSTRUCTIONS FOR FORM 5500. V3.2 SCHEDULE H (FORM 5500) 2000
SCHEDULE H (FORM 5500) 2000 Page 2 | - ----------------------------------------------------- ------------------ Official Use Only ================================================================================
(a) Beginning (b) End of Year of Year ---- ------------- --------- d Employer-related investments: ---- ------------- --------- (1) Employer securities . . . . . . . . . . . . . . . . . d(1) ---- ------------- --------- (2) Employer real property. . . . . . . . . . . . . . . . d(2) ---- ------------- --------- e Buildings and other property used in plan operation. . . . e ---- ------------- --------- f Total assets (add all amounts in lines 1a through 1e). . . f 1,459,300 1,158,334 ---- ------------- --------- ---- ------------- --------- LIABILITIES ---- ------------- --------- g Benefit claims payable . . . . . . . . . . . . . . . . . . g ---- ------------- --------- h Operating payables . . . . . . . . . . . . . . . . . . . . h 1907 ---- ------------- --------- i Acquisition indebtedness . . . . . . . . . . . . . . . . . i ---- ------------- --------- j Other liabilities. . . . . . . . . . . . . . . . . . . . . j ---- ------------- --------- k Total liabilities (add all amounts in lines 1g through 1j) k 1907 0 ---- ------------- --------- ---- ------------- --------- NET ASSETS ---- ------------- --------- l Net assets (subtract line 1k from line 1f). . . . . . . . . l 1,457,393 1,158,334 ---- ------------- ---------
================================================================================ PART II INCOME AND EXPENSE STATEMENT ================================================================================ 2 Plan income, expenses, and changes in net assets for the year. 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. DFEs do not complete line 2a, 2b(1)(E), 2e, 2f, and 2g. - --------------------------------------------------------------------------------
INCOME (a) Amount (b) Total ------- ---------- ---------- A CONTRIBUTIONS: ------- ---------- ---------- (1) Received or receivable in cash from: (A) Employers. . . . . . . a(1)(A) ------- ---------- ---------- (B) Participants . . . . . . . . . . . . . . . . . . . . . . . . . a(1)(B) 427271 ------- ---------- ---------- (C) Others (including rollovers) . . . . . . . . . . . . . . . . . a(1)(C) 34516 ------- ---------- ---------- (2) Noncash contributions . . . . . . . . . . . . . . . . . . . . . . a(2) ------- ---------- ---------- (3) Total contributions. Add lines 2A(1)(A), (B), (C), and line 2A(2) a(3) 461787 ------- ---------- ---------- B EARNINGS ON INVESTMENTS: ------- ---------- ---------- (1) Interest: ------- ---------- ---------- (A) Interest-bearing cash (including money market accounts and certificates of deposit). . . . . . . . . . . . b(1)(A) 469 ------- ---------- ---------- (B) U.S. Government securities . . . . . . . . . . . . . . . . . . b(1)(B) ------- ---------- ---------- (C) Corporate debt instruments . . . . . . . . . . . . . . . . . . (1)(C) ------- ---------- ---------- (D) Loans (other than to participants) . . . . . . . . . . . . . . b(1)(D) ------- ---------- ---------- (E) Participant loans. . . . . . . . . . . . . . . . . . . . . . . b(1)(E) 5521 ------- ---------- ---------- (F) Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . b(1)(F) 92 ------- ---------- ---------- (G) Total interest. Add lines 2b(1)(A) through (F) b(1)(G) 6082 ------- ---------- ---------- (2) Dividends: (A) Preferred stock. . . . . . . . . . . . . . . . . b(2)(A) ------- ---------- ---------- (B) Common stock . . . . . . . . . . . . . . . . . . . . . . . . . b(2)(B) ------- ---------- ---------- (C) Total dividends. Add lines 2b(2)(A) and (B). . . . . . . . . . b(2)(C) 0 ------- ---------- ---------- (3) Rents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b(3) ------- ---------- ---------- (4) Net gain (loss) on sale of assets: (A) Aggregate proceeds . . . b(4)(A) ------- ---------- ---------- (B) Aggregate carrying amount (see instructions) . . . . . . . . . b(4)(B) ------- ---------- ---------- (C) Subtract line 2b(4)(B) from line 2b(4)(A) and enter result . . b(4)(C) 0 ------- ---------- ----------
SCHEDULE H (FORM 5500) 2000 Page 3 | - ----------------------------------------------------- ------------------ Official Use Only ================================================================================
