[Federal Register Volume 81, Number 140 (Thursday, July 21, 2016)]
[Proposed Rules]
[Pages 47534-47681]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-14893]



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Vol. 81

Thursday,

No. 140

July 21, 2016

Part III





Department of Labor





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 Employee Benefits Security Administration





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29 CFR Parts 2520 and 2590Department of Treasury





 Internal Revenue Service





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26 CFR Part 301 Pension Benefit Guaranty Corporation

29 CFR Part 4065





 Proposed Revision of Annual Information Return/Reports; Proposed Rules

  Federal Register / Vol. 81 , No. 140 / Thursday, July 21, 2016 / 
Proposed Rules  

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DEPARTMENT OF LABOR

Employee Benefits Security Administration

29 CFR Parts 2520 and 2590

DEPARTMENT OF THE TREASURY

Internal Revenue Service

26 CFR Part 301

PENSION BENEFIT GUARANTY CORPORATION

29 CFR Part 4065

RIN 1210-AB63


Proposed Revision of Annual Information Return/Reports

AGENCY: Employee Benefits Security Administration, Labor, Internal 
Revenue Service, Treasury, Pension Benefit Guaranty Corporation.

ACTION: Notice of proposed forms revisions.

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SUMMARY: This document contains proposed changes to the Form 5500 
Annual Return/Report forms, including the Form 5500, Annual Return/
Report of Employee Benefit Plan (Form 5500 Annual Return/Report), and 
the Form 5500-SF, Short Form Annual Return/Report of Small Employee 
Benefit Plan (Form 5500-SF). The annual returns/reports are filed for 
employee pension and welfare benefit plans under the Employee 
Retirement Income Security Act of 1974 (ERISA) and the Internal Revenue 
Code (Code). The proposed revisions in this Notice reflect efforts of 
the Department of Labor, the Internal Revenue Service, and the Pension 
Benefit Guaranty Corporation (collectively Agencies) to improve 
employee benefit plan reporting for filers, the public, and the 
Agencies by modernizing financial information filed regarding plans; 
updating fee and expense information on plan service providers with a 
focus on harmonizing annual reporting requirements with the Department 
of Labor's final disclosure requirements enhancing mineability of data 
filed on annual return/reports; requiring reporting by all group health 
plans covered by Title I of ERISA, including adding a new Schedule J 
(Group Health Plan Information); and improving compliance under ERISA 
and the Code through selected new questions regarding plan operations, 
service provider relationships, and financial management of the plan. 
These revisions, which are being proposed in conjunction with a 
recompete of the ERISA Filing and Acceptance System (EFAST2) contract, 
if adopted, generally would apply for plan years beginning on or after 
January 1, 2019. EFAST2 is expected to begin processing the Plan Year 
2019 Form 5500 Annual Return/Report beginning January 1, 2020. The 
proposed revisions would affect employee pension and welfare benefit 
plans, plan sponsors, administrators, and service providers to plans 
subject to annual reporting requirements under ERISA and the Code.

DATES: Written comments must be received by the Department of Labor on 
or before October 4, 2016.

ADDRESSES: To facilitate the receipt and processing of written comment 
letters on the proposed regulation, EBSA encourages interested persons 
to submit their comments electronically. You may submit comments, 
identified by RIN 1210-AB63, by any of the following methods:
    Federal eRulemaking Portal: http://www.regulations.gov.
    Follow instructions for submitting comments.
    Email: [email protected]. Include RIN 1210-AB63 in the subject line of 
the message.
    Mail: Office of Regulations and Interpretations, Employee Benefits 
Security Administration, Attn: RIN 1210-AB63; Annual Reporting and 
Disclosure, Room N-5655, U.S. Department of Labor, 200 Constitution 
Avenue NW., Washington, DC 20210.
    Hand Delivery/Courier: Office of Regulations and Interpretations, 
Employee Benefits Security Administration, Attn: RIN 1210-AB63; Annual 
Reporting and Disclosure, Room N-5655, U.S. Department of Labor, 200 
Constitution Avenue NW., Washington, DC 20210.
    Instructions: All comments received must include the agency name 
and Regulatory Identifier Number (RIN) for this rulemaking (RIN 1210-
AB63). Persons submitting comments electronically are encouraged not to 
submit paper copies. All comments received will be made available to 
the public, posted without change to http://www.regulations.gov and 
http://www.dol.gov/ebsa, and made available for public inspection at 
the Public Disclosure Room, N-1513, Employee Benefits Security 
Administration, U.S. Department of Labor, 200 Constitution Avenue NW., 
Washington, DC 20210, including any personal information provided.

FOR FURTHER INFORMATION CONTACT: Mara S. Blumenthal, Employee Benefits 
Security Administration (EBSA), U.S. Department of Labor, (202) 693-
8523, for questions relating to changes to the Form 5500, Form 5500-SF, 
Schedules A, C, D, G, and H, as well as the general reporting 
requirements under Title I of ERISA; Suzanne Bach, EBSA, U.S. 
Department of Labor, 202-693-8440, for questions relating to the 
collection of group health plan information; Leslie Larson, Internal 
Revenue Service (IRS), at the IRS taxpayer assistance answering service 
at 1-877-829-5500 (a toll-free number), for questions relating to 
Schedule R, Schedule E, as well as the general reporting requirements 
under Internal Revenue Code (Code); Steven Klubock, IRS, at 1-877-829-
5500, for IRS questions relating to the Schedules MB and SB; and Grace 
Kraemer or Theresa Anderson, Pension Benefit Guaranty Corporation 
(PBGC), (202) 326-4000 for questions relating to Schedules MB and SB of 
the Form 5500, and Lines 14 and 19 of Schedule R, as well as questions 
relating to the general reporting requirements under Title IV of ERISA. 
For further information on an item not mentioned above, contact Ms. 
Blumenthal. The telephone numbers referenced above are not toll-free 
numbers, except as otherwise provided.
    Customer service information: Individuals interested in obtaining 
information from the DOL concerning Title I of ERISA may call the EBSA 
Toll-Free Hotline at 1-866-444-EBSA (3272) or visit the DOL's Web site 
(www.dol.gov/ebsa).

SUPPLEMENTARY INFORMATION: 
    Sections 101 and 104 of Title I and section 4065 of Title IV of the 
Employee Retirement Income Security Act of 1974 (ERISA) and sections 
6057(b), 6058(a), and 6059(a) of the Internal Revenue Code of 1986 
(Code), and related regulations, impose annual reporting and filing 
obligations on pension and welfare benefit plans, as well as on certain 
other entities. Plan administrators, employers, and others generally 
satisfy these annual reporting obligations by filing the Form 5500, 
Annual Return/Report of Employee Benefit Plan together with any 
required schedules and attachments (Form 5500 Annual Return/Report), or 
Form 5500-SF, Short Form Annual Return/Report of Small Employee Benefit 
Plan (Form 5500-SF).\1\ Specifically, filing of the

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Form 5500 or, for eligible filers the Form 5500-SF, with any required 
schedules and attachments in accordance with the instructions and 
related regulations, constitutes compliance under Title I of ERISA with 
the applicable limited exemption, alternative method of compliance, and 
simplified reporting prescribed in 29 CFR 2520.103-1, et seq. Such 
filings will also satisfy an applicable plan administrator's annual 
reporting obligation under section 4065 of Title IV of ERISA. Filing of 
a Form 5500 or Form 5500-SF, together with the required attachments and 
schedules in accordance with the instructions, by plan administrators, 
employers, and certain other entities also satisfies the annual filing 
and reporting requirements under Code sections 6057(b), 6058(a) and 
6059(a).\2\
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    \1\ Certain one-participant plans and foreign plans that are not 
subject to the requirements of section 104(a) of ERISA are required 
to file Form 5500-EZ with the IRS on paper, or voluntarily file 
electronically using Form 5500-SF to satisfy certain annual 
reporting and filing obligations imposed by the Code. Beginning with 
the 2015 plan year, however, some filers are required to file their 
annual returns electronically using Form 5500-SF instead of filing a 
paper Form 5500-EZ if the filer is required to file at least 250 
returns of any type with the IRS. See Treasury Regulations section 
301.6058-2 for more information on mandatory electronic filing of 
employee retirement benefit plan returns.
    \2\ Some filing requirements under these provisions are not 
within the scope of this Notice. For example, multiple employer 
welfare arrangements and certain entities claiming exception are 
required to file with the DOL the Form M-1 (Report for Multiple 
Employer Welfare Arrangements (MEWAs) and Certain Entities Claiming 
Exception (ECEs)).
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    The Form 5500 Annual Return/Report serves as the principal source 
of information and data available to the DOL, the IRS, and the PBGC 
(collectively the Agencies) concerning the operations, funding, and 
investments of approximately 806,000 pension and welfare benefit plans. 
These plans cover roughly 143 million workers, retirees, and dependents 
of private sector pension and welfare plans \3\ with estimated assets 
of $8.7 trillion.\4\ Accordingly, the Form 5500 Annual Return/Report is 
essential to each Agency's enforcement, research, and policy 
formulation programs. They are also an important source of information 
and data for use by other federal agencies, Congress, and the private 
sector in assessing employee benefit, tax, and economic trends and 
policies. The Form 5500 Annual Return/Report also serves as the primary 
means by which the operations of plans can be monitored by plan 
participants and beneficiaries and by the general public.
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    \3\ Source: U.S. Department of Labor, EBSA calculations using 
the March 2014 Current Population Survey Annual Social and Economic 
Supplement and the 2013 Medical Expenditure Panel Survey.
    \4\ EBSA projected ERISA covered pension, welfare, and total 
assets based on the 2013 Form 5500 Annual Return/Report filings with 
the U.S. Department of Labor (DOL), reported SIMPLE assets from the 
Investment Company Institute (ICI) Report: The U.S. Retirement 
Market, Second Quarter 2015, and the Federal Reserve Statistical 
Release Z.1 Financial Accounts of the United States (Sept. 18, 
2015).
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    Generally, the Agencies have conducted a notice and comment 
rulemaking initiative to implement significant overhauls of the 
structure of the forms and schedules coincident with changes to the 
EFAST system. Past revisions to the forms and schedules have addressed 
changes to applicable law, changes in employee benefit plans and 
financial markets, and corresponding shifts in agency priorities and 
needs. The Agencies have also made changes to reduce costs and make 
filing and processing more efficient. In interim years, the Agencies 
have made other discrete changes as set forth annually in the ``Changes 
to Note'' section in the instructions, some of which have involved 
targeted rulemaking activity to implement reporting changes required by 
law.\5\ The Agencies' last major tri-agency revision to the Form 5500 
Annual Return/Report was proposed in 2006, 71 FR 41615 (Jul. 21, 2006), 
and finalized in 2007, effective for the 2009 form series. 72 FR 64731 
(Nov. 16, 2007).
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    \5\ See, e.g., Revisions to Annual Return/Report--Multiple-
Employer Plans, Interim Final Rule, 79 FR 66617 (Nov. 10, 2014); 
Filings Required of Multiple Employer Welfare Arrangements and 
Certain Other Related Entities, Final Rule, 78 FR 13781 (Mar. 1, 
2013).
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    This forms revision proposal generally is being coordinated with a 
recompete of the contract for the ERISA Filing Acceptance System II 
(EFAST2)--the wholly electronic system operated by a private-sector 
contractor for the processing of Form 5500 Annual Return/Report. The 
majority of proposed forms revisions are currently targeted for 
implementation in the Plan Year 2019 Form 5500 Annual Return/Report. 
Development of EFAST changes pursuant to a new contract could begin in 
spring 2018, with processing under the new contract starting on January 
1, 2020. However, this planned implementation timeline may be impacted 
if there are modifications to the recompete contract acquisition plan. 
As a result, some forms revisions may be implemented in earlier or 
later form years, including but not limited to the IRS and PBGC changes 
for 2016 as shown in the proposed data elements in Appendix A. To the 
extent changes are made separately from a more general implementation 
of the proposed revisions, the Agencies will seek appropriate clearance 
under the Paperwork Reduction Act of 1995 (PRA) to implement the 
changes in connection with any given year's forms.
    The Agencies expect that the EFAST2 recompete would continue to 
deliver a user-friendly Web site, filing applications and web services, 
and contact center services similar to what is currently being 
provided. The existing EFAST2 web-based filing search application is 
expected to be enhanced and provided by EBSA. The Agencies expect that 
EFAST2 would continue to have the same or improved functionality and 
web services and is expected primarily to rely on existing EFAST2 
software, components and logic. EFAST2 would continue to include a 
user-friendly web portal that provides registration, filing submission, 
filing acceptance, filing data dissemination, and help desk services.
    As part of the comprehensive review of how well the Form 5500 
Annual Return/Report serves to implement the existing employee benefit 
plan filing requirements under Titles I and IV of ERISA and under the 
Code, the Agencies have considered intervening changes to the legal and 
regulatory environment for employee benefit plans, plan sponsors, plan 
service providers and others since the last major revision of the Form 
5500 Annual Return/Report. This includes implementation of the Dodd-
Frank Wall Street Reform and Consumer Protection Act, Public Law 111-
203, 124 Stat. 1376, (Jul. 21, 2010); statutory changes to ERISA and 
the Code relating to defined benefit pension plans in the Moving Ahead 
for Progress in the 21st Century Act (MAP 21) (Pub. L. 112-141); the 
Cooperative and Small Employer Charity Pension Flexibility Act (CSEC 
Act) (Pub. L. 113-98); the Highway and Transportation Funding Act 
(HATFA) (Pub. L. 113-159); the Multiemployer Pension Reform Act of 
2014, Division O of the Consolidated and Further Continuing 
Appropriations Act, 2015, (Pub. L. 113-235) (MPRA), and various 
regulatory actions adopted by the Agencies since the last major changes 
to the forms and instructions, including the DOL's final regulations at 
29 CFR 2550.404a-5, 404c-5, and 408b-2.
    In addition, the enactment of the Patient Protection and Affordable 
Care Act (Affordable Care Act) \6\ expanded DOL's already growing 
oversight responsibilities with respect to the provision of group 
health benefits to workers in private sector employer-sponsored plans 
that provide group health benefits (also referred to herein as ``group 
health plans''). In that regard,

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the DOL has re-evaluated the existing reporting scheme for group health 
plans, which scheme was established well before the enactment of the 
Health Insurance Portability and Accountability Act of 1996, Public Law 
104-191, 110 Stat. 1936 (Aug. 21, 1996); Title I of the Genetic 
Information Nondiscrimination Act of 2008, Public Law 110-233, 122 
Stat. 881 (May 21, 2008); the Mental Health Parity Act of 1996, Public 
Law 104-204, 110 Stat. 2944 (Sept. 26, 1996) and the Mental Health 
Parity and Addiction Equity Act of 2008, Public Law 110-343, 122 Stat. 
3881 (Oct. 3, 2008); the Newborns' and Mothers' Health Protection Act 
of 1996, Public Law 104-204, 110 Stat. 2935 (Sept. 26, 1996); the 
Women's Health and Cancer Rights Act of 1998, Public Law 105-277, 112 
Stat. 2681-436 (Oct. 21, 1998); and Michelle's Law, Public Law 110-381, 
122 Stat. 4081 (Oct. 9, 2008), as well as the Affordable Care Act.
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    \6\ The Patient Protection and Affordable Care Act, Public Law 
111-148, was enacted on March 23, 2010, and the Health Care and 
Education Reconciliation Act of 2010, Public Law 111-152, was 
enacted on March 30, 2010. These statutes generally are collectively 
known as the ``Affordable Care Act.''
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    After reviewing the existing reporting scheme and the DOL's 
experience with oversight and enforcement, the DOL determined that, in 
order for it to more effectively fulfill its responsibilities under the 
expanded requirements under these laws, all plans that provide group 
health benefits should be subject to some level of annual reporting, 
with a focus on compliance issues. As described in more detail below, 
under the proposal, those plans that provide group health benefits that 
are already required to file a Form 5500 Annual Return/Report--
generally all large plans and small plans that are funded with a trust 
or that are otherwise not eligible for the annual reporting relief for 
unfunded and insured plans--would have to file group health plan 
information on a new separate schedule (Schedule J (Group Health Plan 
Information)), as well as complete those elements of the Form 5500 and 
schedules that those plans are already required to complete, as 
modified by this proposal. Plans that provide group health benefits 
that have fewer than 100 participants currently exempt from filing an 
annual report under 29 CFR 2520.104-20 because they are either 
completely ``unfunded'' or partially insured and partially unfunded now 
would be required to file a Form 5500 (except for those questions 
applicable only to pension plans) and the new Schedule J. Under the 
proposal, plans that provide group health benefits that have fewer than 
100 participants that currently are exempt from annual reporting under 
29 CFR 2520.104-20 because they are fully insured would be required to 
file with answers to certain questions on the Form 5500 and the 
Schedule J.
    Certain information collection requirements imposed under the Code, 
but not required under ERISA, had to be removed from the Form 5500 
Annual Return/Report when DOL implemented its EFAST2 electronic filing 
requirement beginning with the 2009 Form 5500 Annual Return/Report. The 
Code did not permit the IRS to mandate electronic filing of ``IRS-
only'' components of the Form 5500 Annual Return/Report with respect to 
filers of fewer than 250 returns, and regulations did not mandate such 
electronic filing with respect to any filers. Specifically, Schedules 
E, P, SSA, and T were not included in the 2009 Form 5500 Annual Return/
Report. Some of those information collection requirements can now be 
added back to the Form 5500 Annual Return/Report. On September 29, 
2014, the Treasury Department issued final regulations under Code 
sections 6058 and 6059 mandating electronic filing of the Form 5500 
Annual Return/Report (including actuarial schedules) for certain 
filers. T.D. 9695, 79 FR 58256 (Sept. 29, 2014). In general, 26 CFR 
301.6058-2 provides that, in order to satisfy the filing requirements 
of Code section 6058, a Form 5500 Annual Return/Report must be filed 
electronically if the filer is required to file at least 250 returns of 
any type during the calendar year that includes the first day of the 
applicable plan year. Similarly, 26 CFR 301.6059-2 provides in general 
that, in order to satisfy the filing requirements of Code section 6059, 
actuarial reports filed with a Form 5500 Annual Return/Report must be 
filed electronically by filers required to file at least 250 returns 
during that calendar year. The regulations are generally effective for 
plan years beginning on or after January 1, 2015, but only for filings 
with a filing deadline (not taking into account filing extensions) 
after December 31, 2015.
    Finally, the Agencies took into account recommendations in reports 
from the Government Accountability Office (GAO), the DOL's Office of 
Inspector General (DOL-OIG), the United States Treasury Inspector 
General for Tax Administration (TIGTA), and the ERISA Advisory Council 
that have been issued since the last major revision of the Form 5500 
Annual Return/Report information collection requirements in connection 
with the 2009 return/report. See, e.g., U.S. Gov't Accountability 
Office, GAO-10-54, Private Pensions: Additional Changes Could Improve 
Employee Benefit Plan Financial Reporting (2009) (available at 
www.gao.gov/assets/300/298052.pdf); U.S. Gov't Accountability Office, 
GAO-14-441, Private Pensions: Targeted Revisions Could Improve 
Usefulness of Form 5500 Information (2014) (available at www.gao.gov/products/GAO-14-441); 2013 ERISA Advisory Council Report: Private 
Sector Pension De-risking and Participant Protections, Dep't of Labor, 
(available at www.dol.gov/ebsa/publications/2013ACreport2.html); Dep't 
of Labor Office Of Inspector Gen., 05-14-003-12-12, EBSA Could Improve 
Its Usage of Form 5500 Data (2014) (available at www.oig.dol.gov/public/reports/oa/2014/05-14-003-12-121.pdf); U.S. Gov't Accountability 
Office, GAO-14-92, Private Pensions: Clarity of Required Reports and 
Disclosures Could Be Improved (2013) (available at www.gao.gov/assets/660/659211.pdf); U.S. Gov't Accountability Office, GAO-14-92, Private 
Pensions: Clarity Of Required Reports And Disclosures Could Be 
Improved, Report to Congressional Requesters (2013) (available at 
www.gao.gov/assets/660/659211.pdf); U.S. Dep't of Labor Office of 
Inspector Gen., 09-13-001-12-121, Employee Benefits Security 
Administration Needs to Provide Additional Guidance And Oversight to 
ERISA Plans Holding Hard-to-Value Alternative Investments (2013) 
(available at www.oig.dol.gov/public/reports/oa/2013/09-13-001-12-121.pdf); U.S. Gov't Accountability Office, GAO-12-665, Private Sector 
Pensions: Federal Agencies Should Collect Data and Coordinate Oversight 
of Multiple-employer Plans (2012) (available at www.gao.gov/assets/650/648285.pdf); U.S. Dep't of Labor Office Of Inspector Gen., 09-12-002-
12-121, Changes Are Still Needed In The ERISA Audit Process To Increase 
Protections For Employee Benefit Plan Participants (2012) (available at 
www.oig.dol.gov/public/reports/oa/2012/09-12-002-12-121.pdf); U.S. 
Gov't Accountability Office, GAO-12-325, 401(K) Plans: Increased 
Educational Outreach and Broader Oversight May Help Reduce Plan Fees 
(2012) (available at www.gao.gov/products/GAO-12-325); U.S. Gov't 
Accountability Office, GAO-08-692, Defined Benefit Plans: Guidance 
Needed to Better Inform Plans of the Challenges and Risks of Investing 
in Hedge Funds and Private Equity (2012) (available at www.gao.gov/products/GAO-08-692); Treasury Inspector Gen. for Tax Administration, 
The Employee Plans Function Should Continue Its Efforts to Obtain 
Needed Retirement Plan Information (2011) (available at 
www.treasury.gov/tigta/auditreports/2011reports/

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201110108fr.pdf); 2011 ERISA Advisory Council Report: Hedge Funds and 
Private Equity Investments, Dep't of Labor, (available at www.dol.gov/ebsa/publications/2011ACreport3.html); 2013 ERISA Advisory Council 
Report: Locating Missing and Lost Participants, Dep't of Labor, 
(available at www.dol.gov/ebsa/publications/2013ACreport3.html#2); 2010 
ERISA Advisory Council Report: Employee Benefit Plan Auditing and 
Financial Reporting Models, Dep't of Labor, (available at www.dol.gov/ebsa/publications/2010ACreport2.html); 2008 ERISA Advisory Council 
Report: Working Group on Hard-to-Value Assets and Target Date Funds, 
Dep't of Labor, (available at www.dol.gov/ebsa/publications/2008ACreport1.html.)
    The DOL also is publishing elsewhere in today's Federal Register a 
Notice of Proposed Rulemaking with proposed amendments to the annual 
reporting regulations at Part 2520 of Chapter XXV of Title 29 of the 
Code of Federal Regulations to implement certain proposed Form 5500 
Annual Return/Report changes under Title I of ERISA. To avoid 
unnecessary duplication of effort, public comments submitted in 
response to this Notice of Proposed Forms Revisions will be treated as 
public comments on the Notice of Proposed Rulemaking to the extent they 
include information relevant to the proposed regulatory amendments.
    Although the Agencies' historical practice of undertaking major 
updates of the Form 5500 Annual Return/Report generally has coincided 
with the move to and upgrades of the EFAST processing system, the 
Agencies also engage in an annual update process of the forms, 
schedules, and instructions. Some annual changes that are anticipated 
to be implemented by the IRS and the PBGC in connection with the 2016 
plan year forms are discussed below. Those changes and other annual 
updates have involved, or may in the future involve, separate public 
notice and comment processes, for example, under the Paperwork 
Reduction Act (PRA). The Agencies intend that any annual update changes 
adopted during the pendency of the changes proposed in this Notice will 
be incorporated into what is published as part of the Notice of Final 
Forms Revisions as part of this process.\7\
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    \7\ Minor changes not requiring notice and comment rulemaking or 
system changes or changes required by enactment of new laws may also 
be made between the publication of the Notice of Final Forms 
Revisions and the date when the revised forms, schedules, and 
instructions are available for e-filing through EFAST2.
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    As with previous major forms revisions cycles, the Agencies 
anticipate actively engaging in outreach and education regarding the 
forms revisions well in advance of the plan year for which the majority 
of the revisions would be effective.

II. Appendices

A. Data Elements for Forms and Schedules

    Appendix A shows the questions/data elements that are on each form 
and schedule in the line-by-line sequence the items would appear on 
that form and schedule, as well as newly ``structured'' attachments, 
rather than showing mock-ups of ``final'' forms, schedules, and 
structured attachments. The Agencies expect that the final forms and 
schedules will have substantially the same format as the existing forms 
and schedules.\8\ The lists of data elements for each individual form, 
schedule, and ``structured'' attachment to the Schedule H, show all of 
the questions that would appear on that form, schedule, or attachment--
current questions, renumbered questions, revised questions, and new 
questions. The data elements are numbered in the sequence that the 
Agencies would expect to use in the final version of the forms and 
schedules. Next to the data elements, the Agencies have, to the extent 
feasible, indicated in brackets:
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    \8\ The Agencies intend to publish mock-ups of the forms on the 
DOL's Web site as part of the third party software developer 
certification process and in furtherance of public education efforts 
about the changes to be implemented.
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    (1) ``[Current]'' if it is the same question with the same line 
number on both the proposal and the current form or schedule; \9\ 
``[Current (2016)]'' indicates IRS changes and/or PBGC changes that 
would first be made part of the forms and schedules for the 2016 form 
year, respectively.
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    \9\ The Agencies used the 2015 forms, schedules, and 
instructions as the ``current'' form version. With respect to IRS-
only changes, the changes for 2016 that appear in the notice 
published by the IRS under the PRA, 81 FR 18687 (Mar. 31, 2016), are 
used in the proposed data elements and instructions and are so 
labeled, instead of showing the changes in the information 
collection under the Code that appear on the 2015 Form 5500 series, 
which the IRS has directed filers not to answer. See IRS Compliance 
Questions on the 2015 Form 5500 Series Returns (https://www.irs.gov/Retirement-Plans/IRS-Compliance-Questions-on-the-2015-Form-5500-Series-Returns).
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    (2) ``[Current Line X]'' if the item is already on the form or 
schedule, but is renumbered in the proposal, to show where the item 
appears on the current form or schedule;
    (3) ``[Current with revisions]'' to indicate, with a short 
explanation, that the item is already on the form or schedule, but 
would be revised; and
    (4) ``[New]'' if the item is a new question or new to that form or 
schedule.
    Dates generally are shown in the data element sheets (as well as 
the instructions) as ``20XX'' for the Form filing year; ``20XX-1'' for 
the prior year, etc.
    The Agencies believe this approach of showing the intended changes 
to the wording of the data elements, but not providing a ``mock up'' of 
the forms and schedules, will reduce costs associated with publication 
of the proposed form changes in the Federal Register and provide 
greater flexibility for the related EFAST2 development processes. The 
Agencies also believe that this approach (i.e., taking the questions 
out of the disclosable form structure), gives a better opportunity to 
review the format, sequencing, and grouping of how the information 
would be asked and entered on each of the forms and schedules and how 
it ultimately could potentially be better presented for disclosure 
purposes. The Agencies seek comments on whether reordering or 
regrouping questions on the Form 5500 and schedules could enhance 
presentation of the information for disclosure purposes or minimize 
burden from a data-gathering, data-entry, recordkeeping, or other 
perspective, as well as suggestions on the structure or appearance of 
the forms as both on-line and printed documents.

B. Proposed Instructions for Form 5500 Annual Return/Report

    Appendix B to this document shows the proposed instructions for the 
Form 5500 and its schedules. The proposed instructions include possible 
additional instructions and definitions for existing line items, as 
well as instructions for new items, and the proposed instructions 
reflect the elimination of current instructions for existing line items 
or schedules that would be deleted under the proposal. The Agencies 
expect that the revised instructions for the year in which the majority 
of the proposed forms changes are implemented, which will be generally 
coincident with the contracting and procurement process for EFAST2, 
will also reflect changes in intervening years, changes to law, and any 
needed additional clarifications and interpretations to the 
instructions for existing and proposed line items, as well as changes 
made in response to comments on the proposal. For ease of use by the 
different types of filers and to eliminate the need for the footnotes 
and exceptions in the current single

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``Quick Reference Chart,'' the Agencies propose separate charts for the 
various types of filers (pension plans, direct filing entities (DFEs), 
group health plans, and welfare plans other than group health plans). 
These charts appear at the end of Appendix B (Form 5500 Annual Return/
Report Instructions). The Agencies believe this proposed change should 
help filers focus on the specific requirements applicable to the type 
of plan or entity for which the Form 5500 Annual Return/Report is being 
filed.
    OMB Control Numbers, PRA Notice, and up to date Business Codes are 
not shown here, but will continue to be included in both the Form 5500 
Annual Return/Report and Form 5500-SF instructions published on the 
EFAST2 Web site for the form year(s) in which the changes are 
implemented.

C. Proposed Instructions for Form 5500-SF

    Appendix C to this document shows the proposed instructions for the 
Form 5500-SF.

III. Request for Comments

    The Agencies believe that the modernization and restructuring of 
the Form 5500 Annual Return/Report being proposed in this Notice would 
support the Agencies' ability to implement strong and effective 
enforcement programs and better respond to inquiries from plan 
participants and beneficiaries, employers, other plan sponsors, and the 
public regarding employee benefit plans. Further, the Agencies believe 
that the proposed revisions would help them more effectively develop 
and implement regulations and other compliance assistance guidance, and 
use data for purposes of economic research, policy formulation, and 
monitoring benefits related developments and activities among ERISA-
covered employee benefit plans.
    The Agencies generally invite comments and suggestions as to other 
alternative solutions and whether and how such alternatives would be 
more, or less, beneficial compared to the proposed changes to the 
forms, schedules, and instructions. Commenters are asked to take into 
account the costs and burdens to plans, participants and beneficiaries, 
plan fiduciaries, plan service providers, and other affected parties, 
in commenting on the proposed annual reporting changes, including any 
suggested alternatives.
    The request for comments includes areas on the existing forms, 
schedules, and instructions that the Agencies have not proposed 
changing, but which may benefit from further guidance, especially with 
regard to how an existing provision or instruction would apply for a 
particular segment of the filing population.

IV. Discussion of Proposed Changes

    The proposed revisions in this Notice reflect priorities of and 
efforts by the DOL, IRS, and PBGC to improve reporting for filers and 
the public, other governmental users, as well as the Agencies by: (1) 
Modernizing financial information filed regarding plans; (2) updating 
fee and expense information on plan service providers, with a focus on 
harmonizing annual reporting requirements with the DOL's final 
disclosure requirements at 29 CFR 2550.408b-2; (3) enhancing 
mineability of data filed on annual return/reports; (4) requiring 
reporting by all group health plans covered by Title I of ERISA, 
including adding a new Schedule J (Group Health Plan Information); and 
(5) improving compliance under ERISA and the Code through selected new 
questions regarding plan operations, service provider relationships, 
and financial management of the plan. The changes in this proposal to 
the forms, schedules, instructions, and DOL regulatory exemptions and 
requirements are intended to further these objectives.

A. Modernize Financial and Plan Operations Information

    An overriding objective of these proposed forms revisions is to 
modernize the Form 5500 Annual Return/Report financial information 
collection so that the presentation of plan trust financial and balance 
sheet information better reflects the investment portfolios and asset 
management practices of employee benefit plans. The basic objective of 
general purpose financial reporting is to provide information about the 
reporting entity for the Agencies' enforcement, research, and policy 
formulation programs; to assist other federal agencies, Congress, and 
the private sector in assessing employee benefit, tax, and economic 
trends and policies; and to assist plan participants and beneficiaries 
and the general public in better monitoring the activities and 
investments of employee benefit plans.
    The financial statements contained in the current Schedule H (Large 
Plan Financial Information) and Schedule I (Small Plan Financial 
Information) are based on data elements that have remained largely 
unchanged since the Form 5500 Annual Return/Report was established in 
1975. Over the past four decades, the U.S. private pension system has 
shifted from defined benefit (DB) pension plans toward defined 
contribution (DC) pension plans, often participant-directed 401(k)-type 
DC pension plans. The financing of retirement benefits has changed 
dramatically coincident with the shift from DB to DC pension plans. In 
1978, when legislation was enacted authorizing 401(k) plans that allow 
employees to contribute to their own retirement plan on a pre-tax 
basis, participants contributed only 29 percent of the contributions to 
DC pension plans and only 11 percent of total contributions to both DB 
and DC pension plans. ``In the years following 1978, employee 
contributions to DC pension plans steadily rose to a peak of 
approximately 60 percent in 1999, where it has remained.'' See Dep't of 
Labor, Private Pension Plan Bulletin Abstract of 2012 Form 5500 Annual 
Reports, at 1 (2015). Simultaneously, the number of single-employer DB 
pension plans has decreased from 92,000 in 1990 to just under 29,000 
single-employer pension plans in 2009. See U.S. Gov't Accountability 
Office, GAO-09-291, Defined Benefit Pensions: Survey Results of the 
Nation's Largest Private Defined Benefit Plan Sponsors Highlights 
(2009) (available at http://www.gao.gov/new.items/d09291.pdf).
    The shift from DB pension plans to DC pension plans has led to 
increased responsibility for participants to manage their own 
retirement savings, which includes having to select among investment 
options in their retirement plans. See Private Pension Plan Bulletin 
Abstract Of 2012 Form 5500 Annual Reports, at 2 (Of the 516,000 section 
401(k)-type plans in 2012, 87.8 percent allowed participants to direct 
investment of all of their assets, and 3.1 percent allowed participants 
to direct investment of a portion of their assets.) The need for more 
relevant and comparable financial information is not limited to 401(k) 
and other DC pension plans; it also extends to DB pension plans. 
Reports from GAO, the DOL-OIG, the ERISA Advisory Council, and the 
TIGTA also have focused on the need for increased transparency and 
accountability generally in connection with employee benefit plan 
investments in hard-to-value and alternative assets, as well as assets 
held through pooled investment vehicles.
1. Changes to Schedule H (Financial Information)--Balance Sheet and 
Income Statement
    Section 103 of ERISA requires plans to include in their annual 
report a statement of assets and liabilities of the plan, aggregated by 
categories and

[[Page 47539]]

reported at current value. It also requires plans to report a statement 
of earnings (losses) and expenses. Although the Form 5500 Annual 
Return/Report has undergone major revisions since its initial 
implementation in 1975, there has been little change to the basic 
balance sheet and income statement information on the Form 5500 Annual 
Return/Report since the return/report was first established. Under the 
proposal, Schedule H, Parts I and II, would retain the essential asset/
liability and income/expense structure of the current reporting 
requirement. The Agencies are proposing, however, to modify the asset 
breakouts on the balance sheet component of the Schedule H to enable 
more accurate and detailed reporting on the types of assets held by a 
plan, including alternative investments, hard-to-value assets, and 
investments through collective investment vehicles. The proposed 
changes take into account the fact that many of these more 
sophisticated and complex investments do not fit neatly into any of the 
existing reporting categories. As a result, filers inconsistently 
report on the various existing categories, and important financial 
information is obscured by consolidation of many diverse investments 
into the catch-all ``other'' category on the balance sheet on the 
Schedule H. The proposal would also update the income/expense statement 
of the Schedule H to get a better picture of earnings and expenses 
associated with plan investments and operations.
    In addition to the Agencies' assessment that Form 5500 Annual 
Return/Report financial reporting would benefit from improved 
transparency and accountability, the proposal to change the asset 
categories on the Schedule H balance sheet is supported by recent 
reports from both the GAO and the DOL-OIG. The GAO has noted that the 
plan asset categories on the Schedule H are not representative of 
current plan investments and provide little insight into the 
investments themselves, the level of associated risk, or the structures 
of these investments. GAO-14-441, Private Pensions: Targeted Revisions 
Could Improve Usefulness of Form 5500 Information, at 11-12. The 
proposed changes to the Schedule H also are consistent with the DOL-OIG 
recommendation that the Form 5500 Annual Return/Report be revised to 
improve reporting of hard-to-value and alternative investments. U.S. 
Dep't of Labor Office of Inspector Gen., 09-13-001-12-121, Employee 
Benefits Security Administration Needs to Provide Additional Guidance 
And Oversight to ERISA Plans Holding Hard-To-Value Alternative 
Investments, at 4, 19.
    Accordingly, the Agencies are proposing the following changes to 
the Schedule H balance sheet and income statement. Current Line 1a, 
``total noninterest bearing cash,'' would be reported as a breakout 
element under General Investments. This would also result in Line 1b 
``Receivables'' and Line 1c ``General Investments'' being renumbered as 
Lines 1a and 1b respectively. Participant loans would continue to be 
reported as a separate line item, but would be reported as a breakout 
element under renumbered Line 1a as a ``receivable'' rather than under 
its current reporting classification under the heading ``General 
Investments.'' This change is responsive to amendments made to 
``Generally Accepted Accounting Principles'' (GAAP) by the Financial 
Accounting Standards Board (FASB), which required participant loans to 
be classified as notes receivable from participants. See Financial 
Accounting Standards Board, No. 2010-25, Plan Accounting--Defined 
Contribution Pension Plans (Topic 962) (2010). As notes receivable, 
participant loans would continue to be reported at their unpaid 
principal balance plus any accrued but unpaid interest.
    Under proposed Line 1b (currently Line 1c) ``General Investments,'' 
the Agencies would add both new categories and new breakouts within 
existing categories. Cash and cash equivalents would be the first 
category under ``General Investments.'' As indicated above, 
``noninterest bearing cash (such as cash on hand or cash in a non-
interest bearing checking account)'' would no longer be separated from 
``General Investments.'' Instead it would be a sub-breakout under 
``cash and cash equivalents.'' The category would also have sub-
breakouts for interest bearing cash (assets that earn interest in a 
financial institution account such as interest bearing checking 
accounts, passbook savings accounts, or money market bank deposit 
accounts). While the breakouts are new, the information is already 
required to be reported on current Line 1c(1).
    The next category under ``General Investments,'' would continue to 
be for reporting ``Debt Interests/Obligations.'' The Form 5500 Annual 
Return/Report currently provides little in the way of detail or 
transparency about the range of plan investments in bonds, loans, and 
other debt instruments and obligations. For example, a single line item 
for ``other loans'' on the Schedule H currently covers, as indicated in 
the Form 5500 Annual Return/Report instructions, the value of loans for 
construction, securities loans, commercial and/or residential mortgage 
loans that are not subject to Code section 72(p), and other 
miscellaneous loans. See, e.g., 2015, Schedule H, Form 5500 Annual 
Return/Report Instructions.
    The general debt heading, as proposed, would keep the existing 
breakout for corporate debt instruments. Breakouts under that category, 
however, would be investment grade debt and high-yield debt, rather 
than ``preferred'' and ``all other,'' as on the current Schedule H. 
This change is intended to have the Schedule H financial information 
for all reporting plans regarding corporate debt instruments correspond 
to the more detailed financial information on Schedule R for defined 
benefit pension plans that have 1,000 participants or more. In 
addition, U.S. government securities would be broken out from other 
government securities. The instructions for the current forms advise 
filers to report such investments on the Schedule H financial 
statements in ``Other'' debt instruments. This proposal, however, 
includes more investment categories on the Schedule H to improve 
transparency from the current ``other'' categories. For example, there 
would be a breakout for other loans (other than loans to participants), 
exchange traded notes, and asset backed securities (other than real 
estate),\10\ and debt obligations associated with real property would 
be reported under the real property category, rather than generally 
under ``Other Debt Obligations.'' Thus, with respect to reporting such 
leveraged or collateralized transactions on the balance sheet portion 
of Schedule H, filers would be advised in the instructions to account 
for such transactions in the appropriate asset category in accordance 
with the individual characteristics of the investment.
---------------------------------------------------------------------------

    \10\ The SEC similarly is working towards more transparency with 
regard to some of these assets. See Securities and Exchange 
Commission, Asset-backed Securities Disclosure and Registration, 79 
FR 57,184 (Sept. 24, 2014). FINRA has also published an Investor 
Alert related on exchange traded notes to increase investor 
awareness of the associated risks. See Exchange-Traded Notes: Avoid 
Unpleasant Surprises, FINRA, www.finra.org/Investors/ProtectYourself/InvestorAlerts/TradingSecurities/P131262. See also 
U.S. Gov't Accountability Office, GAO-12-324, Recent Developments 
Highlight Challenged Of Hedge Fund And Private Equity Investing 
(2012) (discussing plan investment in distressed debt).
---------------------------------------------------------------------------

    The next category under ``General Investments'' would continue to 
be ``Corporate Stocks.'' Under the corporate securities category, 
filers would still distinguish between ``preferred'' and

[[Page 47540]]

``common'' stock for reporting direct holdings of corporate securities. 
There would be new breakouts, however, for ``publicly traded'' and 
``non-publicly traded'' securities under both the ``preferred'' and 
``common'' stock elements. This proposed change is intended to present 
a more complete picture of plan investments in hard-to-value assets.
    The existing reporting line items for certain collective investment 
vehicles that are treated as holding plan assets under the DOL's plan 
asset regulation at 29 CFR 2510.3-101 (i.e., bank common or collective 
trusts (CCTs), insurance company pooled separate accounts (PSAs), 
entities meeting the conditions of DOL regulation 29 CFR 2510.103-12 
(103-12 IEs), and master trusts) generally would be retained, but 
grouped together for reporting under a new category entitled ``Eligible 
Pooled Investment Funds (Other Than Registered Investment Companies).'' 
To increase transparency and improve the quality of data collected 
across various components of the Form 5500 Annual Return/Report, the 
proposal would significantly reconfigure existing reporting of assets 
held through the various types of pooled investment vehicles that have 
plan assets.
    Under the proposal, a plan's investments in CCTs and PSAs would be 
reported in the aggregate on single line items for each vehicle type on 
the Schedule H Line 1b balance sheet information regardless of whether 
the CCT or PSA files a Form 5500 Annual Return/Report as a DFE. This is 
a change from the current rule that has filers break out the underlying 
assets in the respective line items on the Schedule H balance sheet 
under ``general investments'' if the CCT or PSA has not filed a Form 
5500 Annual Return/Report and in the aggregate on the CCT or PSA line 
if the Form 5500 Annual Return/Report has been filed. Instead, as 
discussed in more detail below, the Line 4i(1) Schedule of Assets held 
for Investment of either the plan or the CCT or PSA, depending on 
whether the CCT or PSA has filed, would be where the breakout of 
underlying assets would be reported.
    With respect to 103-12 IE reporting on Schedule H, the proposal 
generally continues the existing reporting requirements. Specifically, 
similar to the requirements for plans that invest in CCTs and PSAs, a 
plan that invests in an entity that files as a 103-12 IE would, in 
identifying each individual 103-12 IE on the Line 4i Schedules of 
Assets, have to include the value of the plan's investment in each 103-
12 IE.
    Reporting regarding investments in master trusts by plans and 
reporting by master trusts, as described in more detail below, would be 
substantially revised, including reporting on the plan's asset and 
liability statements on Schedule H, Part I. Specifically, as they did 
prior to 1999, plans would report their total holdings in master trusts 
on Schedule H, Line 1b, on an aggregate basis, and the reporting 
concept of the master trust investment account (MTIA) would be 
eliminated. The participating plans' fractional interest in the various 
holdings of the master trust (which currently are reflected in the MTIA 
Form 5500 Annual Return/Report) now would be shown on the various 
plans' Schedule H, Line 4i(1) Schedule of Assets Held for Investment at 
End of Year and Line 4i(2) Schedule of Assets Disposed of During the 
Plan Year, as well as on the filings by the master trust itself.
    The DOL views the proposed changes to annual reporting regarding 
these pooled investment vehicles as important and necessary in light of 
the large amount of plan assets (an estimated $1.1 trillion) held by 
CCTs, PSAs, master trusts, and 103-12 IEs. See U.S. Gov't 
Accountability Office, GAO 12-121, Limited Scope Audits Provide 
Inadequate Protections To Retirement Plan Participants, at 1 (2014).
    As part of the focus on better reflecting and understanding how 
plans are investing, the Agencies also propose to replace the single 
line existing category entitled ``Value of Interest in Funds Held in 
Insurance General Accounts (Unallocated Contracts)'' by adding 
breakouts of various types of unallocated contracts. The proposal would 
add to the existing general category breakouts for deposit 
administration, immediate participation guarantees, guaranteed 
investment contracts, and ``other'' unallocated insurance contracts. 
These classes of contracts parallel the existing Schedule A reporting 
on insurance contracts with unallocated funds. Comments are 
specifically solicited on whether this breakout is sufficient or 
whether the value of investments in other or additional classes of 
insurance contracts, such as variable annuity contracts,\11\ should be 
listed on the Schedule H.
---------------------------------------------------------------------------

    \11\ As discussed below, the proposal would add new questions to 
Schedule A regarding variable annuities.
---------------------------------------------------------------------------

    The Agencies are also proposing changes to the existing category 
entitled, ``Partnership/Joint Venture Interests.'' To clarify the 
reporting of these general partnership and joint venture investments, 
new sub-categories are being added to report the value of interest in 
``limited partnerships,'' ``venture capital operating companies 
(VCOCs),'' ``private equity,'' ``hedge funds,'' and ``other 
partnership/joint venture interests.'' The Agencies' proposal was 
informed by the GAO's findings that there was a need for more detail on 
plan investment in hedge funds and private equity funds due to 
substantial increases in the percentage of plans investing in hedge 
funds and private equity. U.S. Gov't Accountability Office, GAO-12-324, 
Recent Developments Highlight Challenges With Hedge Fund And Private 
Equity Investing, at 19 (2012). In making this recommendation, GAO 
acknowledged that although there is no universally accepted definition, 
the term ``hedge fund'' is commonly used to describe pooled investment 
vehicles that are privately organized and administered by professional 
managers who engage in active trading of various types of securities, 
commodity futures, options contracts, and other investment vehicles, 
including relatively illiquid and hard-to-value investments. Similarly, 
``private equity fund'' is commonly used to describe privately managed 
pools of capital that invest in companies that typically are not listed 
on a stock exchange. See, e.g., 2011 ERISA Advisory Council Report: 
Hedge Funds and Private Equity Investments (noting that plan sponsors 
have increased investment of defined benefit pension plan assets in 
hedge funds and/or private equity funds due to the need to increase 
diversification, decrease volatility, and enhance the plan's overall 
performance). The Agencies specifically invite comments on whether 
these definitions are adequate for purposes of Form 5500 Annual Return/
Report financial reporting.
    In addition, because investments in the ``Partnership/Joint venture 
interests'' may or may not be holding plan assets under the DOL's plan 
asset regulation at 29 CFR 2510.3-101, the Agencies are proposing an 
off-balance sheet item in this category where filers would indicate the 
total value of such investments that are plan asset vehicles and those 
that are not.
    The real estate category on the Schedule H balance sheet would be 
expanded and include sub-categories to include investments in 
particular types of assets or pooled investment funds designed to 
invest primarily in real estate or real estate mortgages. In the 
Agencies' view, the current reporting requirements do not accurately 
reveal the extent and type of a plan's real estate and related 
holdings. The

[[Page 47541]]

proposed new breakouts are: Developed real property (other than 
employer real property), undeveloped real property (other than employer 
real property), real estate investment trusts (REITs), mortgage-backed 
securities (including collateralized mortgage obligations (CMOs)), real 
estate operating companies (REOCs), and ``Other'' real estate related 
investments. Adding these breakouts is consistent with the Agencies' 
objective of improving reporting on investments that constitute 
alternative or hard-to-value assets. See OECD/IOPS Good Practices on 
Pension Funds' Use of Alternative Investments and Derivatives, OECD, 
(available at http://www.oecd.org/finance/private-pensions/oecdiopsgoodpracticesonpensionfundsuseofalternativeinvestmentsandderivatives.htm.) Creating more specific categories also should help address 
concerns about inconsistencies in real property reporting cited by the 
report, GAO Targeted Revisions Could Improve Usefulness Of Form 5500 
Information, at 10.
    A significant new reporting category is for investments in 
derivatives. The sub-categories in the derivatives category would be 
futures, forwards, options, swaps, and ``Other.'' As in the other 
general categories, filers would enter a description for assets listed 
as ``Other.'' Obtaining more specific information about the extent to 
which plans are engaged in hedging or in the listed types of derivative 
transactions would help address concerns raised by the GAO about 
limitations on usefulness of data on investments in derivatives under 
the current reporting structure. See generally U.S. Gov't 
Accountability Office, GAO-08-692, Defined Benefit Plans: Guidance 
Needed To Better Inform Plans Of The Challenges And Risks Of Investing 
In Hedge Funds And Private Equity, at 25, 42-43 (expressing specific 
concerns about the way in which pension plans report investments in 
derivatives and suggesting that plan sponsors are currently reporting 
these types of investments in various different categories on the 
Schedule H, limiting the usefulness of the data.)
    The Agencies are also proposing a new category for foreign 
investments with breakouts to separately report holdings of foreign 
equities and debt interests. The Agencies propose that, for this 
reporting purpose, foreign equities would include American Depository 
Receipts, U.S.-traded foreign stocks and stocks traded on foreign 
markets. Foreign debt would include both long-term and short-term 
foreign debt investments, but would not include for purposes of a Form 
5500 Annual Return/Report such foreign securities held through U.S. 
registered investment funds or exchange traded funds, CCTs, PSAs, 103-
12 IEs, or master trusts. There also would be subcategories for foreign 
real estate, currency, and ``Other,'' with a description required for 
anything reported in the ``Other'' category.
    The Agencies also are proposing a new asset category on the 
Schedule H, ``Tangible Personal Property,'' which category currently 
appears on the Schedule I, but not on the Schedule H. Under the 
proposal, the Schedule H would list on its face the main types of 
assets as reportable in this category, i.e. direct investments in 
tangible personal property, with sub-categories for collectibles, 
precious metals, and ``Other.'' There would also be a separate breakout 
category for commodities, which would be divided into ``Precious 
Metals'' and ``Other.'' Moving this category from the Schedule I to the 
Schedule H for all filers required to complete the Schedule H, 
including former Schedule I filers, would add transparency to these 
plan investment holdings. To the extent plans have direct investments 
in tangible personal property and commodities (as opposed to futures 
contracts or exchange traded funds), they are likely to be reported 
unhelpfully from a transparency perspective as ``Other'' on the 
existing Schedule H.
    Finally, the Agencies propose making reporting more transparent for 
assets held through participant-directed brokerage accounts. The 
proposal generally follows the same breakout requirements as the 
current rules. The current rules provide that assets held through 
participant-directed brokerage accounts may be reported either: (1) As 
individual investments in the applicable asset and liability categories 
in Part I and the income and expense categories in Part II, or (2) by 
including on the ``Other'' lines (Line 1c(15) on the balance sheet and 
2c on the income statement) the total aggregate value of the assets and 
the total aggregate investment income (loss) before expenses, provided 
the assets are not loans, partnership or joint venture interests, real 
property, employer securities, or investments, including derivatives, 
that could result in a loss in excess of the account balance of the 
participant or beneficiary who directed the transaction. Under the 
proposal, filers would provide the total current value of all assets 
held through participant-directed brokerage accounts, except there 
would be separate sub-totals for brokerage account investments in 
tangible personal property, loans, partnership or joint venture 
interests, real property, employer securities, and investments that 
could result in a loss in excess of the account balance of the 
participant or beneficiary who directed the transaction. The current 
Form 5500 Annual Return/Report reporting rules already require that 
these types of assets be reported separately from other participant-
directed brokerage account assets, similar to the reporting rules for 
investments in CCTs and PSAs that do not file their own Form 5500 
Annual Return/Report. On the proposed Line 4i Schedules of Assets, 
assets held through a participant-directed brokerage account would be 
permitted to be reported in the aggregate as a single asset held 
directly by the plan. The broker would be identified as the issuer/
borrower/etc. In the element requiring the filer to indicate on what 
line the assets were reported on Line 1b, the filer would enter all the 
subcategories for types of investments held through a participant-
directed brokerage account.
    The Agencies considered requiring filers to break out all assets 
held through a participant-directed brokerage account on the Line 4i 
Schedules of Assets. The Agencies also considered continuing to require 
filers to break out those specific assets that are currently required 
to be broken out on Line 1c. For example, the Agencies considered 
requiring a breakout of information on whether participants are 
investing in alternative and hard-to-value assets through participant-
directed brokerage accounts. The Agencies determined, on balance, 
considering the benefits to the information and the relative potential 
burden, that having on the proposed balance sheet (Line 1b) a general 
breakout of asset types held through participant-directed brokerage 
accounts would be sufficient, and that details of each individual asset 
so held would not be required.
    The proposal to continue to allow filers to report assets held in 
participant-directed brokerage accounts in the aggregate is intended to 
be responsive to comments on the DOL's Request for Information, 
Question 38, 79 FR 49469, 49473 (Aug. 14, 2014) (RFI), which 
specifically asked whether changes should be made to the Schedule H to 
require more detail about investments made through brokerage windows. 
While some commenters on the RFI thought it made sense for the DOL to 
consider changes to the Form 5500 Annual Return/Report with respect to 
brokerage windows, others were concerned about the burden and costs 
such changes would impose on sponsors and participants and were unclear 
about the relative benefit of

[[Page 47542]]

more information. The Agencies do not believe that there would be a 
substantial additional burden imposed by requiring aggregate 
participant-directed brokerage account assets to be reported separately 
instead of the current practice of reporting such assets in the catch-
all ``Other'' category. Similarly, the Agencies believe that there 
would not be a substantial burden change in the proposed requirement to 
break out, on the Line 4i Schedules of Assets, the types of investments 
held in participant-directed brokerage accounts that are not eligible 
for aggregated reporting under current annual reporting rules.
    One of the goals of the proposed change is to get better 
information on securities lending \12\ practices and how they impact 
plan finances and operations. As indicated in the Financial Stability 
Oversight Council's (FSOC) Annual Report for 2014 (available at http://www.treasury.gov/initiatives/fsoc/Documents/FSOC%202014%20Annual%20Report.pdf), the global value of securities 
loans was approximately $1.8 trillion in 2013. Pension plans are a 
large segment of the entities engaged in such transactions. 
Accordingly, the Agencies believe that more precise information is 
needed to understand how these transactions impact plans and how plans 
fit into the overall markets. The Agencies explored adding new breakout 
line items on the asset/liability and income expense statements to 
identify in more detail securities lending transactions. It is the 
understanding of the Agencies, however, that filers are reporting 
securities lending arrangements and similar transactions on the 
financial statements in various different ways, depending on whether 
the plan is borrowing or lending securities and the structure of the 
arrangement or transaction, including transactions such as repurchase 
agreements and sell/buy-back transactions where, technically, the plan 
no longer owns the securities. Accordingly, the Agencies believe that 
the best way to get information on securities financing transactions, 
without creating particularized line items that might not work for all 
types of transactions, is to instruct filers to report assets in the 
appropriate categories on the Schedule H and then identify the 
transactions in response to the newly proposed compliance questions. 
The new compliance question would ask whether the plan has investment 
acquisitions that are leveraged, including assets subject to 
collateralized lending activities (e.g., securities lending 
arrangements, repurchase agreements (repos), etc.). If ``Yes,'' the 
plan would be required to identify whether the plan engaged in 
securities lending arrangements, including repurchase agreements or 
sell/buy-backs, or other transactions that subjected plan assets to a 
mortgage, lien, or other security interest, and to describe the 
arrangement. The plan would then have to report, as a total, the amount 
of cash obligated in connection with collateralized lending activities 
at end of year, the value of securities obligated in connection with 
collateralized lending activities at end of year, the value of other 
assets obligated in connection with collateralized lending activities 
at end of year, and the approximate ratio of collateralized/leveraged 
investments to total plan assets at end of year. The Agencies 
specifically request comments on whether there could be effective 
breakout line items on the balance sheet that would more clearly show 
assets that are subject to securities lending or similar arrangements 
or whether there are specific instructions that would be helpful for 
filers to know where to categorize the various components of such 
transactions on both the balance sheet and earnings statements on the 
Schedule H.
---------------------------------------------------------------------------

    \12\ The term ``securities loans'' generally refers to the 
collateralized loan of a security from one party to another. Such a 
loan can have a pre-specified term, such as one business day, one 
week, or one month, or it can be ``open.'' An open loan is ongoing 
until one of the parties to the trade decides to end it.
---------------------------------------------------------------------------

    Under the ``Income and Expense'' statement in Part II of the 
Schedule H, the Agencies propose retaining the same basic structure for 
reporting income as on the current Schedule H, but with additional 
breakout categories. Notably, the ``interest'' income category includes 
a new breakout for government securities other than U.S. government 
securities, and the unrealized appreciation (depreciation) of assets 
category would be broken out to report separately partnership/joint 
venture interests, commodities investments, derivatives, employer 
securities, foreign investments (other than those held through U.S. 
registered investment funds), and employer real property, in addition 
to the existing breakouts for real estate, CCTs, PSAs, MTIAs, 103-12 
IEs, and registered investment companies. These proposed changes are 
intended to better support investment monitoring by asset class and 
provide more consistent data for research and policy purposes.
    The proposal would also add new breakout categories to the 
``Administrative Expenses'' category of the Income and Expenses section 
of the balance sheet. The Agencies have determined that to get a better 
picture of plan expenses, particularly those related to service 
providers, more detail in this category is warranted. Accordingly, data 
elements would be added for ``Salaries and allowances,'' ``Independent 
Qualified Public Accountant (IQPA) Audit fees,'' ``Recordkeeping and 
Other Accounting Fees,'' ``Bank or Trust Company Trustee/Custodial 
Fees'' ``Actuarial fees'' ``Legal fees,'' ``Valuation/appraisal fees,'' 
and ``Trustee fees/expenses (including travel, seminars, meetings.'' 
\13\
---------------------------------------------------------------------------

    \13\ Other than IQPA Audit Fees and Bank or Trust Company 
Trustee/Custodial Fees, these questions were on the Form 5500 prior 
to 1999. See 1998 Form 5500, Line 32(g).
---------------------------------------------------------------------------

    The Agencies are also proposing to change administrative expense 
reporting to identify when participant accounts are charged directly. 
The Agencies believe that this information is important to better 
understand how compensation arrangements impact participants, 
especially in defined contribution pension plans. The Agencies 
considered requiring filers to break out direct expenses on a service 
provider by service provider basis on Schedule C to show how and when 
they are charged to participant accounts rather than at the plan level. 
To minimize reporting burden under the proposal, however, the 
information would be reported only in the aggregate. Therefore, instead 
of requesting this information on the Schedule C, the Agencies have 
proposed revising the expense information on Schedule H. Specifically, 
the ``Total'' administrative expense line item on Schedule H would now 
require that administrative expenses charged directly against 
participant accounts be separately reported from those direct expenses 
charged to other plan asset sources. Filers would separate transaction-
based charges to individual participant accounts and plan level 
expenses apportioned among participant accounts. With respect to the 
latter, filers would indicate whether the expenses were apportioned per 
capita, pro rata by account balance, or ``Other'' apportionment method 
that they would describe. This would give the Agencies and other users 
of the Form 5500 Annual Return/Report data a better idea of how and 
when participants are being charged administrative expenses, which is 
particularly important for defined contribution pension plans.

[[Page 47543]]

2. Proposed Changes to Schedule H, Line 4i Schedules of Assets
    As indicated above, the proposed modernization of the financial 
reporting required on the Schedule H would include structural, data 
element, and instruction changes to the Line 4i Schedules of Assets. 
The current Line 4i Schedules (``Schedule of Assets Held for Investment 
at End of Year'' and ``Schedule of Assets Acquired and Disposed Within 
Year'') are required under section 103 of ERISA to be included in the 
annual report, as currently implemented in the DOL's regulations at 29 
CFR 2520.103-11.\14\ These schedules are filed by plans required to 
file the Schedule H and by certain DFEs. The schedules are a central 
element of the financial disclosure structure of ERISA because they are 
the only place in the Form 5500 Annual Return/Report where plans are 
required to list individual plan investments, identified by major 
characteristics, such as issue, maturity date, rate of interest, cost, 
and current value. Accordingly, these schedules are the only part of 
the Form 5500 Annual Return/Report that can be used to evaluate the 
year-to-year performance of a plan's individual investments. The 
reported information, however, suffers from several shortcomings.
---------------------------------------------------------------------------

    \14\ To see the proposed changes to the DOL's regulations to 
implement these data element and instruction revisions, please see 
the DOL's Notice of Proposed Rulemaking--Annual Reporting, published 
elsewhere today in the Federal Register.
---------------------------------------------------------------------------

    Perhaps most fundamentally, this information currently is not 
reported in a data-capturable format. Thus, although an image or 
picture of the attachments that are currently filed as non-standard 
attachments to filers' electronic Form 5500 Annual Return/Report 
filings is available through the EFAST2 public disclosure function, it 
is not viewable as part of the Schedule H, nor is the information 
included in the data sets that DOL prepares from the return/report 
filing data and publishes on its Web site (www.dol.gov/ebsa/foia/foia-5500.html). Also, the Line 4i Schedules of Assets are not always found 
in the same place in each Form 5500 Annual Return/Report filing. For 
example, the Line 4i Schedules of Assets are often incorporated in the 
larger audit report of the plan's IQPA that itself is filed as a 
nonstandard attachment to the Form 5500 Annual Return/Report.\15\ The 
schedules also do not require standardized methods for identifying and 
describing assets on the Line 4i Schedules of Assets. Under the current 
reporting rules, the same stock or mutual fund may be identified with 
various different names or by use of different abbreviations. The 
creation of more detailed and structured Line 4i Schedules of Assets is 
a specific recommendation of both the DOL-OIG and the GAO. See DOL 
Inspector Gen. EBSA Needs To Provide Additional Guidance And Oversight 
To ERISA Plans Holding Hard-To-Value Alternative Investments, at 4-5; 
GAO Private Pensions: Targeted Revisions Could Improve Usefulness of 
Form 5500 Information, at 37.
---------------------------------------------------------------------------

    \15\ See EFAST2 FAQ 24a, (available at www.dol.gov/ebsa/faqs/faq-EFAST2.html) (advising filers of options in EFAST2 for filing 
the accountant's opinion and accompanying financial statements, 
indicating that they do not need to be ``tagged'' separately for 
filing purposes.)
---------------------------------------------------------------------------

    The first proposed improvement would require filers to complete 
standardized Line 4i Schedules of Assets in a data-capturable format. 
The Agencies anticipate that EFAST2 would have separate ``structured'' 
locations for entering the data into the Form 5500 Annual Return/Report 
filing, using a standardized format that would enable incorporation of 
the Line 4i Schedules of Assets information into the datasets that 
EFAST and EBSA make available from each year's Form 5500 Annual Return/
Report and Form 5500-SF filings and enable DOL to more readily disclose 
the information, as required under Title I of ERISA.
    As under the current reporting structure, there would continue to 
be two separate schedules of assets.\16\ The first would be the 
existing Schedule of Assets Held for Investment at End of Year. The 
second would modify the existing ``Schedule of Assets Acquired and 
Disposed of Within Year'' to a ``Schedule of Assets Disposed of During 
the Plan Year.'' The objective of the current Schedule of Assets 
Acquired and Disposed of Within Year was to ensure that the Form 5500 
Annual Return/Report (which generally captures financial information at 
the beginning and the end of the plan year) captured information on 
assets that may not have been held either at the beginning of the year 
or end of year because they were bought and sold within the same year. 
That structure, however, suffers from a significant gap in information 
about alternative investments and hard-to-value assets because neither 
of the current Schedules of Assets provides information on the sale of 
such assets if purchased in one year and sold in the middle of a 
subsequent year. The change in the Schedule of Assets Disposed of 
During the Plan Year to cover all investment assets disposed of during 
the plan year would close that gap, while continuing to capture 
transactions that involve the purchase and sale of investment assets 
within the same plan year.
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    \16\ The current Line 4i question generally asks whether the 
plan held assets for investment, referring to both Schedules of 
Assets. Because all filers, except filers for terminated plans, 
answer ``Yes'' to indicate that they have assets held at end of 
year, answers to the current question do not reveal whether the plan 
also had assets acquired and disposed of during the plan year. The 
proposal would separate the question into two parts: Line 4i(1) 
asking whether the plan held investments at the end of the year; and 
Line 4i(2) asking whether the plan disposed of assets during the 
plan year. If the answer was ``Yes'' to either question, the 
corresponding Schedule of Assets would need to be attached.
---------------------------------------------------------------------------

    Both of the proposed Line 4i Schedules of Assets would continue to 
require filers to enter, as applicable, the existing data elements (1) 
identifying the issuer, borrower, lessor, or similar party; (2) 
describing the investment and identifying, as applicable, the issue, 
maturity date, rate of interest, par, or maturity value, including 
whether the asset/investment is subject to surrender charge; (3) 
reporting the cost of the asset; and (4) reporting the current value of 
the asset.
    A new data element on the Line 4i(1) Schedule of Assets Held for 
Investment would require the filer to indicate whether the plan or 
reporting DFE held the investments directly, through a master trust, 
CCT, PSA, or a 103-12 IE. If the assets are held through a DFE, the 
filer (whether a plan or an investing DFE) would be required to list 
each DFE as an investment and enter for each DFE in which the filer was 
invested, the name, employer identification number (EIN), and plan 
number (PN) used by the DFE on its own Form 5500. If a PSA or CCT in 
which the reporting plan or DFE invests has not filed a Form 5500 
Annual Return/Report, the filer would have to check a box to indicate 
that the CCT or PSA has not filed a Form 5500 Annual Return/Report, and 
the investing plan or DFE would have to break out the underlying assets 
of the CCT or PSA on its own Line 4i(1) Schedule of Assets Held for 
Investment at End of Year. This aspect of the proposal is intended 
better to coordinate the information currently reported by plans and 
investing DFEs on Schedule D and on the Line 4i(1) Schedule of Assets 
Held for Investment at End of Year.
    The current instructions tell filers to use an asterisk to identify 
investments that involved a party-in-interest on the Line 4i Schedule 
of Assets Held for Investment at End of Year. Review of Form 5500 
Annual Return/Report data, however, suggests that many filers may not 
be aware of the requirement, which is currently explained only in the 
instructions for Schedule H of the Form

[[Page 47544]]

5500 Annual Return/Report. Identification of the involvement of a 
party-in-interest, therefore, has been inconsistent and incomplete. To 
address the issue, the proposal would replace the current requirement 
to include an asterisk with a check box to indicate whether the 
investment involved a party-in-interest.
    To indicate the type of asset generally, filers generally would be 
required to indicate on the Line 4i Schedule of Assets the category 
under which the value of the asset was included on the Schedule H asset 
statement (proposed Line 1b), or if held through a CCT or PSA that has 
not filed, where the individual assets would have been included on Line 
1b if not held through the CCT or PSA.
    The proposal would add to the Line 4i(1) Schedule of Assets Held 
for Investment at End of Year a requirement to report investment 
identifiers such as CUSIP (Committee on Uniform Securities 
Identification Procedures), CIK (Central Index Key), and LEI (Legal 
Entity Identifier), if applicable, for each asset. Filers would also be 
expected to provide any other uniform number applicable to the entity 
or asset being reported, such as the Financial Instrument Global 
Identifier (FIGI), which is now coming into more common usage.\17\ The 
use of CUSIP in particular has been recognized by the GAO as a way to 
improve end-users' ability to aggregate analyses of the information 
contained on the Schedules of Assets. GAO Private Pensions: Targeted 
Revisions Could Improve Usefulness Of Form 5500 Information, at 17.
---------------------------------------------------------------------------

    \17\ See U.S. Bank Adopts Bloomberg's New Industry-standard for 
Trustee Reporting, Bloomberg, (available at http://www.bloomberg.com/company/announcements/u-s-bank-adopts-bloombergs-new-industry-standard-for-trustee-reporting/) (reporting that U.S. 
Bank is the first corporate trustee to adopt Bloomberg's 
transparent, open-source methodology.)
---------------------------------------------------------------------------

    The Agencies recognize that some identifiers, particularly the LEI, 
are not yet widely used. The LEI is included in the proposal in 
anticipation of increased use by the time the rule becomes final. The 
LEI is intended to identify legally distinct entities that engage in a 
financial transaction. It has support from both industry and government 
agencies who view having a universal identifier of parties to financial 
transactions, such as the LEI, as an important response to the 2008 
financial crisis and the best way to track and understand the true 
nature of risk exposures across the financial system. See, e.g., 
Statement on Legal Entity Identification for Financial Contracts, 75 FR 
74146, 74147 (Nov. 30, 2010) (noting that precise and accurate 
identification of legal entities engaged in financial transactions is 
important to private markets and government regulation); Executive 
Office of the President of the United States, Nat'l Science and 
Technology Council, Smart Disclosure and Consumer Decision-making: 
Report of the Task Force on Smart Disclosure, at 13 (2013) (noting that 
the Administration is working to promote a LEI system). The use of LEI 
to identify pension plan transactions is particularly important because 
pension plan investments make up a large percentage of all investment 
assets and, as previously discussed, plans are increasingly invested in 
alternative investments that involve complicated financial structures 
and transactions.
    Under the proposal, filers would continue to be required to set 
forth the current value of each investment asset listed on the Line 4i 
Schedules of Assets. To improve reporting on hard-to-value assets where 
the current value is by definition not readily available, filers would 
be required to check a box for each individual investment listed to 
indicate whether the asset is ``hard-to-value.'' This requirement is 
meant to supplement the current compliance question on the Schedule H 
that asks whether the plan held any investment assets whose value was 
not readily determinable on an established market or set by a third 
party independent appraisal. See, e.g., 2015 Form 5500 Annual Return/
Report Instructions for Schedule H. The aggregate compliance question, 
by itself, does not provide particularly useful information on hard-to-
value assets. An examination of Form 5500 Annual Return/Report filings 
suggests substantial non-compliance or inaccurate reporting in the ways 
plans answer the question. See also DOL-OIG EBSA Needs To Provide 
Additional Guidance And Oversight To ERISA Plans Holding Hard-To-Value 
Alternative Investments, at 4-5, 18, and 19 (recognizing that the Form 
5500 Annual Return/Report has a ``limited ability to capture 
information on hard-to-value investments'' and recommending that EBSA 
``improve Form 5500 [Annual Return/Report] data collection, analysis, 
and targeting of plans with hard-to-value investments.''). The Agencies 
believe that the requirement for filers to indicate for each specific 
investment asset whether the asset is hard-to-value is in keeping with 
the goals of obtaining better information regarding plan assets.
    The instructions would also include a clearer definition of hard-
to-value assets for this purpose. Specifically, assets that are not 
listed on any national exchanges or over-the-counter markets, or for 
which quoted market prices are not available from sources such as 
financial publications, the exchanges, or the National Association of 
Securities Dealers Automated Quotations System (NASDAQ), would be 
required to be identified as hard-to-value assets on the Line 4i 
Schedules of Assets. CCTs and PSAs that are invested primarily in hard-
to-value assets must themselves be identified as hard-to-value assets, 
regardless of whether they are valued at least annually. Similar to the 
existing treatment in the instructions for registered investment 
companies, CCTs, and PSAs under the current rules, those registered 
investment companies, CCTs, and PSAs that are valued at least annually 
and are invested primarily in assets that are listed on any national 
exchanges or over-the-counter markets, or for which quoted market 
prices are available from sources such as financial publications, the 
exchanges, or the NASDAQ, however, would not need to be identified as 
hard-to-value assets on the Line 4i Schedules of Assets.
    A non-exhaustive list of examples of assets that would be required 
to be identified as hard-to-value on the proposed Schedules of Assets 
includes: Non-publicly traded securities, real estate, private equity 
funds; hedge funds; and real estate investment trusts (REITs). The 
Agencies believe this definition is generally consistent with the FASB 
audit and accounting requirements defining assets with a readily 
determinable fair value. See, e.g., FASB Accounting Standards 
Codification TM (ASC) (Topic 820).
    As discussed above, filers generally would be permitted to 
aggregate participant-directed brokerage account reporting on the Line 
4i Schedules of Assets by indicating the value of all the brokerage 
account investments as a single entry (identifying the brokerage 
account information). In the element requiring filers to indicate the 
location where the asset was aggregated for purposes of balance sheet 
reporting on Line 1b, the filer would have to indicate all of the 
following applicable categories of investments: Tangible personal 
property, loans, partnership or joint venture interests, real property, 
employer securities, investments that could result in a loss in excess 
of the account balance of the participant or beneficiary who directed 
the transaction, and any asset that would be categorized as ``Other.''
    For the second of the Line 4i Schedules of Assets, which would 
correlate under the proposal to Schedule H, Line 4i(2), as noted above,

[[Page 47545]]

the Agencies propose to change ``Schedule of Assets Acquired and 
Disposed Within Year'' to ``Schedule of Assets Disposed of During the 
Plan Year.'' Filers currently report some information regarding the 
disposal of hard-to-value assets and alternative investments either on 
the Schedule H, Line 4i Schedule of Assets if the assets were both 
acquired and disposed of during the plan year, or, if the value of the 
transaction was five percent or more of total plan assets, on the 
Schedule H, Line 4j ``Schedule of Reportable Transactions.'' The 
Agencies believe, however, that requiring reporting of hard-to-value 
assets and alternative investments acquired in one year and disposed of 
in another year, including investments that fall under the five percent 
limit of Line 4j,\18\ would provide the Agencies with a more complete 
report of the plan's annual investments. The limitations on what assets 
need to be reported on the Schedule of Assets Disposed of During the 
Plan Year would remain unchanged from the current exceptions from 
reporting on the Schedules of Assets not held at the end of the plan 
year. Thus, the following would continue to be excluded from the Line 
4i(2) Schedule of Assets Disposed of During the Plan Year:
---------------------------------------------------------------------------

    \18\ Title I of ERISA contemplates reporting transactions 
involving three percent or more of plan assets. ERISA section 
103(b)(3)(H). By prior rulemaking, the DOL has limited that 
reporting requirement to transactions involving five percent or more 
of plan assets. The Agencies continue to believe that generally 
keeping the limit at transactions involving five percent or more of 
plan assets, with this change to the Line 4i schedules, will provide 
sufficient information about significant transactions during the 
plan year.
---------------------------------------------------------------------------

    1. Debt obligations of the U.S. or any U.S. agency.
    2. Interests issued by a company registered under the Investment 
Company Act of 1940 (e.g., a mutual fund).
    3. Bank certificates of deposit with a maturity of one year or 
less.
    4. Commercial paper with a maturity of 9 months or less if it is 
valued in the highest rating category by at least two nationally 
recognized statistical rating services and is issued by a company 
required to file reports with the Securities and Exchange Commission 
under section 13 of the Securities Exchange Act of 1934.
    5. Participations in a bank common or collective trust (CCT).
    6. Participations in an insurance company pooled separate account 
(PSA).
    7. Securities purchased from a broker-dealer registered under the 
Securities Exchange Act of 1934 and either: (1) Listed on a national 
securities exchange and registered under section 6 of the Securities 
Exchange Act of 1934 or (2) quoted on NASDAQ.
    Likewise, assets disposed of during the plan year would continue to 
exclude any investment that was not held by the plan on the last day of 
the plan year if that investment is reported in the annual report for 
that plan year in any of the following schedules:
    1. The schedule of loans or fixed income obligations in default 
required by Schedule G, Part I;
    2. The schedule of leases in default or classified as uncollectible 
required by Schedule G, Part II;
    3. The schedule of nonexempt transactions required by Schedule G, 
Part III; or
    4. The schedule of reportable transactions required by Schedule H, 
line 4j.
    The new proposed Line 4i(2) Schedule of Assets Disposed of Within 
Year, generally would have the same data elements as the current 
Schedule of Assets Acquired and Disposed of Within Year. To implement 
the change in the schedule from ``acquired and disposed of during the 
plan year'' to ``disposed of during the plan year,'' however, filers 
would have to indicate the acquisition date. Basic parallel changes 
would be made to the Line 4i(2) Schedule to keep it generally 
consistent with the Line 4i(1) Schedule.
    Under the proposal, the Line 4j Schedule of Reportable (5%) 
Transactions would remain essentially unchanged. The current schedule 
of reportable transactions requires the filer to include information on 
the identity of the party involved in the reportable transaction or 
series of transactions. Consistent with the Line 4i Schedules of 
Assets, a checkbox is being added to this schedule to indicate whether 
the reportable transaction or series of transactions involved a person 
known to be a party-in-interest. Under the proposal, the Line 4j 
Schedule of Reportable (5%) Transactions would be structured in a 
standard format for data input and collection purposes; filers would 
not be able to use a nonstandard attachment.
3. Proposed Changes to DFE Reporting
    As described in parts A.1 and A.2 above in the context of the new 
Schedule H balance sheet information and the updated schedules of 
assets, respectively, the proposal includes changes as to what 
information about DFEs and their underlying investments needs to be 
reported by both the plan and the DFE. The proposal includes 
correlative changes to the Schedule D that are described below, 
including the elimination of the requirement of plans to complete 
Schedule D. The Agencies considered a number of alternatives in 
developing a proposal to address problems and concerns with regard to 
the consistency and quality of the reporting of assets held through 
collective investment vehicles, including DFEs. The Agencies considered 
whether both DFEs and plans should be required, on their Line 4i 
Schedule of Assets, to show the underlying investments of DFEs. The 
Agencies also considered eliminating filings for PSAs, CCTs, and 103-12 
IEs and simply requiring plans to report on the Line 4i Schedules of 
Assets the plan's proportionate share of each of the underlying assets 
held by each PSA, CCT, or 103-12 IE in which the plan is invested. The 
Agencies invite comments on the most effective and efficient way to 
address the inconsistent and limited reporting of information invested 
through DFEs. The Agencies are particularly interested in information 
on how investments in DFEs relate to investment alternatives in 
participant-directed accounts and how much of the underlying assets of 
DFEs consist of hard-to-value and alternative investments.
    This revised reporting structure for both the Schedule H and the 
Line 4i Schedules of Assets for reporting investments through pooled 
investment vehicles is intended to enable the Agencies, plan 
fiduciaries and service providers, and other users of the data to have 
a better and more complete picture of the investments of plans. For 
nearly 44 percent of all assets held by large pension plans, the public 
information on plans' investments on the Form 5500 Annual Return/Report 
is limited to the class of the pooled investment arrangements rather 
than the financial class of the underlying investments (including hard-
to-value and alternative investments). See Dep't of Labor, 2010 Form 
5500 Direct Filing Entity Bulletin: Abstract of 2010 Form 5500 Annual 
Reports (2013), at 6. The proposed changes to reporting information 
about assets held through DFEs on the Line 4i Schedules of Assets, as 
well as the proposed changes to the Schedule H balance sheet 
information, is also supported by the GAO's recommendation that the 
Agencies take steps to reduce the difficulty associated with matching a 
plan's investments with those reported in the DFE's filing. GAO Private 
Pensions: Targeted Revisions Could Improve Usefulness of Form 5500 
Information, at 14-15.
    The proposed filing requirements for master trusts, CCTs and PSAs, 
103-12

[[Page 47546]]

IEs, group insurance arrangements (GIAs), and the plans that invest 
through these vehicles and the proposed revisions to Schedule D 
reporting are described more fully below.
a. DFE Reporting--Master Trusts
    Some plans participate in certain trusts, accounts, and other 
investment arrangements that file the Form 5500 Annual Return/Report as 
a DFE. In general, a master trust for Form 5500 Annual Return/Report 
filing purposes is a trust maintained by a bank or similar institution 
to hold the assets of more than one plan sponsored by a single employer 
or by a group of employers under common control. Unlike CCTs and PSAs, 
not every plan participating in the master trust necessarily has a 
proportionate share of all of the assets of the master trust. To get 
information about each plan's holdings within the master trust, the 
annual return/report has historically asked for information about so-
called MTIAs. The Agencies understand that the MTIA reporting 
requirements are unique to the Form 5500 Annual Return/Report, do not 
fully correspond to actual trust accounting practices used for master 
trusts, and may not be well understood or consistently complied with by 
plans that use master trusts for investment and reinvestment of assets. 
Accordingly, the proposal would eliminate MTIA reporting and replace it 
with what is intended to be a simpler approach.
    Under the MTIA reporting concept, each pool of assets held in a 
master trust is treated as a separate MTIA if: (1) Each plan that has 
an interest in the pool has the same fractional interest in each of the 
assets in the pool as its fractional interest in the pool, and (2) each 
such plan cannot dispose of its interest in any asset in the pool 
without disposing of its interest in the pool. Under this test, it is 
possible for a single asset to be an MTIA if ownership of the asset 
meets the above test. Currently, a separate Form 5500 Annual Return/
Report must be filed for each MTIA, among other things, listing the 
underlying assets of the MTIA on Schedule H and the aggregate value of 
each investing plan's ownership interest in the MTIA on Schedule D. The 
filing of each MTIA is deemed to be part of the Form 5500 Annual 
Return/Report of the investing plan, and the plan administrator is, 
therefore, ultimately responsible for MTIAs filing their Form 5500 
Annual Return/Report, even if the bank or other third party is the 
person that files for the MTIA.
    According to GAO, MTIAs account for roughly 20.4% of the total 
assets of large defined contribution pension plans. See Private 
Pensions: Targeted Revisions Could Improve Usefulness Of Form 5500 
Information, at 14. Accuracy of filings showing investments in master 
trusts (regardless of reporting structure) is therefore important to 
have a complete picture of plan investments. To facilitate consistent 
reporting, the Agencies now propose to eliminate the concept of a 
separate MTIA filing as part of the changes to Schedules D and H and 
the Line 4i Schedules of Assets. Prior to 1999, master trusts were 
required to file the Form 5500 Annual Return/Report; information about 
MTIAs was provided in an attachment to the consolidated master trust 
filing. See, e.g., 1998 Form 5500 Annual Return/Report and 
Instructions. Under the proposal, master trust filing would return to 
something closer to the pre-1999 structure.
    Specifically, a Form 5500 Annual Return/Report would be required to 
be filed for each master trust in which a plan has an interest. The 
master trust, like a MTIA under the current rules, would be required to 
include as part of its Form 5500 Annual Return/Report, a Schedule D to 
list all participating plans. The Schedule D listing of participating 
plans would include the requirement to report the total value of each 
participating plan's investment assets in the master trust. Plans would 
report their investments in master trusts in detail on their Schedule 
H, Line 4i(1) Schedule of Assets Held for Investment at End of Year, 
including the name and EIN of the master trust used on the master 
trust's Form 5500 Annual Return/Report. Plans would also list the 
aggregate value of their investment in master trusts on the Schedule H 
balance sheet.
    The proposal also would change the instructions to address what the 
Agencies understand to be inconsistency in the way master trust 
expenses are reported. Specifically, under the proposal, the master 
trust's report would include expenses that are allocable equally to all 
plans investing in the master trust. All other expenses would have to 
be allocated to the individual participating plans and reported at the 
individual plan level.
    Finally, the regulations and instructions would provide that to be 
a master trust for reporting purposes, either the master trust must 
operate on a calendar year or the master trust and all of the plans 
invested in the master trust must operate on the same fiscal year. 
Where the master trust is on a calendar year and a participating plan 
on a fiscal year other than a calendar year, similar to Schedule A 
reporting of insurance contracts, the information reported by the plan 
would be for the master trust year ending within the plan year.
    The combined changes for reporting by both investing plans and 
master trusts on both the Schedule H balance sheet and the Line 4i 
Schedules are intended better to effectuate the purposes underlying the 
current combination of MTIA, Schedule H (including the Line 4i 
Schedules), and Schedule D reporting. This should make it easier to 
understand the finances of the master trust as a whole, as well as the 
finances of the plans investing through a master trust. The Agencies 
invite comments to provide alternative suggestions on how to improve 
the transparency and accuracy of reporting plans' proportionate 
ownership of interests in assets held through a master trust.
b. DFE Reporting--CCTs and PSAs
    As with the existing rules, under the proposal, a Form 5500 Annual 
Return/Report may be, but is not required to be, filed for a CCT or a 
PSA. The proposal would change the filing requirements with respect to 
CCTs and PSAs as follows. As discussed above, regardless of whether a 
CCT or PSA in which the plan invests files a Form 5500 Annual Return/
Report as a DFE, the plan would report the interests in the CCT or PSA 
on the CCT or PSA line of the Schedule H balance sheet (Part I, Line 
1b), although there would be breakouts within those categories to give 
a general idea of the types of assets held through the CCT or PSA. The 
changes should result in a clearer statement of total plan assets 
invested through these collective investment vehicles.
    The current requirement to break out the assets of non-filing CCTs 
or PSAs would be retained, but the proposal would shift the details of 
the underlying investments to the newly structured Line 4i(1) Schedule 
of Assets. Under the proposed revisions, investing plans, on their own 
Line 4i Schedules of Assets, would be required to list each underlying 
investment, identifying that the investment was held through a non-
filing CCT or PSA, including the CCT's or PSA's name and other 
identifying information, as well as the information on the underlying 
asset.\19\
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    \19\ As discussed above, if the CCT or PSA files a Form 5500 
Annual Return/Report, the holdings in the CCT or PSA could be listed 
on the plan's Line 4i(1) Schedule of Assets at the CCT/PSA level 
(corresponding to the breakout categories on the balance sheet 
statement). Thus, the PSA or CCT filing of a Form 5500 Annual 
Return/Report, including the Line 4i(1) Schedule of Assets Held for 
Investment, would relieve each participating plan from reporting 
detailed information regarding the underlying investments.

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[[Page 47547]]

    In this regard, the Agencies note that under current DOL 
regulations CCTs and PSAs are required to provide information about the 
underlying assets of the CCT or PSA to participating plans and provide 
plans with relief from reporting the underlying assets of the CCT or 
PSA if the CCT or PSA files the Form 5500 Annual Return/Report, but 
that CCTs and PSAs are not required themselves to file the Schedules of 
Assets. The regulation would be amended to provide that plans are 
relieved from breaking out the individual assets on the Schedule H, 
Line 4i Schedules of Assets, if the CCT or PSA instead files its own 
Form 5500, including the Schedule H and the Schedule of Assets Held for 
Investment. Also, the regulation would indicate that providing the 
information needed for a plan to complete the Line 4i Schedules of 
Assets constitutes compliance with the requirement to transmit 
information regarding the assets held by the CCT or PSA. With this 
change, information regarding the underlying investments of CCTs and 
PSAs, which have been provided only to plan fiduciaries, will now be 
part of the annual return/report data set; it will be filed either by 
the participating plans or by the CCT or PSA.
c. DFE Reporting--103-12 IE
    The DOL's regulation at 29 CFR 2520.103-12 provides that an entity 
in which two or more unrelated plans invest that is not a CCT, PSA, or 
master trust, and which is deemed to hold plan assets under the DOL's 
regulations at 29 CFR 2510.3-101 that voluntarily chooses to file a 
Form 5500 Annual Return/Report for itself on behalf of its investing 
plans, is treated as a ``103-12 IE'' filing entity for Form 5500 Annual 
Return/Report reporting purposes. Under the proposal, reporting for 
these pooled investment vehicles generally remains unchanged, except to 
the extent that the data elements for the existing forms and schedules 
have changed for all filers. For a plan to be able to report 
investments in such entities as a single investment on the balance 
sheet portion of Schedule H, as under the current reporting rules, the 
entity in which the plan invested would have to complete its own Form 
5500, together with a Schedule H and Line 4i Schedules of Assets, as 
well as Schedules A, C, D, G, as revised in the proposal, and the 
entity's own IQPA report. Under the proposal, similar to reporting 
assets held through participant-directed brokerage accounts, filers 
would have to indicate all the Line 1b balance sheet breakout 
categories for types of underlying investment of each 103-12 IE, but 
would not have to identify each individual investment.
d. DFE Reporting--GIAs
    The reporting requirements for GIAs would generally remain 
unchanged, except GIAs would be subject to the same changes in 
reporting as comparable welfare plans, including the new requirements 
for welfare plans that provide health benefits. As under the current 
rules, welfare plans that are fully insured, including group health 
plans, would still have the exemption from filing the Form 5500 Annual 
Return/Report if they participate in a GIA that has filed its Form 5500 
Annual Return/Report. GIAs would continue to be required to file all 
the same forms, schedules, and attachments as a large group health plan 
funded with a trust. GIAs that provide group health coverage would be 
required to file a separate Schedule J for each separate employer's 
participating plan.
e. DFE Reporting--Changes to Schedule D
    The Agencies propose to continue the Schedule D requirement for 
DFEs in which plans invest, but not for plans participating in DFEs. 
DFEs would continue to report identifying information about the 
participating plan and the dollar value of each investing plan's 
interests in the DFE as of the end of the DFE reporting year. 
Participating plans, because they would now be reporting detailed 
information about investments in DFEs on their Line 4i Schedules of 
Assets, would no longer have to complete the Schedule D.
4. Better Information on Plan Terminations, Mergers, and Consolidations
    The Agencies propose revisions to existing Schedule H and Form 
5500-SF questions on plan terminations, mergers, and consolidations. 
First, the Agencies propose expanding the question that asks whether 
the plan has adopted a resolution to terminate so that it also asks for 
the effective date of the plan termination, the year in which assets 
were distributed to plan participants and beneficiaries, and whether 
the plan transferred assets or liabilities to another plan.
    Second, the proposal would add a question asking filers to indicate 
whether another plan transferred assets or liabilities to the reporting 
plan (other than pursuant to a direct rollover). If the plan received a 
transfer of assets or liabilities from another plan, the filer would be 
asked to provide the date and type of transfer (merger, consolidation, 
spinoff, other). This new information is intended to provide better 
information on transfers of participant benefit obligations over the 
years.
    Third, if the plan is a defined contribution pension plan that 
terminated and transferred plan assets to a financial institution and 
established accounts in the name of missing participants, the filer 
would be asked to provide the name and EIN of the financial 
institution, the date the assets were transferred to the institution, 
the number of accounts established, and the total amount transferred. 
Although the question would not ask the filer to identify individual 
affected participants or beneficiaries, this requirement is designed to 
help missing participants locate information about their accounts, in 
some cases years after the plan termination when the plan or plan 
sponsor may no longer exist or have records of the accounts it 
established. Asking for information about accounts created for missing 
participants after plan termination would also be responsive to the 
ERISA Advisory Council's recommendations that the DOL use the Form 5500 
Annual Return/Report to obtain more consistent reporting on accounts 
that hold missing participant plan assets. See 2013 ERISA Advisory 
Council Report: Locating Missing and Lost Participants, Dep't of Labor 
(available at www.dol.gov/ebsa/publications/2013ACreport3.html#2).
    In this 2013 report, the Advisory Council noted that another issue 
with ``lost'' or ``missing'' participants for ongoing plans as well as 
terminating plans, especially 401(k) plans, is ``uncashed'' checks, 
particularly checks sent to participants who have left employment where 
the Code permits the plan to ``cash out'' the participant. Id. The 
report noted that a plan was not necessarily able to tell whether 
uncashed checks were sent to the wrong address (a ``lost'' or 
``missing'' participant issue) or whether a participant received the 
check but had not cashed it. To get better information about the 
magnitude of the problem with respect to defined contribution pension 
plans and to make plan fiduciaries aware that they should, at a 
minimum, have procedures in place to verify that a participant's 
address is good before a check is mailed and to keep track of the 
number of uncashed checks and the amount involved, the proposal would 
also add to both the Schedule H and the Form 5500-SF a compliance 
question for defined contribution pension plans asking whether there 
were any uncashed checks at the end of the plan year. If there were any 
uncashed checks at the end of the year, filers would be required

[[Page 47548]]

to report how many uncashed checks there were and the total dollar 
value of the uncashed checks. Defined contribution pension plan filers 
would also be asked to describe briefly in an open text field the 
procedures that they followed to verify a participant's address and 
with respect to monitoring the uncashed checks. The proposed 
instructions provide that for Form 5500 Annual Return/Report reporting 
purposes, an uncashed check is one that is no longer negotiable or is 
subject to limited payability.
    In proposing to add a compliance question instead of telling filers 
how to account for the assets associated with uncashed checks on the 
Schedule H, the Agencies recognize that the ERISA Advisory Council 
indicated that there are questions regarding how the underlying assets 
represented by uncashed checks should be reported on the Form 5500 
Annual Return/Report. Because of the variety of situations that might 
result in uncashed checks and the different ways uncashed checks might 
be accounted for in an ongoing plan, the Agencies have chosen to add a 
compliance question, leaving flexibility in the balance sheet reporting 
on Schedule H and on the Form 5500-SF and, where applicable, the IQPA 
report.
    The ERISA Advisory Council and some of the witnesses who testified 
recommended that the DOL publish guidance to advise plan fiduciaries 
how to handle uncashed checks, among other issues regarding missing or 
lost participants and beneficiaries and how to address the assets 
associated with those participants or beneficiaries. In making this 
recommendation, it was recognized that there was a tension between the 
mandatory distribution requirements under the Code and fiduciary 
responsibilities. In the absence of further guidance with regard to how 
to handle uncashed checks, the DOL notes (as stated above) that plans 
should at least have policies and procedures in place to verify 
participant addresses, for searching for missing participants and for 
fiduciaries to keep track of or be made aware of the number of uncashed 
checks and the total value of such checks that remained uncashed at the 
end of the plan year. Depending on the type of plan, the terms of the 
plan, and the status of the plan sponsor, there may be actions needed 
to satisfy fiduciary obligations with regard to benefit payments.
5. Changes to Financial Reporting for Small Plans
a. Changes to Form 5500-SF
    In general, small plans that are invested only in ``eligible'' plan 
assets and otherwise meet the existing requirements for eligibility to 
file the Form 5500-SF would continue to be able to file the Form 5500-
SF.\20\ Welfare plans with fewer than 100 participants that do not 
provide group health benefits and that are required to file an annual 
return/report and that meet the eligibility requirements for the Form 
5500-SF will still be able to use the Form 5500-SF to satisfy their 
filing requirement. Welfare plans with fewer than 100 participants that 
provide group health benefits are not eligible to use the Form 5500-
SF.\21\ For Form 5500-SF filers, there would be a modest additional 
breakout on the balance sheet information to give a basic picture of 
the types of eligible assets in which Form 5500-SF eligible small plans 
are invested. Specifically, filers would have to categorize the plans' 
investments into one of the following categories: (1) Cash/cash 
equivalents; (2) money market funds; (3) publicly traded stock 
(preferred/common); (4) publicly traded bonds, including government 
securities; (5) interests in registered investment companies (mutual 
funds, unit investment trusts, closed end funds); (6) interests in 
PSAs; (7) interests in CCTs; and (8) interests in insurance policies/
contracts other than PSAs, e.g. annuity contracts. In contrast to the 
Schedule H balance sheet financial breakout categories, there would be 
no ``Other'' category for the balance sheet financials on the Form 
5500-SF. If a small plan were to be invested in any assets other than 
those in the eight listed categories, it would not be eligible to file 
the Form 5500-SF.
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    \20\ The Form 5500-SF was developed and adopted for 2009 Form 
5500 Annual Return/Report in part to provide a simplified report 
required under the Pension Protection Act of 2006. The DOL continues 
to believe, as discussed when implementing the 2009 forms revisions, 
72 FR 64731 (Nov. 16, 2007), that the requirement in the PPA to 
provide ``'simplified'' reporting for plans with fewer than 25 
participants is satisfied by making available the simplified 
reporting in the 5500-SF only to those plans invested in eligible 
assets--generally easy to value assets. Section 1103(b) of the 
Pension Protection Act of 2006, (PPA) 120 Stat. 780, 1057, requires 
the Secretary of the Treasury/IRS and the Secretary of Labor to 
provide for the filing of a simplified annual return for any 
retirement plan which covers fewer than 25 participants on the first 
day of the plan year and which (1) meets the minimum coverage 
requirements of section 410(b) of the Internal Revenue Code without 
being combined with any other plan of the business that covers the 
employees of the business; (2) does not cover a business that is a 
member of an affiliated service group, a controlled group of 
corporations, or a group of businesses under common control; and (3) 
does not cover a business that uses the services of leased employees 
(within the meaning of section 414(n) of the Code). The PPA 
provision does not include specific requirements as to the form or 
content of the simplified filing.
    \21\ Currently welfare plans with fewer than 100 participants, 
including those that provide group health benefits, that are not 
exempt from the requirement to file an annual return/report (e.g., 
those that are funded with a trust) are permitted to file the Form 
5500-SF, if otherwise eligible.
---------------------------------------------------------------------------

    As discussed in more detail below, the proposal would eliminate the 
current Form 5500 and Form 5500-SF line items that require the filer to 
input ``plan characteristics codes'' onto the form from a list in the 
instructions. Instead, the filer would complete a series of separate 
questions. In general, those changes involve requesting information 
about plan characteristics as a series of ``Yes''/``No'' and check box 
questions to make the forms easier to complete, make the forms more 
straightforward as a disclosure document, and improve the quality of 
the data. In addition, as with Form 5500 Schedule H filers, the 
proposal would require that the Form 5500-SF filed for a participant-
directed individual account plan must include an electronic copy of the 
comparative chart of designated investment alternatives (DIAs) 
currently required to be provided to participants of such plans under 
29 CFR 2550.404a-5. The Agencies believe that although this information 
would not be filed in a data captured structure and, thus, would not be 
as readily data mineable, attaching the already required 404a-5 
comparison chart would allow participants and beneficiaries in 
participant-directed individual account plans to access the most recent 
and prior year comparative charts through the EFAST Form 5500 Annual 
Return/Report public disclosure feature. It would also enable the 
Agencies to monitor more effectively compliance by participant-directed 
individual account plans with this important disclosure requirement. It 
also would provide important information regarding investment features 
and investment fees and expenses. We also understand that private third 
parties would be able to use the copies of the comparative charts to 
develop more individualized tools to help plan sponsors, plan 
fiduciaries, and participants and beneficiaries evaluate and compare 
their plans' investment options. The Agencies believe that a 
requirement that the plan administrator of a participant-directed 
individual account plan attach an electronic copy of an existing 
document should be less burdensome than adding new questions that would 
require the same data to be entered onto the form or schedules to 
collect the information.

