I am first duly sworn and state I am: Name. Keep a copy for your records. 2.Fill in the short plan year beginning and ending dates in the space provided and check the appropriate box in Part I, line B, of the Form 5500. Individuals who have a DWI conviction must get a substance use assessment and complete either an education program or treatment program. The substance was packaged or delivered in a manner normally used for the illegal delivery of controlled substances. 2.