================================================================================================================== (A) Amount (B) Total ------- ---------- --------- (5) Unrealized appreciation (depreciation) of assets: (A) Real estate. . . . . . . . . . . . . . . . . . . . . . . b(5)(A) ------- ---------- --------- (B) Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b(5)(B) ------- ---------- --------- (C) Total unrealized appreciation of assets. Add lines 2B(5)(A) and (B) b(5)(C) 0 ------- ---------- --------- (6) Net investment gain (loss) from common/collective trusts . . . . . . . . . b(6) ------- ---------- --------- (7) Net investment gain (loss) from pooled separate accounts . . . . . . . . . b(7) -83968 ------- ---------- --------- (8) Net investment gain (loss) from master trust investment accounts . . . . . b(8) ------- ---------- --------- (9) Net investment gain (loss) from 103-12 investment entities . . . . . . . . b(9) ------- ---------- --------- (10) Net investment gain (loss) from registered investment companies (e.g., mutual funds). . . . . . . . . . . . . . . . . . . . . . . . . . . b(10) -47272 ------- ---------- --------- c Other income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c ------- ---------- --------- d Total income. Add all INCOME amounts in column (b) and enter total. . . . . . . d 336629 ------- ---------- --------- EXPENSES e Benefit payment and payments to provide benefits: ------- ---------- --------- (1) Directly to participants or beneficiaries, including direct rollovers . . . . . . . . . . . . . . . . . . . . . . . e(1) 625016 ------- ---------- --------- (2) To insurance carriers for the provision of benefits. . . . . . . . . . . . . . . . . . . . . . . . e(2) ------- ---------- --------- (3) Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e(3) ------- ---------- --------- (4) Total benefit payments. Add lines 2E(1) through (3). . . . . . . . . . . . e(4) 625016 ------- ---------- --------- f Corrective distributions (see instructions) . . . . . . . . . . . . . . . . . . f ------- ---------- --------- g Certain deemed distributions of participant loans (see instructions). . . . . . g ------- ---------- --------- h Interest expense. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . h ------- ---------- --------- i Administrative expenses: (1) Professional fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i(1) ------- ---------- --------- (2) Contract administrator fees . . . . . . . . . . . . . . . . . . . . . . . . i(2) 10672 ------- ---------- --------- (3) Investment advisory and management fees . . . . . . . . . . . . . . . . . . i(3) ------- ---------- --------- (4) Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i(4) ------- ---------- --------- (5) Total administrative expenses. Add lines 2I(1) through (4). . . . . . . . . i(5) 10672 ------- ---------- --------- j Total expenses. Add all EXPENSE amounts in column (b) and enter total . . . . . j 635688 ------- ---------- --------- NET INCOME AND RECONCILIATION k Net income (loss) (subtract line 2j from line 2d) . . . . . . . . . . . . . . . k -299059 ------- ---------- --------- l Transfers of assets ------- ---------- --------- (1) To this plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . l(1) ------- ---------- --------- (2) From this plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . l(2) ===================================================================================================================
- -------------------------------------------------------------------------------- PART III ACCOUNTANT'S OPINION - -------------------------------------------------------------------------------- 3 The opinion of an independent qualified public accountant for this plan is (see instructions): a ATTACHED to this Form 5500 and the opinion is: (1) [ ] Unqualified (2) [ ] Qualified (3) [X] Disclaimer (4) [ ] Adverse b NOT ATTACHED because: (1) [ ] the Form 5500 is filed for a CCT, PSA or MTIA. (2) [ ] the opinion will be attached to the next Form 5500 pursuant to 29 CFR 2520.104-50. c Also check this box if the accountant performed a limited scope audit pursuant to 29 CFR 2520.103-8 and/or 2520.103-12(d) . . . . . . . . . [X] d If an accountant's opinion is attached, enter the name and EIN of the accountant (or accounting firm) -------------------------------------------- DELOITTE & TOUCHE 13-3891517 --------------------------------------------------------------------------- --------------------------------------------------------------------------- SCHEDULE H (FORM 5500) 2000 Page 4 | - ----------------------------------------------------- ------------------ Official Use Only ================================================================================