[[Page 47549]]

The Agencies seek comment as to whether there would be any real 
additional burden, other than transition costs to move to the new 
method, to enter the data in a structured format rather than attaching 
a copy of the existing document.
b. Changes to Filing Exemptions and Requirements for Small Plans Not 
Eligible To File the Form 5500-SF
    As discussed above, various oversight and advisory bodies have 
identified a significant need for better information regarding employee 
benefit plan investments, in particular regarding plans invested in 
hard-to-value and alternative investments. In that regard, the Agencies 
are proposing a number of changes for small plans that are not Form 
5500-SF eligible filers. First, the Schedule I would be eliminated. 
Like the Form 5500-SF, the Schedule I does not require small plan 
filers to provide detailed plan asset information. Since small plan 
filers are the majority of annual return/report filers overall (taking 
into account both Form 5500-SF and Form 5500 filers), this shortcoming 
impairs the utility of the Form 5500 Annual Return/Report as a tool to 
obtain a meaningful picture of small plan investments in hard-to-value 
and other assets. As the GAO has noted, the limited financial 
information provided on the Schedule I creates a challenge for 
participants, beneficiaries, oversight agencies, researchers, and other 
users of the Form 5500 or Form 5500 data. GAO Targeted Revisions Could 
Improve Usefulness of Form 5500 Information, at 18. Accordingly, under 
the proposed change, small plans that are not eligible to file the Form 
5500-SF and that currently file the Schedule I would be required to 
complete the Schedule H and the applicable Line 4i Schedules of assets. 
Small plans with simple investment portfolios would not see a 
significant increase in their annual reporting burden. Although this 
would result in additional reporting details for those small plans with 
complex portfolios that include hard-to-value or alternative 
investments, the Agencies believe that such small plans should have 
more transparent financial statements. In light of changes in the 
financial environment and increasing concern about investments in hard-
to-value assets and alternative investments, the Agencies continue to 
believe that requiring small plans invested in such assets to report 
separate financial information regarding hard-to-value investments is 
important for regulatory, enforcement, and disclosure purposes. 
Although such small plans would be required to complete the Schedule H 
instead of the Schedule I, including the Line 4i(1) and 4i(2) Schedules 
of Assets, to minimize increased burden, small plans that meet the 
specified requirements, as they can under the current rules, would 
continue to be eligible for a waiver of the annual examination and 
report of an independent qualified public accountant (IQPA) under 29 
CFR 2520.104-46. As is currently the case, under the proposal, all 
welfare plans with fewer than 100 participants that are required to 
file an annual return/report are eligible for a waiver of the annual 
examination and report of an IQPA under 29 CFR 2520.104-46(b)(2).
    The Agencies are also proposing to change the rules for determining 
when a plan is exempt from the requirement to include an IQPA report 
with its filing. In that regard, the Agencies are proposing to add to 
the Form 5500 a new question, for defined contribution pension plans 
only, asking for the number of participants with account balances at 
the beginning of the plan year. Defined contribution pension plans 
would determine whether they have to file as a large plan and whether 
they have to attach an IQPA report based on the number of participants 
with account balances as of the beginning of the plan year, as reported 
on the face of the Form 5500 or Form 5500-SF. Currently, the IQPA 
requirement is based on the total number of participants (including 
those eligible but not participating in a Code section 401(k) or 403(b) 
plan) at the beginning of the plan year. With the changes in the 
reporting requirements for small plans (for example, the elimination of 
the Schedule I), this would minimize burden, but would still provide a 
picture of the types of investments and fees of small plans (plans with 
fewer than 100 participants that have an account balance) without 
requiring them to cover the cost of an audit. For first plan year 
filings, the plan would have to have fewer than 100 participants with 
account balances both at the beginning of the plan year and the end of 
the plan year.
    The proposal would also require a Schedule C to be filed by small 
pension plans that are not eligible to file the Form 5500-SF, small 
welfare plans that provide group health benefits that are not unfunded 
or insured (e.g., funded using a trust), and other small welfare plans 
that are not unfunded or insured plans and are not eligible to file the 
Form 5500-SF. Currently, only large plans must file a Schedule C, thus 
excluding a large portion of plans from having to disclose service 
provider fees. The Agencies recognize the burdens small plans face in 
complying with disclosure obligations, but requiring certain small 
plans to file a Schedule C would address some of the GAO's concerns 
that not all critical information on indirect compensation is being 
reported to the Agencies. See GAO Targeted Revisions Could Improve 
Usefulness of Form 5500 Information, at 25-26 (``Given these various 
exceptions to fee reporting requirements, Schedule C may not provide 
participants, the government, or the public with information about a 
significant portion of plan expenses and limits the ability to identify 
fees that may be questionable.''). In addition, the rule would better 
align financial information reporting with recently adopted disclosure 
rules to broaden the fees that are reported by the affected plans. Id. 
at 50.
6. New Information on Employer Matching Contributions, Employee 
Participation Rates, and Plan Design for Defined Contribution Pension 
Plans
    The Agencies are proposing changes that are intended to collect 
better information on pension plan coverage and performance as 
retirement savings vehicles. The focus is on participant-directed 
defined contribution pension plans, which are becoming the primary 
source of retirement savings for many of America's workers. 
Specifically, the proposal would add new questions to the Form 5500, 
Form 5500-SF, and Schedule R on participation, contributions, and asset 
allocation by age, and participant-level diversification. The questions 
ask for the number of participants making catch-up contributions, 
investing in default investment options, maximizing the employer match, 
and deferring compensation. Also, questions would be added to the Form 
5500 and Form 5500-SF to collect information on the number of 
participants in defined contribution pension plans with account 
balances as of the beginning of the plan year and on the number of 
participants that terminated employment during the plan year that had 
their entire account balance distributed. There are also new questions 
about whether the plan uses a default investment alternative for 
participants who fail to direct assets in their account and which type 
of investment alternative is used.
7. Changes to Reporting on Schedule G (Financial Transaction Schedules)
    The proposal would reconfigure Schedule G's reporting to require 
more uniform and detailed information on loans, fixed income 
obligations, and

[[Page 47550]]

leases in default, including swaps/options and derivative transactions. 
By creating specific data elements on the existing Schedule G line 
items for plans to identify specifically swaps and options that would 
otherwise generically have been reported as loans or fixed income 
obligations in default or uncollectible, the proposed Schedule G is 
intended to provide a more complete picture of issues of default, 
uncollectibility, or conflict of interest (nonexempt) transactions with 
respect to plan investment in these types of hard-to-value assets.
8. Re-introduction of Schedule E To Improve Information on Employee 
Stock Ownership Plans (ESOPs)
    Prior to 2009, the Schedule E (ESOP Annual Information) was an IRS 
component of the Form 5500 Annual Return/Report used to collect 
information regarding ESOPs. As with the other ``IRS-only'' schedules 
that are part of the Form 5500 Annual Return/Report, the Schedule E was 
removed from the 2009 Form 5500 Annual Return/Report when DOL mandated 
electronic filing of the Form 5500 Annual Return/Report as part of 
EFAST2 due to statutory limits on the IRS's authority to mandate 
electronic filing of such information for filers of fewer than 250 
returns. A limited number of the questions on the Schedule E were moved 
to the Schedule R beginning with the 2009 Form 5500 Annual Return/
Report. The Schedule R is not an ``IRS-only'' schedule nor were the 
questions that were moved to the Schedule R IRS-only. Accordingly, 
filing of the current ESOP information on the Schedule R was subject to 
DOL's electronic filing mandate under Title I of ERISA.
    The Agencies propose to bring back to the Form 5500 Annual Return/
Report a revised version of the Schedule E, which now generally would 
be required reporting under both Title I of ERISA and the Code and thus 
would be open to public inspection. The new version would include some 
of the questions on the pre-2009 Schedule E, revisions to other 
questions, and additional new questions. The questions moved to the 
Schedule R for the 2009 revisions would be removed from the Schedule R 
and instead be included on the new and revised Schedule E. The Agencies 
believe the use of a single schedule for all ESOP questions would 
simplify the filing of Form 5500 Annual Return/Report for both ESOP and 
non-ESOP filers. In addition, a single schedule for ESOPs would also be 
a more effective and efficient information collection tool for the 
Agencies.
    The questions on the proposed Schedule E are divided into sections 
based on whether the ESOP stock was acquired by a securities 
acquisition loan, whether the stock is readily tradable on an 
established securities market (including stock acquired by securities 
acquisition loans), whether the ESOP has an outstanding securities 
acquisition loan, and some miscellaneous questions.
    Part I of the proposed Schedule E would apply only if the ESOP 
acquired common or preferred stock with the proceeds of a securities 
acquisition loan. Several questions relate to the valuation of the 
stock acquired by the ESOP and, in particular, cases where a premium is 
paid for a controlling interest in a company where, in fact, a 
controlling interest is not acquired. Questions would also be included 
regarding the release of common stock from a suspense account and its 
allocation. For example, a question would ask for the method used when 
stock is released from the suspense account (similar to Line 5 of the 
2008 Schedule E) in accordance with Treasury regulations. See 26 CFR 
54.4975-7(b)(8). As with Line 4 of the 2008 Schedule E, the proposed 
Schedule E would also ask if the ESOP holds preferred stock and further 
ask for the method by which the preferred stock is convertible into 
common stock.
    Part II of the proposed Schedule E would ask questions related to 
compliance issues when stock that is not readily tradable on an 
established securities market is acquired by an ESOP. Specifically, 
with respect to each acquisition of stock, the proposed schedule would 
ask for information on the relationship of the seller of the stock to 
the plan or to the employer, and whether the seller is a party-in-
interest or a disqualified person under the prohibited transaction 
rules of Title I of ERISA and the Code, respectively. Further, the 
proposed schedule would ask for the total consideration paid and the 
date of the transaction. The proposed schedule would also ask if the 
stock was valued by an independent appraiser and, if not, the identity 
of the person who valued the stock. Lastly, Part II would ask for the 
valuation method(s) used to value the stock. Each of these questions 
would assist the Agencies in identifying possible issues in the 
acquisition of stock, including whether the stock was properly valued 
and whether a prohibited transaction may have occurred.
    Part III of the proposed Schedule E asks questions applicable to 
ESOPs with outstanding securities acquisition loans. Unlike the 2008 
Schedule E which only asked whether the ESOP had a securities 
acquisition loan, the proposed Schedule E would ask for more 
information regarding these loans. The proposed schedule asks for basic 
information regarding the amount and date of the loan, as well as the 
interest rate on the loan. In order to address possible prohibited 
transactions and situations where the ESOP may have paid too much for 
the stock, the proposed Schedule E also would ask for the lender's 
relationship to the plan and the plan sponsor, whether the lender is a 
disqualified person or a party-in-interest, and whether the loan was 
guaranteed by a disqualified person or a party-in-interest. Part III 
also would ask questions regarding whether the loan is in default and 
whether the loan has been refinanced. A loan that is in default raises 
issues as to whether the plan sponsor is making substantial and 
recurring payments to the ESOP and whether the ESOP has been 
terminated, in which case all of the ESOP shares should be distributed.
    Part IV of the proposed Schedule E would include miscellaneous 
questions. Specifically, to address compliance concerns under Title I 
of ERISA, the proposed schedule would ask whether employee elective 
deferrals were used to satisfy any securities acquisition loan. With 
the exception of the elective deferral question, which addresses a DOL 
compliance issue and not an issue under the Code, the Part IV questions 
are carried over from the 2008 Schedule E and continue to address 
significant compliance issues under the Code, including whether the 
amount of the dividend is reasonable and whether the requirements of 26 
CFR 1.404(k)-3T are satisfied. Specifically, the proposed Schedule E 
would ask whether the ESOP is maintained by an S corporation and 
whether there are any disqualified persons under Code section 409(p)(4) 
(lines 1a and 1b of the 2008 Schedule E), whether any unallocated 
securities (or proceeds from unallocated securities) were used to repay 
an exempt loan (Line 6 of the 2008 Schedule E), and whether the plan 
sponsor paid dividends deductible under Code section 404(k) (Line 2b of 
the 2008 Schedule E). This last question is further broken down on the 
proposed schedule to include information as to the amount of the 
deduction, the dividend rate, and whether the dividends were used to 
reacquire stock held by the ESOP.
    As described above, several of the questions on the proposed 
Schedule E would be IRS-only questions. These questions are subject to 
the electronic filing rules imposed by Treasury

[[Page 47551]]

regulations, but they are not subject to the DOL electronic filing 
mandate. The IRS-only questions would be identified on the Schedule E 
itself or in the Schedule E instructions. Accordingly, although filers 
would be required to answer most questions on the proposed Schedule E 
electronically using EFAST2, some filers who are not subject to the IRS 
electronic filing requirements and elect not to answer the questions 
through EFAST2 would have the option of answering the IRS-only 
questions on the IRS's Form 5500 SUP ``Annual Return of Employee 
Benefit Plan Supplemental Information,'' which is a separate paper 
based IRS-only information collection system maintained by the IRS 
outside of the EFAST2 system.

B. Improve Fee and Service Provider Transparency (Schedules C and H)

    The Agencies continue to make efforts to improve the reporting and 
disclosure of service provider compensation. The key focus of the 
proposed changes in this regard is to harmonize Form 5500, Schedule C, 
reporting of indirect compensation with the disclosures required under 
the DOL's final regulation under Title I of ERISA on service provider 
compensation at 29 CFR 2550.408b-2. As discussed above in the section 
on small plan reporting changes, the proposal would also expand 
Schedule C reporting to those pension plans required to file the Form 
5500, regardless of size.\22\ The current Form 5500, Schedule C 
indirect compensation reporting rules, including the exception from 
reporting of ``eligible indirect compensation,'' were implemented for 
the 2009 forms. See 72 FR 74731 (Nov. 16, 2007). Those changes were 
part of a three-pronged regulatory initiative that included the DOL's 
plan-level disclosure regulations under 29 CFR 2550.408b-2 and 
participant-level disclosure regulations under 29 CFR 2550.404a-5. At 
the time the Schedule C rules were finalized, the 408b-2 disclosure 
regulations had not yet been promulgated. Some elements of the Schedule 
C, for example, the eligible indirect compensation provisions, were 
adopted in light of the fact that it was not certain at the time what 
the 408b-2 final rule would require. Those provisions were also meant 
to respond to concerns from the regulated community, especially large 
service providers with many ERISA-covered plan clients, about having to 
create two different record-keeping systems to meet the various 
requirements of Form 5500 Annual Return/Report and 408b-2 disclosures 
should the later promulgated 408b-2 provisions differ from the Form 
5500 Annual Return/Report reporting requirements on indirect 
compensation. With the service provider disclosure rules now final at 
29 CFR 2550.408b-2, the Agencies are proposing various changes to the 
Schedule C to better harmonize it with the disclosure requirements 
under the 408b-2 final rule.
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    \22\ Form 5500-SF filers would not be required to file the 
Schedule C, but small defined contribution pension plans filing the 
Form 5500-SF, as well as any defined contribution pension plans 
required to file the Form 5500, Schedule H, would be required to 
attach the comparison chart required to be disclosed to participants 
and beneficiaries under the DOL's regulation at 29 CFR 2550.404a-5. 
Form 5500-SF filers also would continue to be required to answer a 
question on total insurance fees and commissions, that parallels the 
total insurance fee and commission question on Schedule A.
---------------------------------------------------------------------------

    First, the Schedule C would be changed to require reporting of 
indirect compensation only for ``covered'' service providers and for 
compensation that is required to be disclosed, as defined in 29 CFR 
2550.408b-2(c)(1). The Agencies expect that this change would improve 
Schedule C reporting because it would essentially require the pension 
plan administrator to report the actual compensation paid to or 
received by covered service providers based on the expected 
compensation included in the 408b-2 disclosures that the service 
provider furnished to the plan as part of the process of establishing 
and maintaining the service contract or arrangement with the plan. The 
instructions similarly have been clarified to track more closely the 
language of the 408b-2 regulation.
    In making this an across-the-board Schedule C change to provide for 
consistency in the annual return/report requirements, the Agencies 
recognize that the changes proposed to the Schedule C would also apply 
to certain welfare plans that are not subject to the 408b-2 regulation. 
The principal consequence of the proposed changes for those welfare 
plans is to narrow the classes of service providers that would be 
required to be reported and more clearly define the types of 
compensation that must be reported on the Schedule C. Thus, we believe 
that the proposed changes will be improvement for welfare plan 
reporting.
    Another key element of the proposed changes to Schedule C 
consistent with the final regulations at 29 CFR 2550.408b-2 is the 
elimination of the reporting concept of ``eligible indirect 
compensation.'' Under the current reporting rules, the types of 
indirect compensation that can be treated as ``eligible indirect 
compensation'' are fees or expense reimbursement payments charged to 
investment funds and reflected in the value of the investment or return 
on investment of the participating plan or its participants, finder's 
fees, ``soft dollar'' revenue, float revenue, and/or brokerage 
commissions or other transaction-based fees for transactions or 
services involving the plan that were not paid directly by the plan or 
plan sponsor (whether or not they are capitalized as investment costs). 
Under the current requirements, rather than disclosing the identity of 
the service provider and reporting information about the services 
provided and compensation received by the service provider, the plan 
administrator must merely confirm that the plan received certain 
written disclosures that describe: (1) The existence of the indirect 
compensation; (2) the services provided for the indirect compensation 
or the purpose for payment of the indirect compensation; (3) the amount 
(or estimate) of the compensation or a description of the formula used 
to calculate or determine the compensation; and (4) the identity of the 
party or parties paying and receiving the compensation. The GAO has 
been critical of the concept of ``eligible indirect compensation'' and 
other limitations on Schedule C reporting of indirect compensation 
received by plan service providers. See GAO Private Pensions: 
Additional Changes Could Improve Employee Benefit Plan Financial 
Reporting. In its response published with that report, the DOL 
generally agreed that reporting indirect compensation on Schedule C 
should be coordinated with the implementation of new requirements in 
the then proposed regulation under section 408(b)(2) of ERISA. Part of 
the reason for the concept of eligible indirect compensation was the 
timing of the move to the electronic filing system and attendant forms 
changes relative to the timing of the 408b-2 regulation. There is no 
counterpart to ``eligible indirect compensation'' under 29 CFR 
2550.408b-2. In this regard, the proposed Schedule C would eliminate 
current Line 1 (which enables plans to acknowledge that they had 
service providers that received only eligible indirect compensation). 
Current Line 2, used for reporting both direct and indirect 
compensation, would be made new Line 1. To effectuate the elimination 
of the ``eligible indirect compensation'' reporting concept, there 
would no longer be a corresponding element to current Line 2(f), which 
asks whether a listed service provider that received other direct or 
indirect compensation also received eligible indirect compensation.

[[Page 47552]]

    In changing the reporting requirements to better track the 408b-2 
regulation, the Agencies recognize that part of the reason for having 
developed the concept of ``eligible indirect compensation'' was concern 
expressed by commenters that it would be difficult to generate specific 
dollar amounts at the plan level, especially in the case of omnibus 
level charges. In that regard, the proposed Schedule C instructions 
borrow from instructions in the Schedule A on determining plan-level 
allocation of insurance contract fees and commissions. Specifically, 
the Schedule C instructions permit any reasonable method of allocation 
to be used to estimate plan level fees for the Schedule C, provided the 
method is disclosed to the plan administrator. This approach provides a 
substantial amount of flexibility for service providers in determining 
the amounts to report. The DOL invites comments on this proposed method 
for plan level allocation of indirect compensation generated at an 
``omnibus'' level, including whether there are particular types of 
indirect compensation for which it would be unduly expensive or 
burdensome to report a dollar amount or estimate at the plan level.
    To further conform the Schedule C reporting rules to the disclosure 
requirements in 29 CFR 2550.408b-2, filers would be required to report 
``covered'' service providers who have received $1,000 or more in total 
direct and indirect compensation (i.e., money or anything else of 
monetary value in connection with services rendered to the plan or the 
person's position with the plan during the plan year, including 
payments from participants' accounts). As on the current Schedule C, 
plans would only need to report other service providers (e.g., an 
accountant that received only direct compensation) who received $5,000 
or more in direct compensation in connection with services rendered to 
the plan or the person's position with the plan during the plan year, 
including payments from participants' accounts.
    To make reporting of the information specific to each service 
provider more straightforward, instead of having repeating line items 
on Schedule C, the proposal would have filers use a separate Schedule C 
for each service provider required to be reported. With this formatting 
change, the proposed Line 1 of the Schedule C generally would retain 
the same identifying elements as the current Line 2, with the following 
changes. Similar to the proposal to amend the regulation at 2550.408b-
2, see 79 FR 13949, 13962 (Mar. 14, 2014), this proposal seeks to add 
to Schedule C a requirement to report contact information for service 
providers that are not natural persons. Filers would be required to 
identify a person or office, including contact information, that the 
plan administer may contact with regard to the information required to 
be disclosed on the Schedule C.
    The proposal would also clarify and expand the existing question 
that asks the filer to indicate generally whether the service provider 
has a relationship to the employer, an employee organization, or a 
person known to be a party-in-interest. The proposal would now state 
that filers should indicate any relationship of the service provider to 
the plan, for example, employer, plan sponsor, plan sponsor employee, 
plan employee, named fiduciary, employee organization, and ``Other,'' 
with a description. With the prevalence of revenue sharing 
arrangements, the Agencies believe that better information on the 
relationship between service providers and the plan, various 
fiduciaries and parties-in-interest, including relationships among plan 
service providers, is important to understand the relationship between 
compensation and services to the plan. Under the proposal, filers would 
be required on Schedule C, as in the 408b-2 disclosures for pension 
plans, to indicate (by checking a box) whether the service providers 
receiving compensation are fiduciaries within the meaning of section 
3(21) of ERISA.
    As noted in the GAO report, GAO Private Pensions: Targeted 
Revisions Could Improve Usefulness Of Form 5500 Information, some 
filers have expressed confusion about how to answer the current 
question which requires filers to identify both service and fee codes 
in the same line item, despite the instruction that requires entering 
all codes that apply. To address this concern and to improve quality of 
the data, the proposal clarifies the required reporting on the types of 
services provided and the types of compensation received by individual 
service providers by separating the existing compound question into two 
separate reporting elements, one line item to indicate service codes 
and the other to indicate compensation codes. To minimize both burden 
and potential confusion, filers would need to report service codes for 
all service providers, regardless of the type of compensation received, 
but would only have to indicate compensation codes for indirect 
compensation.
    A new service type would be added for information technology/
computer support. ``Information technology/computer support,'' for the 
purposes of Line 1c, would include computer office automation, 
information processing, local and wide area network support, services 
supporting hardware, software, telecommunications systems, including 
automated telephone response systems and systems security.
    The proposed Schedule C instructions would continue to permit 
filers to offset from the total amounts of direct compensation the 
amounts received from a so-called ERISA recapture or ERISA budget 
account or similar account. Because filers are permitted to report a 
net figure, however, it is not possible to determine whether such an 
account has been used. With the increasing use of such accounts, see 
generally Advisory Opinion 2013-03A (Jul. 3, 2013), DOL believes it is 
important for the Form 5500 to indicate whether such accounts are being 
used as part of the plan's fee and revenue sharing structures. The 
proposal thus includes a ``Yes''/``No'' question on Schedule C's 
revised Line 1, to ask whether any such account or arrangement has been 
used by the plan during the plan year.
    The proposal would also add a question asking whether the service 
provider arrangement includes recordkeeping services to a plan without 
explicit compensation for some or all of such recordkeeping services or 
with compensation for such recordkeeping offset or rebated in whole or 
in part based on other compensation received by the service provider, 
or an affiliate or subcontractor. If so, the filer would be required, 
using the same methodology used in the service provider's estimate of 
the cost to the plan of recordkeeping services, to enter as a dollar 
figure the amount of compensation the service provider received for 
recordkeeping services. The Agencies believe that this information will 
better enable a cost comparison in an environment where there are 
different fee structures and methods of calculating compensation.
    The proposed Line 1 would also include a data element that asks 
whether the service provider listed on the Schedule C was also 
identified on Schedule A as having received insurance fees and 
commissions. Filers are not required to report on Schedule C insurance 
fees and commissions that are already reported on Schedule A. The 
question is designed to help users of the Form 5500 Annual Return/
Report data identify service providers where some fees and commissions 
are reported on Schedule A and some on Schedule C.
    In the proposed Line 2, filers would report direct compensation 
paid to the service provider by the plan. The

[[Page 47553]]

Agencies considered having filers break out payments as follows: Direct 
payments by a plan out of a plan account, charges to a plan forfeiture 
account, charges to fee recapture accounts, charges to a plan trust 
account before allocations to individual participant accounts, direct 
charges to individual participant accounts, and ``Other,'' with a 
description. Rather than requiring that detailed breakout on the 
Schedule C, the Agencies concluded that they could still obtain a 
better picture of how the plan pays direct compensation by instead 
adding a breakout of how participant accounts are charged to the 
Schedule H ``Administrative Expense'' line and requiring information 
regarding recapture accounts in the form of a ``Yes/No'' question on 
Schedule C.
    On proposed Line 3, filers would report the total amount of 
compensation received by the covered service provider identified in 
Line 1a in connection with services provided to the plan from sources 
other than the plan or plan sponsor, including charges against plan 
investments. The amount of compensation reported would include 
compensation received by an affiliate or subcontractor in connection 
with the services rendered to the plan, where the compensation is 
reported as part of a bundled service arrangement. Total indirect 
compensation would now be required to be reported as a dollar amount. 
The Agencies recognize that service providers accustomed to disclosing 
fees by way of a formula may not be able to quantify exactly the dollar 
amount of the compensation received during the plan year. Thus, 
although a dollar amount would be required, the proposal would permit 
reporting an estimated dollar amount. If the dollar amount is an 
estimate, the filer still would be required to indicate that a formula 
was used in determining the actual compensation paid to or received by 
the service provider. As with the current Line 3, filers would continue 
to identify the source(s) of the indirect compensation received by the 
covered service provider identified in Line 1, and would also identify 
the type of fee or compensation. For each source, filers would be 
required to enter a dollar figure or estimate of the amount of 
compensation, and, if a formula was used to calculate an estimate, a 
description of the formula.
    To increase overall fee transparency, as well as to identify 
potential conflicts of interest in related party transactions, a new 
question would be added that would require filers to indicate whether 
the arrangement with each covered service provider required to be 
reported on Schedule C involved any related party compensation. If 
``Yes,'' the filer would be required to indicate the services for which 
the compensation was paid, the names of the payor(s) and recipient(s) 
of such compensation, status as an affiliate or subcontractor 
(indicated by checkbox), and the amount of the compensation.
    To further ensure consistency between 29 CFR 2550.408b-2 and 
Schedule C, the proposed rule would also modify the instructions. The 
instructions, as proposed, would increase the threshold for reporting 
non-monetary compensation in Schedule C from $100 to $250. A 
corresponding change also would be made to the Schedule A instructions 
for reporting fees and commissions.
    The proposed instructions also would clarify the requirements for 
reporting the travel or educational expenses of plan employees or 
trustees, including reimbursement, on both Schedule C and Schedule H. 
This clarification is being made in response to requests for further 
guidance following the issuance of Supplemental FAQs About the 2009 
Schedule C (available at http://www.dol.gov/ebsa/faqs/faq-sch-C-supplement.html). The FAQs state that for Schedule C purposes, 
reportable compensation includes money and other things of value, such 
as gifts and trips, received directly or indirectly by a person from 
the plan in connection with services rendered to the plan or the 
person's position in the plan. In addition, they explain that 
disbursements to a plan trustee for transportation, lodging, meals, and 
similar expenses incurred while engaging in official plan business are 
considered reportable compensation. The requests for clarification 
argued that the DOL should not treat as reportable compensation expense 
reimbursements that are not treated as taxable under the Code by the 
IRS.
    The DOL continues to believe that getting information on the value 
of trustee expenses, including expense reimbursement, is important for 
compliance purposes. It is persuaded, however, that amounts that are 
not taxable to the trustee need not be identified as ``indirect'' 
compensation. Therefore, the instructions would be clarified to provide 
that trustee and employee expense reimbursements are required to be 
reported on Schedule C only if the amounts are taxable compensation for 
trustees or employees. Should trustees receive from the plan travel, 
education, conferences or similar expenses, or reimbursements 
therefore, that exceed the limits under the Code, they would have to 
include them as threshold expenses for Schedule C and include the ``fee 
code'' for ``reimbursement'' when identifying trustee compensation. For 
reporting those amounts paid for or reimbursed by the plan regardless 
of whether they are taxable to the trustee, a proposed new breakout 
line item under the ``administrative expenses'' category would be added 
to Schedule H to report aggregate plan expenditures on trustee travel, 
meetings, education and similar expenses, whether paid directly by the 
plan or as a reimbursement to trustees.\23\ Non-monetary compensation 
in the form of travel, conferences, entertainment, etc., provided by 
parties other than the plan, that is not de minimis, as defined in the 
instructions, would continue to be reportable indirect compensation.
---------------------------------------------------------------------------

    \23\ The proposed question is similar to a question that was on 
the Form 5500 prior to 1999. See 1998, Form 5500, Line 32g(8).
---------------------------------------------------------------------------

    The proposed Schedule C still would ask filers to identify service 
providers who fail or refuse to provide information to the filer, 
including a description of the information that the service provider 
failed or refused to provide. The instructions would continue to 
provide that filers, before identifying a fiduciary or covered service 
provider as a person who failed or refused to provide information on 
indirect compensation, should contact the fiduciary or service provider 
to request the necessary information. For these purposes, if a 
``covered'' service provider has failed or refused to provide 
information regarding indirect compensation, that service provider 
would be presumed to meet the $1,000 reporting threshold.
    The Agencies also continue to believe that it is important to have 
filers identify the termination of service providers on the annual 
return/report. That question, however, would be moved to the Schedule H 
from the Schedule C to associate it with a new compliance question, 
described below, asking whether any service providers were terminated. 
Although it would be moved to the Schedule H, the proposal would remain 
substantially unchanged, retaining the requirement to provide 
information for all terminated accountants and actuaries regardless of 
the reason for termination because of the importance of the involvement 
of actuaries and accountants in the preparation of the annual return/
report. The proposal would change the questions to add a check box for 
the filer to indicate whether it was an accountant or actuary that was 
terminated. The instructions for this section would also

[[Page 47554]]

be updated to provide a ``Tip'' stating that if the only reason for a 
change of appointment of an enrolled actuary was a temporary leave of 
absence due to non-work circumstances of the enrolled actuary, the 
filer would so indicate in the ``explanation'' field.
    Along with moving the existing Schedule C question on termination 
of actuaries and accountants to the Schedule H, the proposal would also 
add a question on the Schedule H regarding the termination of any 
service provider for a material failure to meet the terms of a service 
arrangement or failure to comply with Title I of ERISA, including the 
failure to provide required disclosures under 29 CFR 2550.408b-2. 
Although not requiring identification of all service providers in all 
circumstances, the Agencies believe that there are service providers 
other than actuaries or accountants, such as fiduciaries, 
recordkeepers, third party administrators, and custodians who play a 
sufficiently important role in plan operations that information on 
their termination is significant. The Agencies specifically seek 
comments on whether the proposed new question should be limited to a 
narrower class of service providers or specific termination 
circumstances.

C. Better Quality, Accessibility, and Usability of Data (Data 
Mineability)

    Another key component of the proposal is to make the Form 5500 
Annual Return/Report more data mineable and accessible for research, 
policy analysis, and enforcement purposes. EBSA is responsible for 
collecting the Form 5500 Annual Return/Report, in part, to fulfill the 
statutory requirements under Sections 104 and 106 of ERISA, which 
require that DOL make annual reports filed under Title I of ERISA 
available to the public. Section 504 of the Pension Protection Act of 
2006, Public Law 109-280 (PPA), requires DOL to display certain annual 
report information on the Internet within 90 days after filing. EBSA 
must also make the data from all of the reports filed under Title I of 
ERISA available to those seeking the information under the Freedom of 
Information Act (FOIA). EBSA fulfills its FOIA responsibilities by 
making the Form 5500 Annual Return/Report data available for 
downloading in bulk (see http://www.dol.gov/ebsa/foia/foia.html). These 
bulk data files, which EBSA updates at the end of each month with the 
Form 5500 Annual Return/Report data collected during that month, are 
downloaded by private-sector organizations that, in some cases, also 
make the data available on the Internet. Thus, most returns/reports are 
currently open to public inspection, and the contents are public 
information subject to publication on the Internet.
    Mandatory e-filing, which was implemented for the 2009 Form filing 
year, starting January 1, 2010, has changed both the regulated 
community's and the government's ability to use the Form 5500 Annual 
Return/Report data. The data sets developed from e-filing information 
has been helping researchers, businesses, and other plan professionals. 
The Form 5500 Annual Return/Report data sets can be one of the major 
building blocks for a private organization to use in developing 
information for employees and employers on plan administration. In 
addition, the government can provide much more timely and complete data 
as a result of e-filing more cost effectively. For instance, the data 
sets are posted on the Internet and updated monthly. In addition, the 
images of the filings (facsimiles) and the scanned and uploaded 
attachments are made available at no cost to the requester. As 
indicated in the White House Report of the Task Force on Smart 
Disclosure, in commenting on the Form 5500 Annual Return/Report, 
``[s]mart disclosure is also helping employers and employees make 
decisions about 401(k) and other workplace retirement plans. These data 
sets can help employees better understand their retirement options and 
employers better understand the quality of the plans they offer, with 
the help of third parties that analyze the data.'' Id. at 13. The SEC 
has also acknowledged the importance of innovative approaches to data 
collection and use, citing its enhanced data mining as the basis for 
improvements in its enforcement efforts. See New Investigative 
Approaches and Innovative Use of Data and Analytical Tools Help Drive 
Successful Enforcement Year, SEC, (available at http://www.sec.gov/News/PressRelease/Detail/PressRelease/1370543184660).
    The Agencies generally plan to continue the data publication 
processes currently in place and provide an even more robust Form 5500 
Annual Return/Report web-based search application. This application 
would allow users to develop more custom queries to better target 
desired data. Further, this enhanced dissemination service would 
include options to download data in various machine-readable and open 
formats (such as Excel or comma separated value [CSV] files), as 
specified in the President's Open Data policy. Expanding the 
downloadable options would facilitate researching and comparing plan 
information. The dissemination could also support predefined queries 
presented in a dashboard format to graphically illustrate individual 
plan performance as well as performance in comparison to plans of 
similar size or features. Part of the goal of the proposal is to change 
the structure of the data filed as part of the Form 5500 Annual Return/
Report in order to facilitate those applications and expand the use and 
usefulness of the Form 5500 Annual Return/Report data generally, as 
well as to make the Form 5500 Annual Return/Report a better disclosure 
tool.\24\
---------------------------------------------------------------------------

    \24\ The Agencies believe that the proposed changes intended to 
improve the quality of the data, for example, eliminating compound 
questions, using simpler language, moving attachments into text 
fields that show on the face of the form or schedule when completed, 
and adding more definitions and instructions, would also help make 
the Form 5500 Annual Return/Report a more readable disclosure 
document. The GAO has recommended broadly that the Agencies work to 
improve the clarity of required disclosures. See generally GAO 
Private Pensions: Clarity of Required Reports and Disclosures Could 
Be Improved.
---------------------------------------------------------------------------

1. Structured Data Attachments
    A critical way in which the Agencies propose to enhance the 
mineability of the Form 5500 Annual Return/Report data is by 
structuring and standardizing the schedules required to be attached to 
the form. Currently, for example, the Line 4i attachments to Schedule H 
(Schedule of Assets Held for Investment at End of Year, Schedule of 
Assets Disposed of During Plan Year and the Schedule of Reportable 
Transactions) cannot be searched electronically because they currently 
are not filed in a standardized electronic format. As a result, 
policymakers, the Agencies, and the public have difficulty accessing 
key information about the plan's investments. The Agencies' proposal to 
standardize the Schedule H, Line 4i Schedules of Investments is 
intended to be responsive to the OIG's recommendation that the Agencies 
create a searchable reporting format for the Schedule H, Line 4i 
Schedules of Assets and otherwise increase the accessibility of Form 
5500 Annual Return/Report information, particularly information on 
hard-to value assets and multiple-employer plans. See DOL-OIG EBSA 
Needs to Provide Additional Guidance and Oversight to ERISA Plans 
Holding Hard-To-Value Alternative Investments, at 17. See also Private 
Pensions: Targeted Revisions Could Improve Usefulness of Form 5500 
Information, at 37; see also U.S. Gov't Accountability Office, GAO-12-
665, Federal Agencies Should Collect Data And Coordinate Oversight of 
Multiple Employer Plans (2012), at 30.

[[Page 47555]]

    Other currently unstructured data or new elements would also be 
collected as structured data under the proposal, including the lists of 
employers participating in multiple-employer and controlled group plan 
members required to be attached to the Form 5500 Annual Return/Report 
or Form 5500-SF; the Schedule H, Line 4a Schedule of Delinquent 
Contributions; and the Line 4j Schedule of Reportable Transactions. The 
proposal also would eliminate the instructions for Schedule A that 
permit filing as an attachment ``appropriate schedules of current rates 
filed with the appropriate state insurance department or by providing a 
statement regarding the basis of the rates in an attachment, in lieu of 
completing information on ``Contracts With Allocated Funds.'' The 
instructions would instead direct the filer to enter a statement 
regarding the basis of the rates into an open text field on the 
Schedule A. Information on contracts with allocated contracts would 
therefore be completed on the Schedule A as structured data. The 
Agencies specifically invite comments as to whether entering a 
statement in an open text field on the Schedule A, relative to 
attaching a rate schedule(s) or statement regarding the basis of the 
rates, would create a significant burden or make it difficult to 
provide accurate information.
2. Move Information Collection From Attachments to Open Text Fields on 
Face of Forms and Schedules
    This proposal also increases the accessibility of data by replacing 
some of the attachments to the schedules with text fields. Similar to 
the proposed specific data elements for the Schedule H Line 4i 
Schedules, which replace the existing suggested format for an 
unstructured attachment, the Agencies believe that shifting to use of 
text fields on the face of the schedules instead of having information 
be supplied in non-standard attachments concentrates information on the 
Form 5500 and the schedules and thus improves data mineability. For the 
Schedule G (Financial Transaction Schedules), the nonspecific 
requirement to provide ``detailed descriptions'' in an open text field, 
including a variety of elements to report loans and leases in default 
or uncollectible, has been replaced with individual questions on each 
of the elements originally required to be in the detailed description. 
In addition, attachments to the Schedule G in the form of ``Overdue 
Loan Explanation'' and ``Overdue Lease Explanation'' for loans and 
leases that are overdue or uncollectible would be replaced with open 
data fields on the face of the Schedule G. The purpose of these changes 
would be to standardize the information, to make the data less subject 
to individual variation where unwarranted, to simplify reporting on the 
Schedule G transactions for filers, and to make it easier to search and 
use the data.
    The Agencies also are proposing expanded data elements on the 
actuarial schedules (Schedules MB and SB), including information 
previously reported on PDF attachments. Under the proposal, single-
employer and multiemployer plans that are currently required to provide 
a Schedule of Active Participant Data as a PDF attachment would be 
required to input the data into Schedules MB and SB. Supplemental 
information required by enrolled actuaries who have not fully reflected 
regulatory requirements under ERISA or the Code in completing the 
Schedule MB or SB would be reported on the schedules rather than on PDF 
attachments. A number of questions on the Schedule SB would be required 
to be reported on the schedule rather than on PDF attachments. This 
would include reporting of information on the plan's late election to 
apply funding balances to quarterly installments; an adjustment to the 
amount of the credit balance reported in the prior year in the first 
year a plan is subject to the minimum funding requirements of Code 
section 430 or ERISA section 303; use of multiple mortality tables and 
substitute mortality tables; a change in non-prescribed actuarial 
assumptions and a method change for the current plan year; and a 
schedule of amortization bases.
    The Agencies also propose to consolidate certain data reported on 
the Schedule SB on PDF or other similar attachments. The discounted 
employer contribution PDF attachment would be consolidated with the 
list of contributions currently included on the Schedule SB. Also, for 
plans in at-risk status for the current plan year, the PDF attachment 
describing the at-risk assumptions for the assumed form of payment 
would be consolidated with the attachment describing the other 
actuarial assumptions. Withdrawal liability payments will be reported 
separately from plan year contributions on the Schedule MB. In 
addition, for both Schedules SB and MB, the schedule of all 
amortization bases currently filed as a PDF attachment would be 
consolidated with the schedule of new amortization bases.
    New questions would be added requiring multiemployer plans and 
single-employer plans that input data into the Schedule of Active 
Participant Data to report on the Schedules MB and SB the average age 
of active participants, and the average credited service of active 
participants as of the valuation date. Also, multiemployer plans and 
single-employer plans that have retired participants and beneficiaries 
as of the valuation date and terminated vested participants as of the 
valuation date would be required to input data into two new schedules 
on Schedules MB and SB--the Schedule of Retired Participants and 
Beneficiaries Receiving Payment Data and the Schedule of Terminated 
Vested Participant Data. This information on retired participants and 
beneficiaries and terminated vested participants would be reported 
according to age bracket, but information would not be required to be 
reported for an age grouping consisting of 10 or fewer participants. 
Additionally, all plans would report the average age and average in-pay 
annual benefit for retired participants and beneficiaries receiving 
payment. Plans with terminated vested participants would report the 
average age and average annual benefit, and assumed form of payment and 
the assumed first age of payment.
    Expanding the data elements to require that new information and 
information previously reported on PDF attachments be reported in a 
data mineable format would allow for more refined projections of the 
financial positions of multiemployer and single-employer plans. This is 
especially critical for PBGC's multiemployer program, as well as for 
its single-employer program. Information reported in a data mineable 
format would also facilitate more refined projections and calculations 
for individual plans. Computer programs could be written to read the 
data and provide estimated funding calculations and projections for 
plans. This would provide information essential to the Agencies' 
enforcement efforts and for their ability to target plans with likely 
compliance issues. Furthermore, the availability of the data would 
assist private-sector auditors and auditors in validating a plan 
actuary's calculations.
    The data would also provide new opportunities for research. 
Currently, there is no source of system-wide data on defined benefit 
pension plan participants with age, service, and average benefit 
levels. The availability of such data would allow for more refined 
projections of future coverage and benefits adequacy for plan 
participants and beneficiaries. As more of this data is collected over 
the years, the data could be analyzed to identify trends in plan 
coverage and benefits.

[[Page 47556]]

Also, proposed system-wide changes in legislation and regulations could 
be more effectively modeled.
    As discussed in more detail below, the Agencies also propose to 
allow the plan actuary to sign Schedules MB and SB electronically. The 
plan actuary can access the EFAST2 Web site at www.efast.dol.gov to 
register for electronic credentials to sign or submit filings.
3. Plan Characteristics Codes and Other Identifying Codes Replaced With 
Yes/No Questions and Checkboxes on Face of Forms
    In addition, the use of ``codes'' appearing in the instructions 
would be limited and refined to the extent feasible. New ``Yes''/``No'' 
and check box questions would replace most Form 5500 and Form 5500-SF 
questions that currently require filers to list Plan Characteristics 
Codes. These changes are intended to refine how data will be collected 
and overlay all of the other changes being proposed here. On the 
Schedule C, rather than entering, multiple codes to identify both types 
of fees/compensation and kinds of services, the filer would check as 
many boxes as are applicable to indicate all types of services for each 
provider identified. In another element that is for reporting only 
sources of compensation from parties other than the plan or plan 
sponsor, filers will separately indicate all types of fees/
compensation. This is intended to improve the quality of the data, and 
make the Schedule C easier to read from a disclosure perspective. It is 
also intended to address concerns raised by the GAO about the fee and 
service codes. See GAO Private Pensions: Targeted Revisions Could 
Improve Usefulness of Form 5500 Information, at 27. Comments are 
specifically invited regarding whether additional or different types of 
services or fees should be listed in order to improve the picture of 
service providers to the plan.
4. Compound Questions Separated
    The Agencies would separate out reporting for the various types of 
direct filing entities to make clearer what the precise reporting 
requirements are for each type of entity. They would also clarify the 
instructions to the forms and schedules by separating compound 
questions. In this regard, the Agencies recognize that putting one 
question on each line rather than asking filers to complete multiple 
subsections, while streamlining the completion process, would 
nevertheless make some schedules appear longer, even though no 
additional information is actually required to be reported. This is 
particularly evident for Schedules C and G, both of which currently 
contain multiple compound questions.
5. More Detailed Identifiers, Instructions, and Definitions
    The proposal adds clarifying definitions and instructions to 
improve the consistency of responses. For example, the proposal 
clarifies conventions for identifying filers by name and identifying 
number(s). The proposal also requires plans to use legal entity and 
other industry and regulatory identifiers whenever possible. These 
changes are intended to help the Agencies compare plan participation, 
investment options, and investment performance from year-to-year. It 
should also help mitigate confusion about the legal entities with which 
the plan transacts. These changes are intended to address the concerns 
raised by the GAO in recommending that ``the Agencies develop a central 
repository for Employer Identification Numbers (EINs) and Plan Numbers 
(PNs) for filers and service providers to improve the comparability of 
form data across filings.'' GAO Private Pensions: Targeted Revisions 
Could Improve Usefulness of Form 5500 Information, at 37.
    The proposal would add more explicit instructions, for example, on 
reporting delinquent participant contributions and completing the Line 
4i Schedules of Assets. In addition, because filers would be asked to 
identify plan characteristics and type through questions on the face of 
the Form 5500/5500-SF instead of using codes in the instructions, there 
are proposed instructions for various questions in this information 
category. These definitional changes and additions are intended to help 
ensure that data would be reported consistently and would be more 
accessible, thus improving the usefulness of the data.

D. New Group Health Plan Reporting Requirements and Information

    The DOL proposes to expand reporting to all employee benefit plans 
providing group health benefits, including plans that claim 
grandfathered status and retiree-only plans.\25\ Currently, generally 
most plans that provide group health benefits that have fewer than 100 
participants meet the conditions in existing regulations at 29 CFR 
2520.104-20 to be exempt from the requirement to file the Form 5500 
Annual Return/Report because they are fully insured, unfunded, or a 
combination of unfunded and insured.\26\ Although there may be sources 
of aggregate estimates regarding group health plans, the current lack 
of plan level information for employee benefit plans that provide group 
health benefits, especially those that have fewer than 100 
participants, complicates not only DOL's ability to enforce 
regulations, but also diminishes the effectiveness and efficacy of 
EBSA's ability to develop health care regulations. The Affordable Care 
Act also requires the Secretary of Labor to provide Congress with an 
annual report, see, e.g., ``Self-Insured Health Benefit Plans 2015,'' 
\27\ containing general information on self-insured employee health 
benefit plans and financial information regarding employers that 
sponsor such plans. That report is supposed to be based on data 
contained in the Form 5500 Annual Return/Report. However, as noted 
above, many self-insured health benefit plans currently are not 
required to file annually with the DOL and, even for those that do 
file, the Form 5500 Annual Return/Report currently collects only 
limited information.
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    \25\ All ``group health plans'' that meet the definition in 
733(a) of the Act, including plans that claim ``grandfathered'' 
status under 29 CFR 2950.715-1251, would be required to file a Form 
5500 and applicable schedules, including the proposed Schedule J, 
regardless of whether such plans are exempt from certain market 
reform requirements under ERISA Sec.  732(a) (exemption for certain 
small group health plans that have less than two participants who 
are current employees) or ERISA Sec.  733(c) (group health plans 
consisting solely of excepted benefits). Employee welfare benefit 
plans as defined in ERISA Sec.  3(1) that do not meet the definition 
of ``group health plan'' under 733 of the Act (i.e., they do not 
provide medical care) are not subject to the proposed enhanced 
reporting requirements applicable to group health plans.
    \26\ ERISA 733(a) defines a ``group health plan'' as ``. . . an 
employee welfare benefit plan to the extent that the plan provides 
medical care (as defined in paragraph (2) and including items and 
services paid for as medical care) to employees or their dependents 
(as defined under the terms of the plan) directly or through 
insurance, reimbursement, or otherwise.'' (Emphasis added). ERISA 
3(1) defines an ``employee welfare benefit plan'' as ``any plan, 
fund or program which was . . . established or maintained by an 
employer or by an employee organization . . . to the extent that 
such plan, fund or program was established or is maintained for the 
purpose of providing for its participants or their beneficiaries . . 
. medical, surgical, or hospital care or benefits.''
    \27\ Available on the DOL's Web site at: https://www.dol.gov/ebsa/pdf/ACASelfFundedHealthPlansReport2015.pdf.
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    To remedy this information gap, under the proposal, all ERISA-
covered plans that provide group health benefits, regardless of size, 
and regardless of whether funded with a trust, unfunded, or a 
combination unfunded/insured, would be required to file a Form 5500 
Annual Return/Report, including the new Schedule J (Group Health Plan 
Information), as well as any other applicable schedules. However, 
small, fully-insured group health plans would

[[Page 47557]]

be required to only answer a limited number of questions on the Form 
5500 and the new Schedule J. The current exemptions from financial 
reporting on Schedule H, G, and C for insured plans, unfunded plans, 
and plans that are combination of unfunded/insured that meet the 
requirements of 29 CFR 2520.104-44 would continue to apply for all 
welfare plans, including group health plans, regardless of size.\28\ 
The current exemption from financial reporting on Schedule G for 
welfare plans that cover fewer than 100 participants as set forth in 29 
CFR 2520.104-46 would also continue to apply.
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    \28\ Currently, welfare plans that are unfunded, fully-insured, 
or a combination of unfunded and insured are required to file the 
Form 5500, including Schedule A ``Insurance Information'' if 
applicable, but, under 29 CFR 2520.104-44, the plan is not required 
to engage an independent qualified public accountant and need not 
complete Schedules C or H. The proposal would not change these 
reporting provisions. Similarly, the exemption in 29 CFR 2520.104-20 
from filing any Form 5500 for fully insured, unfunded, or 
combination small welfare plans that are not group health plans is 
also not being changed in this proposal.
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    Currently plans that provide group health benefits that have fewer 
than 100 participants that are not unfunded or insured (e.g., funded 
using a trust) are not exempt under 29 CFR 2520.104-20 from the 
requirement to file a Form 5500 Annual Return/Report and are not exempt 
from the financial reporting requirements under 29 CFR 2520.104-44. 
These plans generally file either the Form 5500-SF or the Form 5500 and 
the Schedule H or Schedule I, including financial and compliance 
information. Under the proposed rule, plans that provide group health 
benefits that have fewer than 100 participants that are not unfunded or 
insured (e.g., funded using a trust) would be required to complete the 
Schedule H (because Schedule I is being removed and group health plans 
are not permitted to use Form 5500-SF), as well as Schedule C, if 
applicable. However, unless such a plan is invested in alternative or 
hard-to-value assets, completing the Schedule H would only modestly 
expand the current financial and compliance reporting for the affected 
small welfare plans. Requiring reporting on Schedule H by these plans 
with fewer than 100 participants that provide group health benefits 
would ensure that such plans are filing at least as much financial and 
compliance information as other small welfare plans (those that do not 
provide group health benefits) that are not unfunded or insured (e.g., 
funded using a trust), for which the reporting requirements remain 
largely unchanged.\29\
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    \29\ The proposal does not change the current eligibility 
requirements for small welfare plans that are not group health plans 
to use Form 5500-SF.
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    As indicated above, small, fully insured group health plans would 
be required to answer only certain questions on the Form 5500 and on 
the Schedule J. This limited filing, which would be similar in scope to 
the limited pension plan reporting for plans established under section 
408 of the Code that requires such plans to complete certain Form 5500 
questions and no schedules, see, e.g., 2015 Form 5500 Instructions, 
Limited Pension Plan Reporting, is intended to serve as an annual 
registration statement with basic identifying and insurance 
information. The DOL considered whether to have small, fully insured 
group health plans file a separate registration statement either 
annually or based on certain events following the establishment of the 
plan (e.g., initial, final, change in insurance carrier). However, we 
believe that it will be less burdensome to have such plans file limited 
information through EFAST2, using the Form 5500, particularly for those 
small employers that already use the system to report for their pension 
plans. Comments are specifically solicited in this regard.
    In addition, sections 2715A and 2717 of the Public Health Service 
Act (PHS Act), as added by the Affordable Care Act, established new 
reporting requirements for non-grandfathered group health plans and 
health insurance issuers offering non-grandfathered group or individual 
health insurance coverage.\30\ The DOL is considering whether a group 
health plan could satisfy its reporting obligations under PHS Act 
section 2715A and 2717, as incorporated into section 715(a)(1) of 
ERISA, by filing a completed Form 5500 and Schedule J, and providing 
that information to the parties as required under PHS Act section 2715A 
and 2717 (generally HHS, DOL, Treasury, State insurance commissioners, 
enrollees and the public).\31\ Much of the information required to be 
reported under PHS Act sections 2715A and 2717, for example, data on 
enrollment, claims payment policies and practices, and claims denials 
is information that is to be included in the proposed Schedule J. In an 
effort to reduce duplicative reporting and the attendant costs to plans 
subject to ERISA, the DOL is specifically soliciting comments on the 
feasibility of such an approach as a means of compliance with PHS Act 
sections 2715A and 2717 as incorporated into section 715(a)(1) of 
ERISA.\32\
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    \30\ Section 2715A of the PHS Act extends the transparency 
reporting provisions set forth in section 1311(e)(3) of the 
Affordable Care Act (applicable to issuers of ``qualified health 
plans'' offered through Exchanges) to non-grandfathered group health 
plans and health insurance issuers offering non-grandfathered group 
or individual health insurance coverage. In particular, section 
1311(e)(3) of the Affordable Care Act requires disclosure of: claims 
payment policies and practices, periodic financial disclosures, and 
information on enrollment, disenrollment, number of denied claims, 
rating practices, out-of-network cost-sharing and payments, rights 
under title I of the Affordable Care Act, and other information as 
determined appropriate by the Secretary of Health and Human Services 
Section 2717 of the PHS Act requires non-grandfathered group health 
plans and health insurance issuers offering non-grandfathered group 
or individual health insurance coverage to report on quality of care 
metrics, for example, reporting on effective case management, care 
coordination, chronic disease management, and medication and care 
compliance initiatives. Although sections 2715A and 2717 of the PHS 
Act do not apply to grandfathered group health plans, the proposal 
is to require all group health plans subject to ERISA, including 
grandfathered group health plans, to file Schedule J.
    \31\ Nonfederal governmental plans (as defined in PHS Act 
section 2791(d)(8)(C)) and health insurance issuers (as defined in 
PHS Act section 2791(b)(2) and ERISA section 733(b)(2)) are not 
required to file annual reports pursuant to ERISA sections 103 or 
104. Accordingly, any reporting required of such plans and issuers 
to satisfy PHS Act sections 2715A and 2717 will be addressed 
separately by HHS in future rulemakings and/or guidance.
    \32\ Sections 2715A and 2717 of the PHS Act are also 
incorporated into section 9815(a)(1) of the Code. The Treasury 
Department and the IRS intend to publish proposed regulations in 26 
CFR 54.9815-2715A and 54.9815-2717 clarifying that group health 
plans required to file an annual report pursuant to section 104 of 
ERISA that comply with the reporting requirements in 29 CFR 
2520.103-1 (including filing any required schedules to the annual 
report) would satisfy the reporting requirements of sections 2715A 
and 2717 of the PHS Act, as incorporated in the Code. Group health 
plans that are not required to file an annual report pursuant to 
section 104 of ERISA but that are subject to sections 2715A and 2717 
of the PHS Act as incorporated in the Code, will not be required to 
do any reporting to comply with sections 2715A and 2717 of the PHS 
Act, as incorporated in the Code, unless and until the Treasury 
Department and the IRS issue subsequent further guidance or 
rulemaking regarding any such reporting by such plans.
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1. New Schedule J (Group Health Plan Information)
    The proposed Schedule J (Group Health Plan Information) would 
report information about group health plan operations and ERISA 
compliance, plus compliance with certain provisions of the Affordable 
Care Act.\33\ Group health plans that are part of a GIA and subject to 
the exemption from filing under 29 CFR 2520.104-43 would not be 
required to file the Schedule J. A GIA's Form 5500 Annual Return/Report 
filing,

[[Page 47558]]

however, would have to include a separate Schedule J for each group 
health plan participating in the GIA.
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    \33\ The Schedule J does not relate to the employer shared 
responsibility provisions under section 4980H of the Code, the 
related reporting requirements under section 6056 of the Code, or 
the reporting requirements for providers of minimum essential 
coverage under section 6055 of the Code.
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    The proposed Schedule J would collect information on the 
characteristics of the plan that is providing group health benefits, 
including the approximate number of participants and beneficiaries 
covered under the plan at the end of the plan year, and the number of 
persons offered and receiving coverage under the plan through COBRA, 
Consolidated Omnibus Budget Reconciliation Act of 1985 (Pub. L. 99-272, 
100 Stat. 82), 29 U.S.C. 1161, et seq., whether the plan offers 
coverage for employees, spouses, children, and/or retirees, and what 
type of group health benefits are offered under the plan, for example, 
medical/surgical, pharmacy or prescription drug, mental health/
substance use disorder, wellness program, preventive care, vision, 
dental, or various other types of benefits. With respect to the 
collection of COBRA coverage information, the DOL requests comments 
regarding the costs and feasibility of providing this data, whether the 
proposed data elements would effectively show the annual take up rate 
and the total number of participants electing COBRA coverage, and 
whether any additional data elements regarding COBRA coverage would be 
helpful for the regulated community to evaluate COBRA's impact on plans 
and participants.
    The DOL also proposes that plans that provide group health benefits 
provide information on whether their health plan funding and benefit 
arrangement is through a health insurance issuer and whether benefits 
are paid through a trust or from the general assets of the employer. 
Schedule J would also ask whether there were participant and/or 
employer contributions.\34\ With respect to plans that use a prototype 
health insurance policy or arrangement (sometimes referred to as ``off-
the-shelf'' plans/policies), the DOL is also requesting that such plans 
provide, if applicable, the relevant unique identifying information 
(such as a state assigned policy identification number) of the 
prototype/off-the-shelf policy or arrangement. The DOL requests 
comments on this proposed data element and whether there are specific 
health insurance policy identification systems employed by States or 
issuers that would most accurately and cost effectively provide 
information about usage of such policies to provide plan benefits.
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    \34\ For purposes of Schedule J reporting, ``participant 
contributions'' include all elective contributions under a cafeteria 
plan (arrangement under Code section 125.).
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    Additionally, plans that provide group health benefits are asked to 
report whether one or more of the plan's benefit package options are 
claiming grandfathered status under the Affordable Care Act,\35\ 
whether the plan is a high deductible health plan,\36\ a health 
flexible spending account (FSA) (or includes a health FSA as a 
component), or a health reimbursement arrangement (HRA) \37\ (or 
includes an HRA as a component). Please note that due to PHS Act 
section 2711 (prohibition on annual dollar limits) and 2713 (preventive 
services requirements), HRAs that are subject to the market reforms 
(that is, those that cover two or more active employees and do not 
consist solely of excepted benefits) are considered to comply with the 
annual dollar limit prohibition and preventive service requirement if 
the HRA is ``integrated'' with another group health plan that complies 
with the annual dollar limit prohibition and the preventive services 
requirement.\38\
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    \35\ ``Grandfathered'' health plans generally are those that 
were in existence on March 23, 2010, and haven't been changed in 
ways that substantially cut benefits or increase costs for 
participants. For regulations addressing grandfathered status, see 
29 CFR 2950.715-1251.
    \36\ A ``high deductible health plan'' is defined under section 
223(c)(2) of the Code and generally is a plan that has a higher 
annual deductible than a typical health insurance plan and a maximum 
limit on the sum of the annual deductible and out-of-pocket medical 
expenses that an enrollee must pay for covered expenses.
    \37\ An HRA typically consists of a promise by an employer to 
reimburse medical expenses, including insurance premiums, for the 
year up to a certain amount, with unused amounts available to 
reimburse medical expenses in future years. See IRS Notice 2002-45.
    \38\ An HRA is a group health plan and is subject to the market 
reforms, including the prohibition of annual dollar limits for 
essential health benefits and the requirement to provide coverage of 
certain recommended preventive services without cost sharing. 
Regulations addressing these annual and lifetime limit prohibitions 
state that a stand-alone HRA offered to active employees violates 
these prohibitions but that an ``integrated'' HRA does not violate 
the annual limits prohibition, as long as other group health plan 
coverage offered with the integrated HRA complies with the market 
requirements. See 80 FR 72192 at 72261 (Nov. 18, 2015) and DOL 
Technical Release 2013-03 (Sept. 13, 2013) for a description of the 
lifetime and annual limit requirements applicable to HRAs, including 
the ``integration'' requirements.
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    The proposed Schedule J also would ask whether the plan received 
rebates, refunds, or reimbursements from a service provider such as a 
medical loss ratio (MLR) rebate under the Affordable Care Act and 
offset rebates from favorable claims experience. If so, filers would be 
required to report the type of service provider, the amount received 
and how the rebates were used (e.g., returned to participants, premium 
holiday, payment of benefits, or other). In addition, the proposed 
Schedule J would request that group health plans identify any service 
providers to the plan (not already reported on Schedule A (Insurance 
Information) or Schedule C (Service Provider Information)) by providing 
the name, address, telephone number, employer identification number, 
and, if applicable, the National Insurance Producer Registry--National 
Producer Number (NPN) as established by the National Association of 
Insurance Commissioners (NAIC). Such service providers include a third 
party administrator/claims processor, including an issuer subject to an 
``administrative services only (ASO)'' contract, mental health benefits 
manager, wellness program manager,\39\ substance use disorder benefits 
manager, pharmacy benefit manager/drug provider, or independent review 
organization. Schedule J also asks for the total premium payment made 
for any ``stop loss'' coverage, as well as information on the 
attachment points of coverage, individual claim limits, and/or the 
aggregate claim limit contained in the policy.
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    \39\ A ``wellness program'' is defined in 29 CFR 2590.702(f) to 
include ``any program designed to promote health or prevent 
disease'' and includes programs that condition benefits (including 
cost-sharing mechanisms) or the premium or employer contribution 
amounts on an individual satisfying a standard that is related to a 
health factor as well as those programs that do not include 
conditions for obtaining a reward that are based on an individual 
satisfying a standard that is related to a health factor.
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    For group health plans that are not required to complete a Schedule 
H (generally, fully insured, unfunded plans, or combination insured/
unfunded plans), the proposal would require that information regarding 
employer and participant contributions be reported on the Schedule J, 
including employer contributions received, participant contributions 
received, employer contributions receivable, participant contributions 
receivable, other contributions received or receivable (including non-
cash contributions) and the total of all contributions. Filers would 
also be required to report whether there was a failure to timely 
transmit participant contributions to the plan.
    The proposed Schedule J also would seek claims payment data, 
including information on how many post-service benefit claims (benefit 
claims) were submitted during the plan year, how many benefit claims 
were approved during the plan year, how many benefit claims were denied 
during the plan

[[Page 47559]]

year,\40\ how many benefit claim denials were appealed during the plan 
year, how many appealed claims were upheld as denials, how many were 
payable after appeal, and whether there were any claims for benefits 
that were not adjudicated within the required timeframes. The proposed 
Schedule J would also seek data on how many pre-service claims were 
appealed during the plan year, and how many of those appeals were 
upheld during the plan year as denials and how many were approved 
during the plan year after appeal. With respect to group health plans, 
the DOL claims procedure regulation subdivides claims for benefits into 
various categories, including pre-service and post-service claims. A 
pre-service claim is defined as any claim for a benefit under a group 
health plan with respect to which the terms of the plan condition 
receipt of the benefit, in whole or in part, on approval of the benefit 
in advance of obtaining medical care. A post-service claim is defined 
as any claim for a benefit under a group health plan that is not a pre-
service claim. See 29 CFR 2560.503-1(m). As used throughout this 
proposal, ``claims'' includes both pre-service and post-service claims.
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    \40\ A denial as referenced in this notice is given the same 
meaning as ``adverse benefit determination'' as defined in 29 CFR 
2560.503-1(m)(4). Accordingly, a denial or adverse benefit 
determination is a denial, reduction, or termination of, or a 
failure to provide or make payments (in whole or in part) for, a 
benefit, including any such denial, reduction, termination, or 
failure to provide or make payment that is based on a determination 
of a participant's or beneficiary's eligibility to participate in a 
plan, and including, with respect to group health plans, a denial, 
reduction, or termination of, or a failure to provide or make 
payment (in whole or in part) for, a benefit resulting from the 
application of any utilization review, as well as a failure to cover 
an item or service for which benefits are otherwise provided because 
it is determined to be experimental or investigational or not 
medically necessary or appropriate.
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    In addition, plans would be asked to report whether the plan was 
unable to pay claims at any time during the plan year and, if so, the 
number of unpaid claims. Plans would also be asked to report the total 
dollar amount of claims paid during the plan year, and if the plan 
provides benefits through an insurance policy, to identify any 
delinquent payments to the insurance carrier within the time required 
by the carrier, and whether any delinquencies resulted in a lapse in 
coverage. The proposal would add a similar question to Schedule A; 
delinquencies identified on Schedule A would not need to be reported 
again on Schedule J.
    In an effort to collect more robust data on claims adjudication 
practices and policies, the DOL is considering, in addition to the 
information requested in the new Schedule J, whether to require plans 
to report more information on denied claims, such as the dollar amount 
of claims that were denied during the plan year, the denial code, and/
or whether the claims were for mental health and substance use disorder 
benefits or for medical/surgical benefits. Proposed Schedule J requires 
plans to report the dollar value of claims paid during the plan year. 
Analyzing this data in terms of claims adjudication practices would be 
limited if the dollar amount of claims denied during a plan year is not 
also reported. The DOL understands, however, that reporting information 
on denied claims may present definitional and data classification 
challenges, e.g., possible need for a more uniform classification of 
denial codes for Form 5500 Annual Return/Report reporting than may 
currently be in place across plans and issuers. In addition, there may 
be a need to establish a uniform measure for ``dollar amount,'' for 
example, should it be based on a provider's point-of-service fees, the 
schedule of fees the plan has negotiated with service providers, 
Medicare reimbursement rates, or state-published prevailing fees, or 
some other ``reasonable'' method for determining the dollar amount of 
denied claims. Therefore, the DOL is specifically seeking public 
comments on whether this is reasonable information to collect and, if 
so, the methodology a plan would employ to determine and report the 
``dollar amount of claims denied'' during a plan year, denial code, and 
type of claim. Further, as noted above, the Notice of Proposed 
Rulemaking that is being published with this Notice includes proposed 
conforming amendments in 29 CFR 2590.715-2715A and 29 CFR 2590.715-2717 
to clarify that compliance with the proposed annual reporting 
requirements by plans subject to ERISA that provide group health 
benefits would satisfy the reporting requirements under PHS Act 
sections 2715A and 2717 incorporated in ERISA through ERISA section 
715(a)(1). The DOL is specifically seeking public comments in this 
Notice on the proposed annual reporting requirements for plans that 
provide group health benefits, including the new Schedule J, in light 
of the Supreme Court's recent decision in Gobeille v. Liberty Mutual 
Insurance Co., 136 S.Ct. 936 (2016).
    The proposed Schedule J would also request compliance information 
from plans providing group health benefits. The proposed compliance 
section of the Schedule J asks if all plan assets were held in trust, 
held by an insurance company qualified to do business in a State, or as 
insurance contracts or policies issued by such an insurance company 
consistent with section 403 of ERISA and 29 CFR 2550.403a-1 and 
2550.403b-1, whether plan assets are not held in trust based on 
reliance on Technical Release 92-01, whether the plan's summary plan 
description (SPD) and summaries of any material modifications (SMM), 
and summary of benefits and coverage (SBC) are in compliance with the 
applicable content requirements, whether coverage provided by the plan 
is in compliance with applicable federal laws and the DOL's regulations 
thereunder, which may include the portability and nondiscrimination 
provisions of the Health Insurance Portability and Accountability Act 
of 1996, Title I of the Genetic Information Nondiscrimination Act of 
2008, the Mental Health Parity Act of 1996, the Paul Wellstone and Pete 
Domenici Mental Health Parity and Addiction Equity Act of 2008, the 
Newborns' and Mothers' Health Protection Act of 1996, the Women's 
Health and Cancer Rights Act of 1998, Michelle's Law, and the 
Affordable Care Act. The DOL believes that self-reporting compliance 
information will help inform future compliance studies. Furthermore, 
the DOL believes that the inclusion of such compliance questions will 
encourage plans to evaluate whether or not they meet the group health 
plan requirements of ERISA, potentially increasing the voluntary 
compliance by ERISA plans.
    Finally, the DOL would move the current questions on the Form 5500 
that ask all welfare plans to report on whether they are subject to, 
and if so, have complied with the Form M-1 filing requirements, to the 
Schedule J.\41\ This would limit these questions to welfare plans that 
provide group health benefits. Form 5500/Schedule J filers that must 
file the Form M-1 would not be required to answer on the Schedule J 
those compliance questions answered on the Form M-1.
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    \41\ Multiple Employer Welfare Arrangements that provide health 
benefits must file the M-1 with the Department. The M-1 questions, 
which would be unchanged under the proposal, ask whether the plan 
was subject to the Form M-1 filing requirements during the plan 
year, whether the plan is currently in compliance with the Form M-1 
filing requirements, and for the filer to provide the Receipt 
Confirmation Code for the most recent Form M-1 that was required to 
be filed under the Form M-1 filing requirements.

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[[Page 47560]]

2. Limited Form 5500 Annual Return/Report Reporting for Small, Fully 
Insured Group Health Plans
    The DOL proposes to eliminate the current exemption from filing for 
small, fully insured group health plans and proposes to require only a 
very limited Form 5500/Schedule J filing. As noted above, the DOL has 
not previously collected annual report data on small welfare plans that 
qualify for the exemption under the regulations at 29 CFR 2520.104-20. 
For small fully insured plans that provide health benefits, the DOL is 
proposing to replace that exemption with a new limited exemption as an 
alternative form of reporting. Specifically, these small plans would be 
required to complete Lines 1-5, i.e. basic identifying information, on 
the Form 5500, and Lines 1-8 on Schedule J, i.e., basic participation, 
coverage, insurance company, and benefit information. Requiring small, 
fully insured plans that provide group health benefits to file very 
rudimentary identifying and health benefit and coverage information 
would ensure that the DOL obtains basic information on all ERISA 
covered group health plans. Because these small, fully insured group 
health plans are subject to separate regulatory oversight indirectly by 
reason of state insurance regulation of the insurance provider and 
insurance contract, the DOL is seeking only basic plan and insurance 
information to be filed annually and is not seeking the broader 
Schedule J annual information requested of small self-insured and large 
plans regarding plan administration and benefits.
    This information would allow the DOL to track total health plan 
counts, and coordinate its enforcement efforts relating to plans 
providing benefits through common issuers. For example, fully-insured 
plans using the same insurance provider often have documents containing 
provisions that are similar. Through these new filings, the DOL would 
be able to better identify those plans that may be affected by 
noncompliant provisions and better coordinate its enforcement efforts 
with affected service providers and other Federal and State agencies. 
Also, this information would enhance the DOL's policy analysis and 
research with respect to participant trends.

E. Proposed Changes To Enhance Compliance and Oversight

    One of the critical purposes of the Form 5500 Annual Return/Report 
is to promote compliance both by requiring plan administrators to 
review particular aspects of plan operations in order to meet their 
annual reporting requirement and by enabling the Agencies to review 
basic plan compliance issues in an efficient manner. Accordingly, the 
Agencies propose adding a series of compliance questions on the Form 
5500 and on the Form 5500-SF, and also the Form 5500-SUP for those 
filers who are not subject to the IRS electronic filing mandate in 26 
CFR 301.6058-2 and elect to answer these questions on a paper return.
1. IRS-Only Changes
a. IRS-Only Questions for 2016 Plan Years and Form 5500-SUP
    For certain years prior to 2009, the Schedules E, P, SSA, and T 
were required to be filed to meet annual return requirements under the 
Code and IRS regulations, but they were not information collections of 
the DOL or the PBGC. The DOL electronic filing mandate applied 
beginning with the 2009 Form 5500 Annual Return/Report and resulted in 
the last of these ``IRS-only'' schedules being dropped from the Form 
5500 Annual Return/Report because the IRS could not mandate that these 
schedules be filed electronically. As ``IRS-only'' schedules, they were 
not covered by the DOL electronic filing requirement. Accordingly, with 
the exception of a limited number of questions on the Schedule E that 
were relocated to the Schedule R, the questions on these schedules were 
no longer included on the Form 5500 Annual Return/Report. The questions 
were either eliminated altogether or, in the case of questions on the 
Schedule SSA, added to a new IRS form, Form 8955-SSA, Annual 
Registration Statement Identifying Separated Participants With Deferred 
Vested Benefits. The 2011 TIGTA report, The Employee Plans Function 
Should Continue Its Efforts to Obtain Needed Retirement Plan 
Information, notes that the lack of information contained on Schedules 
E, P, and T can negatively impacts the IRS's ability to effectively 
focus on specific factors of noncompliance when selecting retirement 
plans for examination. This lack of information may result in the IRS 
selecting relatively compliant plans, which increases the burden on 
these plans and affects the IRS's ability to identify and focus on 
potentially noncompliant plans. This could result in participants 
receiving an incorrect amount of benefits. The IRS has decided to make 
changes to the Form 5500 Annual Return/Report to address these issues.
    The IRS added IRS-only compliance questions to the 2015 Form 5500 
and the 2015 Form 5500-SF, but subsequently directed filers not to 
answer the questions for 2015. The IRS is modifying some of these 
questions and intends to make these IRS-only questions mandatory on the 
2016 Form 5500 and Form 5500-SF. See the Federal Register Notice 
``Proposed Collection; Comment Request for the Annual Return/Report of 
Employee Benefit Plan'' published by the IRS on March 31, 2016 (81 FR 
18687). Other IRS-only questions may be added prior to the form year in 
which the EFAST2 contract recompete and other forms revisions are 
implemented. Regardless of the timing of implementation of any of the 
IRS-only questions on the annual return, any comments received in 
response to this notice with respect to these questions will be 
considered in future revisions of these forms.
    The IRS added to the 2016 forms and schedules various questions 
related to common compliance problems that will make it easier for the 
IRS to administer the filing program. Two of the IRS-only questions 
added for 2016 are questions that were optional on the 2014 Form 5500 
and 2014 Form 5500-SF. Both 2014 forms request information regarding 
the preparer of the annual return/report and the plan's trust. IRS 
intends that both the 2016 Form 5500 and the 2016 Form 5500-SF include 
a box in the signature block of the form for information regarding the 
preparer's name and address. Similarly, line 6 of both Schedules H and 
I of the 2016 Form 5500 Annual Return/Report, and line 14 of the 2016 
Form 5500-SF, would request information regarding the name of the 
plan's trust, the trust's employer identification number (EIN), the 
name of the trustee or custodian, and the trustee or custodian's 
telephone number. This information will enable the IRS to more 
efficiently monitor the compliance of the retirement plan trusts exempt 
from tax under Code section 501(a).
    The IRS also included several other compliance questions on the 
2016 Forms 5500 and 5500-SF that are addressed in the 2014 Forms 5500 
and 5500-SF and that require entry of plan characteristics codes. The 
IRS has found that characteristic codes result in inadequate responses 
and are commonly misunderstood by filers, and believes it would be 
better to enhance these codes with separate questions. For example, the 
IRS replaced characteristic code 2J, which identifies the plan as 
including a cash or deferred arrangement under Code section 401(k), 
with a line item on the 2016 Forms 5500 and 5500-SF. Similarly, Code 
3D, a characteristic code that currently applies to pre-approved

[[Page 47561]]

pension plans, is replaced with a separate line item on the 2016 Forms 
5500 and 5500-SF.
    The IRS also added two questions for 2016 that were questions on 
the Schedule T, Qualified Pension Plan Coverage Information, before it 
was eliminated. Specifically, line 4b of the Schedule T asked if the 
employer aggregated plans in testing whether the plan satisfied the 
nondiscrimination and coverage tests of Code sections 401(a)(4) and 
410(b). Also, line 4f of the Schedule T asked whether the plan 
satisfied the coverage requirements of Code section 410(b) on the basis 
of either the ratio percentage test or the average benefit test. These 
questions were added to the 2016 Forms 5500 and 5500-SF. These 
questions are helpful to the IRS when performing pre-audit analysis and 
allowed the IRS to narrow any inquiries when information was requested 
from the plan. The return of these questions also reflects the 
elimination of optional coverage and nondiscrimination demonstrations 
in the IRS determination letter process. See Rev. Proc. 2015-6, 2015-1 
I.R.B. 198 and Announcement 2011-82, 2011-52 I.R.B. 1052.
    The IRS also added other IRS-only questions to the 2016 Forms 5500 
and 5500-SF in order to address various compliance issues. 
Specifically, there are new questions as to whether the plan sponsor 
used the design-based safe harbor rules, the current year ADP test, or 
prior year ADP test for nonhighly compensated employees in accordance 
with 26 CFR 1.401(k)-2(a)(2)(iii) to satisfy the nondiscrimination 
requirements of Code sections 401(k)(12), (13). The IRS also added 
questions as to whether the employer is an adopter of a master and 
prototype plan or a volume submitter plan that is subject to a 
favorable opinion or advisory letter from the IRS, and the date of that 
favorable letter. This question will help determine the plan's remedial 
amendment period and remedial amendment cycle under Code section 401(b) 
and Rev. Proc. 2007-44, 2007-28 I.R.B. 54 (as modified by Rev. Proc. 
2008-56, 2008-2 C.B. 826; and Rev. Proc. 2009-36, 2009-2 C.B.304); 
Notice 2009-97, 2009-2 C.B. 972; and Notice 2010-48, 2010-27 I.R.B. 9. 
The IRS added a similar question for individually-designed plans as to 
whether an individually designed plan received a favorable 
determination letter from the IRS. The IRS has found that issues have 
arisen regarding the failure of plan sponsors to make timely amendments 
to their plan document to reflect changes in the law.
    The IRS also added a question to the 2016 Forms 5500 and 5500-SF as 
to whether any distributions during the plan year were made to an 
employee who attained age 62 and had not separated from service for 
defined benefit plans or money purchase pension plans. The IRS has 
found various qualification and taxability issues related to such 
distributions.
    Those filers who are required by the electronic filing regulations 
to file the Form 5500 Annual Return/Report electronically will be 
required to answer these IRS compliance questions electronically using 
EFAST2 for the 2016 and later plan years. The IRS will provide a paper-
only form containing these IRS compliance items for use by filers who 
are not subject to the electronic filing requirements of the Treasury 
regulations and who elect not to answer the questions through EFAST2. A 
draft of the paper-only form, Form 5500-SUP, Annual Return of Employee 
Benefit Plan Supplemental Information, was released for public comment 
in October, 2014. The 2016 Form 5500-SUP is expected to be modified to 
reflect the changes proposed for 2016 plan year.
b. IRS-Only Questions for Later Plan Years
    In addition to the questions the IRS included on the 2016 Forms 
5500 and 5500-SF, the IRS proposes to add new questions for later plan 
years. Some of these additional questions were previously included on 
the 2008 Schedule E (ESOP Annual Information). Specifically, Line 1a of 
the 2008 Schedule E asked whether the ESOP is maintained by an S 
corporation and, if so, whether any prohibited allocations were made to 
any disqualified persons. Line 2b of the Schedule E asked whether the 
employer maintaining the ESOP paid dividends deductible under Code 
section 404(k). Line 4 of the 2008 Schedule E asked if the ESOP held 
any preferred stock and under what formula that preferred stock was 
convertible into common stock. Line 6 of the 2008 Schedule E asked if 
any unallocated securities were used to pay an exempt loan and, if so, 
asked for the method used. Line 16 of the 2008 Schedule E asked if the 
employer made payments in redemption of stock held by an ESOP to 
terminating participants and deducted them under Code section 404(k). 
All of these questions will be added to the new Schedule E, ESOP Annual 
Information. The IRS notes that any questions added to the proposed 
Schedule E with respect to Code section 404(k) will be included 
pursuant to Code section 6047(e) rather than Code section 6058 (the 
section pursuant to which the other IRS-only question are included on 
the Form 5500). Thus, the disclosure rules of Code section 6104(b) are 
not applicable and a separate process will need to be in place so that 
any information provided with respect to Code section 404(k) will be 
compliant with the appropriate disclosure rules.
    The IRS also proposes to add three questions to the Forms 5500 and 
5500-SF that will insure that the filers are aware of certain Code 
requirements in areas where the IRS has found significant 
noncompliance. In the first area, the IRS proposes to add a question 
for defined benefit pension plans as to whether the plans comply with 
the participation requirements of Code section 401(a)(26). In the 
second, the IRS proposes to ask whether minimum required distributions 
were made to 5% owners in accordance with Code section 401(a)(9). This 
question addresses issues as to the qualification of the plan, the 
taxability of distributions, and the possible imposition of excise 
taxes under Code section 4974. In the third, the IRS proposes to add a 
question as to whether hardship distributions were made during the plan 
year for a section 401(k) plan. The IRS has found various qualification 
and taxability issues related to such distributions.
    The IRS also proposes to add a question to the Forms 5500 and 5500-
SF as to whether the plan provides for designated Roth contributions 
under Code section 402A. The question would identify plans that have 
added Roth contribution features. Designated Roth contributions and 
Roth conversions add a new layer of recordkeeping and tax reporting for 
plan administration, and the IRS has found various issues related to 
recordkeeping and reporting.
    As noted previously, because the plan characteristics codes 
sometimes provide inadequate responses and are commonly misunderstood 
by filers, the IRS proposes to replace these codes with separate 
questions to the Forms 5500 and 5500-SF. For example, the IRS proposes 
to replace characteristic codes 2L and 2M regarding Code sections 
403(b)(1) and 403(b)(7) arrangements with separate line items. Also, 
characteristic code 1I currently applies to frozen defined benefit 
pension plans that do not provide any new benefit accruals as of the 
last day of the plan year. Neither the Form 5500 nor the Form 5500-SF, 
however, currently requests similar information regarding frozen 
defined contribution pension plans. The IRS proposes to add a question 
to these forms for defined contribution pension plans asking whether 
the plans are frozen.

[[Page 47562]]

    The IRS also proposes to add a line item to the Forms 5500 and 
5500-SF for plans electing non-church plan status under Code section 
410(d). 26 CFR 1.410(d)-1(c)(3) provides that a plan administrator may 
elect non-church plan status by attaching a statement to the Form 5500 
Annual Return/Report. Although such statements can be attached to the 
EFAST2 filing as a PDF, the proposed change would facilitate the 
process by which the IRS determines which plans have elected non-church 
plan status and thus allow the IRS to apply the appropriate criteria in 
determining compliance.
    There also is a new IRS question on the Schedule H and Form 5500-SF 
regarding unrelated business taxable income (UBTI) under Code sections 
511 and 512. Although qualified plans are generally required to report 
UBTI on Form 990-T, Exempt Organization Business Income Tax Return, the 
IRS has found it difficult to get timely information regarding this 
taxable income.
    Lastly, a trustee's signature would be added in the trustee 
information section on the Schedule H and the Form 5500-SF. The 
signature is intended to satisfy the requirements under Code section 
6033(a) for an annual information return from every Code section 401(a) 
organization exempt from tax under Code section 501(a). As discussed in 
more detail below, because this is an IRS-only signature, filers who 
file fewer than 250 returns during the year will be able to satisfy 
this signature requirement by filing the Form 5500-SUP.
c. New Schedule for IRS-Only Compliance Questions
    As noted above, the IRS proposes to add various IRS-only questions 
to the Form 5500 Annual Return/Report and to the Form 5500-SF and also 
issue a Form 5500-SUP for those filers who are not subject to the IRS 
electronic filing mandate in 26 CFR 301.6058-2 and elect to answer 
these questions on a paper return. These new IRS-only compliance 
questions do not apply to welfare plans. With respect to the Form 5500 
and the Form 5500-SF, the IRS is considering whether these questions 
should be added to these forms individually based on subject matter or 
whether they should be added collectively on a single IRS-only 
schedule. If the questions are added individually, they would appear on 
the forms and schedules based on subject matter. Thus, for example, 
ESOP questions would appear on a new Schedule E while other compliance 
questions may appear on Form 5500-SF and revised Schedules H, MB, R, 
and SB. On the other hand, if these IRS compliance questions are added 
collectively, they would appear on a completely new IRS-only schedule. 
Comments are specifically requested as to whether a separate schedule 
that would include all of the IRS-only questions should be made part of 
the Form 5500 Annual Return/Report
2. New Schedule H and Form 5500-SF Compliance Questions
    An area of particular recent focus for DOL has been compliance with 
ERISA section 411. Accordingly, the proposal would add a new question 
under Part IV of Schedule H asking whether any person disqualified 
under ERISA section 411 was permitted to serve the plan. ERISA section 
411 disqualifies people who have been convicted of certain crimes from 
serving as an administrator, fiduciary, officer, trustee, custodian, 
counsel, agent, employee, consultant, or adviser of any employee 
benefit plan for a specified period. The statute also prohibits people 
who are currently disqualified from representing a plan in any 
capacity, and from having any decision-making authority or custody or 
control of the monies, funds, assets, or property of an employee 
benefit plan. This proposed question on disqualification would 
facilitate competent plan administration and improve due diligence by 
encouraging the plan administrator to determine whether any of the 
plan's fiduciaries, employees, and service providers potentially 
participated in an act prohibited by ERISA section 411.
    Another proposed compliance question, which also supports the 
Agencies' goals in obtaining better information on investments and 
related fees for defined contribution pension plans, involves whether 
the plan is a participant-directed account plan, and, if so, whether 
the plan provided participants with the fee disclosures required by 29 
CFR 2550.404a-5. As discussed earlier with respect to the Form 5500-SF, 
the proposal also requires administrators to attach the comparison 
chart to Schedule H. These questions would help plan administrators 
comply with 29 CFR 2550.404a-5. This proposed question is also 
responsive to the GAO's recommendation that the Agencies seek specific 
information on QDIAs. GAO Targeted Revisions Could Improve Usefulness 
of Form 5500 Information, at 18. A plan that is a participant-directed 
account plan also must report the number of DIAs under the plan, the 
number of DIAs that are index funds, and whether a designated 
investment manager (DIM) was made available to participants and 
beneficiaries. These new questions appear on both Schedule H and on the 
Form 5500-SF.
    The proposal also would add a new compliance question asking 
whether the employer sponsoring the plan paid administrative expenses 
that were not reported as service provider compensation on Schedule C 
or a plan administrative expense on Schedule H. Where the only 
compensation received by a service provider in connection with a plan 
is direct payment from the plan sponsor, the information is not 
required to be reported on Schedule C. To minimize burden, while still 
providing a clearer picture on the Form 5500 Annual Return/Report of 
all service providers to plans, regardless of who pays those service 
providers, the Agencies are proposing only to ask whether the plan has 
any such service providers rather than require identification and other 
Schedule C information for such service providers. The Agencies are 
requesting comments on whether there should be a minimum threshold 
compensation amount for this question and, if so, what the amount 
should be.
    The proposal also would add a question asking whether the plan 
sponsor or its affiliates provided any services to the plan in exchange 
for direct or indirect compensation. This information would help the 
Agencies obtain a complete picture of the relationship between the plan 
and the plan sponsor, including the extent to which the sponsor may 
also be acting as a fiduciary or service provider. An affirmative 
answer may indicate potential conflicts of interest and would be useful 
for DOL enforcement.
    Another proposed compliance question would require filers to 
indicate whether the plan had any leveraged investment acquisitions, 
the total amount of those acquisitions, and the ratio of the leveraged 
investments to total plan assets. In addition to helping ensure that 
the plan administrator has a complete picture of the potential risk and 
reward associated with the plan's assets, these questions would improve 
the Agencies' understanding of plan operations. Plans with a high ratio 
of leveraged investments, such as options, futures, and margin-type 
investments, may be at greater risk. By identifying these plans, the 
Agencies would be better able to target and track performance of high-
risk plans. This question would only be added to the Schedule H, and 
not the Form 5500-SF. Leveraged investments are not ``eligible plan 
assets'' for purposes of the Form 5500-SF. Small plans that have such 
investments must file the Form 5500.

[[Page 47563]]

    In the existing section regarding the IQPA report, filers would be 
required to indicate whether the accountant orally or in writing 
communicated various governance issues discovered during the audit, 
including errors or irregularities, illegal acts, material internal 
control weaknesses, and the existence of plan qualification issues. 
This question is intended to enhance compliance by highlighting the 
existing duty of the plan administrator to read and review the audit 
report and, if necessary, to engage in a discussion with the auditor 
about the report's contents. In addition to helping the plan 
administrator ensure that the audit is comprehensive, the answers to 
these questions would provide participants with information about 
potential problems with the management of plan assets. Also, in 
situations where the plan administrator reports that the auditor has 
identified problems with the audit, the Agencies would have an 
opportunity to conduct a closer review of the plan's finances.
    In addition to the existing question asking whether the IQPA has 
relied on the limited scope audit provisions in 29 CFR 2520.103-8, the 
proposal would require filers to attach the certification of investment 
information created by certain banks or insurance companies to ensure 
the plan is qualified to be subject to a limited scope audit. This 
change would also encourage plan administrators to maintain 
documentation consistent with the limited scope audit requirements. The 
change is being made in conjunction with revisions to the DOL's 
regulation at 29 CFR 2520.103-8 to set forth specific requirements for 
the attachment, including the requirement that the certification appear 
on a separate document from the list of plan assets covered by the 
certification, which list generally would be required to be reported on 
the Schedule H, Line 4i Schedules of Assets, using the structured data 
entry format through EFAST.
    The required attachment of the proposed, updated certification 
would also make the Agencies' review of limited scope audits more 
robust by enabling them to follow up on plans that use the limited 
scope exemption but fail to attach the necessary certification. See 
DOL-OIG: Changes Are Still Needed in the ERISA Audit Process to 
Increase Protections for Employee Benefit Plan Participants at 17 (EBSA 
should improve the quality of its audit documentation reviews by adding 
procedures to ensure that ``all plan assets are either certified by a 
qualifying financial institution or tested by the IQPA''). Obtaining 
the certification would also allow EBSA to better determine which of 
the plan's assets are subject to a limited scope audit and which 
require a full IQPA report. Id. at 4 (``EBSA's review guide did not 
specifically address audits in which the plan custodian certified some, 
but not all, plan assets in limited scope audits.'')
    The Agencies also propose standardizing information reported on 
Schedule H, Line 4a, to foster filers' compliance with regulations and 
guidance governing delinquent participant contributions and loan 
repayments. Under the proposed changes, filers would complete a 
standardized, structured attachment that includes information about 
whether the correction of the delinquency was made within or outside of 
the Voluntary Fiduciary Correction Program (VFCP) and Prohibited 
Transaction Exemption 2002-51. As under the current requirements, 
filers must continue to report the deficiency until correction is made. 
The proposed changes also facilitate accurate reporting by requiring 
the delinquent contribution information to be included in supplemental 
schedules. Including such information in supplemental schedules would 
help ensure that IQPAs address delinquent contributions and loan 
repayments in their audit reports, consistent with generally accepted 
auditing standards.
    The proposal also includes new questions on Schedule G (Financial 
Transaction Schedules). To gather additional information about the 
plan's transactions and relationships, especially nonexempt prohibited 
transactions, the Agencies propose asking for more detailed information 
about the nature of nonexempt prohibited transactions engaged in by the 
plan. In addition to the current requirement to provide the name and 
contact information for the parties involved with the nonexempt 
transaction, and their relationship to the plan, employer, employee 
organization, plan sponsor, or other party-in-interest, the proposal 
asks filers to check a box indicating the nature of the nonexempt 
transaction. The check boxes generally follow the prohibitions of ERISA 
section 406 and Code section 4975 and include, for example, sale of any 
property to/from the plan, exchange of any property, lease of any 
property to/from the plan, lending of money to/from the plan, other 
extension of credit to/from the plan, furnishing of goods to/from the 
plan, etc. The proposal also asks a new question about whether the 
transaction is discrete or ongoing and whether the transaction has been 
fully corrected, either through or outside of the VFCP. The proposal 
also asks for the date the transaction was fully corrected, a 
description of the corrective action and whether, if a nonexempt 
transaction occurred with respect to a disqualified person, and the 
person was notified, a Form 5330 was filed with the IRS to pay the 
excise tax on the transaction.
    The proposal would add new line items on Schedule A for reporting 
whether any premium payments were overdue and, if so, the amount 
delinquent, and whether there was a policy or contract reported on the 
Schedule that was issued by an insurance company wholly owned by the 
plan or the plan sponsor. An affirmative answer to questions on 
delinquent premium payments and whether the plans holds a contract 
issued by an insurance company that is wholly owned by the plan or plan 
sponsor would alert DOL to potential insurance cancellation and other 
conflict of interest issues.
    The DOL issued new guidance in 2015 regarding economically targeted 
investments (ETIs) made by ERISA-covered retirement plans. ETIs are 
investments that are selected for benefits they create in addition to 
the investment return to the employee benefit plan investor. The DOL 
previously addressed issues relating to ETIs in Interpretive Bulletin 
94-1, 29 CFR 2509.94-1 (IB 94-1) and Interpretive Bulletin 2008-1, 29 
CFR 2509.08-1 (IB 2008-1). IB 94-1 had corrected a misperception that 
investments in ETIs are incompatible with ERISA's fiduciary 
obligations. On October 17, 2008, the department replaced IB 94-1 with 
IB 2008-01. However, the DOL concluded that in the seven years since 
its publication, IB 2008-01 had unduly discouraged fiduciaries from 
considering ETIs and environmental, social and governance (``ESG'') 
factors under appropriate circumstances, and issued Interpretive 
Bulletin 2015-01, 29 CFR 2509.2015-1 (IB-2015-1).
    IB-2015-1 confirmed the DOL's longstanding view from IB 94-1 that 
fiduciaries may not accept lower expected returns or take on greater 
risks in order to secure collateral benefits, but may take such 
benefits into account as ``tiebreakers'' when investments are otherwise 
equal with respect to their economic and financial characteristics. IB-
2015-1 also acknowledges that ESG factors may have a direct 
relationship to the economic and financial value of an investment. When 
they do, these factors are more than just tiebreakers, but rather are 
proper components of the fiduciary's analysis of the economic and 
financial merits of competing investment choices.

[[Page 47564]]

Changes in the financial markets, particularly improved metrics and 
tools allowing for better analyses of investments, are enabling plan 
fiduciaries to make better and more evidence-based decisions on ETIs 
and ESG factors in evaluating the merits of competing investment 
choices. Some private sector sources are developing structured ESG 
research data for evaluating corporate performance. The DOL is 
interested in public comments, including analysis on costs and 
benefits, on whether collecting information related to ETI and ESG 
investment activities of ERISA-covered plans on the Form 5500, such as 
whether plans incorporate ESG factors into their investment analysis, 
would add value to this growing data source and allow ERISA fiduciaries 
to more easily consider the role ESG factors could or should play in 
their investment decisions. The DOL requests comments regarding the 
best way to use the Form 5500 to collect information with respect to 
ESG investment activities that is standardized, comparable, and 
reliable For example, public companies are already subject to 
requirements to disclose material risks, including relevant risks 
associated with climate change, per Securities and Exchange Commission 
Interpretation: Commission Guidance Regarding Disclosure Related to 
Climate Change [Release Nos. 33-9106; 34-61469; FR-82]. The DOL 
specifically requests comments on whether we could use the SEC 
disclosure requirements for public companies as a basis for a Form 5500 
information collection.
3. Schedules MB and SB--New Questions and Identifying Information for 
Attachments
    The Agencies are proposing to add new questions to the actuarial 
schedules (Schedules MB and SB) to enhance compliance. On the Schedule 
SB, reporting of the target normal cost would be revised to separate 
out the plan-related expenses. By requiring this breakdown, the 
Agencies and other users of Schedule SB data such as firms conducting 
actuarial research would be able to more accurately project liabilities 
and future required contributions.
    The Agencies also propose to add a new question to the Schedule SB 
to require single-employer plans with 500 or more participants as of 
the valuation date to report projections of expected benefit payments 
to be paid for the entire plan (not including expected expenses) for 
each of the next ten plan years starting with the plan year to which 
the filing relates. For this purpose the plan would assume that there 
were no additional accruals, experience (e.g., termination, mortality, 
and retirement) consistent with the plan's valuation assumptions, and 
that no new entrants would be covered by the plan. The requirement 
would not be applicable to plans with fewer than 500 participants as of 
the valuation date. This information would enable the Agencies to 
determine how much of a plan's assets are needed to pay benefits to 
participants. This information would also help in assessing the 
adequacy of current assets and contributions to satisfy the disclosed 
benefit commitments. In March 2015, PBGC asked OMB to approve, and in 
June 2015, OMB approved adding a similar question for the 2015 Schedule 
MB, to be reported on a PDF attachment. The Agencies are now proposing 
that the question be added to the Schedule MB itself.
4. Form 5500 and Form 5500-SF PBGC Compliance Questions
    For 2016, PBGC is proposing to add a question to the existing 
question on Schedules H and I, Line 5c, that asks, if a plan is a 
defined benefit plan, whether it is covered by the PBGC insurance 
program. The new question would ask filers that checked the box ``Yes'' 
to enter the My PAA generated confirmation number for the PBGC premium 
filing for this plan year. In this proposal, PBGC is proposing moving 
the questions to the Form 5500 and Form 5500-SF. In comparing Form 5500 
Annual Return/Report data to PBGC premium filing data, the agency has 
found PBGC-covered plans for which no premiums have been paid and 
filers incorrectly claiming that they have PBGC-covered plans. By 
requiring reporting of the My PAA generated confirmation number on the 
Form 5500 and Form 5500-SF, PBGC will be better able to match Form 5500 
Annual Return/Report filings to PBGC premium filings, bring in new 
premium filings, as well as improve the data collected on the Forms. 
Also, for the 21st Century initiative changes, the Agencies are 
proposing to move Line 5c on Schedule H and I to Line 9a(4) of the Form 
5500 and Line 12a(4) of the Form 5500-SF. The new question described 
above about PBGC premium filings would be added to these lines.

F. Miscellaneous Technical and Conforming Changes for Forms and 
Instructions

    Various other technical and conforming changes to the forms, 
schedules, and instructions are being proposed as part of the 
substantial restructuring of the Form 5500 Annual Return/Report 
described in this notice. Several of the more significant of these 
changes are as follows.
    On both the Form 5500 and the Form 5500-SF, filers that check the 
``single-employer plan'' box in accordance with the instructions, but 
which have multiple employers obligated to contribute to the plan that 
are members of a controlled group, would be required to file an 
attachment identifying the participating employers. This requirement 
would be similar to the requirement, effective with the 2014 annual 
return/report forms, to attach a list of participating employers with a 
good faith percentage of the contributions to the plan of each 
participating employer, for plans that file as ``multiple-employer'' 
plans. To implement ERISA section 103(g) resulting from the Cooperative 
and Small Employer Charity Pension Flexibility Act (CSEC Act), Public 
Law 113-97, 128 Stat. 1101 (April 7, 2014), the DOL published an 
interim final rule in November 2014, 79 FR 66617 (Nov. 10, 2014). The 
DOL intends that the CSEC Act reporting changes will be made final 
effective with the implementation of final forms revisions following 
this proposal. Under the CSEC Act interim final rule, filers that check 
the ``multiple-employer plan'' box are required to provide a list of 
participating employers and a good faith estimate of the percentage of 
total contributions made by each participating employer during the plan 
year. The DOL received four comments on the interim final rule and six 
additional comments on an emergency PRA submission published 
separately.
    A central concern of the commenters is that the list of 
participating employers is essentially the client list developed by 
entities that sponsor multiple-employer plans for professional employer 
organizations (PEOs) or other associations. The commenters asserted 
that the publication of the participating employer information could 
negatively affect their business model by enabling competitors to 
target client employers. These commenters suggested that the DOL could 
not implement the CSEC Act law change by asking for the required 
information to be reported on the Form 5500 because the list of 
employers is proprietary information. Certain commenters suggested, in 
the alternative, that if the information was required to be reported, 
it should not be publicly disclosed. One commenter suggested that the 
DOL should not apply the requirement to defined contribution or welfare 
plans because the CSEC legislation focused on ERISA

[[Page 47565]]

minimum funding requirements which do not apply to the majority of 
defined contribution pension plans or to any group health and welfare 
plans. That commenter suggested that the DOL could instead obtain the 
participating employer information through the use of its subpoena 
authority or could limit the requirement by providing an alternate 
method of compliance. The commenter also suggested allowing plans that 
are multiple employer welfare arrangements (MEWAs) that fund benefits 
through VEBAs to satisfy the employer list requirement by submitting 
the VEBA information and either removing the contribution requirement 
entirely or clarifying that the filers need only include gross 
contribution information rather than break out the information by 
employers and employees.\42\
---------------------------------------------------------------------------

    \42\ The DOL notes that the CSEC Act reporting requirements only 
apply to multiple-employer plans and thus the requirement only 
applies to those MEWAs that are in fact plans. Individual plans 
participating in a non-plan MEWA must file their own Form 5500 
Annual Return/Report unless otherwise exempt.
---------------------------------------------------------------------------

    The DOL has considered these comments but has decided not to make 
changes to the multiple-employer plan reporting requirements described 
in the interim final rule. The CSEC Act makes provision of 
participating employer information a reporting requirement under 
section 103 of ERISA. Section 104(a)(1) of ERISA provides generally 
that the contents of the annual report must be open for public 
inspection. The DOL continues to believe that the reporting 
requirements made effective for the 2014 form year by the interim final 
rule are a reasonable and appropriate way to implement Congress's 
directive in the CSEC Act.
    Furthermore, the Agencies believe that this information is 
important for plan oversight, research, and enforcement purposes. 
Because participating employers generally are not otherwise identified 
on the Form 5500 or its schedules,\43\ the Agencies have no other 
information on the number or identity of participating employers in 
multiple-employer plans. The Agencies also believe that similar 
information would be helpful for participating members of a plan that 
covers members of a controlled group that files under the reporting 
rules as a ``single-employer'' plan. Accordingly, under the proposal, a 
new check box would be added for a plan to identify that it covers 
members of a controlled group. Plans checking that box would be 
required to provide the same basic identifying and contribution 
information as are multiple-employer plans under the CSEC Act changes.
---------------------------------------------------------------------------

    \43\ In a requirement added under the PPA, filers are required 
to provide certain information on Schedule R, for each employer that 
contributed more than 5% of total contributions to a multiemployer 
defined benefit pension plan during the plan year (measured in 
dollars).
---------------------------------------------------------------------------

    The Form 5500, as proposed, would ask filers to identify and 
provide contact information for the ``named fiduciary'' under ERISA 
section 3(21). The Agencies note that as for any other address and 
identifying information required on the annual return/report, named 
fiduciary addresses and phone numbers (and those of the employer and 
plan administrator) should be the actual addresses and phone numbers 
for those entities/individuals and not the address of a service 
provider or entity that is completing the filing. This has been an area 
of inaccurate data entry as the entity that fills out the form has not 
always entered correct data in correct boxes. As a result, the data is 
misleading for participants and beneficiaries and for the Agencies.
    New breakout questions would be added to both the Form 5500 and the 
Form 5500-SF, for defined contribution pension plans to report the 
number of participants with account balances as of the beginning of the 
plan year; the number of participants that made contributions during 
the plan year; and the number of participants that terminated 
employment during the plan year that had their entire account balance 
distributed.
    The following new information would also be required to be reported 
on the Form 5500 or Form 5500-SF in the questions that are intended to 
replace the current plan characteristics code structure:
    1. The current requirement for defined benefit pension plans to 
identify whether the filing is for a frozen plan would be extended to 
defined contribution pension plans.
    2. Defined contribution pension plans would now be required to 
identify whether the plan is a SIMPLE 401(k) plan under Code sections 
401(k)(11) and 401(m)(10).
    3. Defined contribution pension plans would now be required to 
identify whether the plan has a designated Roth feature.
    4. Defined contribution pension plans that have participant-
directed brokerage accounts would now be required to enter the number 
of participants using such accounts during the plan year.
    5. Defined contribution pension plans would have to indicate 
whether the plan has an intended qualified default investment 
alternative(s) (QDIA) and, if so, to indicate the type(s) of 
alternative(s).
    6. Pension plans would be required to report if the plan is an 
eligible combined plan under Code section 414(x).
    7. Pension plans would be required to report if a rollover from a 
plan was used to start up the business sponsoring the plan (a Rollovers 
as Business Start-Ups or ROBS transaction).
    8. Pension plans would be required to report if the plan is 
electing church plan status under Code Section 410(d).
    9. Defined contributions pension plans would be required to 
indicate whether they provide financial education and/or financial 
advice for participants.
    10. Plans would be required to report if the plan provides long 
term care insurance.
    11. On the Form 5500, plans that provide group health benefits 
would have to indicate, more specifically, whether they provide 
medical/surgical benefits, pharmacy or prescription drug benefits, 
mental health/substance use disorder benefits, wellness program, 
preventive care services, emergency services, and pregnancy benefits.
    The signature section on the Form 5500 would be revised to add a 
checkbox to indicate whether the plan is a Taft-Hartley plan and to 
provide a dedicated signature area for both a ``management'' and a 
``labor'' trustee.
    In addition to the changes described above, the Schedule A and its 
instructions would be clarified to specify that the plan is required to 
report the insurance carrier's NAIC ``Company Code,'' when reporting 
the ``NAIC number.'' Plans that provide group health benefits through 
an insurance contract would also be required to provide the insurance 
carrier's required health plan identification number (HPID) under the 
Health Insurance Portability and Accountability Act of 1996 (HIPAA). 
Schedule J would require filers to provide the NAIC Producer Code if 
there is a stop loss policy associated with the plan's obligation to 
pay health benefits. The Agencies invite comment on whether a 
particular NAIC type number or other identifying number, as well as the 
HPID, would be best to produce the most consistent and accurate 
identifier of insurance companies required to be identified on the Form 
5500 Annual Return/Report.
    On new Line 2 of the Schedule A, plans would be required to report 
if the policy or contract was issued by an insurance company that is 
wholly owned by the plan or the plan sponsor.
    The current questions and instructions on Schedule A for persons 
covered under an insurance contract

[[Page 47566]]

that reported on Schedule A would be clarified and expanded. The 
instructions are clarified to make explicit that the existing 
requirement to report the approximate number of persons includes 
participants, beneficiaries, and dependents covered under the contract. 
For welfare benefit contracts, the question has also been 
particularized to require the approximate number of persons covered for 
each type of benefit.
    To improve the data, there would be new checkboxes on the Schedule 
A to enable filers to indicate whether the contract covered accidental 
death and disability (AD&D) or long term care insurance. The existing 
element on the Schedule A to identify that plan assets are in insurance 
company ``pooled separate accounts'' would be broken into ``pooled 
separate accounts'' and ``other'' separate accounts. If ``other,'' 
filers would be required to enter a description of the separate 
account. Plans that provide life insurance would be required to 
indicate, on Schedule A, whether a life insurance contract is ``term 
life'' or ``other.'' If the life insurance contract is other than 
``term life,'' the filer would continue to have to enter a description.
    The Schedule C instructions with regard to exceptions for reporting 
employees whose compensation is less than $25,000 would be clarified to 
provide that, for Schedule C purposes, compensation does not include 
the employer portion of FICA and FUTA taxes as part of the total 
compensation of an employee. It does, however, include salary, bonuses, 
overtime, and all indirect compensation from persons other than the 
plan received in connection with the person's position with the plan or 
services provided to the plan. As discussed above, the instructions 
would be modified to specify that expenses for travel, education, 
conferences, meals, etc., whether paid directly by the plan or 
reimbursed to the employee, have to be included in determining total 
compensation of plan employees, but only if such payments would be 
reportable as taxable income to the employee.
    As with similar clarifying changes to Schedule C and the Schedule 
H, Line 4i Schedules of Assets, plans would now be required to report 
on Schedule A the relationship to the plan, employer, employee 
organization, sponsor, fiduciary, or other party-in-interest of the 
agent, broker, or other person to whom commissions or fees were paid.
    When reporting on Schedule A that an insurance company failed to 
provide the information needed to complete the annual return/report, if 
it is ``fee and commission'' information that is not provided, then 
filers would only need to check a box to so indicate. Filers would 
continue to have a place to describe other types of information.
    In addition to the changes described above to the Schedule H, 
filers would be required to report, in the existing section on the IQPA 
report on the Schedule H, the state in which the IQPA report was 
issued.
    The existing questions for Form 5500 Annual Return/Report filers to 
indicate plan funding and benefit arrangements would be added to the 
Form 5500-SF.
    In response to the concerns of certain practitioners regarding 
their ability to comply with filing requirements where PBGC has 
trusteed a plan and there is no longer a plan administrator to complete 
the filing or the ability to pay a service provider for the work 
necessary to fulfill the filing obligation, the Agencies are proposing 
to simplify the final filing requirements for plans trusteed by PBGC 
that have 500 or fewer participants.
    Specifically, the question on whether the plan has come under the 
trusteeship of the PBGC would be moved from current plan characteristic 
code 1H on the Form 5500 and part of Line 4k on the Schedule H and Line 
13b on the Form 5500-SF to a checkbox on Part I of the Form 5500. Form 
5500 Annual Return/Report filers that, as of the date the return/report 
is filed but not later than the due date of the return/report with 
automatic extension, have been trusteed by PBGC under section 4041(c) 
or 4042 of ERISA, would be required to check that box and enter the 
date of PBGC trusteeship in the space provided. Plans with 500 or fewer 
participants (see Part II, Line 6, asking for participant count) that 
check this box would be required to complete all of Part I and Lines 1, 
2, 3, 6, 9a(3) and 9a(4) of Part II; this would be the last Form 5500 
Annual Return/Report they would need to file. Form 5500 Annual Return/
Report filers with plans with more than 500 participants (in Part II, 
Line 6) would be required to complete the Form 5500 in the same manner 
as they have in the past and would need to file a Form 5500 for a 
following short plan year (depending on when the plan was trusteed).
    Similarly, Form 5500-SF filers with plans that, as of the date the 
return/report is filed but not later than the due date of the return/
report with automatic extension, have been trusteed by PBGC under 
section 4041(c) or 4042 of ERISA, would be required to check a box in 
Part 1A and enter the date of PBGC trusteeship in the space provided. 
Plans that check this box would be required to complete all of Part I 
and Lines 1, 2, 3, 5 (if applicable), 6, 9a(3) and 9a(4) of Part II.
    The proposal to simplify final filing requirements is limited to 
PBGC-trusteed plans with 500 or fewer participants for a number of 
reasons. PBGC generally needs the information contained in the final 
annual return/report to calculate its claims for underfunding and 
unpaid minimum funding contributions, to prepare its financial 
statements, and to value participant benefits. Larger plans tend to 
have more complex asset structures and include hard-to-value assets, 
while smaller plans are more likely to lack the resources needed to 
meet their actuarial and filing obligations for the final plan year and 
final short plan year. It has been primarily representatives of small 
plans that have contacted PBGC and DOL to request relief from filing 
requirements for PBGC-trusteed plans.
    In PBGC's experience, larger plans usually comply with the filing 
requirement for the final plan year and the final short plan year. The 
companies that maintain these larger plans typically build the cost of 
plan administration into their balance sheets, even if the plan is 
terminated in an involuntary or distress termination. Moreover, in 
PBGC's experience, for most larger plans, the cost of filing the annual 
return/report is paid from plan assets. Even when paid by the plan 
sponsor, PBGC believes that the cost of filing for a larger plan is a 
relatively insignificant component of the sponsor's overall business 
expenses.
    PBGC also believes that exempting larger plans from completing 
certain schedules or sections of the annual return/report would not 
result in a meaningful cost savings to the plan sponsor and could 
result in the inability to compile important information in the event 
that the plan is terminated. An involuntary or distress termination 
involves a complex actuarial and economic analysis by PBGC that may 
continue for a year or more and does not always result in termination. 
The process of preparing the annual return/report continues through and 
beyond the plan year. PBGC believes that limiting the reporting 
obligations for larger plans anticipating termination might cause a 
plan to stop the ongoing process that culminates with the filing, even 
though a termination is not ultimately approved. This would 
significantly impair PBGC's actuarial and financial analysis for the 
ongoing plan.
    The Agencies also propose to accept the electronic-signature by the 
plan

[[Page 47567]]

actuary on the Schedules MB and SB, and the electronic-signature by the 
plan trustee for trust information on the Form 5500-SF and Schedule H. 
The plan actuary or plan trustee can access the EFAST2 Web site at 
www.efast.dol.gov to register for electronic credentials to sign or 
submit filings. If a plan actuary or a plan trustee chooses not to sign 
electronically, then the actuary or trustee must sign the schedule or 
Form, and an electronic reproduction must be attached to the Form 5500 
or Form 5500-SF. This electronic reproduction must be labeled ``Trustee 
Signature'' for trust information on the Schedule H or Form 5500-SF, 
and ``Actuary Signature'' for the plan actuary on the Schedule MB or 
SB, and must be included as a Portable Document Format (PDF) attachment 
or any alternative electronic attachment allowable under EFAST2, if it 
is not electronically signed.

G. Electronic Filing of Certain IRS-Only Forms

    The Agencies propose to enable filers to file IRS Forms 5500-EZ and 
5558 through EFAST by creating an electronic version of each of these 
forms. The Agencies believe that the anticipated increase in electronic 
filing resulting from the creation of an electronic version of these 
forms would have various beneficial effects. For example, the 
electronic filing of these forms would benefit the filers and the 
Agencies by reducing errors that are more likely to occur during the 
manual preparation and processing of paper returns and reports. 
Electronic filing also results in faster settling of accounts and 
better customer service. See Private Pensions: Targeted Revisions Could 
Improve Usefulness of Form 5500 Information.
1. Form 5500-EZ
    The Form 5500-EZ, Annual Return of One-Participant (Owners and 
Their Spouse) Retirement Plan, is generally used by one-participant 
plans and certain foreign plans to satisfy their filing requirements 
with the IRS under Code section 6058. The Form 5500-EZ is currently 
filed on paper with the IRS. Although the Form 5500-EZ cannot currently 
be filed electronically, one-participant plans and foreign plans 
(beginning with the 2014 plan year) may elect to electronically file 
the Form 5500-SF using the EFAST2 system instead of filing the paper 
Form 5500-EZ with the IRS. One-participant plans and foreign plans that 
file the Form 5500-SF rather than file the Form 5500-EZ are required to 
complete only certain lines on the Form 5500-SF. These lines are the 
same as, or are similar to, lines on the Form 5500-EZ. Accordingly, 
one-participant plans and foreign plans filing the Form 5500-SF are 
required to answer only those questions they would have been required 
to answer if they had filed the Form 5500-EZ. The IRS's electronic 
filing mandate regulation described above applies to filers of the Form 
5500-EZ as well as to filers of Form 5500 and Form 5500-SF. One-
participant plans and foreign plans that file at least 250 returns 
during the applicable calendar year generally are therefore now 
required to file the Form 5500-SF electronically using the EFAST2 
system beginning with the 2015 plan year. See T.D. 9695, 79 FR 58256 
(Sept. 29, 2014).
    The IRS proposes to provide an electronic version of the Form 5500-
EZ to be filed on the EFAST2 system. This electronic version would be 
in addition to the paper version. Accordingly, except to the extent 
they are subject to the electronic filing mandate, one-participant 
plans and foreign plans subject to the filing requirements of the Code 
would be able to elect to file either the paper version of the Form 
5500-EZ with the IRS or file the electronic version through EFAST2. 
These filers would no longer be allowed to file the Form 5500-SF. One-
participant plans and foreign plans that are required by 26 CFR 
301.6058-2 to file electronically would be required to file the 
electronic version of the Form 5500-EZ.
    Currently, less than 15 percent of one-participant plans file the 
electronic Form 5500-SF instead of the paper Form 5500-EZ. The IRS 
believes that creating an electronic version of the Form 5500-EZ to 
replace the Form 5500-SF for one-participant and foreign plans would 
encourage these filers to file electronically because they would no 
longer need to deal with the longer Form 5500-SF and its instructions. 
The IRS further believes that filers would be more likely to file an 
electronic Form 5500-EZ instead of a Form 5500-SF because, unlike when 
filing the Form 5500-SF, they would not need to make a separate 
determination as to which questions to answer. As with any Form 5500-SF 
currently filed by a one-participant plan for purposes of the Code, the 
information filed on the electronic version of the Form 5500-EZ on the 
EFAST2 system will not be published by the DOL on the Internet.
2. Form 5558
    Filers may currently obtain a one-time extension of time to file a 
Form 5500 Annual Return/Report and a Form 8955-SSA, by filing IRS paper 
Form 5558, Application for Extension of Time To File Certain Employee 
Plan Returns, on or before the normal due date of the return/report. 
The IRS proposes to create an electronic version of the Form 5558 to be 
processed through EFAST2, which would enable filers to use the same 
system to request an extension that they use to file Form 5500 Annual 
Return/Report. The electronic filing of this form would benefit the 
filers and the Agencies by reducing errors that are more likely to 
occur during the manual preparation and processing of paper returns and 
reports. Electronic filing also results in faster settling of accounts 
and better customer service. Under this proposal, the paper Form 5558 
would continue to be filed with the IRS by those filers who wish to 
file the Form 5558 on paper.
    The Form 5558 is also currently used for extensions of time to file 
Form 5330, Return of Excise Taxes Related to Employee Benefit Plans. It 
is anticipated that the extension of time to file Form 5330 could not 
be filed electronically using EFAST. The Form 5330 is used to report 
various violations of the Code related to retirement plans and requires 
a payment of excise taxes to the IRS. The instructions to the Form 5558 
state that any tax due to be paid under the Form 5330 must be paid with 
the Form 5558 and that interest is charged on taxes not paid by the due 
date even if an extension of time to file is granted. Accordingly, the 
IRS proposes to create a new paper form for extensions of time to file 
the Form 5330. It is anticipated that this new extension form would 
have provisions similar to those in the Form 5558 to the extent they 
apply to the Form 5330.

H. Regulations Relating to the Proposed Form

    As noted above, certain amendments to the annual reporting 
regulations are necessary to accommodate some of the proposed revisions 
to the forms. The DOL is publishing separately today in the Federal 
Register proposed amendments to the DOL's annual reporting regulations. 
That document includes a discussion of the findings required under 
sections 104 and 110 of ERISA that are necessary for the DOL to adopt 
the Form 5500 Annual Return/Report, including the Form 5500-SF, if 
revised as proposed herein, as an alternative method of compliance, 
limited exemption, and/or simplified report under the reporting and 
disclosure requirements of Part 1 of Subtitle B of Title I of ERISA.

I. Paperwork Reduction Act Statement

    As part of continuing efforts to reduce paperwork and respondent 
burden, the

[[Page 47568]]

general public and Federal agencies are invited to comment on proposed 
and/or continuing collections of information in accordance with the 
Paperwork Reduction Act of 1995 (PRA) (44 U.S.C. 3506(c)(2)(A)). This 
helps to ensure that requested data will be provided in the desired 
format, reporting burden (time and financial resources) will be 
minimized, collection instruments will be clearly understood, and the 
impact of collection requirements on respondents is properly assessed. 
Currently, the DOL is soliciting comments concerning the proposed 
revision of the Form 5500 Annual Return/Report, which is an information 
collection request subject to the PRA. A copy of the ICR may be 
obtained by contacting the person listed in the PRA Addressee section 
below.
    The DOL has submitted a copy of the proposed forms revisions to the 
Office of Management and Budget (OMB) in accordance with 44 U.S.C. 
3507(d) for its review of the DOL's information collection. The IRS and 
the PBGC intend to submit separate requests for OMB review and approval 
based upon the final forms revisions. The DOL and OMB are particularly 
interested in comments that:
     Evaluate whether the proposed collection of information is 
necessary for the proper performance of the functions of the Agencies, 
including whether the information will have practical utility;
     Evaluate the accuracy of the estimate of the burden of the 
proposed collection of information, including the validity of the 
methodology and assumptions used;
     Enhance the quality, utility, and clarity of the 
information to be collected; and
     Minimize the burden of the collection of information on 
those who are to respond, including through the use of appropriate 
automated, electronic, mechanical, or other technological collection 
techniques or other forms of information technology, e.g., permitting 
electronic submission of responses.
    Written comments must be submitted to the office shown in the PRA 
Addressee within 75 days of publication of the Notice of Proposed Forms 
Revision to ensure their consideration.
    PRA Addressee: Address requests for copies of the ICR to G. 
Christopher Cosby, Office of Policy and Research, U.S. Department of 
Labor, Employee Benefits Security Administration, 200 Constitution 
Avenue NW., Room N-5718, Washington, DC 20210. Telephone: (202) 693-
8410; Fax: (202) 219-4745; Email: [email protected]. These are not toll-
free numbers. ICRs submitted to OMB also are available at http://www.RegInfo.gov.
    Type of Review: Revision of a currently approved collection.
    Agencies: Employee Benefits Security Administration (OMB Control 
No. 1210-0110); Internal Revenue Service (OMB Control No. 1545-1610); 
Pension Benefit Guaranty Corporation (OMB Control No. 1212-0057).
    Title: Form 5500 Series.
    Affected Public: Individuals or households; Business or other for-
profit; Not-for-profit institutions.
    Form Number: DOL/IRS/PBGC Form 5500 and Schedules.
    Total Respondents: The total number of annual Form 5500 filers will 
be approximately 2.97 million.
    Total Responses: See ``Total Respondents'' Above.
    Frequency of Response: Annually.
    Estimated Total Burden Hours: 1.52 million.
    Estimated Time per Response, Estimated Burden Hours, Total Annual 
Burden: See below for each Agency.
    Total Annualized Costs: $667.7 million.
    The Agencies' burden estimation methodology excludes certain 
activities from the calculation of ``burden.'' If the activity is 
performed for any reason other than compliance with the applicable 
federal tax administration system or the Title I annual reporting 
requirements, it was not counted as part of the paperwork burden. For 
example, most businesses or financial entities maintain, in the 
ordinary course of business, detailed accounts of assets and 
liabilities, and income and expenses for the purposes of operating the 
business or entity. These recordkeeping activities were not included in 
the calculation of burden because prudent business or financial 
entities normally have that information available for reasons other 
than federal tax or Title I annual reporting. Only time for gathering 
and processing information associated with the tax return/annual 
reporting systems, and learning about the law, was included. In 
addition, an activity is counted as a burden only once if performed for 
both tax and Title I purposes. The Agencies also have designed the 
instruction package for the Form 5500 Annual Return/Report so that 
filers generally will be able to complete the Form 5500 Annual Return/
Report by reading the instructions without needing to refer to the 
statutes or regulations. The Agencies, therefore, have included in 
their PRA calculations a burden for reading the instructions and find 
there is no recordkeeping burden attributable to the Form 5500 Annual 
Return/Report.
    The DOL solicits comments regarding whether or not any 
recordkeeping beyond that which is usual and customary is necessary to 
complete the Form 5500 Annual Return/Report. Comments are also 
solicited on whether the Form 5500 Annual Return/Report instructions 
are generally sufficient to enable filers to complete the Form 5500 
Annual Return/Report without needing to refer to the statutes or 
regulations.

J. Paperwork and Respondent Burden

    Estimated time needed to complete the forms listed below reflects 
the combined requirements of the IRS, the DOL, and the PBGC. The times 
will vary depending on individual circumstances. The estimated average 
times are:

----------------------------------------------------------------------------------------------------------------
                                                                 Pension plans
                              ----------------------------------------------------------------------------------
                                                           Small, ineligible for 5500- Small, eligible for 5500-
                                          Large                        SF                          SF
----------------------------------------------------------------------------------------------------------------
Form 5500....................  1 hr, 52 min..............  1 hr, 20 min..............
Schedule A...................  2 hr, 55 min..............  2 hr, 55 min..............
Schedule MB..................  8 hr, 27 min..............  7 hr, 28 min..............  7 hr, 28 min.
Schedule SB..................  6 hr, 38 min..............  6 hr, 49 min..............  6 hr, 49 min.
Schedule C...................  3 hr, 28 min..............  3 hr, 20 min..............
Schedule E...................  3 hr, 18 min..............  3 hr, 18 min..............
Schedule G...................  13 hr, 51 min.............
Schedule H...................  11 hr, 50 min.............  8 hr, 12 min..............
Schedule R...................  1 hr, 54 min..............  1 hr, 6 min...............
Form 5500-SF.................  ..........................  ..........................  2 hr, 54 min.
----------------------------------------------------------------------------------------------------------------


[[Page 47569]]


----------------------------------------------------------------------------------------------------------------
                                                     Welfare plans that include health benefits
                                  ------------------------------------------------------------------------------
                                                                  Small, unfunded,
                                                               combination  unfunded/
                                             Large            fully insured, or funded    Small, fully-insured
                                                                    with a trust
----------------------------------------------------------------------------------------------------------------
Form 5500........................  1 hr, 46 min.............  1 hr, 15 min............
Schedule A.......................  3 hr, 42 min.............  2 hr, 45 min............
Schedule C.......................  4 hr, 25 min.............  4 hr, 25 min............
Schedule G.......................  11 hr, 4 min.............
Schedule H.......................  12 hr, 46 min............  8 hr, 41 min............
Schedule J.......................  3 hr, 30 min.............  3 hr, 30 min............
Subset of Form 5500 and Schedule   .........................  ........................  20 min.
 J.
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
                                                 Welfare plans that do not include health benefits
                                  ------------------------------------------------------------------------------
                                                                Small, ineligible for   Small, eligible for 5500-
                                             Large                     5500-SF                     SF
----------------------------------------------------------------------------------------------------------------
Form 5500........................  1 hr, 46 min.............  1 hr, 15 min............
Schedule A.......................  3 hr, 42 min.............  2 hr, 45 min............
Schedule C.......................  4 hr, 25 min.............  4 hr, 25 min............
Schedule G.......................  11 hr, 4 min.............
Schedule H.......................  12 hr, 46 min............  8 hr, 41 min............
Form 5500-SF.....................  .........................  ........................  2 hr, 54 min.
----------------------------------------------------------------------------------------------------------------


--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                    Direct filing entities
                                    --------------------------------------------------------------------------------------------------------------------
                                          Master trusts               CCTs                    PSAs                103-12 IEs                GIAs
--------------------------------------------------------------------------------------------------------------------------------------------------------
Form 5500..........................  1 hr, 51 min..........  1 hr, 31 min..........  1 hr, 25 min.........  1 hr, 42 min.........  1 hr, 29 min.
Schedule A.........................  2 hr, 56 min..........  2 hr, 50 min..........  2 hr, 49 min.........  2 hr, 53 min.........  3 hr, 6 min.
Schedule C.........................  3 hr, 43 min..........  1 hr, 18 min..........  41 min...............  2 hr, 41 min.........  1 hr, 52 min.
Schedule D.........................  45 min................  24 min................  17 min...............  33 min...............  29 min.
Schedule G.........................  12 hr, 46 min.........  ......................  .....................  9 hr, 20 min.........
Schedule H.........................  12 hr, 19 min.........  11 hr, 47 min.........  11 hr, 43 min........  12 hr, 16 min........  12 hr, 1 min.
--------------------------------------------------------------------------------------------------------------------------------------------------------

    The aggregate hour burden for the Form 5500 Annual Return/Report 
(including schedules and short form) is estimated to be 1.52 million 
hours annually. The hour burden reflects filing activities carried out 
directly by filers. The cost burden is estimated to be $667.7 million 
annually. The cost burden reflects filing services purchased by filers. 
Presented below is a chart showing the total hour and cost burden of 
the revised Form 5500 Annual Return/Report separately allocated across 
the DOL and the IRS. There is no separate PBGC entry on the chart 
because, as explained below, its share of the paperwork burden is very 
small relative to that of the IRS and the DOL.

--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                      Pension plans         Welfare plans                  Total
                Agency                                           -----------------------------------------------------------------------------   Total
                                                                    Large      Small      Large      Small      Large      Small       DFEs
--------------------------------------------------------------------------------------------------------------------------------------------------------
DOL...................................  Hours 000s..............        323        251        133        294        457        545         32      1,034
                                        $MM.....................      $80.4     $103.6     $118.2     $181.4     $198.6     $285.0       $6.4     $490.0
IRS...................................  Hours 000s..............        196        222         12         35        208        257         18        484
                                        $MM.....................      $42.9     $111.3       $2.1      $16.9      $45.0     $128.2       $2.9     $176.1
--------------------------------------------------------------------------------------------------------------------------------------------------------

    The paperwork burden allocated to the PBGC includes a portion of 
the general instructions, basic plan identification information, a 
portion of Schedule MB, a portion of Schedule SB, a portion of Schedule 
H, and a portion of Schedule R. The PBGC's Estimated Share of Total 
Form 5500 Annual Return/Report Burden is: 1,300 Hours and $1.6 million 
per year.

APPENDIX A

1. Form 5500--Annual Return/Report of Employee Benefit Plan
2. Form 5500-SF--Annual Return Report of Small Employee Benefit Plan
3. Schedule A--Insurance Information
4. Schedule C--Service Provider Information
5. Schedule D--DFE/Participating Plan Information
6. Schedule E--ESOP Information
7. Schedule G--Financial Transaction Schedules
8. Schedule H--Financial Information
9. Schedule H, Line 4a Schedule of Delinquent Participant 
Contributions
10. Schedule H, Line 4i(1) Schedule of Assets Held for Investment at 
End of Year
11. Schedule H, Line 4i(2) Schedule of Assets Disposed of During the 
Plan Year
12. Schedule H, Line 4j Schedule of Reportable Transactions
13. Schedule J--Group Health Plan Information
14. Schedule MB--Multiemployer Defined Benefit Pension Plan 
Actuarial Information and Certain Money Purchase Plan Information
15. Schedule R--Retirement Plan Information
16. Schedule SB--Single Employer Defined Benefit Pension Plan 
Actuarial Information

Form 5500 (Annual Return/Report of Employee Benefit Plan)

Part I Annual Report Identification Information [Same As Current Part I 
Except As Indicated]

    For calendar plan year 20XX or fiscal plan year beginning DD/MM/
20XX and ending DD/MM/20XX+1


[[Page 47570]]


    A [Current A, Except as indicated in boxes (3) and (5)] This 
return/report is for (check the correct box; for DFE's check the DFE 
type):

    (1) [ballot] a single-employer plan
    (2) [ballot] a multiple-employer plan (not multiemployer) 
(Filers checking this box must attach a list of participating 
employer information in accordance with the form instructions)
    (3) [ballot] [New] a plan for a controlled group of 
corporations, a group of trades or businesses under common control, 
or an affiliated service group (see instructions) (Filers checking 
this box must attach a list of controlled group member information 
in accordance with the form instructions)
    (4) [ballot] a multiemployer plan
    (5) [ballot] [Puts DFE checkboxes on face of Form 5500 instead 
of entering ``Codes'' From Instructions] a direct filing entity 
(DFE). Check DFE type (see instructions):

[ballot] Master Trust
[ballot] CCT
[ballot] PSA
[ballot] 103-12 IE
[ballot] GIA

    B [Current, Except Adds Box (5)] This return/report is (check as 
applicable) (see instructions):

    (1) [ballot] the first return/report
    (2) [ballot] an amended return/report
    (3) [ballot] the final return/report
    (4) [ballot] a short plan year return/report (less than 12 
months)
    (5) [ballot] [Current PCC 1H and part of current Schedule H, 
Line 4k for PBGC-trusteed plans revised to include date of 
trusteeship] a plan trusteed by PBGC.

    Filers checking this box, enter date of trusteeship. (Filers 
checking box B(5) for plans that have 500 or fewer participants at 
the beginning of the plan year need to complete only certain line 
items on the Form 5500). (See instructions)
    C [Current] If the plan is a collectively-bargained plan, check 
here [ballot]
    D [Current] Check applicable box if filing under an extension or 
through the DFVC Program:

    (1) [ballot] Form 5558
    (2) [ballot] automatic extension
    (3) [ballot] special extension (enter description)
    (4) [ballot] the DFVC program

Part II Basic Plan Information Enter all requested information. (You 
must use the same plan/DFE name, PN, and EIN as in the previous year's 
annual return/report, except as provided in Line 5.)

    1a [Current] Name of Plan
    1b [Current] Three-digit plan number (PN)
    1c [Current] Effective date of plan
    2a [Current] Plan sponsor's name (employer, if for a single-
employer plan) and address; include room or suite number, city or 
town, state or province, country, and ZIP or foreign postal code (if 
foreign, see instructions)
    2b(1) [Current] Plan sponsor's Employer Identification Number 
(EIN)
    (2) [New] Plan sponsor's legal entity identifier (LEI) if 
available (see instructions)
    2c [Current] Sponsor's telephone number
    2d [Current] Business code (see instructions)
    3a [Current] Plan administrator's name and address
    [Current] [ballot] Check if same as Plan Sponsor Name [ballot] 
Check if same as Plan Sponsor Address
    3b [Current] Administrator's EIN
    3c [Current] Administrator's telephone number
    4a [New] Named Fiduciary's name and address (see instructions).
[ballot] Check if same as Plan Sponsor Name
[ballot] Check if same as Plan Sponsor Address
    4b [New] Named Fiduciary's EIN
    4c [New] Named Fiduciary's telephone number
    5 [Current Line 4, except as indicated] If the name, EIN or LEI 
of the plan sponsor has changed since the last return/report filed 
for this plan, enter the name, EIN, LEI, and the plan number from 
the last return/report:
    5a Sponsor's Name
    5b(1) EIN
    (2) [new] LEI if available
    5c Plan Number
    6 [Current Line 5] Total number of participants at the beginning 
of the plan year
    7 [Current Line 6, Except 7g(1), (3), and (4) now added] Number 
of participants (welfare plans complete only Lines 7a(1), 7(a)(2), 
7b, 7c, 7d, and 7g(3)).
    7a(1) Total number of active participants at the beginning of 
the plan year
    (2) Total number of active participants as of the end of the 
plan year
    7b Retired or separated participants receiving benefits as of 
the end of the plan year
    7c Other retired or separated participants entitled to future 
benefits as of the end of the plan year
    7d Subtotal. Add Lines 7a(2), 7b, and 7c.
    7e Deceased participants whose beneficiaries are receiving or 
are entitled to receive benefits as of the end of the plan year
    7f Total. Add Lines 7d and 7e
    7g If you are filing for defined contribution pension plan, you 
must complete Line 7g(1)-(4). Welfare plans complete only Line 
7g(3). Defined benefit pension plans skip to Line 7h.
    (1) [New] Number of participants with account balances as of the 
beginning of the plan year
    (2) [Current Line 6g] Number of participants with account 
balances as of the end of the plan year
    (3) [New] Number of participants that made contributions during 
the plan year
    (4) [New] Number of participants that terminated employment 
during the plan year that had their entire account balance 
distributed as of the end of the plan year
    7h Number of participants that terminated employment during the 
plan year with accrued benefits that were less than 100% vested:
    8 [Current Line 7] Enter the total number of employers obligated 
to contribute to the plan (only multiemployer plans complete this 
item)
    9a [Current Line 8 Plan Characteristics Codes Entered In A List 
From Instructions Now Separate Questions on Face of Form] Check the 
appropriate box to indicate the type of plan. If the plan provides 
pension benefits, answer the applicable 9a questions below. See the 
instructions for additional details. (Plans that provide only 
welfare benefits check the box for ``Welfare plan'' and then skip to 
question 9b.)

[ballot] [New] Defined benefit pension plan
[ballot] [New] Defined contribution pension plan
[ballot] [New] Welfare plan

    9a(1) Check the appropriate box(es) to indicate how the benefits 
are calculated (Defined benefit pension plans only)

[ballot] [Current PCC 1A] Benefits are primarily pay related
[ballot] [Current PCC 1B] Benefits are primarily flat dollar 
(includes dollars per year of service)
[ballot] [Current PCC 1C] Cash balance plan
[ballot] [Current PCC 1C] Pension equity plan (PEP)
[ballot] [Current PCC 1C] Other hybrid plan
[ballot] [Current PCC 1D] Floor-offset plan

    9a(2) Does your plan have any of the Internal Revenue Code 
arrangements listed below? (Defined benefit pension plans only).

Yes [ballot] No [ballot]

    If ``Yes'', check all that apply.
    [Current PCC 1E] [ballot] Code Section 401(h) arrangement
    [Current PCC 1F] [ballot] Code Section 414(k) arrangement
    9a(3) [Current PCC 1H] Is this a defined benefit pension plan 
that was terminated and closed out for PBGC purposes? (See 
instructions.)

Yes [ballot] No [ballot]

    9a(4) [Current Schedule H, Line 5c, revised to add a new 
sentence at the end on PBGC premium filings. For 2016, PBGC proposed 
that the new sentence be added to Line 5c of the Schedule H] If the 
plan is a defined benefit pension plan, is it covered under the PBGC 
insurance program (see ERISA section 4021)?

[ballot] Yes [ballot] No [ballot] Not determined

    If ``Yes'' is checked, enter the My PAA confirmation number from 
the PBGC premium filing for this plan year. (See instructions.)
    9a(5) [Current PCC 1I] Is this a frozen pension benefit plan? 
(Both defined benefit and defined contribution pension plans must 
answer this question.)

[ballot] Yes [ballot] No

    9a(6) [Current PCC 1D and 2D; new requirement to enter name of 
other plan or arrangement] Are plan benefits subject to offset for 
retirement benefits provided in another plan or arrangement of the 
employer?

[ballot] Yes [ballot] No

    If ``Yes'' enter name, EIN, and LEI of the sponsor and PN of the 
other plan or arrangement

    9a(7) If this is a defined contribution pension plan, indicate 
the type(s) of plan (check all that apply):

[ballot] [Current PCC 2E] Profit-sharing plan
[ballot] [Current PCC 2I] Stock bonus plan
[ballot] [Current PCC 2C] Money purchase plan
[ballot] [Current PCC 2B] Target benefit plan
[ballot] [Current PCC 2D] Offset plan

    9a(8) If this is a defined contribution pension plan, check the 
appropriate box(es) to indicate the type(s) of arrangements under

[[Page 47571]]

which the plan operates for purposes of the Code (check all that 
apply):
[ballot] [Current PCC 2J] Code section 401(k) arrangement
[ballot] [Current PCC 2K] Code section 401(m) arrangement
[ballot] [New] SIMPLE 401(k) plan under Code sections 401(k)(11) and 
401(m)(10)
[ballot] [New] Safe harbor 401(k) plan under Code sections 
401(k)(12) and 401(m)(11)
[ballot] [New] Safe harbor 401(k) plan using automatic contribution 
arrangements under Code sections 401(k)(13) and 401(m)(12)
[ballot] [Current PCC 2N] Code section 408 accounts or annuities
[ballot] [Current PCC 2L] Code section 403(b)(1) arrangement
[ballot] [Current PCC 2M] Code section 403(b)(7) arrangement

    9a(9) If this is a defined contribution pension plan, check all 
the appropriate box(es) to indicate all type(s) of features your 
plan has.

[ballot] [Current PCC 2S] Automatic Enrollment
[ballot] [New] Designated ROTH
[ballot] [Current PCC 2A] Age/service weighted or new comparability 
or similar plan
[ballot] [New] Financial education for participants
[ballot] [New] Financial advice for participants
[ballot] [New] Other (specify)

    9a(10) Is this a participant-directed defined contribution 
pension plan? [ballot] Yes [ballot] No

    If ``Yes,'' check all that apply:

[ballot] [Current PCC 2F] ERISA section 404(c) plan
[ballot] [Current PCC 2G] Total participant-directed account plan
[ballot] [Current PCC 2H] Partial participant-directed account plan
[ballot] [Current PCC 2R] Participant-directed brokerage accounts.

    If you check this box, enter the number of participants using 
the participant-directed brokerage account(s)

    9a(11) [Current PCC 2T; new breakouts to indicate types of 
default accounts] Does the plan have default investment alternatives 
that are intended to be qualified default investment alternatives 
(QDIA) (see instructions) for participants who fail to direct assets 
in their account?

[ballot] Yes [ballot] No

    If ``Yes,'' check all applicable boxes to indicate type(s) of 
QDIA.

[ballot] Target date/life cycle fund
[ballot] Fixed income
[ballot] Money market or equivalent (under 29 CFR 2550.404c-5(e))
[ballot] Balanced fund
[ballot] Professionally managed account
[ballot] Other (specify)

    9a(12) [New] Is this an Eligible Combined Plan under Code 
section 414(x)?

[ballot] Yes [ballot] No

    9a(13) [New] Check this box if a rollover from a plan (including 
an individual retirement plan) was used to start up the business 
(ROBS) sponsoring this plan: [ballot]
    9a(14) If this is a profit sharing or money purchase plan 
combined with an ESOP, or a plan requiring that all or part of 
employer contributions be invested and held, at least for a limited 
period, in employer securities check all that apply. (You must 
attach a Schedule E if the plan is an ESOP or has ESOP features).

[ballot] [Current PCC 2P] Leveraged ESOP
[ballot] [Current PCC 2O] ESOP other than a leveraged ESOP
[ballot] [Current PCC 2Q] ESOP of an S corporation
[ballot] [Current PCC 3I] Other plan requiring that all or part of 
employer contributions be invested and held, at least for a limited 
period, in employer securities

    9a(15) Other Pension Benefit Features (Check all that apply):

[ballot] [Current PCC 3D; 2016 Schedule R Line 17a] IRS Pre-approved 
plan.

    If you check this box enter:

    (1) most recent adoption date
    (2) the IRS opinion or advisory letter's serial number.

[ballot] [Current PCC 3B] Plan covering self-employed individuals
[ballot] [Current PCC 3C] Plan not intended to be qualified under 
Internal Revenue Code
[ballot] [Current PCC 3D-breakout] Master and prototype (M&P) plan
[ballot] [Current PCC 3D-breakout] Volume submitter plan
[ballot] [New] Plan sponsor(s) received services of leased employees
[ballot] [Current PCC 3J] U.S.-based plan that covers residents of 
Puerto Rico and is qualified under both Code section 401 and section 
1165 of Puerto Rico Code
[ballot] [New] Electing church plan under Code Section 410(d).

    9b [Current Line 8b; now multiple questions instead of plan 
characteristic codes entered in a list from instructions; PCC 4T, 
and 4U eliminated] If the plan provides welfare benefits, complete 
Lines 9b(1)-9b(4). Plans that do not provide any welfare benefits 
skip to question 10.
    9b(1) [Modification and expansion of current PCC 4A, 4D, 4E] 
Does the plan provide health, dental, or vision coverage?

[ballot] Yes [ballot] No

    If ``Yes,'' check all that apply:

[ballot] [New Breakout of current PCC 4A] medical/surgical benefits
[ballot] [New Breakout of current PCC 4A] pharmacy or prescription 
drug benefits
[ballot] [New Breakout of current PCC 4A] mental health/substance 
use disorder benefits
[ballot] [New Breakout of current PCC 4A] wellness program
[ballot] [New Breakout of current PCC 4A] preventive care services
[ballot] [New Breakout of current PCC 4A] emergency services
[ballot] [New Breakout of current PCC 4A] pregnancy benefits
[ballot] [Current PCC 4E] vision
[ballot] [Current PCC 4D] dental

    9b(2) Does the plan provide disability benefits?

[ballot] Yes [ballot] No

    If ``Yes,'' check all that apply.

[ballot] [Current PCC 4F] Temporary disability (accident and 
sickness)
[ballot] [Current PCC 4H] Long-term disability

    9b(3) Does the plan provide welfare benefits other than health, 
dental, vision, or disability?

[ballot] Yes [ballot] No

    If ``Yes,'' check all that apply.

[ballot] [Current PCC 4B] Life insurance
[ballot] [Current PCC 4L] Death benefits (include travel accident 
but not life insurance)
[ballot] [New] Long term care insurance
[ballot] [Current PCC 4J] Apprenticeship and training
[ballot] [Current PCC 4C] Supplemental unemployment
[ballot] [Current PCC 4K] Scholarship (funded)
[ballot] [Current PCC 4G] Prepaid legal
[ballot] [Current PCC 4I] Severance pay
[ballot] [Current PCC 4P] Taft-Hartley Financial Assistance for 
Employee Housing Expenses
[ballot] [Current PCC 4Q] Other (Enter description.)

    9b(4) If the plan is a welfare plan that does not provide health 
benefits, check the appropriate box to indicate whether the plan 
will stop or stopped filing in an earlier year in reliance on 29 CFR 
2520.104-20. (If the plan provided group health benefits, it is not 
eligible for the limited exemption in 29 CFR 2520.104-20 and must 
file a Form 5500 Annual Return/Report in accordance with the 
instructions annually, regardless of plan size.)

[ballot] [Current PCC 4R] Unfunded, fully insured, or combination 
unfunded/fully insured welfare plan that does not provide health 
benefits that will not file an annual report for next plan year 
pursuant to 29 CFR 2520.104-20. (Plans that check this box should 
not check ``final return/report'' in Part I, Box B.)
[ballot] [Current PCC 4S] Unfunded, fully insured, or combination 
unfunded/fully insured welfare plan that does not provide health 
benefits that stopped filing annual reports in an earlier plan year 
pursuant to 29 CFR 2520.104-20. (Plans that check this box should 
not check ``first return/report'' in Part I, Box B.)

    10a [Current Line 9a] Plan funding arrangement (Check all that 
apply.)
    (1) [ballot] Insurance
    (2) [ballot] Code section 412(e)(3) insurance contracts
    (3) [ballot] Trust
    (4) [ballot] General assets of the sponsor
    10b [Current Line 9b] Plan benefit arrangement (Check all that 
apply.)
    (1) [ballot] Insurance
    (2) [ballot] Code section 412(e)(3) insurance contracts
    (3) [ballot] Trust
    (4) [ballot] General assets of the sponsor
    11 [Current Line 10, Except check box added for Schedule E and 
Schedule J and Eliminated For Schedule I] Check all applicable boxes 
in 11a and 11b to indicate which schedules are attached, and, where 
indicated, enter the number attached. (See instructions).
    11a Pension Schedules
    (1) [ballot] Schedule R (Retirement Plan Information)
    (2) [ballot] Schedule E (Employee Stock Ownership Plan 
Information)
    (3) [ballot] Schedule MB (Multiemployer Defined Benefit Plan and 
Certain Money

[[Page 47572]]

Purchase Plan Actuarial Information)--signed by the plan actuary
    (4) [ballot] Schedule SB (Single-Employer Defined Benefit Plan 
Actuarial Information)--signed by the plan actuary
    11b General Schedules
    (1) [ballot] Schedule H (Financial Information)
    (2) [ballot] Schedule A (Insurance Information) Enter number of 
Schedules A attached (See instructions.)
    (3) [ballot] Schedule C (Service Provider Information) Enter 
number of Schedules C attached (See instructions.)
    (4) [ballot] Schedule D (DFE/Participating Plan Information)
    (5) [ballot] Schedule G (Financial Transaction Schedules)
    (6) [ballot] Schedule J (Group Health Plan Information)

[Current Part III Form M-1 information moved to Schedule J]

    [JURAT and SIGNATURE BLOCK to appear on first page, as with 
current form]

    CAUTION: A penalty for the late or incomplete filing of this 
return/report will be assessed unless reasonable cause is 
established.
    Under penalties of perjury and other penalties set forth in the 
instructions, I declare that I have examined this return/report, 
including accompanying schedules, statements and attachments, as 
well as the electronic version of this return/report, and to the 
best of my knowledge and belief, it is true, correct, and complete.

    SIGN HERE Signature of plan administrator
    Enter Date:
    Enter name of individual signing as plan administrator

    SIGN HERE Signature of employer/plan sponsor
    [ballot] [New] Check here if two signatures for Taft-Hartley 
plan
    (1) Management trustee signature (2) Labor trustee signature
    Enter Date:
    Enter name(s) of individual(s) signing as employer or plan 
sponsor

    SIGN HERE Signature of DFE
    Enter Date:
    Enter name of individual signing as DFE
    Preparer's name (including firm name, if applicable) and 
address; include room or suite number.
    Preparer's telephone number
    Line A(2) Schedule

    Complete as many entries as needed to report the required 
information for all participating employers.

------------------------------------------------------------------------
 
------------------------------------------------------------------------
Multiple-Employer Plan Participating Employer Information
(Heading for this chart must include Name of Plan, and EIN/PN as shown
 on the Form 5500)
------------------------------------------------------------------------
(a) Name of participating       (b) EIN..........  (c) Percent of Total
 employer.                                          Contributions.
(a) Name of participating       (b) EIN..........  (c) Percent of Total
 employer.                                          Contributions.
------------------------------------------------------------------------

    Line A(3) Schedule

    Complete as many entries as needed to report the required 
information for all participating employers.

------------------------------------------------------------------------
 
------------------------------------------------------------------------
Controlled Group Plan Member Information
(Heading for this chart must include Name of Plan, and EIN/PN as shown
 on the Form 5500). Complete elements (a), (b), and (c) to provide the
 name, EIN, and percent of total contributions of each controlled group
 member.)
------------------------------------------------------------------------
(a) Name of controlled group    (b) EIN..........  (c) Percent of Total
 member.                                            Contributions.
(a) Name of controlled group    (b) EIN..........  (c) Percent of Total
 member.                                            Contributions.
------------------------------------------------------------------------

Form 5500-SF (Short Form Annual Return/Report of Small Employee Benefit 
Plan)

Part I Annual Report Identification Information [Same As Current Part 
I, Except New Box A(3)]

    For calendar plan year 20XX or fiscal plan year beginning DD/MM/
20XX and ending DD/MM/20XX+1

    A [Current except as shown] This return/report is for:

    (1) [ballot] a single-employer plan
    (2) [ballot] a multiple-employer plan (not multiemployer) 
(Filers checking this box must attach a list of participating 
employer information in accordance with the form instructions)
    (3) [ballot] [New] a plan of a controlled group of corporations, 
group of trades or businesses under common control, or an affiliated 
service group (see instructions) (Filers checking this box must 
attach a list of controlled group member information in accordance 
with the form instructions)
    (4) [ballot] a one-participant plan
    (5) [ballot] foreign plan

    B [Current] This return/report is (check as applicable) (see 
instructions):

    (1) [ballot] the first return/report
    (2) [ballot] the final return/report
    (3) [ballot] an amended return/report
    (4) [ballot] a short plan year return/report (less than 12 
months)
    (5) [ballot] [Part of current Line 13b for PBGC-trusteed plans 
revised to include date of trusteeship] A plan trusteed by PBGC. 
Filers checking this box, enter the date of trusteeship __/__/__.

    (If you checked box B(5), you only need to complete only certain 
line items. (See Instructions.)
    C [Current] Check the applicable box if filing under an 
extension or through the DFVC Program:

    (1) [ballot] Form 5558
    (2) [ballot] automatic extension
    (3) [ballot] special extension (enter description)
    (4) [ballot] DFVC program

Part II Basic Plan Information--Enter all requested information [Same 
As Current Part II (Lines 1-6), except as shown] (You must use the same 
plan name, PN, and EIN as in the previous year's annual return/report, 
except as provided in Line 5.)

    1a Name of Plan
    1b Three-digit plan number (PN)
    1c Effective date of plan
    2a [Current except as shown] Plan sponsor's name (employer, if 
for a single-employer plan) and address; include room or suite 
number, city or town, state or province, country, and ZIP or foreign 
postal code (if foreign, see instructions)
    2b(1) Plan sponsor's Employer Identification Number (EIN)
    (2) [New] Plan sponsor's legal entity identifier (LEI) if 
available (see instructions)
    2c Sponsor's telephone number
    2d Business code (see instructions)
    3 [Current except as shown] Plan administrator's name and 
address

[ballot] Check if same as Plan Sponsor Name
[ballot] Check if same as Plan Sponsor Address

    3a Plan Administrator's Name and address
    3b Administrator's EIN
    3c Administrator's telephone number
    4a [New] Named Fiduciary's name and address (see instructions).
    [ballot] Check if same as Plan Sponsor Name
    [ballot] Check if same as Plan Sponsor Address
    4b [New] Named Fiduciary's EIN
    4c [New] Named Fiduciary's telephone number
    5 [Current Line 4 except to add LEI] If the name, EIN, or LEI of 
the plan sponsor has changed since the last return/report filed for 
this plan, enter the name, EIN, LEI, and the plan number from the 
last return/report:
    5a Sponsor's Name
    5b(1) EIN
    (2) [New] LEI (if available)
    5c Plan Number
    6 [Current Line 5] Total number of participants at the beginning 
of the plan year

[[Page 47573]]

    7 [Current Line 6] Number of participants (welfare plans 
complete only Lines 7a(1), 7a(2), 7b, 7c, and 7d).
    7a(1) [Current Line 5d(1)] Total number of active participants 
at the beginning of the plan year
    (2) [Current Line 5d(2)] Total number of active participants as 
of the end of the plan year
    7b [New] Retired or separated participants receiving benefits as 
of the end of the plan year
    7c [New] Other retired or separated participants entitled to 
future benefits as of the end of the plan year
    7d [New] Subtotal. Add Lines 7a(2), 7b, and 7c
    7e [New] Deceased participants whose beneficiaries are receiving 
or are entitled to receive benefits as of the end of the plan year
    7f [New] Total. Add Lines 7d and 7e
    7g If you are filing for defined contribution pension plan, you 
must complete Line 7g(1)-(4). Welfare plans complete only Line 
7g(3). Defined benefit pension plans skip to Line 7h.
    (1) [New] Number of participants with account balances as of the 
beginning of the plan year
    (2) [Current Line 5c] Number of participants with account 
balances as of the end of the plan year
    (3) [New] Number of participants that made contributions during 
the plan year
    (4) [New] Number of participants that terminated employment 
during the plan year that had their entire account balance 
distributed as of the end of the plan year
    7h [Current Line 5e] Number of participants that terminated 
employment during the plan year with accrued benefits that were less 
than 100% vested

Part III--Form 5500-SF Eligibility Information [New ``Part'' title for 
existing eligibility questions]

    8a [Current Line 6a] Were all of the plan's assets during the 
plan year invested in eligible assets? (See instructions.)
[ballot] Yes [ballot] No
    8b [Current Line 6b] Are you claiming a waiver of the annual 
examination and report of an independent qualified public accountant 
(IQPA) under 29 CFR 2520.104-46? (See instructions on waiver 
eligibility and conditions.)
[ballot] Yes [ballot] No
    8c [New] Did the plan provide group health benefits?
[ballot] Yes [ballot] No

    If you answered ``No'' to Line 8a or 8b, or ``Yes'' to Line 8c, 
the plan cannot use Form 5500-SF and must instead file the Form 5500 
and any required Schedules and attachments.

Part IV--Financial Information [Current Part III, with new breakouts]

    9 [Current Line 7] Plan Assets and Liabilities [Columns for (a) 
Beginning of Year (BOY) and (b) End of Year (EOY) Values for 9a-9d]
    9a [Current Line 7a] Total plan assets
    9b [Current Line 7b] Total plan liabilities
    9c [Current Line 7c] Net plan assets (subtract Line 9b from Line 
9a)
    10 [Current Line 8] Income, Expenses, and Transfers for this 
Plan Year
    10a [Current Line 8a] Contributions
    (1) Received or receivable in cash from:
    (A) [Current Line 8a(1)] Employers
    (B) [Current Line 8a(2)] Participants
    (2) [Current Line 8a(3)] Others (including rollovers from IRAs/
other plans)
    10b [Current Line 8b] Other income (loss)
    10c [Current Line 8c] Total income (add Lines 10a(1)(A) and (B), 
10a(2), 10b and 10c)
    10d [Current Line 8d] Benefits paid (including direct rollovers 
and insurance premiums to provide benefits)
    10e [Current Line 8e] Certain deemed and/or corrective 
distributions (see instructions)
    10f [Current Line 8f] Administrative service providers 
(salaries, fees, commissions)
    10g [Current Line 8g] Other expenses
    10h [Current Line 8h] Total expenses (add Lines 10e, 10f, 10g, 
and 10h)
    10i [Current Line 8i] Net income (loss) (subtract Line 10h from 
Line 10d)
    10j [Current Line 8j] Transfers to (from) the plan (see 
instructions)
    11 [New] Specific Assets [Columns for (a) Beginning of Year 
(BOY) and (b) End of Year (EOY) Values] [New]
    11a Cash/cash equivalents
    11b [New] Securities, except employer securities, traded on a 
public exchange
    (1) Stock
    (2) Bonds
    (3) Other
    11c [New breakout] Government securities issued by the United 
States or a State
    11d [New] Interests in registered investment companies (Mutual 
funds, Unit Investment Trusts, Closed End Funds)
    11e [New] Interests in insurance company pooled separate 
accounts (PSAs)
    11f [New] Interests in insurance investment and annuity 
contracts (other than PSAs)
    11g [New] Interests in bank common collective trusts (CCTs)
    11h [New] Interests in bank investment contracts (other than 
CCTs)
    11i [New] Participant loans

Part V--Plan Characteristics Information [Current Part IV]

    12a [Current Line 8a; Now multiple questions instead of Plan 
Characteristic Codes (PCC) entered in a list from Instructions] 
Check the appropriate box to indicate the type of plan. If the plan 
provides pension benefits, answer the applicable 12a questions 
below; see the instructions for additional details. (Plans that 
provide only welfare benefits check the box for ``Welfare Plan'' and 
then skip to question 12b.)
[ballot] Defined benefit pension plan
[ballot] Defined contribution pension plan
[ballot] Welfare plan
    12a(1) Check the appropriate box(es) to indicate how the 
benefits are calculated (Defined benefit pension plans only.)
[ballot] [Current PCC 1A] Benefits are primarily pay related
[ballot] [Current PCC 1B] Benefits are primarily flat dollar 
(includes dollars per year of service)
[ballot] [Current PCC 1C breakout] Cash balance plan
[ballot] [Current PCC 1C breakout] Pension equity plan (PEP)
[ballot] [Current PCC 1C breakout] Other hybrid plan
[ballot] [Current PCC 1D] Floor-offset plan
    12a(2) Does your plan have any of the Internal Revenue Code 
arrangements listed below? Check all that apply. Defined benefit 
pension plans only)
[ballot] [Current PCC 1F] Code Section 414(k) arrangement
    12a(3) [Current PCC 1H] Is this a defined benefit pension plan 
that was terminated and closed out for PBGC purposes (see 
instructions)?
[ballot] Yes [ballot] No
    12a(4) [Current Line 6c, revised to add a new sentence at the 
end on PBGC premium filings. For 2016, PBGC proposed that the new 
sentence be added to Line 5c of the Schedule H] If the plan is a 
defined benefit pension plan, is it covered under the PBGC insurance 
program (see ERISA section 4021)?
[ballot] Yes [ballot] No [ballot] Not determined

    If ``Yes'' is checked, enter the My PAA confirmation number from 
the PBGC premium filing for this plan year. (See instructions)

    12a(5) [Current PCC 1I expanded to include DC as well as DB 
pension plans] Is this a frozen pension benefit plan? (Both defined 
benefit and defined contribution pension plans must answer this 
question.)
[ballot] Yes [ballot] No
    12a(6) [Current PCC 1D and 2D; new requirement to provide 
identifying information about sponsor of other plan or arrangement] 
Are plan benefits subject to offset for retirement benefits provided 
in another plan or arrangement of the employer?
[ballot] Yes [ballot] No

    If ``Yes,'' enter name, EIN, and LEI of sponsor and PN of other 
plan or arrangement

    12a(7) If this is a defined contribution pension plan, indicate 
the type(s) of plan (check all that apply):
[ballot] [Current PCC 2E] Profit-sharing plan
[ballot] [Current PCC 2I] Stock bonus plan
[ballot] [Current PCC 2C] Money purchase plan
[ballot] [Current PCC 2B] Target benefit plan
[ballot] [Current PCC 2D] Offset plan
    12a(8) If this is a defined contribution pension plan, check the 
appropriate box(es) to indicate the type(s) of arrangements under 
which the plan operates for purposes of the Code (check all that 
apply):
[ballot] [Current PCC 2J] Code section 401(k) arrangement
[ballot] [Current PCC 2K] Code section 401(m) arrangement
[ballot] [New] SIMPLE 401(k) plan under Code sections 401(k)(11) and 
401(m)(10)
[ballot] [New] Safe harbor 401(k) plan under Code sections 
401(k)(12) and 401(m)(11)
[ballot] [New] Safe harbor 401(k) plan using automatic contribution 
arrangements under Code sections 401(k)(13) and 401(m)(12)
[ballot] [Current PCC 2N] Code section 408 accounts or annuities
[ballot] [Current PCC 2L] Code section 403(b)(1) arrangement
[ballot] [Current PCC 2M] Code section 403(b)(7) arrangement
    12a(9) If this is a defined contribution pension plan, check the 
appropriate box(es)

[[Page 47574]]

to indicate the type(s) of features your plan has:
[ballot] [Current PCC 2S] Automatic Enrollment
[ballot] [New] Designated ROTH
[ballot] [Current PCC 2A] Age/service weighted or new comparability 
or similar plan
[ballot] [New] Financial education for participants
[ballot] [New] Financial advice for participants
[ballot] [New] Other (specify)
    12a(10) If this a participant-directed defined contribution 
pension plan, check all that apply:
[ballot] [Current PCC 2F] ERISA section 404(c) plan
[ballot] [Current PCC 2G] Total participant-directed account plan
[ballot] [Current PCC 2H] Partial participant-directed account plan
[ballot] [Current PCC 2R] Participant-directed brokerage accounts. 
If you check this box, enter the number of participants using the 
participant-directed brokerage account(s)
    12a(11) [New] (A) Does the plan have default investment 
alternatives that are intended to be qualified default investment 
alternatives (QDIA) (see instructions) for participants who fail to 
direct assets in their account?
[ballot] Yes [ballot] No
    (B) If ``Yes,'' indicate type(s) of QDIA (Check all that apply)
[ballot] Target date/life cycle fund
[ballot] Fixed income
[ballot] Money market or equivalent (under 2550.404c-5(e))
[ballot] Balanced/target allocation fund
[ballot] Professionally managed account
[ballot] Other (specify)
    12a(12) [New] Is this an Eligible Combined Plan under Code 
section 414(x)?
[ballot] Yes [ballot] No
    12a(13) [New] Check this box if a rollover from a plan 
(including an individual retirement plan) was used to start up the 
business (ROBS) sponsoring this plan: [ballot]
    12a(14) Other Pension Benefit Features (check all that apply):
[ballot] [Current PCC 3D; 2016 Line 17a] IRS Pre-approved plan. If 
you check this box enter: (1) most recent adoption date and (2) the 
IRS opinion or advisory letter's serial number
[ballot] [Current PCC 3B] Plan covering self-employed individuals
[ballot] [Current PCC 3C] Plan not intended to be qualified under 
Internal Revenue Code
[ballot] [Current PCC 3D-breakout] Master and prototype (M&P) plan
[ballot] [Current PCC 3D-breakout] Volume submitter plan
[ballot] [New] Plan sponsor(s) received services of leased employees
[ballot] [Current PCC 3J] U.S.-based plan that covers residents of 
Puerto Rico and is qualified under both Code section 401 and section 
1165 of Puerto Rico Code
[ballot] [New] Electing church plan under Code Section 410(d)
    12b If the plan provides welfare benefits, complete Lines 
12b(1)-(3). Plans that do not provide any welfare benefits skip to 
question 13.
    12b(1) Does the plan provide disability benefits?
[ballot] Yes [ballot] No

    If ``Yes,'' check all that apply.

[ballot] [Current PCC 4F] Temporary disability (accident and 
sickness)
[ballot] [Current PCC 4H] Long-term disability
    12b(2) Does the plan provide welfare benefits other than 
disability?
[ballot] Yes [ballot] No

    If ``Yes,'' check all that apply.

[ballot] [Current PCC 4B] Life insurance
[ballot] [Current PCC 4L] Death benefits (include travel accident 
but not life insurance)
[ballot] [New] Long term care insurance
[ballot] [Current PCC 4J] Apprenticeship and training
[ballot] [Current PCC 4C] Supplemental unemployment
[ballot] [Current PCC 4K] Scholarship (funded)
[ballot] [Current PCC 4G] Prepaid legal
[ballot] [Current PCC 4I] Severance pay
[ballot] [Current PCC 4P] Taft-Hartley Financial Assistance for 
Employee Housing Expenses
[ballot] [Current PCC 4Q] Other (Enter description. Caution: If the 
plan provides health benefits, you must file the Form 5500.)
    12b(3) If the plan is a welfare plan that does not provide 
health benefits, check the appropriate box to indicate whether the 
plan will stop or stopped filing in an earlier year in reliance on 
29 CFR 2520.104-20. (If the plan provided group health benefits, it 
is not eligible for the exemption in 29 CFR 2520.104-20 and must 
file a return/report annually, regardless of plan size.)
[ballot] [Current PCC 4R] Unfunded, fully insured, or combination 
unfunded/fully insured welfare plan that will not file an annual 
report for next plan year pursuant to 29 CFR 2520.104-20. (Plans 
that check this box should not check ``final return/report'' in Part 
I, Box B.)
[ballot] [Current PCC 4S] Unfunded, fully insured, or combination 
unfunded/fully insured welfare plan that stopped filing annual 
reports in an earlier plan year pursuant to 29 CFR 2520.104-20. 
(Plans that check this box should not check ``first return/report'' 
in Part I, Box B.)
    13a [New; taken from current Form 5500 Line 9a] Plan funding 
arrangement (check all that apply)
    (1) [ballot] Insurance
    (2) [ballot] Code section 412(e)(3) insurance contracts
    (3) [ballot] Trust
    (4) [ballot] General assets of the sponsor
    13b [New to Form 5500-SF; current Form 5500 Line 9b] Plan 
benefit arrangement (check all that apply)
    (1) [ballot] Insurance
    (2) [ballot] Code section 412(e)(3) insurance contracts
    (3) [ballot] Trust
    (4) [ballot] General assets of the sponsor

Part VI--Plan Operations Compliance Questions [Current Part V]

    During the plan year:

    14a [Current Line 10a revised] Was there a failure to transmit 
to the plan any participant contributions or repayments as of the 
earliest date on which such contributions can reasonably be 
segregated from the employer's general assets as described in 29 CFR 
2510.3-102? Continue to answer ``Yes'' for any prior year failures 
until fully corrected. (See instructions and DOL's Voluntary 
Fiduciary Correction Program.)

[ballot] Yes [ballot] No Amount

    14b [Current Line 10b] Were there any nonexempt prohibited 
transactions with any party-in-interest? (Do not include 
transactions reported on Line 14a.)

[ballot] Yes [ballot] No Amount

    14c [Current Line 10c revised] Was this plan covered by one or 
more fidelity bonds naming the plan as insured that provide coverage 
for losses due to fraud or dishonesty by persons who handle plan 
funds or other property?

[ballot] Yes [ballot] No Amount

    14d [Current Line 10d] Did the plan have a loss, whether or not 
reimbursed by a fidelity bond covering the plan, that was caused by 
fraud or dishonesty?

[ballot] Yes [ballot] No Amount

    14e [Current Line 10e] Were any fees or commissions paid to any 
brokers, agents, or other persons by an insurance carrier, insurance 
service, or other organization that provides some or all of the 
benefits under the plan?

[ballot] Yes [ballot] No Amount

    14f [Current Line 10f] Has the plan failed to provide any 
benefit when due under the plan?

[ballot] Yes [ballot] No Amount

    14g [Current Line 10h] If this is an individual account plan, 
was there a blackout period? (See 29 CFR 2520.101-3.)

[ballot] Yes [ballot] No

    14h [Current Line10i] If 14h was answered ``Yes,'' check the box 
if you either provided the required notice or one of the exceptions 
to providing the notice applied under 29 CFR 2520.101-3:

[ballot] Yes [ballot] No

    14i [New] Is this a participant-directed individual account plan 
(e.g., a 401(k)-type or 403(b) defined contribution pension plan), 
subject to the requirements in 29 CFR 2550.404a-5 to disclose plan 
and investment related information to participants and 
beneficiaries?

[ballot] Yes [ballot] No

    14j [New] If you answered ``Yes'' to Line 14i, did the plan 
provide participants and beneficiaries the plan and investment 
disclosures required under 29 CFR 2550.404a-5?

[ballot] Yes [ballot] No

    If you answered ``Yes,'' you must attach the investment option 
comparative chart or charts that were used to satisfy the disclosure 
requirement in 29 CFR 2550.404a-5(d)(2).

    14k [New] If you answered ``Yes,'' to Line 14i, enter the number 
of designated investment alternatives (DIAs) available under the 
plan and indicate the number of DIAs that are index funds. Also, 
check all that apply to indicate the types of DIAs available under 
the plan:

[ballot] Domestic Stock/Equity
[ballot] Bond/income
[ballot] Balanced/target allocation

[[Page 47575]]

[ballot] Money Market
[ballot] Target date/Lifecycle
[ballot] International/Global Stock/Equity
[ballot] Sector/economy segment
[ballot] Other funds (Describe)

    14l [New] If you answered ``Yes,'' to Line 14j, did the plan 
make available to participants and beneficiaries a designated 
investment manager (DIM)?

[ballot] Yes [ballot] No

    If ``Yes,'' enter name of DIM.

    14m [New] If you answered ``Yes,'' to Line 14j, did the plan 
make available to participants and beneficiaries any brokerage 
window, self-directed brokerage account or similar plan arrangements 
that enabled participants to select investments beyond those 
designated by the plan?

[ballot] Yes [ballot] No

    If you answered ``Yes'' to Line 14m, enter the number of 
participants that utilized the account or arrangement and the total 
amount held in such account(s):

    14n [New] Did the plan trust incur unrelated business taxable 
income (UBTI)?
[ballot] Yes [ballot] No [ballot] NA

    If ``Yes'', enter amount.

    14o [New] Did any employer or employer organization sponsoring 
the plan pay any of the administrative expenses of the plan that 
were not reported on Line 10g?
[ballot] Yes [ballot] No
    14p [New] Did any person who is disqualified under ERISA Section 
411, serve or was permitted to serve the plan in any capacity?
[ballot] Yes [ballot] No
    14q [New] Did the plan sponsor or its affiliates provide any 
services to the plan in exchange for direct or indirect 
compensation?
[ballot] Yes [ballot] No
    14r [New] Have any of the plan's service providers been 
terminated for a material failure to meet the terms of a service 
arrangement or failure to comply with Title I of ERISA, including 
the failure to provide required disclosures under 29 CFR 2550.408b-
2?
[ballot] Yes [ballot] No

    If ``Yes,'' complete elements (1)-(7) to identify the service 
provider.

    (1) Name:
    (2) EIN:
    (3) Enter applicable service code from Line 2c(1) for describe 
services provided to plan:
    (4) Address:
    (5) Telephone:
    (6) Explanation of reason for termination:
    (7) [ballot] Check if termination was due to failure to provide 
required disclosures under 29 CFR 2550.408b-2.
    14s [New (based on 1998 Line 8a)] Is the plan's summary plan 
description (SPD), including any summary descriptions of 
modifications, in compliance with the content requirements in 29 CFR 
2520.102-3? (See instructions.)
[ballot] Yes [ballot] No
    14t [New] If this is an individual account plan, were there any 
checks to participants or beneficiaries that were uncashed as of the 
end of the plan year? [ballot] Yes [ballot] No. If ``Yes,'' complete 
14t(1)-(4)
    (1) Enter number of uncashed checks
    (2) Enter total value of uncashed checks
    (3) Describe the procedures followed by the plan to verify a 
participant's or beneficiary's address before a check was mailed.
    (4) Describe the procedures followed by the plan to monitor 
uncashed checks, including steps to locate ``missing'' participants.

Part VII--Pension Funding Compliance [Current Part VI Renumbered]

    15 [Current Line 11] Is this a defined benefit pension plan 
subject to minimum funding requirements? (If ``Yes,'' see 
instructions and complete Schedule SB (Form 5500) and line 14a 
below)

[ballot] Yes [ballot] No

    15a [Current Line 11a] Enter the unpaid minimum required 
contribution for all years from Schedule SB (Form 5500) Line 44.
    16 [Current Line 12] Is this a defined contribution pension plan 
subject to the minimum funding requirements of section 412 of the 
Code or section 302 of ERISA?


[ballot] Yes [ballot] No. If ``Yes,'' complete Line 15a or Lines 

    15b, 15c, 15d, and 15e below, as applicable.16a 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 letter 
ruling granting the waiver:
    If you completed Line 16a, complete Lines 3, 9, and 10 of 
Schedule MB (Form 5500), and skip to line 20.
    16b Enter the minimum required contribution for this plan year.
    16c Enter the amount contributed by the employer to the plan for 
this plan year:
    16d Subtract the amount in Line 16c from the amount in Line 16b. 
Enter the result (enter a minus sign to the left of a negative 
amount):
    16e Will the minimum funding amount reported on Line 16d be met 
by the funding deadline?

[ballot] Yes [ballot] No [ballot] N/A

Part VIII Plan Termination Information--[Current Part VII Revised and 
Expanded]

    17a [Current Line 13a; Revised to Ask About Any Resolution to 
Terminate] Has a resolution to terminate the plan been adopted in 
any plan year?

[ballot] Yes [ballot] No If ``Yes,'' complete Line 17a(1)-(3) below:

(1) [New] Effective date of plan termination
(2) [New] Year the plan assets were distributed to plan participants 
and beneficiaries
(3) [Current Line 13a] Enter the amount of plan assets that reverted 
to the employer this year:

    17b [Part of current Line 13b with a new subpart to report the 
year.] Were all the plan assets distributed to participants or 
beneficiaries?

[ballot] Yes [ballot] No
    17c [Current Line 13c] Transfer to other plans. If this plan 
transferred assets or liabilities to another plan since the 20XX-1 
filing provide the following information with respect to each plan 
to which the assets or liabilities were transferred. Complete as 
many entries as needed to identify all transfers.

    (1) [Current 13c(2)] EIN
    (2) [Current 13c(3)] PN
    (3) [New] Date of transfer
    (4) [Current 13c(1)] Name of Plan:
    (5) [New] Type of transfer:
[ballot] Merger
[ballot] Consolidation
[ballot] Spinoff
[ballot] Other (Describe)

    (6) [Part of current Line 13b] Were all plan assets transferred 
to another plan?
[ballot] Yes [ballot] No

    17d [New] Transfers from other plans. If another plan 
transferred assets or liabilities to this plan since the 20XX-1 
filing, or in the case of a first plan filing, transferred assets or 
liabilities in conjunction with the creation of this new plan, 
provide the following information with respect to each plan from 
which assets or liabilities were transferred:

    (1) EIN
    (2) PN
    (3) Date of transfer
    (4) Name of Plan:
    (5) Type of transfer: Type of transfer:
[ballot] Merger
[ballot] Consolidation
[ballot] Spinoff
[ballot] Other ([New] Describe)

    17e [New] Terminated Defined Contribution Pension Plans: 
Transfers to Financial Institution. Did this plan, as part of the 
procedures for terminating the plan, transfer plan assets to 
interest bearing federally insured bank accounts in the name of 
missing participants?

[ballot] Yes [ballot] No

    If ``Yes,'' complete elements (1)-(5). List each financial 
institution where plan assets were transferred. You must continue 
reporting this information until the final return/report is filed 
for the plan.

(1) Financial Institution's Name
(2) Financial Institution's EIN
(3) Date of transfer
(4) Number of accounts established
(5) Total amount transferred

Part IX--Trustee Information--[Current Part III But Not Optional; see 
IRS Federal Register Notice ``Proposed Collection; Comment Request for 
the Annual Return/Report of Employee Benefit Plan'']

    18a [Current Line 14a] Name of Trust
    18b [Current Line14b] Trust EIN
    18c [New] Name of Trustee/Custodian Check [ballot] if custodian
    18d [New] Trustee's or custodian's telephone number

    [New--intended to be electronic signature] Date and Signature of 
Trustee/Custodian
    SIGN HERE Signature of plan trustee or custodian:
    Enter Date:
    Enter name of individual signing as trustee or custodian

Part X IRS Compliance Questions [See IRS Federal Register Notice 
``Proposed Collection; Comment Request for the Annual Return/Report of 
Employee Benefit Plan'']

    19a [2016 Line 15a] Is this plan a 401(k) plan?


[[Page 47576]]


[ballot] Yes [ballot] No
    If ``No,'' skip b.
    19b [2016 Line 15b] How did the plan satisfy the 
nondiscrimination requirements for employee deferrals under section 
401(k)(3)? Check all that apply

[ballot] Design-based safe harbor method
[ballot] ``Prior year'' ADP test
[ballot] ``Current year'' ADP test
[ballot] N/A

    20a [2016 Line 16a] What testing method was used to satisfy the 
coverage requirements under section 410(b) for the plan year. Check 
all that apply:

[ballot] Ratio percentage test
[ballot] Average benefit test
[ballot] N/A

    20b [2016 Line 16b] Did the plan satisfy the coverage and 
nondiscrimination requirements of sections 410(b) and 401(a)(4) for 
the plan year by combining this plan with any other plan under the 
permissive aggregation rules?

[ballot] Yes [ballot] No

    21 [New] If this is a defined benefit pension plan, does the 
plan comply with Code section 401(a)(26) participation requirements?

[ballot] Yes [ballot] No

    22a [2016 Line 17b] If the plan is a master and prototype plan 
(M&P) or volume submitter plan that received a favorable IRS opinion 
letter or advisory letter, enter the date of the letter __/__/__ and 
the serial number.
    22b [2016 Line 17d] If the plan is an individually-designed plan 
that received a favorable determination letter from the IRS, enter 
the date of the most recent determination letter _/_/__.
    23a [2016 Line 19] If this is a section 401(k) plan, were 
hardship distributions made during the plan year?

[ballot] Yes [ballot] No

    23b [2016 Line 19] If this is a defined benefit plan or a money 
purchase pension plan, did the plan make any distributions during 
the plan year to employees who have attained age 62 and who were not 
separated from service when the distributions were made? [ballot] 
Yes [ballot] No
    24 [New] Were required minimum distributions made to 5% owners 
who have attained age 70\1/2\ (regardless of whether or not retired) 
as required under section 401(a)(9)(C)?

[ballot] Yes [ballot] No [ballot] N/A

    25 [New] As of the last day of the plan year, has the plan 
ceased to permit contributions and prohibit entry by new 
participants?

[ballot] Yes [ballot] No
    [JURAT and SIGNATURE BLOCK to appear on first page, as with 
current form] CAUTION: A penalty for the late or incomplete filing 
of this return/report will be assessed unless reasonable cause is 
established.
    Under penalties of perjury and other penalties set forth in the 
instructions, I declare that I have examined this return/report, 
including accompanying schedules, statements and attachments, as 
well as the electronic version of this return/report, and to the 
best of my knowledge and belief, it is true, correct, and complete.

SIGN HERE Signature of plan administrator:
Enter Date:
Enter name of individual signing as plan administrator

SIGN HERE Signature of employer/plan sponsor:
Enter Date:
Enter name(s) of individual(s) signing as employer or plan sponsor

[New] Trustee Signature for Purposes of the Code:
SIGN HERE Signature of plan trustee or custodian:
Enter Date:
Enter name of individual signing as trustee or custodian

    Preparer's name (including firm name, if applicable) and 
address; include room or suite number.
Preparer's telephone number

Line A(2) Schedule
    Complete as many entries as needed to report the required 
information for all participating employers.

        Multiple-Employer Plan Participating Employer Information
       [Insert Name of Plan, and EIN/PN as shown on the Form 5500]
------------------------------------------------------------------------
 
------------------------------------------------------------------------
(d) Name of participating         (e) EIN...........  (f) Percent of
 employer.                                             Total
                                                       Contributions.
(d) Name of participating         (e) EIN...........  (f) Percent of
 employer.                                             Total
                                                       Contributions.
------------------------------------------------------------------------

Line A(3) Schedule
    Complete as many entries as needed to report the required 
information for all participating employers.

                Controlled Group Plan Member Information
 [Heading for this chart must include Insert Name of Plan, and EIN/PN as
                         shown on the Form 5500]
   [Complete elements (a), (b), and (c) to provide the name, EIN, and
     percent of total contributions of each controlled group member]
------------------------------------------------------------------------
 
------------------------------------------------------------------------
(d) Name of controlled group      (e) EIN...........  (f) Percent of
 member.                                               Total
                                                       Contributions.
(a) Name of controlled group      (b) EIN...........  (c) Percent of
 member.                                               Total
                                                       Contributions.
------------------------------------------------------------------------

Schedule A--Insurance Information

    [Current Identifying Information] For calendar plan year 20XX or 
fiscal plan year beginning DD/MM/20XX and ending DD/MM/20XX+1

    A Name of Plan
    B Three-digit plan number (PN)
    C Plan sponsor's name as shown on Line 2a of Form 5500
    D Employer Identification Number of plan sponsor (EIN)

    Part I--Information Concerning Insurance Contract Coverage. 
Provide information for each contract on a separate Schedule A. 
Individual contracts grouped as a unit in Parts II and III can be 
reported on a single Schedule A.
    1. Coverage and General Information:

    a. [Current 1a] Name of insurance carrier:
    b. [Current 1b] EIN of insurance carrier:
    c. [More Specific Than Current 1c By Requiring ``Company'' Code 
Instead of NAIC Code Generally] NAIC Company Code
    d. [Current 1d] Contract or policy identification number:
    e. [New] Health plan identification number (HPID) (if subject to 
the Health Insurance Portability and Accountability Act (HIPAA))
    [Current Line 1e moved as breakout by benefit type in new Line 
9]
    f. [Current 1(f) and (g)] Policy or contract year (1) beginning 
___(2) ending ___

    2. [New] Was the policy or contract issued by an insurance 
company that is wholly owned by the plan or the plan sponsor?
[ballot] Yes [ballot] No
    [Current 2 Moved to New Part IV]
    Part II--Investment and Annuity Contract Information. [Current 
Part II] 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 Line 4] Current value of plan's interest under this 
contract in the general account at contract year end.
    4. [Current Line 5, with PSAs. ``Other'' and Variable Annuity 
Contracts broken out; new to provide information on variable annuity 
contract features] Current value of plan's interest under this 
contract in separate accounts and variable annuities at contract 
year end.

[ballot] Pooled separate accounts
[ballot] Other separate accounts
[ballot] Variable annuities. If you check this box, indicate whether 
the variable annuity contact has any of the following (check all 
that apply):
(i) Types of subaccounts:
[ballot] Domestic Stock/Equity
[ballot] Bond/income
[ballot] Balanced/target allocation
[ballot] Money Market
[ballot] Target date/Lifecycle
[ballot] International/Global Stock/Equity
[ballot] Sector/economy segment
[ballot] Other subaccounts (Describe)
(ii) Features
[ballot] Death benefit
[ballot] Guaranteed living benefit
[ballot] Other (specify)

    5. [Current Line 6] 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:
    (i) Enter amount
    (ii) Specify the nature of the costs
    e. Type of contract:
    (i) [ballot] Individual policies

[[Page 47577]]

    (ii) [ballot] Group deferred annuity
    (iii) [ballot] Other (specify)
    f. If contract purchased, in whole or in part, to distribute 
benefits from a terminating plan, check here: [ballot]

    6. [Current Line 7] Contracts With Unallocated Funds (Do not 
include portions of these contracts maintained in separate accounts)

    a. Type of contract:
    (1) [ballot] Deposit administration
    (2) [ballot] Immediate participation guarantee
    (3) [ballot] Guaranteed investment
    (4) [ballot] Other (specify)
    b. Balance at the end of the previous year
    c. Additions:
    (1) Contributions deposited during the year
    (2) Dividends and credits
    (3) Interest credited during the year
    (4) Transferred from separate account
    (5) Other (specify)
    (6) Total additions
    d. Total of balance and additions (add Lines 8b and 8c(6))
    e. Deductions:
    (1) Disbursed from fund to pay benefits or purchase annuities 
during year
    (2) Administration charge made by carrier
    (3) Transferred to separate account
    (4) Other (specify)
    (5) Total deductions
    f Balance at the end of the current year (subtract Line 8e(5) 
from Line 8d)
    Part III Welfare Benefit Contract Information [Current Part III, 
Except As Noted By Line] If more than one contract covers the same 
group of employees of the same employer(s) or members of the same 
employee organizations(s), the information may be combined for 
reporting purposes if such contracts are experience-rated as a unit. 
Where contracts cover individual employees, the entire group of such 
individual contracts with each carrier may be treated as a unit for 
purposes of this report.
    7. [Current Line 8 Combined With Current Line 1e Broken Out By 
Benefit Type; AD&D and Long Term Care Are New Breakouts] Benefit 
type. Check all applicable boxes and enter approximate number of 
persons covered at end of contract year by benefit type. (See 
instructions)
    Columns for the following questions for ``Benefit Type'' and for 
``Approximate number of persons covered for each benefit listed''

    a [ballot] Health (other than dental or vision)
    b [ballot] Dental
    c [ballot] Vision
    d [ballot] Life insurance: [new breakout] [ballot] term [ballot] 
other (specify)
    e [ballot] Temporary disability (accident and sickness)
    f [ballot] Long-term disability
    g [ballot] Supplemental unemployment
    h [ballot] Prescription drug
    i [ballot] [New] Accidental death and disability
    j [ballot] [New] Long term care insurance
    k [ballot] Other (specify)

    8 [Current Line 8i, j, k, l, m] Type of Contract. (Check 
applicable box.)

    a [ballot] Stop-loss (large deductible)
    b [ballot] HMO contract
    c [ballot] PPO contract
    d [ballot] Indemnity contract
    e [ballot] Other (specify)

    9 [Current Line 9, Including Subparts] Experience-rated 
contracts:
    9a Premiums:
    (1) Amount received
    (2) Increase (decrease) in amount due but unpaid
    (3) Increase (decrease) in unearned premium reserve
    (4) Earned ((1) + (2)-(3))
    9b Benefit charges
    (1) Claims paid
    (2) Increase (decrease) in claim reserves
    (3) Incurred claims (add (1) and (2))
    (4) Claims charged
    9c 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. Check here to 
indicate whether these amounts were:
    [ballot] Paid in cash, or [ballot] credited.
    9d Status of policyholder reserves at end of year:
    (1) Amount held to provide benefits after retirement
    (2) Claim reserves
    (3) Other reserves
    9e Dividends or retroactive rate refunds due. (Do not include 
amount entered in Line 9c(2).)

    10. [Current Line 10, Including Subparts] Nonexperience-rated 
contracts:
    10a. Total premiums or subscription charges paid to carrier
    10b. 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 IV, Line 13 (Fee 
and Commission Information) report amount:
    10c [Part of Current Line 10b] Specify nature of costs of amount 
reported on line 10b:
    11 [New]
    a Were there any premium payment delinquencies for premiums due 
but unpaid during the year?

    [ballot] Yes [ballot] No If ``Yes,'' enter number of times 
delinquent and for each delinquency enter the number of days 
delinquent.

    b If you answered ``Yes'' to line 11a, indicate whether any 
premium delinquency resulted in a lapse in coverage. If you answered 
``No'' to line 11a, enter ``N/A''

    [ballot] Yes [ballot] No [ballot] N/A.

Part IV Fee and Commission Information

    12 [Current Line 2] Insurance fee and commission information. 
Enter in Line 12 the total fees and total commissions paid in 
connection with the insurance carrier and contract entered in Line 
1. List the agents, brokers, and other persons in descending order 
of the amount paid.
    12a Total amount of commissions paid.
    12b Total amount of fees paid
    13 [Current Line 3] Persons receiving commissions and fees. 
(Complete as many entries as needed to report all persons).
    13a [Current 3a] Name and address of the agent, broker, or other 
person to whom commissions or fees were paid.
    13b [New] Relationship to plan, employer, employee organization, 
sponsor, fiduciary, or other party-in-interest
    13c [Current 3b] Amount of sales and base commissions paid
    13d [Current 3c] Amount of fees and other commissions paid
    13e [Current 3d] Purpose of fees and other commissions paid
    13f [Current 3e] Organization code (see instructions)

Part V Provision of Information [current Part IV]

    14a [Current Line 11] Did the insurance company fail to provide 
any information necessary to complete Schedule A?

    [ballot] Yes [ballot] No

    14b [Current Line 12, Except Checkbox Added for ``Fee and 
Commission'' and ``Other'' Instead of Just Open Text Field] If the 
answer to Line 14a is ``Yes,'' specify the information not provided: 
[ballot] Fee and commission information [ballot] Other (specify)

Schedule C (Service Provider Information) [NEW FORMAT WHERE SEPARATE 
SCHEDULE C IS FILED FOR EACH SERVICE PROVIDER RATHER THAN SINGLE 
SCHEDULE C FILED THAT COVERS MULTIPLE SERVICE PROVIDERS]

    [Current header and identifying information] For calendar plan 
year 20XX or fiscal plan year beginning DD/MM/20XX and ending DD/MM/
20XX+1
    A Name of plan
    B Three-digit plan number [PN]
    C Plan sponsor's name as shown on Line 2a of Form 5500
    D Employer Identification Number (EIN)

    [New (Revision of current indirect compensation reporting 
language to harmonize with 29 CFR 2550.408b-2)] You must complete a 
separate Schedule C, in accordance with the instructions, for (1) 
each covered service provider who received $1,000 or more in total 
direct and indirect compensation (i.e., money or anything else of 
monetary value) in connection with services rendered to the plan or 
the person's position with the plan during the plan year, including 
payments from participants' accounts and (2) other persons who 
received $5,000 or more in direct compensation in connection with 
services rendered to the plan or the person's position with the plan 
during the plan year, including payments from participants' 
accounts.
    A ``covered service provider'' for Schedule C reporting purposes 
includes: (1) ERISA fiduciary service providers to the plan or to a 
``plan asset'' vehicle in which the plan invests; (2) investment 
advisers registered under Federal or State law; (3) persons who 
provide recordkeeping or brokerage services to a participant-
directed individual account plan in connection with designated 
investment alternatives (e.g., a ``platform provider''); or (4) 
providers of one or more of the following services to the plan who

[[Page 47578]]

received compensation from parties other than from the plan or plan 
sponsor in connection with such services: accounting, auditing, 
actuarial, banking, consulting, custodial, insurance, investment 
advisory, legal, recordkeeping, securities or other investment 
brokerage, third party administration, or valuation services.
    [Deleted--Current Line 1 ``Information on Persons Receiving Only 
Eligible Indirect Compensation'']

Part I Service Provider Information

    1 [Current Line 2, except as indicated] Information on Service 
Providers Receiving Compensation in Connection with Services 
Rendered to the Plan or Their Position with the Plan.
    1a [Current Line 2a, but adds requirement to give contact 
information for service providers that are natural persons] Enter 
name, EIN and address for the service provider. For a self-employed 
individual that does not have an EIN, you may enter ``None'' instead 
of an EIN. If the service provider identified is not an individual, 
in addition to the name, EIN and address of the entity, provide the 
name of and address for an individual or office that the plan would 
contact for information about the service arrangement. (See 
instructions.)