- --------------------------------------------------------------------------------------------- During the plan year: YES NO AMOUNT -- --- -- ------ a Did the employer fail to transmit to the plan any participant contributions within the maximum time period described in 29 CFR 2510.3-102? (see instructions) . . . . . . . . . . . . . . . a 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. (Attach Schedule G (Form 5500) Part I if "Yes" is checked). . . . . . . . . b X -- --- -- ------ c Were any leases to which the plan was a party in default or classified during the year as uncollectible? (Attach Schedule G (Form 5500) Part II if "Yes" is checked). . . . . . . . . . . . . . c X -- --- -- ------ d Did the plan engage in any nonexempt transaction with any party-in-interest? (Attach Schedule G (Form 5500) Part III if "Yes" is checked) . . . . . . . . . . . . . . . . . . . . . . . . . d X -- --- -- ------ e Was this plan covered by a fidelity bond? . . . . . . . . . . . . . e X 500000 -- --- -- ------ f Did the plan have a loss, whether or not reimbursed by the plan's fidelity bond, that was caused by fraud or dishonesty? . . . f 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?. . . . . . . . . . . . . . . . . g 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? . . . . . . . . . . . . . . . h X -- --- -- ------ i Did the plan have assets held for investment? (Attach schedule(s) of assets if "Yes" is checked, and see instructions for format requirements) . . . . . . . . . . . . . . . . . . . . . . . . . . . i X -- --- -- ------ j Were any plan transactions or series of transactions in excess of 5% of the current value of plan assets? (Attach schedule of transactions if "Yes" is checked and see instructions for format requirements) . . . . . . . . . . . . . . . . . . . . . . . . . . . j X -- --- -- ------ k Were all the plan assets either distributed to participants or beneficiaries, transferred to another plan, or brought under the control of the PBGC? .. . . . . . . . . . . . . . . . . . . . . . . k 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) EIN(s) 5b(3) PN(s) ---------------------------------- --------------------- ---------------- ---------------------------------- --------------------- ---------------- ---------------------------------- --------------------- ---------------- ---------------------------------- --------------------- ---------------- |---- | | | | | ------------------ SCHEDULE P ANNUAL RETURN OF FIDUCIARY Official Use Only (FORM 5500) OF EMPLOYEE BENEFIT TRUST THIS SCHEDULE MAY BE FILED TO SATISFY THE OMB No. REQUIREMENTS UNDER SECTION 6033(a) FOR AN ANNUAL 1210-0110 INFORMATION RETURN FROM EVERY SECTION 401(a) ------------- ORGANIZATION EXEMPT FROM TAX UNDER SECTION 501(a). 2000 FILING THIS FORM WILL START THE RUNNING OF THE ------------- Department STATUTE OF LIMITATIONS UNDER SECTION 6501(a) FOR THIS FORM IS of the ANY TRUST DESCRIBED IN SECTION 401(a) THAT IS OPEN TO Treasury EXEMPT FROM TAX UNDER SECTION 501(a). FILE AS AN PUBLIC Internal ATTACHMENT TO FORM 5500 OR 5500-EZ. INSPECTION. Revenue Service FILE AS AN ATTACHMENT TO FORM 5500 OR 5500-EZ ================================================================================ For the trust calendar year 2001 or fiscal trust year beginning , and ending - -------------------------------------------------------------------------------- 1a Name of trustee or custodian RONALD BRENDZEL - -------------------------------------------------------------------------------- b Number, street, and room or suite no. (If a P.O. box, see the instructions for Form 5500 or 5500-EZ.) 95 ENTERPRISE - -------------------------------------------------------------------------------- C City or town State ZIP code ALISO VIEJO CA 92656 - -------------------------------------------------------------------------------- 2a Name of trust SAFEGUARD HEALTH ENTERPRISES, INC. 401(K) PLAN - -------------------------------------------------------------------------------- b Trust's employer identification number 01-0233346 - -------------------------------------------------------------------------------- 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 . . . . . . . . . . . . . . . . . . . . . | 52-1528581 - -------------------------------------------------------------------------------- Under penalties of perjury, I declare that I have examined this schedule, and to the best of my knowledge and belief it is true, correct, and complete. SIGNATURE OF FIDUCIARY /s/ RONALD I. BRENDZEL, SR. VP & SECRETARY DATE 9/29/01 - -------------------------------------------------------------------------------- FOR PAPERWORK REDUCTION ACT NOTICE AND OMB CONTROL NUMBERS, v3.2 SCHEDULE P (FORM 5500) 2001 SEE THE INST. FOR FORM 5500 OR 5500-EZ. Official Use Only OMB No. 1210-0110 Retirement Plan Information This schedule is required to be filed under sections 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. 2001 This Form is Open to Public Inspection. SCHEDULE R (Form 5500) Department of the Treasury Internal Revenue Service ----------- Department of Labor Pension and Welfare Benefits Administration ----------- Pension Benefit Guaranty Corporation - -------------------------------------------------------------------------------- For the calendar plan year 2001 and ending - -------------------------------------------------------------------------------- A Name of plan B Three-digit SAFEGUARD HEALTH ENTERPRISES, INC. 401(K) PLAN plan number > 002 - -------------------------------------------------------------------------------- C Plan sponsor's name as shown on line 2a of D EMPLOYER IDENTIFICATION Form 5500 NUMBER 52-1528581 SAFEGUARD HEALTH ENTERPRISES, INC. - -------------------------------------------------------------------------------- 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..............................1 $____________ 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). 01-0233346 PROFIT-SHARING PLANS, ESOPS, AND STOCK BONUS PLANS, SKIP LINE 3. 3 Number of participants (living or deceased) whose benefits were distributed in a single sum, during the plan year..............................................3 $____________ - -------------------------------------------------------------------------------- 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 [X]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.............................> Month__Day__Year__ 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.............................................6a $____________ b Enter the amount contributed by the employer to the plan for this plan year................................6b $____________ 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)......6c $____________ IF YOU COMPLETED LINE 6C, DO NOT COMPLETE THE REMAINDER OF THIS SCHEDULE. - -------------------------------------------------------------------------------- 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 DO NOT COMPLETE LINE 8 IF THE PLAN IS A MULTIEMPLOYER PLAN OR A PLAN WITH 100 OR FEWER PARTICIPANTS DURING THE PRIOR PLAN YEAR (SEE INST.). 8 Is the employer electing to compute minimum funding for this plan year using the transition rule provided in Code section 412(l)(11) and ERISA section 302(d)(11)?....................................... []Yes []No []N/A - -------------------------------------------------------------------------------- PART III AMENDMENTS - -------------------------------------------------------------------------------- 9 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 - -------------------------------------------------------------------------------- FOR PAPERWORK REDUCTION ACT NOTICE AND OMB CONTROL NUMBERS, SEE THE INSTRUCTIONS FOR FORM 5500. v3.2 SCHEDULE R (FORM 5500) 2000 Official Use Only ANNUAL REGISTRATION STATEMENT IDENTIFYING SEPARATED PARTICIPANTS WITH DEFERRED OMB No. 1210-0110 SCHEDULE SSA VESTED BENEFITS (FORM 5500) 2000 UNDER SECTION 6057(A) OF THE INTERNAL Department of REVENUE CODE THIS FORM IS NOT OPEN the Treasury TO PUBLIC INSPECTION. Internal Revenue > FILE AS AN ATTACHMENT TO FORM 5500 Service - -------------------------------------------------------------------------------- For the calendar plan year 2001 and ending - -------------------------------------------------------------------------------- A Name of plan B Three-digit SAFEGUARD HEALTH ENTERPRISES, INC. 401(K) PLAN plan number > 002 - -------------------------------------------------------------------------------- C Plan sponsor's name as shown on line 2a of D EMPLOYER IDENTIFICATION Form 5500 NUMBER 52-1528581 SAFEGUARD HEALTH ENTERPRISES, INC. - -------------------------------------------------------------------------------- - -------------------------------------------------------------------------------- 1 [] 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 4. - -------------------------------------------------------------------------------- 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. Otherwise, complete the signature area only. - -------------------------------------------------------------------------------- 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. Signature of plan administrator > /s/ /s/ RONALD I. BRENDZEL, SR. VP & SECRETARY ---------------------------------------------- Phone number of plan administrator > 949-425-4178 Date > 9/19/01 - -------------------------------------------------------------------------------- FOR PAPERWORK REDUCTION ACT NOTICE AND OMB CONTROL NUMBERS, SEE THE INSTRUCTIONS FOR FORM 5500. v3.2 SCHEDULE SSA (FORM 5500) 2000 Schedule SSA (Form 5500) 2001 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 USE WITH ENTRY CODE "A","B", "C", "D" "A" or "B" Amount of Vested benefit (a) (b) Enter code for nature (f) Entry Social and form of benefit Defined benefit Code security (c) (d) (e) plan - periodic Number Name of participant Type of Payment payment Annuity frequency - -------------------------------------------------------------------------------- A 144705832 Fluegel, Thomas A A A 265176630 Spiering, Gordon W A A - -------------------------------------------------------------------------------- USE