    (1) Name of Service Provider
    (2) EIN
    (3) LEI (if available)
    (4) Address
    (5) Name of Contact
    (6) Address of Contact
    1b [Current Line 2c, except refers to relationship to plan 
rather than employer, plan sponsor or person known to be party-in-
interest, and enumerates types of parties-in-interest instead of 
having all but the employer or employee organization to be reported 
as ``other'' person known to be a party-in-interest] Indicate 
whether the person identified in Line 1a has one of the following 
relationships to the plan. Check ``not applicable'' if the service 
provider does not have one of the listed relationships:
    (1) [ballot] Employer
    (2) [ballot] Plan Sponsor
    (3) [ballot] Named fiduciary
    (4) [ballot] Plan Sponsor Employee
    (5) [ballot] Plan Employee
    (6) [ballot] Employee Organization
    (7) [ballot] Other party-in-interest (describe)
    (8) [ballot] Not applicable
    1c [Current Line 2b (``Service codes'' only)] Check the 
appropriate box(es) to identify all services provided by the person 
identified in Line 1a:
    (1) [ballot] Plan Administrator
    (2) [ballot] Contract Administrator/third party administrator
    (3) [ballot] Trustee (discretionary)
    (4) [ballot] Trustee (directed)
    (5) [ballot] Investment management
    (6) [ballot] Recordkeeping and information management 
(computing, tabulating, data processing, etc.)
    (7) [ballot] Claims Processing
    (8) [ballot] Custodial (securities)
    (9) [ballot] Custodial (other than securities)
    (10) [ballot] Insurance agents and brokers
    (11) [ballot] Insurance services
    (12) [ballot] Real estate brokerage
    (13) [ballot] Securities brokerage
    (14) [ballot] Investment advisory (participants)
    (15) [ballot] Investment advisory (plan)
    (16) [ballot] Consulting (other than investment advice/
management) (Enter description)
    (17) [ballot] Valuation (appraisals, etc.)
    (18) [ballot] Accounting (including auditing)
    (19) [ballot] Actuarial
    (20) [ballot] Form 5500 Annual Return/Report preparation
    (21) [ballot] Legal
    (22) [ballot] Participant loan processing
    (23) [ballot] Participant communication
    (24) [ballot] Information technology/computer support
    (25) [ballot] Copying and duplicating
    (26) [ballot] Other services (Describe)

    1d [New] Check here [ballot] if the person identified on Line 1a 
was a fiduciary within the meaning of section 3(21) of ERISA at any 
time during the plan year.
    1e [New] Was the person identified in Line 1a also identified on 
Schedule A filed for this plan year as having received insurance 
fees and commissions?

[ballot] Yes [ballot] No
    1f [New] Did the service provider arrangement include use of an 
ERISA recapture, ERISA budget, or similar account during the plan 
year?

[ballot] Yes [ballot] No
    1g(1) [New] Did the service provider arrangement include 
recordkeeping services to a pension plan without explicit 
compensation for some or all of such recordkeeping services or with 
compensation for such recordkeeping offset or rebated in whole or in 
part based on other compensation received by the service provider, 
or an affiliate or subcontractor? Only pension plans answer line 
1g(1) and 1g(2).

[ballot] Yes [ballot] No
    1g(2) [New] If you answered ``Yes'' to line 1g(1), using the 
same methodology used in the service provider's estimate of the cost 
to the plan of recordkeeping services, enter as a dollar figure the 
amount of compensation the service provider received for 
recordkeeping services.
    2 [Current Line 2d] Direct Compensation Paid by or Charged to 
Plan. Enter the total amount of direct payments by the plan to the 
person identified in Line 1a. If none, enter ``-0-''.
    3 [Current Line 2(g) and Line 3 revised] Indirect compensation 
received by covered service providers from sources other than the 
plan or plan sponsor, including charges against plan investments.
    [Current Lines 2f and 2h eliminated]
    3a [Current Line 2(g) as revised because ``eligible indirect 
compensation'' concept eliminated] Total amount of compensation 
received by the covered service provider identified in Line 1a in 
connection with services provided to the plan from sources other 
than the plan or plan sponsor, including charges against plan 
investments. Include compensation received by an affiliate or 
subcontractor in connection with the services rendered to the plan. 
Do not include here related party compensation paid among the 
person, affiliate or subcontractor reported on Line 4. (See 
instructions)
    3b [Current Line 3] For compensation reported on Line 3a, 
identify each source from whom the person identified in Line 1a 
received compensation. (See instructions). Complete as many entries 
as needed to report the required information for each source.

    (1) Enter name
    (2) EIN
    (3) LEI (if available)
    (4) Enter as a dollar figure the amount or estimate of 
compensation received from the source identified in Line 3b(1).
    (5) Check the appropriate box(es) to identify all type(s) of 
fees/compensation received by the provider identified in Line 1a 
from the source identified in Line 3b(1).
    (A) [ballot] Investment management fees
    (B) [ballot] Sales loads (front end and deferred)
    (C) [ballot] Account maintenance fees
    (D) [ballot] ``Soft dollars'' commissions
    (E) [ballot] Securities brokerage commissions and fees
    (F) [ballot] Shareholder servicing fees
    (G) [ballot] Sub-transfer agency (subaccounting) fees
    (H) [ballot] Finders' fees/placement fees
    (I) [ballot] Distribution (12b-1) fees
    (J) [ballot] Insurance brokerage commissions and fees
    (K) [ballot] Insurance mortality and expense charges
    (L) [ballot] Insurance wrap fees
    (M) [ballot] Termination fees (surrender charges, etc.)
    (N) [ballot] Float revenue
    (O) [ballot] Non-monetary compensation (Enter description)
    (P) [ballot] Commissions other than securities and insurance 
(e.g., real estate commissions)
    (Q) [ballot] Recordkeeping fees
    (R) [ballot] Other fees/compensation (Enter description)
    (6) If the amount of compensation reported in Line 3b(4) was an 
estimate based on a formula, check here [ballot] and enter a 
description of the formula used to determine the service provider's 
eligibility for or the amount of the compensation.

    4a [New] Did the service arrangement involve any related party 
compensation? (See instructions). If the answer to Line 4a is 
``Yes,'' complete Line 4b(1)-(4)
    4b(1) Describe the services for which the compensation was paid

    (2) Enter names of
    (A) the payor and
    (B) the recipient of the compensation
    (3) Identify status as an [ballot] affiliate or [ballot] 
subcontractor
    (4) Enter the amount of the compensation

Part II Service Providers Who Fail or Refuse to Provide Information 
[Current Part II; because a separate Schedule C would be provided for 
each service provider, no need to provide the name and EIN of the 
service provider who failed or refused to provide information; current 
Lines 4a and 4b eliminated]

    5a [Current Line 4] Check this box if the service provider 
failed or refused to provide the information necessary to complete 
this Schedule.
    5b [Current Line 4c] Describe the information that the service 
provider failed or refused to provide.

[[Page 47579]]

Schedule D

    [Current header and identifying information] For calendar plan 
year 20XX or fiscal plan year beginning DD/MM/20XX and ending DD/MM/
20XX+1

    A Name of plan
    B Three-digit plan number (PN)
    C Plan or DFE sponsor's name as shown on Line 2a of Form 5500:
    D Employer Identification Number (EIN)

    [Current Part I eliminated]
    [Current Part II, with added items for dollar value of investing 
plan/DFE interest as of end of reporting DFE year and check box 
whether DFE had investors other than plans covered by Title I of 
ERISA that file the Form 5500 Annual Return/Report].

    1 Information on Participating Plans (to be completed by DFEs) 
Complete as many entries as needed to report all participating 
plans.
    1a Plan name (as shown on Line 1a of the plan's most recent Form 
5500/Form 5500-SF):
    1b Name of plan sponsor (as shown on line 2a of the plan's most 
recent Form 5500/Form 5500-SF):
    1c(1) EIN of sponsor of investing plan (as shown on Line 2b of 
the plan's most recent Form 5500/Form 5500-SF)
    1(c)(2) PN of investing plan (as shown on Line 1b of the plan's 
most recent Form 5500/Form 5500-SF)
    1d [New] Dollar value of investing plan/DFE interest at end of 
reporting DFE year:
    1e [New] If the DFE had investors other than plans that are 
required to file the Form 5500 or Form 5500-SF (see instructions), 
check here [ballot].

Schedule E (ESOP Annual Information)

Heading [Change from 2008 to list DOL and IRS/Treasury instead of just 
Treasury/IRS]

    [Change from 2008 to add Title I Authority to Code Authority]--
This schedule is required to be filed under section 104 of the 
Employee Retirement Income Security Act of 1974 (ERISA) and sections 
6058(a) and 6047(e) of the Internal Revenue Code (the Code).
    [Change from 2008, which specified Schedule E NOT Open to Public 
Inspection] Disclosure: This Form is Open to Public Inspection.
    [2008 Basic Identifying Information] For calendar plan year 20XX 
or fiscal plan year beginning DD/MM/20XX and ending DD/MM/20XX+1

    A Name of plan:
    B Plan number
    C Plan sponsor's name as shown on Line 2a of Form 5500
    D EIN

    Part I Employer Stock Acquired with a Securities Acquisition 
Loan [New]--Complete this Part only if the ESOP had an outstanding 
securities acquisition loan within the meaning of Code section 
4975(d)(3) and ERISA section 408(b)(3) during the plan year.

Common Stock

    1a [New] Enter the number of common shares of employer stock 
held in the ESOP at the end of the plan year.
    1b [New] Enter percent of issued and outstanding common stock 
held in the ESOP at the end of the plan year.
    1c [Current Schedule R, Line 12] Are the shares readily tradable 
on an established securities market? [ballot] Yes [ballot] No
    1d [New] Enter number of allocated common shares at the end of 
the plan year.
    1e [New] Enter number of unallocated common shares at the end of 
the plan year.
    1f [2008 Schedule E, Line 5] If common stock was released from a 
loan suspense account, indicate the methods used:
    [ballot] Principal and interest
    [ballot] Principal only
    [ballot] Other (Describe method):

Preferred Stock

    1g [2008 Schedule E, Line 4] Did the ESOP hold preferred stock 
at the end of the plan year?
    [ballot] Yes [ballot] No
    1h [New breakout] If convertible based on a ratio, enter ratio.
    1i [New breakout] If convertible by some other method, describe 
the method of conversion.
    Part II [New breakout] Employer Stock Acquired Complete this 
Part only if the ESOP acquired during the plan year employer 
securities not readily tradable on an established securities market. 
Complete as many entries as necessary to report each separate 
transaction.
    2a [New] Enter seller's relationship to plan, employer, or other 
party-in-interest (if no relationship, enter ``unrelated third 
party'')
    2b [New] Is seller a party-in-interest? [ballot] Yes [ballot] No
    2c [New] Enter total consideration paid for stock
    2d [New] Enter date of transaction
    2e [New] Check the applicable box and enter the identifying 
information if an independent fiduciary, trustee, or investment 
manager approved the transaction

[ballot] Trustee
[ballot] Investment Manager
[ballot] Independent fiduciary
    Name
    Street Address
    City
    State
    Zip Code
    EIN
    2f [New] Identify the independent appraiser that valued the 
employer securities. (If an independent appraiser did not value the 
employer securities, enter ``None.'' CAUTION: See Code section 
401(a)(28)(C) if you enter ``None.'')

    Name
    Street Address
    City
    State
    Zip Code
    EIN
    2g [New] What valuation approach was used to value the stock 
acquired? (Check all that apply.)

[ballot] Asset
[ballot] Income
[ballot] Market
[ballot] Book Value
[ballot] Other (Enter description):

    Part III Securities Acquisition Loans [2008 Schedule E, Line 2a, 
with new breakouts as indicated]--Complete this Part only if the 
ESOP had outstanding securities acquisition loans within the meaning 
of Code section 4975(d)(3) and ERISA section 408(b)(3) during the 
plan year. Complete as many entries as necessary to report all 
outstanding loans.
    3a [New breakout] Lender's relationship to plan, employer, or 
other party-in-interest (if no relationship, enter ``unrelated third 
party'')
    3b [New breakout] [ballot] Check box if lender is a party-in-
interest?
    3c [New breakout] Is the loan guaranteed by a party-in-interest?

[ballot] Yes [ballot] No

    3d [New breakout] Enter original amount of loan
    3e [2008 Schedule E, Line 9a] Enter date of loan
    3f [New breakout] Enter interest rate (if variable enter terms)
    3g [New breakout] Is the loan in default?

[ballot] Yes [ballot] No If ``Yes,'' enter the amount overdue.

    3h [New breakout] (1) Was the loan refinanced or amended during 
the plan year?

[ballot] Yes [ballot] No

    If ``Yes,'' complete Line 3h(2) and (3)
    (2) Enter date of amendment or refinancing.
    (3) Enter the outstanding balance at date of refinancing or 
amendment
    Part IV Other General Information
    4a [New] Were employee elective deferrals used to satisfy any 
securities acquisition loan?

[ballot] Yes [ballot] No

    4b [2008 Schedule E, Lines 1a and 1b] If the ESOP is maintained 
by an S corporation, are there any disqualified persons as described 
in Code section 409(p)(4)?

[ballot] Yes [ballot] No

    4c [2008 Schedule E, Line 6] Were unallocated securities or 
proceeds from the sale of unallocated securities used to repay any 
exempt loan (within the meaning of Code section 4975(d)(3) and ERISA 
section 408(b)(3))?

[ballot] Yes [ballot] No

    If ``Yes,'' attach a description of the transaction.
    4d [2008 Schedule E, Line 2b] Did the employer maintaining the 
ESOP pay dividends (deductible under Code section 404(k)) on the 
employer's stock held by the ESOP during the employer's tax year in 
which the plan year ends?

[ballot] Yes [ballot] No

    If ``Yes,'' answer (d)(1)-(3).
    (1) What was the amount of the deduction taken?
    (2) What was the dividend rate?
    (3) Did the employer make payments in redemption of stock held 
by an ESOP to ESOP participants and deduct them under Code section 
404(k)(1)?

[ballot] Yes [ballot] No


[[Page 47580]]



Schedule G--Financial Transactions

    [Current header and identifying information] For calendar plan 
year 20XX or fiscal plan year beginning DD/MM/20XX and ending DD/MM/
20XX+1
    [Identification information same as current Schedule G]

    A Name of plan
    B Three-digit plan number (PN)
    C Plan sponsor's name as shown on Line 2a of Form 5500
    D Employer Identification Number (EIN)

Part I. [Current Part I] Schedule of Loans or Fixed Income Obligations 
in Default or Classified as Uncollectible

    1 [Current Line 1] Schedule of Loans in Default or Classified as 
Uncollectible. Complete as many entries as needed to report all 
loans in default or classified as uncollectible. (See Instructions.)
    1a [Current Part I(b)] Identity and address of obligor

    Name
    Street Address
    City
    State
    Zip Code

    1b [New Breakout] Relationship to plan. (Check all boxes that 
apply.) Obligor is a:
[ballot] [New breakout] participant
[ballot] [Current Part I(a)] party-in-interest (e.g. employer, 
employee organization, employee of the plan, or other party-in-
interest)

    Enter description of the relationship (If no relationship 
exists, enter ``unrelated third party'')

    1c [Part of Current Part I(c)] Check to indicate whether the 
loan is:
[ballot] in default
[ballot] uncollectible
    1d [Current Part I(d)] Enter original amount of loan
    1e [Part of Current Part I(c)] Enter original interest rate. If 
variable, describe terms.
    1f [Part of Current Part I(c)] Date of loan origination
    1g [Part of Current Part I(c)] Maturity date
    1h (1) [Part of Current Part I(c)] Was the loan secured by 
collateral? [ballot] Yes [ballot] No If ``Yes,'' complete elements 
(2) and (3).
    (2) [New breakout] Was the security interest perfected? [ballot] 
Yes [ballot] No
    (3) [Part of Current Part I(c)] Enter a description of 
collateral and value of collateral:
    Collateral type
    Collateral value
    1i [Part of Current Part I(c)] Scheduled payment frequency 
(e.g., monthly, annually). Enter description
    1j [Current Part I(e) and (f)] Amount received during reporting 
year:
    Principal
    Interest
    1k [Current Part I(h) and (i)] Amount overdue:
    Principal
    Interest
    1l [Current instructions require an attachment with this 
information]. Enter a description of what steps the plan 
administrator has taken or will be taking to collect overdue amounts 
for each loan listed.

    2 Schedule of Fixed Income Obligations in Default or Classified 
as Uncollectible. [Breaks out fixed income obligations from loans; 
current Schedule G has filers completing same elements for both 
loans and fixed income obligations.] Complete as many entries as 
needed to report all fixed income obligations in default or 
classified as uncollectible. (See Instructions.)

    2a [Current Part I(b)] Identity and address of obligor
    Name
    Street Address
    City
    State
    Zip Code
    2b [Current Part I(a)] Check [ballot] if party-in-interest (e.g. 
employer, employee organization, employee of the plan, or other 
party-in-interest) was involved in the transaction.
    [New breakout] Enter description of the relationship. If no 
relationship exists, enter ``unrelated third party.''
    2c [Part of current Part I(c)] Check to indicate whether the 
fixed income obligation is:

[ballot] in default
[ballot] uncollectible

    2d [New breakout; part of description in current Part I(c)] 
Check applicable boxes to indicate the nature of the fixed income 
obligation:

[ballot] Bond
[ballot] Option
[ballot] Swap
[ballot] Future contract
[ballot] Forward contract
[ballot] Other (Enter description)

    2e [Part of current Part I(c)] Date of issuance
    2f [Part of current Part I(c)] Maturity date
    2g [Part of current Part I(c)] Enter coupon yield or interest 
rate
    2h [Current Part I(e)] Principal amount of fixed income 
obligation
    2i [Current Part I(h) and (i)] Amount overdue:

Principal
Interest

    2j [Current instructions require an attachment with this 
information] Enter a description of what steps the plan 
administrator has taken or will be taking to collect overdue amounts 
for each fixed income obligation listed.

    Part II Schedule of Leases in Default or Classified as 
Uncollectible. Complete as many repeating entries as needed to 
report all leases in default or classified as uncollectible. (See 
instructions.)

    3a [Current Part II(b)] Identity and address of lessor/lessee:
    Name
    Street Address
    City
    State
    Zip Code
    3b [Current Part II(a) and (c)] Relationship to plan, employer, 
employee organization, or other party-in-interest (if no 
relationship, enter ``unrelated third party''). Check to indicate 
whether lessor/lessee is [ballot] party-in-interest and enter 
description of relationship (including whether plan is lessor or 
lessee):
    3c [Part of current Part II] Overdue Lease Explanation. Check to 
indicate whether the lease is in [ballot] default [ballot] 
uncollectible.
    3d [Part of current Part II(d)] Enter the address of the leased 
property:
    Street Address
    City
    State
    Zip Code
    3e [Part of current Part II(d)] Enter date of lease origination
    3f [Current Part II(e)] Original cost of leased property
    3g [Current Part II(f)] Current value of leased property at time 
of lease
    3h [Current Part II(g)] Gross rental receipts during the plan 
year
    3i [Current Part II(h)] Expenses paid during the plan year
    3j [Current Part II(i)] Net receipts
    3k [Part of current Part II(d)] Scheduled payment frequency 
(e.g., monthly, annually)
    3l [Part of current Part II(d)] Lease expiration date
    3m [Current Part II(j)] Amount in arrears
    3n [Current instructions require an attachment with this 
information]. Enter an explanation of what steps the plan 
administrator has taken or will be taking to collect overdue amounts 
for each lease listed.

    Part III Nonexempt Transactions. Complete as many entries as 
needed to report all nonexempt transactions.
    CAUTION: If a nonexempt prohibited transaction occurred with 
respect to a disqualified person, the disqualified person should 
generally file a Form 5330 with the IRS to pay the excise tax on the 
transaction.

    Line 4 [Current Part III(a)]
    4a Name and address of party-in-interest (or parties in 
interest, if multiple) involved in the nonexempt prohibited 
transaction:
    Name
    Street Address
    City
    State
    Zip Code:
    4b [Current Part III(b)] Relationship to plan, employer, 
employee organization, plan sponsor, fiduciary, or other party-in-
interest
    4c [Revision of Current Part III(c), but current requirement to 
provide a description of transaction replaced with checkboxes; 
written description only required for ``other''] Type of nonexempt 
transaction (Check all that apply):

[ballot] Sale of any property to/from the plan
[ballot] Exchange of any property
[ballot] Lease of any property to/from the plan
[ballot] Lending of money to/from the plan
[ballot] Other extension of credit to/from the plan
[ballot] Furnishing of goods to/from the plan
[ballot] Furnishing of services to/by the plan
[ballot] Furnishing of facilities to/by the plan
[ballot] Other transfer to a party-in-interest, of any income or 
assets of the plan
[ballot] Other use by or for the benefit of a party-in-interest, of 
any income or assets of the plan
[ballot] Acquisition, on behalf of the plan, of any employer 
security or employer real property in violation of ERISA 407(a)
[ballot] Acting in a fiduciary's individual or any other capacity in 
any transaction involving the plan on behalf of a party (or 
represent a party) whose interests are

[[Page 47581]]

adverse to the interests of the plan or the interests of its 
participants and beneficiaries
[ballot] A receipt of any consideration for his or her personal 
account by a party-in-interest who is a fiduciary from any party 
dealing with the plan in connection with a transaction involving the 
income or assets of the plan
[ballot] Other (enter description)

    4d [New] Check the appropriate box (see instructions) to 
describe nature of transaction:

[ballot] Discrete
[ballot] Ongoing

    4e [Part of current Part III (c)] Date of the transaction or, if 
ongoing, date of first instance
    4f [Part of current Part III (c)] Amount involved in nonexempt 
transaction
    4g [Current Part III (j)] Net gain (or loss) on the transaction
    4h [New] Has the transaction been fully corrected (see 
instructions)? [ballot] Yes [ballot] No

    If ``Yes'', check the correct box below and complete (i) and 
(j):

[ballot] Transaction corrected outside VFCP
[ballot] Transaction corrected through the VFCP
[ballot] Transaction pending correction through VFCP
    4i [New] If the transaction was fully corrected, enter the date 
the transaction was fully corrected: MM/DD/20YY
    4j [New] If the nonexempt transaction was corrected enter a 
description of the corrective action (i.e. reversal, disgorgement, 
loan repaid, payment to plan, etc.)
    4k [New] If the nonexempt transaction occurred with respect to a 
disqualified person, and the person was notified, was a Form 5330 
filed with the IRS?

[ballot] Yes
[ballot] No
[ballot] Unknown
[ballot] Not required-VFCP
[ballot] Disqualified person was not notified

Schedule H--Financial Information

    [Current header and identifying information] For calendar plan 
year 20XX or fiscal plan year beginning DD/MM/20XX and ending DD/MM/
20XX+1

    A Name of Plan
    B Three-digit plan number (PN)
    C Plan sponsor's name as shown on line 2a of Form 5500
    D Employer Identification Number of plan sponsor (EIN)

Part I Asset and Liability Statement

    1. [Current Line 1, except reference to ``MTIA'' changed to 
``Master Trust;'' changes to individual data elements as indicated] 
Current value of plan assets and liabilities at the beginning and 
end of the plan year. Combine the value of plan assets held in more 
than one trust. 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 unless the value is reportable on Lines 1b(5)-
1b(8). Do not enter the value of that portion of an insurance 
contract which guarantees, during this plan year, to pay a specific 
dollar benefit at a future date. Round off amounts to the nearest 
dollar. Master trusts, CCTs, PSAs, and 103-12 IEs do not complete 
Lines 1a(1), (2) and (3), 1g, 1h, and 1i. CCTs, PSAs, and 103-12 IEs 
also do not complete Lines 1(c)(1) and (2) and 1d. (See 
instructions.)

    Assets [Columns for (a) Beginning of Year (BOY) and (b) End of 
Year (EOY) Values]
    [Current Line 1a Moved to Line 1b(1)]

    1a [Current 1b] Receivables (less allowance for doubtful 
accounts):

    (1) [Current 1b(1)] Employer contributions
    (2) [Current 1b(2)] Participant contributions
    (3) [Current 1c(8)] Notes receivable from participants 
(participant loans)
    (4) [Current 1b(3)] Other

    1b [Current 1c; with changes as indicated] General investments--

    (1) [Current 1a] Total noninterest-bearing cash
    (2) [Current 1c(1) with new breakouts])
    (A) Interest-bearing cash
    (B) Certificates of deposit
    (C) Money market accounts
    (3) [New breakouts] Debt interests/obligations (other than 
employer securities, participant loans, and foreign investments)
    (A) [Current 1c(2)] U.S. Government securities
    (B) [New] Other government securities
    (C) [Current 1c(3) Corporate debt instruments (other than 
employer securities)
    (i) Investment grade
    (ii) High-yield debt
    (D) [New] Exchange Traded Notes
    (E) [New] Asset backed securities (other than real estate)
    (F) [New and Partial Current 1c(7)] Other debt interests
    (4) [Current 1c(4)] Corporate stocks (other than employer 
securities and foreign investments):
    (A) [New breakout] Publicly traded
    (i) Preferred
    (ii) Common
    (B) [New breakout] Non-publicly traded
    (i) Preferred
    (ii) Common
    (5) [Current 1c(13)] Registered investment companies (Mutual 
funds, Unit Investment Trusts, Closed End Funds)
    (6) [New breakout] Eligible Pooled Investment Vehicles (other 
than registered investment companies)
    (A) [Current 1c(10] Total value of interest in pooled separate 
accounts (PSA)
    (B) [Current 1c(9)] Total value of interest in common collective 
trusts (CCT)
    (C) [Current 1c(12)] Value of interest in 103-12 investment 
entities (103-12 IEs) (See instructions)
    (D) [Current 1c(11)] Total value of interest in master trusts
    (7) [Current 1c(14)] Value of interest in funds held in 
insurance general account (unallocated contracts)
    (A) [New breakout] Deposit administration
    (B) [New breakout] Immediate participation guarantee
    (C) [New breakout] Guaranteed investment contracts
    (D) [New breakout] Other unallocated insurance contracts 
(Describe)
    (8)(A) [Current 1c(5)] Partnership/joint venture interests
    (i) [New breakout] Value of interest in limited partnerships
    (ii) [New breakout] Value of interest in venture capital 
operating companies (VCOC)
    (iii) [New breakout] Private equity
    (iv) [New breakout] Hedge funds
    (v) [New breakout] Other partnership/joint venture interests 
(Describe)
    (B) [New sub-part question not part of sum on balance sheet]

    (i) Total partnership/joint venture interests that do not hold 
plan assets under the DOL's plan asset regulation at 29 CFR 2510.3-
101.
    (ii) Total partnership/joint venture interests that hold plan 
assets under the DOL's plan asset regulation at 29 CFR 2510.3-101.

    (9) [Current 1c(6)] Real Estate Investments (other than employer 
real property and foreign investments)
    (A) [New breakout] Developed real property (other than employer 
real property)
    (B) [New breakout] Undeveloped real property (other than 
employer real property)
    (C) [New breakout] Publicly Traded Real Estate Investment Trusts 
(REITs)
    (D) [New breakout] Non-Publicly Traded Real Estate Investment 
Trusts (REITs)
    (E) [New breakout] Mortgage-Backed Securities (Including 
Collateralized Mortgage Obligations)
    (F) [New breakout] Real Estate Operating Company (REOC)
    (G) [New breakout] Other real estate related investments 
(Describe)
    (10) [New breakout] Commodities (direct investments)
    (A) [New breakout] Precious metals
    (B) [New breakout] Other (Describe)
    (11) [New breakout] Derivatives
    (A) [New breakout] Futures
    (B) [New breakout] Forwards
    (C) [New breakout] Options
    (D) [New breakout] Swaps
    (E) [New breakout] Other (Describe, e.g., collateralized debt 
obligations other than real estate)
    (12) [Current 3g on Schedule I] Tangible Personal Property 
(including collectibles)
    (13) [New breakout] Foreign investments (Other than those held 
through registered investment companies or eligible pooled 
investment vehicles)
    (A) Equities
    (B) Debt interests
    (C) Real estate
    (D) Currency
    (E) Other (Describe)
    (14) [New breakout] Value of assets held in participant-directed 
brokerage accounts (See instructions)
    (A) Tangible personal property
    (B) Loans
    (C) Partnership or joint venture interests
    (D) Real property
    (E) Employer securities
    (F) Investments that could result in a loss in excess of the 
account balance of the participant or beneficiary who directed the 
transaction, including derivatives
    (G) Other (including cash/cash equivalents, registered 
investment companies, corporate equities, corporate debt 
instruments)
    1c [Current 1d except breakout for non-publicly traded stock and 
debt] Employer-related investments

[[Page 47582]]

    (1) Employer securities
    (A) Publicly traded stock
    (B) Non-publicly traded stock
    (C) Publicly traded debt instruments
    (D) Non-publicly traded debt
    (2) Employer real property
    1d [Current 1e] Buildings and other property used in plan 
operation
    1e [Current 1c(15)] Other ([New] Describe)
    1f [Current 1f] Total assets (Add Lines 1a through 1e.)
    Liabilities [Columns for (a) BOY (b) EOY Values]
    1g [Current 1g] Benefit claims payable
    1h [Current 1h] Operating payables
    1i [Current 1i] Acquisition indebtedness
    1j [Current 1j] Other liabilities
    1j(1) [New] Enter description
    1k [Current 1k] Total liabilities (add all amounts in Lines 1g 
through 1j)

Net Assets

    1l [Current] Net assets (subtract Line 1k from Line 1f)

Part II Income and Expense Statement

    2 [Current 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. Master trusts, CCTs, PSAs, and 103-12 IEs do not 
complete Lines 2a, 2b, 2e, 2f, and 2g.
    2a [Current 2a] Contributions--
    (1) Received or receivable in cash from:
    (A) Employers
    (B) Participants
    (C) Others (including rollovers from IRAs/other plans)
    (2) Noncash contributions
    (3) Total contributions. Add Lines 2a(1)(A), (B), (C), and Line 
2a(2).
    2b [Current 2b(1)(E) with new breakouts] Interest on notes 
receivable from participants (participant loans)
    (1) Received in cash
    (2) Receivable in cash
    (3) Total. Add Lines 2b(1) and 2b(2).

    2c [Current 2b with new breakouts] Earnings on investments. 
Provide the total of all earnings by asset type including interest, 
dividends, gain (loss) on sale of property, unrealized appreciation 
(depreciation), net investment gain (loss), as appropriate for asset 
type. Report on Lines 2c(1)(A) and 2(c)(2)(A), respectively, 
interest and dividends on debt and equity instruments held directly 
by the plan.
    (1) Interest on debt instruments/obligations
    (A) Interest bearing cash (including money market and 
certificates of deposit)
    (B) U.S. government securities
    (C) Other government securities
    (D) Corporate debt instruments
    (E) Loans (other than to participants)
    (F) Other
    (G) Total interest. Add Line 2c(1)(A) through (F)
    (2) Dividends (other than employer securities)
    (A) Preferred stock
    (B) Common stock
    (C) Registered investment company shares (e.g., mutual funds)
    (D) Total dividends. Add Line 2c(2)(A) through (C).
    (3) Rents
    (4) Net gain (loss) on sale of assets
    (A) Aggregate proceeds
    (B) Aggregate carrying amount (see instructions)
    (C) Subtract Line 2c(4)(B) from Line 2c(4)(A) and enter result
    (5) Unrealized appreciation (depreciation) of assets
    (A) Real estate
    (B) Partnership/joint venture interests that do not hold plan 
assets
    (C) Commodities (direct investments)
    (D) Derivatives
    (E) Employer securities
    (F) Foreign investments (other than those held through U.S. 
registered investment funds)
    (G) Employer real property
    (H) Other (Describe)
    (6) Pooled Investment Vehicles
    (A) Net investment gain (loss) from common/collective trusts
    (B) Net investment gain (loss) from pooled separate accounts
    (C) Net investment gain (loss) from master trusts
    (D) Net investment gain (loss) from 103-12 investment entities
    (E) Net investment gain (loss) from registered investment 
companies (e.g., mutual funds)
    2d [Current 2d] Total income. Add all income amounts in column 
(b).
    Expenses--[Current]
    2e [Current 2e] Benefit payment and payments to provide 
benefits:
    (1) Directly to participants or beneficiaries
    (A) [New breakout from current 2d(1)] Direct rollovers
    (B) [New] Hardship distributions made from a section 401(k) plan
    (C) [Current 2016 Line 4o] Distributions to employees who have 
attained age 62 and who were not separated from service when the 
distributions were made for a defined benefit plan or a money 
purchase pension plan
    (D) [Current 2e(1) except rollovers no longer reported in other] 
Other
    (2) [Current] To insurance carriers for the provision of 
benefits
    (3) [Current] Other
    (4) [Current] Total benefit payments. Add Lines 2e(1) through 
(3).
    2f [Current] Corrective distributions (See instructions.)
    2g [Current] Certain deemed distributions of participant loans 
(See instructions.)
    2h [Current] Interest expense
    2i [Current 2i with new breakouts as indicated] Administrative 
expenses:
    (1) [New Breakout (1998 Line 32g(1)] Salaries and allowances
    (2) [Current 2i(2)] Contract administrator fees
    (3) [Current 2i(3)] Investment advisory and management fees
    (4) [New Breakout] IQPA Audit fees
    (5) [New based on 1998 Line 32g(2)] Recordkeeping and other 
accounting fees
    (6) [New Breakout] Bank or Trust Company Trustee/Custodial Fees
    (7) [New Breakout (1998 Line 32g(3))] Actuarial fees
    (8) [New Breakout (1998 Line 32g(6))] Legal fees
    (9) [New Breakout (1998 Line 32g(7))] Valuation/appraisal fees
    (10) [New Breakout (1998 Line 32g(8))] Trustee fees/expenses 
(including travel, seminars, meetings, etc.)
    (11) [Current 2i(4)] Other
    (12) [12(C) is Current 2i(5); (A) and (B) are new breakouts] 
Total administrative expenses
    (A) Total paid by the plan, except charges directly against 
participant accounts
    (B) Total payments charged directly against participant accounts
    (i) Transaction-based charges to individual participant accounts
    (ii) Plan level expenses apportioned among participant accounts
    (iii) Indicate how apportioned:
    [ballot] per capita
    [ballot] pro rata by account balance
    [ballot] other (describe):
    (C) Total. (The amount shown in (C) should be the total of 
elements (A) and (B). Element (C) should also be the same as the 
total of Lines 2i(1) through (11).)
    2j [Current 2j] Total expenses. Add all expense amounts in 
column (b) (EOY) and enter total.
    Net Income and Reconciliation
    2k [Current] Net income (loss). Subtract Line 2j from Line 2d.
    2l [Current] Transfers of assets--
    (1) [Current 2l(1)] Transfers to this plan. Total at EOY
    (2) [Current 2l(2)] Transfers from this plan. Total at EOY

Part III Accountant's Opinion.

    Subject to certain exceptions, the administrator of an employee 
benefit plan who files a Schedule H must engage an Independent 
Qualified Public Accountant (IQPA) pursuant to ERISA section 
103(a)(3)(A) and 29 CFR 2520.103-1(b). This requirement also applies 
to a Form 5500 Annual Return/Report filed for a 103-12 IE and for a 
GIA (see 29 CFR 2520.103-12 and 29 CFR 2520.103-2). The IQPA's 
report must be attached to the Form 5500 Annual Return/Report when a 
Schedule H is attached unless you check Line 3h(1), (2), (3), or (4) 
on the Schedule H. An IQPA Report generally consists of an 
Accountant's Opinion, Financial Statements, Notes to the Financial 
Statements, and Supplemental Schedules.
    3 [Current] Complete Lines 3a through 3g if the opinion of an 
IQPA is attached to this Form 5500 Annual Return/Report. Complete 
Line 3h if an opinion is not attached.
    3a [Current] The attached opinion of an IQPA for this plan is 
(see instructions):
    (1) [ballot] Unqualified
    (2) [ballot] Qualified
    (3) [ballot] Disclaimer
    (4) [ballot] Adverse
    3b [Current question; new requirement to attach 
certification(s)] Did the IQPA perform a limited scope audit 
pursuant to 29 CFR 2520.103-8 and/or 103-12(d)?
    [ballot] Yes [ballot] No

    If ``Yes'' you must attach a copy of the certification(s). 
(Although you must attach a copy of the certification(s), you do not 
need to include any attachments to the

[[Page 47583]]

certification itemizing the assets to which the certification(s) 
apply.)

    3c [Current] Enter the name and EIN of the IQPA (or accounting 
firm) below:
    (1) Name
    (2) EIN
    (3) Name of audit engagement partner
    3d [New] Identify the state in which the opinion was issued
    3e [New] Did you review and discuss the IQPA report with the 
accountant?
[ballot] Yes [ballot] No
    3f [New] Did the accountant advise you whether the IQPA report, 
including the financial statements and/or notes required to be 
attached to this return/report or the IQPA's communications with 
those charged with governance (SAS 114 and 115), disclosed any of 
the following (check all that apply):
    (1) [ballot] Errors or irregularities
    (2) [ballot] Illegal acts
    (3) [ballot] Material internal control weaknesses
    (4) [ballot] A loss contingency indicating that assets are 
impaired or a liability incurred
    (5) [ballot] That the plan sponsor may not be a going concern
    (6) [ballot] The existence of plan qualification issues pursuant 
to the Internal Revenue Code
    (7) [ballot] Any unusual or infrequent events or transactions 
occurring subsequent to the plan year end that might significantly 
affect the usefulness of the financial statements in assessing the 
plan's present or future ability to pay benefits (explain)
    3g [New] Did your IQPA have a peer review performed in 
accordance with their state's requirements?
[ballot] Yes [ballot] No

    If ``Yes,'' complete elements (1) through (5).

    (1) Name of peer reviewer
    (2) Year of their last peer review
    (3) Rating received in their last peer review report
    (4) Number of years that the peer reviewer has been the firm's 
peer reviewer
    (5) Whether the peer review covered employee benefit plans
    3h [Current 3d] The opinion of an IQPA is not attached because 
(check appropriate box):
    (1) [ballot] This form is filed for a CCT, PSA, or master trust.
    (2) [ballot] Pursuant to 29 CFR 2520.104-50, the IQPA report 
will be attached to the next Form 5500 Annual Return/Report.
    (3) [ballot] The IQPA report was not completed in time. If you 
check this box, you must explain the reason for the failure to 
comply with the IQPA requirement in a timely fashion and indicate 
date by which an amended filing will be made with an IQPA report.
    (4) [Current 4k on Schedule I] [ballot] The plan is a small plan 
and is eligible to claim a small plan audit waiver of the annual 
examination and report of an IQPA under the conditions set forth in 
29 CFR 2520.104-46. (See instructions). In addition to meeting other 
conditions in 29 CFR 2520.104-46, in order to be a small plan for 
this purpose, the plan must have fewer than 100 participants as of 
the beginning of the plan year as reported on Form 5500 or be 
eligible to claim small plan status under 29 CFR 103-1(d) and had 
120 or fewer participants as of the beginning of the plan year. 
Defined benefit pension plans and welfare plans use the number 
reported on Form 5500, Line 6 for this measure. Defined contribution 
pension plans use the number reported on Form 5500, Line 7g(1). (See 
instructions.)

Part IV Compliance Questions

    Employee benefit plans must complete all lines that apply. 
Employee benefit plans must complete all lines that apply. Small 
employee benefit plans that were eligible for and claimed the small 
plan audit waiver by checking Line 3g(4), must complete all elements 
in Part IV, except such small plans do not need to attach Schedules 
G or the Line 4j Schedule of Reportable Transactions, even if they 
answer ``Yes'' to Lines 4b, 4c, 4d, or 4j. CCTs and PSAs complete 
only Line 4i(1). Master trusts and 103-12 IEs complete only Lines 
4b, 4c, 4d, 4i, 4j, and 4s. GIAs complete only Lines 4b, 4c, 4d, 4i, 
4j, and 4k.
    During the plan year:

    4a [Current; but would require use of specified structured data 
format to complete and file Line 4a schedule] Was there a failure to 
transmit to the plan any participant contributions or repayments as 
of the earliest date on which such contributions can reasonably be 
segregated from the employer's general assets as described in 29 CFR 
2510.3-102?? (See instructions). Continue to answer ``Yes'' for any 
prior year failures until fully corrected. (See instructions and 
DOL's Voluntary Fiduciary Correction Program.) If you answered 
``Yes,'' you must complete the Line 4a schedule to provide details 
about the failure to transmit, including any corrective action 
taken.
[ballot] Yes [ballot] No Amount
    4b [Current] 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. If 
you answered ``Yes,'' see instructions for requirements to attach 
Schedule G (Form 5500) Part I. Small plans that were eligible for 
and claimed the small plan audit waiver under 29 CFR 2520.104-46 do 
not need to attach Schedule G Part I.
[ballot] Yes [ballot] No Amount
    4c [Current] Were any leases to which the plan was a party in 
default or classified during the year as uncollectible? If you 
answered ``Yes,'' see instructions for requirements to attach 
Schedule G (Form 5500) Part II. Small plans that were eligible for 
and claimed the small plan audit waiver under 29 CFR 2520.104-46 do 
not need to attach Schedule G Part II.
    [ballot] Yes [ballot] No Amount
    4d [Current] Were there any nonexempt prohibited transactions 
with any party-in-interest? (Do not include transactions reported on 
Line 4a. If you answered ``Yes,'' see instructions for requirements 
to attach Schedule G (Form 5500) Part III. Small plans that were 
eligible for and claimed the small plan audit waiver under 29 CFR 
2520.104-46 do not need to attach Schedule G Part III.
[ballot] Yes [ballot] No Amount
    4e [Current Line 4e revised] Was this plan covered by one or 
more fidelity bonds naming the plan as insured that provide coverage 
for losses due to fraud or dishonesty by persons who handle plan 
funds or other property? (See instructions.)
[ballot] Yes [ballot] No Amount
    4f [Current] Did the plan have a loss, whether or not reimbursed 
by the plan's fidelity bond, that was caused by fraud or dishonesty?
[ballot] Yes [ballot] No Amount
    4g [Current Line 4g revised] Did the plan hold any assets that 
either did not have a readily determinable fair value or were not 
valued by an independent third party appraiser? (See instructions)
[ballot] Yes [ballot] No Amount
    4h [Current] 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?
[ballot] Yes [ballot] No Amount
    4i [Current Line 4i; Except would now break out question into 
4i(1) and 4i(2) and require use of specified structured data format 
to complete and file Schedules of Assets]
    (1) Did the plan have assets held for investment at the end of 
the year? If ``Yes,'' you must complete the Line 4i(1) Schedule of 
Assets Held for Investment at End of Year.
[ballot] Yes [ballot] No
    (2) Did the plan have assets held for investment that were sold 
or otherwise disposed of during the plan year (see instructions)? If 
``Yes,'' you must complete the Line 4i(2) Schedule of Assets 
Disposed of During the Plan Year.
[ballot] Yes [ballot] No
    4j [Current, but would require use of specified structured data 
format to complete and file Line 4j Schedule of Reportable 
Transactions] Were any plan transactions or series of transactions 
in excess of 5% of the current value of plan assets? If ``Yes,'' you 
must complete the Schedule of Reportable Transactions. (See 
instructions). Small plans that were eligible for and claimed the 
small plan audit waiver do not need to attach the Line 4j Schedule 
of Reportable Transactions.
[ballot] Yes [ballot] No
    [Part of current Line 4k moved to Form 5500; part moved to Part 
V of Schedule H]
    4k [Current 4l] Has the plan failed to provide any benefit when 
due under the plan?
[ballot] Yes [ballot] No Amount
    4l [Current 4m] If this is an individual account plan, was there 
a blackout period? (See instructions and 29 CFR 2520.101-3.)
[ballot] Yes [ballot] No Amount
    4m [Current 4n] If you answered ``Yes'' to Line 4l, check the 
``Yes'' box here if you either provided the required notice or one 
of the exceptions to providing the notice applied under 29 CFR 
2520.101-3.
[ballot] Yes [ballot] No
    4n [New] Is this a participant-directed individual account plan 
(e.g., a 401(k)-type or 403(b) defined contribution pension plan), 
subject to the requirements in 29 CFR 2550.404a5 to disclose plan 
and investment related information to participants and 
beneficiaries?
[ballot] Yes [ballot] No
    4o [New] If you answered ``Yes'' to Line 4n, did the plan 
provide participants and

[[Page 47584]]

beneficiaries the plan and investment disclosures required under 29 
CFR 2550.404a-5?

[ballot] Yes [ballot] No

    If you answered ``Yes,'' you must attach the investment option 
comparative chart or charts that were used to satisfy the disclosure 
requirement in 29 CFR 2550.404a-5(d)(2).
    4p [New] If you answered ``Yes,'' to Line 4n, enter the number 
of designated investment alternatives (DIAs) available under the 
plan and indicate the number of DIAs that are index funds. Also, 
check all that apply to indicate the types of DIAs available under 
the plan:
[ballot] Domestic Stock/Equity
[ballot] Bond/income
[ballot] Balanced/target allocation
[ballot] Money Market
[ballot] Target date/Lifecycle
[ballot] International/Global Stock/Equity
[ballot] Sector/economy segment
[ballot] Other funds (Describe)

    4q [New] If you answered ``Yes,'' to Line 4n, did the plan make 
available to participants and beneficiaries a designated investment 
manager (DIM)?

[ballot] Yes [ballot] No Enter name of DIM.
    4r [New] If you answered ``Yes,'' to Line 4n, did the plan make 
available to participants and beneficiaries any brokerage window, 
self-directed brokerage account or similar plan arrangements that 
enabled participants to select investments beyond those designated 
by the plan?

[ballot] Yes [ballot] No

    If you answered ``Yes'' to Line 4r, enter the number of 
participants that utilized the account or arrangement
    4s [New] Did the plan trust incur unrelated business taxable 
income (UBTI)?

[ballot] Yes [ballot] No [ballot] NA

    If ``Yes,'' enter amount,
    4t [New] Were all plan assets valued at least annually at fair 
market value?

[ballot] Yes [ballot] No

    4u [New] Did any employer sponsoring the plan pay any of the 
administrative expenses of the plan that were not reported on 
Schedule H, Line 2i?

[ballot] Yes [ballot] No

    4v [New] Did any person who is disqualified under ERISA Section 
411, serve or was permitted to serve the plan in any capacity?

[ballot] Yes [ballot] No

    4w [New] Does the plan have investment acquisitions that are 
leveraged, including assets subject to collateralized lending 
activities (e.g., securities lending arrangements, repurchase 
agreements (repos), etc.)?
[ballot] Yes [ballot] No If ``Yes,'' you must complete Lines 4w(1), 
(2), and (3).
    (1) Check box to indicate type of activity:
[ballot] securities lending, including repurchase agreements or 
sell/buy-backs
[ballot] other, e.g., transactions that subjected plan assets to a 
mortgage, lien, or other security interest (describe)
    (2) (A) amount of cash obligated in connection with 
collateralized lending activities at end of year
    (B) value of securities obligated in connection with 
collateralized lending activities at end of year
    (C) other assets obligated in connection with collateralized 
lending activities at end of year
    (3) approximate ratio of collateralized/leveraged investments to 
total plan assets at end of year
    4x [New] Did the plan sponsor or its affiliates provide any 
services to the plan in exchange for direct or indirect 
compensation?
[ballot] Yes [ballot] No

    4y [New (based on 1998 Line 8a)] Is the plan's summary plan 
description (SPD), including any summary descriptions of 
modifications, in compliance with the content requirements in 29 CFR 
2520.102-3? (See instructions.)

[ballot] Yes [ballot] No

    4z [New] If this is an individual account plan, were there any 
checks to participants or beneficiaries that were uncashed as of the 
end of the plan year? [ballot] Yes [ballot] No. If ``Yes,'' complete 
4z(1)-(4)
    (1) Enter number of uncashed checks
    (2) Enter total value of uncashed checks
    (3) Describe the procedures followed by the plan to verify a 
participant's or beneficiary's address before a check was mailed.
    (4) Describe the procedures followed by the plan to monitor 
uncashed checks, including steps to locate ``missing'' or ``lost'' 
participants.

Part V Termination Information on Accountants, Enrolled Actuaries and 
Other Service Provider

    (See Instructions.) (Complete as many entries as needed.)
    5 [Current Part III of Schedule C except adds check boxes to 
element (c)] Has any accountant or actuary been terminated? [ballot] 
Yes [ballot] No If ``Yes, complete elements (a)-(f).
    5a Name
    5b EIN
    5c [Current element (c), but adds check boxes to distinguish 
between accountant and actuary] Position and title (See 
instructions.)

[ballot] Accountant
[ballot] Actuary
    5d Address
    5e Telephone
    5f Explanation of reason for termination
    6 [New] Have any of the plan's service providers, other than an 
accountant or actuary who has been identified in Line 5, been 
terminated for a material failure to meet the terms of a service 
arrangement or failure to comply with Title I of ERISA, including 
the failure to provide required disclosures under 29 CFR 2550.408b-
2? [ballot] Yes [ballot] No If ``Yes,'' complete elements (a)-(e) to 
identify the service provider.
    6a Name
    6b EIN
    6c Address
    6d Telephone
    6e Explanation of reason for termination
    6f [ballot] Check if termination was due to failure to provide 
required disclosures under 29 CFR 2550.408b-2.

Part VI Plan Termination Information

    7a [Revised to ask about any resolution to terminate regardless 
of when adopted] Has a resolution to terminate the plan been 
adopted? You must continue to report a pending resolution until the 
plan terminates and is no longer filing the Form 5500 Annual Return/
Report. (See instructions.)?
[ballot] Yes [ballot] No If ``Yes,'' complete Line 7a(1)-(3) below:
    (1) [New] Effective date of plan termination:
    (2) [New] Year the plan assets were distributed to plan 
participants and beneficiaries:
    (3) [Current 5a] The amount of plan assets that reverted to the 
employer this year
    7b [Current 5b] Transfer to other plans. Did this plan transfer 
assets or liabilities to another plan since the (20XX-1) filing?
[ballot] Yes [ballot] No If ``Yes,'' complete elements (1)-(5) to 
provide the following information with respect to each plan to which 
the assets or liabilities were transferred. Complete as many entries 
as needed to identify all transfers.
    (1) [Current 5b(2)] EIN
    (2) [Current 5b(3)] PN
    (3) [New] Date of transfer:
    (4) [Current 5b(1)] Name of Plan (Use name on transferee plan's 
Form 5500 Annual Return/Report filing.):
    (5) [New] Type of transfer:

[ballot] Merger
[ballot] Consolidation
[ballot] Spinoff
[ballot] Other (Describe)

    (6) [Part of current Line 4k] Were all plan assets transferred 
to another plan? [ballot] Yes [ballot] No

[Current 5c moved to Form 5500]

    7c [New] Transfers from other plans. Did another plan 
transferred assets or liabilities to this plan since the (20XX-1) 
filing, or in the case of a first plan filing, transfer assets or 
liabilities in conjunction with the creation of this new plan?
[ballot] Yes [ballot] No If ``Yes,'' provide the following 
information with respect to each plan from which assets or 
liabilities were transferred:
    (1) EIN
    (2) PN
    (3) Date of transfer
    (4) Name of Plan (Use name on transferor Plan's Form 5500 Annual 
Return/Report filing.):
    (5) Type of transfer:

[ballot] Merger
[ballot] Consolidation
[ballot] Spinoff
[ballot] Other (Describe)

    7d [New] Terminated Defined Contribution Pension Plans: 
Transfers to Financial Institution. Did this plan, as part of the 
procedures for terminating the plan, transfer plan assets to 
interest bearing federally insured bank accounts in the name of 
missing participants? [ballot] Yes [ballot] No If ``Yes,'' complete 
elements (1)-(5). List each financial institution where plan assets 
were transferred. You must continue reporting this information until 
the final return/report is filed for the plan.

[[Page 47585]]

    (1) Financial Institution's Name
    (2) Financial Institution's EIN
    (3) Date of transfer
    (4) Number of accounts established
    (5) Total amount transferred
    7e [Part of current Line 4k with a new subpart to report the 
year.] Were all the plan assets distributed to participants or 
beneficiaries? [ballot] Yes [ballot] No

Part VI--Trustee Information--[Current Part V but proposed no longer 
optional starting 2016 See IRS Federal Register Notice ``Proposed 
Collection; Comment Request for the Annual Return/Report of Employee 
Benefit Plan'']

    8 Complete as many entries as needed to identify all trusts 
holding plan assets. Do not include trusts that are part of pooled 
investment funds that hold the assets of two or more unrelated 
plans.
    8a [Current] Name of Trust
    8b [Current] Trust EIN
    8c [New] Name of Trustee/Custodian
    (1) [New] Trustee/Custodian Address
    (2) [New] Telephone Number
    (3) [New--intended to be electronic signature] Date and 
Signature of Trustee/Custodian:

Trustee Signature for Purposes of the Code

    SIGN HERE Signature of plan trustee or custodian:
    Enter Date:
    Enter name of individual signing as trustee or custodian:

                                                              Schedule H Line 4a--Schedule of Delinquent Participant Contributions
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
 
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(a) Amount remitted late to plan  (b) Amount due,     (c) Number of       (d)(1) Amount       (e) Amount pending  (f) Amount          (g) Check here if   (h) For any amount  (i)(1) If
 during plan year                  but unremitted      contribution        corrected in VFCP   correction in       corrected outside   participant loan    reported in         reporting for a
                                   during the plan     cycles involved    (2) Amount not       VFCP                VFCP                repayments are      Element (d), did    multiemployer
                                   year                (number of          corrected under                                             included:           you file your IRS   plan, amount, if
                                                       payrolls)           PTE 2002-51.                                                [ballot]            Form 5330 and pay   any, determined
                                                                                                                                                           applicable excise   during the plan
                                                                                                                                                           taxes?              year to be
                                                                                                                                                          [ballot] Yes         uncollectible
                                                                                                                                                           [ballot] No.       (2) Explain what
                                                                                                                                                                               steps were taken
                                                                                                                                                                               to collect
                                                                                                                                                                               overdue amounts
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

    Line 4i(1) Schedule of Assets Held for Investment at End of Year 
(Complete as many entries in each element as needed to identify all 
assets held for investment at end of year)

--------------------------------------------------------------------------------------------------------------------------------------------------------
  (a) Assets Held directly by the plan (including assets held through an participant-directed brokerage window) For each asset which the plan holds for
              investment purposes that is not a type of assets required to be listed in (b) through (e) below, complete elements (i)-(vii).
---------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                       (vii) Description
                                                                                                                                        of  investment,
                                                                                                                                         including, as
                                                                                                                                       applicable, share
                                                                                                                                        class, maturity
                                                                                                                                         date, rate of
                                                                                                                                       interest, par or
                                                                              (iv) CUSIP, CIK,                                          maturity value,
 (i) Check if issuer, borrower,       (ii) Name of      (iii) Is the asset   LEI, NAIC Company                    (vi) Indicate Sch.   including whether
lessor or similar party is party-  issuer, borrower,     a hard-to-value        Code, other         (v) Cost       H, Line 1b asset    asset/investment
      in- interest [ballot]        lessor, or similar  asset? [ballot] Yes      registration                          category.          is subject to
                                         party             [ballot] No            number:                                              surrender charge.
                                                                                                                                       See instructions
                                                                                                                                         for reporting
                                                                                                                                          assets held
                                                                                                                                           through a
                                                                                                                                         participant-
                                                                                                                                      directed brokerage
                                                                                                                                            account.
--------------------------------------------------------------------------------------------------------------------------------------------------------
 
--------------------------------------------------------------------------------------------------------------------------------------------------------
 
--------------------------------------------------------------------------------------------------------------------------------------------------------


--------------------------------------------------------------------------------------------------------------------------------------------------------
    (b) Investments in Master Trust (repeat as many entries as needed to identify holdings in master trusts) For each master trust in which the plan
 invested, break out plan's interest in each asset in the master trust(s) in elements (i)-(viii). Do not include master trust holdings in which the plan
                                                                    has no interest.
---------------------------------------------------------------------------------------------------------------------------------------------------------
                                   (i) Enter name, EIN/PN of sponsor of master trust used on master trust's Form 5500.
---------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                      (viii) Description
                                                                                                                                        of  investment,
                                                                                                                                         including, as
                                                                             (v) Enter all that                                        applicable, share
                                     (iii) Name of     (iv) Is the asset a   apply: EIN, CUSIP,                                         class, maturity
 (ii) Check if issuer, borrower,   issuer, borrower,      hard-to-value        CIK, LEI, NAIC                    (vii) Indicate Sch.     date, rate of
lessor or similar party is party-  lessor, or similar  asset? [ballot] Yes  Company Code, other     (vi) Cost      H, Line 1b asset    interest, par or
      in- interest [ballot]           party  (See          [ballot] No          registration                           category         maturity value,
                                     instructions)                                number:                                              including whether
                                                                                                                                       asset/investment
                                                                                                                                         is subject to
                                                                                                                                       surrender charge.
--------------------------------------------------------------------------------------------------------------------------------------------------------
 
--------------------------------------------------------------------------------------------------------------------------------------------------------
 
--------------------------------------------------------------------------------------------------------------------------------------------------------


[[Page 47586]]


--------------------------------------------------------------------------------------------------------------------------------------------------------
    (c) Investments in PSAs and CCTs (repeat as many entries as needed to identify holdings in PSAs and CCTs) If the PSA filed a Form 5500, complete
   elements (i)-(vii) indicating the value of the plan's shares in the PSA or CCT. For PSAs or CCTs that have not filed a Form 5500, break out plan's
 proportionate interest in each asset in the PSA of CCT in elements (i)-(ix) and include the name and identifying numbers for the non-filing CCT or PSA,
                                       as well a description of the asset held through the non-filing CCT or PSA.
---------------------------------------------------------------------------------------------------------------------------------------------------------
                         (i) Enter name, EIN/PN of sponsor of CCT/PSA.                           (ii) Check if issuer, borrower, lessor or similar party
------------------------------------------------------------------------------------------------              is party-in-interest [ballot]
                                                                                                --------------------------------------------------------
                                                                                                                                       (ix) Description
                                                                                                                                        of investment,
                                                                                                                                         including, as
                                      (iv) Name of                            (vi) ) Enter all                                         applicable, share
(iii) Did the PSA or CCT filed a   issuer, borrower,    (v) Is the asset a    that apply: EIN,                                          class, maturity
    Form 5500 Yes [ballot] No      lessor, or similar     hard-to-value       CUSIP, CIK, LEI,                     (viii) Indicate       date, rate of
            [ballot]                  party  (see      asset? [ballot] Yes   NAIC Company Code:    (vii) Cost      Sch. H, Line 1b     interest, par or
                                     Instructions)         [ballot] No       Other registration                    asset  category      maturity value,
                                                                                  number:                                              including whether
                                                                                                                                       asset/investment
                                                                                                                                         is subject to
                                                                                                                                       surrender charge.
--------------------------------------------------------------------------------------------------------------------------------------------------------
 
--------------------------------------------------------------------------------------------------------------------------------------------------------
 
--------------------------------------------------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
 (d) Investments in 102-12 Investment Entities (repeat as many entries as needed to identify holdings in 103-12
   IEs). For each 103-12IE in which the plan invested, complete elements (i)-(vii) indicating the value of the
                          plan's shares in the in each 103-12IE in elements (i)-(viii).
-----------------------------------------------------------------------------------------------------------------
                        (i)Enter name, EIN of provider of the 103-12 IE.                          (ii) Check if
------------------------------------------------------------------------------------------------     issuer,
                                                                                                    borrower,
                                                                                                    lessor or
                                                                                                  similar party
                                                                                                   is party-in-
                                                                                                     interest
                                                                                                     [ballot]
                                                                                                ----------------
                                                                                                      (viii)
                                                (v) Enter all                                     Description of
                                                 that apply:                                       investment,
                                (iv) Is the      EIN, CUSIP,                                      including, as
    (iii) Name of issuer,     asset a hard-to-  CIK, LEI, NAIC                   (vii) Indicate    applicable,
borrower, lessor, or similar    value asset?    Company Code:      (vi) Cost     Line 1b asset     share class,
  party (See instructions)      [ballot] Yes        Other                          category.      maturity date,
                                [ballot] No      registration                                        rate of
                                                   number:                                        interest, par
                                                                                                   or maturity
                                                                                                      value,
                                                                                                    including
                                                                                                  whether asset/
                                                                                                  investment is
                                                                                                    subject to
                                                                                                    surrender
                                                                                                     charge.
----------------------------------------------------------------------------------------------------------------
 
----------------------------------------------------------------------------------------------------------------
 
----------------------------------------------------------------------------------------------------------------

    Line 4i(2) Schedule of Assets Disposed of During the Plan Year 
[Current elements of Schedule of Assets Acquired and Disposed of 
During Plan Year; element (b) currently unlettered] (Complete as 
many entries as necessary to identify all assets sold during plan 
year

--------------------------------------------------------------------------------------------------------------------------------------------------------
         (a) Enter name, EIN of issuer, borrower, lessor, or similar party           (b) Check if issuer, borrower, lessor or similar party is party-in-
------------------------------------------------------------------------------------                          interest [ballot]
                                                                                    --------------------------------------------------------------------
                                                                                                                                         (j) Description
                                 (d) Enter all                                                                                            of investment,
                               that apply: EIN,                                                                                             including
    (c) Check if asset was     CUSIP, CIK, LEI,  (e) Sch. H, Line                                        (h) Expenses     (i) Net gain    maturity date,
  acquired during plan year      NAIC Company       1b category        (f) Cost         (g) Selling     incurred with      (loss) on         rate of
           [ballot]               Code, Other                                              price         disposal of      transaction       interest,
                                 registration                                                               asset                          collateral,
                                    number:                                                                                                  par, or
                                                                                                                                          maturity value
--------------------------------------------------------------------------------------------------------------------------------------------------------
 
--------------------------------------------------------------------------------------------------------------------------------------------------------
 
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Schedule H, Line 4j--Schedule of Reportable Transactions 
[Current Line 4j Schedule, except (a) is new and remaining elements 
are re-lettered in sequence] Complete as many repeating elements as 
necessary to identify all reportable transactions.

----------------------------------------------------------------------------------------------------------------
  (a) Check here if transaction     (b) Identity of     (c) Description of asset  (include    (d) Purchase price
 involved a person/entity known     party  involved    interest rate and maturity in case of -------------------
to be party-in-interest [ballot] --------------------                 a loan)
---------------------------------                    ----------------------------------------
                                                          (g) Expense                          (i) Current value
                                                         incurred with                            of asset on
        (e) Selling price          (f) Lease rental       transaction      (h) Cost of asset   transaction date
                                                        (including all
                                                             fees)
----------------------------------------------------------------------------------------------------------------
 
----------------------------------------------------------------------------------------------------------------

[New Schedule] Schedule J (Form 5500)--Group Health Plan Information

    For calendar plan year 20XX or fiscal plan year beginning DD/MM/
20XX and ending DD/MM/20XX+1

    A Name of plan
    B Three-digit plan number (PN)
    C Plan sponsor's name as shown on Line 2a of Form 5500
    D Employer Identification Number (EIN)
    Plans that have fewer than 100 participants at the beginning of 
the plan year and are fully insured (see instructions) complete only 
basic identifying information and Part I, Lines 1-8. GIAs must 
complete a separate Schedule J for each participating plan.

Part I--Group Health Plan Characteristics

    1 Approximate number of persons (including participants, 
beneficiaries and dependents of participants) covered under the plan 
at the end of the plan year?

    2 The plan offers health coverage to the following (check all 
that apply):

[ballot] employees

[[Page 47587]]

[ballot] spouses
[ballot] children
[ballot] retirees
[ballot] retirees only

    3 Indicate which of the following types of benefit(s) and design 
characteristics are included under the plan. (Check all that apply):
[ballot] medical/surgical benefits
[ballot] mental health/substance use disorder benefits
[ballot] pharmacy or prescription drug benefits
[ballot] wellness program
[ballot] preventive care services
[ballot] emergency services
[ballot] pregnancy benefits
[ballot] vision
[ballot] dental

    4 Health funding and benefit arrangement (check all that apply):
    4a(1)(a) [ballot] health insurance issuer. If you check this 
box, enter name(s), EIN, and National Insurance Product Registry 
Number of insurance carriers providing benefits under the plan.
    4a(1)(b) If the health funding or benefit arrangement is through 
a prototype/off-the-shelf insurance product, enter the 
identification number of the prototype/off-the-shelf insurance 
product.
    4a(1)(c) Please check whether one or both of the following are 
used to pay premiums:

[ballot] employer contributions
[ballot] participant contributions

    4a(2) [ballot] benefits paid from general assets of the employer

[ballot] employer contributions
[ballot] participant contributions
    4a(3) [ballot] trust

[ballot] employer contributions
[ballot] participant contributions

    5 Check all that apply to the plan:

[ballot] one or more benefit package options claiming grandfathered 
status under the Affordable Care Act
[ballot] high deductible health plan
[ballot] health reimbursement arrangement (HRA) or plan includes an 
HRA
[ballot] health flexible spending account (FSA) or plan includes an 
FSA

    6a How many persons were offered COBRA benefits during the plan 
year?
    6b Of the persons counted in line 6a, how many persons elected 
COBRA benefits?
    6c How many persons were receiving coverage under the plan 
through COBRA during the plan year?
    7a Did the plan or plan sponsor receive any rebates, 
reimbursement, or refunds other than those reported on Schedule A 
from service providers during the plan year? [ballot] Yes [ballot] 
No If ``Yes,'' you must complete Line 7b. If ``No,'' skip to Line 8.
    7b(1) If you answered ``Yes'' to Line 7a, enter separately the 
amount and date received of each rebate, reimbursement, or refund. 
For each rebate, reimbursement, or refund listed, complete elements 
7b(2) and 7b(3).
    (2) Type of service provider that provided each rebate, 
reimbursement, or refund

[ballot] health insurance issuer
[ballot] third-party administrator
[ballot] pharmacy benefit manager
[ballot] other (specify)

    (3) How each rebate, reimbursement, or refund was used (Check 
all that apply):

[ballot] amount returned to participants
[ballot] premium holiday
[ballot] payment of benefits
[ballot] other

    8a If any benefits were provided pursuant to an insurance policy 
that was not reported on Schedule A, were there any premium payment 
delinquencies for premiums due but unpaid during the year? [ballot] 
Yes [ballot] No If ``Yes,'' enter number of times delinquent and for 
each delinquency enter the number of days delinquent
    8b If you answered ``Yes'' to line 8a, indicate whether any 
premium delinquency resulted in a lapse in coverage. If you answered 
``No'' to line 8a, enter ``N/A''. [ballot] Yes [ballot] No [ballot] 
N/A

Part II--Service Provider and Stop Loss Insurance Information

    (Repeat as many line entries as necessary to report all service 
providers under each category that have not already been reported on 
Schedule A or Schedule C.)
    9 Third Party Administrator/Claims Processor, including a health 
insurance issuer subject to an ``administrative services only 
(ASO)'' or other agreement: [ballot] N/A

    a Name, address and telephone number
    b EIN
    c NAIC NPN
    d If third party administrator/claims processing or similar 
services are being provided to the plan through a prototype/off-the-
shelf ASO arrangement, enter the identification number of such 
insurance product

    10 Mental Health Benefits Manager: [ballot] N/A

    a Name, address and telephone number
    b EIN
    c NAIC NPN

    11 Substance Use Disorder Benefits Manager: [ballot] N/A

    a Name, address and telephone number
    b EIN
    c NAIC NPN

    12 Pharmacy Benefit Manager/Drug Provider: [ballot] N/A

    a Name, address and telephone number
    b EIN
    c NAIC NPN

    13 Independent Review Organization: [ballot] N/A

    a Name, address and telephone number
    b EIN
    c NAIC NPN

    14 Wellness Program Manager: [ballot] N/A (may be the same 
contact information for wellness program required under 29 CFR 
2590.702(f)(2)(v)).

    a Name, address and telephone number
    b EIN
    c NAIC NPN

    15 Was there a stop loss policy associated with the plan's 
obligation to pay health benefits? If so, complete the following 
(Include information on all stop loss policies issued in connection 
with plan benefits, including policies with the employer/plan 
sponsor as the insured).

    a Name of insurance carrier
    b EIN
    c NAIC NPN
    d Total premium
    e Attachment point of coverage
    Individual attachment point of coverage (if applicable)
    Aggregate attachment point of coverage (if applicable)
    f Claim Limit
    Individual claim limit (if applicable)
    Aggregate claim limit (if applicable)
    g Policy or contract year from ____ to ____.
    h Check this box if the employer/plan sponsor is the insured 
[ballot]

Part III--Financial Information.

    Plans that complete Schedule H skip to Part IV.
    16 Contributions received during the plan year or receivable as 
of end of plan year:
    a Employer contributions received
    b Employer contributions receivable
    c Participant contributions received
    d Participant contributions receivable
    e Other contributions received or receivable (including non-
cash)
    f Total contributions. Add Lines 16 a-e.
    17 Was there a failure to transmit to the plan any participant 
contributions or repayments as of the earliest date on which such 
contributions can reasonably be segregated from the employer's 
general assets as described in 29 CFR 2510.3-102? [ballot] Yes 
[ballot] No

Part IV--Health Benefit Claims Processing and Payment.

    18a Enter the number of post-service benefit claims submitted 
during the plan year.
    (1) How many of those claims were approved during the plan year?
    (2) How many of those claims were denied during the plan year?
    (3) How many of those claims were pending at the end of the plan 
year?
    18b Enter the number of post-service benefit claim denials 
appealed during the plan year.
    (1) How many of those appeals were upheld during the plan year 
as denials?
    (2) How many of those appeals were overturned and approved 
during the plan year after appeal?
    18c Enter the number of pre-service benefit claims appealed 
during the plan year.
    (1) How many of those appeals were upheld during the plan year 
as denials?
    (2) How many of those appeals were approved during the plan year 
after appeal?
    19 Were there any claims for benefits or appeals of adverse 
benefit determinations that were not adjudicated within the required 
timeframes? [ballot] Yes [ballot] No. If ``Yes,'' enter
    (1) Number of claims
    (2) Number of appeals
    20 Did the plan fail to pay any claims during the plan year 
within one (1) month of being approved for payment? [ballot] Yes 
[ballot] No If ``Yes,'' enter the
    (1) Number of claims not paid within one (1) month
    (2) Total amount not paid within one (1) month

[[Page 47588]]

    (3) Number of claims not paid within three (3) months or longer
    21 Total dollar amount of benefits paid pursuant to claims 
during the plan year.

Part V--Compliance Information. [Current Form 5500 Part III; the move 
limits plans required to complete this part to those providing health 
benefits] Plans that file the Form M-1, skip questions 24-30.

    22a Were all plan assets held in trust, held by an insurance 
company qualified to do business in a State, or as insurance 
contracts or policies issued by such an insurance company? (See 
section 403 of ERISA and 29 CFR 2550.403a-1 and 2550.403b-1)?

[ballot] Yes [ballot] No If you check ``No,'' you must complete Line 
22b.
    22b Check all that apply and enter an explanation if checking 
``Other'':

[ballot] Plan assets not held in trust based on reliance on 
Technical Release 92-01
[ballot] Other (explain)

    23 Are the plan's summary plan description (SPD), including any 
summary descriptions of modifications, and summary of benefits and 
coverage (SBC) in compliance with the applicable content 
requirements? (See instructions.)
    23a Summary Plan Description (SPD): [ballot] Yes [ballot] No
    23b Summary of Benefits and Coverage (SBC) [ballot]Yes 
[ballot]No
    24 Is the coverage provided by the plan in compliance with the 
provisions of the Health Insurance Portability and Accountability 
Act of 1996, as incorporated in ERISA, and the Department's 
regulations thereunder?

[ballot] Yes [ballot] No [ballot] N/A

    25 Is the coverage provided by the plan in compliance with the 
provisions of Title I of the Genetic Information Nondiscrimination 
Act of 2008 as incorporated in ERISA, and the Department's 
regulations issued thereunder?

[ballot] Yes [ballot] No [ballot] N/A

    26 Is the coverage provided by the plan in compliance with the 
Mental Health Parity Act of 1996 and the Paul Wellstone and Pete 
Domenici Mental Health Parity and Addiction Equity Act of 2008 and 
the Department's regulations issued thereunder?

[ballot] Yes [ballot] No [ballot] N/A

    27 Is the coverage provided by the plan in compliance with the 
Newborns' and Mothers' Health Protection Act of 1996 and the 
Department's regulations issued thereunder?
[ballot] Yes [ballot] No [ballot] N/A

    28 Is the coverage provided by the plan in compliance with the 
Women's Health and Cancer Rights Act of 1998?

[ballot] Yes [ballot] No [ballot] N/A

    29 Is the coverage provided by the plan in compliance with 
Michelle's Law?
[ballot] Yes [ballot] No [ballot] N/A

    30 Is the coverage provided by the plan in compliance with the 
Affordable Care Act and the Department's regulations issued 
thereunder?
[ballot] Yes [ballot] No [ballot] N/A

    31a Was the plan subject to the Form M-1 filing requirements 
during the plan year? (See instructions and 29 CFR 2520.101-2.) 
[ballot] Yes [ballot] No If ``Yes'' is checked, complete Lines 31b 
and 31c.
    31b Is the plan currently in compliance with the Form M-1 filing 
requirements? (See instructions and 29 CFR 2520.101-2.) [ballot] Yes 
[ballot] No
    31c Enter the Receipt Confirmation Code for the 20XX Form M-1 
annual report. If the plan was not required to file the 20XX Form M-
1 annual report, enter the Receipt Confirmation Code for the most 
recent Form M-1 that was required to be filed under the Form M-1 
filing requirements. (Failure to enter a valid Receipt Confirmation 
Code will subject the Form 5500 Annual Return/Report filing to 
rejection as incomplete.)

Receipt Confirmation Code

Schedule MB--Multiemployer Defined Benefit Plan and Certain Money 
Purchase Plan Actuarial Information

    [Current header and identifying information] For calendar plan 
year 20XX or fiscal plan year beginning DD/MM/20XX and ending DD/MM/
20XX+1
    A Name of Plan
    B Three-digit plan number (PN)
    C Plan sponsor's name as shown in Line 2a of the Form 5500 or 
5500-SF
    D Employer Identification Number (EIN)
    E Type of plan: (1) [ballot] Multiemployer Defined Benefit (2) 
[ballot] Money Purchase (see instructions)
    1 [Current]
    1a Enter the valuation date:
    1b Assets:
    (1) Current value of assets
    (2) Actuarial value of assets for funding standard account
    1c(1) Accrued liability for plan using immediate gain method
    1c(2) Information for plans using spread gain methods:
    (a) Unfunded liability for methods with bases
    (b) Accrued liability under entry age normal method
    (c) Normal cost under entry age normal method
    1c(3) Accrued liability under unit credit cost method
    1d Information on current liabilities of the plan:
    (1) Amount excluded from current liability attributable to pre-
participation service (see instructions)
    (2) ``RPA '94'' information:
    (a) Current liability
    (b) Expected increase in current liability due to benefits 
accruing during the plan year
    (c) Expected release from ``RPA `94'' current liability for the 
plan year
    (3) Expected plan disbursements for the plan year
    2 [Current] Operational information as of the beginning of this 
plan year:
    a Current value of assets (see instructions)

----------------------------------------------------------------------------------------------------------------
                                                                     (1) Number of
                                                                      participants        (2) Current liability
----------------------------------------------------------------------------------------------------------------
b ``RPA `94'' current liability/participant count breakdown
----------------------------------------------------------------------------------------------------------------
    (1) For retired participants and beneficiaries receiving
     payment
----------------------------------------------------------------------------------------------------------------
    (2) For terminated vested participants
----------------------------------------------------------------------------------------------------------------
    (3) For active participants
----------------------------------------------------------------------------------------------------------------
        (a) Non-vested benefits
        (b) Vested benefits
        (c) Total active
----------------------------------------------------------------------------------------------------------------
    (4) Total
----------------------------------------------------------------------------------------------------------------

    c If the percentage resulting from dividing Line 2a by Line 
2(b)(4), column (2), is less than 70%, enter such percentage.
    3 [Current, except report withdrawal liability payments 
separately from employer contributions and there is minor re-wording 
of Lines 3(b) and (c).] Contributions made to the plan for the plan 
year by employer(s) including withdrawal liability payments and 
contributions to the plan made by employees:

[[Page 47589]]



----------------------------------------------------------------------------------------------------------------
  3 Contributions made to the plan for the plan year by employer(s) including withdrawal liability payments and
                                  contributions to the plan made by employees:
-----------------------------------------------------------------------------------------------------------------
                                       (b) Contribution amount       (c) Withdrawal      (d) Contribution amount
        (a) Date (MM-DD-YYYY)             paid by employers        liability payments       paid by employees
----------------------------------------------------------------------------------------------------------------
 
----------------------------------------------------------------------------------------------------------------
Totals:
----------------------------------------------------------------------------------------------------------------

    4 Information on plan status:
    4a [Current] Funded percentage for monitoring plan's status 
(Line 1b(2) divided by Line 1c(3))
    4b [Current] Enter code to indicate plan's status (see 
instructions for attachment of supporting evidence of plan's 
status). If code is ``N,'' go to Line 5.
    4c [Current] Is the plan making the scheduled progress under any 
applicable funding improvement or rehabilitation plan? [ballot] Yes 
[ballot] No
    4d [Current] If the plan is in critical status or critical and 
declining status, were any benefits reduced (see instructions)? 
[ballot] Yes [ballot] No
    4e [Current] If Line 4d is ``Yes,'' enter the reduction in 
liability resulting from the reduction in benefits (see 
instructions), measured as of the valuation date.
    4f [Current] If the rehabilitation plan projects emergence from 
critical status or critical and declining status, enter the plan 
year in which it is projected to emerge.
    If the rehabilitation plan is based on forestalling possible 
insolvency, check here [ballot] and enter the plan year in which 
insolvency is expected.
    5 [Current instructions and for 2016 as data element, except 
prior Line 5i (Reorganization) is deleted and Lines 5j-n are 
renumbered to reflect MPRA 2014 changes] Actuarial cost method used 
as the basis for the plan year's funding standard account 
computations (check all that apply):
    5a [ballot] Attained age normal
    5b [ballot] Entry age normal
    5c [ballot] Accrued benefit (unit credit)
    5d [ballot] Aggregate
    5e [ballot] Frozen initial liability
    5f [ballot] Individual level premium
    5g [ballot] Individual aggregate
    5h [ballot] Shortfall
    5i [Current Line 5j] [ballot] Other (specify):
    5j [Current Line 5k] If box h is checked, enter period of use of 
shortfall method
    5k [Current Line 5l] Has a change been made in funding method 
for this plan year? [ballot] Yes [ballot] No
    5l [Current Line 5m] If Line 5k is ``Yes,'' was the change made 
pursuant to Revenue Procedure 2000-40 or other automatic approval? 
[ballot] Yes [ballot] No
    5m [Current Line 5n] If Line 5k is ``Yes,'' and line l is 
``No,'' enter the date (MM/DD/YYYY) of the ruling letter (individual 
or class) approving the change in the funding method.
    6 [Current--except that Lines 6(g)(2) and 6(h)(2) with check 
boxes are added to be answered if a statement showing the actuary's 
estimate of the rate of return (actuarial or market value) and 
calculation of the rate is attached.] Checklist of certain actuarial 
assumptions:
[GRAPHIC] [TIFF OMITTED] TP21JY16.000

    7 [Current except that information on amortization charges and 
credits that was previously reported for Lines 9c and 9h as an 
attachment would be reported on Line 7 of the form.]

[[Page 47590]]



----------------------------------------------------------------------------------------------------------------
      Amortization Bases (This will have a variable number of repeating rows; but typically fewer than 50)
-----------------------------------------------------------------------------------------------------------------
                                                                               (4) Years
                                    (2) Outstanding   (3) Valuation date     remaining in      (5) Amortization
        (1) Type of base              balance of           base was          amortization           amount
                                  remaining payments      established           period
----------------------------------------------------------------------------------------------------------------
 
----------------------------------------------------------------------------------------------------------------
Totals:
----------------------------------------------------------------------------------------------------------------

    8 Miscellaneous information:
    8a [Current] If a waiver of a funding deficiency has been 
approved for this plan year, enter the date (MM/DD/YYYY) of the 
letter ruling granting the approval.
    8b(1)(a) [Current] Is the plan required to provide a projection 
of expected benefit payments? [ballot] Yes [ballot] No
    8b(1)(b) [Current except moved to the face of the form] If 
8b(1)(a) is ``Yes,'' complete the schedule below:

------------------------------------------------------------------------
                               Schedule of Projection of Expected Annual
          Plan Year                         Benefit Payments
------------------------------------------------------------------------
Current plan year
------------------------------------------------------------------------
Current plan year plus 1
------------------------------------------------------------------------
Etc.
------------------------------------------------------------------------
Current plan year plus 9
------------------------------------------------------------------------

    8b(2)(a) [Current] Is the plan required to provide a Schedule of 
Active Participant Data ? (see instructions) [ballot] Yes [ballot] 
No
    8b(2)(b) [Current except moved to the face of the form] If 
8b(2)(a) is ``Yes,'' complete the schedule below and items 8b(2)(c) 
and 8b(2)(d).
[GRAPHIC] [TIFF OMITTED] TP21JY16.001

    8b(2)(c) [New] Average age of active participants as of the 
valuation date
    8b(2)(d) [New] Average credited service of active participants 
as of the valuation date
    8b(3)(a) [New] Is the plan required to provide a Schedule of 
Retired Participants and Beneficiaries Receiving Payment Data? (See 
the instructions) [ballot] Yes [ballot] No
    8b(3)(b) [New] If 8b(3)(a) is ``Yes,'' complete the schedule 
below and items 8b(3)(c) and 8b(3)(d).

  Schedule of Retired Participants and Beneficiaries Receiving Payment
                                  Data
------------------------------------------------------------------------
                                                     Average Annual In-
        Attained Age                 Number          Pay Benefit Amount
------------------------------------------------------------------------
Under 55
------------------------------------------------------------------------
55 to 59
------------------------------------------------------------------------
Etc.
------------------------------------------------------------------------
90 and up
------------------------------------------------------------------------

    8b(3)(c) [New] Average Age for Retired Participants and 
Beneficiaries as of the valuation date
    8b(3)(d) [New] Average Annual In-Pay Benefit for Retired 
Participants and Beneficiaries as of the valuation date
    8b(4)(a) [New] Is the plan required to provide a Schedule of 
Terminated Vested Participant Data? (See the instructions) [ballot] 
Yes [ballot] No
    8b(4)(b) [New] If 8b(4)(a) is ``Yes,'' complete the schedule 
below and items 8b(4)(c) through 8b(4)(f).

[[Page 47591]]



             Schedule of Terminated Vested Participant Data
------------------------------------------------------------------------
                                                       Average Annual
        Attained Age                 Number            Benefit Amount
------------------------------------------------------------------------
Under 25
------------------------------------------------------------------------
25 to 29
------------------------------------------------------------------------
Etc.
------------------------------------------------------------------------
70 and up
------------------------------------------------------------------------

    8b(4)(c) [New] Average age of terminated vested participants as 
of the valuation date
    8b(4)(d) [New] Average annual benefit of terminated vested 
participants as of the valuation date
    8b(4)(e) [New] Assumed form of payment shown
    8b(4)(f) [New] Assumed age of first payment for benefits shown
    8c [Current] Are any of the plan's amortization bases operating 
under an extension of time under section 412(e) (as in effect prior 
to 2008) or section 431(d) of the Code? [ballot] Yes [ballot] No
    8d [Current] If Line 8c is ``Yes,'' provide the following 
additional information:
    (1) Was an extension granted automatic approval under section 
431(d)(1) of the Code? [ballot] Yes [ballot] No
    (2) If Line 8d(1) is ``Yes,'' enter the number of years by which 
the amortization period was extended.
    (3) Was an extension approved by the Internal Revenue Service 
under section 412(e) (as in effect prior to 2008) or 431(d)(2) of 
the Code? [ballot] Yes [ballot] No
    (4) If Line 8d(3) is ``Yes,'' enter the number of years by which 
the amortization period was extended (not including the number of 
years in Line (2))
    (5) If Line 8d(3) is ``Yes,'' enter the date of the ruling 
letter approving the extension
    (6) If Line 8d(3) is ``Yes,'' is the amortization base eligible 
for amortization using interest rates applicable under section 
6621(b) of the Code for years beginning after 2007? [ballot] Yes 
[ballot] No
    8(e) [Current] If box 5h is checked or Line 8c is ``Yes,'' enter 
the difference between the minimum required contribution for the 
year and the minimum that would have been required without using the 
shortfall method or extending the amortization base(s).
    Line 9 [Current, except a check box is added to Line 9f to be 
answered if an explanation of a prior year credit balance/funding 
deficiency discrepancy is attached.]

[[Page 47592]]

[GRAPHIC] [TIFF OMITTED] TP21JY16.002


[[Page 47593]]


    10 [Current] Contribution necessary to avoid an accumulated 
funding deficiency (see instructions)
    11 [Current] Has a change been made in the actuarial assumptions 
for the current plan year?
    If ``Yes,'' see instructions. [ballot] Yes [ballot] No
    Statement by Enrolled Actuary [Current, except that information 
previously reported on an attachment per the instructions will be 
reported on the Schedule.] To the best of my knowledge, the 
information supplied in this schedule and accompanying schedules, 
statements, and attachments, if any, is complete and accurate. Each 
prescribed assumption was applied in accordance with applicable law 
and regulations. In my opinion, each other assumption is reasonable 
(taking into account the experience of the plan and reasonable 
expectations) and such other assumptions, in combination, offer my 
best estimate of anticipated experience under the plan.

Signature of actuary

    Date
    Type or print name of actuary
    Most recent enrollment number
    Firm name
    Telephone number (including area code)
    Address of firm
    If the actuary has not fully reflected any regulation or ruling 
promulgated under the statute in completing this schedule, provide 
the information requested in the instructions in this line and check 
here [ballot]

SCHEDULE R (Form 5500) Retirement Plan Information

    [Current header and identifying information] For calendar plan 
year 20XX or fiscal plan year beginning DD/MM/20XX and ending DD/MM/
20XX+1
    A Name of plan
    B Three-digit plan number (PN)
    C Plan sponsor's name as shown on line 2a of Form 5500
    D Employer Identification Number (EIN)

Part I Distributions.

    All references to distributions relate only to payments of 
benefits during the plan year.
    1 [Current] Total value of distributions paid in property other 
than in cash or the forms of property specified in the instructions
    2 [Current] 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):
    EIN(s):
    Profit-sharing plans, ESOPs, and stock bonus plans, skip Line 3.
    3 [Current Line 3, with new breakout numbers for active, 
terminated vested, retired] Number of participants (living or 
deceased) whose benefits were distributed in a single sum, during 
the plan year
    [Columns for (1) number of participants/(2) payment of 
annuities/(3) payment of lump sums]
    Active
    Terminated Vested
    Retired
    4 [New] Were required minimum distributions made to 5% owners 
who have attained age 70 \1/2\ (regardless of whether or not 
retired) as required under section 401(a)(9) of the Internal Revenue 
Code? [ballot] Yes [ballot] No [ballot] N/A

Part II Funding Information

    (If the plan is not subject to the minimum funding requirements 
of section of 412 of the Internal Revenue Code or ERISA section 302, 
skip this Part)
    5 [Current Line 4] Is the plan administrator making an election 
under Code section 412(d)(2) or ERISA section 302(d)(2)? [ballot] 
Yes [ballot] No [ballot] N/A
    If the plan is a defined benefit pension plan, go to Line 9.
    6 [Current Line 5] If a waiver of the minimum funding standard 
for a prior year is being amortized in this plan year, see 
instructions and enter the date of the ruling letter granting the 
waiver.
    If you completed Line 6, complete Lines 3, 9, and 10 of Schedule 
MB and do not complete the remainder of this schedule.
    7a [Current Line 6] Enter the minimum required contribution for 
this plan year (include any prior year accumulated funding 
deficiency not waived).
    7b [Current] Enter the amount contributed by the employer to the 
plan for this plan year
    7c [Current] Subtract the amount in Line 7b from the amount in 
Line 7a. Enter the result (enter a minus sign to the left of a 
negative amount)
    If you completed line 7c, skip Lines 9 and 10.
    8 [Current Line 7] Will the minimum funding amount reported on 
Line 7c be met by the funding deadline? [ballot] Yes [ballot] No 
[ballot] N/A
    9 [Current Line 8] If a change in actuarial cost method was made 
for this plan year pursuant to a revenue procedure or other 
authority providing automatic approval for the change or a class 
ruling letter, does the plan sponsor or plan administrator agree 
with the change?
[ballot] Yes [ballot] No [ballot] N/A

Part III Determination and Amendment

    10 [Current Line 9] If this is a defined benefit pension plan, 
were any amendments adopted during this plan year that increased or 
decreased the value of benefits? If ``Yes,'' check the appropriate 
box. If no, check the ``No'' box'': [ballot] Increase [ballot] 
Decrease [ballot] Both [ballot] No
    11a [Current 2016 Line 22a] If the plan is a master and 
prototype plan (M&P) or volume submitter plan that received a 
favorable IRS opinion letter or advisory letter, enter the date of 
the letter _/_/_ and the serial number ___
    11b [Current 2016 Line 22b] If the plan is an individually-
designed plan that received a favorable determination letter from 
the IRS, enter the date of most recent determination letter: _/_/_.
    [Current Part IV ESOPs--moved to new Schedule E]

Part IV [current Part V] Additional Information for Multiemployer 
Defined Benefit Pension Plans

    12 [Current Line 13] Enter the following information for each 
employer that contributed more than 5% of total contributions to the 
plan during the plan year (measured in dollars). See instructions. 
Complete as many entries as needed to report all applicable 
employers.
    a Name of contributing employer
    b EIN
    c Dollar amount contributed by employer
    d Date collective bargaining agreement expires (If employer 
contributes under more than one collective bargaining agreement, 
check box [ballot] and see instructions regarding required 
attachment. Otherwise, enter the applicable date.)
    e Contribution rate information (If more than one rate applies, 
check this box [ballot] and see instructions regarding required 
attachment. Otherwise, complete Lines 12e(1) and 12e(2).)
    (1) Contribution rate (in dollars and cents)
    (2) Base unit measure:

[ballot] Hourly
[ballot] Weekly
[ballot] Unit of production
[ballot] Other (specify)

    13 [Current Line 14] Enter the number of participants on whose 
behalf no contributions were made by an employer as an employer of 
the participant for:
    a The current year
    b The plan year immediately preceding the current plan year
    c The second preceding plan year
    14. [Current Line 15] Enter the ratio of the number of 
participants under the plan on whose behalf no employer had an 
obligation to make an employer contribution during the current plan 
year to:
    a The corresponding number for the plan year immediately 
preceding the current plan year
    b The corresponding number for the second preceding plan year
    15 [Current Line 16] Information with respect to any employers 
who withdrew from the plan during the preceding plan year:
    a Enter the number of employers who withdrew during the 
preceding plan year:
    b If Line 15a is greater than 0, enter the aggregate amount of 
withdrawal liability assessed or estimated to be assessed against 
such withdrawn employers.
    16 [Current Line 17] If assets and liabilities from another plan 
have been transferred to or merged with this plan during the plan 
year, check box and see instructions regarding supplemental 
information to be included as an attachment. [ballot]

[[Page 47594]]

Part V [Current Part VI] Additional information for Single-Employer and 
Multiemployer Defined Benefit Pension Plans

    17 [Current Line 18] If any liabilities to participants or their 
beneficiaries under the plan as of the end of the plan year consist 
(in whole or in part) of liabilities to such participants and 
beneficiaries under two or more pension plans as of immediately 
before such plan year, check box and see instructions regarding 
supplemental information to be included as an attachment. [ballot]
    18 [Current Line 19] If the total number of participants is 
1,000 or more, complete Lines (a) through (c)
    a Enter the percentage of plan assets held as:
    Stock:
    Investment-Grade Debt:
    High-Yield Debt:
    Real Estate:
    Other:

    b Provide the average duration of the combined investment-grade 
and high-yield debt:

[ballot] 0-3 years
[ballot] 3-6 years
[ballot] 6-9 years
[ballot] 9-12 years
[ballot] 12-15 years
[ballot] 15-18 years
[ballot] 18-21 years
[ballot] 21 years or more

    c What duration measure was used to calculate Line 18(b)?
[ballot] Effective duration [ballot] Macaulay duration [ballot] 
Modified duration [ballot] Other (specify)

Part VI [New Part; all of these questions on IRS List for 2015 changes 
and published in draft on the IRS's Form 5500-SUP]

    Nondiscrimination and Coverage
    19a If this is a section 401(k) plan, check the correct box to 
indicate how the plan is intended to satisfy the nondiscrimination 
requirements for employee deferrals and employer matching 
contributions (as applicable) under section 401(k)(3) and 401(m)(2)?
[ballot] Design-based safe harbor method [ballot] ADP/ACP test 
[ballot] Both

    b If the ADP test is used, did the plan perform ADP testing for 
the plan year using the ``current year testing method'' for 
nonhighly compensated employees (Treas. Reg. sections 1.401(k)-
2(a)(2)(ii) [ballot] Yes [ballot] No
    20a Check the box to indicate the method used by the plan to 
satisfy the coverage requirements under section 410(b): [ballot] 
ratio percentage test [ballot] average benefit test [ballot] N/A
    b Does the plan satisfy the coverage and nondiscrimination tests 
of sections 410(b) and 401(a)(4) by combining this plan with any 
other plans under the permissive aggregation rules?

[ballot] Yes [ballot] No

    21 If this is a defined benefit pension plan, does the plan 
comply with Code section 401(a)(26) participation requirements?

[ballot] Yes [ballot] No

Part VII [New Part/New Questions]

    Participation Information in Defined Contribution Pension Plans 
(Only defined contribution pension plans need to complete this 
Part.)
    22a Were employees participating in the plan eligible to receive 
employer contributions even if they did not make any elective 
deferrals?
[ballot] Yes [ballot] No If ``Yes,'' answer Line 22b.

    22b Check the appropriate box to indicate how the employer's 
contribution is calculated and enter the percent or dollar amount or 
other formula:

[ballot] % of a participant's compensation (provide percentage)
[ballot] $ per participant (provide amount)
[ballot] Other (specify)

    23a Does the plan provide for employer matching contributions 
contingent on employee elective deferrals? [ballot] Yes [ballot] No 
If ``Yes,'' answer Line 23b-d.

    23b Check the appropriate box and enter the percentage, amount 
or formula to indicate the minimum elective deferrals necessary to 
qualify for an employer matching contribution (if there is no 
minimum, check ``other'' and enter ``none''):

[ballot] % of a participant's contribution up to a limit (provide 
percentage)
[ballot] $ per participant (provide amount)
[ballot] Other (specify)

    23c Check the appropriate box and enter the percentage, amount 
or other formula to indicate the maximum employer matching 
contribution under the terms of the plan.

[ballot] % of a participant's compensation (provide percentage)
[ballot] $ per participant (provide amount)
[ballot] Other (Specify)

    23d Enter the number of participants making sufficient elective 
deferrals to receive the maximum employer match.
    24a Does the plan have automatic enrollment? [ballot] Yes 
[ballot] No If ``Yes,'' answer Lines 24b(1)-(3).
    24b (1) Enter the default elective deferral as a percentage of a 
participant's compensation in the first year after a participant is 
automatically enrolled?
    (2) Does the plan have automatic escalation, assuming a 
participant has made no active elections? [ballot] Yes [ballot] No 
If ``Yes,'' enter the maximum elective deferral as a percentage of a 
participant's compensation.
    (3) Enter the number of participants that have not made any 
investment decisions and remain in the plan's default investment 
account(s):
    25 Enter the number of participants making catch-up 
contributions.