WITH ENTRY CODE USE WITH ENTRY CODE "A" of "B" "C" Amount of vested benefit (a) Defined contribution plan (i) (j) Entry (g) (h) Previous sponsor's Previous Code Units or Share Total value employer plan number Identification number - -------------------------------------------------------------------------------- 33524.00 11529.00 Official Use Only QUALIFIED PENSION PLAN COMVERAGE OMB No. 1210-0110 SCHEDULE T INFORMATION (FORM 5500) 2000 UNDER SECTION 6057(A) OF THE INTERNAL Department of REVENUE CODE THIS FORM IS NOT OPEN the Treasury TO PUBLIC INSPECTION. Internal Revenue > FILE AS AN ATTACHMENT TO FORM 5500 Service - -------------------------------------------------------------------------------- For the calendar plan year 2001 and ending - -------------------------------------------------------------------------------- Department of the Treasury Internal Revenue Service - -------------------------------------------------------------------------------- For the calendar plan year 2000 and ending - -------------------------------------------------------------------------------- A Name of plan B Three-digit SAFEGUARD HEALTH ENTERPRISES, INC. 401(K) PLAN plan number > 002 - -------------------------------------------------------------------------------- C Plan sponsor's name as shown on line 2a of D EMPLOYER IDENTIFICATION Form 5500 NUMBER 52-1528581 SAFEGUARD HEALTH ENTERPRISES, INC. - -------------------------------------------------------------------------------- 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 QSLOBs 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 [ ] 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. v2.3 SCHEDULE SSA (FORM 5500) 2000 SCHEDULE T (FORM 5500) 2000 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 Month__ Day__ Year__ employer at any time during the plan year? 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: [ ] Yes [ ] No (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 c(1)_____________ (2) Number of excludable employees as defined in IRS regulations (see instructions) c(2)_____________ (3) Number of nonexcludable employees. (Subtract line 4c(2) from line 4c(1)) c(3)_____________ (4) Number of nonexcludable employees (line 4c(3)) who are HCEs c(4)_____________ (5) Number of nonexcludable employees (line 4c(3)) who benefit under the plan c(5)_____________ (6) Number of benefiting nonexcludable employees (line 4c(5)) who are HCEs c(6)_____________ - -------------------------------------------------------------------------------- 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) d ________________ e Identify any disaggregated part of the plan and enter the ratio percentage or exception (see instructions). __________________ (1)Disaggregated part: Ratio percentage: Exception: e(1) ______________ (2)Disaggregated part: Ratio percentage: Exception: e(2) ______________ (3)Disaggregated part: Ratio percentage: Exception: e(3) ______________ F This plan satisfies the coverage requirements on the basis of (check one): [ ] the ratio percentage test [ ] average benefit test (1) (2) - -------------------------------------------------------------------------------- EX-99.1 7 doc6.txt Exhibit 99.1 - ------------- SafeGuard Health Enterprises, Inc 95 Enterprise, Suite 100 Aliso Viejo, CA 92656-2605 Tel: (949) 425-4300 Fax: (949) 425-4533 CERTIFICATION PURSUANT TO 18 U.S.C. SECTION 1350, AS ADOPTED PURSUANT TO SECTION 906 OF THE SARBANES-OXLEY ACT OF 2002; QUARTERLY REPORT ON FORM 10-Q FOR THE QUARTER ENDED JUNE 30, 2002 Each of the undersigned hereby certifies in his capacity as an officer of SafeGuard Health Enterprises, Inc., (the "Company") that the Annual Report of the Company on Form 10-K for the year ended December 31, 2001, (the "Report") incorporated by reference into the Form S-8 for the Company 401(k) Plan attached hereto, complies with the requirements of Section 13(a) of the Securities Exchange Act of 1934 and that the information contained in the Report fairly presents, in all material respects, the financial condition of the Company at the end of such period and the results of operations of the Company for such period. Pursuant to the requirements of Section 13 or 15(d) of the Securities Exchange Act of 1934, the Registrant has duly caused this certification to be signed on its behalf by the undersigned, thereunto duly authorized, in the City of Aliso Viejo, State of California, on the 27th day of August 2002. SAFEGUARD HEALTH ENTERPRISES, INC. By: /s/ James E. Buncher ----------------------- James E. Buncher President and Chief Executive Officer (Principal Executive Officer) By: /s/ Dennis L. Gates ---------------------- Dennis L. Gates Senior Vice President and Chief Financial Officer (Chief Accounting Officer) -----END PRIVACY-ENHANCED MESSAGE-----