Schedule SB--Single-Employer Defined Benefit Plan Actuarial Information

    [Current header and identifying information] For calendar plan 
year 20XX or fiscal plan year beginning DD/MM/20XX and ending DD/MM/
20XX+1
    A Name of Plan
    B Three-digit plan number (PN)
    C Plan sponsor's name as shown in Line 2a of the Form 5500 or 
5500-SF
    D Employer Identification Number (EIN)
    E Type of plan: [ballot] Single [ballot] Multiple-A [ballot] 
Multiple-B
    F Prior year plan size: [ballot] 100 or fewer [ballot] 101-500 
[ballot] More than 500

Part I Basic Information

    1 [Current] Enter the valuation date:
    2 [Current] Assets:
    a Market value
    b Actuarial value

----------------------------------------------------------------------------------------------------------------
                             3 [Current] Funding target/participant count breakdown
-----------------------------------------------------------------------------------------------------------------
                                            (1) Number of          (2) Vested Funding       (3) Total Funding
                                             participants                Target                   Target
----------------------------------------------------------------------------------------------------------------
a For retired participants and
 beneficiaries receiving payment
----------------------------------------------------------------------------------------------------------------
b For terminated vested participants
----------------------------------------------------------------------------------------------------------------
c For active participants
----------------------------------------------------------------------------------------------------------------
d Total
----------------------------------------------------------------------------------------------------------------

    4 Current, except that allocation of total must be completed by 
participant groups and formatting (1), (2), etc. changed to conform 
to other tables on the form.] If the plan is in at-risk status, 
check the box and complete Lines (a) through (d) [ballot]

[[Page 47595]]



------------------------------------------------------------------------
                                                     (2) Funding target
                                                     reflecting at-risk
                                                      assumptions, but
                                                        disregarding
                               (1) Funding target    transition rule for
                                  disregarding      plans that have been
                               prescribed at-risk     in at-risk status
                                   assumptions       for fewer than five
                                                      consecutive years
                                                      and disregarding
                                                       loading factor
------------------------------------------------------------------------
a For retired participants
 and beneficiaries receiving
 payment
------------------------------------------------------------------------
b For terminated vested
 Participants
------------------------------------------------------------------------
c For active participants
------------------------------------------------------------------------
Total
------------------------------------------------------------------------

    5 [Current] Effective interest rate __%
    6 Target normal cost [Current, except allocation of plan-related 
expenses separated from the target normal cost.].
    a [New allocation] Target normal cost (without plan expenses)
    b [New allocation] Plan-related expenses
    c Total [Reflects current Line 6]

Part II Beginning of Year Carryover and Prefunding Balances

[[Page 47596]]

[GRAPHIC] [TIFF OMITTED] TP21JY16.003

    14 [Current instructions for Line 7 with minor rewording, 
checkbox added] If Line 7 does not equal Line 13 from the prior 
year, provide an explanation in this line and check here [ballot]
    15 [Current instructions for Line 8 with minor rewording, 
checkbox added] If Line 8 reflects a late election to apply the 
balances to quarterly installments, provide an explanation in this 
line and check here [ballot]
    16 [Current instructions for Line 9 with minor rewording, 
checkbox added] If Line 9 has been adjusted so that it does not 
match the amount for the pre-effective date plan year, provide an 
explanation in this line and check here [ballot]

Part III Funding Percentages

    17 [Current Line 14] Funding target attainment percentage __%
    18 Adjusted funding target attainment
    a [Current Line 15] Adjusted funding target attainment 
percentage __%
    b [Current instructions for Line 15 with minor rewording, 
checkbox added] If an attachment is included reconciling differences 
between valuation results and amounts used to calculate the AFTAP, 
check here [ballot]
    19 [Current Line 16] Prior year's funding percentage for 
purposes of determining whether carryover/prefunding balances may be 
used to reduce current year's funding requirement __%
    20 [Current Line 17] If the current value of the assets of the 
plan is less than 70 percent of the funding target, enter such 
percentage __%

Part IV Contributions and Liquidity Shortfalls

[[Page 47597]]



--------------------------------------------------------------------------------------------------------------------------------------------------------
                        21 [Current line 18 and line 19 attachment] Contributions made to the plan by employer(s) and employees:
---------------------------------------------------------------------------------------------------------------------------------------------------------
             (a)                      (b)               (c)               (d)               (e)              (f)              (g)              (h)
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                         Discounted/
                                                   Plan year to                       Number of days      increased
                                Amount paid by         which       Interest rate to     to discount        employer      Allocation to    Amount paid by
      Date (MM/DD/YYYY)           employer(s)      contribution     adjust employer      employer       contributions    contributions      employees
                                                      applies        contributions     contributions     at valuation      in line 22
                                                                                                             date
--------------------------------------------------------------------------------------------------------------------------------------------------------
 
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total
--------------------------------------------------------------------------------------------------------------------------------------------------------

    22 [Current Line 19] Discounted employer contributions--see 
instructions for small plans with a valuation date after the 
beginning of the year:
    a Contributions allocated toward unpaid minimum required 
contributions for prior years
    b Contributions made to avoid restrictions adjusted to valuation 
date
    c Contributions allocated toward minimum required contribution 
for current year adjusted to valuation date
    23 [Current Line 20, except new checkbox added to Line 23c.] 
Quarterly contributions and liquidity shortfalls:
    a Did the plan have a ``funding shortfall'' for the prior year? 
[ballot] Yes [ballot] No
    b If Line 23a is ``Yes,'' were required quarterly installments 
for the current year made in a timely manner? [ballot] Yes [ballot] 
No
    c [Minor rewording of the question and new check box added] If 
Line 23a is ``Yes,'' see instructions. If a liquidity requirement 
certification is attached, complete the following table as 
applicable and check here [ballot]:

----------------------------------------------------------------------------------------------------------------
                         Liquidity shortfalls as of the end of quarter of this plan year
-----------------------------------------------------------------------------------------------------------------
               (1) 1st                         (2) 2nd                  (3) 3rd                  (4) 4th
----------------------------------------------------------------------------------------------------------------
 
----------------------------------------------------------------------------------------------------------------
 
----------------------------------------------------------------------------------------------------------------

Part V Assumptions Used to Determine Funding Target and Target Normal 
Cost --

    24 [Current Line 21] Discount rate:

----------------------------------------------------------------------------------------------------------------
                                                a Segment rates:
-----------------------------------------------------------------------------------------------------------------
                                                                                            [ballot] N/A, full
            1st segment: %                  2nd segment: %           3rd segment: %          yield curve used
----------------------------------------------------------------------------------------------------------------
%                                      %......................  %......................
 
----------------------------------------------------------------------------------------------------------------

    b Applicable month (enter code)
    25 [Current Line 22] Weighted average retirement age
    26 [Current Line 23] Mortality Table(s):
    26a Mortality table(s) (see instructions) [ballot] Prescribed--
combined [ballot] Prescribed separate [ballot] Substitute
    26b [Attachment to current Line 23, new checkbox added.] If more 
than one mortality table was used, provide an explanation in this 
line describing the mortality table used for each population and the 
size of that population and check here. [ballot]
    26c [Attachment to current Line 23, new checkbox added.] If 
substitute mortality tables are used, provide in this line of a 
summary of plan populations for which substitute mortality tables 
are used, plan populations for which the prescribed tables are used, 
and the last plan year for which IRS approval of the substitute 
mortality tables applies and check here [ballot].

Part VI Miscellaneous Items

    27 [Current Line 24] Has a change been made in the non-
prescribed actuarial assumptions for the current plan year? If 
``Yes,'' see instructions regarding required attachment [ballot] Yes 
[ballot] No.
    28 [Current Line 25, minor rewording, new checkbox added.] If a 
method change has been made for the current plan year, provide a 
description of the change in this line and check here. [ballot]
    29 Participant schedules
    29a(i) [Current Line 26] Is the plan required to provide a 
Schedule of Active Participant Data? (See instructions) [ballot] Yes 
[ballot] No
    a(ii) [Current Line 26 instructions moved to the face of the 
form] If 29a(i) is ``Yes,'' complete the schedule below and items 
29a(iii) and (iv). If the plan is hard frozen and average annual 
accrued benefit data is entered instead of average compensation 
data, check this box [ballot] (see instructions)

[[Page 47598]]

[GRAPHIC] [TIFF OMITTED] TP21JY16.004

    a(iii) [New] Average age of active participants as of the 
valuation date
    a(iv) [New] Average credited service of active participants as 
of the valuation date
    29b(i) [New] Is the plan required to provide a Schedule of 
Retired Participants and Beneficiaries Receiving Payment Data?(See 
instructions) [ballot] Yes [ballot] No.
    b(ii) [New] If 29b(i) is ``Yes,'' complete the schedule below 
and items 29b(iii) and b(iv).

  Schedule of Retired Participants and Beneficiaries Receiving Payment
                                  Data
------------------------------------------------------------------------
                                                     Average Annual In-
        Attained Age                 Number          Pay Benefit Amount
------------------------------------------------------------------------
Under 55
------------------------------------------------------------------------
55 to 59
------------------------------------------------------------------------
Etc.
------------------------------------------------------------------------
90 and up
------------------------------------------------------------------------

    b(iii) [New] Average Age for Retired Participants and 
Beneficiaries as of the valuation date
    b(iv) [New] Average Annual In-Pay Benefit for Retired 
Participants and Beneficiaries as of the valuation date
    29c(i) [New] Is the plan required to provide a Schedule of 
Terminated Vested Participant Data? (See the instructions) [ballot] 
Yes [ballot] No
    c(ii) [New] If c(i)(a) is ``Yes,'' complete the schedule below 
and items c(iii) through c(vi).

             Schedule of Terminated Vested Participant Data
------------------------------------------------------------------------
                                                     Average Annual In-
        Attained Age                 Number          Pay Benefit Amount
------------------------------------------------------------------------
Under 25
------------------------------------------------------------------------
25 to 29
------------------------------------------------------------------------
Etc.
------------------------------------------------------------------------
70 and up
------------------------------------------------------------------------

    c(iii) [New] Average age of terminated vested participants as of 
the valuation date
    c(iv) [New] Average annual benefit of terminated vested 
participants as of the valuation date
    c(v) [New] Assumed form of payment shown
    c(vi) [New] Assumed age of first payment for benefits shown
    30a [New] Is the plan required to provide a projection of 
expected benefit payments? (see instructions) [ballot] Yes [ballot] 
No
    b [New] If ``Yes,'' complete the schedule below:

------------------------------------------------------------------------
                                            Schedule of Projection of
               Plan Year                     Expected Annual Benefit
                                                     Payments
------------------------------------------------------------------------
Current plan year
------------------------------------------------------------------------
Current plan year plus 1
------------------------------------------------------------------------
Etc.
------------------------------------------------------------------------
Current plan year plus 9                 ...............................
------------------------------------------------------------------------


[[Page 47599]]

    31 [Current Line 27] If the plan is subject to the alternative 
funding rules, enter applicable code and see instructions regarding 
attachment

Part VII Reconciliation of Unpaid Minimum Required Contributions For 
Prior Years

    32 [Current Line 28] Unpaid minimum required contributions for 
all prior years
    33 [Current Line 29; reference updated] Discounted employer 
contributions allocated toward unpaid minimum required contributions 
from prior years [Current Line 19a] (Line 22a)
    34 [Current Line 30; references updated] Remaining amount of 
unpaid minimum required contributions [Current Line 28 minus Line 
29] (Line 32 minus Line 33)

Part VIII Minimum Required Contribution For Current Year

    35 [Current Line 31] Target normal cost and excess assets (see 
instructions):
    a [Current Line 6] Target normal cost (Line 6c)
    b [Current] Excess assets, if applicable, but not greater than 
Line 35a
    36 [Current Line 32]

------------------------------------------------------------------------
  Amortization Installments    Outstanding balance       Installment
------------------------------------------------------------------------
a Net shortfall amortization
 installment
------------------------------------------------------------------------
b Waiver amortization
 installment
------------------------------------------------------------------------

    [Current attachment] Schedule of Amortization Bases

----------------------------------------------------------------------------------------------------------------
                                            Amortization installments
-----------------------------------------------------------------------------------------------------------------
                                                                              (iv) Years
                                  (ii) Present value    (iii) Valuation      remaining in      (v) Current year
        (i) Type of base             of remaining        date base was       amortization         installment
                                     installments         established           period
----------------------------------------------------------------------------------------------------------------
 
----------------------------------------------------------------------------------------------------------------
Total
----------------------------------------------------------------------------------------------------------------

    37 [Current Line 33] If a waiver has been approved for this plan 
year, enter the date of the ruling letter granting approval (Month/
Day/Year) and the waived amount
    38 [Current Line 34; reflects renumbering of references] Total 
funding requirement before reflecting carryover/prefunding balances 
[Current Lines 31a-31b + 32a + 32b -33] (Lines 35a-35b + 36a + 36b-
37)

----------------------------------------------------------------------------------------------------------------
                                          Carryover balance        Prefunding balance         Total balance
----------------------------------------------------------------------------------------------------------------
39 [Current Line 35] Balances elected
 for use to offset funding
 requirement.
----------------------------------------------------------------------------------------------------------------

    40 [Current Line 36; reflects renumbering of references] 
Additional cash requirement [Current Line 34 minus Line 25] (Line 38 
minus Line 39)
    41 [Current Line 37; reflects renumbering of reference] 
Contributions allocated toward minimum required contribution for 
current year adjusted to valuation date [Current Line 19c] (Line 
22c)
    42 [Current Line 38; reflects renumbering of references] Present 
value of excess contributions for current year (see instructions)
    a Total [Current Line 37 over Line 36] (excess, if any, of Line 
41 over Line 40)
    b Portion included in [Current Line 38a] Line 42a attributable 
to use of prefunding and funding standard carryover balances
    43 [Current Line 39; reflects renumbering of references] Unpaid 
minimum required contribution for current year [Current Line 36 over 
Line 37] (excess, if any, of Line 40 over Line 41)
    44 [Current Line 40; reflects renumbering of references] Unpaid 
minimum required contributions for all years

Part IX Pension Funding Under Pension Relief Act of 2010 (See 
Instructions)

    45 [Current Line 41; reflects renumbering of references] If an 
election was made to use PRA 2010 funding relief for this plan:
    a Schedule elected [ballot] 2 plus 7 years [ballot] 15 years
    b Eligible plan year(s) for which the election in [Current Line 
41a] Line 45a was made [ballot] 2008 [ballot] 2009 [ballot] 2010 
[ballot] 2011
    46 [Current Line 42] Amount of acceleration adjustment
    47 [Current Line 43] Excess installment acceleration amount to 
be carried over to future plan years
    Statement by Enrolled Actuary--Current--except that information 
previously reported on an attachment per the instructions will be 
reported on the Schedule.
    To the best of my knowledge, the information supplied in this 
schedule and accompanying schedules, statements, and attachments, if 
any, is complete and accurate. Each prescribed assumption was 
applied in accordance with applicable law and regulations. In my 
opinion, each other assumption is reasonable (taking into account 
the experience of the plan and reasonable expectations) and such 
other assumptions, in combination, offer my best estimate of 
anticipated experience under the plan.
    Signature of actuary
    Date
    Type or print name of actuary
    Most recent enrollment number
    Firm name
    Telephone number (including area code)
    Address of firm
    If the actuary has not fully reflected any regulation or ruling 
promulgated under the statute in completing this schedule, provide 
the information requested in the instructions in this line and check 
here [ballot]

APPENDIX B

20XX Instructions for Form 5500 Annual Return/Report of Employee 
Benefit Plan

    Code section references are to the Internal Revenue Code unless 
otherwise noted. ERISA refers to the Employee Retirement Income 
Security Act of 1974.

EFAST2 Processing System

    Under the computerized ERISA Filing Acceptance System (EFAST2), 
you must electronically file your 20XX Form 5500. Your Form 5500 
entries will be initially screened electronically. For more 
information, see the instructions for Electronic Filing Requirement 
and the EFAST2 Web site at www.efast.dol.gov. You cannot file a 
paper Form 5500 Annual Return/Report by mail or other delivery 
service.

About the Form 5500

    The Form 5500, Annual Return/Report of Employee Benefit Plan, 
including all required schedules and attachments (Form

[[Page 47600]]

5500 Annual Return/Report), is used to report information concerning 
employee benefit plans and Direct Filing Entities (DFEs). Any 
administrator or sponsor of an employee benefit plan subject to 
ERISA must file information about each benefit plan every year 
(pursuant to Code section 6058 and ERISA sections 104 and 4065). 
Some plans participate in certain trusts, accounts, and other 
investment arrangements that file the Form 5500 Annual Return/Report 
as DFEs. See Who Must File and When To File.
    The Internal Revenue Service (IRS), Department of Labor (DOL), 
and Pension Benefit Guaranty Corporation (PBGC) have consolidated 
certain returns and report forms to reduce the filing burden for 
plan administrators and employers. Employers and administrators who 
comply with the instructions for the Form 5500 generally will 
satisfy the annual reporting requirements for the DOL under Title I 
of ERISA and for PBGC under Title IV of ERISA and for the IRS under 
Code sections 6057(b), 6058, and 6059.
    Defined contribution and defined benefit pension plans may have 
to file additional information with the IRS, including Form 5330, 
Return of Excise Taxes Related to Employee Benefit Plans, Form 5310-
A, Notice of Plan Merger or Consolidation, Spinoff, or Transfer of 
Plan Assets or Liabilities; Notice of Qualified Separate Lines of 
Business, and Form 8955-SSA, Annual Registration Statement 
Identifying Separated Participants with Deferred Vested Benefits. 
See www.irs.gov for more information.
    Plans covered by the PBGC have special additional requirements, 
including premiums and reporting certain transactions directly with 
that agency. See PBGC's Web site (www.pbgc.gov/practitioners/) for 
information on premium payments and reporting and disclosure.
    Each Form 5500 must accurately reflect the characteristics and 
operations of the plan or arrangement being reported. The 
requirements for completing the Form 5500 will vary according to the 
type of plan or arrangement. The section What To File summarizes 
what information must be reported for different types of plans and 
arrangements. The Quick Reference Charts of Form 5500, Schedules and 
Attachments for (1) Pension Plans; (2) Direct Filing Entities (Other 
than GIAs); (3) Group Health Plans (and GIAs Providing Group Health 
Benefits); and (4) Welfare Plans Other Than Group Health, at the end 
of these instructions, give a brief guide to the annual return/
report requirements of the 20XX Form 5500 for the various types of 
plans and other entities filing a Form 5500 Annual Return/Report. 
See also the ``Troubleshooters Guide to Filing the ERISA Annual 
Reports'' available on www.dol.gov/ebsa, which is intended to help 
filers comply with the Form 5500 and Form 5500-SF annual reporting 
requirements and avoid common reporting errors.
    The Form 5500 must be filed electronically as noted above. See 
Section 3_Electronic Filing Requirement and the EFAST2 Web site at 
www.efast.dol.gov. Your Form 5500 entries will be initially screened 
electronically. Your entries must satisfy this screening for your 
filing to be received. Once received, your form may be subject to 
further detailed review, and your filing may be rejected based upon 
this further review.
    ERISA and the Code provide for the assessment or imposition of 
penalties for not submitting the required information when due. See 
Penalties.
    Annual reports filed under Title I of ERISA must be made 
available by plan administrators to plan participants and 
beneficiaries and by the DOL to the public pursuant to ERISA 
sections 104 and 106. Pursuant to Section 504 of the Pension 
Protection Act of 2006 (PPA) Pub. L. 109-280, this availability for 
defined benefit pension plans must include the posting of the Form 
5500, Schedule SB or MB, and all of the Schedule SB or MB 
attachments on any plan sponsor intranet Web site (or Web site 
maintained by the plan administrator on behalf of the plan sponsor) 
that is used for the purpose of communicating with employees and not 
the public. Section 504 also requires DOL to display such 
information on DOL's Web site within 90 days after the filing of the 
plan's annual return/report. To see plan year 2009 and later forms, 
including actuarial information, see www.dol.gov/ebsa. See 
www.dol.gov/ebsa/actuarialsearch.html for plan year 2008 and short 
plan year 2009 actuarial information filed under the previous paper-
based system.

Changes to Note

    [The instructions for the year in which the revisions are 
implemented will include such items in the ``Changes to Note'' 
section.]

Table of Contents

    [The Instructions will continue include a Table of Contents in 
substantially the same format as the existing Table of Contents, 
updated as required.]

How To Get Assistance

    If you need help completing this form or have related questions, 
call the EFAST2 Help Line at 1-866-GO-EFAST (1-866-463-3278) (toll-
free) or access the EFAST2 or IRS Web sites. The EFAST2 Help Line is 
available Monday through Friday from 8:00 a.m. to 8:00 p.m., Eastern 
Time.
    You can access the EFAST2 Web site 24 hours a day, 7 days a week 
at www.efast.dol.gov to:
     File the Form 5500-SF or Form 5500, and any needed 
schedules or attachments.
     Check on the status of a filing you submitted.
     View filings posted by EFAST2.
     Register for electronic credentials to sign or submit 
filings.
     View forms and related instructions.
     Get information regarding EFAST2, including approved 
software vendors.
     See answers to frequently asked questions about the 
Form 5500-SF, the Form 5500 and its schedules, and EFAST2.
     Access the main EBSA and DOL Web sites for news, 
regulations, and publications.
    You can access the IRS Web site 24 hours a day, 7 days a week at 
www.irs.gov to:
     View forms, instructions, and publications.
     See answers to frequently asked tax questions.
     Search publications on-line by topic or keyword.
     Send comments or request help by email.
     Sign up to receive local and national tax news by 
email.
    You can order other IRS forms and publications at the IRS Web 
site at www.irs.gov/orderforms. You can order EBSA publications by 
calling 1-866-444-EBSA (3272).

Section 1: Who Must File

    A return/report must be filed every year for every pension 
benefit plan, welfare benefit plan, and for every entity that files 
as a DFE as specified below (pursuant to Code section 6058 and ERISA 
sections 104 and 4065). If you are a small plan (generally under 100 
participants at the beginning of the plan year), that does not 
provide group health benefits, you may be eligible to file the Form 
5500-SF instead of the Form 5500. For more information, see the 
instructions to the Form 5500-SF.

Pension Benefit Plan

    All pension benefit plans covered by ERISA must file an annual 
return/report except as provided in this section. The return/report 
must be filed whether or not the plan is ``tax-qualified,'' benefits 
no longer accrue, contributions were not made this plan year, or 
contributions are no longer made. Pension benefit plans required to 
file include both defined benefit plans and defined contribution 
plans.
    The following are among the pension benefit plans for which a 
return/report must be filed.
    1. Profit-sharing plans, stock bonus plans, money purchase 
plans, 401(k) plans, etc.
    2. 403(b) plans subject to Title I of ERISA. For more 
information regarding filing requirements for these annuity 
arrangements under Code section 403(b)(1) and custodial accounts 
established under Code section 403(b)(7) for regulated investment 
company stock, see Field Assistance Bulletins 2009-02 and 2010-01.
    3. Individual retirement accounts (IRAs) established by an 
employer under Code section 408(c).
    4. Church pension plans electing coverage under Code section 
410(d).
    5. Pension benefit plans that cover residents of Puerto Rico, 
the U.S. Virgin Islands, Guam, Wake Island, or American Samoa. This 
includes a plan that elects to have the provisions of section 
1022(i)(2) of ERISA apply.
    6. Plans that satisfy the Actual Deferral Percentage 
requirements of Code section 401(k)(3)(A)(ii) by adopting the 
``SIMPLE'' provisions of section 401(k)(11).
    See What To File for more information about what must be 
completed for pension plans.

Do Not File a Form 5500 Annual Return/Report for a Pension Benefit Plan 
That Is Any of the Following:

    1. An unfunded excess benefit plan. See ERISA section 4(b)(5).
    2. An annuity or custodial account arrangement under Code 
sections 403(b)(1) or (7) not established or maintained by an 
employer as described in DOL Regulation 29 CFR 2510.3-2(f).

[[Page 47601]]

    3. A Savings Incentive Match Plan for Employees of Small 
Employers (SIMPLE) that involves SIMPLE IRAs under Code section 
408(p).
    4. A simplified employee pension (SEP) or a salary reduction SEP 
described in Code section 408(k) that conforms to the alternative 
method of compliance in 29 CFR 2520.104-48 or 2520.104-49. A SEP is 
a pension plan that meets certain minimum qualifications regarding 
eligibility and employer contributions.
    5. A church pension benefit plan not electing coverage under 
Code section 410(d).
    6. A pension plan that is maintained outside the United States 
primarily for the benefit of persons substantially all of whom are 
nonresident aliens. However, certain foreign plans are required to 
file the Form 5500-EZ with the IRS or may file the Form 5500-SF 
electronically with EFAST2. See the instructions to the Form 5500-EZ 
for the filing requirements. For more information, go to 
www.irs.gov/ep or call 1-877-829-5500.
    7. An unfunded pension plan for a select group of management or 
highly compensated employees that meets the requirements of 29 CFR 
2520.104-23, including timely filing of a registration statement 
with the DOL.
    8. An unfunded dues financed pension benefit plan that meets the 
alternative method of compliance provided by 29 CFR 2520.104-27.
    9. An individual retirement account or annuity not considered a 
pension plan under 29 CFR 2510.3-2(d).
    10. A governmental plan.
    11. A ``one-participant plan,'' as defined below. However, 
certain one-participant plans are required to file the Form 5500-EZ, 
Annual Return of One-Participant (Owners and Their Spouses) 
Retirement Plan with the IRS or, may file the Form 5500-SF, Short 
Form Annual Return/Report of Employee Benefit Plan, electronically 
with EFAST2. For this purpose, a ``one-participant plan'' is:
    a. A pension benefit plan that covers only an individual or an 
individual and his or her spouse who wholly own a trade or business, 
whether incorporated or unincorporated; or
    b. A pension benefit plan for a partnership that covers only the 
partners or the partners and the partners' spouses.
    See the instructions to the Form 5500-EZ and the Form 5500-SF 
for filing requirements. For more information, go to www.irs.gov/ep 
or call 1-877-829-5500.

Welfare Benefit Plan

Plans that Provide Health Benefits (Group Health Plans)

    All employee benefit plans covered by Title I of ERISA that 
provide group health benefits consisting of medical care as defined 
in section 733(a)(2) of ERISA are required to file a Form 5500 
Annual Return/Report, unless specifically exempt below, regardless 
of the plan size or type of funding.
    MEWA Reminders: The administrator of a group health plan 
required to file a Form M-1, Report for Multiple Employer Welfare 
Arrangements (MEWAs) and Certain Entities Claiming Exception (ECEs), 
must also file the Form 5500 Annual Return/Report for the group 
health plan. The administrator of a group health plan that provides 
benefits wholly or partially through a Multiple Employer Welfare 
Arrangement (MEWA) as defined in ERISA section 3(40) must file a 
Form 5500 Annual Return/Report, unless the plan is part of a Group 
Insurance Arrangement (GIA) that files a Form 5500 Annual Return/
Report as a DFE on behalf of all the participating plans.

Welfare Benefit Plans Other Than Group Health Plans

    All welfare benefit plans covered by ERISA that do not provide 
health benefits consisting of medical care as defined in section 
733(a)(2) of ERISA are required to file a Form 5500, except as 
provided in this section. Welfare benefits other than group health 
include disability, life insurance, apprenticeship and training, 
scholarship funds, severance pay, etc. See What To File for more 
information.
    [CAUTION] If the plan provides both health benefits and other 
types of benefits, then it is subject to the filing requirements for 
a plan that provides health benefits, including the requirement that 
all such plans file the Form 5500 regardless of size.

Do Not File a Form 5500 Annual Return/Report for a Welfare Benefit Plan 
That Is Any of the Following:

    1. A welfare benefit plan that does not provide health benefits 
and that covered fewer than 100 participants as of the beginning of 
the plan year and is unfunded, fully insured, or a combination of 
insured and unfunded, as specified in 29 CFR 2520.104-20.
    Note. To determine whether the plan covers fewer than 100 
participants for purposes of this filing exemption for insured, 
unfunded and combination insured/unfunded welfare plans that do not 
provide health benefits, see instructions for Lines 6 and 7 on 
counting participants in a welfare plan. See also 29 CFR 2510.3-
3(d).
    a. An unfunded welfare benefit plan has its benefits paid as 
needed directly from the general assets of the employer or employee 
organization that sponsors the plan. Plans that are NOT unfunded 
include those plans that received employee (or former employee) 
contributions during the plan year and/or used a trust or separately 
maintained fund (including a Code section 501(c)(9) trust) to hold 
plan assets or act as a conduit for the transfer of plan assets 
during the year. A welfare benefit plan with employee contributions 
that is associated with a cafeteria plan under Code section 125 may 
be treated for annual reporting purposes as an unfunded welfare plan 
if it meets the requirements of DOL Technical Release 92-01, 57 FR 
23272 (June 2, 1992) and 58 FR 45359 (Aug. 27, 1993). The mere 
receipt of COBRA contributions or other after-tax participant 
contributions (e.g., retiree contributions) by a cafeteria plan 
would not by itself affect the availability of the relief provided 
for cafeteria plans that otherwise meet the requirements of DOL 
Technical Release 92-01. See 61 FR 41220, 41222-23 (Aug. 7, 1996).
    b. A fully insured welfare benefit plan has its benefits 
provided exclusively through insurance contracts or policies, the 
premiums of which must be paid directly to the insurance carrier by 
the employer or employee organization from its general assets or 
partly from its general assets and partly from contributions by its 
employees or members (which the employer or employee organization 
forwards within three (3) months of receipt). The insurance 
contracts or policies discussed above must be issued by an insurance 
company or similar organization that is qualified to do business in 
any state.
    c. A combination unfunded/insured welfare benefit plan has its 
benefits provided partially as an unfunded plan and partially as a 
fully insured plan. An example of such a plan is a welfare benefit 
plan that provides disability benefits as in a above and life 
insurance benefits as in b above. See 29 CFR 2520.104-20.
    2. A welfare benefit plan maintained outside the United States 
primarily for persons substantially all of whom are nonresident 
aliens.
    3. A governmental plan.
    4. An unfunded or insured welfare benefit plan maintained for a 
select group of management or highly compensated employees, which 
meets the requirements of 29 CFR 2520.104-24.
    5. An employee benefit plan maintained only to comply with 
workers' compensation, unemployment compensation, or disability 
insurance laws.
    6. A group health plan or other welfare benefit plan that 
participates in a group insurance arrangement (GIA) that files a 
Form 5500 Annual Return/Report on behalf of the group health plan or 
other welfare benefit plan as specified in 29 CFR 2520.103-2. See 29 
CFR 2520.104-43.
    7. An apprenticeship or training plan meeting all of the 
conditions specified in 29 CFR 2520.104-22.
    8. An unfunded dues financed welfare benefit plan that does not 
provide health benefits exempted by 29 CFR 2520.104-26.
    9. A church plan under ERISA section 3(33).
    10. A welfare benefit plan that covers only an individual or an 
individual and his or her spouse who wholly own a trade or business, 
whether incorporated or unincorporated, or that covers only the 
partners or the partners and the partners' spouses. See 29 CFR 
2510.3-3(b).

Direct Filing Entity (DFE)

    Some plans participate in certain trusts, accounts, and other 
investment arrangements that file the Form 5500 Annual Return/Report 
as a DFE in accordance with the Direct Filing Entity (DFE) Filing 
Requirements. A Form 5500 Annual Return/Report must be filed for a 
master trust. A Form 5500 Annual Return/Report is not required but 
may be filed for a common/collective trust (CCT), a pooled separate 
account (PSA), an investment entity that hold plan assets permitted 
under 29 CFR 2520.103-12(103-12 IE), or a group insurance 
arrangement (GIA). Plans that participate in CCTs, PSAs, 103-12 IEs, 
or GIAs that file as DFEs, however, generally are eligible for 
certain annual reporting relief. For reporting purposes, a CCT, PSA, 
103-12

[[Page 47602]]

IE, or GIA is not considered a DFE unless a Form 5500 and all 
required attachments are filed for it in accordance with the Direct 
Filing Entity (DFE) Filing Requirements.
    Note. Special requirements also apply to Schedules D and H 
attached to the Form 5500 filed by plans participating in master 
trusts, CCTs, PSAs, and 103-12 IEs. See these schedules and their 
instructions.

Section 2: When To File

    Plans and GIAs. File 20XX returns/reports for plan and GIA years 
that began in 20XX. All required forms, schedules, statements, and 
attachments must be filed by the last day of the 7th calendar month 
after the end of the plan or GIA year (not to exceed 12 months in 
length) that began in 20XX. If the plan or GIA year differs from the 
20XX calendar year, fill in the fiscal year beginning and ending 
dates in the space provided.
    Short Years. For a plan year of less than 12 months (short plan 
year), file the form and applicable schedules by the last day of the 
7th calendar month after the short plan year ends or by the extended 
due date, if filing under an authorized extension of time. 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. 
For purposes of this return/report, the short plan year ends on the 
date of the change in accounting period or upon the complete 
distribution of assets of the plan. Also see the instructions for 
Final Return/Report to determine if ``the final return/report'' box 
in Line B should be checked.
    DFEs other than GIAs. File 20XX returns/reports no later than 
9\1/2\ months after the end of the DFE year that ended in 20XX. A 
Form 5500 Annual Return/Report filed for a DFE must report 
information for the DFE year (not to exceed 12 months in length). If 
the DFE year differs from the 20XX calendar year, fill in the fiscal 
year beginning and ending dates in the space provided.
    Notes. (1) If the filing due date falls on a Saturday, Sunday, 
or Federal holiday, the return/report may be filed on the next day 
that is not a Saturday, Sunday, or Federal holiday. (2) If the 
20XX+1 Form 5500 is not available before the plan or DFE filing is 
due, use the 20XX Form 5500 and enter the 20XX+1 fiscal year 
beginning and ending dates on the line provided at the top of the 
form.

Extension of Time To File

Using Form 5558

    A plan or GIA may obtain a one-time extension of time to file a 
Form 5500 Annual Return/Report (up to 2\1/2\ months) by filing IRS 
Form 5558, Application for Extension of Time To File Certain 
Employee Plan Returns, on or before the normal due date (not 
including any extensions) of the return/report. You MUST file Form 
5558 with the IRS. Approved copies of the Form 5558 will not be 
returned to the filer. A copy of the completed extension request 
must, however, be retained with the filer's records.
    File Form 5558 with the Department of the Treasury, Internal 
Revenue Service Center, Ogden, UT 84201-0045.

Using Extension of Time To File Federal Income Tax Return

    An automatic extension of time to file the Form 5500 Annual 
Return/Report until the due date of the federal income tax return of 
the employer will be granted if all of the following conditions are 
met:
    (1) the plan year and the employer's tax year are the same;
    (2) the employer has been granted an extension of time to file 
its federal income tax return to a date later than the normal due 
date for filing the Form 5500 Annual Return/Report; and
    (3) a copy of the application for extension of time to file the 
federal income tax return is maintained with the filer's records. An 
extension granted by using this automatic extension procedure CANNOT 
be extended further by filing a Form 5558, nor can it be extended 
beyond a total of 9\1/2\ months beyond the close of the plan year.
    Note. An extension of time to file the Form 5500 Annual Return/
Report does not operate as an extension of time to file a Form 5500 
Annual Return/Report filed for a DFE (other than a GIA), to file 
PBGC premiums or annual financial and actuarial reports (if required 
by section 4010 of ERISA) or to file the Form 8955-SSA (Annual 
Registration Statement Identifying Separated Participants with 
Deferred Vested Benefits) (required to be filed with the IRS under 
Code section 6057(a)).

Other Extensions of Time

    The IRS, DOL, and PBGC may announce special extensions of time 
under certain circumstances, such as extensions for Presidentially-
declared disasters or for service in, or in support of, the Armed 
Forces of the United States in a combat zone. See www.irs.gov, 
www.efast.dol.gov, and www.pbgc.gov/practitioners for announcements 
regarding such special extensions. If you are relying on one of 
these announced special extensions, check the appropriate box on 
Form 5500, Part I, Line D, and enter a description of the announced 
authority for the extension.

Delinquent Filer Voluntary Compliance (DFVC) Program

    The DFVC Program facilitates voluntary compliance by plan 
administrators who are delinquent in filing annual reports under 
Title I of ERISA by permitting administrators to pay reduced civil 
penalties for voluntarily complying with their DOL annual reporting 
obligations. If the Form 5500 is being filed under the DFVC Program, 
check the appropriate box in Form 5500, Part I, Line D, to indicate 
that the Form 5500 is being filed under the DFVC Program. See 
www.efast.dol.gov for additional information.
    Plan administrators are reminded that they can use the online 
calculator available at www.dol.gov/ebsa/calculator/dfvcpmain.html 
to compute the penalties due under the program. Payments under the 
DFVC Program also may be submitted electronically. For information 
on how to pay DFVC Program payments online, go to www.dol.gov/ebsa.
    [CAUTION] Filers who wish to participate in the DFVC Program for 
plan years prior to 20XX-3 must use the 20XX version of Form 5500 
or, if applicable, Form 5500-SF. Use the Form 5500 Version Selection 
Tool available at www.efast.dol.gov for further information.

Section 3: Electronic Filing Requirement

    Under the computerized ERISA Filing Acceptance System (EFAST2), 
you must file your 20XX Form 5500 Annual Return/Report 
electronically. You may file online using EFAST2's web-based filing 
system or you may file through an EFAST2-approved vendor. Detailed 
information on electronic filing is available at www.efast.dol.gov. 
For telephone assistance, call the EFAST2 Help Line at 1-866-GO-
EFAST (1-866-463-3278). The EFAST2 Help Line is available Monday 
through Friday from 8:00 a.m. to 8:00 p.m., Eastern Time.
    [CAUTION] Annual returns/reports filed under Title I of ERISA 
must be made available by plan administrators to plan participants 
and beneficiaries and by the DOL to the public pursuant to ERISA 
sections 104 and 106. Even though the Form 5500 Annual Return/Report 
must be filed electronically, the administrator must keep a copy of 
the Form 5500, including schedules and attachments, with all 
required signatures on file as part of the plan's records and must 
make a paper copy available upon request to participants, 
beneficiaries, and the DOL as required by section 104 of ERISA and 
29 CFR 2520.103-1. Filers may use electronic media for record 
maintenance and retention, so long as they meet the applicable 
requirements.
    Generally, questions on the Form 5500 relate to the plan year 
entered at the top of the first page of the form. Therefore, answer 
all questions on the 20XX Form 5500 with respect to the 20XX plan 
year unless otherwise explicitly stated in the instructions or on 
the form itself.
    Your entries must be in the proper format in order for the 
EFAST2 system to process your filing. For example, if a question 
requires you to enter a dollar amount, you cannot enter a word. Your 
software will not let you submit your return/report unless all 
entries are in the proper format. To reduce the possibility of 
correspondence and penalties:
     Complete all lines on the Form 5500 unless otherwise 
specified. Also complete and attach, as required, applicable 
schedules and attachments.
     Do not enter ``N/A'' or ``Not Applicable'' on the Form 
5500 Annual Return/Report unless specifically permitted. ``Yes'' or 
``No'' questions on the forms and schedules cannot be left blank, 
unless specifically permitted. Answer either ``Yes'' or ``No,'' but 
not both.
    All schedules and attachments to the Form 5500 must be properly 
identified, and must include the name of the plan or DFE, EIN, and 
plan number (PN) as found on the Form 5500, lines, 1a, 2b, and 1b, 
respectively. At the top of each attachment, indicate the schedule 
and line, if any to which the attachment relates.
    Check your return/report for errors before signing or submitting 
it to EFAST2. Your filing software or, if you are using it, the 
EFAST2 web-based filing system will allow you to check your return/
report for errors. If,

[[Page 47603]]

after reasonable attempts to correct your filing to eliminate any 
identified problem or problems, you are unable to address them, or 
you believe that you are receiving the message in error, call the 
EFAST2 Help Line at 1-866-GO-EFAST (1-866-463-3278) or contact the 
service provider you used to help prepare and file your annual 
return/report.
    Once you complete the return/report and finish the electronic 
signature process, you can electronically submit it to EFAST2. When 
you electronically submit your return/report, EFAST2 is designed to 
immediately notify you if your submission was received and whether 
the return/report is ready to be processed by EFAST2. If EFAST2 does 
not notify you that your submission was successfully received and is 
ready to be processed, you will need to take steps to correct the 
problem or you may be deemed a non-filer subject to penalties from 
DOL, IRS, and/or PBGC.
    Once EFAST2 receives your return/report, the EFAST2 system 
should be able to provide a filing status within 20 minutes. The 
person submitting the filing should check back into the EFAST2 
system to determine the filing status of your return/report. The 
filing status message will include a list of filing errors or 
warnings that EFAST2 may have identified in your filing. If EFAST2 
did not identify any filing errors or warnings, EFAST2 will show the 
filing status of your return/report as ``Filing_Received.'' Persons 
other than the submitter can check whether the filing was received 
by the system by calling the EFAST2 Help Line at 1-866-GO-EFAST (1-
866-463-3278) and using the automated telephone system.
    To reduce the possibility of correspondence and penalties from 
the DOL, IRS, and/or PBGC, you should do the following: (1) Before 
submitting your return/report to EFAST2, check it for errors, and 
(2) after you have submitted it to EFAST2, verify that you have 
received a filing status of ``Filing Received'' and attempt to 
correct and resolve any errors or warnings listed in the status 
report. For more information on whether the filing must be corrected 
and resubmitted or corrected as an amended filing, go to the EFAST2 
Web site at www.efast.dol.gov, Frequently Asked Questions (FAQs), or 
call the EFAST2 Help Line at 1-866-GO-EFAST (1-866-463-3278).
    Note. Even after being received by the EFAST2 system, your 
return/report filing may be subject to further detailed review by 
DOL, IRS, and/or PBGC, and your filing may be deemed deficient based 
upon this further review. See Penalties on Page X.
    [CAUTION] Do not enter social security numbers in response to 
questions asking for an employer identification number (EIN). 
Because of privacy concerns, the inclusion of a social security 
number or any portion thereof on the Form 5500 or on a schedule or 
attachment that is open to public inspection may result in the 
rejection of the filing. If you discover a filing disclosed on the 
EFAST2 Web site that contains a social security number, immediately 
call the EFAST2 Help Line at 1-866-GO-EFAST (1-866-463-3278).
    Employers without an EIN must apply for one as soon as possible. 
The EBSA does not issue EINs. To apply for an EIN from the IRS:
     Mail or fax Form SS-4, Application for Employer 
Identification Number, obtained at the IRS Web site at www.irs.gov.
     Call 1-800-829-4933 to receive your EIN by telephone.
     Select the Online EIN Application link at www.irs.gov. 
The EIN is issued immediately once the application information is 
validated. (The online application process is not yet available for 
corporations with addresses in foreign countries).
    [CAUTION] Do not attach a copy of the annual registration 
statement (IRS Form 8955-SSA) identifying separated participants 
with deferred vested benefits, or a previous year's Schedule SSA 
(Form 5500) to your 20XX Form 5500 Annual Return/Report. The annual 
registration statement must be filed directly with the IRS and 
cannot be attached to a Form 5500 Annual Return/Report submission 
with EFAST2.

Amended Return/Report

    File an amended return/report to correct errors and/or omissions 
in a previously filed annual return/report for the 20XX plan year. 
The amended Form 5500 and any amended schedules and/or attachments 
must conform to the requirements in these instructions. See the DOL 
Web site at www.efast.dol.gov for information on filing amended 
returns/reports for prior years.
    [TIP] Check the Line B(2) box for ``an amended return/report'' 
if you filed a previous 20XX annual return/report that was given a 
``Filing_Received,'' ``Filing_Error,'' or ``Filing_Stopped'' status 
by EFAST2. Do not check the Line B box for ``an amended return/
report'' if your previous submission attempts were not successfully 
received by EFAST2 because of problems with the transmission of your 
return/report. For more information, go to the EFAST2 Web site at 
www.efast.dol.gov or call the EFAST2 Help Line at 1-866-GO-EFAST (1-
866-463-3278).

Final Return/Report

    If all assets under the plan (including insurance/annuity 
contracts) have been distributed to the participants and 
beneficiaries or legally transferred to the control of another plan, 
and when all liabilities for which benefits may be paid under a 
welfare benefit plan have been satisfied, check the final return/
report box in Part I, Line B(3) at the top of the Form 5500. Do not 
mark the final return/report box if you are reporting participants 
and/or assets at the end of the plan year. If a trustee has been 
appointed for a terminated defined benefit pension plan pursuant to 
ERISA section 4042, the last plan year for which the return/report 
must be filed is the year in which the trustee is appointed. If you 
are in this situation, you may contact DOL at 
[email protected]. See specific instructions for Part I, Line 
B(5) for the simplified filing requirements for plans with 500 or 
fewer participants.

Examples:

Mergers/Consolidations

    A final return/report should be filed for the plan year (12 
months or less) that ends when all plan assets were legally 
transferred to the control of another plan.
    [TIP] Remember to identify, on Schedule H, Line 5, the plan to 
which assets were transferred. The transferee plan must also report 
the merger/consolidation on its own Form 5500, Schedule H Line 5.

Pension and Welfare Plans That Terminated Without Distributing All 
Assets

    If the plan was terminated, but all plan assets were not 
distributed, a return/report must be filed for each year the plan 
has assets. The return/report must be filed by the plan 
administrator, if designated, or by the person or persons who 
actually control the plan's assets/property.

Group Health Plans and Other Welfare Plans Still Liable To Pay Benefits

    A welfare plan cannot file a final return/report if the plan is 
still liable to pay benefits for claims that were incurred prior to 
the termination date, but not yet paid. See 29 CFR 2520.104b-
2(g)(2)(ii).

Signature and Date

    For purposes of Title I of ERISA, the plan administrator is 
required to file the Form 5500. If the plan administrator does not 
sign a filing, the filing status will indicate that there is an 
error with your filing, and your filing will be subject to further 
review, correspondence, rejection, and civil penalties. The plan 
administrator must electronically sign the Form 5500 Annual Return/
Report or 5500-SF submitted to EFAST2.
    Note. If the plan administrator is an entity, the electronic 
signature must be in the name of a person authorized to sign on 
behalf of the plan administrator.
    [CAUTION] After submitting your filing, you must check the 
Filing Status. If the filing status is ``Processing Stopped,'' it is 
possible your submission was not sent with a valid electronic 
signature as required, and depending on the error, may be considered 
not to have been filed. By looking closer at the Filing Status, you 
can see specific error messages applicable to the transmitted filing 
and determine whether it was sent with a valid electronic signature 
and what other errors may need to be corrected.
    Authorized Service Provider Signatures. If the plan 
administrator elects to have a service provider who manages the 
filing process for the plan get EFAST2 signing credentials and 
submit the electronic Form 5500 Annual Return/Report for the plan:
    (1) the service provider must receive specific written 
authorization from the plan administrator to submit the plan's 
electronic filing;
    (2) the plan administrator must manually sign a paper copy of 
the electronically completed Form 5500 Annual Return/Report, and the 
service provider must include a PDF copy of the manually signed Form 
5500 as an attachment to the electronic Form 5500 Annual Return/
Report submitted to EFAST2;
    (3) the service provider must communicate to the plan 
administrator any inquiries received from EFAST2, DOL, IRS or PBGC 
regarding the filing;
    (4) the service provider must communicate to the plan 
administrator that, by electing to use this option, the image of the 
plan administrator's manual signature will be

[[Page 47604]]

included with the rest of the return/report posted by the Labor 
Department on the Internet for public disclosure; and
    (5) the plan administrator must keep the manually signed copy of 
the Form 5500, with all required schedules and attachments, as part 
of the plan's records. For more information on the electronic 
signature option, see the EFAST2 All-Electronic Filing System FAQs 
at www.dol.gov/ebsa/faqs/faq-EFAST2.html.
    [CAUTION] Service providers should consider implications of IRS 
tax return preparer rules.
    Note. The Code permits either the plan sponsor/employer or the 
administrator to sign the filing. However, any Form 5500 Annual 
Return/Report that is not electronically signed by the plan 
administrator will be subject to rejection and civil penalties under 
Title I of ERISA.
    For DFE filings, a person authorized to sign on behalf of the 
DFE must sign for the DFE.
    The Form 5500 Annual Return/Report must be filed electronically 
and signed. To obtain an electronic signature, go to 
www.efast.dol.gov and register in EFAST2 as a signer. You will be 
provided with a UserID and PIN. Both the UserID and PIN are needed 
to sign the Form 5500. The plan administrator must keep a copy of 
the Form 5500, including schedules and attachments with all required 
signatures on file as part of the plan's records. See 29 CFR 
2520.103-1.
    Electronic signatures on annual returns/reports filed under 
EFAST2 are governed by the applicable statutory and regulatory 
requirements.

Preparer Information

    Enter the ``Preparer's name (including firm's name, if 
applicable), address, and telephone number'' at the bottom of the 
first page of Form 5500. A preparer is any person who prepares an 
annual return/report for compensation, or who employs one or more 
persons to prepare the annual return/report for compensation. If the 
person who prepared the annual return/report is not the employer 
named in Line 2a or the plan administrator named in Line 3a, you 
must name the person on this line. If there are several people who 
prepare Form 5500 and applicable schedules, please name the person 
who is primarily responsible for the preparation of the annual 
return/report.
    Note. You must complete preparer information if you are required 
to file at least 250 returns of any type with the IRS during the 
calendar year. However, if you are a small filer (files fewer than 
250 returns of any type with the IRS during the calendar year), and 
you do not enter preparer information on the Form 5500, then you 
must file the paper Form 5500-SUP with the IRS. See the Treasury 
regulations on ``Employee Retirement Benefit Plan Returns Required 
on Magnetic Media'' (See 79 FR 58256 at http://federalregister.gov/a/2014-23161) and Instructions for Form 5500-SUP for more 
information.

Change in Plan Year

    Generally, only defined benefit pension plans need to get 
approval for a change in the plan year. See Code section 412(d)(1). 
However, under Rev. Proc. 87-27, 1987-1 C.B. 769, these pension 
plans may be eligible for automatic approval of a change in plan 
year. If a change in plan year for a pension or welfare benefit plan 
creates a short plan year, file the form and applicable schedules by 
the last day of the 7th calendar month after the short plan year 
ends or by the extended due date, if filing under an authorized 
extension of time. Fill in the short plan year beginning and ending 
dates in the space provided in Part I and check the appropriate box 
in Part I, Line B of the Form 5500. For purposes of this return/
report, the short plan year ends on the date of the change in 
accounting period or upon the complete distribution of assets of the 
plan. Also, see the instructions for the Final Return/Report to 
determine if ``Final Return/Report'' in Line B should be checked.

Penalties

    Plan administrators and plan sponsors must provide complete and 
accurate information and must otherwise comply fully with the filing 
requirements. ERISA and the Code provide for the DOL and the IRS, 
respectively, to assess or impose penalties for not giving complete 
and accurate information and for not filing complete and accurate 
statements and returns/reports. Certain penalties are administrative 
(i.e., they may be imposed or assessed by one of the governmental 
agencies delegated to administer the collection of the annual 
return/report data). Others require a legal conviction.

Administrative Penalties

    Listed below are various penalties under ERISA and the Code that 
may be assessed or imposed for not meeting the annual return/report 
filing requirements. Generally, whether the penalty is under ERISA 
or the Code, or both, depends upon the Agency for which the 
information is required to be filed. One or more of the following 
administrative penalties may be assessed or imposed in the event of 
incomplete filings or filings received after the due date unless it 
is determined that your failure to file properly is for reasonable 
cause:
    1. A penalty of up to $1,100 a day (or higher amount if adjusted 
pursuant to the Federal Civil Penalties Inflation Adjustment Act of 
1990, as amended) for each day a plan administrator fails or refuses 
to file a complete and accurate report. See ERISA section 502(c)(2) 
and 29 CFR 2560.502c-2.
    2. A penalty of $25 a day (up to $15,000) for not filing returns 
for certain plans of deferred compensation, trusts and annuities, 
and bond purchase plans by the due date(s). See Code section 
6652(e).
    3. A penalty of $1,000 for each failure to file an actuarial 
statement (Schedule MB (Form 5500) or Schedule SB (Form 5500)) 
required by the applicable instructions. See Code section 6692.

Other Penalties

    1. Any individual who willfully violates any provision of Part 1 
of Title I of ERISA shall on conviction be fined not more than 
$100,000 or imprisoned not more than 10 years, or both. See ERISA 
section 501.
    2. A penalty up to $10,000, five (5) years imprisonment, or 
both, may be imposed for making any false statement or 
representation of fact, knowing it to be false, or for knowingly 
concealing or not disclosing any fact required by ERISA. See section 
1027, Title 18, U.S. Code, as amended by section 111 of ERISA.

Section 4: What To File

    The Form 5500 Annual Return/Report reporting requirements vary 
depending on whether the Form 5500 is being filed for a ``large 
plan,'' a ``small plan,'' and/or a DFE, and on the particular type 
of plan (e.g., group health plan, welfare plan other than group 
health, defined benefit pension plan, defined contribution pension 
plan) or the kind of DFE involved (i.e. common/collective trust 
(CCT), pooled separate account (PSA), master trust, 103-12 
investment entity (103-12 IE), or group insurance arrangement (GIA). 
The instructions below provide detailed information about each of 
the Form 5500 schedules and which plans and DFEs are required to 
file them.
    The schedules are grouped in the instructions by type: (1) 
Pension Benefit Schedules; and (2) General Schedules (including the 
new Schedule J (Group Health Plan Information). Each schedule is 
listed separately with a description of the subject matter covered 
by the schedule and the plans and DFEs that are required to file the 
schedule.
    Filing requirements also are listed by type of filer: (1) Filing 
Requirements for Pension Benefit Plan; (2) Filing Requirements for 
Plans Providing Group Health Benefits; (3) Filing Requirements for 
Welfare Benefit Plan Other Than Group Health; and (4) DFE Filing 
Requirements. For each filer type, there is a list of the schedules 
that must be filed with the Form 5500 (including where applicable, 
separate lists for large plan filers, small plan filers, and 
different types of DFEs). The filing requirements also are 
summarized at the end of these instructions in a series of ``Quick 
Reference Charts of Form 5500, Schedules, and Attachments'' for the 
various types of filers.
    Generally, a return/report filed for a pension benefit plan or 
welfare benefit plan other than a group health plan that covered 
fewer than 100 participants as of the beginning of the plan year 
should be completed following the requirements below for a ``small 
plan,'' and a return/report filed for a plan that covered 100 or 
more participants as of the beginning of the plan year should be 
completed following the requirements below for a ``large plan.''
    Use the number of participants required to be entered in Line 6 
of the Form 5500 to determine whether a plan is a ``small plan'' or 
``large plan.''

Exceptions:

    (1) 80-120 Participant Rule: If the number of participants 
reported at the beginning of the year was between 80 and 120 
(inclusive), and a Form 5500 Annual Return/Report or Form 5500-SF 
was filed for the prior plan year, you may elect to complete the 
return/report in the same category (``large plan'' or ``small 
plan'') as was filed for the prior

[[Page 47605]]

return/report. Thus, if a Form 5500-SF or a Form 5500 Annual Return/
Report was filed for the 20XX-1 plan year as a small plan, and the 
plan either had fewer than 100 participants as of the beginning of 
the plan year as reported on Form 5500 Annual Return/Report or the 
plan is eligible to claim small plan status under 29 CFR 103-1(d) 
and had 120 or fewer participants as of the beginning of the plan 
year, you may elect to complete the 20XX Form 5500 and schedules in 
accordance with the instructions for a small plan, including for 
eligible filers, filing the Form 5500-SF instead of the Form 5500. 
Defined benefit pension plans, welfare plans, and defined 
contribution pension plans that check the ``first plan'' year box 
use the number reported on Form 5500, Line 6 for this measure. 
Defined contribution pension plans use the number reported on Form 
5500, Line 7g(1)).
    (2) Short Plan Year Rule: If the plan had a short plan year of 
seven (7) months or less for either the prior plan year or the plan 
year being reported on the 20XX Form 5500, an election can be made 
to defer filing the accountant's report in accordance with 29 CFR 
2520.104-50. If such an election was made for the prior plan year, 
the 20XX Form 5500 must be completed following the requirements for 
a large plan, including the attachment of the Schedule H and the 
accountant's reports, regardless of the number of participants 
entered in Part II, Line 6 for defined benefit pension plans, 
welfare plans, and defined contribution pension plans that check the 
``first plan'' year box, or Line 7g(1) for defined contribution 
pension plans.

Form 5500 Schedules

Pension Schedules

    Schedule R (Retirement Plan Information) is required for both 
tax-qualified and nonqualified pension benefit plan unless otherwise 
specified under Limited Pension Plan Reporting. For additional 
information, see the Schedule R instructions.
    Schedule MB (Multiemployer Defined Benefit Plan and Certain 
Money Purchase Plan Actuarial Information) is required for most 
multiemployer defined benefit pension plans and for defined 
contribution pension plans that currently amortize a waiver of the 
minimum funding requirements specified in the instructions for the 
Schedule MB. For additional information, see the instructions for 
the Schedule MB and the Schedule R.
    Schedule SB (Single-Employer Defined Benefit Plan Actuarial 
Information) is required for most single-employer defined benefit 
pension plans, including multiple-employer defined benefit pension 
plans. For additional information, see the instructions for the 
Schedule SB.
    Schedule E (ESOP Annual Information) is required for all pension 
benefit plans with ESOP benefits. For additional information, see 
the Schedule E instructions.

General Schedules

    Schedule H (Financial Information) is required for pension 
benefit plans and welfare benefit plans that are not eligible to 
file the Form 5500-SF and for all DFE filings. All plans and DFEs 
required to file the Schedule H are also generally required to 
attach to the Form 5500 Annual Return/Report a ``Schedule of Assets 
Held for Investment At End of Year,'' and, if applicable, a 
``Schedule of Assets Disposed of During the Plan Year,'' a 
``Schedule of Reportable Transactions,'' and a ``Schedule of 
Delinquent Participant Contributions.'' For additional information, 
see the Schedule H instructions.
    Large employee benefit plans, 103-12 IEs, and GIAs filing the 
Schedule H are generally required to engage an independent qualified 
public accountant (IQPA) and attach a report of the IQPA pursuant to 
ERISA section 103(a)(3)(A).
    Small employee benefit plans are not required to attach a report 
of the IQPA if they meet the conditions for eligibility for a waiver 
of the audit requirements as set forth in 2520.104-46. For these 
purposes, defined benefit pension plans, welfare plans, and defined 
contribution pension plans that check the ``first plan'' year box 
use the participant count on Line 6, and defined contribution 
pension plans can use the participant count on Line 7g(1).
    Exceptions: Insured, unfunded, or combination unfunded/insured 
welfare plans including group health plans, as described in 29 CFR 
2520.104-44(b)(1), and certain pension plans and arrangements, as 
described in 29 CFR 2520.104-44(b)(2) and in Limited Pension Plan 
Reporting, are exempt from completing the Schedule H.
    Schedule A (Insurance Information) is required if any benefits 
under an employee benefit plan are provided by an insurance company, 
insurance service or other similar organization, or through a 
managed care organization or a health maintenance organization. This 
includes investment contracts with insurance companies, such as 
guaranteed investment contracts, pooled separate accounts, and 
variable annuities. Schedule A is not required for fully insured 
group health plans with fewer than 100 participants. For additional 
information, see the Schedule A instructions.
    Note. Do not file Schedule A for Administrative Services Only 
(ASO) contracts. You do not file Schedule A for a plan if a Schedule 
A is filed for the contract as part of the Form 5500 Annual Return/
Report filed directly by a master trust or 103-12 IE in which that 
plan invested/participated during the plan year.
    Schedule C (Service Provider Information) is generally required 
for all pension plans filing the Form 5500, master trusts, 103-12 
IEs, and GIAs to report the information required for: (1) each 
covered service provider who received $1,000 or more in total direct 
and indirect compensation (i.e., money or anything else of monetary 
value in connection with services rendered to the plan or the 
person's position with the plan during the plan year) and (2) other 
persons who received $5,000 or more in direct compensation in 
connection with services rendered to the plan or the person's 
position with the plan during the plan year. For additional 
information, including the definition of a ``covered service 
provider,'' see the Schedule C instructions. Schedule C is also 
required for welfare benefit plans, including group health plans, 
unless the plan is exempt under 29 CFR 2520.104-44 from completing 
the accountant's report requirement and completing Schedule H.
    Schedule D (DFE/Participating Plan Information) Schedule D is 
required when the Form 5500 is filed for a DFE. For additional 
information, see the Schedule D instructions.
    Schedule G (Financial Transaction Schedules) is required for a 
large plan, master trust, 103-12 IE, or GIA when Schedule H 
(Financial Information) lines 4b, 4c, and/or 4d are checked ``Yes.'' 
Part I of the Schedule G reports loans or fixed income obligations 
in default or classified as uncollectible. Part II of the Schedule G 
reports leases in default or classified as uncollectible. Part III 
of the Schedule G reports nonexempt transactions. For additional 
information, see the Schedule G instructions.
    [CAUTION] An unfunded, fully insured, or combination unfunded/
insured welfare plan with 100 or more participants exempt under 29 
CFR 2520.104-44 from completing Schedule H must still complete 
Schedule G, Part III, to report nonexempt transactions.
    Schedule J (Group Health Plan Information). All plans that 
provide group health benefits must complete the Schedule J (Group 
Health Plan Information) to report coverage, participation, claims, 
benefit, and other group health information. Small, fully insured 
plans only need to complete lines 1-8.

Filing Requirements

Pension Benefit Plans

    Pension benefit plan filers must complete the Form 5500 Annual 
Return/Report, including the signature block and, unless otherwise 
specified, attach the following schedules and information:

Small Pension Plan

    The following schedules (including any additional information 
required by the instructions to the schedules) must be attached to a 
Form 5500 filed for a small pension plan that is neither exempt from 
filing nor is filing the Form 5500-SF:
    1. Schedule A (as many as needed), to report insurance, annuity, 
and investment contracts held by the plan.
    2. Schedule C (as many as needed) to report information on 
service providers who received compensation at or above the 
applicable $1,000 and $5,000 thresholds.
    3. Schedule H, to report plan financial information, unless 
exempt. See Limited Pension Plan Reporting.
    4. Schedule MB or SB, to report actuarial information, if 
applicable.
    5. Schedule R, to report retirement plan information, if 
applicable.
    [CAUTION] Unless you have checked Schedule H, Line 3h(4) to 
indicate that the plan has fewer than 100 participants and is 
claiming a small plan audit waiver of the annual examination and 
report of an IQPA under 29 CFR 2520.104-46, you must attach the 
report of the independent qualified public accountant (IQPA) or 
check Schedule H, Line 3h(2) to indicate that the plan is eligible 
and elects to defer attaching the

[[Page 47606]]

IQPA's opinion pursuant to 29 CFR 2520.104-50 in connection with a 
short plan year of seven months or less.

Large Pension Plan

    The following schedules (including any additional information 
required by the instructions to the schedules) must be attached to a 
Form 5500 filed for a large pension plan:
    1. Schedule A (as many as needed), to report insurance, annuity, 
and investment contracts held by the plan.
    2. Schedule C (as many as needed) to report information on 
service providers who received compensation at or above the 
applicable $1,000 and $5,000 thresholds.
    3. Schedule G, to report loans or fixed income obligations in 
default or determined to be uncollectible as of the end of the plan 
year, leases in default or classified as uncollectible, and 
nonexempt transactions, i.e., file Schedule G if Schedule H (Form 
5500) lines 4b, 4c, and/or 4d are checked ``Yes.''
    4. Schedule H, to report financial information, unless exempt. 
See Limited Pension Plan Reporting.
    5. Schedule MB or SB, to report actuarial information, if 
applicable.
    6. Schedule R, to report retirement plan information, if 
applicable.

Eligible Combined Plans

    Section 903 of PPA established rules for a new type of pension 
plan, an ``eligible combined plan,'' effective for plan years 
beginning after December 31, 2009. See Code section 414(x) and ERISA 
section 210(e). An eligible combined plan consists of a defined 
benefit pension plan and a defined contribution pension plan that 
includes a qualified cash or deferred arrangement under Code section 
401(k), with the assets of the two plans held in a single trust, but 
clearly identified and allocated between the plans. The eligible 
combined plan design is available only to employers that employed an 
average of at least two, but not more than 500 employees, on 
business days during the calendar year preceding the plan year as of 
which the eligible combined plan is established and that employs at 
least two employees on the first day of the plan year that the plan 
is established. Because an eligible combined plan includes both a 
defined benefit pension plan and a defined contribution pension 
plan, the Form 5500 filed for the plan must include all the 
information, schedules, and attachments that would be required for 
either a defined benefit pension plan (such as a Schedule SB) or a 
defined contribution pension plan.

Limited Pension Plan Reporting

    The pension benefit plans or arrangements described below are 
eligible for limited annual reporting:
    1. IRA Plans: A pension plan using individual retirement 
accounts or annuities (as described in Code section 408) as the sole 
funding vehicle for providing pension benefits need complete only 
Form 5500, Part I and Part II, lines 1 through 4, and 9a(8) (check 
the box for ``Code section 408 accounts and annuities on Form 5500).
    2. Fully Insured Pension Plan: A pension benefit plan providing 
benefits exclusively through an insurance contract or contracts that 
are fully guaranteed and that meet all of the conditions of 29 CFR 
2520.104-44(b)(2) during the entire plan year must complete all the 
requirements listed under this Pension Benefit Plan Filing 
Requirements section, except that such a plan is exempt from 
attaching Schedule H, and an independent qualified public 
accountant's opinion, and from the requirement to engage an IQPA.
    [CAUTION] A pension benefit plan that has insurance contracts of 
the type described in 29 CFR 2520.104-44 as well as other assets 
must complete all requirements for a pension benefit plan, except 
that the value of the plan's allocated contracts (see below) should 
not be reported in Part I of Schedule H. All other assets should be 
reported on Schedule H and any other required schedules. If Schedule 
H is filed, attach an accountant's report in accordance with the 
Schedule H instructions.
    Note. For purposes of the annual return/report and the 
alternative method of compliance set forth in 29 CFR 2520.104-44, a 
contract is considered to be ``allocated'' only if the insurance 
company or organization that issued the contract unconditionally 
guarantees, upon receipt of the required premium or consideration, 
to provide a retirement benefit of a specified amount. This amount 
must be provided to each participant without adjustment for 
fluctuations in the market value of the underlying assets of the 
company or organization, and each participant must have a legal 
right to such benefits, which is legally enforceable directly 
against the insurance company or organization. For example, deposit 
administration, immediate participation guarantee, guaranteed 
investment contracts, and variable annuities are NOT allocated 
contracts for Form 5500 Annual Return/Report purposes.

Welfare Benefit Plans that Provide Group Health Benefits

    Large group health plans must follow the filing rules for large 
welfare plans and also must file the Schedule J (Group Health Plan 
Information).
    Small group health plans that are unfunded or a combination of 
unfunded and insured file the complete Form 5500 and the complete 
Schedule J and Schedule A, if applicable. Small group health plans 
that are fully insured need only complete Lines 1-5 of the Form 5500 
and Lines 1-8 of the Schedule J (and they do not complete Schedule 
A). Small group health plans that are funded with a trust generally 
follow the rules for large group health plans funded with a trust 
(except small welfare plans are not required to complete Schedule G 
or the other separate schedules listed in 29 CFR 2020.104-46(c)).

Other Welfare Benefit Plans

    Welfare benefit plans that do not provide group health benefits 
must complete the Form 5500 Annual Return/Report, including the 
signature block and, unless otherwise specified, attach the 
following schedules and information:

Small Welfare Plan

    The following schedules (including any additional information 
required by the instructions to the schedules) must be attached to a 
Form 5500 filed for a small welfare plan that is neither exempt from 
filing the annual return/report nor filing the Form 5500-SF:
    1. Schedule A (as many as needed), to report insurance contracts 
held by the plan.
    2. Schedule H to report plan financial information, unless 
exempt.
    3. Schedule C (as many as needed) to report information on 
service providers who received compensation at or above the 
applicable $1,000 and $5,000 thresholds, unless exempt.

Large Welfare Plan

    The following schedules (including any additional information 
required by the instructions to the schedules) must be attached to a 
Form 5500 filed for a large welfare plan:
    1. Schedule A (as many as needed), to report insurance and 
investment contracts held by the plan.
    2. Schedule C (as many as needed) to report information on 
service providers who received compensation at or above the 
applicable $1,000 and $5,000 thresholds, unless exempt.
    3. Schedule G, to report loans or fixed income obligations in 
default or determined to be uncollectible as of the end of the plan 
year, leases in default or classified as uncollectible, and 
nonexempt transactions, i.e., file Schedule G if Schedule H (Form 
5500) lines 4b, 4c, and/or 4d are checked ``Yes'' or if a large 
welfare plan that is not required to file a Schedule H has nonexempt 
transactions.
    4. Schedule H, to report financial information, unless exempt.
    [TIP] Attach the report of the independent qualified public 
accountant (IQPA) identified on Schedule H, Line 3c, unless Line 
3e(2) or (3) is checked. Neither Schedule H nor an IQPA's opinion is 
required to be attached to a Form 5500 filed for an unfunded, fully 
insured or combination unfunded/insured welfare plan that meets the 
requirements of 29 CFR 2520.104-44. However, Schedule G, Part III, 
must be attached to the Form 5500 to report any nonexempt 
transactions for a large welfare plan. A large welfare benefit plan 
that uses a ``voluntary employees' beneficiary association'' (VEBA) 
under Code section 501(c)(9) is generally not exempt from the 
requirement of engaging an IQPA.

Direct Filing Entity (DFE) Filing Requirements

    Only one Form 5500 Annual Return/Report should be filed for each 
DFE for all plans participating in the DFE; however, the Form 5500 
filed for the DFE, including all required schedules and attachments, 
must report information for the DFE year (not to exceed 12 months in 
length) that ends with or within the participating plan's year.
    Any Form 5500 filed for a DFE is an integral part of the annual 
return/report of each participating plan, and the plan administrator 
may be subject to penalties for failing to file a complete annual 
report unless

[[Page 47607]]

both the DFE's Form 5500 and the plan's Form 5500 are properly 
filed. The information required for a Form 5500 Annual Return/Report 
filed for a DFE varies according to the type of DFE. The following 
paragraphs provide specific guidance for the reporting requirements 
for each type of DFE.

Master Trust

    The administrator filing a Form 5500 Annual Return/Report for an 
employee benefit plan is required to file or have a designee file a 
Form 5500 for each master trust in which the plan participated at 
any time during the plan year. For reporting purposes, a ``master 
trust'' is a trust for which a regulated financial institution (as 
defined below) serves as trustee or custodian (regardless of whether 
such institution exercises discretionary authority or control with 
respect to the management of assets held in the trust), and in which 
assets of more than one plan sponsored by a single employer or by a 
group of employers under common control are held.
    ``Common control'' is determined on the basis of all relevant 
facts and circumstances (whether or not such employers are 
incorporated).
    A ``regulated financial institution'' means a bank, trust 
company, or similar financial institution that is regulated, 
supervised, and subject to periodic examination by a state or 
federal agency. A securities brokerage firm is not a ``similar 
financial institution'' as used here. See DOL Advisory Opinion 93-
21A (available at www.dol.gov/ebsa).
    The Form 5500 submitted for the master trust must comply with 
the Form 5500 Annual Return/Report instructions for a Large Pension 
Plan, unless otherwise specified in the forms and instructions. The 
master trust must file:
    1. Form 5500, except lines C, D, 1c, 2d, and 6 through 10. Be 
certain to check the ``master trust'' box Part I, Line A, as the DFE 
type.
    2. Schedule A (as many as needed) to report insurance, annuity 
and investment contracts held by the master trust.
    3. Schedule C (as many as needed) to report information on 
service providers who received compensation at or above the 
applicable $1,000 and $5,000 thresholds.
    4. Schedule D, to list all plans that participated in the master 
trust during its year.
    5. Schedule G, to report loans or fixed income obligations in 
default or determined to be uncollectible as of the end of the 
master trust year, all leases in default or classified as 
uncollectible, and nonexempt transactions.
    6. Schedule H, except Lines 1a(1), 1a(2), 1a(3), 1g, 1h, 1i, 2a, 
2b, 2e, 2f, 2g, 4a, 4e, 4f, 4g, 4h, 4k, 4l, 4m, and 5, to report 
financial information. The opinion of an independent qualified 
public accountant (IQPA) is not required for a master trust.
    7. Additional information required by the instructions to the 
above schedules, including, for example, the Schedules of Assets and 
the Schedule of Reportable Transactions. For purposes of the 
schedule of reportable transactions, the 5% figure shall be 
determined by comparing the current value of the transaction at the 
transaction date with the current value of the investment account 
assets at the beginning of the applicable fiscal year of the master 
trust. All attachments must be properly labeled.
    Note. If the plan uses more than one master trust, a separate 
annual report for each master trust must be filed.

Common/Collective Trust (CCT) and Pooled Separate Account (PSA)

    A Form 5500 Annual Return/Report is not required to be filed for 
a CCT or PSA. However, the administrator of a large plan or DFE that 
participates in a CCT or PSA that files as specified below is 
entitled to reporting relief that is not available to plans or DFEs 
participating in a CCT or PSA for which a Form 5500 Annual Return/
Report is not filed.
    For reporting purposes, ``common/collective trust'' and ``pooled 
separate account'' are, respectively: (1) a trust maintained by a 
bank, trust company, or similar institution or (2) an account 
maintained by an insurance carrier, which is regulated, supervised, 
and subject to periodic examination by a state or federal agency in 
the case of a CCT, or by a state agency in the case of a PSA, for 
the collective investment and reinvestment of assets contributed 
thereto from employee benefit plans maintained by more than one 
employer or controlled group of corporations as that term is used in 
Code section 1563. See 29 CFR 2520.103-3, 103-4, 103-5, and 103-9.
    Note. For reporting purposes, a separate account that is not 
considered to be holding plan assets pursuant to 29 CFR 2510.3-
101(h)(1)(iii) does not constitute a pooled separate account.
    The Form 5500 Annual Return/Report submitted for a CCT or PSA 
must comply with the Form 5500 Annual Return/Report instructions for 
a Large Pension Plan, unless otherwise specified in the forms and 
instructions.
    The CCT or PSA must file:
    1. Form 5500, except lines C, D, 1c, 2d, and 6 through 10. Check 
``CCT'' or ``PSA,'' as appropriate, in Part I, Line A, as the DFE 
type.
    2. Schedule D, to list all plans that participated in the CCT or 
PSA during its year.
    3. Schedule H, except Lines 1a(1), 1a(2), 1a(3), 1c, 1d, 1g, 1h, 
1i, 2a, 2b, 2e, 2f, and 2g, to report financial information. CCTs 
and PSAs are not required to attach an IQPA report or complete Part 
IV, except Line 4(i)(1). CCTs and PSAs must attach the Line 4i(1) 
Schedule of Assets Held for Investment at End of Year.
    [CAUTION] Different requirements apply to Schedule H attached to 
the Form 5500 filed by plans and DFEs participating in CCTs and 
PSAs, depending upon whether a DFE Form 5500 has been filed for the 
CCT or PSA. See the instructions for these schedules.

103-12 Investment Entity (103-12 IE)

    DOL Regulation 2520.103-12 provides an alternative method of 
reporting for plans that invest in an entity (other than a master 
trust, CCT, or PSA), whose underlying assets include ``plan assets'' 
within the meaning of 29 CFR 2510.3-101 of two or more plans that 
are not members of a ``related group'' of employee benefit plans. 
Such an entity for which a Form 5500 is filed constitutes a ``103-12 
IE.'' A Form 5500 is not required to be filed for such entities; 
however, filing a Form 5500 as a 103-12 IE provides certain 
reporting relief, including the limitation of the examination and 
report of the independent qualified public accountant (IQPA) 
provided by 29 CFR 2520.103-12(d), to participating plans and DFEs. 
For this reporting purpose, a ``related group'' of employee benefit 
plans consists of each group of two or more employee benefit plans 
(1) each of which receives 10% or more of its aggregate 
contributions from the same employer or from a member of the same 
controlled group of corporations (as determined under Code section 
1563(a), without regard to Code section 1563(a)(4) thereof); or (2) 
each of which is either maintained by, or maintained pursuant to a 
collective-bargaining agreement negotiated by, the same employee 
organization or affiliated employee organizations. For purposes of 
this paragraph, an ``affiliate'' of an employee organization means 
any person controlling, controlled by, or under common control with 
such organization. See 29 CFR 2520.103-12.
    The Form 5500 submitted for an entity holding plan assets that 
is permitted under 29 CFR 2520.103-12 to file a Form 5500 must 
comply with the Form 5500 instructions for a Large Pension Plan, 
unless otherwise specified in the forms and instructions.
    The 103-12 IE must file:
    1. Form 5500, except lines C, D, 1c, 2d, and 6 through 10. Check 
103-12 IE in part I, Line A, as the DFE type.
    2. Schedule A (as many as needed), to report insurance, annuity 
and investment contracts held by the 103-12 IE.
    3. Schedule C (as many as needed) to report information on 
service providers who received compensation at or above the 
applicable $1,000 and $5,000 thresholds.
    4. Schedule D, to list all plans that participated in the 103-12 
IE during its year.
    5. Schedule G, to report loans or fixed income obligations in 
default or determined to be uncollectible as of the end of the 103-
12 IE year, leases in default or classified as uncollectible, and 
nonexempt transactions.
    6. Schedule H, except lines 1a(1), 1a(2), 1a(3), 1c, 1d, 1g, 1h, 
1i, 2a, 2b, 2e, 2f, 2g, 4a, 4e, 4f, 4g, 4h, 4j, 4k, 4l, 4m, and 5, 
to report financial information.
    7. Additional information required by the instructions to the 
above schedules, including, for example, the report of the 
independent qualified public accountant (IQPA) identified on 
Schedule H, Line 3c, the Line 4i(1) Schedule of Assets Held for 
Investment at End of Year, and the Line 4i(2) Schedule of Assets 
Disposed of During the Plan Year. All attachments must be properly 
labeled.

Group Insurance Arrangement (GIA)

    Each welfare benefit plan, regardless of whether it provides 
group health benefits, that is part of a group insurance arrangement 
is exempt from the requirement to file a Form 5500 Annual Return/
Report if a consolidated

[[Page 47608]]

report for all the plans in the arrangement was filed in accordance 
with 29 CFR 2520.104-43. For reporting purposes, a ``group insurance 
arrangement'' provides benefits to the employees of two or more 
unaffiliated employers (not in connection with a multiemployer plan 
or a collectively-bargained multiple-employer plan), fully insures 
one or more welfare plans of each participating employer, uses a 
trust or other entity as the holder of the insurance contracts, and 
uses a trust as the conduit for payment of premiums to the insurance 
company.
    The GIA must file:
    1. Form 5500, except lines C and 2d. Check ``GIA'' in Part I, 
Line A, as the DFE type.
    2. Schedule A (as many as needed), to report insurance, annuity 
and investment contracts held by the GIA.
    3. Schedule C (as many as needed) to report information on 
service providers who received compensation at or above the 
applicable $1,000 and $5,000 thresholds.
    4. Schedule D, to list all plans that participated in the GIA 
during its year.
    5. Schedule G, to report loans or fixed income obligations in 
default or determined to be uncollectible as of the end of the GIA 
year, leases in default or classified as uncollectible, and 
nonexempt transactions.
    6. Schedule H, except lines 4a, 4e, 4f, 4g, 4h, 4l, 4m, and 5, 
to report financial information.
    7. Separate Schedules J for each participating employer, if the 
GIA provides group health benefits.
    8. Additional information required by the instructions to the 
above schedules, including, for example, the report of the 
independent qualified public accountant (IQPA) identified on 
Schedule H, Line 3c, the Schedules of Assets and the Schedule of 
Reportable Transactions. (All attachments must be properly labeled.)

Section 5: Line-by-Line Instructions for the 20XX Form 5500 and 
Schedules

Part I--Annual Return/Report Identification Information

    File the 20XX Form 5500 Annual Return/Report for a plan year 
that began in 20XX or a DFE year that ended in 20XX. Enter the 
beginning and ending dates in Part I. The 20XX Form 5500 Annual 
Return/Report must be filed electronically.
    One Form 5500 is generally filed for each plan or entity 
described in the instructions to the boxes in Line A. Do not check 
more than one box.
    Line A(1)--Box for Single-Employer Plan. Check this box if the 
Form 5500 is filed for a single-employer plan. A single-employer 
plan for this Form 5500 reporting purpose is an employee benefit 
plan maintained by one employer or one employee organization.
    Note. Do not check this box even if all of the employers 
maintaining the plan are members of the same controlled group or 
affiliated service group under Code sections 414(b), (c), or (m). 
Check Box A(3).
    Line A(2)--Box for Multiple-Employer Plan. Check this box if 
Form 5500 is being filed for a multiple-employer plan. A multiple-
employer plan is a plan that is maintained by more than one employer 
and is not one of the plans described in A(3) or A(4). A multiple-
employer plan can be collectively bargained and collectively funded, 
but if covered by PBGC termination insurance, must have properly 
elected before September 27, 1981, not to be treated as a 
multiemployer plan under Code section 414(f)(5) or ERISA sections 
3(37)(E) and 4001(a)(3), and have not revoked that election or made 
an election to be treated as a multiemployer plan under Code section 
414(f)(6) or ERISA section 3(37)(G). Participating employers do not 
file individually for this type of plan.
    Note. Do not check this box if all of the employers maintaining 
the plan are members of the same controlled group or affiliated 
service group under Code sections 414(b), (c), or (m).
    ``Multiple-Employer Plan Participating Employer Information.'' 
If you checked box A(2) for ``Multiple-Employer Plan,'' you must 
complete the ``Multiple-Employer Plan Participating Employer 
Information'' attachment. Enter the name of the plan, EIN, and plan 
number (PN) as found on the plan's Form 5500. Complete as many 
entries as needed to report the required information for all 
participating employers.
    Provide a good faith estimate of each employer's percentage of 
the total contributions (including employer and participant 
contributions) made by all participating employers during the year. 
Any employer who was obligated to make contributions to the plan for 
the plan year, made contributions to the plan for the plan year, or 
whose employees were covered under the plan is a ``participating 
employer'' for this purpose. If a participating employer made no 
contributions, enter ``-0-'' in element (c).
    Multiple employer welfare plans that are exempt under 29 CFR 
2520.104-20 or 29 CFR 2520.104-44 from the obligation to file 
financial statements with their annual report are required to 
include only a list of participating employers with the 
corresponding EIN/PN numbers in elements (a) and (b) of the 
``Multiple Employer Plan Participating Employer Information'' 
attachment included with their Form 5500.
    Line A(3)--Box for Controlled Group. Check this box for a 
``controlled group'' of corporations that is filing a single Form 
5500 for reporting purposes. A ``controlled group'' is a controlled 
group of corporations under Code section 414(b), a group of trades 
or businesses under common control under Code section 414(c), or an 
affiliated service group under Code section 414(m).
    ``Controlled Group Member Information.'' If you checked box A(3) 
for ``Controlled Group Plan,'' you must complete the ``Controlled 
Group Member Information'' attachment. Complete as many entries as 
needed to report the required information for all employers that are 
participating members of the controlled group sponsoring the plan. 
Provide a good faith estimate of each employer's percentage of the 
total contributions (including employer and participant 
contributions) made by all employers made during the year. Any 
employer that was a member of the controlled group who was obligated 
to make contributions to the plan for the plan year, made 
contributions to the plan for the plan year, or whose employees were 
covered under the plan is a ``participating employer'' for this 
purpose. If a participating employer made no contributions, enter 
``-0-'' in element (c).
    Line A(4)--Multiemployer Plan. Check this box if the Form 5500 
is filed for a multiemployer plan. A plan is a multiemployer plan 
if: (a) more than one employer is required to contribute, (b) the 
plan is maintained pursuant to one or more collective bargaining 
agreements between one or more employee organizations and more than 
one employer; (c) an election under Code section 414(f)(5) and ERISA 
section 3(37)(E) has not been made; and (d) the plan meets any other 
applicable conditions of 29 CFR 2510.3-37. A plan that has made a 
proper election under ERISA section 3(37)(G) and Code section 
414(f)(6) on or before August 17, 2007, is also a multiemployer 
plan. Participating employers do not file individually for these 
plans.
    Line A(5)--Direct Filing Entity (DFE). If filing as a DFE, check 
the box to indicate the correct entity type.
    Line B(1)--First Return/Report. Check this box if an annual 
return/report has not been previously filed for this plan or DFE. 
For the purpose of completing this box, filings made for ``one 
participant'' plans for purposes of the Code and not Title I are not 
considered an annual return/report.
    Line B(2)--Amended Return/Report. Check this box if you have 
already filed for the 20XX plan year and are now filing an amended 
return/report to correct errors and/or omissions on the previously 
filed return/report. See instructions on page xx.
    Check the Line B box for an ``amended return/report'' if you 
filed a previous 20XX annual return/report that was given a 
``Filing_Received,'' ``Filing_Error,'' or ``Filing_Stopped'' status 
by EFAST2. Do not check the Line B box for an ``amended return/
report'' if your previous submission attempts were not successfully 
received by EFAST2 because of problems with the transmission of your 
return/report. For more information, go to the EFAST2 Web site at 
www.efast.dol.gov or call the EFAST2 Help Line at 1-866-GO-EFAST (1-
866-463-3278).
    Line B(3)--Final Return/Report. Check this box if this Form 5500 
is the last annual return/report required to be submitted for this 
plan. (See Final Return/Report.)
    Note. Do not check box B(3) (Final Return/Report) if in Line 
9b(4), you check the box to indicate that the plan is an unfunded, 
fully insured, or combination unfunded/fully insured welfare plan 
(other than a group health plan) that will not file an annual report 
for next plan year pursuant to 29 CFR 2520.104-20. Only check the 
box on Line 9b(4) for a welfare plan that is not required to file a 
Form 5500 for the next plan year because the welfare plan that does 
not provide group health benefits has become eligible for an annual 
reporting exemption. For example, certain unfunded and insured life 
insurance or disability plans may be required to file the 20XX Form 
5500 and be exempt from filing a Form 5500 for the plan

[[Page 47609]]

year 20XX if the number of participants covered as of the beginning 
of the 20XX plan year drops below 100. See Who Must File. Should the 
number of participants covered by such a plan increase to 100 or 
more in a future year, the plan must resume filing Form 5500 and 
check the box on Line 9b(4) to indicate on that year's Form 5500 
that the filer is an unfunded, fully insured, or combination 
unfunded/fully insured welfare plan that stopped filing annual 
reports in an earlier plan year pursuant to 29 CFR 2520.104-20. See 
29 CFR 2520.104-20.
    Line B(4)--Short Plan Year Return/Report. Check this box if this 
Form 5500 is being filed for a plan year period of less than 12 
months. Provide the dates in Part I, Plan Year Beginning and Ending.
    Line B(5)--Plan Trusteed by PBGC. All plans that, as of the due 
date of this return, have been trusteed by PBGC under section 
4041(c) or 4042 of ERISA, must check this box and enter the date of 
trusteeship in the space provided. Plans with 500 or fewer 
participants as of the beginning of the plan year (see Part II, Line 
6, asking for participant count) only complete all of Part I and 
lines 1, 2, 3, 6, 9a(3) and 9a(4) in Part II. Plans with more than 
500 participants continue to file in accordance with the 
requirements for large defined benefit pension plans.
    Line C--Collectively-Bargained Plan. Check this box when the 
contributions to the plan and/or the benefits paid by the plan are 
subject to the collective bargaining process (even if the plan is 
not established and administered by a joint board of trustees and 
even if only some of the employees covered by the plan are members 
of a collective bargaining unit that negotiates contributions and/or 
benefits). The contributions and/or benefits do not have to be 
identical for all employees under the plan.
    Line D--Extension and DFVC Program. Check the appropriate box 
here if:
     You filed for an extension of time, using a completed 
Form 5558, Application for Extension of Time To File Certain 
Employee Plan Returns, and maintain a copy of the Form 5558 with the 
filer's records;
     You are filing using the automatic extension of time to 
file Form 5500 Annual Return/Report until the due date of the 
federal income tax return of the employer and maintain a copy of the 
employer's extension of time to file the income tax return with the 
plan's records;
     You are filing using a special extension of time to 
file the Form 5500 Annual Return/Report that has been announced by 
the IRS, DOL, and PBGC. If you checked that you are using a special 
extension of time, enter a description of the extension of time in 
the space provided; or
     You are filing under DOL's Delinquent Filer Voluntary 
Compliance (DFVC) Program.

Part II--Basic Plan Information

    Line 1a. Enter the formal name of the plan or DFE. If an annual 
return/report has previously been filed on behalf of the plan, 
regardless of the type of Form that was filed (Form 5500, Form 5500-
EZ, or Form 5500-SF), use the same name or abbreviation as was used 
on the prior filings. Once you use an abbreviation, continue to use 
it for that plan on all future annual return/report filings with the 
IRS, DOL, and PBGC. Do not use the same name or abbreviation for any 
other plan, even if the first plan is terminated.
    Line 1b. Enter the three-digit plan or entity number (PN) that 
the employer or plan administrator assigned to the plan or DFE. This 
three-digit number, in conjunction with the employer identification 
number (EIN) entered on Line 2b, is used by the IRS, DOL, and PBGC 
as a unique 12-digit number to identify the plan or DFE.
    Start at 001 for plans providing pension benefits, plans 
providing pension and welfare benefits, or DFEs (master trusts, 
CCTs, and PSAs) except GIAs, as illustrated in the table below.
    Start at 501 for plans providing only welfare benefits and GIAs. 
Do not use 888 or 999.
    Once you use a plan or DFE number, continue to use it for that 
plan or DFE on all future filings with the IRS, DOL, and PBGC. 
Failure to use the same three-digit plan/DFE number may result in 
correspondence from DOL or IRS. Do not use this unique three-digit 
number for any other plan or DFE, even if the first plan or DFE is 
terminated.

  You Should Assign a Plan Number (PN) as Described Below for Each Form
5500 (and Form 5500-SF) With the Same EIN of Plan or DFE Sponsor Entered
                              Into Line 2b
------------------------------------------------------------------------
 
------------------------------------------------------------------------
Pension benefit plans and Master         001 to the first plan or DFE.
 trusts, CCTs, PSAs, and 103-12 IEs.      Consecutively number other
                                          plans providing pension
                                          benefits with the same plan
                                          sponsor or other master
                                          trusts, CCTs, PSAs, or 103-12
                                          IEs with the same sponsor as
                                          002, 003 . . .
Welfare benefit plans, including group   501 to the first plan or GIA.
 health, and GIAs.                        Consecutively number others as
                                          502, 503 . . .
------------------------------------------------------------------------

    Exception. If Part II, Line 9a is completed and 333 (or a higher 
number in a sequence beginning with 333) was previously assigned to 
the plan, that number may be entered on Line 1b.
    Line 1c. Enter the date the plan first became effective.
    Line 2a. Limit your response to the information required in each 
row as specified below:
    1. Enter the name of the plan sponsor or, in the case of a Form 
5500 filed for a DFE, the name of the insurance company, financial 
institution, or other sponsor of the DFE (e.g., in the case of a 
GIA, the trust or other entity that holds the insurance contract, or 
in the case of a master trust, one of the sponsoring employers). If 
the plan covers only the employees of one employer, enter the 
employer's name.
    The term ``plan sponsor'' means:
     The employer, for an employee benefit plan that a 
single employer established or maintains;
     The employee organization in the case of a plan of an 
employee organization; or
     The association, committee, joint board of trustees, or 
other similar group of representatives of the parties who establish 
or maintain the plan, if the plan is established or maintained 
jointly by one or more employers and one or more employee 
organizations, or by two or more employers.
    Note. In the case of a multiple-employer plan, file only one 
annual return/report for the plan. If an association or other entity 
is not the sponsor, enter the name of a participating employer as 
sponsor. For a plan of a controlled group of corporations, the name 
of one of the sponsoring members should be entered. In either case, 
the same name must be used in all subsequent filings of the Form 
5500 Annual Return/Report or Form 5500-SF for the multiple-employer 
plan or controlled group (see instructions for Line 5 concerning 
change in sponsorship).
    2. Enter any ``in care of'' (C/O) name.
    3. Enter the current street address. A post office box number 
may be entered in addition to the street address if the Post Office 
does not deliver mail to the sponsor's street address.
    4. Enter the name of the city.
    5. Enter the two-character abbreviation of the U.S. state or 
possession and zip code.
    6. Enter the foreign routing code, if applicable. Leave U.S. 
state and zip code blank if entering a foreign routing code and 
country name.
    7. Enter the foreign country, if applicable. Do not abbreviate 
the country name after ``Enter the foreign country.''
    8. Enter the D/B/A (the doing business as) or trade name of the 
sponsor if different from the plan sponsor's name.
    9. Enter any second address. Use only a street address here, not 
a P.O. box.
    Note. You can also use the IRS Form 8822-B, Change of Address--
Business, to notify the IRS if the address provided here is a change 
in your business mailing address or your business location.
    Line 2b(1). Enter the nine-digit employer identification number 
(EIN) assigned to the plan sponsor/employer, for example, 00-
1234567. In the case of a DFE, enter the employer identification 
number (EIN) assigned to the CCT, PSA, master trust, 103-12 IE, or 
GIA.
    [CAUTION] Do not use a social security number in lieu of an EIN. 
The Form 5500 Annual Return/Report is open to public inspection, and 
the contents are public

[[Page 47610]]

information and are subject to publication on the Internet. Because 
of privacy concerns, the inclusion of a social security number or 
any portion thereof on this line may result in the rejection of the 
filing.
    Employers without an EIN must apply for one as soon as possible. 
The EBSA does not issue EINs. To apply for an EIN from the IRS:
     Mail or fax Form SS-4, Application for Employer 
Identification Number, obtained at the IRS Web site at www.irs.gov.
     Call 1-800-829-4933 to receive your EIN by telephone.
     Select the Online EIN Application link at www.irs.gov. 
The EIN is issued immediately once the application information is 
validated. (The online application process is not yet available for 
corporations with addresses in foreign countries or Puerto Rico.)
    A multiple-employer plan or plan of a controlled group of 
corporations should use the EIN of the sponsor identified in Line 
2b(1). The EIN must be used in all subsequent filings of the Form 
5500 for these plans (see instructions to Line 5 concerning change 
in EIN).
    If the plan sponsor is a group of individuals, such as for the 
Board of Trustees for a multiemployer plan, get a single EIN for the 
group. When you apply for the EIN, provide the name of the group, 
such as ``Joint Board of Trustees of the Local 187 Machinists' 
Retirement Plan.'' (If filing IRS Form SS-4, enter the group name on 
Line 1.)
    Note. Except in the case of certain DFEs, the EIN of the plan 
sponsor is not the EIN of the fund (trust or custodial account) 
associated with plan.
    Line 2b(2). If available, enter the global legal entity 
identification number (LEI). With respect to any company, the LEI is 
the ``legal entity identifier'' assigned by or on behalf of an 
internationally recognized standards setting body and required for 
reporting purposes by the U.S. Department of the Treasury's Office 
of Financial Research or a financial regulator. In the case of a 
financial institution, if a ``legal entity identifier'' has not been 
assigned, then provide the RSSD ID assigned by the National 
Information Center of the Board of Governors of the Federal Reserve 
System, if any.
    Line 2c. Enter the current telephone number for the plan 
sponsor. Use numbers only, including area code, and do not include 
any special characters.
    Line 2d. Enter the six-digit business code that best describes 
the nature of the plan sponsor's business from the list of business 
codes on pages XX-XY. If more than one employer or employee 
organization is involved, enter the business code for the main 
business activity of the employers and/or employee organizations.
    Line 3a. Limit your response to the information required in each 
row as specified below:
    1. Enter the current name and address of the plan administrator 
unless the administrator is the sponsor identified in Line 2. If 
both the plan administrator name and address are the same as the 
plan sponsor name and address, check the ``Same as Plan Sponsor'' 
box and disregard items 2 through 6 below. If the Form 5500 is 
submitted for a DFE, check the appropriate box in Part I, Line A, 
and enter the appropriate DFE code.
    The term ``plan administrator'' means:
     The person or group of persons specified as the 
administrator by the instrument under which the plan is operated;
     The plan sponsor/employer if an administrator is not so 
designated; or
     Any other person prescribed by regulations if an 
administrator is not designated and a plan sponsor cannot be 
identified.
    2. Enter any ``in care of'' (C/O) name.
    3. Enter the current street address. A post office box number 
may be entered, in addition to the street address, if the Post 
Office does not deliver mail to the administrator's street address.
    4. Enter the name of the city.
    5. Enter the two-character abbreviation of the U.S. state or 
possession and zip code.
    6. Enter the foreign routing code and foreign country, if 
applicable. Leave U.S. state and zip code blank if entering foreign 
routing code and country information.
    Line 3b. Enter the plan administrator's nine-digit EIN. A plan 
administrator must have an EIN for Form 5500 reporting purposes.
    If the plan administrator does not have an EIN, apply for one as 
explained in the instructions for Line 2b. One EIN should be entered 
for a group of individuals who are, collectively, the plan 
administrator.
    Do not use a social security number in lieu of an EIN. The Form 
5500 and its schedules and attachments are open to public 
inspection, and the contents are public information and are subject 
to publication on the Internet. Because of privacy concerns, the 
inclusion of a social security number or any portion thereof on this 
Form 5500 or any of it schedules or attachments may result in the 
rejection of the filing.
    Note. Employees of the plan sponsor who perform administrative 
functions for the plan are generally not the plan administrator 
unless specifically designated in the plan document. If an employee 
of the plan sponsor is designated as the plan administrator, that 
employee must get an EIN.
    Line 3c. Enter the current telephone number for the plan 
administrator.
    Line 4. A plan must have at least one fiduciary (a person or 
entity) named in the written plan document, or through a process 
described in the plan, as having control over the plan's operation. 
The named fiduciary can be identified by office or by name. For some 
plans, it may be an administrative committee or a company's board of 
directors.
    Enter the name and current address of the ``named fiduciary'' 
unless the named fiduciary is the plan sponsor identified in Line 2. 
If both the fiduciary name and address are the same as the plan 
sponsor name and address, check the ``Same as Plan Sponsor'' box. If 
the named fiduciary is an entity such as a committee or board, 
include the name and contact information for a specific individual, 
as well as the name of the entity. If you are unable to determine 
who is the ``named fiduciary,'' enter the name and identifying 
information of the person who appointed the plan trustee.
    Line 5. If the plan sponsor's or DFE's name, EIN, or LEI have 
changed since the last return/report was filed for this plan or DFE, 
enter the plan sponsor's or DFE's name, EIN, LEI, and the plan 
number as it appeared on the last return/report filed.
    [CAUTION] The failure to indicate on Line 5 that a plan or plan 
sponsor was previously identified by a different name, employer 
identification number (EIN), LEI, or plan number could result in 
correspondence from the DOL and the IRS.
    Line 5a. Enter the plan sponsor's name as it appeared on the 
last return/report filed.
    Line 5b(1). Enter the plan sponsor's EIN as it appeared on the 
last return/report filed.
    Line 5b(2). Enter the plan sponsor's LEI (if available) as it 
appeared on the last return/report filed.
    Line 5c. Enter the plan sponsor's plan number as it appeared on 
the last return/report filed.
    Lines 6 and 7. All filers must complete both lines 6 and 7 
unless the Form 5500 is filed for an IRA Plan described in Limited 
Pension Plan Reporting or for a DFE.
    The description of ``participant'' in the instructions below is 
only for purposes of these lines.
    An individual becomes a participant covered under an employee 
welfare benefit plan on the earliest of:
     the date designated by the plan as the date on which 
the individual begins participation in the plan;
     the date on which the individual becomes eligible under 
the plan for a benefit subject only to occurrence of the contingency 
for which the benefit is provided; or
     the date on which the individual makes a contribution 
to the plan, whether voluntary or mandatory.
    See 29 CFR 2510.3-3(d)(1). This includes former employees who 
are receiving group health continuation coverage benefits pursuant 
to Part 6 of ERISA and who are covered by the employee welfare 
benefit plan. Covered dependents are not counted as participants. A 
child who is an ``alternate recipient'' entitled to health benefits 
under a qualified medical child support order (QMCSO) should not be 
counted as a participant for lines 6 and 7. An individual is not a 
participant covered under an employee welfare plan on the earliest 
date on which the individual (a) is ineligible to receive any 
benefit under the plan even if the contingency for which such 
benefit is provided should occur, and (b) is not designated by the 
plan as a participant. See 29 CFR 2510.3-3(d)(2).
    [TIP] Before counting the number of participants, especially in 
a welfare benefit plan, it is important to determine whether the 
plan sponsor has established one or more plans for Form 5500/Form 
5500-SF reporting purposes. As a matter of plan design, plan 
sponsors can offer benefits through various structures and 
combinations. For example, a plan sponsor could create (i) one plan 
providing major medical benefits, dental benefits, and vision 
benefits, (ii) two plans with one providing major medical benefits 
and the other providing self-insured dental and vision benefits; or 
(iii) three separate plans. You must review the governing documents 
and actual operations to determine whether welfare benefits are 
being

[[Page 47611]]

provided under a single plan or separate plans.
    The fact that you have separate insurance policies for each 
different welfare benefit does not necessarily mean that you have 
separate plans. Some plan sponsors use a ``wrap'' document to 
incorporate various benefits and insurance policies into one 
comprehensive plan. In addition, whether a benefit arrangement is 
deemed to be a single plan may be different for purposes other than 
Form 5500/Form 5500-SF reporting. For example, special rules may 
apply for purposes of HIPAA, COBRA, and Internal Revenue Code 
compliance. If you need help determining whether you have a single 
welfare benefit plan for Form 5500/Form 5500-SF reporting purposes, 
you should consult a qualified benefits consultant or legal counsel.
    For pension benefit plans, ``alternate payees'' entitled to 
benefits under a qualified domestic relations order (QDRO) are not 
to be counted as participants for this line.
    For pension benefit plans, ``participant'' for this line means 
any individual who is included in one of the categories below:
    1. Active participants (i.e., any individuals who are currently 
in employment covered by the plan and who are earning or retaining 
credited service under the plan). This includes any individuals who 
are eligible to elect to have the employer make payments under a 
Code section 401(k) qualified cash or deferred arrangement. Active 
participants also include any nonvested individuals who are earning 
or retaining credited service under the plan. This does not include 
(a) nonvested former employees who have incurred the break in 
service period specified in the plan or (b) former employees who 
have received a ``cash-out'' distribution or deemed distribution of 
their entire nonforfeitable accrued benefit.
    2. Retired or separated participants receiving benefits (i.e., 
individuals who are retired or separated from employment covered by 
the plan and who are receiving benefits under the plan). This does 
not include any individual to whom an insurance company has made an 
irrevocable commitment to pay all the benefits to which the 
individual is entitled under the plan.
    3. Other retired or separated participants entitled to future 
benefits (i.e., any individuals who are retired or separated from 
employment covered by the plan and who are entitled to begin 
receiving benefits under the plan in the future). This does not 
include any individual to whom an insurance company has made an 
irrevocable commitment to pay all the benefits to which the 
individual is entitled under the plan.
    4. Deceased individuals who had one or more beneficiaries who 
are receiving or are entitled to receive benefits under the plan. 
This does not include any individual to whom an insurance company 
has made an irrevocable commitment to pay all the benefits to which 
the beneficiaries of that individual are entitled under the plan.
    Line 7g. Enter in element (1) the number of participants who 
have account balances at the beginning of the year. Enter in element 
(2) the number of participants included on Line 7f (total 
participants at the end of the plan year) who have account balances 
at the end of the plan year. For example, for a Code section 401(k) 
plan the number entered on Line 7g should be the number of 
participants counted on line 7f who have made a contribution, or for 
whom a contribution has been made, to the plan for this plan year or 
any prior plan year. Enter in element (3) the number of participants 
that made contributions to the plan (regardless of whether the 
employer made contributions) during the plan year. Both defined 
contribution pension plans and welfare plans complete element (3). 
Enter in element (4) the number of participants that terminated 
employment during the plan year that had their entire account 
balance distributed during the plan year. Only defined contribution 
pension plans complete element (4).
    Welfare plans should leave Line 7g(1), (2), and (4) blank. 
Defined benefit pension plans should also leave Line 7g blank.
    Line 7h. Include any individual who terminated employment during 
this plan year, whether or not he or she (a) incurred a break in 
service, (b) received an irrevocable commitment from an insurance 
company to pay all the benefits to which he or she is entitled under 
the plan, and/or (c) received a cash distribution or deemed cash 
distribution of his or her nonforfeitable accrued benefit. 
Multiemployer plans and multiple-employer plans that are 
collectively bargained do not have to complete Line 7h.
    Line 8. Only multiemployer plans should complete Line 8. 
Multiemployer plans must enter the total number of employers 
obligated to contribute to the plan. For purposes of Line 8 of the 
Form 5500, an employer obligated to contribute is defined as an 
employer who, during the 20XX plan year, is a party to the 
collective bargaining agreement(s) pursuant to which the plan is 
maintained or who may otherwise be subject to withdrawal liability 
pursuant to ERISA section 4203. Any two or more contributing 
entities (e.g., places of business with separate collective 
bargaining agreements) that have the same nine-digit employer 
identification number (EIN) must be aggregated and counted as one 
employer for this purpose.
    Line 9. Benefits Provided Under the Plan. Answer all questions 
in Line 9a based on the reporting year of the plan or arrangement.
    Line 9a(1). Defined Benefit Pension Features; How Benefits Are 
Calculated. If benefits are based primarily on pay, check the box 
``Benefits are primarily pay related.''
    If benefits are primarily flat dollar, including dollars per 
year of service, check the box ``Benefits are primarily flat 
dollar.''
    Check the box for ``Cash balance'' if the plan has a ``cash 
balance'' formula under which the accumulated benefit provided under 
the formula is expressed as the current balance of a hypothetical 
account maintained for the participant. For this purpose, a ``cash 
balance'' formula is a lump sum based benefit formula in a defined 
benefit pension plan by whatever name (for example, personal account 
plan, life cycle plan, cash account plan, etc.)
    Check the box for ``Pension equity plan (PEP)'' if the plan has 
a ``pension equity plan formula under which the accumulated benefit 
provided under the formula is expressed as the current value of an 
accumulated percentage of the participant's final average 
compensation or is expressed as a current single-sum dollar amount 
equal to a percentage of the participant's highest average 
compensation (with a permitted lookback period for determining 
highest average compensation, such as highest 5 out of the last 10 
years).
    Check the box for ``Other hybrid plan'' if the plan provides a 
lump sum based benefit formula that is different from the cash 
balance or pension equity plan formula. Note that a benefit formula 
does not constitute a lump sum based benefit formula unless a 
distribution of the benefits under that formula in the form of a 
single-sum payment equals the accumulated benefit under that formula 
(except to the extent the single-sum payment is greater to satisfy 
the requirements of Code section 411(d)(6)).
    Line 9a(2) Code Section Arrangements for Defined Benefit Pension 
Plans. Check the box for ``Code section 401(h) arrangement'' if the 
plan contains separate accounts under Code section 401(h) to provide 
employee health benefits.
    Check the box for ``Code section 414(k) arrangement'' if 
benefits are based partly on the balance of the separate account of 
the participant (also include appropriate defined contribution 
pension feature codes).
    Line 9a(3) Terminated Defined Benefit Pension Plan. Check 
``yes'' if the plan is covered by PBGC and was terminated and closed 
out for PBGC purposes before the end of the plan year (or a prior 
plan year), and either (1) the plan terminated in a standard (or 
distress) termination and completed the distribution of plan assets 
in satisfaction of all benefit liabilities (or all ERISA Title IV 
benefits for distress termination); or (2) a trustee was appointed 
for a terminated plan pursuant to ERISA section 4042.
    Line 9a(4) PBGC Covered Defined Benefit Pension Plan. If you are 
uncertain whether the plan is covered under the PBGC termination 
insurance program, check the box ``Not determined'' and contact the 
PBGC either by phone at 1-800-736-2444, by Email at 
[email protected], or in writing to Pension Benefit Guaranty 
Corporation, Standard Termination Compliance Division, Suite 930, 
Processing and Technical Assistance Branch, 1200 K Street, NW., 
Washington, DC 20005-4026. If you checked the box ``Yes,'' enter the 
My PAA generated confirmation number for the premium filing for this 
plan year (see filing receipt). If you amended your premium filing 
for this plan year, enter the confirmation number for that filing 
and not for the previous filing(s). Defined contribution pension 
plans and welfare plans need not complete this item.
    Line 9a(5) Frozen Plans. Check ``Yes'', if the plan is frozen. 
Both defined contribution and defined benefit pension plans must 
indicate whether the plan is frozen.
    Line 9a(6) Offset Arrangement. Both defined benefit and 
contribution plans that are part of an offset arrangement must 
answer this question. Check ``Yes'' if plan benefits are subject to 
offset for retirement benefits provided in another plan or 
arrangement of the employer. If you have checked ``Yes,''

[[Page 47612]]

enter the name, EIN, and if available, LEI of sponsor, and PN of the 
other plan or arrangement.
    Line 9a(7) Defined Contribution Pension Plan Type(s). If this is 
a defined contribution pension plan, check all the type(s) that 
apply.
    Line 9a(8) Defined Contribution Pension Plan Arrangements. If 
this is a defined contribution pension plan, check all the type(s) 
of arrangements under which the plan operates.
    Line 9a(9) Defined Contribution Pension Plan Features. If this 
is a defined contribution pension plan, check all that apply to 
indicate features of the plan.
    Check automatic enrollment feature if the plan has elective 
contributions from payroll and provides for automatic enrollment in 
the plan.
    A designated Roth account is a feature in new or existing 
401(k), 403(b) or governmental 457(b) plans that permit such plans 
to accept designated Roth contributions and certain rollovers. If a 
plan adopts this feature, employees can designate some or all of 
their elective contributions (also referred to as elective 
deferrals) as designated Roth contributions (which are included in 
gross income), rather than traditional, pre-tax elective 
contributions.
    Check the box for ``Age/service weighted plan'' if allocations 
are based on age, service, or age and service. New comparability or 
similar plan: Allocations are based on participant classifications 
and a classification(s) consists entirely or predominantly of highly 
compensated employees; or the plan provides an additional allocation 
rate on compensation above a specified threshold, and the threshold 
or additional rate exceeds the maximum threshold or rate allowed 
under the permitted disparity rules of Code section 401(l).
    Check ``Other'' if the plan has any other particularized 
features for defined contribution pension plans that are not listed 
above and enter a short description in the space provided.
    Line 9a(10) Participant-Directed Defined Contribution Pension 
Plan. If you check ``Yes'' to identify that the plan is a 
participant-directed defined contribution plan, check the box for 
ERISA section 404(c) plan if the plan, or any part of it, is 
intended to meet the conditions of 29 CFR 2550.404c-1.
    Check the box for total participant-directed account plan if 
participants have the opportunity to direct the investment of all 
the assets allocated to their individual accounts, regardless of 
whether 29 CFR 2550.404c is intended to be met.
    Check partial participant-directed account if participants have 
the opportunity to direct the investment of a portion of the assets 
allocated to their individual accounts, regardless of whether 29 CFR 
2550.404c is intended to be met. Do not check both ``total'' and 
``partial'' participant-directed account.
    Check the box for participant-directed brokerage accounts (also 
referred to as ``open brokerage windows'') if the plan provides such 
accounts as an investment option under the plan. If you check that 
the plan has participant-directed brokerage accounts, enter the 
number of participants that invested through such accounts during 
the plan year.
    Line 9a(11) Qualified Default Investment Alternatives (QDIAs). 
Regardless of whether the plan is total or partial participant-
directed, if the plan uses default investment alternatives that are 
intended to be QDIA(s) for participants who fail to direct assets in 
their account, also check the box to so indicate. If the plan uses a 
QDIA for participants who fail to direct assets in their account, 
indicate the type of default investment alternative: target date/
life fund; fixed income; money market or equivalent; balanced fund; 
professionally managed account; or other. If other, specify the type 
of account. If you checked the box for ``Other,'' you may be using 
an investment alternative that does not satisfy the QDIA 
requirements in the Department of Labor's regulation at 29 CFR 
2550.404c-5.
    Line 9a(12) Eligible Combined Plan Under Code section 414(x). If 
the plan is an eligible combined plan under Code section 414(x), 
check ``Yes.''
    Note. In the case of an eligible combined plan under Code 
section 414(x) and ERISA section 210(e), you must answer all 
applicable line items for both the defined benefit pension features 
and the defined contribution pension features of the plan.
    Line 9a(13). Check this box if a rollover from a plan was used 
to start up the business (ROBS) sponsoring this plan.
    Line 9a(14). If the plan is an employee stock ownership plan 
(ESOP) or has ESOP features, check all applicable boxes. You must 
also attach a Schedule E if the plan is an ESOP or has ESOP 
features.
    Line 9a(15) Other Pension Benefit Features. Check all that 
apply.
    Notes: (1) If a plan sponsor or an employer adopted a pre-
approved plan that includes a master & prototype plan or a volume 
submitter plan, enter the most recent adoption date and the IRS 
favorable opinion or advisory letter's serial number. (2) Sponsors 
of Puerto Rico plans, check the box to indicate that the plan is not 
intended to be qualified under Code sections 401, 403, or 408 only 
if:
    1. only Puerto Rico residents participate;
    2. the trust is exempt from income tax under the laws of Puerto 
Rico, and
    3. the plan administrator has not made the election under ERISA 
section 1022(i)(2), and, therefore, the plan is not intended to 
qualify under section 401(a) of the Internal Revenue Code (U.S).
    Line 9b Welfare Benefit Plan Characteristics. Plans that provide 
welfare benefits must answer all applicable questions in Line 9b. 
Plans that provide only pension benefits skip to question 10.
    Line 9b(1) Group Health Benefits. If the plan provides health, 
dental, or vision coverage, answer ``Yes'' and check all that apply. 
If you answered ``Yes'' here, you must attach Schedule J--Group 
Health Plan Information. Plans that offer excepted benefits that 
consist of limited scope dental or vision benefits must still file a 
Schedule J.
    Line 9b(2) Disability. If the plan provides disability benefits, 
answer ``Yes'' and check all that apply.
    Line 9b(3) Other Welfare Benefits. If the plan provides welfare 
benefits other than group health or disability, answer ``Yes'' and 
check all that apply. If the type of benefits is not listed, check 
``other'' and enter a description.
    Line 9b(4) Welfare Plans That Do Not Provide Health Benefits 
That Relied on or Will Be Relying on 29 CFR 2520.104.20. Welfare 
plans that provide health benefits must file the Form 5500 annually 
and cannot rely on the exemption from reporting under 29 CFR 
2520.104-20.
    Line 10 Funding and Benefit Arrangements. Check all boxes that 
apply to indicate the funding and benefit arrangements used during 
the plan year. The ``funding arrangement'' is the method for the 
receipt, holding, investment, and transmittal of plan assets prior 
to the time the plan actually provides benefits. The ``benefit 
arrangement'' is the method by which the plan provides benefits to 
participants. For purposes of Line 10:
    ``Insurance'' means the plan has an account, contract, or policy 
with an insurance company, insurance service, or other similar 
organization, or through a managed care organization or a health 
maintenance organization during the plan or DFE year. (This includes 
investments with insurance companies such as guaranteed investment 
contracts (GICs).) An annuity account arrangement under Code section 
403(b)(1) that is required to complete the Form 5500 should check 
``insurance'' for both the plan funding arrangement and plan benefit 
arrangement. Do not check ``insurance'' if the sole function of the 
insurance company was to provide administrative services.
    ``Code section 412(e)(3) insurance contracts'' are contracts 
that provide retirement benefits under a plan that are guaranteed by 
an insurance carrier. In general, such contracts must provide for 
level premium payments over the individual's period of participation 
in the plan (to retirement age), premiums must be timely paid as 
currently required under the contract, no rights under the contract 
may be subject to a security interest, and no policy loans may be 
outstanding. If a plan is funded exclusively by the purchase of such 
contracts, the otherwise applicable minimum funding requirements of 
section 412 of the Code and section 302 of ERISA do not apply for 
the year and neither the Schedule MB nor the Schedule SB is required 
to be filed.
    ``Trust'' includes any fund or account that receives, holds, 
transmits, or invests plan assets other than an account or policy of 
an insurance company. A custodial account arrangement under Code 
section 403(b)(7) that is required to complete the Form 5500 should 
check ``trust'' for both the plan funding arrangement and the plan 
benefit arrangement.
    ``General assets of the sponsor'' means either the plan had no 
assets or some assets were commingled with the general assets of the 
plan sponsor prior to the time the plan actually provided the 
benefits promised.
    Example. If the plan holds all its assets invested in registered 
investment companies and other non-insurance company

[[Page 47613]]

investments until it purchases annuities to pay out the benefits 
promised under the plan, box 10a(3) should be checked as the funding 
arrangement and box 10b(1) should be checked as the benefit 
arrangement.
    Note. An employee benefit plan that checks boxes on Lines 
10a(1), 10a(2), 10b(1), and/or 10b(2) must attach Schedule A (Form 
5500), Insurance Information, to provide information concerning each 
contract year ending with or within the plan year. See the 
instructions to the Schedule A and enter the number of Schedules A 
on Line 11b(2), if applicable.JY2.
    Line 11. Check the boxes on Line 11 to indicate the schedules 
being filed and, where applicable, count the schedules and enter the 
number of attached schedules in the space provided.

20XX Instructions for Schedule A (Form 5500) Insurance Information

General Instructions

Who Must File

    Schedule A (Form 5500) must be attached to the Form 5500 filed 
for every defined benefit pension plan, defined contribution pension 
plan, and welfare benefit plan required to file a Form 5500 Annual 
Return/Report if any benefits under the plan are provided by an 
insurance company, insurance service, or other similar organization, 
or through a managed care organization or a health maintenance 
organization. This includes investment and annuity contracts with 
insurance companies such as guaranteed investment contracts (GICs) 
and variable annuities. In addition, Schedules A must be attached to 
a Form 5500 filed for GIAs, master trusts, and 103-12 IEs for each 
insurance or annuity contract held in the master trust, or by the 
103-12 IE or the GIA. Plans with fewer than 100 participants that 
provide group health benefits that are fully insured do not complete 
Schedule A.
    TIP. If Form 5500 Line 10a(1), 10a(2), 10b(1), or 10b(2) is 
checked, indicating that either the plan funding arrangement or plan 
benefit arrangement includes an account, policy, or contract with an 
insurance company (or similar organization), at least one Schedule A 
would be required to be attached to the Form 5500 filed for a 
pension or welfare plan to provide information concerning the 
contract year ending with or within the plan year.
    Do not file Schedule A for a contract that is an Administrative 
Services Only (ASO) contract, a fidelity bond or policy, or a 
fiduciary liability insurance policy. Also, if a Schedule A for a 
contract or policy is filed as part of a Form 5500 for a master 
trust or 103-12 IE that holds the contract, do not include a 
Schedule A for the contract or policy on the Form 5500s filed for 
the plans participating in the master trust or 103-12 IE. Schedule A 
is not required to be attached by a small, fully insured group 
health plan.
    Check the Schedule A box on the Form 5500 (Part II, Line 
11b(2)), and enter the number attached in the space provided if one 
or more Schedules A are attached to the Form 5500.

Specific Instructions

    Information entered on Schedule A should pertain to the 
insurance contract or policy year ending with or within the plan 
year (for reporting purposes, a year cannot exceed 12 months).
    Example. If an insurance contract year begins on July 1 and ends 
on June 30, and the plan year begins on January 1 and ends on 
December 31, the information on the Schedule A attached to the 20XX 
Form 5500 should be for the insurance contract year ending on June 
30, 20XX.
    Exception. If the insurance company maintains records on the 
basis of a plan year rather than a policy or contract year, the 
information entered on Schedule A may pertain to the plan year 
instead of the policy or contract year.
    Include only the contracts issued to or held by the plan, GIA, 
master trust, or 103-12 IE for which the Form 5500 is being filed.
    Lines A, B, C, and D. This information must be the same as 
reported in Part II of the Form 5500 to which this Schedule A is 
attached.
    Do not use a social security number in lieu of an EIN. The 
Schedule A and its attachments are open to public inspection, and 
the contents are public information and are subject to publication 
on the Internet. Because of privacy concerns, the inclusion of a 
social security number or any portion thereof on this Schedule A or 
any of its attachments may result in the rejection of the filing.
    You can apply for an EIN from the IRS online, by telephone, by 
fax, or by mail depending on how soon you need to use the EIN. For 
more information, see Section 3: Electronic Filing Requirement under 
General Instructions to Form 5500. The EBSA does not issue EINs.

Part I--Information Concerning Insurance Contract Coverage, Fees, and 
Commissions

    Line 1a. Enter the name of the insurance carrier. If you are 
reporting the same insurance carrier on multiple Schedules A to 
report different contracts, use the same name on each Schedule A.
    Line 1b. Enter the EIN of the insurance carrier. If you are 
reporting the same insurance carrier on multiple Schedules A to 
report different contracts, use the same EIN on each Schedule A.
    Line 1c. Enter the five-digit ``Company Code'' number assigned 
by the National Association of Insurance Commissioners (NAIC) to the 
insurance company. Do not use the NAIC ``group code'' or a state-
issued identity number for the insurance company.
    Line 1d. If individual policies with the same carrier are 
grouped as a unit for purposes of this report, and the group does 
not have one identification number, you may use the contract or 
identification number of one of the individual contracts, provided 
this number is used consistently to report these contracts as a 
group and the plan administrator maintains the records necessary to 
disclose all the individual contract numbers in the group upon 
request. Use separate Schedules A to report individual contracts 
that cannot be grouped as a unit.
    Line 1e. For contracts or policies providing group health 
benefits, enter the health plan identifier (HPID) required under the 
Health Insurance Portability and Accountability Act (HIPAA).
    Line 1f. Enter the beginning and ending dates of the policy year 
for the contract identified in elements (1) and (2). Leave 1(f) 
blank if separate contracts covering individual employees are 
grouped.

Part II--Investment and Annuity Contract Information

    Line 3. Enter the current value of the plan's interest at year 
end in the contract reported on Line 6 e.g., deposit administration 
(DA), immediate participation guarantee (IPG), guaranteed investment 
contracts (GIC), or variable annuity contract.
    Exception. Contracts reported on Line 6 need not be included on 
Line 3 if: (1) the Schedule A is filed for a defined benefit pension 
plan and the contract was entered into before March 20, 1992; or (2) 
the Schedule A is filed for a defined contribution pension plan and 
the contract is a fully benefit-responsive contract, i.e., it 
provides a liquidity guarantee by a financially responsible third 
party of principal and previously accrued interest for liquidations, 
transfers, loans, or hardship withdrawals initiated by plan 
participants exercising their rights to withdraw, borrow, or 
transfer funds under the terms of a defined contribution pension 
plan that does not include substantial restrictions to participants' 
access to plan funds.
    Important Reminder. Plans may treat multiple individual annuity 
contracts, including Code section 403(b)(1) annuity contracts, 
issued by the same insurance company as a single group contract for 
reporting purposes on Schedule A.
    Line 4. Enter the current value of the plan's interest under 
this contract in separate accounts at contract year end. Check 
whether the separate account is a pooled separate account (PSA), 
other separate account, or variable annuity. If other, enter a 
description of the separate account.

Line 5 Contracts with Allocated Funds

    Line 5a. Enter a description of the basis of the rates.
    Line 5b. Enter the amount of premiums paid to the carrier.
    Line 5c. Enter the amount, if any, of premiums due but unpaid at 
the end of year.
    Line 5d. If the carrier, service, or other organization incurred 
any specific costs in connection with the acquisition or retention 
of the contract or policy, enter the amount and specify the nature 
of the costs.
    Line 5e. Check the appropriate box to indicate whether this is 
for individual policies, a group deferred annuity or other. If you 
check ``Other,'' you must enter a description of the type of 
contract.
    Line 5f. If the contract being reported here was purchased, in 
whole or in part, to distribute benefits from a terminating plan, 
you must check the box in Line 5f.

Line 6 Contracts with Unallocated Funds

    Lines 6a-f. Report contracts with unallocated funds. Do not 
include portions of these contracts maintained in separate

[[Page 47614]]

accounts. Show deposit fund amounts rather than experience credit 
records when both are maintained.

Part III--Welfare Benefit Contract Information

    Line 7. Since plan coverage may fluctuate during the year, the 
administrator should estimate the number of persons that were 
covered for each benefit by the contract at the end of the policy or 
contract year.
    Persons, for purposes of this line, includes participants, 
beneficiaries, and dependents of participants that are covered under 
the insurance contract (such as with family coverage). Where 
contracts covering individual employees are grouped, compute entries 
as of the end of the plan year.
    Line 8a. Report a stop-loss insurance policy that is an asset of 
the plan on Schedule A.
    Note. Employers sponsoring welfare plans may purchase a stop-
loss insurance policy with the employer as the insured to help the 
employer manage its risk associated with its liabilities under the 
plan. These employer contracts with premiums paid exclusively out of 
the employer's general assets without any employee contributions 
generally are not plan assets and are not reportable on Schedule A, 
but may be required to be reported on Schedule J.
    Line 11. Indicate whether there were any premium delinquencies 
during the reporting year. You must answer ``Yes'' or ``No.'' Do not 
leave Line 11a blank. If you answered ``Yes,'' you must indicate 
both the number of times delinquent for premiums due but unpaid 
during the year, and for each delinquency, the number of days 
delinquent. If you answered ``no'' to line 11a, check ``N/A.'' If 
any premium payments that were not made within the time required by 
the insurance carrier that resulted in a lapse of insurance 
coverage, you must answer ``Yes'' to Line 11a even if coverage was 
retroactively reinstated.

Part IV--Fee and Commission Information

    Lines 12 and 13. Report on Line 12 the total of all insurance 
fees and commissions directly or indirectly attributable to the 
contract or policy placed with or retained by the plan.
    Totals. Enter on Line 12 the total of all such commissions and 
fees paid to agents, brokers, and other persons listed on Line 13. 
Complete a separate Line 13 item (elements (a) through (f)) for each 
person listed.
    For purposes of Lines 12 and 13, commissions and fees include 
sales and base commissions and all other monetary and non-monetary 
forms of compensation where the broker's, agent's, or other person's 
eligibility for the payment or the amount of the payment is based, 
in whole or in part, on the value (e.g., policy amounts, premiums) 
of contracts or policies (or classes thereof) placed with or 
retained by an ERISA plan, including, for example, persistency and 
profitability bonuses. The amount (or pro rata share of the total) 
of such commissions or fees attributable to the contract or policy 
placed with or retained by the plan must be reported in Lines 12a 
and b and in Lines 13c and d, as appropriate.
    Insurers must provide plan administrators with an allocation of 
commissions and fees attributable to each contract. Any reasonable 
method of allocating commissions and fees to policies or contracts 
is acceptable, provided the method is disclosed to the plan 
administrator. A reasonable allocation method could, in the 
Department of Labor's view, allocate fees and commissions to a 
Schedule A based on a calendar year calculation even if the plan 
year or policy year was not a calendar year. For additional 
information on these Schedule A reporting requirements, see ERISA 
Advisory Opinion 2005-02A, available on the Internet at www.dol.gov/ebsa.
    Where benefits under a plan are purchased from and guaranteed by 
an insurance company, insurance service, or other similar 
organization, and the contract or policy is reported on a Schedule 
A, payments of reasonable monetary compensation by the insurer out 
of its general assets to affiliates or third parties for performing 
administrative activities necessary for the insurer to fulfill its 
contractual obligation to provide benefits, where there is no direct 
or indirect charge to the plan for the administrative services other 
than the insurance premium, then the payments for administrative 
services by the insurer to the affiliates or third parties do not 
need to be reported on lines 12 and 13 of Schedule A. This would 
include compensation for services such as recordkeeping and claims 
processing services provided by a third party pursuant to a contract 
with the insurer to provide those services but would not include 
compensation provided by the insurer incidental to the sale or 
renewal of a policy, such as finder's fees, insurance brokerage 
commissions and fees, or similar fees.
    Schedule A reporting also is not required for compensation paid 
by the insurer to a ``general agent'' or ``manager'' for that 
general agent's or manager's management of an agency or performance 
of administrative functions for the insurer. For this purpose, (1) a 
``general agent'' or ``manager'' does not include brokers 
representing insureds, and (2) payments would not be treated as paid 
for managing an agency or performance of administrative functions 
where the recipient's eligibility for the payment or the amount of 
the payment is dependent or based on the value (e.g., policy 
amounts, premiums) of contracts or policies (or classes thereof) 
placed with or retained by ERISA plan(s).
    Schedule A reporting is not required for occasional non-monetary 
gifts or meals of insubstantial value that are tax deductible for 
federal income tax purposes by the person providing the gift or meal 
and would not be taxable income to the recipient. For this exemption 
to be available, the gift or gratuity must be both occasional and 
insubstantial. For this exemption to apply, the gift must be valued 
at less than $50, the aggregate value of gifts from one source in a 
calendar year must be less than $250, but gifts with a value of less 
than $10 do not need to be counted toward the $250 annual limit. If 
the $250 aggregate value limit is exceeded, then the aggregate value 
of all the gifts will be reportable. For this purpose, non-monetary 
gifts of less than $10 also do not need to be included in 
calculating the aggregate value of all gifts required to be reported 
if the $250 limit is exceeded.
    Gifts from multiple employees of one service provider should be 
treated as originating from a single source when calculating whether 
the $50 or $250 thresholds apply. On the other hand, in applying the 
threshold to an occasional gift received from one source by multiple 
employees of a single service provider, the amount received by each 
employee should be separately determined in applying the $50 and 
$250 thresholds. For example, if 11 employees of a broker attend a 
business conference put on by an insurer designed to educate and 
explain the insurer's products for employee benefit plans, and the 
insurer provides, at no cost to the attendees, refreshments valued 
at $25 per individual, the gratuities would not be reportable on 
lines 12 and 13 of the Schedule A even though the total cost of the 
refreshments for all the employees would be $275.
    These thresholds are for purposes of Schedule A reporting. 
Filers are cautioned that the payment or receipt of gifts and 
gratuities of any amount by plan fiduciaries may violate ERISA and 
give rise to civil liabilities and criminal penalties.
    Line 13. Identify agents, brokers, and other persons 
individually in descending order of the amount paid. Complete as 
many entries as necessary to report all required information. 
Complete 13a-f for each person as specified below.
    13a. Enter the name and address of the agents, brokers, or other 
persons to whom commissions or fees were paid.
    13b. Enter any relationship of the person identified in Line 13a 
to the plan sponsor, to the participating employer or employee 
organization, or to any person known to be a party-in-interest, for 
example, employer, plan sponsor, employee of employer, vice-
president of employer, union officer, affiliate of plan 
recordkeeper/fiduciary/investment manager, etc.
    13c. Report all sales and base commissions here. For purposes of 
this element, sales and/or base commissions are monetary amounts 
paid by an insurer that are charged directly to the contract or 
policy and that are paid to a licensed agent or broker for the sale 
or placement of the contract or policy. All other payments should be 
reported in Line 13d as fees.
    13d. Fees to be reported here represent payments by an insurer 
attributable directly or indirectly to a contract or policy to 
agents, brokers, and other persons for items other than sales and/or 
base commissions (e.g., service fees, consulting fees, finders' 
fees, profitability and persistency bonuses, awards, prizes, and 
non-monetary forms of compensation). Fees paid to persons other than 
agents and brokers should be reported here, not in Parts II and III 
on Schedule A as acquisition costs, administrative charges, etc.
    13e. Enter the purpose(s) for which fees were paid.
    13f. Enter the most appropriate organization code for the 
broker, agent, or other person entered in Line 13a.

[[Page 47615]]

Code Type of Organization

    1 Banking, Savings & Loan Association, Credit Union, or other 
similar financial institution
    2 Trust Company
    3 Insurance Agent or Broker
    4 Agent or Broker other than insurance
    5 Third party administrator
    6 Investment Company/Mutual Fund
    7 Investment Manager/Adviser
    8 Labor Union
    9 Foreign entity (e.g., an agent or broker, bank, insurance 
company, etc., not operating within the jurisdictional boundaries of 
the United States)
    0 Other
    For plans, GIAs, master trusts, and 103-12 IEs required to file 
Part I of Schedule C, commissions and fees listed on the Schedule A 
are not required to be reported again on Schedule C. The amount of 
the compensation that must be reported on Schedule A must, however, 
be taken into account in determining whether the agent's, broker's, 
or other person's direct or indirect compensation in relation to the 
plan or DFE is $1,000 or more indirect compensation or combined 
direct and indirect compensation or $5,000 or more in direct 
compensation and, thus, requiring the compensation not listed on the 
Schedule A to be reported on the Schedule C. See FAQs about the 
Schedule C available on the EBSA Web site at www.dol.gov/ebsa/faqs.

Part V--Provision of Information

    The insurance company, insurance service, or other similar 
organization is required under ERISA section 103(a)(2) to provide 
the plan administrator with the information needed to complete this 
return/report. If you do not receive this information in a timely 
manner, contact the insurance company, insurance service, or other 
similar organization.
    Line 14. If information is missing on Schedule A due to a 
refusal by the insurance company, insurance service, or other 
similar organization to provide information, check ``Yes'' on Line 
14. If you answer ``Yes'' to Line 14, you must complete Line 14b. If 
you received all the information necessary to receive the Schedule 
A, check ``No'' and leave Line 14b blank.
    TIP. The insurance company, insurance service, or other similar 
organization is statutorily required to provide you with all of the 
information necessary to complete the Schedule A, but need not 
provide the information on a Schedule A itself.
    On Line 14b, check the box if the information not provided was 
``fee and commission information.'' For all other types of 
information, check ``Other,'' and enter a description of the 
information not provided.

20XX Instructions for Schedule C (Form 5500) (Service Provider 
Information)

General Instructions

Who Must File

    Schedule C (Form 5500) must be attached to a Form 5500 filed for 
pension or welfare benefit plans, master trusts, 103-12 IEs, or GIAs 
required to file the Form 5500 to report certain information 
concerning service providers, except as provided below. Remember to 
check the Schedule C box on the Form 5500 (Part II, Line 11b(3)) and 
enter the number attached in the space provided to indicate the 
number of Schedules C attached to the Form 5500.
    All plans required to complete a Schedule C must complete a 
separate Schedule C, in accordance with the instructions, to report 
the information required for: (1) Each ``covered service provider,'' 
as defined below, who received $1,000 or more in total direct and 
indirect compensation (i.e., money or anything else of monetary 
value) in connection with services rendered to the plan or the 
person's position with the plan during the plan year, including 
payments from participants' accounts and (2) other persons who 
received $5,000 or more in direct compensation in connection with 
services rendered to the plan or the person's position with the plan 
during the plan year, including payments from participants' 
accounts.
    A ``covered service provider'' for Schedule C reporting has the 
same meaning as ``covered service provider'' in 29 CFR 2550.408b-
2(c)(1)(iii) and includes: (1) Persons who provide services as an 
ERISA fiduciary directly to the plan; (2) persons who provide 
services as an ERISA fiduciary to an investment contract, product, 
or entity that holds plan assets (as determined pursuant to section 
3(42) and 401 of the Act and 29 CFR 2510.3-101) and in which the 
plan has a direct equity investment; (3) persons who provide 
services to the plan as investment advisers registered under Federal 
or State law; (4) persons who provide recordkeeping or brokerage 
services to a participant-directed individual account plan in 
connection with a designated investment alternative (DIA) (e.g., a 
``platform provider''); and (5) persons who provide of one or more 
of the following services to the plan who received indirect 
compensation from parties other than from the plan or plan sponsor 
in connection with such services: Accounting, auditing, actuarial, 
banking, consulting, custodial, insurance, investment advisory, 
legal, recordkeeping, securities or other investment brokerage, 
third party administration, or valuation services.
    Welfare plans are not subject to the service provider disclosure 
regulation at 29 CFR 2550.408b-2, but all plans, including welfare 
plans, that are required to file the Schedule C should use the 
provisions and definitions 29 CFR 2550.408b-2 as a guide in 
completing the Schedule C.

Exceptions.

    1. Employees of the plan whose only compensation in relation to 
the plan was less than $25,000 for the plan year. With regard to 
reporting plan employees' salaries, total salaries (before taxes and 
other deductions) paid to employees should be used to determine 
whether an employee has received less than $25,000 during the plan 
year. Do not include the employer portion of FICA and FUTA taxes as 
part of the total compensation of an employee. Include salary, 
bonuses, overtime. Also include indirect compensation from persons 
other than the plan received in connection with the person's 
position with the plan or services provided to the plan. Include 
expenses for travel, educational, conference, meals, etc., whether 
paid directly by the plan or reimbursed to the employee, only if 
such payments would be reportable as taxable income to the employee.
    2. Employees of the plan sponsor or other business entity where 
the plan sponsor or business entity is reported on the Schedule C as 
a service provider, provided the employee did not separately receive 
reportable direct or indirect compensation in relation to the plan;
    3. Persons whose only compensation in relation to the plan 
consists of insurance fees and commissions listed in a Schedule A 
filed for the plan;
    4. Payments made directly by the plan sponsor that are not 
reimbursed by the plan. In the case of a multiemployer or multiple-
employer plan, where the ``plan sponsor'' would be the joint board 
of trustees for the plan, payments by contributing employers, 
directly or through an employer association, or by participating 
employee organizations, should be treated the same as payments by a 
plan sponsor; and
    5. Welfare plans, including group health plans, that are 
required to file the Form 5500 and that do not have to complete the 
Schedule H because they meet the conditions of the DOL's regulation 
at 29 CFR 2520.104-44 or Technical Release 92-01, also do not have 
to file the Schedule C.
    Part II of the Schedule C must be completed to report service 
providers who fail or refuse to provide information necessary to 
complete Part I of this Schedule.
    For plans, GIAs, master trusts, and 103-12 IEs required to file 
Part I of Schedule C, commissions and fees listed on the Schedule A 
are not required to be reported again on Schedule C. The amount of 
the compensation that must be reported on Schedule A must, however, 
be taken into account in determining whether the service provider's 
direct or indirect compensation in relation to the plan or DFE meets 
the Schedule C reporting threshold, thus, requiring the compensation 
not listed on the Schedule A to be reported on the Schedule C.
    Lines A, B, C, and D. This information must be the same as 
reported in Part II of the Form 5500 to which this Schedule C is 
attached.
    Do not use a social security number in Line D in lieu of an EIN. 
The Schedule C and its attachments are open to public inspection, 
and the contents are public information subject to publication on 
the Internet. Because of privacy concerns, the inclusion of a social 
security number or any portion thereof on this Schedule C or any of 
its attachments may result in the rejection of the filing.
    You can apply for an EIN from the IRS online, by telephone, by 
fax, or by mail depending on how soon you need to use the EIN. For 
more information, see Section 3: Electronic Filing Requirement under 
General Instructions to Form 5500. The EBSA does not issue EINs.
    Do not list the PBGC or the IRS on Schedule C as service 
providers.
    Either the cash or accrual basis may be used for the recognition 
of transactions

[[Page 47616]]

reported on the Schedule C as long as the filer uses one method 
consistently. The basis used by various service providers may be 
different from that of the filing plan or DFE, as long as each 
service provider is also using one method consistently from year to 
year and providing the information to the plan consistently.
    If service provider compensation is reported on a Schedule C 
filed as a part of a Form 5500 Annual Return/Report filed for a 
master trust or a 103-12 IE, do not report the same compensation 
again on the Schedule C filed for the plans that participate in the 
master trust or 103-12 IE. If a service provider paid or retained by 
a master trust performs services only for certain of the 
participating plans, the service provider must be reported on the 
Schedule C(s) for the plan(s) for which the services were performed; 
only compensation received in connection with services provided to 
all plans participating in the master trust should be reported at 
the master trust level.

Schedule C Reportable Compensation

    For Schedule C purposes, reportable compensation includes money 
and any other thing of value (for example, gifts, awards, trips) 
received by a person, directly or indirectly, from the plan 
(including fees charged as a percentage of assets and deducted from 
investment returns and payments from parties other than the plan) in 
connection with services rendered to the plan or the person's 
position with the plan. Amounts are considered to have been received 
in connection with services rendered to the plan if the person's 
eligibility for a payment is based, in whole or in part, on services 
that were rendered to the plan or on a transaction or series of 
transactions with the plan. This includes any compensation that the 
covered service provider, an affiliate, or a subcontractor received 
in connection with termination of the contract or arrangement. 
Reportable compensation would not include amounts that would have 
been received had the service not been rendered or the transaction 
had not taken place and that cannot be reasonably allocated to the 
services performed or transaction(s) with the plan. The term 
``person'' for this purpose includes individuals, trades and 
businesses (whether incorporated or unincorporated). See ERISA 
section 3(9).
    Since, in most cases, the ``spread'' earned by a broker-dealer 
in a principal transaction would not be commission compensation paid 
by the covered plan for ``services,'' but instead would be 
considered ``profit'' for a non-service transaction, such as a 
purchase or sale of securities (i.e., where the broker-dealer acts 
as principal, not as an agent), the ``spread'' received would not be 
``compensation'' (direct or indirect) for Schedule C purposes. For 
this purpose, the Department will rely upon the definition of the 
term ``commission'' used by the SEC under Section 28(e) of the 
Securities Exchange Act of 1934, as amended, per SEC Release No. 34-
45194.
    Similarly, the broker-dealer's sale of IPO securities to the 
plan does not occur ``in connection with'' services to the plan, but 
occurs as a result of a separate, non-service transaction where the 
broker-dealer is acting as a principal (e.g., a dealer who buys and 
sells securities from its inventory, as an underwriter or otherwise, 
and receives a ``mark-up'' or ``spread'' on the price vis-a-vis its 
own separate purchase or sale activities as a dealer). Thus, the 
broker-dealer is not a service provider to the plan in its role as a 
securities dealer, and its affiliates who may receive fees for 
underwriting and/or managing an underwriting syndicate for an IPO 
would not be receiving such fees ``in connection with'' services 
provided to the covered plan.
    The investment of plan assets and payment of premiums for 
insurance contracts are not in and of themselves payments for 
services rendered to the plan for purposes of Schedule C reporting 
and the investment and payment of premiums themselves are not 
reportable compensation for purposes of Part I of the Schedule C.
    Direct Compensation--Payments Received from the Plan. Direct 
compensation for Schedule C purposes has the same meaning as 
``direct compensation'' in 29 CFR 2550.408b-2(c)(1)(viii)(B)(1), and 
includes payments received directly from the plan by a service 
provider in connection with services rendered to the plan, or a 
covered service provider, its affiliate or subcontractor in 
connection with the services rendered to the plan. Direct 
compensation includes, for example, direct payments by the plan out 
of a plan account, charges to plan forfeiture accounts and plan fee 
recapture trust accounts, charges to a plan's trust account before 
allocations are made to individual participant accounts, and direct 
charges to plan participant individual accounts. For example, the 
plan sponsor may pay for certain plan administrative services by 
writing a check from the plan account. Alternatively, a covered 
service provider may be paid a fixed per capita fee from 
participants' accounts in the covered plan when participants take 
out plan loans. Payments made by the plan sponsor, which are not 
reimbursed by the plan, are not subject to Schedule C reporting 
requirements even if the sponsor is paying for services rendered to 
the plan. Payments by made by the plan sponsor that are reimbursed 
by the plan are treated as direct payments by the plan.
    Indirect Compensation--Amounts Received from Parties Other Than 
the Plan or Plan Sponsor. Indirect compensation for Schedule C 
purposes has the same meaning as ``indirect compensation'' in 29 CFR 
2550.408b-2(c)(1)(viii)(B)(2), and includes compensation received by 
the covered service provider, an affiliate or subcontractor in 
connection with the services rendered to the plan from any source 
other than directly from the plan, plan sponsor, by an affiliate or 
subcontractor from the covered service provider, or by the covered 
service provider from an affiliate. Compensation received from a 
subcontractor is indirect compensation unless it is received in 
connection with services performed under the subcontractor's 
contract or arrangement with the covered service provider or an 
affiliate for performing one or more services provided for by the 
contract or arrangement with the plan. Indirect compensation 
includes amounts received by the covered service provider, affiliate 
or subcontractor that are charged against the investments of the 
plan (e.g., mutual funds or other investment funds) and reflected in 
the plan's return on investment.
    For example, indirect compensation would include payments that 
an independent recordkeeper receives from investment issuers to 
compensate the recordkeeper for administrative services it performs 
for the investment issuer when those payments are received in 
connection with investments that such plans make in the issuers' 
products. If a covered service provider, affiliate or subcontractor 
receives revenue sharing payments from an investment fund (e.g., 
mutual fund), investment provider or other plan service provider or 
person in connection with the services the covered service provider, 
affiliate or subcontractor rendered to a covered plan, that 
compensation would be ``indirect compensation.'' Amounts charged 
against the fund for other ordinary operating expenses of the fund, 
such as attorneys' fees, accountants' fees, printers' fees, are not 
reportable indirect compensation received by the attorneys, 
accountants, or printers for Schedule C purposes. Also, brokerage 
costs associated with a broker-dealer effecting securities 
transactions within the portfolio of a mutual fund or for the 
portfolio of an investment fund that holds ``plan assets'' for ERISA 
purposes are not reportable compensation paid to the broker as a 
plan service provider for Schedule C purposes.
    If a service provider charges the plan a fee or commission, but 
agrees to offset the fee or commission with any revenue received 
from a party other than the plan or plan sponsor, for example, as 
part of a commission recapture or other offset arrangement, only the 
amount paid directly by the plan after any revenue sharing offset 
should be entered as direct compensation in Line 2. If the amount 
deposited into the plan's trust account by the record keeper is net 
of the record keeper's service fees, however, the amount the record 
keeper retains would be reportable indirect compensation for 
Schedule C purposes. Amounts paid to persons out of the plan's ERISA 
fee recapture trust account for services rendered to the plan are 
considered direct compensation to the receiving service provider 
reportable in Line 1g. If the record keeper retains the revenue 
sharing income but reflects some or all of it on the record keeper's 
accounts as a credit to the plan (as opposed to depositing in the 
plan's trust account), payments by the record keeper to itself or 
other persons for rendering services to the plan that reduce the 
plan's credit balance would be reportable indirect compensation to 
the persons receiving the payments reportable in Line 3.
    Compensation paid among the covered service provider, an 
affiliate, or a subcontractor, in connection with the services 
provided to the plan is not reportable indirect compensation. 
Rather, those payments may be required to be reported as Related 
Party Compensation on Line 4.
    Special rules for non-monetary compensation of insubstantial 
value,

[[Page 47617]]

guaranteed benefit insurance policies, bundled service arrangements, 
and allocating compensation among multiple plans:
    Excludable Non-Monetary Compensation: You may exclude non-
monetary compensation of insubstantial value (such as gifts or meals 
of insubstantial value) that is tax deductible for federal income 
tax purposes by the person providing the gift or meal and would not 
be taxable income to the recipient. The gift or gratuity must be 
valued at less than $50, and the aggregate value of gifts from one 
source in a calendar year must be less than $250, but gifts with a 
value of less than $10 do not need to be counted toward the $250 
limit. If the $250 aggregate value limit is exceeded, then the value 
of all the gifts over $10 will be reportable. Gifts received by one 
person from multiple employees of one entity must be treated as 
originating from a single source when calculating whether the $50 or 
$250 threshold applies. On the other hand, gifts received from one 
person by multiple employees of one entity can be treated as 
separate compensation when calculating the $50 and $250 thresholds.
    These thresholds are for purposes of Schedule C reporting only. 
Filers are cautioned that gifts and gratuities of any amount paid to 
or received by plan fiduciaries may violate ERISA and give rise to 
civil liabilities and criminal penalties.
    Fully Insured Group Health and Similarly Fully Insured Benefits: 
Where benefits under a plan are purchased from and guaranteed by an 
insurance company, insurance service, or other similar organization, 
and the contract or policy is reported on a Schedule A, payments of 
reasonable monetary compensation by the insurer out of its general 
assets to persons for performing administrative activities necessary 
for the insurer to fulfill its contractual obligation to provide 
benefits, where there is no direct or indirect charge to the plan 
for the administrative services other than the insurance premium, 
would not be treated as indirect compensation for services provided 
to the plan for Schedule C reporting purposes. This would include 
compensation for services such as recordkeeping and claims 
processing provided by a third party pursuant to a contract with the 
insurer to provide those services, but would not include 
compensation provided by the insurer incidental to the sale or 
renewal of a policy, such as finder's fees, insurance brokerage 
commissions and fees, or similar fees. Insurance investment 
contracts are not eligible for this exception.
    [CAUTION] Allocating Compensation Among Multiple Plans: Where 
reportable compensation is received by a person in connection with 
several plans or DFEs, any reasonable method of allocating the 
compensation among the plans or DFEs may be used provided that the 
allocation method is disclosed to the plan administrator. If a such 
a reasonable method of allocation is used in determining the 
compensation attributable to the plan, then in calculating the 
$1,000 and $5,000 thresholds for purposes of determining whether a 
person must be identified in Part I, the amount of compensation 
received by the person that is determined to be attributable to the 
plan or DFE filing the Form 5500 should be used, not the aggregate 
amount of compensation received in connection with all the plans or 
DFEs.

Specific Instructions

Part I--Service Provider Information

    Line 1a. As explained above, a separate Schedule C must be 
filed, in accordance with the instructions, to report the 
information for: (1) Each covered service provider who received 
$1,000 or more in total direct and indirect compensation (i.e., 
money or anything else of monetary value in connection with services 
rendered to the plan or the person's position with the plan during 
the plan year, including payments from participants' accounts and 
(2) other persons who received $5,000 or more in direct compensation 
in connection with services rendered to the plan or the person's 
position with the plan during the plan year, including payments from 
participants' accounts.
    Enter in Line 1a the covered service provider or other person's 
name and complete Lines 1a(1)-(6). If the service provider 
identified is not an individual, provide the name and address for an 
individual or office at the service provider that the plan could 
contact for information about the service arrangement in Lines 
1a(5)-(6). If the name of an individual is entered in Line 1a and 
the individual does not have an EIN, enter the EIN of the 
individual's employer. If the person is self-employed and does not 
have an EIN, you may enter the person's address and telephone 
number. Do not use a social security number in lieu of an EIN. The 
Schedule C and its attachments are open to public inspection and are 
subject to publication on the Internet. Because of privacy concerns, 
the inclusion of a social security number or any portion thereof on 
this Schedule C or any of its attachments may result in the 
rejection of the filing. Also enter the service provider's LEI, if 
available.
    Line 1b. Check the appropriate box to indicate the relationship 
of the service provider identified in Line 1a to the plan. Check 
Line 1b(7) ``Other'' and enter a description, e.g., vice-president 
of employer, union officer, affiliate of the plan sponsor, 
recordkeeper, fiduciary, investment manager, etc., if the service 
provider has a relationship to the plan other than ``service 
provider'' that is not one of relationships listed in Line 1b(1)-
(6). If the service provider has no relationship to the plan other 
than the service provider relationship being reported on the 
Schedule C, check the box in Line 1b(8) for ``not applicable.''
    Line 1c. Types of Services. Check all the appropriate box(es) to 
describe the types of services provided. The ``plan administrator'' 
for purposes of Line 1c is the person who has been designated as the 
administrator by the terms of the instrument under which the plan is 
operated; or if no plan administrator is designated, the plan 
sponsor. See ERISA section 3(16). The plan administrator should be 
identified in the plan's summary plan description. For most employee 
benefit plans, the plan administrator is the employer, a committee 
of employees, a company executive, or in some cases a person or 
organization hired to be the plan administration. The plan's ``third 
party administrator'' often is not the same as the ``plan 
administrator'' for this purpose.
    Line 1d. Check the box if the person identified in Line 1a was a 
fiduciary within the meaning of section 3(21) of ERISA during the 
plan year. Every employee benefit plan must be established and 
maintained pursuant to a written instrument. The instrument must 
provide for one or more ``named fiduciaries'' who jointly or 
severally have authority to control and management the operation and 
administration of the plan. Under ERISA section 402(a), ``the term 
named fiduciary means a fiduciary who is named in the plan 
instrument, or who, under a procedure specified in the plan, is 
identified as a fiduciary (a) by a person who is an employer or 
employee organization with respect to the plan or (b) by such an 
employer and such employee organization acting jointly.'' Other 
persons may be functional fiduciaries because they exercise control 
over plan assets, have discretionary authority for administration or 
management of the plan, or provide investment advice for a fee.
    Line 1e. Check ``Yes'' if the person identified in Line 1a also 
was identified on Schedule A as having received insurance fees and 
commissions.
    Line 1f. Check ``Yes,'' if the arrangement with the service 
provider included the use of an ERISA recapture, ERISA budget or 
similar account during the plan year.
    Line 1g. Check ``Yes'' in Line 1g(1) if the arrangement with the 
service provider identified in Line 1a included recordkeeping 
services to a pension plan without explicit compensation for some or 
all of such recordkeeping services or with compensation for such 
recordkeeping offset or rebated in whole or in part based on other 
compensation received by the service provider, or an affiliate or 
subcontractor. If ``Yes,'' use the same methodology to develop a 
dollar estimate of the cost to the plan of recordkeeping services 
provided in the service provider's 408-b(2) disclosure, enter in 
Line 1g(2), as a dollar figure, the amount of compensation the 
service provider received for recordkeeping services.
    Line 2--Direct Compensation. Report the amount of direct 
compensation received by the person or covered service provider 
(including its affiliate or subcontractor) identified in Line 1a.
    TIP. The total reported in Line 2 generally would be those 
payments that would be includable as administrative expenses on 
Schedule H, Line 2i. Do not leave Line 2 blank. If no direct 
compensation was received, enter ``0''.
    Line 3--Indirect Compensation. Complete Line 3 to report 
indirect compensation received by the covered service provider, 
affiliate or subcontractor from persons other than the plan or plan 
sponsor, including charges against the plan's investments.
    Note: You must separately report in Line 4 certain related party 
compensation paid among the person identified in Line 1a and the 
affiliate or subcontractor.
    Line 3a. Enter the total amount of indirect compensation plan 
from sources other than

[[Page 47618]]

the plan or plan sponsor received by the covered service provider, 
affiliate or subcontractor in connection with services provided to 
the plan, including charges against the plan's investments. This 
should equal the total of the amounts or estimates reported on the 
Line 3b(4) entries.
    Line 3b. Complete as many entries (Lines 3b(1)-(6)) as necessary 
to identify all sources of indirect compensation reported in Line 
3a. If the name of an individual is entered in Line 3a and the 
individual does not have an EIN, enter the EIN of the individual's 
employer. If the person is self-employed and does not have an EIN, 
you may enter the person's address and telephone number. Do not use 
a social security number in lieu of an EIN. The Schedule C and its 
attachments are open to public inspection and are subject to 
publication on the Internet. Because of privacy concerns, the 
inclusion of a social security number or any portion thereof on this 
Schedule C or any of its attachments may result in the rejection of 
the filing. Also enter the service provider's LEI, if available.
    Line 3b(4). Enter as a dollar figure the amount or estimate of 
compensation received from the source. If an estimate is reported, 
you must complete Line 3b(6).
    Line 3b(5). Types of Compensation. Check all the appropriate 
box(es) to describe the types of compensation received from the 
source.
    Line 4--Related Party Compensation. You must report on Line 4 as 
related party compensation any compensation that is paid among the 
service provider, affiliates and subcontractors in connection with 
the services rendered to the plan if the amount was set on a per 
transaction basis, (e.g., commissions, soft dollars, finder's fees 
or other similar incentive compensation based on business placed or 
retained) or is charged directly against the plan's investment and 
reflected in the net value of the investment (e.g., Rule 12b-1 fees, 
distribution fees, management fees shareholder servicing fees). This 
does not include compensation received by an employee from his or 
her employer on account of work performed by the employee. Other 
revenue sharing payments among the covered service provider, 
affiliate or subcontractor in connection with the services rendered 
to the plan do not need to be reported as related party 
compensation.

Part II--Service Providers Who Fail or Refuse To Provide Information

    Line 5. Check the box in Line 5a to identify each covered 
service provider who you believe failed or refused to provide any of 
the information necessary to complete Part I of this schedule. In 
Line 5b describe the information that the service provider failed or 
refused to provide.
    Important Reminder. Before identifying a service provider as a 
person who failed or refused to provide information, you should 
contact the service provider to request the necessary information 
and tell them that you will list them on the Schedule C as a service 
provider who failed or refused to provide information if they do not 
provide the necessary information.
    On Line 5b, include in the description of the information that 
the service failed or refused to provide whether you are relying on 
the exemption at 29 CFR 2550.408b-2(c)(1)(ix) with respect to the 
failure of any fiduciary or service provider to provide information 
required to complete Part I of Schedule C.
    [CAUTION]. The failure of certain service providers to provide 
information needed to complete the annual return/report, including 
Schedule C, may give rise to a prohibited transaction under section 
408(b)(2) of ERISA, see 29 CFR 2550.408b-2(c)(1)(vi), that must be 
reported on Schedule H, Line 4d and, as applicable, attach a 
Schedule G.

20XX Instructions for Schedule D

(Form 5500 DFE/Participating Plan Information)

General Instructions

Who Must File

    When the Form 5500 is filed for a Direct Filing Entity (DFE) 
that is a master trust (MT), 103-12 Investment Entity (103-12 IEs), 
common/collective trust (CCT), pooled separate account (PSA), or 
group insurance arrangement (GIA) the Schedule D (Form 5500) is 
required to provide information about plans participating in the 
DFE. A Form 5500 Annual Return/Report filed for a CCT, PSA, MT, 103-
12 IE, or GIA should be identified as a ``DFE'' on Part I, Line 
A(5), of the Form 5500 and the Schedule D box should be checked on 
the Form 5500, Part II, Line 11b(4). For more information, see 
instructions for Direct Filing Entity (DFE) Filing Requirements.

Specific Instructions

    Lines A, B, C, and D. The information must be the same as 
reported in Part II of the Form 5500 to which this Schedule D is 
attached.
    Do not use a social security number in Line D in lieu of an EIN. 
The Schedule D and its attachments are open to public inspection, 
and the contents are public information and are subject to 
publication on the Internet. Because of privacy concerns, the 
inclusion of a social security number or any portion thereof on this 
Schedule D or any of its attachments may result in the rejection of 
the filing.
    You can apply for an EIN from the IRS online, by telephone, by 
fax, or by mail depending on how soon you need to use the EIN. For 
more information, see Section 3: Electronic Filing Requirement under 
General Instructions to Form 5500. The EBSA does not issue EINs.

Information on Participating Plans

    Complete as many repeating entries as necessary to enter the 
information specified below for all plans invested or participated 
in the DFE at any time during the DFE year.
    [CAUTION] The administrator of each participating plan is 
required to provide the CCT, PSA, MT, and 103-12IE with the plan 
number, name of the plan sponsor and EIN of the plan sponsor being 
reported on the plan's Form 5500 so that the DFE can timely and 
accurately complete its Schedule D. Failure to provide that 
information to the DFE may result in the plan's Form 5500 Annual 
Return/Report being treated as incomplete and subject to rejection. 
See 29 CFR 2520.103-9(b).
    Complete a separate Line 1 (elements (a) through (e)) for each 
plan investing or participating in the DFE.
    Line 1a. Enter the name of each plan that invested or 
participated in the DFE at any time during the DFE year.
    Line 1b. Enter the name of the sponsor of each plan investing or 
participating in the DFE.
    Line 1c. Enter the nine-digit EIN and three-digit PN for each 
plan named in Line 1a. This is the EIN and PN entered on lines 2b 
and 1b of the plan's Form 5500 or Form 5500-SF. GIAs should enter 
the EIN of the sponsor of the participating plan listed in Line 1(b) 
of the Schedule D. Do not use a social security number in lieu of an 
EIN. The Schedule D and its attachments are open to public 
inspection, and the contents are public information and are subject 
to publication on the Internet. Because of privacy concerns, the 
inclusion of a social security number or any portion thereof on this 
Schedule D or any of its attachments may result in the rejection of 
the filing.
    Line 1d. Enter the dollar value of each investing plan's 
interest in the DFE as of the end of the DFE year. GIAs do not 
complete Line 1d.
    1e. If the DFE had investors other than plans that are required 
to file the Form 5500 or Form 5500-SF, such as governmental plans, 
``one-participant'' plans, or non-plan investors, check the box in 
Line 1e.

20XX Instructions for Schedule E (Form 5500) ESOP Annual Information

General instructions

Who Must File

    Every employer or plan administrator of a pension benefit plan 
that provides ESOP benefits must file a Schedule E (Form 5500).

Specific Instructions

    Lines A, B, C, and D. This information should be the same as 
reported in Part II of the Form 5500 to which this Schedule E is 
attached. If necessary, you may abbreviate the plan name to fit the 
space provided.
    Part I Employer Stock Acquired with a Securities Acquisition 
Loan. A ``securities acquisition loan'' is an exempt loan to an ESOP 
to the extent that the proceeds are used to acquire employer 
securities for the plan.
    Line 1a. Enter the number of common shares of employer stock 
held in the ESOP at the end of the plan year.
    Line 1b. Enter the percent of issued and outstanding common 
stock held in the ESOP at the end of the plan year.
    Line 1c. A security is readily tradable on an established 
securities market if it is traded on a national securities exchange 
that is registered under section 6 of the Securities Exchange Act of 
1934 or if it is traded on a foreign national exchange that is 
officially recognized, sanctioned, or supervised by a governmental 
authority and the security is deemed by the Securities Exchange 
Commission as having a ``ready market''. Treasury Regulations 
1.401(a)(35)-1(f)(5)(ii).
    Line 1d. Enter the number of shares of common stock that were 
allocated at the end of the plan year.

[[Page 47619]]

    Line 1e. Enter the number of shares of common stock that were 
unallocated at the end of the plan year.
    Line 1f. If common stock was released from a loan suspense 
account, check the appropriate box(es) to indicate the method(s) 
used. If you check ``Other'' you must provide a description of the 
method used.
    Line 1g. Check ``Yes'' if the ESOP holds preferred stock. Under 
section 409(l)(3) of the Code preferred stock is stock convertible 
at any time into stock that meets the requirements of sections 
409(l)(1) for readily tradable stock or section 409(l)(2) for non-
readily tradable stock. The stock must be convertible at a 
conversion price which (as of the date of acquisition) is 
reasonable.
    If you answered ``Yes'' and the preferred stock was acquired by 
the ESOP in a securities acquisition loan, answer Lines 1h-i.
    Lines 1h-i. Respond to these questions only if preferred stock 
was acquired by the ESOP in a securities acquisition loan.
    Line 1i. If, for example, the conversion price is variable or 
incorporates the issuance of stock warrants, a description of the 
method used must be provided.

Part II Employer Stock Acquired.

    Respond to these questions only if during the plan year any non-
readily tradable employer securities were purchased by the ESOP, 
including employer securities acquired with the proceeds from a 
securities acquisition loan.
    Line 2b. For purposes of this form, a party in interest is 
deemed to include a disqualified person. See Code section 
4975(e)(2). See Instructions for Schedule G for the definition of 
party in interest.
    Line 2e. Check the appropriate box and enter the applicable 
identifying information if a trustee, investment manager, or 
independent fiduciary directly or indirectly approved the 
transaction.
    Line 2f. Section 401(a)(28(C) of the Code provides that, in 
order for an ESOP to be a qualified plan under the Code, all 
valuations of employer securities which are not readily tradable on 
an established securities market with respect to activities carried 
on by the plan must be by an independent appraiser.
    Line 2g. Check the appropriate box(es) to indicate what 
valuation approach(es) were used to set the value of the stock 
acquired. If you check ``Other,'' enter a description.

Part III Securities Acquisition Loans.

    Complete Part III only if the ESOP had outstanding securities 
acquisition loans within the meaning of Code section 4975(d)(3) and 
ERISA section 408(b)(3) during the plan year. Complete as many Line 
3 (elements (a)-(h)) as needed to identify each such loan.

Part IV Other General Information

    Line 4b. As described in Code section 409(p), a disqualified 
person, for purposes of this section, is generally, any person whose 
deemed-owned shares of the S corporation, as defined in section 
409(p)(4)(C), including synthetic equity shares, as defined in 
Treasury Regulations section 1.409(p)-1(f)(2) are at least ten 
percent of the deemed-owned shares of the S corporation and that 
person's synthetic equity shares of the S corporation. In addition, 
disqualified persons include a person and each of such person's 
family members, as defined in section 409(p)(4)(D), if the aggregate 
number of deemed-owned shares of this family group, including 
synthetic equity, is at least twenty percent of the deemed owned 
shares of the S corporation and the synthetic equity shares of such 
persons.
    Line 4d(3). Payments in redemption of stock held by an ESOP 
include reacquisition payments that are used to make benefit 
distributions to participants or beneficiaries.

20XX Instructions for Schedule G (Form 5500) Financial Transaction 
Schedules

Who Must File

    Large plans, small pension plans that are not exempt from the 
annual IQPA audit under 29 CFR 104-46 (see instructions to Schedule 
H, Line 3h(4)), master trusts, 103-12 IEs, and GIAs, must attach 
Schedule G to their Form 5500 if they are required to file a 
Schedule H and they have the following to report:
     Loans and/or fixed income obligations in default or 
determined to be uncollectible as of the end of the plan year,
     Leases in default or classified as uncollectible, and
     Nonexempt transactions that occurred or remained 
uncorrected during the plan year.
    Check the Schedule G box on the Form 5500 (Part II, Line 11b(5)) 
if you are attaching Schedule G. Complete as many entries as 
necessary to report the required information.
    [CAUTION] The plans described below, although exempt from 
certain other financial reporting requirements, are still required 
to file Schedule G, Part III to report nonexempt transactions:
     An unfunded, fully insured, or combination unfunded/
insured welfare plan, including group health plans, with 100 or more 
participants exempt under 29 CFR 2520.104-44 from completing 
Schedule H.
     A plan that is required to file a Form M-1, Report for 
Multiple Employer Welfare Arrangements (MEWAs) and Certain Entities 
Claiming Exception (ECEs).
    The Schedule G consists of three parts:
     Part I to report any loans or fixed income obligations 
in default or determined to be uncollectible as of the end of the 
plan year.
     Part II to report any leases in default or classified 
as uncollectible.
     Part III to report nonexempt transactions.

Specific Instructions

    Lines A, B, C, and D. This information must be the same as 
reported in Part II of the Form 5500 to which this Schedule G is 
attached.
    Do not use a social security number in Line D in lieu of an EIN. 
The Schedule G and its attachments are open to public inspection, 
and the contents are public information and are subject to 
publication on the internet. Because of privacy concerns, the 
inclusion of a social security number or any portion thereof on this 
Schedule G or any of its attachments may result in the rejection of 
the filing.
    You can apply for an EIN from the IRS online, by telephone, by 
fax, or by mail depending on how soon you need to use the EIN. For 
more information, see Section 3: Electronic Filing Requirement under 
General Instructions to Form 5500. The EBSA does not issue EINs.

Part I--Loans or Fixed Income Obligations in Default or Classified as 
Uncollectible

    List all loans or fixed income obligations in default or 
determined to be uncollectible as of the end of the plan year or the 
fiscal year of the GIA, master trust, or 103-12 IE. Include:
     Obligations where the required payments have not been 
made by the due date;
     Fixed income obligations that have matured, but have 
not been paid, for which it has been determined that payment will 
not be made; and
     Loans that were in default even if renegotiated during 
the year.
    The due date, payment amount, and conditions for determining 
default in the case of a note or a loan are usually contained in the 
documents establishing the note or loan. A loan is in default when 
the borrower is unable to pay the obligation upon maturity. 
Obligations that require periodic repayment can default at any time. 
Generally loans and fixed income obligations are considered 
uncollectible when payment has not been made and there is little 
probability that payment will be made. A fixed income obligation has 
a fixed maturity date at a specified interest rate.
    Line 1. Schedule of Loans in Default or Classified as 
Uncollectible Complete as many entries as needed to report all loans 
in default or classified as uncollectible.
    Do not report on Line 1 participant loans under an individual 
account plan with investment experience segregated for each account, 
that are made according to 29 CFR 2550.408b-1, and that are secured 
solely by a portion of the participant's vested accrued benefit. 
Report all other participant loans in default or classified as 
uncollectible on Part I, and list each loan individually.
    CAUTION: You may not attach an amortization schedule in lieu of 
completing as many repeating Line 1 entries as necessary to identify 
loans in default or classified as uncollectible.
    1a. Identity and address of obligor. Enter the name, street 
address, city, state, and zip code for the obligor. A post office 
box number may be entered in addition to the street address if the 
Post Office does not deliver mail to the obligor's street address.
    1b. Relationship of Obligor to Plan. Check the appropriate boxes 
to indicate whether the obligor is a party-in-interest or a plan 
participant. Also enter a description of the relationship of the 
obligor to the plan, such as employer, employee organization, plan 
sponsor, fiduciary, service provider, or other party in or other 
party-in-interest, (if no relationship, enter ``unrelated third 
party'').
    1c. Status of Loan. Check to the appropriate box to indicate 
whether the loan is in default or has been determined to be 
uncollectible. Generally, loans are considered uncollectible when 
payment has not been made and there is little probability that 
payment will be made. The documents establishing the loan normally 
specify its

[[Page 47620]]

terms, due date, payment amount, and conditions for determining 
default. A loan is in default when the borrower is unable to pay the 
obligation when due. Obligations that require periodic repayment can 
default at any time.
    1d. Original Principal Amount of Loan. Enter original amount of 
loan.
    1e. Original Interest Rate of Loan. Enter original interest rate 
of the loan. If the original interest rate of the loan was variable, 
enter in the space provided, a description of the terms of the 
variable interest rate.
    1f. Origination Date. Enter the date the loan originated.
    1g. Original Maturity Date. Enter the original maturity date of 
the loan. If the maturity date was extended to a different date, 
include the new maturity date in element (l) in the description of 
steps taken to collect the loan.
    1h. Loan Collateral. In Line 1h, check the appropriate box to 
indicate whether the loan secured by collateral. If you answered 
``Yes,'' complete Lines 1h(2) and (3). In Line 1h(2), indicate 
whether the security interest in the collateral was perfected. In 
Line 1h(3), enter a description of the collateral type and its 
value.
    1i. Scheduled Payment Frequency. Enter the scheduled payment 
frequency (e.g., monthly, annually).
    1j. Payments Received. Enter the amount of principal and 
interest payments received during the plan year.
    1k. Amount Overdue. Enter separately the principal and interest 
amounts overdue as of the end of the plan year. Include the amount, 
of principal and interest that is overdue from previous plan years.
    1l. Steps Taken to Collect. Describe what steps have been taken 
or will be taken to collect overdue amounts, including renegotiation 
of original terms of the loan.

Line 2--Schedule of Fixed Income Obligations in Default or Classified 
as Uncollectible.

    Complete as many entries as needed to report all fixed income 
obligations in default or classified as uncollectible.
    2a. Identity and address of obligor. Enter the name, street 
address, city, state, and zip code for the obligor. A post office 
box number may be entered in addition to the street address if the 
Post Office does not deliver mail to the obligor's street address.
    2b. Relationship of Obligor to Plan. Check the box to indicate 
whether the obligor is a party-in-interest. Also enter a description 
of the relationship of the obligor to the plan, such as employer, 
employee organization, plan sponsor, fiduciary, service provider, or 
other party in or other party-in-interest (if no relationship, enter 
``unrelated third party'').
    2c. Status of Fixed Income Obligation. Check the appropriate box 
to indicate whether the loan is in default or has been determined to 
be uncollectible. Generally, fixed income obligations are considered 
uncollectible when payment has not been made and there is little 
probability that payment will be made. The documents establishing 
the obligation normally specify its terms, due date, payment amount, 
and conditions for determining default. A fixed income obligation is 
in default when the obligee is unable to pay the obligation when 
due. Obligations that require periodic repayment can default at any 
time.
    2d. Nature of Fixed Income Obligation. Check applicable boxes to 
indicate the nature of the fixed income obligation. See Schedule H, 
Line 1b instructions for more information on types of fixed income 
obligations.
    2e. Date of issuance. Enter the date the fixed income obligation 
was issued.
    2f. Maturity date. Enter the original maturity date of the 
obligation. If the maturity date was extended to a different date, 
include the new maturity date in the description of steps taken to 
collect the obligation in element (l).
    2g. Yield/Interest Rate. Enter yield or interest rate for the 
obligation provided for in the note or contract establishing the 
obligation.
    2h. Principal amount of fixed income obligation. Enter the 
principal amount of the obligation at the time the plan entered into 
the transaction.
    2i. Amount Overdue. Enter separately the principal and interest 
amounts overdue as of the end of the plan year. Include the amount 
of principal and interest that is overdue from previous plan years.
    2j. Steps Taken to Collect. Enter a description of what steps 
the plan administrator has taken or will be taking to collect 
overdue amounts for each loan.

Part II Leases in Default or Classified as Uncollectible.

    List any leases in default or classified as uncollectible. A 
lease is an agreement conveying the right to use property, plant, or 
equipment for a stated period. A lease is in default when the 
required payment(s) has not been made. An uncollectible lease is one 
where the required payments have not been made and for which there 
is little probability that payment will be made.
    3a. Identity and address of obligor. Enter the name, street 
address, city, state, and zip code for the obligor. A post office 
box number may be entered in addition to the street address if the 
Post Office does not deliver mail to the obligor's street address.
    3b. Relationship of Obligor to Plan. Check the appropriate boxes 
to indicate whether the obligor is a party-in-interest or a plan 
participant. Also enter a description of the relationship of the 
obligor to the plan, such as employer, employee organization, plan 
sponsor, fiduciary, service provider, or other party-in-interest (if 
no relationship, enter ``unrelated third party'').
    3c. Status of Lease. Check to the appropriate box to indicate 
whether the lease is in default or has been determined to be 
uncollectible. Generally, leases are considered uncollectible when 
payment has not been made and there is little probability that 
payment will be made. The documents establishing the lease normally 
specify its terms, due date, payment amount, and conditions for 
determining default. A lease is in default when the lessee is unable 
to pay the obligation when due. Obligations that require periodic 
repayment can default at any time.
    3d. Address of Leased Property. You must enter the name, street 
address, city, state, and zip code of the leased property. You may 
not use a post office box.
    3e. Date of Lease Origination. Enter date of lease origination.
    3f. Original Cost of Leased Property. Enter the cost to acquire 
the property.
    3g. Current Value of Leased Property at Time of Lease. Enter the 
value of the leased property at time the plan entered into the 
lease.
    3h. Annual Lease Payments Due. Enter the gross rental amounts 
due during the plan year.
    3k. Scheduled Payment Frequency. Indicate the lease payment 
schedule, i.e., monthly, annually.
    3l. Lease Expiration Date: Enter the lease expiration date.
    3m. Amount In Arrears. Enter the amount of payments under the 
lease that are in arrears.
    3n. Steps Taken to Collect. Enter an explanation of what steps 
the plan administrator has taken or will be taking to collect 
overdue amounts for each lease listed.

Part III Nonexempt Transactions

    You must report all nonexempt party-in-interest transactions, 
regardless of whether they are disclosed in the accountant's report, 
unless the nonexempt transaction is:
    1. Statutorily exempt under Part 4 of Title I of ERISA;
    2. Administratively exempt under ERISA section 408(a);
    3. Exempt under Code sections 4975(c) or 4975(d);
    4. The holding of participant contributions in the employer's 
general assets for a welfare plan that meets the conditions of ERISA 
Technical Release 92-01;
    5. A transaction of a 103-12 IE with parties other than the 
plan; or
    6. A delinquent participant contribution or a delinquent 
participant loan repayment reported on Schedule H, Line 4a.
    Nonexempt transactions with a party-in-interest include any 
direct or indirect:
    A. Sale or exchange, or lease, of any property between the plan 
and a party-in-interest.
    B. Lending of money or other extension of credit between the 
plan and a party-in-interest.
    C. Furnishing of goods, services, or facilities between the plan 
and a party-in-interest.
    D. Transfer to, or use by or for the benefit of, a party-in-
interest, of any income or assets of the plan.
    E. Acquisition, on behalf of the plan, of any employer security 
or employer real property in violation of ERISA section 407(a).
    F. Dealing with the assets of the plan for a fiduciary's own 
interest or own account
    G. Acting in a fiduciary's individual or any other capacity in 
any transaction involving the plan on behalf of a party (or 
represent a party) whose interests are adverse to the interests of 
the plan or the interests of its participants or beneficiaries.
    H. A receipt of any consideration for his or her own personal 
account by a party-in-interest who is a fiduciary from any party 
dealing with the plan in connection with a transaction involving the 
income or assets of the plan.

[[Page 47621]]

    For purposes of this form, party-in-interest is deemed to 
include a disqualified person. See Code Section 4975(e)(2). The term 
``party-in-interest'' means, as to an employee benefit plan:
    A. Any fiduciary (including, but not limited to, any 
administrator, officer, trustee or custodian), counsel, or employee 
of the plan;
    B. A person providing services to the plan;
    C. An employer, any of whose employees are covered by the plan;
    D. An employee organization, any of whose members are covered by 
the plan;
    E. An owner, direct or indirect, of 50% or more of:
    (1) the combined voting power of all classes of stock entitled 
to vote or the total value of shares of all classes of stock of a 
corporation,
    (2) the capital interest or the profits interest of a 
partnership, or
    (3) the beneficial interest of a trust or unincorporated 
enterprise that is an employer or an employee organization described 
in C or D;
    F. A relative of any individual described in A, B, C, or E;
    G. A corporation, partnership, or trust or estate of which (or 
in which) 50% or more of:
    (1) the combined voting power of all classes of stock entitled 
to vote or the total value of shares of all classes of stock of such 
corporation,
    (2) the capital interest or profits interest of such 
partnership, or
    (3) the beneficial interest of such trust or estate is owned 
directly or indirectly, or held by, persons described in A, B, C, D, 
or E;
    H. An employee, officer, director (or individual having powers 
or responsibilities similar to those of officers or directors), or a 
10% or more shareholder, directly or indirectly, of a person 
described in B, C, D, E, or G, or of the employee benefit plan; or
    I. A 10% or more (directly or indirectly in capital or profits) 
partner or joint venture of a person described in B, C, D, E, or G.
    If you are unsure whether a transaction is exempt or not, you 
should consult with either the plan's independent qualified public 
accountant or legal counsel or both.
    You may indicate that an application for an administrative 
exemption is pending.
    If the plan is a qualified pension plan and a nonexempt 
prohibited transaction occurred with respect to a disqualified 
person, the disqualified person must file an IRS Form 5330, Return 
of Excise Taxes Related to Employee Benefit Plans, to pay the excise 
tax on the transaction.
    4a. Identity and Address of Party Involved in Non-exempt 
Transaction. Enter the name, street address, city, state, and zip 
code for the obligor. A post office box number may be entered in 
addition to the street address if the post office does not deliver 
mail to the obligor's street address.
    4b. Relationship to Plan. Enter a description of the 
relationship of the party involved in the transaction to the plan, 
such as employer, employee organization, plan sponsor, fiduciary, 
service provider, or other party-in-interest.
    4c. Type of Nonexempt Transaction. Check all of the boxes that 
apply to the nonexempt transaction.
    4d. Nature of Transaction. Check the appropriate box to indicate 
the nature of the transaction. A transaction is a discrete 
transaction if it was a single occurrence that did not continue in 
time, for example, the sale of property between a plan and a party-
in-interest is a discrete transaction. An ongoing transaction is one 
that is continuous over a period of time, such as a lease or other 
obligation that requires regular payments for a continuing time 
period.
    4e. Date of Transaction. Enter the date the transaction occurred 
or was entered into. If ongoing, enter the date of the commencement 
or first instance.
    4f. Principal Amount Of Nonexempt Transaction. Enter the 
principal amount of the transaction.
    4g. Net Gain (Or Loss) On the Transaction. Enter the net gain 
(or loss) on the transaction.
    4h-j. Correction of Transaction. Check the appropriate box to 
indicate whether the transaction has been corrected, and if so, when 
and how the transaction was corrected. The DOL Voluntary Fiduciary 
Correction Program (VFCP) describes how to apply the specific 
transactions covered (for example, delinquent participation 
contributions to pension and welfare plans) and acceptable methods 
for correcting violations. In addition, applicants that satisfy both 
the VFCP requirements and the conditions of Prohibited Transaction 
Exemption (PTE) 2002-51 are eligible for immediate relief from 
payment of certain prohibited excise taxes for certain corrected 
transactions, and are also relieved from the obligation to file the 
Form 5330 with the IRS. For more information, see 71 FR 20261 (Apr. 
19, 2006) and 71 FR 20135 (Apr. 19, 2006). If conditions of PTE 
2002-51 are satisfied, corrected transactions should be treated as 
exempt under Code section 4975(c) when answering Schedule G, Part 
III. Information about the VFCP is also available on the internet at 
www.dol.gov/ebsa.
    4k. Filing of Form 5330 and Payment of Excise Taxes. Check the 
appropriate box to indicate whether a Form 5330 with payment of 
excise taxes to the IRS was required and if so, whether the Form 
5330 was in fact filed.

20XX Instructions for Schedule H (Form 5500) (Financial Information)

General Instructions

Who Must File

    Schedule H (Form 5500) must be attached to a Form 5500 filed for 
any pension or welfare benefit plan required to file the Form 5500, 
unless subject to one of the exceptions listed below or permitted to 
file the Form 5500-SF. Master trusts, CCTs, PSAs, 103-12 IEs, and 
GIAs also must complete as part of their Form 5500 Annual Return/
Report filing some or all of the Schedule H, depending on type of 
entity filing. See the instructions to the Form 5500 in Section 4: 
Direct Filing Entity (DFE) Filing Requirements.
    Exceptions: (1) Fully insured, unfunded, or a combination of 
unfunded/insured welfare plans, including plans that provide health 
benefits, and fully insured pension plans that meet the requirements 
of 29 CFR 2520.104-44, are exempt from completing the Schedule H.
    (2) Plans that are eligible to file and in fact file a Form 
5500-SF for the 20XX plan year are not required to file a Schedule H 
for that year. See What To File. and Instructions for Form 5500-SF.
    Check the Schedule H box on the Form 5500 (Part II, Line 11b(1)) 
if a Schedule H is attached to the Form 5500.

Specific Instructions

    Lines A, B, C, and D. This information must be the same as 
reported in Part II of the Form 5500 to which this Schedule H is 
attached.
    Do not use a social security number in Line D in lieu of an EIN. 
The Schedule H and its attachments are open to public inspection, 
and the contents are public information and are subject to 
publication on the Internet. Because of privacy concerns, the 
inclusion of a social security number or any portion thereof on this 
Schedule H or any of its attachments may result in the rejection of 
the filing.
    You can apply for an EIN from the IRS online, by telephone, by 
fax, or by mail depending on how soon you need to use the EIN. For 
more information, see Section 3: Electronic Filing Requirement under 
General Instructions to Form 5500. The EBSA does not issue EINs.

Part I--Asset and Liability Statement

    Note. The cash, modified cash, or accrual basis may be used for 
recognition of transactions in Parts I and II, as long as you use 
one method consistently. Round off all amounts reported on the 
Schedule H to the nearest dollar. Any other amounts are subject to 
rejection. Check all subtotals and totals carefully.
    If the assets of two or more plans are maintained in a fund or 
account that is not reported on lines 1b(6) through 1b(8), complete 
Parts I and II of the Schedule H by entering the plan's allocable 
part of each line item.
    If assets of one plan are maintained in two or more trust funds, 
report the combined financial information in Parts I and II.
    Current value means fair market value where available. 
Otherwise, it means the fair value as determined in good faith under 
the terms of the plan by a trustee or a named fiduciary, assuming an 
orderly liquidation at time of the determination. See ERISA section 
3(26).
    Note. Amounts reported in column (a) must be the same as 
reported for the end of the plan year for corresponding line items 
of the return/report for the preceding plan year. Do not include 
contributions designated for the 20XX plan year in column (a).
    1a(1). Employer contributions. Noncash basis filers must include 
contributions due the plan by the employer but not yet paid. Do not 
include other amounts due from the employer such as the 
reimbursement of an expense or the repayment of a loan.
    1a(2). Participant contributions. Noncash basis filers must 
include contributions withheld by the employer from participants

[[Page 47622]]

and amounts due directly from participants that have not yet been 
received by the plan. Do not include the repayment of participant 
loans.
    1a(3). Notes receivable from participants (participant loans). 
Enter the current value of all loans to participants, including 
residential mortgage loans that are subject to Code section 72(p). 
Include the sum of the value of the unpaid principal balances, plus 
accrued but unpaid interest, if any, for participant loans made 
under an individual account plan with investment experience 
segregated for each account, which are made in accordance with 29 
CFR 2550.408b-1 and secured solely by a portion of the participant's 
vested accrued benefit. When applicable, combine this amount with 
the current value of any other participant loans. Do not include in 
column (b) a participant loan that has been deemed distributed 
during the plan year under the provisions of Code section 72(p) and 
Treasury Regulations section 1.72(p)-1, if both of the following 
circumstances apply:
    1. Under the plan, the participant loan is treated as a directed 
investment solely of the participant's individual account; and
    2. As of the end of the plan year, the participant is not 
continuing repayment under the loan.
    If both of these circumstances apply, report the loan as a 
deemed distribution on Line 2g. However, if either of these 
circumstances does not apply, the current value of the participant 
loan (including interest accruing thereon after the deemed 
distribution) must be included in column (b) without regard to the 
occurrence of a deemed distribution.
    Note. After a participant loan that has been deemed distributed 
is reported on Line 2g, it is no longer to be reported as an asset 
on Schedule H unless, in a later year, the participant resumes 
repayment under the loan. However, such a loan (including interest 
accruing thereon after the deemed distribution) that has not been 
repaid is still considered outstanding for purposes of applying Code 
section 72(p)(2)(A) to determine the maximum amount of subsequent 
loans. Also, the deemed distribution is not treated as an actual 
distribution for other purposes, such as the qualification 
requirements of Code section 401, including, for example, the 
determination of top-heavy status under Code section 416 and the 
vesting requirements of Treasury Regulations section 1.411(a)-
7(d)(5). See Q&As 12 and 19 of Treasury Regulations section 1.72(p)-
1.
    The entry on Line 1a(3), column (b), of Schedule H (participant 
loans--end of year) must include the current value of any 
participant loan that was reported as a deemed distribution on Line 
2h for any earlier year if the participant resumes repayment under 
the loan during the plan year. In addition, the amount to be entered 
on Line 2h must be reduced by the amount of the participant loan 
that was reported as a deemed distribution on Line 2h for the 
earlier year.
    Line 1a(4). Other Receivables. Noncash basis filers must include 
amounts due to the plan that are not includable in Lines 1a(1), 
1a(2), and 1a(3). These amounts may include investment income earned 
but not yet received by the plan and other amounts due to the plan 
such as amounts due from the employer or another plan for expense 
reimbursement or from a participant for the repayment of an 
overpayment of benefits.
    Line 1b(1). Total noninterest-bearing cash. Total noninterest 
bearing cash includes, among other things, cash on hand or cash in a 
noninterest bearing checking account.
    1b(2). Interest-bearing cash and cash equivalents. Include all 
assets that earn interest in a financial institution account, such 
as interest bearing checking accounts, passbook savings accounts in 
Line 1b(2)(A). Report certificates of deposit on Line 1b(2)(B). 
Report money market accounts on Line 1b(2)(C).
    Line 1b(3). Debt Interests/Obligations. Enter in the appropriate 
categories any debt interests/obligations held directly by the plan.
    Line 1b(3)(A). U.S. Government securities. Include securities 
issued or guaranteed by the U.S. Government or its designated 
agencies such as U.S. Savings Bonds, Treasury Bonds, Treasury Bills, 
Federal National Mortgage Association (FNMA), and Government 
National Mortgage Association (GNMA).
    Line 1b(3)(B). Other government securities. Include here state 
and municipal bonds. Report bonds issued by foreign governments in 
Line 1b(13).
    Line 1b(3)(C). Corporate debt instruments (other than employer 
securities). Include investment securities (other than employer 
securities defined below in Line 1c(1)) issued by a corporate entity 
at a stated interest rate repayable on a particular future date such 
as most bonds, debentures, convertible debentures, commercial paper 
and zero coupon bonds. Do not include debt securities of 
governmental units that should be reported on Line 1b(3)(A). For 
purposes of the breakouts on Line 1b(3)(C)(i) and (ii), investment-
grade debt-instruments are those with an S&P rating of BBB--or 
higher, a Moody's rating of Baa3 or higher, or an equivalent rating 
from another rating agency. High-yield debt instruments are those 
that have ratings below these rating levels. If the debt does not 
have a rating, it should be included in the ``high-yield'' category 
if it does not have the backing of a government entity. Unrated debt 
with the backing of a government entity would generally be included 
in the ``investment-grade'' category unless it is generally accepted 
that the debt should be considered as ``high-yield.'' Use the 
ratings in effect as of the beginning of the plan year. See the 
instructions for Schedule R, Line 18.
    Line 1b(3)(D). Exchange Traded Notes. Report here unsecured, 
unsubordinated debt securities that are traded on an exchange and 
that are not registered investment companies under the Investment 
Company Act of 1940.
    Line 1b(3)(E). Asset backed securities (other than real estate). 
An asset-backed security generally is one that is collateralized by 
a discrete pool of assets (such as loans or receivables) and that 
makes payments based primarily on the performance of those assets. 
Do not include here securities backed by real estate or real estate-
related loans.
    Line 1b(3)(F). Other debt instruments. Include here, debt 
instruments not otherwise includable in Lines 1a(3) (participant 
loans), 1b(3)(A)-(E), 1b(9)(E) (mortgage-backed securities) or 
1b(9)(G) (e.g., construction and mortgage loans).
    Line 1b(4). Corporate Stocks (Other than Employer Securities, 
Private Equity, and Foreign Investments). Include here publicly 
traded and non-publicly traded domestic equities owned directly by 
the plan. Do not include employer securities, foreign stocks, or 
private equity here.
    Line 1b(4)(A). Publicly Traded Corporate Stocks. Enter in 
element (i) the total value of all ``preferred'' corporate stock 
that is publicly traded. Include stock issued by corporations (other 
than employer securities defined in Line 1c(1) below) that is 
accompanied by preferential rights such as the right to share in 
distributions of earnings at a higher rate or which has general 
priority over the common stock of the same entity. Include the value 
of warrants convertible into preferred stock. Enter in element (ii) 
the total value of all ``common'' corporate stock that is publicly 
traded. This includes any stock (other than employer securities 
defined in Line 1c(1)) that represents regular ownership of the 
corporation and is not accompanied by preferential rights. Include 
the value of warrants convertible into common stock.
    Line 1b(4)(B). Corporate Stocks That Are Not Publicly Traded. 
Enter in element (i) the total value of nonpublicly traded preferred 
stock and in element (ii) the total value of nonpublicly traded 
common stock. See instructions for Line 1b(4)(A) for a description 
of ``preferred'' and ``common'' stock.
    Line 1b(5). Registered Investment Companies (Mutual funds, Unit 
Investment Trusts, Closed End Funds). A registered investment 
company is an investment company registered under the Investment 
Company Act of 1940. These are mutual funds (legally known as open-
end companies), closed-end funds (legally known as closed-end 
companies), and unit investment trusts (UITs) (legally known as unit 
investment trusts).
    Lines 1b(6)(A) and (B). Interests in CCTs and PSAs. Enter 
information, in the appropriate elements as of the beginning and end 
of the filing plan or DFE year, about interests in PSAs and CCTs, 
regardless of whether the CCT or PSA has filed its own Form 5500 
Annual Return/Report.
    CAUTION: The plan's or DFE's interest in common/collective 
trusts (CCTs) and pooled separate accounts (PSAs) must be allocated 
and reported in the appropriate categories on an investment by 
investment basis on the Line 4i Schedules, with the box checked to 
identify that the investment was held through a CCT or PSA, unless 
the CCT or PSA has filed its own Form 5500, including Schedule H, 
and the Line 4i(1) Schedule of Assets Held for Investment at End of 
Year. See instructions for Line 4i(1) Schedule of Assets Held for 
Investment at End of Year, element (a).
    Note. For reporting purposes, a separate account that is not 
considered to be holding plan assets pursuant to 29 CFR 2510.3-
101(h)(1)(iii) does not constitute a PSA.

[[Page 47623]]

    Line 1b(6)(C). Interests in 103-12 investment entities (103-12 
IEs). Enter the total value of the plan's interest in all 103-12 IEs 
on Line 1b(6)(C)(1)(a).
    Line 1b(6)(D). Master Trust. Enter the total value of the plan's 
interest in all master trusts on Line 1b(6)(D)(1)(a).
    CAUTION. If the plan participated in a master trust, it must 
separately list on the Line 4i(1) Schedule of Assets Held for 
Investment at End of Year all of the master trust assets in which 
the plan had a proportionate interest, indicating that the asset was 
held through the master trust. See instructions for Line 4i(1) 
Schedule of Assets Held for Investment at End of Year, element (a).
    Line 1b(7). Value of Interest in Funds Held in Insurance General 
Account (Unallocated Contracts). Use the same method for determining 
the value of the insurance contracts reported here as you used for 
Line 3 of Schedule A, or, if Line 3 is not required, Line 6 of 
Schedule A.
    Line 1b(8). Partnership and Joint Venture Interests. Enter in 
the appropriate element information about partnership and joint 
venture interests.
    Line 1b(8)(A)(1). Value of Interest in Limited Partnerships. 
Include the value of the plan's participation in a partnership or 
joint venture regardless of whether the underlying assets of the 
partnership or joint venture are considered to be plan assets under 
29 CFR 2510.3-101. Do not include here the value of a plan's 
interest in a partnership or joint venture that satisfies all of the 
requirements for being a 103-12 Investment Entity (103-12 IE), 
including the requirement that such an entity timely files its own 
Form 5500 Annual Return/Report and associated schedules and 
attachments. Report the value of a 103-12 IE on Line 1b(6)(C). 
Partnerships and joint ventures should be reported in one of the 
partnership/joint venture categories where it fits best, or in 
another category where it fits better. For example, a real estate 
partnership that does not fit into one of the other real estate 
reporting categories would be reported on proposed Line 1c(9)(G) and 
a joint venture that invests in foreign investments would be 
reported in the appropriate subcategory in Line 1b(13).
    Line 1b(8)(A)(2). Value of Interest in Venture Capital Operating 
Companies (VCOC). A ``venture capital operating company'' is an 
operating company that meets the conditions of 29 CFR 2510.3-101(d).
    Line 1b(8)(A)(3). Private Equity. Include on this line private 
equity stakes and interests in private equity funds. ``Private 
equity fund'' is commonly used to describe privately managed pools 
of capital that invest in companies that typically are not listed on 
a stock exchange. Report stock ownership of non-publicly traded 
corporate stocks that are not private equity investments on Line 
1b(4)(B).
    Line 1b(8)(A)(4). Hedge Funds. The term ``hedge fund'' is 
commonly used to describe pooled investment vehicles that are 
privately organized and administered by professional managers who 
engage in active trading of various types of securities, commodity 
futures, options contracts, and other investment vehicles, including 
relatively illiquid and hard-to-value investments.
    Line 1b(8)(A)(5). Other Partnership/Joint Venture Interests. 
Report here any other partnership or joint venture interests in 
which the plan has invested that are not reported on lines 1b(8)(A)-
(D).
    Line 1b(8)(B). Plan Asset Status Under DOL Regulation 29 CFR 
2510.3-101. Enter into Line 1b(8)(B)(i) the total of all 
partnerships/joint venture interests reported in Line 1b(8)(A) that 
do not hold plan assets under the DOL's plan asset regulation at 29 
CFR 2510.3-101. In Line 1b8(B)(2) enter the total partnership/joint 
venture interests that hold plan assets under the DOL's plan asset 
regulation at 29 CFR 2510.3-101. To avoid double-counting, do not 
include amounts reported on Line 1b(8)(B)(1) and (2) in the total 
assets reported on Line 1f.
    Line 1b(9). Real Estate Investments (Other Than Employer Real 
Property). Enter information about real estate and real estate based 
interests in the appropriate element.
    Line 1b(9)(A)-(B). Real property (Other Than Employer Real 
Property). Report here direct ownership interest of the plan in real 
property other than employer real property in the appropriate 
category.
    Line 1b(9)(C)-(D). Real Estate Investment Trusts (REITs). Report 
here entities that invest in real estate that are REITs as set forth 
in Code Sec.  856.
    Line 1b(9)(E). Mortgage-Backed Securities (Including 
Collateralized Mortgage Obligations). Report here all types of 
mortgage-backed securities, which generally are debt obligations 
that represent claims to the cash flows from pools of mortgage 
loans, most commonly on residential property. Collateralized 
mortgage obligations (CMOs) are one type of mortgage-backed 
security.
    Line 1b(8)(F). Real Estate Operating Company (REOC). Report here 
investments in ``real estate operating companies'' (REOCs). A REOC 
is an operating company that meets the conditions of 29 CFR 2510.3-
101(e).
    Line 1b(9)(G). Other real estate related investments. Include 
here any residential mortgages that are not covered under IRC 72(p), 
commercial mortgages, construction loans, and any other real estate-
related investments not includable on lines 1b(9)(A)-(F) that are 
not employer real property reportable on Line 1c(2) or buildings or 
other property used in plan operations reportable on Line 1d.
    Line 1b(10). Commodities (Direct investments). Enter direct 
investments in commodities on Line 1b(10). Enter total value of 
precious metals in Line 1b(10)(A) and the total value of all other 
commodities in Line 1b(10)(B).
    Line 1b(11). Derivatives. Enter information about direct 
investments in derivatives in the appropriate element in Line 
1b(11). Derivatives include futures, forwards, options, and swaps. 
Enter a description for any derivatives reported in Line 1b(11)(E) 
``Other.''
    Line 1b(12). Tangible personal property (including 
collectibles). Enter the total value of any collectibles or other 
personal property owned by the plan. Include all property that has 
concrete existence and is capable of being processed, such as goods, 
wares, merchandise, furniture, machines, equipment, animals, 
automobiles, etc. This includes collectibles, such as works of art, 
rugs, antiques, metals, gems, stamps, coins, alcoholic beverages, 
musical instruments, and historical objects (documents, clothes, 
etc.). Do not include any intangible property, such as patents, 
copyrights, goodwill, franchises, notes, mortgages, stocks, claims, 
interests, or other property that embodies intellectual or legal 
rights.
    Line 1b(13). Foreign investments (Other than through U.S.-
registered investment funds). Enter information about foreign 
investments in the appropriate element. Do not include the value of 
U.S.-based pooled investment vehicles that are designed to invest in 
foreign securities. Instead, report such pooled investment vehicles 
in the appropriate categories on Line 1b(5)-(7).
    Line 1b(14). Participant-directed brokerage accounts. Report 
assets held through participant-directed brokerage accounts in the 
appropriate sub-elements on Line 1b(14). Report in the aggregate all 
other investments through participant-directed brokerage accounts, 
that are not reportable in the separate categories in Lines 
1b(14)(A)-(F), including stocks, bonds, registered investment funds, 
etc., on Line 1b(14)(G).
    Line 1c(1). Employer securities. An employer security is any 
security issued by an employer (including affiliates) of employees 
covered by the plan. These may include common stocks, preferred 
stocks, bonds, zero coupon bonds, debentures, convertible 
debentures, notes, and commercial paper. Report in the appropriate 
category any types of employer securities held by the plan.
    Line 1c(2). Employer real property. The term ``employer real 
property'' means real property (and related personal property) that 
is leased to an employer of employees covered by the plan, or to an 
affiliate of such employer. For purposes of determining the time at 
which a plan acquires employer real property for purposes of this 
line, such property shall be deemed to be acquired by the plan on 
the date on which the plan acquires the property or on the date on 
which the lease to the employer (or affiliate) is entered into, 
whichever is later.
    Line 1d. Buildings and other property used in plan operation. 
Include the current (not book) value of the buildings and other 
property used in the operation of the plan. Report in 1c(9) and 
1c(2), as applicable, rather than Line 1d, buildings or other 
property held as plan investments that are not used in the operation 
of the plan.
    Line 1e. Other. Include all other investments not includable in 
lines 1b through 1d and enter a description.
    Line 1f. Total assets. Add all amounts in lines 1a through 1e.
    Note. Do not include the value of future pension payments on 
lines 1g, h, i, j, or k.
    Line 1g. Benefit claims payable. Noncash basis plans must 
include the total amount of benefit claims that have been processed 
and approved for payment by the plan. Include welfare plan 
``incurred but not reported'' (IBNR) benefit claims on this line.

[[Page 47624]]

    Line 1h. Operating payables. Noncash basis plans must include 
the total amount of obligations owed by the plan which were incurred 
in the normal operations of the plan and have been approved for 
payment by the plan but have not been paid.
    Line 1i. Acquisition indebtedness. ``Acquisition indebtedness,'' 
for debt-financed property other than real property, means the 
outstanding amount of the principal debt incurred:
    1. By the organization in acquiring or improving the property;
    2. Before the acquisition or improvement of the property if the 
debt was incurred only to acquire or improve the property; or
    3. After the acquisition or improvement of the property if the 
debt was incurred only to acquire or improve the property and was 
reasonably foreseeable at the time of such acquisition or 
improvement. For further explanation, see Code section 514(c).
    Line 1j. Other liabilities. Noncash basis plans must include 
amounts owed for any liabilities that would not be classified as 
benefit claims payable, operating payables, or acquisition 
indebtedness and enter a description of such liabilities.
    Line 1k. Total liabilities. Add all amounts in lines 1g through 
1k.

Net Assets

    Line 1l. Net assets. Enter the net assets as of the beginning 
and end of the plan year. (Subtract Line 1k from Line 1f.) The entry 
in column (b) must equal the sum of the entry in column (a) plus 
Lines 2k and 2l(1), minus 2l(2).

Part II Income and Expense Statement

    Line 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. 
Master trusts, CCTs, PSAs, and 103-12 IEs do not complete lines 2a, 
2b, 2e, 2f, and 2g.
    Line 2a. Contributions. Include the total cash contributions 
received and/or (for accrual basis plans) due to be received.
    Note. Plans using the accrual basis of accounting should not 
include contributions designated for years before the 20XX plan year 
on Line 2a.
    Line 2a (1). Contributions Received or receivable. Enter 
contributions received, or for accrual basis filers receivable, from 
employers in element (A), from participants in element (B). In 
element (C) enter all other contributions received or receivable, 
including rollovers from other qualified retirement plans.
    Line 2a(1)(B). For welfare plans, report all employee 
contributions, including all elective contributions under a 
cafeteria plan (Code section 125). For pension benefit plans, 
participant contributions, for purposes of this item, also include 
elective contributions under a qualified cash or deferred entities 
arrangement. (Code section 401(k)).
    Line 2a(2). Noncash contributions. Use the current value, at 
date contributed, of securities or other noncash property.
    Line 2a(3). Total contributions. Add Lines 2a(1)(A), (B), (C), 
and Line 2a(2).
    Line 2b. Interest Income on Notes Receivable from Participants 
(Participant Loans). Enter interest income on participant loans. 
Also include here interest income on residential mortgage loans to 
participants under Code Sec.  72(p).
    Line 2c. Earnings on Investments. Report in Line 2c(1)(A)-(E) 
the total interest paid directly to the plan by the issuer . Report 
the total of all other earnings on debt interests or obligations in 
Line 2c(1)(F).
    Report in Line 2c(2)(A) the total dividends on corporate stocks 
(other than employer securities) paid directly to the plan by the 
issuer of any corporate stocks. Report the total of all other 
earnings on corporate stocks in Line 2c(2)(B).
    In Line 2c(1)-(6), report the total of all earnings by asset 
type, including interest, dividends, gain (loss) on sale of 
property, unrealized appreciation (depreciation), and, if the asset 
has been sold during the plan year, the net investment gain (loss), 
as appropriate for asset type.
    Interest includes interest earned on interest-bearing cash, 
including earnings from sweep accounts, STIF accounts, money market 
accounts, certificates of deposit, government securities etc.
    For accrual basis plans, include any dividends declared for 
stock held on the date of record, but not yet received as of the end 
of the plan year.
    Generally, rents represent the income earned on the real 
property. Include ``rent'' reporting as part of earnings as a 
``Net'' figure. Net rents are determined by taking the total rent 
received and subtracting all expenses directly associated with the 
property. If the real property is jointly used as income producing 
property and for the operation of the plan, net that portion of the 
expenses attributable to the income producing portion of the 
property against the total rents received.
    Net gain (loss) on sale of assets equals the sum of the net 
realized gain (or loss) on each asset held at the beginning of the 
plan year which was sold or exchanged during the plan year, and on 
each asset that was both acquired and disposed of within the plan 
year.
    Note. As current value reporting is required for the Form 5500 
Annual Return/Report, assets are revalued to current value at the 
end of the plan year. For purposes of this form, the increase or 
decrease in the value of assets since the beginning of the plan year 
(if held on the first day of the plan year) or their acquisition 
date (if purchased during the plan year) is included as part of 
total earnings for particular assets.
    The sum of the realized gain (or loss) of assets sold or 
exchanged during the plan year is to be calculated as follows:
    1. Include for each category of asset in Line 2c, where 
applicable, the sum of the amount received for these former assets;
    2. Include for each category of asset in Line 2c, the sum of the 
current value of these former assets as of the beginning of the plan 
year and the purchase price for assets both acquired and disposed of 
during the plan year.
    If entering a negative number, enter a minus sign ``-'' to the 
left of the number.
    Note. Bond write-offs should be reported as realized losses.
    To calculate total unrealized appreciation of assets in each 
category subtract the current value of assets at the beginning of 
the year plus the cost of any assets acquired during the plan year 
from the current value of assets at the end of the year to obtain 
this figure. If entering a negative number, enter a minus sign ``-'' 
to the left of the number.
    Line 2d. Total income. Add all income amounts (c) and enter 
total in the space provided.
    Line 2e(1). Include the current value of all cash, securities, 
or other property at the date of distribution. Include all eligible 
rollover distributions as defined in Code section 401(a)(31)(D) paid 
at the participant's election to an eligible retirement plan 
(including an IRA within the meaning of section 401(a)(31)(E)).
    2e(2). Include payments to insurance companies and similar 
organizations, managed care organizations, and health maintenance 
organizations for the provision of plan benefits (e.g., paid-up 
annuities, accident insurance, health insurance, vision care, dental 
coverage, stop-loss insurance whose claims are paid to the plan (or 
which is otherwise an asset of the plan)), etc.
    2e(3). Include all payments made to other organizations or 
individuals providing benefits. Generally, these are individual 
providers of welfare benefits such as legal services, day care 
services, training, and apprenticeship services.
    Line 2f. Corrective Distributions. Include on this line all 
distributions paid during the plan year of excess deferrals under 
Code section 402(g)(2)(A)(ii), excess contributions under Code 
section 401(k)(8), and excess aggregate contributions under Code 
section 401(m)(6). Include allocable income distributed. Also 
include on this line any elective deferrals and employee 
contributions distributed or returned to employees during the plan 
year, as well as any attributable income that was also distributed.
    Line 2g. Certain Deemed Distributions of Participant Loans. 
Report on Line 2g a participant loan that has been deemed 
distributed during the plan year under the provisions of Code 
section 72(p) and Treasury Regulations section 1.72(p)-1 only if 
both of the following circumstances apply:
    1. Under the plan, the participant loan is treated as a directed 
investment solely of the participant's individual account; and
    2. As of the end of the plan year, the participant is not 
continuing repayment under the loan.
    If either of these circumstances does not apply, a deemed 
distribution of a participant loan should not be reported on Line 
2g. Instead, the current value of the participant loan (including 
interest accruing thereon after the deemed distribution) must be 
included on Line 1a(3), column (b) (participant loans--end of year), 
without regard to the occurrence of a deemed distribution.
    Note. The amount to be reported on Line 2g of Schedule H must be 
reduced if, during the plan year, a participant resumes

[[Page 47625]]

repayment under a participant loan reported as a deemed distribution 
on Line 2g for any earlier year. The amount of the required 
reduction is the amount of the participant loan reported as a deemed 
distribution on Line 2g for the earlier year. If entering a negative 
number, enter a minus sign ``-'' to the left of the number. The 
current value of the participant loan must then be included in Line 
1a(3), column (b), of Schedule H (Notes receivable from 
participants)
    Although certain participant loans deemed distributed are to be 
reported on Line 2g of the Schedule H and are not to be reported on 
the Schedule H as an asset thereafter (unless the participant 
resumes repayment under the loan in a later year), they are still 
considered outstanding loans and are not treated as actual 
distributions for certain purposes. See Q&As 12 and 19 of Treasury 
Regulations section 1.72(p)-1.
    Lines 2h-2j Expenses. Report expenses on the appropriate line 
items below.
    CAUTION. Master trust expenses that are not allocable to all 
plans investing in the master trust must be reported at the 
individual plan level. Only master trust expenses that are 
reasonably equally attributable to each participating plan may be 
reported at the master trust level. This includes administrative 
expenses associated with investments in which not all plans in the 
master trust have an interest.
    Line 2h. Interest Expense. Interest expense is a monetary charge 
for the use of money borrowed by the plan. This amount should 
include the total of interest paid or to be paid (for accrual basis 
plans) during the plan year.
    Line 2i. Administrative Expenses. Report all administrative 
expenses (by specified category) paid by or charged to the plan, 
including those that were not subtracted from the gross income of 
CCTs, PSAs, master trusts, and 103-12 IEs in determining their net 
investment gain(s) or loss(es). Expenses incurred in the general 
operations of the plan are classified as administrative expenses. 
Include, in the appropriate categories in lines 2i(1)-(11), the 
total fees paid (or in the case of accrual basis plans, costs 
incurred during the plan year but not paid as of the end of the plan 
year) by the plan for plan salaries and allowances, outside contract 
administrator, investment advisory and management fees, IQPA audit 
fees, recordkeeping and other accounting fees, bank or trust company 
trustee/custodial fees, actuarial fees, legal fees, and valuation/
appraisal services.
    Line 2i(1). Salaries and Allowances. Report total salaries and 
expenses for plan employees in Line 2i(1).
    Line 2i(2). Contract administrator fees. Enter the total fees 
paid (or in the case of accrual basis plans, costs incurred during 
the plan year but not paid as of the end of the plan year) to a 
contract administrator for performing administrative services for 
the plan. For purposes of the return/report, a contract 
administrator is any individual, partnership, or corporation, 
responsible for managing the clerical operations (e.g., handling 
membership rosters, claims payments, maintaining books and records) 
of the plan on a contractual basis. Do not include salaried staff or 
employees of the plan or banks or insurance carriers.
    Line 2i(3). Investment Advisory and Management Fees. Enter the 
total fees paid (or in the case of accrual basis plans, costs 
incurred during the plan year but not paid as of the end of the plan 
year) to an individual, partnership or corporation (or other person) 
for advice to the plan relating to its investment portfolio. These 
may include fees paid to manage the plan's investments, fees for 
specific advice on a particular investment, and fees for the 
evaluation for the plan's investment performance.
    Line 2i(4). IQPA Audit Fees. Enter in Line 2j(4) fees for the 
annual audit of the plan by an independent qualified public 
accountant (IQPA); for payroll audits, and any other audit fees paid 
by the plan.
    Line 2i(5). Recordkeeping and Other Accounting Fees. Include 
fees for accounting/bookkeeping services other than amounts paid for 
audit fees reportable in Line 2i(4).
    Line 2i(6). Bank or Trust Company Trustee/Custodial Fees. Report 
here bank or trust company trustee/custodial fees.
    Line 2i(7). Actuarial Fees. Include fees for actuarial services 
rendered to the plan, including preparation of Schedules MB or SB, 
as applicable.
    Line 2i(8). Legal Fees. Include payments to a lawyer for 
rendering legal opinions, litigation, and advice (but not for 
providing legal services as a benefit to plan participants).
    Line 2i(9). Valuation/appraisal Fees. Include the fee(s) for 
valuations or appraisals to determine the cost, quality, or value of 
an item such as real property, personal property (gemstones, coins, 
etc.), and for valuations of closely held securities for which there 
is no ready market.
    Line 2i(10). Trustee Fees and Expenses. Include the total fees 
and expenses paid to or on behalf of plan trustees (or in the case 
of accrual basis plans, costs incurred during the plan year but not 
paid as of the end of the plan year). Include direct payment by the 
plan or reimbursement by the plan to trustees of expenses associated 
with trustees such as lost time, seminars, travel, meetings, 
educational conferences, etc. Do not include in Line 2i(10) amounts 
paid to plan employees to perform bookkeeping/accounting functions 
that should be included in Line 2i(5).
    Line 2i(11). Other Expenses. Other expenses are those that 
cannot be included in Lines 2-(1) through 2-(10). These may include 
plan expenditures such as salaries and other compensation and 
allowances, expenses for office supplies and equipment, cars, 
telephone, postage, rent, expenses associated with the ownership of 
a building used in the operation of the plan, and all miscellaneous 
expenses. Include premium payments to the PBGC when paid from plan 
assets.
    Line 2i(12)(C). Total Administrative Expenses. Add all 
administrative expense amounts in column (b) in lines 2i(1) through 
(11) and enter total (b).
    Line 2j. Total expenses. Add all expense amounts in column (b) 
and enter total (b).
    Line 2l. Include in these reconciliation figures the value of 
all transfers of assets or liabilities into or out of the plan 
resulting from, among other things, mergers and consolidations. A 
transfer of assets or liabilities occurs when there is a reduction 
of assets or liabilities with respect to one plan and the receipt of 
these assets or the assumption of these liabilities by another plan. 
A transfer is not a shifting of one plan's assets or liabilities 
from one investment to another. A transfer is not a distribution of 
all or part of an individual participant's account balance that is 
reportable on IRS Form 1099-R, Distributions From Pensions, 
Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance 
Contracts, etc. (See the instructions for Line 2f). Transfers out at 
the end of the year should be reported as occurring during the plan 
year.
    Note. If this Schedule H is filed for a CCT, PSA, master trust, 
or 103-12 IE, report the value of all asset transfers to the CCT, 
PSA, master trust, or 103-12 IE, including those resulting from 
contributions to participating plans on Line 2l(1), and report the 
total value of all assets transferred out of the CCT, PSA, master 
trust, or 103-12 IE, including assets withdrawn for disbursement as 
benefit payments by participating plans, on Line 2l(2). 
Contributions and benefit payments are considered to be made to/by 
the plan (not to/by a CCT, PSA, master trust, or 103-12 IE).

Part III--Accountant's Opinion

    Line 3. The administrator of an employee benefit plan who files 
a Schedule H generally must engage an Independent Qualified Public 
Accountant (IQPA) pursuant to ERISA section 103(a)(3)(A) and 29 CFR 
2520.103-1(b). This requirement also applies to a Form 5500 Annual 
Return/Report filed for a 103-12 IE and for a GIA (see 29 CFR 
2520.103-12 and 29 CFR 2520.103-2). The IQPA's report must be 
attached to the Form 5500 when a Schedule H is attached unless you 
checked Schedule H, Line 3h(1), (2), or (3) or (4).
    [CAUTION] If you checked Schedule H, Line 3h(3) to indicate that 
the required IQPA's report is not attached to the Form 5500, the 
filing is subject to rejection as incomplete and penalties may be 
assessed.
    Notes. (1) An IQPA Report generally consists of an Accountant's 
Opinion, Financial Statements, Notes to the Financial Statements, 
and Supplemental Schedules. 29 CFR 2520.103-1(b) requires that any 
separate financial statements prepared in order for the IQPA to form 
the opinion and notes to these financial statements must be attached 
to the Form 5500. Any separate statements must include the 
information required to be disclosed in Parts I and II of the 
Schedule H; however, they may be aggregated into categories in a 
manner other than that used on the Schedule H. The separate 
statements must consist of reproductions of Parts I and II or 
statements incorporating by reference Parts I and II. See ERISA 
section 103(a)(3)(A), and the DOL regulations 29 CFR 2520.103-
1(a)(2) and (b), 2520.103-2, and 2520.104-50.
    (2) Delinquent participant contributions reported on Line 4a 
must be treated as part of the separate schedules referenced in 
ERISA section 103(a)(3)(A) and 29 CFR 2520.103-1(b) and 2520.103-
2(b) for purposes of preparing the IQPA's opinion described on Line 
3 even though they are not

[[Page 47626]]

required to be listed on Part III of the Schedule G. If the 
information contained on Line 4a is not presented in accordance with 
regulatory requirements, i.e., when the IQPA concludes that the 
scheduled information required by Line 4a does not contain all the 
required information or contains information that is inaccurate or 
is inconsistent with the plan's financial statements, the IQPA 
report must make the appropriate disclosures in accordance with 
generally accepted auditing standards. Delinquent participant 
contributions that are exempt because they satisfy the DOL Voluntary 
Fiduciary Correction Program (VFCP) requirements and the conditions 
of prohibited transaction exemption (PTE) 2002-51 do not need to be 
treated as part of the schedule of nonexempt party-in-interest 
transactions.
    Lines 3a(1) through 3a(4). These boxes identify the type of 
opinion offered by the IQPA.
    Line 3a(1). Check if an unqualified opinion was issued. 
Generally, an unqualified opinion is issued when the IQPA concludes 
that the plan's financial statements present fairly, in all material 
respects, the financial status of the plan as of the end of the 
period audited and the changes in its financial status for the 
period under audit in conformity with generally accepted accounting 
principles (GAAP) or another comprehensive basis of accounting 
(OCBOA), e.g., cash basis.
    Line 3a(2). Check if a qualified opinion was issued. Generally, 
a qualified opinion is issued by an IQPA when the plan's financial 
statements present fairly, in all material respects, the financial 
status of the plan as of the end of the audit period and the changes 
in its financial status for the period under audit in conformity 
with GAAP or OCBOA, except for the effects of one or more matters 
described in the opinion.
    Line 3a(3). Check if a disclaimer of opinion was issued. A 
disclaimer of opinion is issued when the IQPA does not express an 
opinion on the financial statements because he or she has not 
performed an audit sufficient in scope to enable him or her to form 
an opinion on the financial statements.
    Line 3a(4). Check if the plan received an adverse accountant's 
opinion. Generally, an adverse opinion is issued by an IQPA when the 
plan's financial statements do not present fairly, in all material 
respects, the financial status of the plan as of the end of the 
audit period and the changes in its financial status for the period 
under audit in conformity with GAAP or OCBOA.
    Line 3b. Limited Scope Audit and Certification of Assets. Check 
``Yes'' if a box is checked on Line 3a, and the only limitation on 
the scope of the plan's audit was pursuant to DOL regulations 29 CFR 
2520.103-8 and 2520.103-12(d) because the examination and report of 
an IQPA did not extend to: (1) statements or information regarding 
assets held by a bank, similar institution, or insurance carrier 
that is regulated and supervised and subject to periodic examination 
by a state or federal agency provided that the statements or 
information are prepared by and certified to by the bank or similar 
institution or an insurance carrier, or (2) information included 
with the Form 5500 filed for a 103-12 IE. The term ``similar 
institution'' as used here does not extend to securities brokerage 
firms (see DOL Advisory Opinion 93-21A). See 29 CFR 2520.103-8 and 
2520.103-12(d).
    [CAUTION] Check ``No'' if the scope of the plan's audit was 
limited for any reason in addition to that pursuant to DOL 
regulations 29 CFR 2520.103-8 and 2520.103-12.
    You must attach a copy of the certification(s) if the audit 
opinion was limited in scope pursuant to DOL regulations 29 CFR 
2520.103-8 and 2520.103-12(d) (regardless of whether you checked 
``yes'' for Line 3b). Although you must attach a copy of the 
certification(s), you do not need to include any attachments to the 
certification itemizing the assets to which the certification(s) 
apply.
    Note. These regulations do not exempt the plan administrator 
from engaging an IQPA or from attaching the IQPA's report to the 
Form 5500. If you check Line 3b, you must also check the appropriate 
box on Line 3a to identify the type of opinion offered by the IQPA.
    Line 3c. Enter the name and EIN of the accountant (or accounting 
firm) in the space provided on Line 3c. Do not use a social security 
number or any portion thereof in lieu of an EIN. The Schedule H is 
open to public inspection, and the contents are public information 
and are subject to publication on the Internet. Because of privacy 
concerns, the inclusion of a social security number or any portion 
thereof on this Schedule H may result in the rejection of the 
filing. If the name of an accounting firm is entered in Line 3c(1), 
enter the name of the audit engagement partner in Line 1c(3).
    Line 3d. Enter the state in which the accountant's opinion was 
issued.
    Line 3e. Check ``Yes'' if you reviewed and discussed the IQPA 
report with the accountant preparing the report?
    Line 3f. If you answered ``Yes,'' to Line 3e, check all that 
apply.
    Line 3h(1). Check this box only if the Schedule H is being filed 
for a CCT, PSA, or master trust.
    Line 3h(2). Check this box if the plan has elected to defer 
attaching the IQPA's opinion for the first of two (2) consecutive 
plan years, one of which is a short plan year of seven (7) months or 
fewer. The Form 5500 for the first of the two (2) years must be 
complete and accurate, with all required attachments, except for the 
IQPA's report, including an attachment explaining why one of the two 
(2) plan years is of seven (7) or fewer months duration and stating 
that the annual report for the immediately following plan year will 
include a report of an IQPA with respect to the financial statements 
and accompanying schedules for both of the two (2) plan years. The 
Form 5500 for the second year must include: (a) financial schedules 
and statements for both plan years; (2) a report of an IQPA with 
respect to the financial schedules and statements for each of the 
two (2) plan years (regardless of the number of participants covered 
at the beginning of each plan year); and (3) a statement identifying 
any material differences between the unaudited financial information 
submitted with the first Form 5500 and the audited financial 
information submitted with the second Form 5500. See 29 CFR 
2520.104-50.
    Note. Do not check the box on Line 3h(2) if the Form 5500 is 
filed for a 103-12 IE or a GIA. A deferral of the IQPA's opinion is 
not permitted for a 103-12 IE or a GIA. If the box for 103-12 IE or 
GIA is checked on Form 5500, Part I, Line A(5), an IQPA's opinion 
must be attached to the Form 5500 and the type of opinion must be 
reported on Schedule H, Line 3a.
    Line 3h(4). Small Plan Audit Waiver. Check ``Yes'' if you are a 
small plan claiming a waiver of the annual examination and report of 
an independent qualified public accountant (IQPA) under 29 CFR 
2520.104-46. Large plans are not eligible for the audit waiver under 
29 CFR 2520.104-46. You are eligible to claim the waiver if this 
filing is for:
    1. A small welfare plan, or
    2. A small pension plan for a plan year that began on or after 
April 18, 2001, that complies with the conditions of 29 CFR 
2520.104-46 summarized below.
    Note. For plans that check ``No,'' the IQPA report must make the 
appropriate disclosures in accordance with generally accepted 
auditing standards if the information reported on Line 4a is not 
presented in accordance with regulatory requirements.
    The following summarizes the conditions of 29 CFR 2520.104-46 
that must be met for a small pension plan with a plan year beginning 
on or after April 18, 2001, to be eligible for the waiver. For more 
information regarding these requirements, see the EBSA's Frequently 
Asked Questions on the Small Pension Plan Audit Waiver Regulation 
and 29 CFR 2520.104-46, which are available at www.dol.gov/ebsa, or 
call the EFAST2 Help Line at 1-866-GO-EFAST (1-866-463-3278) (toll-
free).
    Condition 1: At least 95 percent of plan assets are ``qualifying 
plan assets'' as of the end of the preceding plan year, or any 
person who handles assets of the plan that do not constitute 
qualifying plan assets is bonded in accordance with the requirements 
of ERISA section 412 (see the instructions for Line 4e), except that 
the amount of the bond shall not be less than the value of such non-
qualifying assets. The determination of the ``percent of plan 
assets'' as of the end of the preceding plan year and the amount of 
any required bond must be made at the beginning of the plan's 
reporting year for which the waiver is being claimed. For purposes 
of this line, you will have satisfied the requirement to make these 
determinations at the beginning of the plan reporting year for which 
the waiver is being claimed if they are made as soon after the date 
when such year begins as the necessary information from the 
preceding reporting year can practically be ascertained. See 29 CFR 
2580.412-11, 14 and 19 for additional guidance on these 
determinations, and 29 CFR 2580.412-15 for procedures to be used for 
estimating these amounts if there is no preceding plan year.
    The term ``qualifying plan assets,'' for purposes of this line 
means:
    1. Any assets held by any of the following regulated financial 
institutions:
    a. A bank or similar financial institution as defined in 29 CFR 
2550.408b-4(c);

[[Page 47627]]

    b. An insurance company qualified to do business under the laws 
of a state;
    c. An organization registered as a broker-dealer under the 
Securities Exchange Act of 1934; or
    d. Any other organization authorized to act as a trustee for 
individual retirement accounts under Code section 408.
    2. Shares issued by an investment company registered under the 
Investment Company Act of 1940 (e.g., mutual funds);
    3. Investment and annuity contracts issued by any insurance 
company qualified to do business under the laws of a state;
    4. In the case of an individual account plan, any assets in the 
individual account of a participant or beneficiary over which the 
participant or beneficiary has the opportunity to exercise control 
and with respect to which the participant or beneficiary is 
furnished, at least annually, a statement from a regulated financial 
institution referred to above describing the assets held or issued 
by the institution and the amount of such assets;
    5. Qualifying employer securities, as defined in ERISA section 
407(d)(5); and
    6. Participant loans meeting the requirements of ERISA section 
408(b)(1).
    Condition 2: The administrator must disclose the following 
information in the summary annual report (SAR) furnished to 
participants and beneficiaries, in accordance with 29 CFR 2520.104b-
10. For defined benefit pension plans that are required pursuant to 
section 101(f) of ERISA to furnish an Annual Funding Notice (AFN), 
the administrator must instead either provide the information to 
participants and beneficiaries with the AFN or as a stand-alone 
notification at the time a SAR would have been due and in accordance 
with the rules for furnishing an SAR, although such plans do not 
have to furnish a SAR.
    1. The name of each regulated financial institution holding or 
issuing qualifying plan assets and the amount of such assets 
reported by the institution as of the end of the plan year (this SAR 
disclosure requirement does not apply to qualifying employer 
securities, participant loans and individual account assets 
described in paragraphs 4,5 and 6 above);
    2. The name of the surety company issuing the fidelity bond, if 
the plan has more than 5% of its assets in non-qualifying plan 
assets;
    3. A notice that participants and beneficiaries may, upon 
request and without charge, examine or receive from the plan 
evidence of the required bond and copies of statements from the 
regulated financial institutions describing the qualifying plan 
assets; and
    4. A notice that participants and beneficiaries should contact 
the EBSA Regional Office if they are unable to examine or obtain 
copies of the regulated financial institution statements or evidence 
of the required bond, if applicable.
    A Model Notice that plans can use to satisfy the enhanced SAR 
(or Annual Funding Notice) disclosure requirements to be eligible 
for the audit waiver is available as an Appendix to 29 CFR 2520.104-
46.
    Condition 3: In addition, in response to a request from any 
participant or beneficiary, the administrator, without charge to the 
participant or beneficiary, must make available for examination, or 
upon request furnish copies of, each regulated financial institution 
statement and evidence of any required bond.
    Examples. Plan A, which has a plan year that began on or after 
April 18, 2001, had total assets of $600,000 as of the end of the 
20XX-1 plan year that included: investments in various bank, 
insurance company and mutual fund products of $520,000; investments 
in qualifying employer securities of $40,000; participant loans 
(meeting the requirements of ERISA section 408(b)(1)), totaling 
$20,000; and a $20,000 investment in a real estate limited 
partnership. Because the only asset of the plan that did not 
constitute a ``qualifying plan asset'' is the $20,000 real estate 
limited partnership investment and that investment represents less 
than 5% of the plan's total assets, no fidelity bond is required as 
a condition for the plan to be eligible for the waiver for the 20XX 
plan year.
    Plan B is identical to Plan A except that of Plan B's total 
assets of $600,000 as of the end of the 20XX-1 plan year, $558,000 
constitutes ``qualifying plan assets'' and $42,000 constitutes non-
qualifying plan assets. Because 7%--more than 5%--of Plan B's assets 
do not constitute ``qualifying plan assets,'' Plan B, as a condition 
to be eligible for the waiver for the 20XX plan year, must ensure 
that it has a fidelity bond in an amount equal to at least $42,000 
covering persons handling its non-qualifying plan assets. Inasmuch 
as compliance with ERISA section 412 generally requires the amount 
of the bond be not less than 10% of the amount of all the plan's 
funds or other property handled, the bond acquired for ERISA section 
412 purposes may be adequate to cover the non-qualifying plan assets 
without an increase (i.e., if the amount of the bond determined to 
be needed for the relevant persons for ERISA section 412 purposes is 
at least $42,000). As demonstrated by the foregoing example, where a 
plan has more than 5% of its assets in non-qualifying plan assets, 
the required bond is for the total amount of the non-qualifying plan 
assets, not just the amount in excess of 5%.
    If you need further information regarding these requirements, 
see 29 CFR 2520.104-46 which is available at www.dol.gov/ebsa or 
call the EFAST2 Help Line at 1-866-GO EFAST (1-866-463-3278) (toll-
free).

Part IV--Compliance Questions

    Lines 4a through 4z. Plans completing Schedule H must answer all 
these lines with either ``Yes'' or ``No.'' Do not leave any answer 
blank, unless otherwise directed. For Lines 4a through 4h and Line 
4l, if the answer is ``Yes,'' an amount must be entered.
    Report investments in CCTs, PSAs, master trusts, and 103-12 IEs, 
but not the investments made by these entities. Plans with all of 
their funds held in a master trust should check ``No'' on Line 4b 
and 4c. CCTs and PSAs complete only Line 4i(1). Master trusts and 
103-12 IEs complete only Lines 4b, 4c, 4d, 4i(1) and (2), 4j, and 
4s. GIAs complete only Lines 4b, 4c, 4d, 4i(1) and (2), 4j, and 4k. 
Except as otherwise provided, all plans and DFEs that have not 
checked on Form 5500 that this is the ``final'' return/report and 
have indicated that they have no assets (``-0-'') must check ``Yes'' 
on Line 4i(1) and complete the Line 4i(1) Schedule of Assets Held 
for Investment at End of Year. Where applicable, they must also 
check ``Yes'' on Line 4i(2) and complete the Line 4i(2) Schedule of 
Assets Disposed of During the Plan Year.
    Small welfare plans that are required to complete the Schedule 
H, do not have to complete the attachments to Line 4(a), Line 4i(1) 
and (2), and Line 4j, even if the answer to any of those questions 
is ``Yes.''
    Line 4a. Amounts paid by a participant or beneficiary to an 
employer and/or withheld by an employer for contribution to the plan 
are participant contributions that become plan assets as of the 
earliest date on which such contributions can reasonably be 
segregated from the employer's general assets (see 29 CFR 2510.3-
102). Plans that check ``Yes'' must enter the aggregate amount of 
all late contributions for the year. The total amount of the 
delinquent contributions should be included on Line 4a of the 
Schedule H for the year in which the contributions were delinquent 
and should be carried over and reported again on Line 4a of the 
Schedule H, for each subsequent year until the year after the 
violation has been fully corrected, which correction includes 
payment of the late contributions and reimbursement of the plan for 
lost earnings or profits. If no participant contributions were 
received or withheld by the employer during the plan year, answer 
``No.''
    An employer holding these assets after that date commingled with 
its general assets will have engaged in a prohibited use of plan 
assets (see ERISA section 406). If such a nonexempt prohibited 
transaction occurred with respect to a disqualified person (see Code 
section 4975(e)(2)), file IRS Form 5330, Return of Excise Taxes 
Related to Employee Benefit Plans, with the IRS to pay any 
applicable excise tax on the transaction.
    Participant loan repayments paid to and/or withheld by an 
employer for purposes of transmittal to the plan that were not 
transmitted to the plan in a timely fashion must be reported either 
on Line 4a in accordance with the reporting requirements that apply 
to delinquent participant contributions or on Line 4d. See Advisory 
Opinion 2002-02A, available at www.dol.gov/ebsa.
    [CAUTION] Delinquent participant contributions reported on Line 
4a should be treated as part of the separate schedules referenced in 
ERISA section 103(a)(3)(A) and 29 CFR 2520.103-1(b) and 2520.103-
2(b) for purposes of preparing the IQPA's opinion described on Line 
3 even though they are not required to be listed on Part III of the 
Schedule G. If the information contained on Line 4a is not presented 
in accordance with regulatory requirements, i.e., when the IQPA 
concludes that the scheduled information required by Line 4a does 
not contain all the required information or contains information 
that is inaccurate or is inconsistent with the plan's financial 
statements, the IQPA report must make the appropriate disclosures in 
accordance with generally accepted auditing standards. For more 
information, see EBSA's Frequently Asked Questions About Reporting

[[Page 47628]]

Delinquent Contributions on the Form 5500, available on the Internet 
at www.dol.gov/ebsa. These Frequently Asked Questions clarify that 
plans have an obligation to include delinquent participant 
contributions on their financial statements and supplemental 
schedules and that the IQPA's report covers such delinquent 
contributions even though they are not required to be included on 
Part III of the Schedule G. Although all delinquent participant 
contributions must be reported on Line 4a, delinquent contributions 
for which the DOL VFCP requirements and the conditions of PTE 2002-
51 have been satisfied do not need to be treated as nonexempt party-
in-interest transactions.
    [TIP] The VFCP describes how to apply, the specific transactions 
covered (which transactions include delinquent participant 
contributions to pension and welfare plans), and acceptable methods 
for correcting violations. In addition, applicants that satisfy both 
the VFCP requirements and the conditions of PTE 2002-51 are eligible 
for immediate relief from payment of certain prohibited transaction 
excise taxes for certain corrected transactions, and are also 
relieved from the obligation to file the IRS Form 5330 with the IRS. 
For more information, see 71 FR 20261 (Apr. 19, 2006) and 71 FR 
20135 (Apr. 19, 2006). Information about the VFCP is also available 
on the Internet at www.dol.gov/ebsa.
    All participant contributions that were delinquent during the 
plan year must be reported on Line 4a even if violations have been 
corrected.
    Line 4a Schedule of Delinquent Participant Contributions. 
Complete the ``Line 4a Schedule of Delinquent Participant 
Contributions'' if you entered ``Yes.''
    Element (a). Enter the total amount of delinquent contributions 
from this and previous years that were remitted during the plan 
year. Include contributions due in previous years that were remitted 
during this plan year. If you include participant loan repayments on 
Line 4a, you must apply the same supplemental schedule and IQPA 
disclosure requirements to the loan repayments as applied to 
delinquent transmittals of participant contributions. If you include 
participant loan repayments, check the box in element (g).
    Element (b). Enter the total amount of delinquent contributions 
due, but unremitted during the plan year. You must carry these over 
and report them for each subsequent year until they are fully 
correct. Include contributions due in previous plan years, but still 
unremitted.
    Element (c). Enter the number of payrolls for which the 
contributions were delinquent and uncorrected.
    Element (d). Enter in element d(1) the total amount of 
delinquent contributions that were corrected under VFCP. See 71 FR 
20261 (Apr. 19, 2006). Information about the VFCP is also available 
on the Internet at www.dol.gov/ebsa. Enter in element d(2) any 
amount that were corrected under the VFCP, but not under PTE 2002-
51. See 71 FR 20135 (Apr. 19, 2006). For all amount reported in 
element (d), complete element (h) to indicate whether you filed Form 
5330 with the IRS and paid any applicable excise taxes.
    Element (e). Enter the amount of delinquent contributions 
pending correction in VFCP as of the date of the Form 5500 Annual 
Return/Report filing.
    Element (f). Enter the total amount of delinquent contributions 
for which the contributions were paid and the plan reimbursed fully 
for lost earnings or profits outside of the VFCP. See the VFCP for 
more information on how to fully correct delinquent participant 
contributions.
    Element (g). Check the box in element (g) if you included 
delinquent participant loan repayments on Line 4a and in element 
(a).
    Element (h). Check ``Yes'' for any amount reported in element 
(h) if you filed your Form 5330 with the IRS and paid all applicable 
excise taxes associated with the delinquent contributions and/or 
delinquent participant loan repayments. For more information on Form 
5330, see http://www.irs.gov/Retirement-Plans/Form-5330-Corner.
    Element (i). Only multiemployer plans complete this item. In 
element (i)(1), enter the amount of participant contributions from 
participating employers in the multiemployer plan that has been 
determined during the plan year to be uncollectible (including 
contributions due in previous plan years but still unremitted). In 
element (i)(2), explain what steps were taken to collect overdue 
amounts (including whether claims were submitted on performance 
bonds) before determining the amount that is uncollectible.
    Line 4b. Plans that check ``Yes'' must enter the amount and 
complete Part I of Schedule G. The due date, payment amount and 
conditions for determining default of a note or loan are usually 
contained in the documents establishing the note or loan. A loan by 
the plan is in default when the borrower is unable to pay the 
obligation upon maturity. Obligations that require periodic 
repayment can default at any time. Generally, loans and fixed income 
obligations are considered uncollectible when payment has not been 
made and there is little probability that payment will be made. A 
fixed income obligation has a fixed maturity date at a specified 
interest rate. Do not include participant loans made under an 
individual account plan with investment experience segregated for 
each account that were made in accordance with 29 CFR 2550.408b-1 
and secured solely by a portion of the participant's vested accrued 
benefit. Small plans that were eligible for and claimed the small 
plan audit waiver do not need to attach Schedule G.
    Line 4c. Plans that check ``Yes'' must enter the amount and 
complete Part II of Schedule G. A lease is an agreement conveying 
the right to use property, plant, or equipment for a stated period. 
A lease is in default when the required payment(s) has not been 
made. An uncollectible lease is one where the required payments have 
not been made and for which there is little probability that payment 
will be made. Small plans that were eligible for and claimed the 
small plan audit waiver do not need to attach Schedule G.
    Line 4d. Plans that check ``Yes'' must enter the amount and 
complete Part III of Schedule G. Small plans that were eligible for 
and claimed the small plan audit waiver do not need to attach 
Schedule G. Check ``Yes'' if any nonexempt transaction with a party-
in-interest occurred regardless of whether the transaction is 
disclosed in the IQPA's report. Do not check ``Yes'' or complete 
Schedule G, Part III, with respect to transactions that are:
    (1) Statutorily exempt under Part 4 of Title I of ERISA;
    (2) Administratively exempt under ERISA section 408(a);
    (3) Exempt under Code sections 4975(c) or 4975(d);
    (4) The holding of participant contributions in the employer's 
general assets for a welfare plan that meets the conditions of ERISA 
Technical Release 92-01;
    (5) A transaction of a 103-12 IE with parties other than the 
plan; or
    (6) Delinquent participant contributions or delinquent 
participant loan repayments reported on Line 4a.
    Note. See the instructions for Part III of the Schedule G (Form 
5500) concerning nonexempt transactions and party-in-interest.
    You may indicate that an application for an administrative 
exemption is pending. If you are unsure as to whether a transaction 
is exempt or not, you should consult with either the plan's IQPA or 
legal counsel or both.
    [TIP] Applicants that satisfy the VFCP requirements and the 
conditions of PTE 2002-51 (see the instructions for Line 4a) are 
eligible for immediate relief from payment of certain prohibited 
transaction excise taxes for certain corrected transactions, and are 
also relieved from the obligation to file the IRS Form 5330 with the 
IRS. For more information, see 71 FR 20261 (Apr. 19, 2006) and 71 FR 
20135 (Apr. 19, 2006). When the conditions of PTE 2002-51 have been 
satisfied, the corrected transactions should be treated as exempt 
under Code section 4975(c) for the purposes of answering Line 4d.
    Line 4e. Plans that check ``Yes'' must enter the aggregate 
amount of fidelity bond coverage for all claims. Check ``Yes'' only 
if the plan itself (as opposed to the plan sponsor or administrator) 
is a named insured under a fidelity bond from an approved surety 
covering plan officials and that protects the plan from losses due 
to fraud or dishonesty as described in 29 CFR part 2580. Generally, 
every plan official of an employee benefit plan who ``handles'' 
funds or other property of such plan must be bonded. Generally, a 
person shall be deemed to be ``handling'' funds or other property of 
a plan, so as to require bonding, whenever his or her duties or 
activities with respect to given funds are such that there is a risk 
that such funds could be lost in the event of fraud or dishonesty on 
the part of such person, acting either alone or in collusion with 
others. Section 412 of ERISA and 29 CFR part 2580 describe the 
bonding requirements, including the definition of ``handling'' (29 
CFR 2580.412-6), the permissible forms of bonds (29 CFR 2580.412-
10), the amount of the bond (29 CFR part 2580, subpart C), and 
certain exemptions such as the exemption for unfunded plans, certain 
banks and insurance companies (ERISA section 412), and the exemption 
allowing plan officials to purchase bonds from surety companies

[[Page 47629]]

authorized by the Secretary of the Treasury as acceptable reinsurers 
on federal bonds (29 CFR 2580.412-23).
    Information concerning the list of approved sureties and 
reinsures is available on the Internet at www.fms.treas.gov/c570. 
For more information on the fidelity bonding requirements, see Field 
Assistance Bulletin 2008-04, available on the Internet at 
www.dol.gov/ebsa.
    Note. Plans are permitted under certain conditions to purchase 
fiduciary liability insurance. These fiduciary liability insurance 
policies are not written specifically to protect the plan from 
losses due to dishonest acts and cannot be reported as fidelity 
bonds on Line 4e.
    Line 4f. Check ``Yes,'' if the plan suffered or discovered any 
loss as a result of any dishonest or fraudulent act(s) even if the 
loss was reimbursed by the plan's fidelity bond or from any other 
source. If the plan suffered such a loss, enter the full amount of 
the loss. If the full amount of the loss has not yet been 
determined, provide an estimate and disclose that the figure is an 
estimate as determined in good faith by a plan fiduciary. You must 
keep, in accordance with ERISA section 107, records showing how the 
estimate was determined.
    CAUTION: Willful failure to report is a criminal offense. See 
ERISA section 501.
    Line 4g. Check ``Yes'' if the plan had assets of which the 
current value was neither readily determinable on an established 
market nor set by an independent third party appraiser. Enter in the 
amount column the fair market value of the assets referred to on 
Line 4g whose value was not readily determinable on an established 
market and which were not valued by an independent third-party 
appraiser in the plan year. Generally, as it relates to these 
questions, an appraisal by an independent third party is an 
evaluation of the value of an asset prepared by an individual or 
firm who knows how to judge the value of such assets and does not 
have an ongoing relationship with the plan or plan fiduciaries 
except for preparing the appraisals.
    TIP: Do not check ``Yes'' on Line 4g for mutual fund shares or 
insurance company investment contracts for which the plan receives 
valuation information at least annually. Also, do not check ``Yes'' 
on Line 4g if the plan is a defined contribution pension plan and 
the only assets the plan holds, that do not have a readily 
determinable value on an established market, are: (1) participant 
loans not in default, or (2) assets over which the participant 
exercises control within the meaning of section 404(c) of ERISA.
    Current value means fair market value where available. 
Otherwise, it means the fair value as determined in good faith under 
the terms of the plan by a trustee or a named fiduciary, assuming an 
orderly liquidation at the time of the determination. See ERISA 
section 3(26). An accurate assessment of fair market value is 
essential to a pension plan's ability to comply with the 
requirements set forth in the Code (e.g., the exclusive benefit rule 
of Code section 401(a)(2), the limitations on benefits and 
contributions under Code section 415, and the minimum funding 
requirements under Code section 412) and must be determined 
annually.
    Examples of assets that may not have a readily determinable 
value on an established market (e.g., NYSE, AMEX, over the counter, 
etc.) include real estate, nonpublicly traded securities, shares in 
a limited partnership, derivatives, notes and stock not traded on an 
exchange, private equity, and collectibles.
    Although the current value of plan assets must be determined 
each year, there is no requirement that the assets (other than 
certain nonpublicly traded employer securities held in ESOPs) be 
valued every year by independent third-party appraisers.
    Line 4h. Check ``Yes'' if the plan received during the plan year 
noncash contributions of which the current value was neither readily 
determinable on an established market nor set by an independent 
third party appraiser. Enter in the amount column the fair market 
value of the assets referred to on Line 4g whose value was not 
readily determinable on an established market and which were not 
valued by an independent third-party appraiser in the plan year. See 
instructions for Line 4g.
    Line 4i. Schedules of Assets. Check ``Yes'' in elements (1) and/
or (2) and complete, as appropriate, the ``Line 4i(1) Schedule of 
Assets Held for Investment at End of Year'' and the ``Line 4i(2) 
Schedule of Assets Disposed of During the Plan Year.'' You may not 
create your own schedules of assets in the form of an attachment or 
otherwise. You must complete the schedule through IFile or using 
EFAST-approved third-party software. If the plan both disposed of 
assets during the plan year and held assets for investment at end of 
year, you must complete both the Line 4i(1) and 4i(2) schedules. 
Generally, all plans that are ongoing must answer ``Yes'' to Line 
4i(1) and complete the ``Line 4i(1) Schedule of Assets Held for 
Investment at End of Year.''
    Notes: (1) Participant loans under an individual account plan 
with investment experience segregated for each account, that are 
made in accordance with 29 CFR 2550.408b-1 and that are secured 
solely by a portion of the participant's vested accrued benefit, may 
be aggregated for reporting purposes in Line 4i. Under identity of 
borrower enter ``Participant loans,'' under rate of interest enter 
the lowest rate and the highest rate charged during the plan year 
(e.g., 8%-10%), under the cost and proceeds columns enter zero, and 
under current value enter the total amount of these loans. (2) 
Column (d) cost information for the Line 4i(1) Schedule of Assets 
Held for Investment at End of Year and the column (c) cost of 
acquisitions information for the Line 4i(2) Schedule of Assets 
Disposed of During the Plan Year may be omitted when reporting 
investments of an individual account plan that a participant or 
beneficiary directed with respect to assets allocated to his or her 
account (including a negative election authorized under the terms of 
the plan). Likewise, cost information for investments in Code 
sections 403(b)(1) annuity contracts and 403(b)(7) custodial 
accounts may also be omitted. (3) Investments in Code section 
403(b)(1) annuity contracts and Code section 403(b)(7) custodial 
accounts generally may also be treated as one asset held for 
investment for purposes on the Line 4i schedules. For 403(b)(7) 
accounts, show the corresponding Line 1b(5)(A) categories to show 
the types of investment accounts.
    Line 4i(1). Schedule of Assets Held for Investment at End of 
Year. Assets held for investment purposes for purposes of the Line 
4i(1) Schedule of Assets Held for Investment at End of Year includes 
all investment assets held by the plan on the last day of the plan 
year other than cash and cash equivalents reported on Line 1b(1) and 
(2) that are held at end of year. You must complete the Schedule of 
Assets Held for Investment at End of Year if you answered ``Yes'' to 
Line 4(i)(1).
    Line 4i(1) Schedule of Assets Held for Investment at End of Year 
(Complete as many entries in each element as needed to identify all 
assets held for investment at end of year)

--------------------------------------------------------------------------------------------------------------------------------------------------------
 
--------------------------------------------------------------------------------------------------------------------------------------------------------
  (a) Assets Held directly by the plan (including assets held through an participant-directed brokerage window) For each asset which the plan holds for
              investment purposes that is not a type of assets required to be listed in (b) through (e) below, complete elements (i)-(vii).
--------------------------------------------------------------------------------------------------------------------------------------------------------
(i) Check if issuer, borrower,   (ii) Name of        (iii) Check if      (iv) CUSIP, CIK,   (v) Cost           (vi) Indicate      (vii) Description of
 lessor or similar party is       issuer, borrower,   asset is hard-to-   LEI, NAIC                             Sch. H, Line 1b    investment,
 party-in- interest [ballot]      lessor, or          value asset         Company Code,                         asset category     including, as
                                  similar party                           other                                                    applicable share
                                                                          registration                                             class, maturity date,
                                                                          number:                                                  rate of interest, par
                                                                                                                                   or maturity value,
                                                                                                                                   including whether
                                                                                                                                   asset/investment is
                                                                                                                                   subject to surrender
                                                                                                                                   charge. See
                                                                                                                                   instructions for
                                                                                                                                   reporting assets held
                                                                                                                                   through a participant-
                                                                                                                                   directed brokerage
                                                                                                                                   account.
--------------------------------------------------------------------------------------------------------------------------------------------------------


[[Page 47630]]


--------------------------------------------------------------------------------------------------------------------------------------------------------
 
--------------------------------------------------------------------------------------------------------------------------------------------------------
    (b) Investments in Master Trust (repeat as many entries as needed to identify holdings in master trusts) For each master trust in which the plan
 invested, break out plan's proportionate interest in each asset in the master trust(s) in elements (i)-(viii). Do not include master trust holdings in
                                                             which the plan has no interest.
--------------------------------------------------------------------------------------------------------------------------------------------------------
(i) Enter name, EIN/PN of sponsor of master trust used on master trust's Form 5500......................................................................
--------------------------------------------------------------------------------------------------------------------------------------------------------
(ii) Check if issuer, borrower,  (iii) Name of       (iv) Check if       (v) Enter all      (vi) Cost          (vii) Indicate     (viii) Description of
 lessor or similar party is       issuer, borrower,   asset is hard-to-   that apply: EIN,                      Sch. H, Line 1b    investment,
 party-in- interest [ballot]      lessor, or          value asset         CUSIP, CIK, LEI,                      asset category     including, as
                                  similar party       [ballot]            NAIC Company                                             applicable share
                                  (See                                    Code, other                                              class, maturity date,
                                  instructions)                           registration                                             rate of interest, par
                                                                          number:                                                  or maturity value,
                                                                                                                                   including whether
                                                                                                                                   asset/investment is
                                                                                                                                   subject to surrender
                                                                                                                                   charge.
--------------------------------------------------------------------------------------------------------------------------------------------------------


--------------------------------------------------------------------------------------------------------------------------------------------------------
 
--------------------------------------------------------------------------------------------------------------------------------------------------------
    (c) Investments in PSAs and CCTs (repeat as many entries as needed to identify holdings in PSAs and CCTs) If the PSA filed a Form 5500, complete
   elements (i)-(vii) indicating the value of the plan's shares in the PSA or CCT. For PSAs or CCTs that have not filed a Form 5500, break out plan's
 proportionate interest in each asset in the PSA of CCT in elements (i)-(ix) and include the name and identifying numbers for the non-filing CCT or PSA,
                                       as well a description of the asset held through the non-filing CCT or PSA.
--------------------------------------------------------------------------------------------------------------------------------------------------------
(i) Enter name, EIN/PN of sponsor of CCT/PSA............................................................................................................
--------------------------------------------------------------------------------------------------------------------------------------------------------
(ii) Check if issuer,          (iii) Check here  (iv) Name of      (v) Check if      (vi) Enter all    (vii) Cost       (viii) Indicate  (ix)
 borrower, lessor or similar    if PSA or CCT     issuer,           asset is hard-    that apply:                        Sch. H, Line     Description of
 party is party-in- interest    filed a Form      borrower,         to-value asset    EIN, CUSIP,                        1b asset         investment,
 [ballot]                       5500 [ballot]     lessor, or        [ballot]          CIK, LEI, NAIC                     category         including, as
                                                  similar party                       Company Code:                                       applicable
                                                  (see                                Other                                               share class,
                                                  Instructions).                      registration                                        maturity date,
                                                                                      number:                                             rate of
                                                                                                                                          interest, par
                                                                                                                                          or maturity
                                                                                                                                          value, and
                                                                                                                                          whether asset/
                                                                                                                                          investment is
                                                                                                                                          subject to
                                                                                                                                          surrender
                                                                                                                                          charge.
--------------------------------------------------------------------------------------------------------------------------------------------------------


--------------------------------------------------------------------------------------------------------------------------------------------------------
 
--------------------------------------------------------------------------------------------------------------------------------------------------------
                   (d) Investments in 102-12 Investment Entities (repeat as many entries as needed to identify holdings in 103-12 IEs)
--------------------------------------------------------------------------------------------------------------------------------------------------------
(i) Enter name, EIN of provider of the 103-12 IE........................................................................................................
--------------------------------------------------------------------------------------------------------------------------------------------------------
(ii) Check if issuer, borrower,   (iii) Name of       (iv) Check if       (v) Enter all that  (vi) Cost           (vii) Indicate      (viii) Description
 lessor or similar party is        issuer, borrower,   asset is hard-to-   apply: EIN,                             Line 1b asset       of investment,
 party-in- interest [ballot]       lessor, or          value asset         CUSIP, CIK, LEI,                        category            including, as
                                   similar party       [ballot]            NAIC Company                                                applicable share
                                   (See                                    Code: Other                                                 class, maturity
                                   instructions)                           registration                                                date, rate of
                                                                           number:                                                     interest, par or
                                                                                                                                       maturity value,
                                                                                                                                       including whether
                                                                                                                                       asset/investment
                                                                                                                                       is subject to
                                                                                                                                       surrender charge.
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Element (a). Assets Held Directly By the Plan. Investments held 
by the plan are all assets held by the plan except interests in 
master trusts; interests in pooled separate accounts (PSAs) and 
common collective trusts (CCTs), regardless of whether the PSA or 
CCT files a Form 5500; and interests in 103-12 Investment Entities 
(103-12 IEs). For each asset held directly by the plan, complete 
elements (i)-(vii).
    Participant-directed brokerage account assets reported in the 
aggregate on Line 1b(14) generally may be treated as one asset held 
for investment for purposes here, except investments in tangible 
personal property, loans, partnership or joint venture interests, 
real property, employer securities, and investments that could 
result in a loss in excess of the account balance of the participant 
or beneficiary who directed the transaction must be reported as 
separate aggregations of assets on Line 4i(1)(a), with an indication 
of which of the Line 1b(14) breakouts that the asset was reported as 
being held through a participant-directed brokerage account.
    Element a(ii). Check the box in element a(i) if the issuer of 
the investment is a person known to be a party-in-interest to the 
plan. This includes when the seller, issuer, lender, or similar 
party is the employer, employee organization, a service provider to 
the plan, or other party interest, including a subcontractor or 
affiliate.
    Element a(iii). Enter the name of the seller, issuer, lender, or 
similar party. If the person is a plan sponsor, service provider, or 
direct filing entity also identified on the Form 5500, Schedule C or 
any other of the Schedule H Line 4 schedules, or is a DFE that files 
its own Form 5500, use the same name in all places.
    Element a(iv). Check here if the asset is a ``hard-to-value'' 
asset. Assets that are not listed on any national exchanges or over-
the-counter markets, or for which quoted market prices are not 
available from sources such as financial publications, the 
exchanges, or the National Association of Securities Dealers 
Automated Quotations System (NASDAQ), are required to be identified 
as hard-to-value assets on the Schedule of Assets Held for 
Investment at End of Year. Bank collective investment funds or 
insurance company

[[Page 47631]]

pooled separate accounts that are primarily invested in assets that 
are listed on national exchanges or over-the-counter markets and are 
valued at least annually need not be identified as hard-to-value 
assets. CCTs or PSAs invested primarily in hard-to-value assets must 
also be identified as a hard-to-value asset. A non-exhaustive list 
of examples of assets that would be required to be identified as 
hard-to-value on the proposed schedules of assets is: non-publicly 
traded securities, real estate, private equity funds; hedge funds; 
and real estate investment trusts (REITs).
    Element a(v). If the person is a plan sponsor, service provider, 
or direct filing entity also identified on the Form 5500, Schedule 
C, or Schedule D, or any other of the Schedule H Line 4 schedules, 
or is a DFE that files its own Form 5500, use the same 
identification numbers in all places. If the person identified in 
element (c), has a CUSIP, CIK number, LEI, NAIC Company Code, or 
other government or market exchange registration or identity number, 
you must include all that apply here.
    Element a(vi). Enter the acquisition cost of the asset.
    Element a(vii). Enter in element a(vii) in which category the 
asset was part of the total on Line 1b.
    Element a(viii). Enter a description of the investment, 
including, as applicable maturity date, rate of interest, par, or 
maturity value, including whether asset/investment is subject to 
surrender charge. Include any restriction on transferability of 
corporate securities. (Include lending of securities permitted under 
Prohibited Transactions Exemption 81-6.)
    Element (b)--Investments in Master Trusts. For each master trust 
in which the plan invested, complete elements (b)(ii)-(vi) for each 
asset in which the plan had an interest. Do not include assets held 
by the master trust in which the plan does not hold an interest.
    Example. A master trust in which Plan A, Plan B, and Plan C 
invest, has various assets, including a parcel of real estate. Only 
Plan A and Plan B are invested in the parcel of real estate. The 
remaining assets of the master trust are held proportionately by all 
three plans. Plans A and B should report information on their 
holding in all of the assets of the plan, including the parcel of 
real estate. Plan C should report only its proportionate interest in 
the assets other than the parcel of real estate.
    Element (c)--Investments in PSAs and CCTs. For all investments 
in PSAs and CCTs, enter the name, EIN/PN of the sponsor of the PSA 
or CCT, regardless of whether the PSA or CCT filed a Form 5500 in 
element (c)(i).
    Check the box in element (c)(iii) to indicate whether the CCT or 
PSA filed a Form 5500. If the CCT or PSA did not file a Form 5500, 
leave element (c)(iii) blank.
    If the CCT or PSA filed a Form 5500, make sure to report in 
element (c)(i) the same name, EIN/PN as reported on the CCT or PSA's 
Form 5500. If the CCT or PSA filed a Form 5500, enter ``same name'' 
in element (c)(iv).
    If the CCT or PSA did not file a Form 5500, you must provide the 
name of the issuer, borrower, lessor, or similar party of each 
individual asset in the CCT or PSA in element c(iv). Complete as 
many entries in elements (c)(ii)-(ix) as needed to identify the 
assets held by each CCT or PSA that did not file a Form 5500.
    For an investment in a CCT or PSA that filed a Form 5500, check 
the box in element c(v) to indicate if the CCT or PSA is primarily 
invested in hard-to-value assets.
    Element (d). Investments in 103-12 Investment Entities. Complete 
as many entries as need to identify holdings in 103-12 IEs. Do not 
report in element (d) investments in any entities other than in an 
entity that filed a Form 5500 for itself as a 103-12 IE.
    Line 4i(2) Assets Disposed of During Plan Year.
    You must identify on the Line 4i(2) Schedule each investment 
asset sold during the plan year except:
    1. Debt obligations of the U.S. or any U.S. agency.
    2. Interests issued by a company registered under the Investment 
Company Act of 1940 (e.g., a mutual fund).
    3. Bank certificates of deposit with a maturity of one year or 
less.
    4. Commercial paper with a maturity of 9 months or less if it is 
valued in the highest rating category by at least two nationally 
recognized statistical rating services and is issued by a company 
required to file reports with the Securities and Exchange Commission 
under section 13 of the Securities Exchange Act of 1934.
    5. Participations in a bank common or collective trust.
    6. Participations in an insurance company pooled separate 
account.
    7. Securities purchased from a broker-dealer registered under 
the Securities Exchange Act of 1934 and either: (1) listed on a 
national securities exchange and registered under section 6 of the 
Securities Exchange Act of 1934 or (2) quoted on NASDAQ.
    Assets disposed of during the plan year shall not include any 
investment that was not held by the plan on the last day of the plan 
year if that investment is reported in the annual report for that 
plan year in any of the following:
    1. The schedule of loans or fixed income obligations in default 
required by Schedule G, Part I;
    2. The schedule of leases in default or classified as 
uncollectible required by Schedule G, Part II;
    3. The schedule of nonexempt transactions required by Schedule 
G, Part III; or
    4. The schedule of reportable transactions required by Schedule 
H, Line 4j.
    Line 4i(2). Schedule of Assets Disposed of During the Plan Year. 
You must complete the ``Schedule of Assets Disposed of During the 
Plan Year'' if you answered ``Yes'' to Line 4(i)(2).
    Element (a). Enter the name of the seller, issuer, lender, or 
similar party. If the person is a plan sponsor, service provider, or 
direct filing entity also identified on the Form 5500, Schedule C, 
or Schedule D, or any other of the Schedule H Line 4 schedules, use 
the same name in all places. If the asset was held through a master 
trust, 103-12 IE, CCT, or PSA provide the name, EIN and PN of the 
entity. For DFEs use the same identifying information used on the 
entity's own Form 5500. For CCTs and PSAs, check the appropriate box 
to indicate whether or not the CCT or PSA filed a Form 5500.
    Element (b). Indicate in element (b) whether the seller, issuer, 
lender, or similar party is the employer, employee organization, or 
other party interest, including a subcontractor or affiliate.
    Element (c). Check if the asset was acquired during the plan 
year.
    Element (d). In element (e) enter the employer identification 
number (EIN) of issuer, borrower, lessor, similar party. If the 
person is a plan sponsor, service provider, or direct filing entity 
also identified on the Form 5500, Schedule C, or Schedule D, or any 
other of the Schedule H, Line 4 schedules, use the same name in all 
places.
    Element (e). Enter in element (c) in which category the asset 
was part of the total on Line 1(b).
    Element (a).
    Element (f). Enter the acquisition cost here.
    Element (g). Enter the sale price.
    Element (h). Enter the total expenses incurred with disposal of 
asset, including any termination or surrender charges.
    Element (i). Enter the net gain (loss) on the asset.
    Element (j). Enter a description of the investment, including 
maturity date, rate of interest, collateral, par, or maturity value.
    Line 4j. Check ``Yes'' and attach to the Form 5500 the following 
schedule if the plan had any reportable transactions (see 29 CFR 
2520.103-6 and the examples provided in the regulation). You may not 
create your own schedules of assets, but must complete the schedules 
through IFile or using EFAST-approved third-party software.
    A reportable transaction includes:
    1. A single transaction within the plan year in excess of 5% of 
the current value of the plan assets;
    2. Any series of transactions with or in conjunction with the 
same person, involving property other than securities, which amount 
in the aggregate within the plan year (regardless of the category of 
asset and the gain or loss on any transaction) to more than 5% of 
the current value of plan assets;
    3. Any transaction within the plan year involving securities of 
the same issue if within the plan year any series of transactions 
with respect to such securities amount in the aggregate to more than 
5% of the current value of the plan assets; and
    4. Any transaction within the plan year with respect to 
securities with, or in conjunction with, a person if any prior or 
subsequent single transaction within the plan year with such person, 
with respect to securities, exceeds 5% of the current value of plan 
assets.
    The 5% figure is determined by comparing the current value of 
the transaction at the transaction date with the current value of 
the plan assets at the beginning of the plan year. If this is the 
initial plan year, you may use the current value of the plan assets 
at the end of the plan year to determine the 5% figure.
    If the assets of two or more plans are maintained in one trust, 
except as provided

[[Page 47632]]

below, the plan's allocable portion of the transactions of the trust 
shall be combined with the other transactions of the plan, if any, 
to determine which transactions (or series of transactions) are 
reportable (5%) transactions.
    For investments in common/collective trusts (CCTs), pooled 
separate accounts (PSAs), 103-12 IEs, and registered investment 
companies determine the 5% figure by comparing the transaction date 
value of the acquisition and/or disposition of units of 
participation or shares in the entity with the current value of the 
plan assets at the beginning of the plan year. If the Schedule H is 
attached to a Form 5500 filed for a plan with all plan funds held in 
a master trust, check ``No'' on Line 4j. Plans with assets in a 
master trust that have other transactions should determine the 5% 
figure by subtracting the current value of plan assets held in the 
master trust from the current value of all plan assets at the 
beginning of the plan year and check ``Yes'' or ``No,'' as 
appropriate. Do not include individual transactions of CCTs, PSAs, 
master trusts, 103-12 IEs, and registered investment companies in 
which this plan or DFE invests.
    In the case of a purchase or sale of a security on the market, 
do not identify the person from whom purchased or to whom sold.
    Special rule for certain participant-directed transactions. 
Transactions under an individual account plan that a participant or 
beneficiary directed with respect to assets allocated to his or her 
account (including a negative election authorized under the terms of 
the plan) should not be treated for purposes of Line 4j as 
reportable transactions. The current value of all assets of the 
plan, including these participant-directed transactions, should be 
included in determining the 5% figure for all other transactions.
    Line 4j. Schedule of Reportable Transactions. You must complete 
the ``Schedule of Reportable Transactions'' if you answered ``Yes'' 
to Line 4(j).
    Element (a). Check the box in element (a) if the seller, issuer, 
lender, or similar party is the employer, employee organization, 
service provider, or other party interest, including a subcontractor 
or affiliate.
    Element (b). Enter the name and EIN of the seller, issuer, 
lender, or similar party. If the person is a plan sponsor, service 
provider, or direct filing entity also identified on the Form 5500, 
Schedule C, or Schedule D, or any other of the Schedule H Line 4 
schedules, use the same name in all places.
    Element (c). Enter a description of the asset, including 
interest rate and maturity date in the case of the loan.
    Element (d). Enter the purchase price, regardless of whether the 
transaction being reported here is the acquisition or disposal of an 
asset.
    Element (e). If the transaction was the disposal of an asset, 
enter the sale price.
    Element (f). If the transaction involved a lease, enter a 
description of the lease terms including annual rental and duration 
of lease.
    Element (g). Enter the total expenses incurred in connection 
with the transaction, including fees and commissions.
    Element (h). Enter the cost of the asset.
    Element (i). Enter the current value of the asset on transaction 
date.
    Line 4k. You must check ``Yes'' if any benefits due under the 
plan were not timely paid or not paid in full. This would include 
minimum required distributions to 5% owners who have attained 70\1/
2\ whether or not retired and/or non-5% owners who have attained 
70\1/2\ and have retired or separated from service, see section 
401(a)(9) of the Code. Include in this amount the total of any 
outstanding amounts that were not paid when due in previous years 
that have continued to remain unpaid.
    Do not enter ``Yes'' if the only benefits not paid are those 
owed to ``missing'' or ``lost'' participants, and the plan 
fiduciaries have acted in compliance with the Department of Labor's 
Field Assistance Bulletin 2014-01 to attempt to locate the 
participants.
    Line 4l ``Blackout Period.'' Check ``Yes'' if there was a 
``blackout period.'' A blackout period is a temporary suspension of 
more than three (3) consecutive business days during which 
participants or beneficiaries of a 401(k) or other individual 
account pension plan were unable to, or were limited or restricted 
in their ability to, direct or diversify assets credited to their 
accounts, obtain loans from the plan, or obtain distributions from 
the plan. A ``blackout period'' generally does not include a 
temporary suspension of the right of participants and beneficiaries 
to direct or diversity assets credited to their accounts, obtain 
loans from the plan, or obtain distributions from the plan if the 
temporary suspension is: (1) part of the regularly scheduled 
operations of the plan that has been disclosed to participants and 
beneficiaries; (2) due to a qualified domestic relations order 
(QDRO) or because of a pending determination as to whether a 
domestic relations order is a QDRO; (3) due to an action or a 
failure to take action by an individual participant or because of an 
action or claim by someone other than the plan regarding a 
participant's individual account; or (4) by application of federal 
securities laws. For more information, see 29 CFR 2520.101-3 
(available at www.dol.gov/ebsa).
    Line 4m. If there was a blackout period, did you provide the 
required notice not less than 30 days nor more than 60 days in 
advance of restricting the rights of participants and beneficiaries 
to change their plan investments, obtain loans from the plan, or 
obtain distributions from the plan? If so, check ``Yes.'' See 29 CFR 
2520.101-3 for specific notice requirements and for exceptions from 
the notice requirement. Also, answer ``Yes'' if one of the 
exceptions to the notice requirement under 29 CFR 2520.101-3 
applies.
    Line 4n. Disclosures for Participant-Directed Accounts. All 
individual account plans that provide for participant-direction must 
provide specified disclosures under 29 CFR 2550.404a-5 with respect 
to each participant or beneficiary that, pursuant to the terms of 
the plan, has the right to direct the investment of assets held in, 
or contributed to, his or her individual account. Included in the 
required disclosures is a comparison chart.
    4o. If you answered ``Yes'' to Line 4n, check the box to 
indicate whether the plan provided participants and beneficiaries 
the plan and investment disclosures required under 29 CFR 2550.404a-
5(d)(2). If you answered ``Yes,'' attach the comparison chart(s) 
provided to participants and beneficiaries.
    4p. If you answered ``Yes,'' to Line 4n, enter the number of 
designated investment alternatives (DIAs) available under the plan, 
indicate the number of DIAs that are index funds, and check the 
appropriate box(es) to indicate the types of DIAs available.
    4q. If you answered ``Yes,'' to Line 4n, check the appropriate 
box to indicate whether the plan made available to participants and 
beneficiaries a designated investment manager (DIM). If you answered 
``Yes,'' enter the name of the DIM.
    4r. Check ``Yes,'' if the plan made available to participants 
and beneficiaries any brokerage window, self-directed brokerage 
account or similar plan arrangements that enabled participants to 
select investments beyond those designated by the plan. If you 
answered ``Yes'' to Line 4r, enter the number of participants that 
utilized the account or arrangement.
    Line 4s. Unrelated business taxable income generally means the 
gross income derived from any unrelated trade or business (as 
defined in Code section 513) regularly conducted and not 
substantially related to the plan's exempt purpose under Code 
section 512, less the deductions directly connected with carrying on 
the trade or business. See IRS Publication 598 for more information. 
Check ``N/A'' if this plan does not have a trust, such as 412(e)(3) 
fully insured plans or certain 403(b) annuity plans.
    Plans that check ``Yes'' must enter any amount of unrelated 
business taxable income. Form 990-T, Exempt Organization Business 
Income Tax Return, is required for any gross income of $1000 or more 
generated by an employer's trust by the 15th day of the 4th month 
following the end of the trust's tax year. See Instructions to Form 
990-T for more details.
    Note. You are required to complete Line 4s if you are required 
to file at least 250 returns of any type with the IRS during the 
calendar year. However, if you are a small filer (file fewer than 
250 returns of any type with the IRS during the calendar year), and 
you do not voluntarily complete this Line 4s, then you must file the 
Form 5500-SUP with the IRS on paper.
    Line 4t. Under the Code, all defined contribution pension plans 
must provide for a valuation of investments held by the trust at 
least once a year in a manner consistently followed and uniformly 
applied. Fair market value on the valuation date specified in the 
plan is to be used for this purpose and the respective accounts of 
participants are to be adjusted accordingly. See Rev. Rul. 80-155. 
Plans that check ``No'' may result in disqualification of the plan 
under Treasury Regulations section 1.401-1(a)(2).
    Line 4u. Check ``Yes'' if the employer sponsoring the plan paid 
any of the

[[Page 47633]]

administrative expenses of the plan that were not reimbursed by the 
plan.
    Line 4v. Check ``Yes'' if any person who is disqualified under 
ERISA Section 411, served or was permitted to serve the plan in any 
capacity. Section 411 of ERISA establishes a bar against certain 
persons serving as employee benefit plan fiduciaries or service 
providers because they have been convicted of any of a broad range 
of specified crimes. Prohibited positions and activities include 
consultants and advisers to plans and any entity whose activities 
are in whole or substantial part devoted to providing goods or 
services to employee benefit plans. As amended by the Comprehensive 
Crime Control Act of 1984, section 411 of ERISA prohibits such 
persons from serving plans for a period of thirteen years after such 
judgment or the end of imprisonment resulting from a disqualifying 
conviction, whichever is later, unless the sentencing court, under 
appropriate circumstances, has reduced the period of prohibition to 
not less than three years or has determined that service in any of 
the prohibited capacities would not be contrary to the purposes of 
ERISA. The prohibition takes effect upon the date of conviction (the 
date of entry of judgment by the trial court) or the end of 
imprisonment, whichever is later.
    Line 4w. If the plan has investment acquisitions that are 
leveraged, including assets subject to collateralized lending 
activities (e.g., securities lending arrangements, repurchase 
agreements (repos), etc.), check ``Yes.'' If you check ``Yes,'' 
check the appropriate box to indicate whether securities lending, 
including repurchase agreements or sell/buy-backs or ``Other,'' 
including transactions that subjected plan assets to a mortgage, 
lien, or other security interest. If you check ``Other,'' enter a 
description. Then separately enter in Line 4w(2) the total amount of 
cash obligated, the total value of securities obligated, and the 
total value of other assets obligated in connection with 
collateralized lending activities at the end of the plan year. In 
Line 4w(3) enter the approximate ratio of collateralized/leveraged 
investments (including cash that is obligated) to total plan assets 
at the end of the year list total amount and approximate ratio of 
leveraged investments to total plan assets.
    Line 4x. Check ``Yes'' if the plan sponsor or its affiliates 
provide any services to the plan in exchange for direct or indirect 
compensation.
    Line 4y. See 29 CFR 2520.102-2 and 2520.102-3 for style, format, 
and content requirements for summary plan descriptions. For 
distribution requirements see 29 CFR 2520.104b.
    Line 4z. Defined contribution pension plans must complete Line 
4z. For purposes of Line 4z, an uncashed check is one that is no 
longer negotiable or is subject to limited payability. Check 
``Yes,'' if there were any uncashed checks as of the end of the plan 
year. If ``Yes,'' indicate the number of checks that were uncashed 
at the end of the plan year and the total value of the checks. 
Briefly describe the procedures followed by the plan to verify a 
participant's or beneficiary's address before a check was mailed. 
Plans must ensure that they use measures reasonably calculated to 
ensure actual receipt of materials by plan participants and 
beneficiaries, which would include procedures to keep track of 
participants' and beneficiaries' current mailing addresses so that 
information is less likely to be mailed to a bad address. See CFR 
2520.104b-1(b). Also, briefly describe the procedures followed by 
the plan to address the uncashed checks, including steps to locate 
``missing participants.''
    Plans should have procedures to keep track of uncashed checks. 
The procedures for ongoing plans should include procedures for 
locating ``missing'' participants. Plans may use the steps described 
in FAB 2014-01 to search for lost participants or beneficiaries, 
which may be helpful in particular where a check was returned as 
``undeliverable.'' The procedures should also include a method by 
which plan fiduciaries keep track or are made aware of the number of 
uncashed checks and the amount involved. Such procedures could 
include contractually requiring any third party administrators to 
keep the plan administrator regularly informed of uncashed checks. 
For missing participant and beneficiary searches and distributions 
from terminating defined contribution pension plans, see 29 CFR 
2550.404a-3; DOL Field Assistance Bulletin 2014-01 (Aug. 14, 2014).

Part V--Termination Information on Service Providers

    Complete Part V if there was a termination in the appointment of 
an accountant or enrolled actuary during the 20XX plan year 
regardless of the reason or to identify any service providers, other 
than accountants or actuaries identified above, that have been 
terminated for a material failure to meet the terms of a service 
arrangement or failure to comply with Title I of ERISA, including 
the failure to provide required disclosures under 29 CFR 2550.408b-
2.
    Line 5. Termination Information on Accountants and Actuaries. 
Information on the termination of an accountant or actuary must be 
provided on the Form 5500 Annual Return/Report for the plan year 
during which the termination occurred. For example, if an accountant 
was terminated in the 20XX plan year after completing work on an 
audit for the 20XX-1 plan year, the termination should be reported 
on the Schedule H filed with the 20XX plan year Form 5500 Annual 
Return/Report. If the accountant is a firm (such as a corporation, 
partnership, etc.), report when the service provider (not an 
individual within the firm) was terminated.
    An enrolled actuary is by definition an individual and not a 
firm, and you must report when the individual is terminated.
    Provide an explanation of the reasons for the termination of an 
accountant or enrolled actuary. Include a description of any 
material disputes or matters of disagreement concerning the 
termination, even if resolved prior to the termination. If an 
individual is listed, and the individual does not have an EIN, the 
EIN to be entered should be the EIN of the individual's employer.
    [TIP] If the only reason for change of appointment was a 
temporary leave of absence due to non-work circumstances of the 
enrolled actuary, so indicate in the ``explanation'' field.
    Do not use a social security number in lieu of an EIN. The 
Schedule C and its attachments are open to public inspection, and 
the contents are public information and are subject to publication 
on the Internet. Because of privacy concerns, the inclusion of a 
social security number or any portion thereof on this Schedule C or 
any of its attachments may result in the rejection of the filing.
    The plan administrator must also provide the terminated 
accountant or enrolled actuary with a copy of the explanation for 
the termination provided in Line 5f, along with a completed copy of 
the notice below.

Notice to Terminated Accountant or Enrolled Actuary

    I, as plan administrator, verify that the explanation that is 
reproduced below or attached to this notice is the explanation 
concerning your termination reported on the Schedule C (Form 5500) 
attached to the 20XX Form 5500, Annual Return/Report of Employee 
Benefit Plan, for the ________ (enter name of plan).
    This Form 5500 is identified in Line 2b by the nine-digit EIN__-
__(enter sponsor's EIN), and in Line 1b by the three-digit PN___ 
(enter plan number).
    You have the opportunity to comment to the Department of Labor 
concerning any aspect of this explanation. Comments should include 
the name, EIN, and PN of the plan and be submitted to: Office of 
Enforcement, Employee Benefits Security Administration, U.S. 
Department of Labor, 200 Constitution Avenue, NW., Washington, DC 
20210. [INSERT EMAIL ADDRESS]

Signed
Dated

    Line 6. Information on Service Providers Terminated for Material 
Failure. Provide information for any service providers, other than 
accountants or actuaries identified above, that have been terminated 
for a material failure to meet the terms of a service arrangement or 
failure to comply with Title I of ERISA, including the failure to 
provide required disclosures under 29 CFR 2550.408b-2.
    Lines 6a-d. Provide identifying information in the appropriate 
lines.
    Lines 6e-f. If the reason for termination was the failure to 
provide required disclosures under 29 CFR 2550.408b-2, in addition 
to providing an explanation in Line 6e, check the box in Line 6f.

Part VI--Plan Termination Information

    Line 7a. Check ``Yes'' if a resolution to terminate the plan was 
adopted during this or any prior plan year, unless the termination 
was revoked and no assets reverted to the employer. If ``Yes'' is 
checked, enter in Line 7a(1) the effective date of plan termination, 
enter in Line 7a(2) the plan year in which assets were distributed 
to participants and beneficiaries (including insurance/annuity 
contracts) and enter in Line 7a(3) the amount of plan assets that 
reverted to the employer during the plan year in connection with the 
implementation of such termination. Enter

[[Page 47634]]

``0'' if no reversion occurred during the current plan year.
    Line 7b. Transfer to other plans. If the plan transferred assets 
or liabilities to another plan since the date of the most recent 
filing, report the EIN and PN of the plan to which the assets and 
liabilities were transferred (i.e., the ``transferee plan''). In 
addition, report the date of the transfer and check the box that 
best describes the type of transfer (see Definitions below). Do not 
use a social security number in lieu of an EIN or include an 
attachment that contains visible social security numbers. The 
Schedule H is open to public inspection, and the contents are public 
information and are subject to publication on the Internet. Because 
of privacy concerns, the inclusion of a social security number or 
any portion thereof on this Schedule H or the inclusion of a visible 
social security number or any portion thereof on an attachment may 
result in the rejection of the filing.
    Note. A distribution of all or part of an individual 
participant's account balance that is reportable on Form 1099-R 
should not be included on Line 7b. Do not submit Form 1099-R with 
the Form 5500 Annual Return/Report.
    IRS Form 5310-A, Notice of Plan Merger or Consolidation, 
Spinoff, or Transfer of Plan Assets or Liabilities; Notice of 
Qualified Separate Lines of Business, may be required to be filed at 
least 30 days before any plan merger or consolidation or any 
transfer of plan assets or liabilities to another plan. There is a 
penalty for not filing IRS Form 5310-A on time. In addition, a 
transfer of benefit liabilities involving a plan covered by PBGC 
insurance may be reportable to the PBGC. See PBGC Form 10, Post-
Event Notice of Reportable Events, and PBGC Form 10-Advance, Advance 
Notice of Reportable Events.
    Line 7c. Transfers from other plans. If another plan transferred 
assets or liabilities to this plan since the date of the most recent 
filing, report the EIN and PN of the plan from which the assets and 
liabilities were transferred (i.e., the ``transferor plan''), the 
date of the transfer, and the box that best describes the type of 
transfer.
    ``Consolidation'' means a transaction in which two or more plans 
transfer all of their assets and liabilities to a new plan and, as a 
result, cease to exist (because the transferor plans become part of 
the new transferee plan). It differs from a Merger because in a 
Merger, the transferee plan existed before the transaction. In a 
consolidation, the transferee plan is a new plan that is created in 
the Consolidation. Thus, the plan that exists after the 
Consolidation follows the PBGC premium filing rules for new plans.
    ``Merger'' means a transaction in which one or more plans 
transfer all of their assets and liabilities to an existing plan 
and, as a result, cease to exist (because the transferor plan(s) 
become part of the transferee plan). It differs from a Consolidation 
because in a Consolidation, the transferee plan did not exist before 
the transaction. In a Merger, the transferee plan is an existing 
plan and follows the rules for a preexisting, ongoing plan.
    ``Spinoff'' means a transaction in which the transferor plan 
transfers only part of its assets and/or liabilities to the 
transferee plan. The transferee plan may be a new plan that is 
created in the Spinoff, or it may be a preexisting plan that simply 
receives part of the assets or liabilities of the transferor plan.
    Note: If Final Return/Report is checked on the Form 5500 of Form 
5500-SF, information should be entered an at least one of lines 7a 
or 7b. Participant-directed transfers do not need to be reported on 
Line 7c. If you reported transfers of assets and liabilities to this 
plan on Line 2l(1), information should be entered in Line 7c.
    Line 7d. Terminated Defined Contribution Pension Plans: 
Transfers to Financial Institutions. If the filer is a defined 
contribution pension plan, indicate whether, as part of the 
procedures for terminating the plan, transferred plan assets to a 
financial institution(s), establishing interest bearing federally 
insured bank accounts in the name of missing participants in 
connection with terminating the plan. If ``Yes,'' complete elements 
(1)-(5). List each financial institution where plan assets were 
transferred and continue reporting until the plan terminates and the 
final return/report is filed. For more information on making 
provisions for lost or missing participants, see DOL Field 
Assistance Bulletin 2014-01.

Part VII--Trust Information

    Line 8a. Enter the ``Name of trust.'' If a plan uses more than 
one trust or custodial account for its fund, you should enter the 
primary trust or custodial account in which the greatest dollar 
amount or largest percentage of the plan assets as of the end of the 
plan year is held on this Line. For example, if a plan uses three 
different trusts, X, Y, Z, with the percentages of plan assets, 35%, 
45%, and 20%, respectively, trust Y that held the 45% of plan assets 
would be entered in Line 6a.
    Line 8b. You may use this line to enter the ``Trust's Employer 
Identification Number (EIN)'' assigned to the employee benefit trust 
or custodial account, if one has been issued to you. The trust EIN 
should be used for transactions conducted for the trust. If you do 
not have a trust EIN, enter the EIN you would use on Form 1099-R, 
Distributions From Pensions, Annuities, Retirement or Profit-Sharing 
Plans, IRAs, Insurance Contracts, etc., to report distributions from 
employee benefit plans and on Form 945, Annual Return of Withheld 
Federal Income Tax, to report withheld amounts of income tax from 
those payments.
    Do not use a social security number in lieu of an EIN. Form 5500 
and its attachments are open to public inspection, and the contents 
are public information and are subject to publication on the 
Internet. Because of privacy concerns, the inclusion of a social 
security number or any portion thereof may result in the rejection 
of the filing.
    Trust EIN can be obtained from the IRS by applying for one on 
Form SS-4, Application for Employer Identification Number. See 
Instructions to Line 2b (Form 5500) for applying for an EIN. Also 
see the online IRS EIN application page at https://federal-ein-online.com/ for further information.
    Line 8c. Enter the name and other identifying information of the 
plan trustee or custodian. Enter the telephone number for the plan 
trustee or custodian.
    Note. You must enter trust information from Lines 8a through 8c 
if you are required to file at least 250 returns of any type with 
the IRS during the calendar year. However, if you are a small filer 
(files fewer than 250 returns of any type with the IRS during the 
calendar year), and you do not enter trust information here, then 
you must file the paper Form 5500-SUP with the IRS. See the Treasury 
regulations on ``Employee Retirement Benefit Plan Returns Required 
on Magnetic Media.'' (See 79 FR 58256 at http://federalregister.gov/a/2014-23161) and Instructions for Form 5500-SUP for more 
information.

Trustee/Custodian Signature

    The plan trustee or custodian may electronically sign this 
schedule or attach to the Form 5500 an electronic reproduction of 
the Schedule H signed by the plan's trustee. This electronic 
reproduction must be labeled ``Trustee Signature'' and must be 
included as a Portable Document Format (PDF) attachment or any 
alternative electronic attachment allowable under EFAST2 if this is 
not electronically signed. If there is more than one trustee or 
custodian, the trustee or custodian authorized by the others may 
sign. If the plan trustee or custodian is an entity, the signature 
must be the name of a person authorized to sign on behalf of the 
plan trustee or custodian.
    Note. Trust information reported in this Schedule is for the 
purpose of satisfying the requirements under Code section 6033(a) 
for an annual information return from every section 401(a) 
organization exempt from tax under section 501(a). The statute of 
limitations under Code section 6501(a) for any trust described in 
section 401(a), which is exempt from tax under section 501(a), will 
not start to run until you timely file with the appropriate trust 
information on this Schedule.

Schedule J (Form 5500) Group Health Plan Information

General Instructions

Who Must File

    Schedule J (Form 5500) must be attached to a Form 5500 filed for 
group health plans, except as provided below. The term ``group 
health plan'' means an employee welfare benefit plan to the extent 
that the plan provides medical care (as defined in ERISA Sec.  
733(a)(2) and including items and services paid for as medical care) 
to employees or their dependents (as defined under the terms of the 
plan) directly or through insurance, reimbursement, or otherwise. 
This includes group health plans that are funded through a trust, 
unfunded, fully-insured, or a combination of more than one of these 
funding arrangements. This also includes plans that claim 
``grandfathered'' status under 29 CFR 2950.715-1251, and plans that 
are exempt from certain market reform requirements under ERISA Sec.  
732(a) (exemption for certain small group health plans that have 
less than two participants who are current employees) or ERISA Sec.  
733(c) (group health plans consisting solely

[[Page 47635]]

of excepted benefits). See the Form 5500 Annual Return/Report 
Instructions ``Who Must File'' section for more information. It also 
includes retirement plans that provide retiree health benefits and 
welfare plans that provide a variety of benefits, including medical 
benefits.
    Small (fewer than 100 participants at the beginning of the plan 
year), fully-insured group health plans only need to complete Part 
I, Lines 1-8 of Schedule J, except they must complete the entire 
Schedule J where the only policy is a ``stop loss'' policy, 
including stop loss policies with the employer/plan sponsor as the 
insured.
    If a plan provides multiple types of benefits such as group 
health, life, and disability, only report information about group 
health benefit participation, claims, benefit types, compliance, 
etc., on Schedule J.
    Plans must complete one Schedule J for all the health benefit 
coverages they provide. GIAs must complete a separate Schedule J for 
each participating plan.
    Check the Schedule J box on the Form 5500 (Part II, Line 11b(6)) 
if a Schedule J is attached to the Form 5500.
    Part I of the Schedule J must be completed to report certain 
characteristics of the group health plan.
    Part II of the Schedule J must be completed to report service 
providers providing services to the group health plan. You must 
include information on third party administrators and claims 
processors; mental health benefits managers, substance use disorder 
benefits managers, pharmacy benefit managers (PBM), independent 
review organizations (IRO), and wellness program managers. Multiple 
entries for each may be entered. Service providers that render 
services in relation to the group health plan that are reported on 
the Schedule C or the Schedule A do not need to be reported on 
Schedule J.
    Part III of the Schedule J must be completed by plans that do 
not file Schedule H to report financial information.
    Part IV of the Schedule J must be completed to report claims 
processing and payment information.
    Part V of the Schedule J must be completed to report compliance 
information for plans that do not file the Form M-1. Plans that file 
the Form M-1, skip questions 24-30.
    For more information and guidance for group health plans, visit 
EBSA's Web site at www.dol.gov/ebsa. For information on state 
regulation of health insurance, contact your State Insurance 
Department. For information on HHS regulation of health insurance, 
go to the Web site of the Center for Consumer Information and 
Insurance Oversight at https://www.cms.gov/cciio/.

Specific Instructions

Part I--Group Health Plan Characteristics

    You must enter information related to certain characteristics of 
the group health plan.
    Line 1. Report the number of persons covered by the plan at the 
end of the plan year. Persons, for purposes of this line, include 
participants, beneficiaries, and dependents of participants covered 
under the plan.
    Line 2. Check all that apply to indicate who is eligible for 
coverage under the plan.
    Line 3. Check all that apply to indicate the type of benefits 
and design characteristics included under the plan.
    Line 4. Check all that apply to indicate the funding and benefit 
arrangement(s) for the plan. If the plan offers benefit package 
options that are fully insured (i.e. benefits are provided under a 
group policy purchased from a health insurance issuer to fund the 
benefits), in Line 4a(1)(a), check ``Health Insurance Issuer'' and 
enter the name(s), EIN and National Insurance Product Registry 
Number of insurance carriers providing benefits under the plan. If 
the health funding or benefit arrangement is through a health 
insurance issuer, and the product is an ``off-the-shelf'' or 
``prototype'' policy, product, or arrangement, enter in Line 
4a(1)(b) any unique identification information for the product or 
policy (e.g., a state assigned product identification number). Check 
all that apply under 4a(1)(c).
    If the plan offers benefit package options that are self-insured 
(i.e., provide benefits from the general assets of the employer or 
through a trust), check all that apply under 4a(2) and/or 4a(3).
    A Health Insurance Issuer means an insurance company, insurance 
service, or insurance organization (including a health maintenance 
organization, as defined in ERISA Sec.  733(b)(3)), that is licensed 
to engage in the business of insurance in a State and that is 
subject to State laws regulating insurance (within the meaning of 
ERISA Sec.  514(b)(2)).
    Line 5. Check all characteristics that apply to the plan. With 
regard to plans that claim grandfathered status, certain changes may 
cause the plan to relinquish its grandfathered status such as 
elimination of benefits, certain increases in cost-sharing 
requirements, and certain decreases in contribution rates by 
employers or employee organizations. For more information about 
grandfathered group health plans, see 29 CFR 2590.715-1251.
    In general, a health flexible spending account (FSA) is a 
benefit designed to reimburse employees for medical care expenses 
(as defined in Code section 213(d), other than premiums) incurred by 
the employee, or the employee's spouse, dependents, and any children 
who, as of the end of the taxable year, have not attained age 27. 
See Code section 106(c)(2) and 26 CFR 1.125-5. A health 
reimbursement arrangement (HRA) typically consists of a promise by 
an employer to reimburse medical expenses, including insurance 
premiums, for the year up to a certain amount, with unused amounts 
available to reimburse medical expenses in future years. See IRS 
Notice 2002-45. A high deductible health plan (HDHP) is a group 
health plan subject to specific cost-sharing requirements as defined 
in section 223(c)(2) of the Code.
    Line 6a. Indicate the total number of persons offered COBRA 
continuation coverage under the plan during the plan year.
    Line 6b. From the universe of persons listed in line 6a, 
indicate the number of persons who subsequently elected COBRA 
coverage. Include any persons who elected coverage after the end of 
the plan year.
    Line 6c. Indicate the number of persons covered under the plan 
through COBRA continuation coverage at any time during the plan 
year.
    Line 7. Indicate on Line 7a whether the plan received a rebate, 
reimbursement, or refund from a service provider such as a health 
insurance issuer, third-party administrator, or pharmacy benefit 
manager. Include multiple entries if necessary. Include all 
distributions from service providers including refunds, dividends, 
demutualization payments, rebates, and excess surplus distributions. 
Any medical loss ratio (MLR) rebates received pursuant to Section 
2718 of the Public Health Service Act must be reported here. Also, 
include refunds returned to the plan based on low claims experience 
or termination of a service contract. Do not include dividends or 
retroactive rate refunds reported on Schedule A, Line 9. If you 
answer ``Yes'' to Line 7a, you must complete Line 7b. Complete a 
separate entry for Lines 7b(1)-(3) for each rebate, reimbursement, 
or refund, entering in Line 7b(1) the amount(s) and date(s) the 
rebate(s), reimbursement(s), or refund(s) were received. Check the 
appropriate box in b(2) to indicate the source and the appropriate 
box in b(3) to specify how the funds were used or allocated.
    Line 8. Indicate whether there were any premium delinquencies 
during the reporting year. You must answer ``Yes'' or ``No.'' Do not 
leave Line 8a blank. If you answered ``Yes,'' you must indicate both 
the number of times delinquent for premiums due but unpaid during 
the year, and for each delinquency, the number of days delinquent. 
If you answered ``No'' to line 8a, check ``N/A'' on line 8b. If any 
premium payments that were not made within the time required by the 
insurance carrier resulted in a lapse of health insurance coverage, 
you must answer ``Yes'' to Line 8b even if coverage was 
retroactively reinstated.

Part II--Service Provider and Stop Loss Insurance Information

    Lines 9-13. Enter identifying information for third party 
administrator/claims processor, including insurance issuers subject 
to an ``administrative services only'' (ASO) contract or other 
agreement that are not reported on Schedule A or Schedule C, mental 
health benefits managers, substance use disorder benefits managers, 
pharmacy benefit manager/drug providers, and independent review 
organizations on the appropriate line. Repeat as many line entries 
as necessary to report all service providers under each category.
    Element (c). If applicable, enter the National Producer Number 
(NPN) of the service provider in element (c) for each type of 
service provider. The NPN is a unique NAIC identifier assigned 
through the licensing application process or the NAIC reporting 
systems to individuals and business entities (including, but not 
limited to producers, adjusters, and navigators) engaged in 
insurance related activities regulated by a state insurance 
department. The NPN is used to track those individuals and business 
entities on a national basis.
    Line 14. Wellness Program Manager. If there was a wellness 
program associated with

[[Page 47636]]

the plan, enter the contact information for the wellness program 
manager. A ``wellness program'' is defined in 29 CFR 2590.702(f) to 
include ``any program designed to promote health or prevent 
disease'' and includes programs that condition benefits (including 
cost-sharing mechanisms) or the premium or employer contribution 
amounts on an individual satisfying a standard that is related to a 
health factor as well as those programs that do not include 
conditions for obtaining a reward that are based on an individual 
satisfying a standard that is related to a health factor.
    Line 15. ``Stop Loss'' Insurance. If there was stop loss 
insurance associated with the plan, enter the name and identifying 
information for the insurance carrier providing the coverage in 
elements (a)-(c). This includes policies entered into by the plan 
sponsor for obligations of the plan sponsor to pay benefits under 
the plan.
    Line 15d. Enter the total premium paid to the stop loss 
provider.
    Line 15e. Enter the applicable attachment points for individual 
claims and aggregate claims. For this purpose, attachment points are 
the threshold dollar amounts which, when reached, the stop loss 
coverage begins to pay benefit claims.
    Line 15f. Enter any applicable individual and aggregate claim 
limits at which the stop loss ceases coverage. For example, stop 
loss coverage may only cover individual claims up to a certain 
dollar amount or cease paying claims after an aggregate dollar 
amount is met.
    Line 15g. Enter the policy or contract year beginning and end 
dates for the policy ending with or within the plan year.
    Line 15h. Check the box if the employer or plan sponsor is the 
insured party under the stop-loss policy.

Part III--Financial Information

    Note: Form 5500 filers that file Schedule H can skip this 
section and proceed to Part IV Claims Processing and Payment.
    Line 16a. Report the total cash contributions received from 
employer(s). In the absence of a trust (e.g., where a cafeteria plan 
elects not to establish a trust in reliance on Technical Release No. 
92-01), include employer contributions applied directly to the 
payment of benefits or expenses attendant to the provision of health 
benefits.
    Line 16b. For accrual basis plans, report the total cash 
contributions receivable from employer(s).
    Line 16c. Report the total cash contributions received from 
employees, including all elective contributions under a cafeteria 
plan (Code section 125 arrangement) attendant to the provision of 
health benefits.
    Line 16d. For accrual basis plans, report the total cash 
contributions receivable from employees, including all receivable 
elective contributions under a cafeteria plan (Code section 125 
arrangement) attendant to the provision of health benefits.
    Line 16e. Report other contributions received or receivable, 
including non-cash contributions, which should be reported at the 
current value at the date contributed.
    Line 16f. Enter the total contributions. Add lines 16a-e.
    Line 17. Amounts paid by a participant or beneficiary to an 
employer and/or withheld by an employer for contribution to the plan 
are participant contributions that become plan assets as of the 
earliest date on which such contributions can reasonably be 
segregated from the employer's general assets (see 29 CFR 2510.3-
102). For Schedule J purposes, participant contributions include all 
elective contributions under a cafeteria plan (Code section 125 
arrangement). Indicate whether there was a failure to timely 
transmit participant contributions to the plan during the filing 
period. Continue to answer ``Yes'' for any prior year failures until 
fully corrected.

Part IV--Health Benefit Claims Processing and Payment

    Every employee benefit plan shall establish and maintain 
reasonable procedures governing the filing of benefit claims, 
notification of benefit determinations, and appeal of adverse 
benefit determinations. See 29 CFR 2560.503-1 and 2590.715-2719(a). 
These questions ask you to quantify the number of benefit claims 
processed during the year. Unless otherwise instructed, do not 
provide dollar amounts instead of number of benefit claims 
processed.
    A pre-service benefit claim means any claim for a benefit under 
a group health plan with respect to which the terms of the plan 
condition receipt of the benefit, in whole or in part, on approval 
of the benefit in advance of obtaining medical care and includes 
urgent care and concurrent care claims.
    A post-service benefit claim means any claim for a benefit under 
a group health plan that is not a pre-service claim and is typically 
a request for payment that you or your health care provider submits 
to your health insurer when you get items or services you think are 
covered.
    ``Claims Adjudication'' is a term used in the insurance industry 
to refer to the process of paying claims submitted or denying them 
after comparing claims to the benefit or coverage requirements.
    Line 18a(1)-(3). Enter the number of post-service benefit claims 
submitted during the plan year regardless of whether the claim was 
approved or denied. Do not include duplicate claims, i.e., claims 
denied as previously considered. Enter the number of post-service 
benefit claims paid during the plan year. Enter the number of post-
service benefit claims denied during the plan year. Do not include 
duplicate claims, i.e., denied as previously considered.
    Line 18b(1)-(2). Enter the number of post-service benefit claims 
appealed during the plan year. Then, enter the number of post-
service claim denials upheld upon appeal and the number that were 
payable after appeal.
    Line 18c(1)-(2). Enter the number of pre-service benefit claims 
appealed. Then, enter the number of pre-service claim denials upheld 
upon appeal and the number that were payable after appeal.
    Line 19. Indicate whether there were any pre-service or post-
service benefit claims that were not adjudicated within the required 
time frames. In accordance with 29 CFR 2560.503-1(f)(2)(iii)(A), the 
plan administrator shall notify the claimant of the plan's benefit 
determination (whether adverse or not) within a reasonable period of 
time appropriate to the medical circumstances, but not later than 15 
days after the receipt of the claim. In accordance with 29 CFR 
2560.503-1(f)(2)(iii)(B) the plan administrator shall notify the 
claimant of the plan's adverse benefit determination on a post-
service claim within a reasonable period of time, but not later than 
30 days after receipt of the claim. This period may be extended one 
time for up to 15 days in circumstances where the delay is beyond 
the plan's control and the plan notifies the claimant of the 
extension prior to the expiration of the initial review period of 
why the extension is needed and the date by which the plan expects 
to render a decision.
    Line 20. Indicate whether, at any time during the year, the 
group health plan failed to pay benefit claims within one month of 
being approved for payment. If you answer ``Yes,'' indicate the 
number of claims the plan failed to pay, total dollar amount of 
claims not paid within one (1) month, and the number of claims not 
paid within three (3) months or longer.
    Example. A plan sponsor of an unfunded plan experienced 
financial difficulty in February and was unable to pay health 
benefit claims until May. In May, the plan sponsor's revenues 
increased and claims were paid. The plan must report the number of 
claims the plan was unable to pay from February to May even though 
the claims were subsequently paid in May.
    Line 21. Enter the total dollar amount of health benefit claims 
paid during the year. Do not include administrative expenses in the 
amount of claims paid.

Part V--Compliance Information

    Line 22. Trust compliance. Indicate whether all plan assets are 
maintained consistent with ERISA Sec.  403 and 29 CFR 2550.403a-1 
and 2550.403b-1. Pursuant to Technical Release 92-01, the DOL has 
opted to take a non-enforcement policy with respect to violations 
resulting solely because of a failure to hold participant 
contributions in trust in the case of a cafeteria plan described in 
section 125 of the Internal Revenue Code.
    Line 23. General Disclosure Compliance. Indicate whether the 
following disclosure documents are in compliance with the applicable 
content requirements:
     Summary plan description (SPD)--See 29 CFR 2520.104b-2.
     Summary of Benefits and Coverage (SBC)--See 29 CFR 
2590.715-2715.
     Summary of material modification (SMM)--See 29 CFR 
2520.104b-3.
     Summary annual reports (SAR)--See 29 CFR 2520.104b-
10(d).
    A Reporting and Disclosure Guide for Employee Benefit Plans 
describing basic reporting and disclosure requirements under ERISA 
can be found at http://www.dol.gov/ebsa/pdf/rdguide.pdf.

Health Benefit Compliance

    Plans that file the Form M-1, skip questions 24-30. Guidance 
material and additional compliance assistance information

[[Page 47637]]

that may be helpful in understanding the requirements listed below 
is available in publications, fact sheets, and frequently asked 
questions available on EBSA's Web site at www.dol.gov/ebsa. 
Interested persons may also call and speak to a benefits advisor 
about these laws, by calling the EBSA toll-free hotline at 1-866-
444-3272. A self-auditing tool to determine compliance with Part 7 
of Title I of ERISA is available at http://www.dol.gov/ebsa/pdf/cagappa.pdf.
    Line 24. HIPAA Compliance. The Health Insurance Portability and 
Accountability Act of 1996 (Pub. L. 104-191) (HIPAA) amended ERISA 
to provide for, among other things, improved portability and 
continuity of health insurance coverage.
    Line 25. GINA Compliance. The Genetic Information 
Nondiscrimination Act of 2008 (Pub. L. 110-233) (GINA) amended ERISA 
to prohibit the use of genetic information to adjust group premiums 
or contributions, prohibit the collection of genetic information, 
and prohibit requesting individuals to undergo genetic testing.
    Line 26. Mental Health Parity Compliance. The Mental Health 
Parity Act of 1996 (Pub. L. 104-204, as amended by Pub. L. 107-116 
and Pub. L. 107-147) (MHPA) amended ERISA to provide parity in the 
application of aggregate lifetime and annual dollar limits for 
certain mental health benefits with such dollar limits on medical 
and surgical benefits. The Paul Wellstone and Pete Domenici Mental 
Health Parity and Addiction Equity Act of 2008 (Pub. L. 110-343) 
(MHPAEA) amended ERISA by expanding the MHPA rules to cover benefits 
for substance use disorders, and adding new rules for parity in 
financial requirements and treatment limitations.
    Line 27. Newborns' and Mothers' Health Protection Compliance. 
The Newborns' and Mothers' Health Protection Act of 1996 (Pub. L. 
104-204) (Newborns' Act) amended ERISA to provide new protections 
for mothers and their newborn children with regard to group health 
plan coverage of the length of hospital stays in connection with 
childbirth.
    Line 28. Women's Health and Cancer Rights Compliance. The 
Women's Health and Cancer Rights Act of 1998 (Pub. L. 105-277) 
(WHCRA) amended ERISA to provide new rights under group health plans 
for coverage of reconstructive surgery in connection with a 
mastectomy.
    Line 29. Michelle's Law Compliance. Michelle's Law (Pub. L. 110-
381) amended ERISA to provide dependent children with protections 
against termination of group health plan coverage while on a 
medically necessary leave of absence from a postsecondary 
educational institution.
    Line 30. Affordable Care Act Compliance. The Affordable Care Act 
amended ERISA to provide a wide range of protections for 
participants of group health plans. For more information on the 
Affordable Care Act, see www.dol.gov/ebsa/healthreform.

Form M-1 Compliance Information.

    Line 31a. You must answer either ``Yes'' or ``No'' to Line 31a. 
Do not leave the answer blank. If the plan is a multiple employer 
welfare arrangement or an Entity Claiming Exception (ECE) subject to 
the Form M-1, Report for Multiple Employer Welfare Arrangements 
(MEWAs) and Certain Entities Claiming Exception (ECEs) filing 
requirements, check ``Yes'' and complete elements 31b and 31c. If 
the answer is ``No,'' skip elements 31b and 31c.
    Generally, a Form M-1 must be filed each year by March 1st 
following the calendar year in which a plan operates subject to the 
Form M-1 filing requirement. (For example, a plan MEWA that was 
operating in 20XX must file the 20XX Form M-1 annual report by March 
1, 20XX+1.) In addition, Form M-1 filings are necessary in the case 
of certain registration, origination, or special events. See the 
instructions for Form M-1 at http://www.askebsa.dol.gov/mewa, and 29 
CFR 2520.101-2 for more information regarding the Form M-1 filing 
requirements for plan MEWAs and ECEs.
    Line 31b. All plans that answered ``Yes'' in Line 31a must 
complete Line 31b by answering either ``Yes'' or ``No.'' Do not 
leave the answer blank if you answered ``Yes'' in Line 31a.
    Line 31c. All plans that answered ``Yes'' in Line 31a must enter 
a Receipt Confirmation Code for the 20XX Form M-1 annual report that 
was required to be filed with the Department of Labor under the Form 
M-1 filing requirements. The Receipt Confirmation Code is a unique 
code generated by the Form M-1 electronic filing system. You can 
find this code under the ``completed filings'' area when you log 
into your Form M-1 electronic filing system at http://www.askebsa.dol.gov/mewa. If a plan was not required to file a 20XX 
Form M-1 annual report, enter the Receipt Confirmation Code for the 
most recent Form M-1 that was required to be filed under the Form M-
1 filing requirements on or before the date of filing the 20XX Form 
5500. (For example, if a plan was not required to file a 20XX Form 
M-1 annual report by March 1, 20XX+1 for the 20XX calendar year 
because it experienced a registration event between October 1 and 
December 31, 20XX, and made a timely Form M-1 registration filing, 
the plan must enter on Line 31c of the 20XX Form 5500 the Receipt 
Confirmation Code issued for the Form M-1 registration filing.)
    If a plan that is subject to the Form M-1 filing requirements 
was not required to file a 20XX Form M-1 annual report, enter the 
Receipt Confirmation Code for the most recent Form M-1 that was 
required to be filed under the Form M-1 filing requirements on or 
before the date of filing the 20XX Form 5500. (For example, if a 
plan was not required to file a 20XX Form M-1 annual report by March 
1, 20XX for the 20XX calendar year because it experienced a 
registration event between October 1 and December 31, 20XX, and made 
a timely Form M-1 registration filing, the plan must provide the 
Receipt Confirmation Code for the Form M-1 registration filing.)
    The failure of a plan required to complete Schedule J to answer 
Line 31a, and if applicable, lines 31b and 31c, or enter a valid 
Receipt Confirmation Code in Line 31c, will subject the Form 5500 
filing to rejection as incomplete and civil penalties may be 
assessed pursuant to ERISA Section 502(c)(2) and 29 CFR 2560.502c-2.

20XX Instructions for Schedule MB (Form 5500)--Multiemployer Defined 
Benefit Plan and Certain Money Purchase Plan Actuarial Information

General Instructions

Who Must File

    As the first step, the plan administrator of any multiemployer 
defined benefit pension plan that is subject to the minimum funding 
standards (see Code sections 412 and 431 and Part 3 of Title I of 
ERISA) must obtain a completed Schedule MB (Form 5500) that is 
prepared and signed by the plan's enrolled actuary as discussed 
below in the Statement by Enrolled Actuary section. The plan 
administrator must retain with the plan records the Schedule MB that 
is prepared and electronically signed by the plan's actuary. The 
electronic-signature by the plan actuary is acceptable. The plan 
actuary can access the EFAST2 Web site at www.efast.dol.gov to 
register for electronic credentials to sign.
    The plan administrator of a multiemployer defined benefit 
pension plan must ensure that the information from the actuary's 
Schedule MB is entered electronically into the annual return/report 
being submitted. When entering the information, whether using 
EFAST2-approved software or EFAST2's web-based filing system, all 
the fields required for the type of plan must be completed (see 
instructions for fields that need to be completed).
    Further, if a plan actuary chooses not to sign electronically, 
then the actuary must manually sign the Schedule MB and an 
electronic reproduction must be filed with the Form 5500. The plan 
administrator of a multiemployer defined benefit pension plan must 
attach to the Form 5500 an electronic reproduction of the Schedule 
MB prepared and signed by the plan's enrolled actuary. This 
electronic reproduction must be labeled ``MB Actuary Signature'' and 
must be included as a Portable Document Format (PDF) attachment or 
any alternative electronic attachment allowable under EFAST2.
    If a money purchase defined contribution pension plan (including 
a target benefit plan) has received a waiver of the minimum funding 
standard, and the waiver is currently being amortized, lines 3, 9, 
and 10 of Schedule MB must be completed but it need not be signed by 
an enrolled actuary. In such a case, the Form 5500 or the Form 5500-
SF that is submitted under EFAST2 must include the Schedule MB with 
lines 3, 9, and 10 completed, but is not required to include a 
signed Schedule MB.
    Note. Schedule MB does not have to be filed with the Form 5500-
EZ, but, if required, it must be retained (in accordance with the 
instructions for Form 5500-EZ under the What to File section). 
Similarly, if a plan is a one-participant plan that meets the 
requirements for filing a Form 5500-EZ, but a Form 5500-SF is 
instead filed for the plan, the Schedule MB, if required, does not 
have to be filed with the Form 5500-SF, but it must be retained (in 
accordance with the instructions for the Form 5500-SF under Schedule 
MB in the Specific Instructions Only for ``One-Participant Plans and 
Certain

[[Page 47638]]

Foreign Plans'' section). Also, the funding standard account for the 
plan must continue to be maintained, even if the Schedule MB is not 
filed.
    Check the Schedule MB box on the Form 5500 (Part II, Line 
10a(2)) if a Schedule MB is attached to the Form 5500.
    Lines A through E must be completed for ALL plans. If the 
Schedule MB is attached to a Form 5500 or Form 5500-SF, Lines A, B, 
C, and D should include the same information as reported in Part II 
of the Form 5500 or Form 5500-SF. You may abbreviate the plan name.
    Do not use a social security number in Line D in lieu of an EIN. 
The Schedule MB and its attachments are open to public inspection if 
filed with a Form 5500 or Form 5500-SF, and the contents are public 
information and are subject to publication on the Internet. Because 
of privacy concerns, the inclusion of a social security number or 
any portion thereof on this Schedule MB or any of its attachments 
may result in the rejection of the filing.
    You can apply for an EIN from the IRS online, by telephone, by 
fax, or by mail depending on how soon you need to use the EIN. For 
more information, see Section 3: Electronic Filing Requirement under 
the General Instructions to Form 5500 and How to File--Electronic 
Filing Requirement under the General Instructions to Form 5500-SF. 
The EBSA does not issue EINs.
    Note. (1) For split-funded plans, the costs and contributions 
reported on Schedule MB must include those relating to both trust 
funds and insurance carriers. (2) For plans with funding standard 
account amortization charges and credits, see the instructions for 
lines 9c and 9h. (3) For terminating multiemployer plans, Code 
section 412(e)(4) and ERISA section 301(c) provide that minimum 
funding standards apply until the last day of the plan year in which 
the plan terminates within the meaning of section 4041A(a)(2) of 
ERISA. Accordingly, the Schedule MB is not required to be filed for 
any later plan year.

Statement by Enrolled Actuary

    An enrolled actuary must sign Schedule MB with either an 
electronic signature or a handwritten signature unless, as described 
above, the plan is a money purchase defined contribution pension 
plan that has received a waiver of the minimum funding standard. The 
signature of the enrolled actuary may be qualified to state that it 
is subject to attached qualifications. See Treasury Regulations 
section 301.6059-1(d) for permitted qualifications. Except as 
otherwise provided in these instructions, a stamped or machine 
produced signature is not acceptable. If the actuary has not fully 
reflected any final or temporary regulation, revenue ruling, or 
notice promulgated under the statute in completing the Schedule MB, 
check the box on the last line of page 1. If this box is checked, 
indicate on this line whether an accumulated funding deficiency or a 
contribution that is not wholly deductible would result if the 
actuary had fully reflected such regulation, revenue ruling, or 
notice. In addition, the actuary may offer any other comments 
related to the information contained in Schedule MB.
    The actuary must provide the completed and signed Schedule MB 
and transmit it to the plan administrator to be retained with the 
plan records and included (in accordance with these instructions) 
with the Form 5500 Annual Return/Report that is submitted under 
EFAST2. The plan's actuary is permitted to electronically sign the 
Schedule MB or sign on page one using the actuary's signature or by 
inserting the actuary's typed name in the signature line followed by 
the actuary's handwritten initials. The actuary's most recent 
enrollment number must be entered on the Schedule MB that is 
prepared and signed by the plan's actuary.

Attachments

    All attachments to the Schedule MB must be properly identified, 
and must include the name of the plan, the plan sponsor's EIN, and 
the plan number. Put ``Schedule MB'' and the line number to which 
the attachment relates at the top of each attachment. Do not include 
attachments that contain a visible social security number. The 
Schedule MB and its attachments are open to public inspection, and 
the contents are public information and are subject to publication 
on the Internet. Because of privacy concerns, the inclusion of a 
visible social security number or any portion thereof on an 
attachment may result in the rejection of the filing.

Specific Instructions

    Line 1. All entries must be reported as of the valuation date.
    Line 1a. Actuarial Valuation Date. The valuation for a plan year 
may be as of any date in the plan year, including the first or last 
day of the plan year. Valuations must be performed within the period 
specified by Code section 431(c)(7) and ERISA section 304(c)(7).
    Line 1b(1). Current Value of Assets. Enter the current value of 
assets as of the valuation date. The current value is the same as 
the fair market value. Do not adjust for items such as the existing 
credit balance or the outstanding balances of certain amortization 
bases. Contributions designated for 20XX should not be included in 
this amount. Note that this entry may be different from the entry in 
Line 2a. Such a difference may result, for example, if the valuation 
date is not the first day of the plan year, or if insurance 
contracts are excluded from assets reported on Line 1b(1) but not on 
Line 2a.
    Rollover amounts or other assets held in individual accounts 
that are not available to provide defined benefits under the plan 
should not be included on Line 1b(1), regardless of whether they are 
reported on the 20XX Schedule H (Form 5500) (Line 1I, column (a)). 
Additionally, asset and liability amounts must be determined in a 
consistent manner. Therefore, if the value of any insurance 
contracts have been excluded from the amount reported on Line 1b(1), 
liabilities satisfied by such contracts should also be excluded from 
the liability values reported on Lines 1c(1), 1c(2), and 1d(2) of 
the Schedule MB.
    Line 1b(2). Actuarial Value of Assets. Enter the value of assets 
determined in accordance with Code section 431(c)(2) and ERISA 
section 304(c)(2). Do not adjust for items such as the existing 
credit balance or the outstanding balances of certain amortization 
bases, and do not include contributions designated for 20XX in this 
amount.
    Line 1c(1). Accrued Liability for Immediate Gain Methods. 
Complete this line only if you use an immediate gain method (see 
Rev. Rul. 81-213, 1981-2 C.B. 101, for a definition of immediate 
gain method).
    Lines 1c(2)(a), (b), and (c). Information for Plans Using Spread 
Gain Methods. Complete these lines only if you use a spread gain 
method (see Rev. Rul. 81-213 for a definition of spread gain 
method).
    Line 1c(2)(a). Unfunded Liability for Methods with Bases. 
Complete this line only if you use the frozen initial liability or 
attained age normal cost method.
    Lines 1c(2)(b) and (c). Entry Age Normal Accrued Liability and 
Normal Cost. For spread gain methods, these calculations are used 
for purposes of the full funding limitation (see Rev. Rul. 81-13, 
1981-1 C.B. 229).
    Line 1d(1). Amount Excluded from Current Liability. Leave Line 
1(d)(1) blank.
    Line 1d(2)(a). Current Liability. All multiemployer plans, 
regardless of the number of participants, must provide the 
information indicated in accordance with these instructions. The 
interest rate used to compute the current liability must be in 
accordance with guidelines issued by the IRS and, pursuant to the 
Pension Protection Act of 2006 (PPA), must not be more than 5 
percent above and must not be more than 10 percent below the 
weighted average of the rates of interest, as set forth by the 
Treasury Department, on 30-year Treasury securities during the 4-
year period ending on the last day before the beginning of the 20XX 
plan year.
    The current liability must be computed using the mortality 
tables referenced in section 1.431(c)(6)-1 of the Treasury 
Regulations.
    Each other actuarial assumption used in calculating the current 
liability must be the same assumption used for calculating other 
costs for the funding standard account. See Notice 90-11, 1990-1 
C.B. 319. The actuary must take into account rates of early 
retirement and the plan's early retirement and turnover provisions 
as they relate to benefits, where these would significantly affect 
the results. Regardless of the valuation date, current liability is 
computed taking into account only credited service through the end 
of the prior plan year. No salary scale projections should be used 
in these computations. Do not include the expected increase in 
current liability due to benefits accruing during the plan year 
reported on Line 1d(2)(b) in these computations.
    Line 1d(2)(b). Expected Increase in Current Liability. Enter the 
amount by which the current liability is expected to increase due to 
benefits accruing during the plan year on account of credited 
service and/or salary changes for the current year. One year's 
salary scale may be reflected.
    Line 1d(2)(c). Expected Release From Current Liability for the 
Plan Year. Enter the expected release from current liability on 
account of disbursements (including single-

[[Page 47639]]

sum distributions) from the plan expected to be paid after the 
valuation date but prior to the end of the plan year (see also Q&A-7 
of Rev. Rul. 96-21, 1996-1 C.B. 64).
    Line 1d(3). Expected Plan Disbursements. Enter the amount of 
plan disbursements expected to be paid for the plan year.
    Line 2. All entries must be reported as of the beginning of the 
20XX plan year. Lines 2a and 2b should include all assets and 
liabilities under the plan except for assets and liabilities 
attributable to: (1) rollover amounts or other amounts in individual 
accounts that are not available to provide defined benefits, or (2) 
benefits for which an insurer has made an irrevocable commitment as 
defined in 29 CFR 4001.2.
    Line 2a. Current Value of Assets. Enter the current value of net 
assets as of the first day of the plan year. Except for plans with 
excluded assets as described above, this entry should be the same as 
reported on the 20XX Schedule H (Form 5500) (line 1l, column (a)). 
Note that contributions designated for the 20XX plan year are not 
included on those lines.
    Line 2b. Current Liability (beginning of plan year). Enter the 
current liability as of the first day of the plan year. Do not 
include the expected increase in current liability due to benefits 
accruing during the plan year. See the instructions for Line 
1d(2)(a) for actuarial assumptions used in determining current 
liability.
    Column (1)--Enter the number of participants and beneficiaries 
as of the beginning of the plan year. If the current liability 
figures are derived from a valuation that follows the first day of 
the plan year, the participant and beneficiary count entries should 
be derived from the counts used in that valuation in a manner 
consistent with the derivation of the current liability reported in 
column (2).
    Column (2)--Include the current liability attributable to all 
benefits, with subtotals for vested and nonvested benefits in the 
case of active participants.
    Line 2c. This calculation is required under ERISA section 
103(d)(11). Do not complete if Line 2a divided by Line 2b(4), column 
(2), is 70% or greater.
    Line 3. Contributions Made to Plan. Show all employer 
contribution amounts (column b), withdrawal liability payments 
(column c) and employee contribution amounts (column d) for the plan 
year. Employer contribution amounts should not include withdrawal 
liability payments which should be reported separately. Include 
employer contribution amounts and withdrawal liability payments made 
not later than 2\1/2\ months (or the later date allowed under Code 
section 431(c)(8) and ERISA section 304(c)(8)) after the end of the 
plan year. Show only contribution amounts and withdrawal liability 
payments actually made to the plan by the date this Schedule MB is 
signed.
    Add the amounts in columns (b), (c) and (d) and enter the 
results on the total line. All contribution amounts and withdrawal 
liability payments must be credited toward a particular plan year.
    Line 4. Information on Plan Status. All multiemployer plans 
regardless of the number of participants must provide the 
information indicated in accordance with these instructions.
    Line 4a. All plans enter the funded percentage for monitoring 
the plan's status. This is Line 1b(2) divided by Line 1c(3).
    Line 4b. Enter the code for the status of the multiemployer plan 
for the plan year, as certified by the plan actuary (or as elected 
by the plan sponsor in accordance with Code section 432(b)(4)(A) and 
ERISA section 305(b)(4)(A)), using one of the following codes:

Code Plan Status

E Endangered Status
S Seriously Endangered Status
C Critical Status
D Critical and Declining Status
N Not in Endangered or Critical Status

    If the plan is certified to be in endangered status, seriously 
endangered status, critical status, or critical and declining 
status, attach a copy of the actuarial certification of such status 
to this Schedule MB. Also attach an illustration showing the details 
(including year-by-year cash flow projections demonstrating the 
solvency of the plan over the relevant period if the plan is 
certified as being in critical and declining status) providing 
support for the actuarial certification of status and label the 
illustration ``Schedule MB, Line 4b--Illustration Supporting 
Actuarial Certification of Status.'' For example, if a plan is 
certified as being in critical status based on Code section 
432(b)(2)(B), show the funded percentage (if applicable) and the 
projection of the funding standard account for the year in which the 
accumulated funding deficiency occurs. All supporting documentation 
should include descriptions of the assumptions used.
    Line 4c. If, in the plan year in which the Schedule MB is filed, 
a certification was required to be made under Code section 
432(b)(3)(A)(ii) and ERISA section 305(b)(3)(A)(ii) with respect to 
scheduled progress during the plan year for which the Schedule MB is 
filed, check ``Yes'' or ``No'' to reflect the certification. Attach 
documentation comparing the current status of the plan to the 
scheduled progress under the applicable funding improvement or 
rehabilitation plan to this Schedule MB. Label the documentation 
``Schedule MB, Line 4c--Documentation Regarding Progress Under 
Funding Improvement or Rehabilitation Plan.''
    Lines 4d and 4e. If Code C (Critical Status) or Code D (Critical 
and Declining Status) was entered on Line 4b, an entry on line 4d is 
required. For purposes of Lines 4d and 4e, in determining whether 
benefits have been reduced, only adjustable benefits that would 
otherwise be protected under Code section 411(d)(6) and ERISA 
section 204(g) are taken into account if the plan is certified as in 
critical status. Plans that are certified as being in critical and 
declining status should determine whether benefits have been 
reduced, including all benefits that were adjusted (only adjustable 
benefits that would otherwise be protected under Code section 
411(d)(6) and ERISA section 204(g) are taken into account), any 
benefits that have been suspended under Code section 432(e)(9), and 
any benefit reductions due to partition under ERISA section 4233. 
For a plan that has benefits suspended under Code section 432(e)(9) 
and/or partitioned under ERISA section 4233, attach a full 
description of the transaction and label the attachment ``Schedule 
MB, Lines 4d and 4e--Description of Benefit Reductions Due to 
Suspension or Partition.'' In addition, only benefit reductions that 
are first reflected in Line 1c(3) for the current year's Schedule MB 
should be reported, and this amount should not include any amounts 
previously reported on any prior year's Schedule MB.
    Line 4f. If Code C (Critical Status) or Code D (Critical and 
Declining Status) was entered on Line 4b you must complete Line 4f. 
If the rehabilitation plan projects emergence from critical status 
or critical and declining status, enter the plan year in which the 
plan is projected to emerge. If the rehabilitation plan is based on 
forestalling possible insolvency, check the box provided and enter 
the plan year in which the insolvency is expected.
    Line 5. Actuarial Cost Method. Enter the primary method used. If 
the plan uses one actuarial cost method in one year as the basis of 
establishing an accrued liability for use under the frozen initial 
liability method in subsequent years, answer as if the frozen 
initial liability method was used in all years. The projected unit 
credit method is included in the ``Accrued benefit (unit credit)'' 
category of Line 5c. If a method other than a method listed on Lines 
5a through 5g is used, check the box for Line 5i and specify the 
method. For example, if a modified individual level premium method 
for which actuarial gains and losses are spread as a part of future 
normal cost is used, check the box for 5i and describe the cost 
method.
    Check the appropriate box for the underlying actuarial cost 
method used as the basis for this plan year's funding standard 
account computation. If box 5h is checked, enter the period of use 
of the shortfall method in Line 5j. For this purpose, enter the 
calendar year (YY) which includes the first day of the plan year in 
which the shortfall method was first used.
    Changes in funding methods include changes in actuarial cost 
method, changes in asset valuation method, and changes in the 
valuation date of plan costs and liabilities or of plan assets. 
Changes in the funding method of a plan include not only changes to 
the overall funding method used by the plan, but also changes to 
each specific method of computation used in applying the overall 
method. Generally, these changes require IRS approval. If the change 
was made pursuant to Rev. Proc. 2000-40, 2000-2 C.B. 357, or 
pursuant to other automatic approval (such as the Preservation of 
Access to Care for Medicare Beneficiaries and Pension Relief Act of 
2010 (PRA 2010), Pub. L. 111-192), check ``Yes'' for Line 5l. If 
approval was granted for this plan by either an individual ruling 
letter or a class ruling letter, enter the date of the applicable 
ruling letter in Line 5m. Note that the plan sponsor's agreement to 
certain changes in funding methods should be reported on Line 9 of 
Schedule R (Form 5500).
    Shortfall Method: Only certain plans may elect the shortfall 
funding method (see

[[Page 47640]]

Treasury Regulations section 1.412(c)(1)-2). Advance approval from 
the IRS for the election of the shortfall method of funding is NOT 
required if it is first adopted for the first plan year to which 
Code section 412 applies. In addition, pursuant to PPA section 
201(b), a plan does NOT need advance approval from the IRS to adopt 
or cease using the shortfall method if the plan (1) has not adopted 
or ceased using the shortfall method during the 5-year period ending 
on the day before the date the plan is to use the method, and (2) is 
not operating under an amortization period extension and did not 
operate under such an extension during such 5-year period. In such a 
case, check ``Yes'' for Line 5l. If a plan utilizes this automatic 
approval to apply the shortfall method, the benefit increase 
limitations of Code section 412(c)(7) apply.
    If a plan is not eligible for automatic approval as set forth in 
the preceding paragraph, advance approval from the IRS is required 
if the shortfall funding method is adopted at a later time, if a 
specific computation method is changed, or if the shortfall method 
is discontinued. In such a case there is no automatic limitation on 
benefit increases.
    Line 6. Actuarial Assumptions. If gender-based assumptions are 
used in developing plan costs, enter those rates where appropriate 
in Line 6. Note that requests for gender-based cost information do 
not suggest that gender-based benefits are legal. If unisex tables 
are used, enter the values in both ``Male'' and ``Female'' lines. 
Check ``N/A'' for Line 6b if the question is not applicable.
    Attach a statement of actuarial assumptions (if not fully 
described by Line 6) and actuarial methods used to calculate the 
figures shown in Lines 1 and 9 (if not fully described by Line 5), 
and label the statement ``Schedule MB, Line 6--Statement of 
Actuarial Assumptions/Methods.'' The statement must describe all 
actuarial assumptions used to determine the liabilities. For 
example, the statement for non-traditional plans (e.g., cash balance 
plans) must include the assumptions used to convert balances to 
annuities.
    Also attach a summary of the principal eligibility and benefit 
provisions on which the valuation was based, including the status of 
the plan (e.g., eligibility frozen, service/pay frozen, benefits 
frozen), optional forms of benefits, special plan provisions, 
including those that apply only to a subgroup of employees (e.g., 
those with imputed service), supplemental benefits, an 
identification of benefits not included in the valuation (e.g., 
shutdown benefits), a description of any significant events that 
occurred during the year, a summary of any changes in principal 
eligibility or benefit provisions since the last valuation, a 
description (or reasonably representative sample) of plan early 
retirement factors, and any change in actuarial assumptions or cost 
methods and justifications for any such change (see section 103(d) 
of ERISA). Label the summary ``Schedule MB, Line 6--Summary of Plan 
Provisions.''
    Line 6a. Current Liability Interest Rate. Enter the interest 
rate used to determine current liability. The interest rate used 
must be in accordance with the guidelines issued by the IRS and, 
pursuant to PPA, must not be more than 5 percent above and must not 
be more than 10 percent below the weighted average of the rates of 
interest, as set forth by the Treasury Department, on 30-year 
Treasury securities during the 4-year period ending on the last day 
before the beginning of the 20XX plan year. Enter the rate to the 
nearest .01 percent.
    Line 6b. Check ``Yes,'' if the rates in the contract were used 
(e.g., purchase rates at retirement).
    Line 6c. Mortality Table. The mortality table published in 
section 1.431(c)(6)-1 of the Treasury Regulations must be used in 
the calculation of current liability for non-disabled lives. Enter 
the mortality table code for non-disabled lives used for valuation 
purposes as follows:

------------------------------------------------------------------------
                         Mortality Table                           Code
------------------------------------------------------------------------
1951 Group Annuity..............................................       1
1971 Group Annuity Mortality (G.A.M.)...........................       2
1971 Individual Annuity Mortality (I.A.M.)......................       3
UP-1984.........................................................       4
1983 I.A.M......................................................       5
1983 G.A.M......................................................       6
1983 G.A.M. (solely per Rev. Rul. 95-28)........................       7
UP-1994.........................................................       8
Mortality table applicable to current plan year under section          9
 1.431(c)(6)-1 of the Income Tax Regulations....................
RP-2000.........................................................      10
RP-2000 (with Blue Collar Adjustment)...........................      11
Other...........................................................       A
None............................................................       0
------------------------------------------------------------------------

    Code 6 includes all sex-distinct versions of the 1983 G.A.M. 
table other than the table published in Rev. Rul. 95-28, 1995-1 C.B. 
74. Thus, for example, Code 6 also would include the 1983 G.A.M. 
male-only table used for males, where the 1983 G.A.M. male-only 
table with a 6-year setback is used for females. Code A includes 
mortality tables other than those listed in Codes 1 through 9, 
including any unisex version of the 1983 G.A.M. table.
    Where an indicated table consists of separate tables for males 
and females, add F to the female table (e.g., 1F). When a projection 
is used with a table, follow the code with ``P'' and the year of 
projection (omit the year if the projection is unrelated to a single 
calendar year); the identity of the projection scale should be 
omitted. When an age setback or set forward is used, indicate with 
``-'' or ``+'' and the number of years. For example, if for females 
the 1951 Group Annuity Table with Projection C to 1971 is used with 
a 5-year setback, enter ``1P71-5.'' If the table is not one of those 
listed, enter ``A'' with no further notation. If the valuation 
assumes a maturity value to provide the post-retirement income 
without separately identifying the mortality, interest and expense 
elements, enter on Line 6c, under ``Post-retirement,'' the value of 
$1.00 of monthly pension beginning at the plan's weighted average 
retirement age, assuming the normal form of annuity for an unmarried 
person. In such a case, leave Lines 6d and 6e blank.
    Line 6d. Valuation Liability Interest Rate. Enter the assumption 
as to the expected interest rate (investment return) used to 
determine all the calculated values except for current liability. If 
the assumed rate varies with the year, enter the weighted average of 
the assumed rate for 20 years following the valuation date. Enter 
rates to the nearest .01 percent.
    Line 6e. Expense Loading. If there is no expense loading, check 
the ``N/A'' boxes under ``Pre-retirement'' and ``Post-retirement''. 
For instance, there would be no expense loading attributable to 
investments if the rate of investment return on assets is adjusted 
to take investment expenses into account. If there is a single 
expense loading not separately identified as pre-retirement or post-
retirement, enter it under ``Pre-retirement'' and check the ``N/A'' 
box under ``Post-Retirement.'' Where expenses are assumed other than 
as a percentage of plan costs or liabilities, enter the assumed pre-
retirement expense as a percentage of the plan's normal cost, and 
enter the post-retirement expense as a percentage of plan 
liabilities. If the normal cost of the plan is zero, enter the 
assumed pre-retirement expense as a percentage of the sum of Lines 
9c(1), 9c(2), and 9c(3), minus Line 9h. Enter rates to the nearest 
.1 percent.
    Line 6f. Salary Scale. If a uniform level annual rate of salary 
increase is used, enter that annual rate. Otherwise, enter the level 
annual rate of salary increase that is equivalent to the rate(s) of 
salary increase used. Enter the annual rate as a percentage to the 
nearest .01 percent, used for a participant from age 25 to assumed 
retirement age. If the plan's benefit formula is not related to 
compensation, check the ``N/A'' box.
    Line 6g. Estimated Investment Return--Actuarial Value. Enter on 
Line 6g(1) the estimated rate of return on the actuarial value of 
plan assets for the 1-year period ending on the valuation date. For 
this purpose, the rate of return is determined by using the formula 
2I/(A + B-I), where I is the dollar amount of the investment return 
under the asset valuation method used for the plan, A is the 
actuarial value of the assets one year ago, and B is the actuarial 
value of the assets on the current valuation date. Enter rates to 
the nearest .1 percent. If entering a negative number, enter a minus 
sign (``-'') to the left of the number.
    Note. Use the above formula even if the actuary feels that the 
result of using the formula does not represent the true estimated 
rate of return on the actuarial value of plan assets for the 1-year 
period ending on the valuation date. The actuary may attach a 
statement showing both the actuary's estimate of the rate of return 
and the actuary's calculations of that rate, and label the statement 
``Schedule MB, Line 6g--Estimated Rate of Investment Return 
(Actuarial Value).'' Check the box on Line 6g(2) if a statement is 
attached.
    Line 6h. Estimated Investment Return--Current (Market) Value. 
Enter on Line 6h(1)

[[Page 47641]]

the estimated rate of return on the current value of plan assets for 
the 1-year period ending on the valuation date. (The current value 
is the same as the fair market value--see Line 1b(1) instructions.) 
For this purpose, the rate of return is determined by using the 
formula 2I/(A + B-I), where I is the dollar amount of the investment 
return, A is the current value of the assets one year ago, and B is 
the current value of the assets on the current valuation date. Enter 
rates to the nearest .1 percent. If entering a negative number, 
enter a minus sign (``-'') to the left of the number.
    Note. Use the above formula even if the actuary feels that the 
result of using the formula does not represent the true estimated 
rate of return on the current value of plan assets for the 1-year 
period ending on the valuation date. The actuary may attach a 
statement showing both the actuary's estimate of the rate of return 
and the actuary's calculations of that rate, and label the statement 
``Schedule MB, Line 6h--Estimated Rate of Investment Return (Current 
Value).'' Check the box on Line 6h(2) if a statement is attached.
    Line 7. Schedule of Amortization Bases Established. List all 
amortization bases established in the current or prior plan years 
that have an outstanding balance as of the valuation date for the 
current plan year. Use the following table to indicate the type of 
base established and enter the appropriate code under ``Type of 
base.'' List amortization bases and charges and/or credits as of the 
valuation date. Bases that are considered fully amortized because 
there is a credit for the plan year on Line 9j(3) should be listed. 
If entering a negative number, enter a minus sign (``-'') to the 
left of the number.

Code Type of Amortization Base

1 Experience gain or loss
2 Shortfall gain or loss
3 Change in unfunded liability due to plan amendment
4 Change in unfunded liability due to change in actuarial 
assumptions
5 Change in unfunded liability due to change in actuarial cost 
method
6 Waiver of the minimum funding standard
7 Initial unfunded liability (for new plan)

    Line 8a and 8d. Funding Waivers or Extensions. If a funding 
waiver or extension request is approved after the Schedule MB is 
filed, an amended Schedule MB must be filed with Form 5500 to report 
the waiver or extension approval (also see instructions for Line 
9k(1)).
    Line 8b(1)(a). Schedule of Projection of Expected Benefit 
Payments. Check ``Yes'' only if this is a multiemployer plan covered 
by Title IV of ERISA that has 500 or more total participants as of 
the valuation date.
    Line 8b(1)(b). If Line 8b(1)(a) is ``Yes,'' on Line 8b(1)(b), 
provide a projection of benefits expected to be paid for the entire 
plan (not to include expected expenses) in each of the next ten 
years starting with the current plan year of this filing assuming 
(1) no additional accruals, (2) experience (e.g., termination, 
mortality, and retirement) are in line with valuation assumptions, 
and (3) no new entrants are covered by the plan.
    Line 8b(2)(a). Schedule of Active Participant Data. Check 
``Yes'' on Line 8b(2)(a) only if this is a multiemployer plan 
covered by Title IV of ERISA that has active participants. If Line 
8(2)(a) is ``Yes,'' complete the schedule in Line 8b(2)(b) with the 
active plan participant data used in the valuation for this plan 
year and enter the average age and average credited service of the 
active participants as of the valuation date on Lines 8b(2)(c) and 
8b(2)(d), respectively.
    Include all active participants in the averages, even ones that 
are not required to be shown in the schedule under the instructions 
below.
    For each column, enter the number of active participants with 
the specified number of years of credited service divided according 
to age group. For participants with partial years of credited 
service, round the total number of years of credited service to the 
next lower whole number. Years of credited service are the years 
credited under the plan's benefit formula.
    Plans reporting 1,000 or more active participants on Line 
2b(3)(c), column (1), and using compensation to determine benefits, 
must also provide average compensation data. For each grouping, 
enter the average compensation of the active participants in that 
group. For this purpose, compensation is the compensation taken into 
account for each participant under the plan's benefit formula, 
limited to the amount defined under section 401(a)(17) of the Code. 
Do not enter the average compensation in any grouping that contains 
fewer than 20 participants.
    Cash balance plans (or any similar plans) reporting 1,000 or 
more active participants on Line 2b(3)(c), column (1), must also 
provide average cash balance account data, regardless of whether all 
active participants have cash balance accounts. For each age/service 
bin, enter the average cash balance account of the active 
participants in that bin. Do not enter the average cash balance 
account in any age/service bin that contains fewer than 20 active 
participants.
    General Rule. In general, data to be shown in each age/service 
bin includes:
    1. the number of active participants in the age/service bin,
    2. the average compensation of the active participants in the 
age/service bin, and
    3. the average cash balance account of the active participants 
in the age/service bin, using $0 for anyone who has no cash balance 
account-based benefit.
    If the accrued benefit is the greater of a cash balance benefit 
or some other benefit, average in only the cash balance account. If 
the accrued benefit is the sum of a cash balance account benefit and 
some other benefit, average in only the cash balance account. For 
both the average compensation and the average cash balance account, 
do not enter an amount for age/service bins with fewer than 20 
active participants.
    In lieu of the above, two alternatives are provided for showing 
compensation and cash balance accounts. Each alternative provides 
for two age/service scatters (one showing compensation and one 
showing cash balance accounts) as follows:
    Alternative A:
     Scatter 1--Provide participant count and average 
compensation for all active participants, whether or not 
participants have account-based benefits.
     Scatter 2--Provide participant count and average cash 
balance account for all active participants, whether or not 
participants have account-based benefits.
    Alternative B:
     Scatter 1--Provide participant count and average 
compensation for all active participants, whether or not 
participants have account-based benefits (i.e., identical to Scatter 
1 in Alternative A).
     Scatter 2--Provide participant count and average cash 
balance account for only those active participants with account 
based benefits. If the number of participants with account-based 
benefits in a bin is fewer than 20, the average account should not 
be shown even if there are more than 20 active participants in this 
bin on Scatter 1.
    In general, information should be determined as of the valuation 
date. Average cash balance accounts may be determined as of either:
    1. the valuation date or
    2. the day immediately preceding the valuation date.
    Average cash balance accounts that are offset by amounts from 
another plan may be reported either as amounts prior to taking into 
account the offset or as amounts after taking into account the 
offset. Do not report the offset amount. For this or any other 
unusual or unique situation, the attachment should include an 
explanation of what is being provided.
    Line 8b(3)(a). Schedule of Retired Participants and 
Beneficiaries Receiving Payment Data. Check ``Yes'' only if this is 
a multiemployer plan covered by Title IV of ERISA that has retired 
participants and beneficiaries. If Line 8b(3)(a) is ``Yes,'' 
complete the schedule in Line 8b(3)(b) with the retired plan 
participant and beneficiaries receiving payment data used in the 
valuation for this plan year and enter the average age and average 
in-pay annual benefit as of the valuation date of the retired 
participants and beneficiaries on Lines 8b(3)(c) and 8b(3)(d), 
respectively. Do not report average annual in-pay benefit 
information for age brackets where there are 10 or less retired 
participants and beneficiaries receiving payment in the average.
    Line 8b(4)(a). Schedule of Terminated Vested Participant Data. 
Check ``Yes'' only if this is a multiemployer plan covered by Title 
IV of ERISA that has terminated vested participants. If Line 
8b(4)(a) is ``Yes,'' complete the schedule in Line 8b(4)(b) with the 
terminated vested participant data used in the valuation for this 
plan year and enter the average age and average annual benefit as of 
the valuation date of the terminated vested participants in Line 
8b(4)(c) and 8b(4)(d), respectively. Do not report average annual 
benefit information for age brackets where there are 10 or less 
terminated vested participants in the average. Include the assumed 
form of payment and the assumed first age of payment in Lines 
8b(4)(e) and 8b(4)(f), respectively, for the benefit amounts shown 
in the schedule.
    Line 9. Shortfall Method. Under the shortfall method of funding, 
the normal cost in the funding standard account is the charge

[[Page 47642]]

per unit of production (or per unit of service) multiplied by the 
actual number of units of production (or units of service) that 
occurred during the plan year. Each amortization installment in the 
funding standard account is similarly calculated.
    Line 9c. Amortization Charges. The outstanding balance and 
amortization charges and credits must be calculated as of the 
valuation date for the plan year. Line 9c(3) should only include 
information related to the amortization bases extended and amortized 
using the interest rate under section 6621(b) of the Code.
    Line 9d. Interest as Applicable. Interest as applicable should 
be charged to the last day of the plan year.
    Line 9f. Note that the credit balance or funding deficiency at 
the end of ``Year X'' should be equal to the credit balance or 
funding deficiency at the beginning of ``Year X+1.'' If such credit 
balances or funding deficiencies are not equal, check the box on 
Line 9f(2), attach an explanation and label the attachment 
``Schedule MB, Line 9f--Explanation of Prior Year Credit Balance/
Funding Deficiency Discrepancy.'' For example, if the difference is 
because contributions for a prior year that were not previously 
reported are received this plan year, attach a listing of the 
amounts and dates of such contributions. As another example, if the 
difference is due to the application of funding relief under the 
Preservation of Access to Care for Medicare Beneficiaries and 
Pension Relief Act of 2010 (PRA 2010), Pub. L. 111-192, the 
attachment should show how the information on the Schedule MB filed 
for any previous plan year would have differed if it had reflected 
application of the special funding relief in accordance with 
published guidance (to the extent that the plan sponsor has applied 
the special funding relief).
    Line 9h. Amortization Credits. The outstanding balance and 
amortization credits must be calculated as of the valuation date.
    Line 9j(1). ERISA Full Funding Limitation. Instructions for this 
line are reserved pending published guidance.
    Line 9j(2). ``RPA '94'' Override. Instructions for this line are 
reserved pending published guidance.
    Line 9j(3). Full Funding Credit. Enter the excess of (1) the 
accumulated funding deficiency, disregarding the credit balance and 
contributions for the current year, if any, over (2) the greater of 
Lines 9j(1) or 9j(2).
    Line 9k(1). Waived Funding Deficiency Credit. Enter a credit for 
a waived funding deficiency for the current plan year (Code section 
431(b)(3)(C)). If a waiver of a funding deficiency is pending, 
report a funding deficiency. If the waiver is granted after Form 
5500 or Form 5500-SF is filed, file an amended Form 5500 or Form 
5500-SF, as applicable, with an amended Schedule MB to report the 
funding waiver (see Amended Return/Report in the instructions for 
Form 5500 or Line B--Box for Amended Return/Report in the 
instructions for Form 5500-SF, as applicable).
    Line 9k(2). Other Credits. Enter a credit in the case of a plan 
for which the accumulated funding deficiency is determined under the 
funding standard account if such plan year follows a plan year for 
which such deficiency was determined under the alternative minimum 
funding standard.
    Line 9o. Reconciliation Account. The reconciliation account is 
made up of those components that upset the balance equation of 
Treasury Regulations section 1.412(c)(3)-1(b). Valuation assets must 
not be adjusted by the reconciliation account balance when computing 
the required minimum funding.
    Line 9o(1). This amount is equal to the prior year's accumulated 
reconciliation amount due to prior waived funding deficiencies, 
increased with interest at the valuation rate to the current 
valuation date.
    Line 9o(2)(a). If an amortization extension is being amortized 
at an interest rate that differs from the valuation rate, enter the 
prior year's ``reconciliation amortization extension outstanding 
balance,'' increased with interest at the valuation interest rate to 
the current valuation date, and decreased by the year end 
amortization amount based on the amortization interest rate from the 
prior plan year.
    Line 9o(3). Enter the sum of Lines 9o(1) and 9o(2)(b) (each 
adjusted with interest at the valuation rate to the current 
valuation date, if necessary).
    Note. The net outstanding balance of amortization charges and 
credits minus the prior year's credit balance minus the amount on 
Line 9o(3) (each adjusted with interest at the valuation rate, if 
necessary) must equal the unfunded liability.
    Line 10. Contribution Necessary to Avoid Deficiency. Enter the 
amount from Line 9n. If applicable, file IRS Form 5330, Return of 
Excise Taxes Related to Employee Benefit Plans, with the IRS to pay 
the excise tax on the funding deficiency. There is a penalty for not 
filing the Form 5330 on time.
    Line 11. In accordance with ERISA section 103(d)(3), attach a 
justification for any change in actuarial assumptions for the 
current plan year and label the attachment--``Schedule MB, Line 11--
Justification for Change in Actuarial Assumptions.''

20XX Instructions for Schedule R (Form 5500) (Retirement Plan 
Information)

General Instructions

Purpose of Schedule

    Schedule R (Form 5500) reports certain information on retirement 
plan distributions, funding, nondiscrimination, coverage, and the 
adoption of amendments, as well as certain information on single-
employer and multiemployer defined benefit pension plans.
    Electronic Attachments. All attachments to Schedule R must be 
properly identified, must include the name of the plan, plan 
sponsor's EIN, and plan number. Place ``Schedule R'' and the 
Schedule R line number at the top of each attachment to identify the 
information to which the attachment relates. Do not include 
attachments that contain a visible social security number. The 
Schedule R and its attachments are open to public inspection, and 
the contents are subject to publication on the Internet. Because of 
privacy concerns, the inclusion of a visible social security number 
or any portion thereof on an attachment may result in the rejection 
of the filing.

Who Must File

    Schedule R must be attached to a Form 5500 filed for both tax-
qualified and nonqualified pension benefit plans. The parts of 
Schedule R that must be completed depend on whether the plan is 
subject to the minimum funding standards of Code section 412 or 
ERISA section 302 and the type of plan. See line item requirements 
under Specific Instructions for more details.
    Exceptions: Schedule R should not be completed when the Form 
5500 Annual Return/Report is filed for a pension plan that uses, as 
the sole funding vehicle for providing benefits, individual 
retirement accounts or annuities (as described in Code section 408). 
See the Form 5500 Annual Return/Report instructions for Limited 
Pension Plan Reporting for more information.
    Check the Schedule R box on the Form 5500 (Part II, Line 10a(1)) 
if a Schedule R is attached to the Form 5500.

Specific Instructions

    Lines A, B, C, and D. This information must be the same as 
reported in Part II of the Form 5500 to which this Schedule R is 
attached.
    Do not use a social security number in Line D instead of an EIN. 
Schedule R and its attachments are open to public inspection, and 
the contents are public information and are subject to publication 
on the Internet. Because of privacy concerns, the inclusion of a 
social security number or any portion thereof on Schedule R or any 
of its attachments may result in the rejection of the filing.
    You can apply for an EIN from the IRS online, by telephone, by 
fax, or by mail depending on how soon you need to use the EIN. For 
more information, see Section 3: Electronic Filing Requirement. The 
EBSA does not issue EINs.
    ``Participant'' for purposes of Schedule R, means any present or 
former employee who at any time during the plan year had an accrued 
benefit in the plan (account balance in a defined contribution 
pension plan).

Part I--Distributions

    ``Distribution'' includes only payments of benefits during the 
plan year, in cash, in kind, by purchase for the distributee of an 
annuity contract from an insurance company, or by distribution of 
life insurance contracts. It does not include:
    1. Corrective distributions of excess deferrals, excess 
contributions, or excess aggregate contributions, or the income 
allocable to any of these amounts;
    2. Distributions of automatic contributions pursuant to Code 
section 414(w);
    3. The distribution of elective deferrals or the return of 
employee contributions to correct excess annual additions under Code 
section 415, or the gains attributable to these amounts; and
    4. A loan deemed as a distribution under Code section 72(p).
    Note. It does, however, include a distribution of a plan loan 
offset amount as defined in Treasury Regulations section 1.402(c)-2, 
Q&A 9(b).
    Line 1. Enter the total value of all distributions made during 
the year

[[Page 47643]]

(regardless of when the distribution began) in any form other than 
cash, annuity contracts issued by an insurance company, distribution 
of life insurance contracts, marketable securities within the 
meaning of Code section 731(c)(2), or plan loan offset amounts. Do 
not include eligible rollover distributions paid directly to 
eligible retirement plans in a direct rollover under Code section 
401(a)(31) unless such direct rollovers include property other than 
that enumerated in the preceding sentence.
    Line 2. Enter the EIN(s) of any payor(s) (other than the plan 
sponsor or plan administrator on Line 2b or 3b of the Form 5500) who 
paid benefits reportable on IRS Form 1099-R on behalf of the plan to 
participants or beneficiaries during the plan year. This is the EIN 
that appears on the IRS Forms 1099-R that are issued to report the 
payments. Include the EIN of the trust if different than that of the 
sponsor or plan administrator. If more than two payors made such 
payments during the year, enter the EINs of the two payors who paid 
the greatest dollar amounts during the year. For purposes of this 
Line 2, take into account all payments made during the plan year, in 
cash or in kind, that are reportable on IRS Form 1099-R, regardless 
of when the payments began, but take into account payments from an 
insurance company under an annuity only in the year the contract was 
purchased.
    Line 3. Enter in the appropriate location, broken out by active, 
terminated vested, and retired, the number of living or deceased 
participants whose benefits under the plan were distributed during 
the plan year in the form of a single-sum distribution, either as an 
annuity or a lump sum. For this purpose, a distribution of a 
participant's benefits will not fail to be a single-sum distribution 
merely because, after the date of the distribution, the plan makes a 
supplemental distribution as a result of earnings or other 
adjustments made after the date of the single-sum distribution. Also 
include any participants whose benefits were distributed in the form 
of a direct rollover to the trustee or custodian of a qualified plan 
or individual retirement account. Profit-sharing plans, ESOPs, and 
stock bonus plans skip Line 3.
    Line 4. Check ``Yes'' if the required minimum distributions were 
made to 5% owners who attained age 70\1/2\ and older. Required 
Minimum Distributions (RMDs) generally are minimum amounts that a 
retirement plan account owner must withdraw annually starting with 
the year that he or she reaches 70\1/2\ years of age or, if later, 
the year in which he or she retires. However, if the account owner 
is a 5% owner of the business sponsoring the retirement plan, the 
RMDs must begin once the account holder is age 70\1/2\, regardless 
of whether he or she is retired.
    Note. You must complete Line 4 if you are required to file at 
least 250 returns of any type with the IRS during the calendar year. 
However, if you are a small filer (files fewer than 250 returns of 
any type with the IRS including information returns (for example, 
Forms W-2 and Forms 1099), income tax returns, employment tax 
returns, and excise tax returns during the calendar year), and you 
do not complete this line, then you must file the paper Form 5500-
SUP with the IRS. See Instructions for Form 5500-SUP for more 
information.

Part II--Funding Information

    Complete Part II only if the plan is subject to the minimum 
funding requirements of Code section 412 or ERISA section 302.
    All qualified defined benefit and defined contribution pension 
plans are subject to the minimum funding requirements of Code 
section 412 unless they are described in the exceptions listed under 
Code section 412(e)(2). These exceptions include profit- sharing or 
stock bonus plans, insurance contract plans described in Code 
section 412(e)(3), and certain plans to which no employer 
contributions are made.
    Nonqualified employee pension benefit plans are subject to the 
minimum funding requirements of ERISA section 302 unless 
specifically exempted under ERISA sections 4(a) or 301(a). The 
employer or plan administrator of a single-employer or multiple-
employer defined benefit pension plan that is subject to the minimum 
funding requirements must file Schedule SB as an attachment to Form 
5500. Schedule MB is filed for multiemployer defined benefit pension 
plans and certain money purchase defined contribution pension plans 
(whether they are single-employer or multiemployer plans). However, 
Schedule MB is not required to be filed for a money purchase defined 
contribution pension plan that is subject to the minimum funding 
requirements unless the plan is currently amortizing a waiver of the 
minimum funding requirements.
    Line 5. Check ``Yes'' if, for purposes of computing the minimum 
funding requirements for the plan year, the plan administrator is 
making an election intended to satisfy the requirements of Code 
section 412(d)(2) or ERISA section 302(d)(2). Under Code section 
412(d)(2) and ERISA section 302(d)(2), a plan administrator may 
elect to have any amendment, adopted after the close of the plan 
year for which it applies, treated as having been made on the first 
day of the plan year if all of the following requirements are met:
    1. The amendment is adopted no later than two and one-half 
months (two years for a multiemployer plan) after the close of such 
plan year;
    2. The amendment does not reduce the accrued benefit of any 
participant determined as of the beginning of such plan year; and
    3. The amendment does not reduce the accrued benefit of any 
participant determined as of the adoption of the amendment unless 
the plan administrator notified the Secretary of the Treasury of the 
amendment and the Secretary either approved the amendment or failed 
to disapprove the amendment within 90 days after the date the notice 
was filed. See Treasury Temporary Regulations section 11.412(c)-7(b) 
for details on when and how to make the election and what 
information to include on the statement of election, which must be 
filed with the Form 5500 Annual Return/Report.
    Line 6. If a money purchase defined contribution pension plan 
(including a target benefit plan) has received a waiver of the 
minimum funding standard, and the waiver is currently being 
amortized, complete Lines 3, 9, and 10 of Schedule MB. See 
instructions for Schedule MB. Attach Schedule MB to Form 5500. The 
Schedule MB for a money purchase defined contribution pension plan 
does not need to be signed by an enrolled actuary.
    Line 7a. The minimum required contribution for a money purchase 
defined contribution pension plan (including a target benefit plan) 
for a plan year is the amount required to be contributed for the 
year under the formula set forth in the plan document. If there is 
an accumulated funding deficiency for a prior year that has not been 
waived, that amount should also be included as part of the 
contribution required for the current year.
    Line 7b. Include all contributions for the plan year made not 
later than 8\1/2\ months after the end of the plan year. Show only 
contributions actually made to the plan by the date the form is 
filed. For example, do not include receivable contributions for this 
purpose.
    Line 7c. If the minimum required contribution exceeds the 
contributions for the plan year made not later than 8\1/2\ months 
after the end of the plan year, the excess is an accumulated funding 
deficiency for the plan year. File IRS Form 5330, Return of Excise 
Taxes Related to Employee Benefit Plans, with the IRS to pay the 
excise tax on the deficiency. There is a penalty for not filing IRS 
Form 5330 on time.
    Line 8. Check ``Yes'' if the minimum required contribution 
remaining in Line 7c will be made not later than 8\1/2\ months after 
the end of the plan year. If ``Yes,'' and contributions are actually 
made by this date, then there will be no reportable deficiency and 
IRS Form 5330 will not need to be filed.
    Line 9. Revenue Procedure 2000-40, 2000-2 C.B. 357, providing 
for automatic approval for a change in funding method for a plan 
year, generally does not apply unless the plan administrator or an 
authorized representative of the plan sponsor explicitly agrees to 
the change. If a change in funding method made pursuant to such a 
revenue procedure (or a class ruling letter) is to be applicable for 
the current plan year, this line generally must be checked ``Yes.'' 
In certain situations, however, the requirement that the plan 
administrator or an authorized representative of the plan sponsor 
agree to the change in funding method will be satisfied if the plan 
administrator or an authorized representative of the plan sponsor is 
made aware of the change.
    In these situations, this line must be checked ``N/A.'' See 
section 6.01(2) of Rev. Proc. 2000-40. If the plan's change in 
funding method is not made pursuant to a revenue procedure or other 
authority providing automatic approval which requires plan sponsor 
agreement, or to a class ruling letter (e.g., it is pursuant to a 
regulation or the Preservation of Access to Care for Medicare 
Beneficiaries and Pension Relief Act of 2010 (PRA 2010), Pub. L. 
111-192), then this line should be checked ``N/A.''

Part III--Determination and Amendments

    Line 10. If this is a defined benefit pension plan, indicate as 
follows whether there were

[[Page 47644]]

any amendments adopted during this plan year that increased or 
decreased the value of benefits:
     Check ``No'' if no amendments were adopted during this 
plan year that increased or decreased the value of benefits.
     Check ``Increase'' if an amendment was adopted during 
the plan year that increased the value of benefits in any way. This 
includes an amendment providing for an increase in the amount of 
benefits or rate of accrual, more generous lump sum factors, COLAs, 
more rapid vesting, additional payment forms, or earlier eligibility 
for some benefits.
     Check ``Decrease'' if an amendment was adopted during 
the plan year that decreased the value of benefits in any way. This 
includes a decrease in future accruals, closure of the plan to new 
employees, or accruals being frozen for some or all participants.
     If the amendments that were adopted increased the value 
of some benefits but decreased the value of others, check ``Both.''
    Line 11a. If a plan sponsor or an employer adopted a pre-
approved plan that includes a master & prototype plan (a 
standardized or nonstandardized M&P) or a volume submitter plan, 
enter the date of the most recent favorable opinion or advisory 
letter issued by the IRS and the serial number listed on that 
favorable letter.
    Line 11b. If it is an individually-designed plan and received a 
favorable determination letter from the IRS, enter the date of the 
most recent determination letter. Leave it blank if this individual-
designed plan has never received a favorable determination letter.

Part IV--Additional Employer Information for Multiemployer Defined 
Benefit Pension Plans

    If this is not a multiemployer plan, skip this Part.
    Required attachments. Multiemployer defined benefit pension 
plans that are in Endangered Status or Critical Status must attach a 
summary of their Funding Improvement Plan or Rehabilitation Plan (as 
updated, if applicable) and also any update to a Funding Improvement 
Plan or Rehabilitation Plan.
    The summary of any Funding Improvement Plan or Rehabilitation 
Plan must reflect such plan in effect at the end of the plan year 
(whether the original Funding Improvement Plan or Rehabilitation 
Plan or as updated) and must include a description of the various 
contribution and benefit schedules that are being provided to the 
bargaining parties and any other actions taken in connection with 
the Funding Improvement Plan or Rehabilitation Plan, such as use of 
the shortfall funding method or extension of an amortization period. 
The summary must also identify the first year and the last year of 
the Funding Improvement Period or the Rehabilitation Period. If an 
extended Funding Improvement Period (of 13 or 18 years) or 
Rehabilitation Period (of 13 years) applies because of an election 
under section 205 of the Worker, Retiree, and Employer Recovery Act 
of 2008 (``WRERA''), the summary must include a statement to that 
effect and the date that the election was filed with the IRS.
    The summary must also include a schedule of the expected annual 
progress for the funded percentage or other relevant factors under 
the Funding Improvement Plan or Rehabilitation Plan. If the sponsor 
of a multiemployer plan in Critical Status has determined that, 
based on reasonable actuarial assumptions and upon exhaustion of all 
reasonable measures, the plan cannot emerge from Critical Status by 
the end of the Rehabilitation Period as described in Code section 
432(e)(3)(A)(ii), the summary must include an explanation of the 
alternatives considered, why the plan is not reasonably expected to 
emerge from Critical Status by the end of the Rehabilitation Period, 
and when, if ever, it is expected to emerge from Critical Status 
under the Rehabilitation Plan.
    The plan sponsor is required to annually update a Funding 
Improvement Plan or Rehabilitation Plan that was adopted in a prior 
year. The update must be filed as an attachment to the Schedule R. 
The update attachment must identify the modifications made to the 
Funding Improvement Plan or Rehabilitation Plan during the plan 
year, including contribution increases, benefit reductions, or other 
actions.
    The attachment described above must be labeled ``Schedule R, 
Summary of Funding Improvement Plan,'' or ``Schedule R, Summary of 
Rehabilitation Plan'' as appropriate, and if applicable, ``Schedule 
R, Update of Funding Improvement Plan or Rehabilitation Plan.'' Each 
attachment must also include the plan name, the plan sponsor's name 
and EIN, and the plan number.
    Line 12. This line should be completed only by multiemployer 
defined benefit pension plans that are subject to the minimum 
funding standards (see Code section 412 and Part 3 of Title I of 
ERISA). Enter the information on Lines 13a through 13e for any 
employer that contributed more than five (5) percent of the plan's 
total contributions for the 20XX plan year. List employers in 
descending order according to the dollar amount of their 
contributions to the plan. Complete as many entries as are necessary 
to list all employers that contributed more than five (5) percent of 
the plan's contributions.
    Line 12a. Enter the name of the employer contributing to the 
plan.
    Line 12b. Enter the EIN of the employer contributing to the 
plan. Do not enter a social security number in lieu of an EIN; 
therefore, ensure that you have the employer's EIN and not a social 
security number. The Form 5500 Annual Return/Report is open to 
public inspection, and the contents are public information and are 
subject to publication on the Internet. Because of privacy concerns, 
the inclusion of a social security number or any portion thereof on 
this line may result in the rejection of the filing.
    EINs can be obtained from the IRS online, by telephone, by fax, 
or by mail depending on when you need to use the EIN. For more 
information, see Section 3: Electronic Filing Requirement. The EBSA 
does not issue EINs.
    Line 12c. Dollar Amount Contributed. Enter the total dollar 
amount contributed to the plan by the employer for all covered 
workers in all locations for the plan year. Do not include the 
portion of an aggregated contribution that is for another plan, such 
as a welfare benefit plan, a defined contribution pension plan or 
another defined benefit pension plan.
    Line 12d. Collective Bargaining Agreement Expiration Date. Enter 
the date on which the employer's collective bargaining agreement 
expires. If the employer has more than one collective bargaining 
agreement requiring contributions to the plan, check the box and 
include, as an attachment, the expiration date of each collective 
bargaining agreement (regardless of the amount of contributions 
arising from such agreement). Label the attachment: ``Schedule R, 
line 12d--Collective Bargaining Agreement Expiration Date.'' Include 
the plan name and the sponsor's name and EIN.
    Line 12e. Contribution Rate Information. Enter the contribution 
rate (in dollars and cents) per contribution base unit in Line 
12e(1) and the base unit measure in Line 12e(2). Indicate whether 
the base unit is measured on an hourly, weekly, unit-of-production, 
or other basis. If ``Other,'' specify the base unit measure used. If 
the contribution rate changed during the plan year, enter the last 
contribution rate in effect for the plan year.
    If the employer has different contribution rates for different 
classifications of employees or different places of business, check 
the box in the first line of Line 12e and list in an attachment each 
contribution rate and corresponding base unit measure under which 
the employer made contributions (regardless of the amount of 
contributions resulting from each rate). Label the attachment: 
``Schedule R, Line 12e--Information on Contribution Rates and Base 
Units.'' Include the plan name and the sponsor's name and EIN.
    Line 13. Enter the number of participants on whose behalf no 
contributions were made by an employer as an employer of the 
participant. For purposes of Line 13, count only those participants 
whose last contributing employer had withdrawn from the plan by the 
beginning of the relevant plan year. Disregard any participants 
whose employers had not withdrawn from the plan, even if, in the 
relevant year, no contributions were made by the employer on behalf 
of those participants. Thus, for the limited purposes of Line 13 and 
notwithstanding any contrary definition of such participants 
applicable elsewhere, the deferred vested and retired participants 
of employers who have not withdrawn from the plan should not be 
included in these numbers.
    Note. Withdrawal liability payments are not to be treated as 
contributions for the purpose of determining the number of 
participants for Line 13.
    Line 13a. Enter the number of participants for the 20XX plan 
year described in the Line 13 instructions.
    Line 13b. Enter the number of participants for the 20XX-1 plan 
year described in the Line 13 instructions.
    Line 13c. Enter the number of participants for the 20XX-2 plan 
year described in the Line 13 instructions.
    Line 14. Enter the ratio of number of participants on whose 
behalf no employer

[[Page 47645]]

had an obligation to make a contribution for the 20XX plan year to 
the corresponding number for each of the two preceding plan years. 
For the purpose of these ratios, count all participants whose 
employers have withdrawn from the plan as well as all deferred 
vested and retired participants of employers still active in the 
plan (unless the collective bargaining agreement specifically 
requires the employer to make contributions for such participants).
    Line 14a. Enter the ratio of the number of participants as 
described in the Line 14 instructions for the 20XX plan year to the 
number for the 20XX-1 plan year.
    Line 14b. Enter the ratio of the number of participants as 
described on the Line 14 instructions for the 20XX plan year to the 
number for the 20XX-2 plan year.
    Note. Withdrawal liability payments are not to be treated as 
contributions for determining the number of participants on Line 14.
    Line 15a. Enter the number of employers that withdrew from the 
plan during the 20XX-1 plan year.
    Line 15b. If Line 15a is greater than zero, enter the aggregate 
amount of withdrawal liability assessed against these employers. If 
the withdrawal liability for one or more withdrawing employers has 
not yet been determined, include the amounts estimated to be 
assessed against them in the aggregate amount.
    The definitions of withdrawal are those contained in Section 
4203 of ERISA. If the plan is in the building and construction, 
entertainment, or another industry that has special withdrawal 
rules, withdrawing employers should only be counted if the 
withdrawal adheres to the special rules applying to its specific 
industry.
    Line 16. If assets and liabilities from another plan were 
transferred to or merged with the assets and liabilities of this 
plan during the 20XX plan year, check the box and provide the 
following information as an attachment. The attachment should 
include the names and employer identification numbers of all plans 
that transferred assets and liabilities to, or merged with, this 
plan. For each plan, including this plan, the attachment should also 
include the actuarial valuation of the total assets and total 
liabilities for the year preceding the transfer or merger, based on 
the most recent data available as of the day before the first day of 
the 20XX plan year. Label the attachment ``Schedule R, Line 16--
Information on Assets and Liabilities Transferred to or Merged with 
This Plan'' and include the plan name and the plan sponsor's name 
and EIN.

Part V--Additional Information for Single-Employer and Multiemployer 
Defined Benefit Pension Plans

    Line 17. If any liabilities to participants or their 
beneficiaries under the plan at the end of the plan year consist of 
liabilities under two (2) or more plans as of the last day of the 
plan year immediately before the 20XX plan year, check the box and 
provide the following information as an attachment. The attachment 
should include the names, employer identification numbers, and plan 
numbers of all plans, including the current plan, that provided a 
portion of liabilities of the participants and beneficiaries in 
question. The attachment should also include the funding percentage 
of each plan as of the last day of the 20XX-1 plan year. For single-
employer plans, the funding percentage is the funding target 
attainment percentage, where the numerator is the value of plan 
assets reduced by the sum of the amount of the prefunding balance 
and the funding standard carryover balance, and the denominator is 
the funding target for the plan (for this purpose, if the plan is in 
at risk status, then the funding target is determined as if the plan 
were not in at risk status). For multiemployer plans, the funding 
percentage is the ratio where the numerator is the actuarial value 
of the plan's assets and the denominator is the accrued liability of 
the plan. For a terminated plan for which the funding percentage is 
required to be reported, write ``Terminated'' in the space where the 
plan's funding percentage would otherwise have been reported. Label 
the attachment ``Schedule R, Line 17--Funded Percentage of Plans 
Contributing to the Liabilities of Plan Participants'' and include 
the plan name and the plan sponsor's name and EIN.
    Line 18. This line must be completed for all defined benefit 
pension plans (except DFEs) with 1,000 or more participants at the 
beginning of the plan year. To determine if the plan has 1,000 or 
more participants, use the participant count shown on Line 3d(1) of 
the Schedule SB for single-employer plans or on Line 2b(4)(1) of the 
Schedule MB for multiemployer plans.
    Line 18a. Show the beginning-of-year distribution of assets for 
the categories shown. Use the market value of assets and do not 
include the value of any receivables. These percentages, expressed 
to the nearest whole percent, should reflect the total assets held 
in stocks, investment-grade debt instruments, high-yield debt 
instruments, real estate, or other asset classes, regardless of how 
they are listed on the Schedule H. The percentages in the five 
categories should sum to 100 percent. Assets held in trusts, 
accounts, mutual funds, and other investment arrangements should be 
disaggregated and properly distributed among the five asset 
components. The assets in these trusts, accounts, mutual funds, and 
investment arrangements should not be included in the ``Other'' 
component unless these investments contain no stocks, bonds, or real 
estate holdings. The same methodology should be used in 
disaggregating trust assets as is used when disclosing the 
allocation of plan assets on the sponsor's 10-K filings to the 
Securities and Exchange Commission. Real estate investment trusts 
(REITs) should be listed with stocks, while real estate limited 
partnerships should be included in the Real Estate category.
    Investment-grade debt-instruments are those with an S&P rating 
of BBB--or higher, a Moody's rating of Baa3 or higher, or an 
equivalent rating from another rating agency. High-yield debt 
instruments are those that have ratings below these rating levels. 
If the debt does not have a rating, it should be included in the 
``high-yield'' category if it does not have the backing of a 
government entity. Unrated debt with the backing of a government 
entity would generally be included in the ``investment-grade'' 
category unless it is generally accepted that the debt should be 
considered as ``high-yield.'' Use the ratings in effect as of the 
beginning of the plan year.
    Line 18b. Check the box that shows the average duration of the 
plan's combined investment-grade and high-yield debt portfolio. If 
the average duration falls exactly on the boundary of two boxes, 
check the box with the lower duration. To determine the average 
duration, use the ``effective duration'' or any other generally 
accepted measure of duration. Report the duration measure used in 
Line 19c. If debt instruments are held in multiple debt portfolios, 
report the weighted average of the average durations of the various 
portfolios where the weights are the dollar values of the individual 
portfolio.

Part VI Nondiscrimination and Coverage

    Note. You must complete this part from Lines 19 through 21 if 
you are required to file at least 250 returns of any type with the 
IRS, including information returns (for example, Forms W-2 and Forms 
1099), income tax returns, employment tax returns, and excise tax 
returns, during the calendar year. However, if you are a small filer 
(files fewer than 250 returns of any type with the IRS during the 
calendar year), and you do not complete these lines, you must file 
Form 5500-SUP with the IRS on paper. See the Treasury regulations on 
``Employee Retirement Benefit Plan Returns Required on Magnetic 
Media'' (See 79 FR 58256 at http://federalregister.gov/a/2014-23161) 
and Instructions for Form 5500-SUP for more information.
    19a. Check ``Yes'' if the plan includes a cash or deferred 
arrangement (CODA), under which a covered employee may elect to have 
the employer either contribute an amount to the plan's trust on 
behalf of the employee or to pay the employee directly in cash or 
some other taxable benefit. The contributions go into an individual 
account, with the employee often choosing the investments based on 
options provided under the plan. In some plans, the employer also 
makes contributions, such as contributions that match the employee's 
contributions up to a certain percentage.
    Line 19b. If Line 19a is ``Yes,'' check the applicable method 
used to satisfy the nondiscrimination requirements of Code section 
401(k). A safe harbor 401(k) plan is similar to a traditional 401(k) 
plan but, among other things, it must provide for employer 
contributions. These contributions may be employer matching 
contributions, limited to employees who defer, or employer 
contributions made on behalf of all eligible employees, regardless 
of whether they make elective deferrals. The safe harbor 401(k) plan 
is not subject to the complex annual nondiscrimination tests that 
apply to traditional 401(k) plans. Check ``Design-based safe harbor 
method'' if this is a safe harbor 401(k) plan that is a SIMPLE 
401(k) plan under Code section 401(k)(11), a safe harbor 401(k) plan 
under Code section 401(k)(12), or a qualified automatic

[[Page 47646]]

contribution arrangement under Code section 401(k)(13).
    If the plan, by its terms, does not satisfy the safe harbor 
method, it generally must satisfy the regular nondiscrimination 
test, known as the actual deferral percentage (ADP) test. Check the 
appropriate box to indicate if the plan uses the ``current year'' 
ADP test or the ``prior year'' ADP test. Check ``current year'' ADP 
test if the plan uses the current year testing method under which 
the ADP test is performed by comparing the current plan year's ADP 
for HCEs with the current plan year's (rather than the prior plan 
year's) ADP for NHCEs. Check all boxes that apply for a plan that 
tests different groups of employees on a disaggregated basis. Check 
``N/A'' if the plan is not required to test for nondiscrimination 
under Code section 401(k)(3), such as a plan in which no HCE is 
benefiting.
    Line 20a. Check the applicable testing method used to satisfy 
the minimum coverage requirements under Code section 410(b). Check 
``N/A'' if the plan is deemed to satisfy section 410(b) 
automatically, such as a plan in which no HCE is benefitting. Check 
all boxes that apply for a plan that tests different groups of 
employees on a disaggregated basis.
    Line 20b. Check ``Yes'' if this plan was permissively aggregated 
with another plan to satisfy requirements under Code sections 410(b) 
and 401(a)(4). Generally, each single plan must separately satisfy 
the coverage and nondiscrimination requirements. However, an 
employer may designate two or more separate plans as a single plan 
for purposes of applying the ratio percentage test of Treasury 
Regulations section 1.410(b)-2(b)(2) or the nondiscretionary 
classification test of Treasury Regulations section 1.401(b)-4. Two 
or more plans that are permissively aggregated and treated as a 
single plan for purposes of the minimum coverage test of Code 
section 410(b) must also be treated as a single plan for purpose of 
the nondiscrimination test under Code section 401(a)(4). See 
Treasury Regulations sections 1.410(b)-7 and 1.401(a)(4)-(9) for 
more information.
    Line 21. Check ``Yes'' if the plan does not satisfy any 
exceptions under Treasury Regulation section 1.401(a)26)-1(b) if it 
benefitted at least the lesser of: 50 employees of the employer, or 
the greater of: 40 percent of all employees of the employer, or 2 
employees (or if there is only 1 employee, such employer). The 
definition of employer includes all related employers under Code 
sections 414(b), (c) or (m). In performing the participation tests, 
the employees who are excludable are generally the same as those who 
are excludable for purposes of performing coverage tests under Code 
section 410(b), see Treasury Regulation section 1.401(a)(26)-6. In 
addition, for most plans the definition of who is benefiting under 
the plan for the purposes of the participation tests is the same as 
the definition of benefiting employees for purposes of coverage 
tests under Code section 410(b), see Treasury Regulation section 
1.401(a)(26)-5.

Part VII Participation Information in Defined Contribution Pension 
Plans

    Line 22. Employer Contributions. Check ``Yes'' in Line 22a if 
the employer provided contributions to the participant's defined 
contribution pension account regardless of whether the participant 
made any contributions. If ``Yes'' is checked in Line 22a, enter in 
Line 22b the appropriate line the formula describing how the amount 
of such employer contributions was determined. See formula examples 
below.
    Example 1: The employer provided 1.5% of compensation for each 
participant. Check the ``% of a participant's compensation'' formula 
and enter ``1.5'' in the corresponding amount line.
    Example 2: The employer provided one flat dollar amount ($500) 
to each participant. Check the ``$ per participant'' formula and 
enter ``500'' in the corresponding amount line.
    Example 3: The employer used a different kind of formula or 
method. Check ``Other'' and enter a description in the text field.
    Line 23. Employer Matching Contributions. If the plan offers 
employer matching contributions, check ``Yes'' in Line 23a. If you 
checked ``Yes'' in Line 23a, check the appropriate box in Line 23b 
to identify the formula used to determine the amount of the employer 
matching contribution for each participant. If the employer matches 
participant contributions at a certain rate up to a limit, check ``% 
of a participant's contribution up to a limit'' and enter the 
percentage. In Line 23c, enter the maximum employer contribution by 
checking the applicable box and providing either the percentage of a 
participant's compensation or the dollar amount that corresponds to 
the maximum. If the plan uses a different type of formula, check 
``Other'' and describe the formula in the open text field. See 
formula examples below.
    Example 1: The employer provides a 50% match on participant 
contributions of up to 6% of the participant's compensation. When 
the participant is contributing at or above the maximum, the 
employer contributes 3% of the participant's compensation. Check the 
``% of a participant's contribution up to a limit'' formula and 
enter ``50''. The maximum match that the employer will contribute is 
``3''.
    Example 2: The employer provides a 50% match on a participant's 
contributions up to $3,000 contribution by the employee. At that 
maximum level the employer would be contributing $1,500. Check the 
``$ per participant'' formula and enter ``1500'' in the 
corresponding amount line.
    Example 3: The employer provides 100% match up to the first 3% 
of employee's salary deferrals and 50% for the next 2%. Check the 
``Other'' box and describe the formula in the open text field.
    Line 24. Automatic Enrollment. Answer ``Yes'' in Line 24a if the 
plan has automatic enrollment. If you answer ``Yes,'' enter the 
default elective deferral as a percentage of a participant's 
compensation in the first year after a participant is automatically 
enrolled. In Line 24b, indicate whether the plan has automatic 
escalation, assuming a participant has made no active elections. If 
the plan has automatic escalation, indicate the maximum elective 
deferral as a percentage of a participant's compensation. In Line 
24c enter the number of participants that remain in the plan's 
default investment account(s) and have not directed any assets into 
other plan investments.
    Line 25. Catch-up Contributions. Enter the number of 
participants making catch-up contributions.

20XX Instructions for Schedule SB (Form 5500)--Single-Employer Defined 
Benefit Plan Actuarial Information

General Instructions

    Note. Final regulations under certain portions of Code section 
430 (sections 430(d), 430(f), 430(g), 430(h), and 430(i)) and Code 
section 436 (and the corresponding provisions of ERISA (sections 
206(g) and 303)) were published in the Federal Register July 31, 
2008, and October 15, 2009, and apply for plan years beginning on or 
after January 1, 2010. Proposed regulations providing additional 
rules under Code sections 430(a), 430(j) and 4971 (and the 
corresponding provisions of ERISA (section 303)) were published in 
the Federal Register on April 15, 2008. The final regulations that 
relate to those proposed regulations have a later effective date 
than the final regulations published October 15, 2009. With respect 
to provisions for which the final regulations do not apply to a plan 
for the plan year, plan sponsors must follow a reasonable 
interpretation of the statute, taking into account the provisions of 
the Worker, Retiree, and Employer Recovery Act of 2008 (``WRERA''), 
Public Law 110-458, the Preservation of Access to Care for Medicare 
Beneficiaries and Pension Relief Act of 2010 (``PRA 2010''), Public 
Law 111-192, Moving Ahead for Progress in the 21st Century Act 
(``MAP-21''), Public Law 112-141, and any other amendments to the 
funding rules that are enacted. For this purpose, plan sponsors may 
rely on the provisions of the proposed regulations or the final 
regulations, as applicable, but must take into account the 
provisions of WRERA, PRA 2010, MAP-21, any other amendments to the 
funding rules that are enacted, and any applicable published 
guidance.

Who Must File

    As the first step, the plan administrator of any single-employer 
defined benefit pension plan (including a multiple-employer defined 
benefit pension plan) that is subject to the minimum funding 
standards (see Code section 412 and Part 3 of Title I of ERISA) must 
obtain a completed Schedule SB (including attachments) that is 
prepared and signed by the plan's enrolled actuary as discussed 
below in the Statement by Enrolled Actuary section. The plan 
administrator must retain with the plan records the Schedule SB that 
is prepared and signed by the plan's actuary. The electronic-
signature by the plan actuary is acceptable. The plan actuary can 
access the EFAST2 Web site at www.efast.dol.gov to register for 
electronic credentials to sign.
    The plan administrator must ensure that the information from the 
actuary's Schedule SB is entered electronically into the annual

[[Page 47647]]

return/report being submitted. When entering the information, 
whether using EFAST2-approved software or EFAST2's web-based filing 
system, all the fields required for the type of plan must be 
completed (see instructions for fields that need to be completed).
    Further, if a plan actuary chooses not to sign electronically, 
then the actuary must manually sign the Schedule SB and an 
electronic reproduction must be filed with the Form 5500. The plan 
administrator of a single-employer defined benefit pension plan must 
attach to the Form 5500 or Form 5500-SF an electronic reproduction 
of the Schedule SB (including attachments) prepared and signed by 
the plan's enrolled actuary. This electronic reproduction must be 
labeled ``SB Actuary Signature'' and must be included as a Portable 
Document Format (PDF) attachment or any alternative electronic 
attachment allowable under EFAST2.
    Note. The Schedule SB (Form 5500) does not have to be filed with 
the Form 5500-EZ, but it must be retained (in accordance with the 
Instructions for Form 5500-EZ under the What To File section). 
Similarly, the Schedule SB does not have to be filed with the Form 
5500-SF for a one-participant plan (as defined in the Form 5500-EZ 
instructions) that is eligible for the Form 5500-SF and elects to 
file such form instead of the Form 5500-EZ. However, the Schedule SB 
must be retained in accordance with the Instructions for Form 5500-
SF under the section headed Specific Instructions Only for ``One-
Participant Plans.'' The enrolled actuary must complete and sign the 
Schedule SB and forward it to the person responsible for filing the 
Form 5500-EZ or Form 5500-SF, even if the Schedule SB is not filed.
    Check the Schedule SB box on the Form 5500 (Part II, Line 
10a(3)) if a Schedule SB is attached to Form 5500. Check ``Yes'' on 
Line 11 in Part VI of the Form 5500-SF if a Schedule SB is required 
to be prepared for the plan, even if Schedule SB is not required to 
be attached to Form 5500-SF (see instructions in the Note above, 
pertaining to ``one-participant plans'').
    Note. This schedule is not filed for a multiemployer plan nor 
for a money purchase defined contribution pension plan (including a 
target benefit plan) for which a waiver of the minimum funding 
requirements is currently being amortized. Information for these 
plans must be filed using Schedule MB (Form 5500).

Specific Instructions

    Lines A through F. Identifying Information. Lines A-F must be 
completed for all plans. Lines A through D should include the same 
information as reported in corresponding lines in Part II of the 
Form 5500, Form 5500-SF, or Form 5500-EZ filed for the plan. You may 
abbreviate the plan name (if necessary) to fit in the space 
provided.
    Do not use a social security number in line D instead of an EIN. 
The Schedule SB and its attachments are open to public inspection if 
filed with a Form 5500 or Form 5500-SF, and the contents are public 
information and are generally subject to publication on the 
Internet. Because of privacy concerns, the inclusion of a social 
security number or any portion thereof on the Schedule SB or any of 
its attachments may result in the rejection of the filing.
    You can apply for an EIN from the IRS online, by telephone, by 
fax, or by mail depending on how soon you need to use the EIN. For 
more information, see Section 3: Electronic Filing Requirement under 
General Instructions to Form 5500. The EBSA does not issue EINs.
    Line E. Type of Plan. Check the applicable box to indicate the 
type of plan. A single-employer plan for this reporting purpose is 
an employee benefit plan maintained by one employer or one employee 
organization. A multiple-employer plan is a plan that is maintained 
by more than one employer, but is not a multiemployer plan. (See the 
Instructions for Form 5500, box A for additional information on the 
definition of a multiemployer plan.)
    1. Check ``Single'' if the Form 5500, Form 5500-SF, or Form 
5500-EZ is filed for a single-employer plan (including a plan 
maintained by more than one member of the same controlled group).
    2. Check ``Multiple-A'' if the Form 5500 or Form 5500-SF is 
being filed for a multiple-employer plan and the plan is subject to 
the rules of Code section 413(c)(4)(A) (i.e., it is funded as if 
each employer were maintaining a separate plan). This includes plans 
established before January 1, 1989, for which an election was made 
to fund in accordance with Code section 413(c)(4)(A).
    3. Check ``Multiple-B'' if the Form 5500 or Form 5500-SF is 
being filed for a multiple-employer plan and the plan is subject to 
the rules of Code section 413(c)(4)(B) (i.e., it is funded as if all 
participants were employed by a single employer).
    If ``Multiple-A'' is checked, with the exception of Part III, 
the data entered on Schedule SB should be the sum of the individual 
amounts computed for each employer. The percentages reported in Part 
III should be calculated based on the reported aggregate numbers 
rather than by summing up the individual percentages. The Schedule 
SB data for each employer's portion of the plan must be submitted as 
an attachment. This is accomplished by completing and attaching a 
Schedule SB for each employer or by attaching a document containing 
that information (e.g., a table showing a row for each Schedule SB 
data item and a column for each employer). Label the attachment 
``Schedule SB--Information for Each Individual Employer.''
    Line F. Prior Year Plan Size. Check the applicable box based on 
the highest number of participants (both active and inactive) on any 
day of the preceding plan year, taking into account participants in 
all defined benefit pension plans maintained by the same employer 
(or any member of such employer's controlled group) who are or were 
also employees of that employer or member. For this purpose, 
participants whose only defined benefit pension plan is a 
multiemployer plan (as defined in Code section 414(f)) are not 
counted, and participants who are covered in more than one of the 
defined benefit pension plans described above are counted only once. 
Inactive participants include vested terminated and retired 
employees as well as beneficiaries of deceased participants. If this 
is the first plan year that a plan described in this paragraph 
exists, complete this line based on the highest number of 
participants that the plan was reasonably expected to have on any 
day during the first plan year.

General Instructions, Parts I through IX, Statement by Enrolled 
Actuary, and Attachments

    Except as noted below, Parts I through VIII must be completed 
for all single and multiple-employer defined benefit pension plans, 
regardless of size or type. See instructions for Line 31 for 
additional information to be provided for certain plans with special 
circumstances. Part IX is completed only for those plans for which 
an alternative amortization schedule was elected under section 
430(c)(2)(D) of the Code or section 303(c)(2)(D) of ERISA, as 
amended by PRA 2010, and for those plans for which funding relief 
was elected under section 107 of Pension Protection Act of 2006, as 
added by PRA 2010.
    The Pension Protection Act of 2006, as amended (PPA), provides 
delayed effective dates for the funding rules under Code section 430 
for plans meeting certain criteria (certain multiple-employer plans 
maintained by eligible cooperative plans, and eligible charity 
plans, as described in PPA section 104). Eligible plans to which 
these delayed effective dates apply do not need to complete the 
entire Schedule SB, but will have to file information relating to 
pre-PPA calculations in an attachment using the 2007 Schedule B 
form. See the instructions for Line 31 for more information about 
which lines of Schedule SB need to be completed and what additional 
attachments are required.
    PPA provides funding relief for certain defined benefit pension 
plans (other than multiemployer plans) maintained by a commercial 
passenger airline or by an employer whose principal business is 
providing catering services to a commercial passenger airline, based 
on an alternative 17-year funding schedule. Plans using this funding 
relief do not need to complete the entire Schedule SB, but are 
required to provide supplemental information as an attachment to 
Schedule SB. Alternatively, these plans can elect to apply the 
funding rules generally applicable to single-employer defined 
benefit pension plans, but amortize the funding shortfall over 10 
years instead of the standard 7-year period and use a special 
interest rate to determine the funding target. Plans using this 10-
year funding option must complete the entire Schedule SB and provide 
additional information. See the instructions for Line 31 for more 
information about which lines of Schedule SB need to be completed 
and what additional attachments are required.
    MAP-21 amended Code section 430(h)(2)(C) and ERISA section 
302(h)(2)(C) to provide that, for certain purposes, each of the 
three segment rates described in those sections is adjusted as 
necessary to fall within a specified range that is determined based 
on an average of the corresponding

[[Page 47648]]

segment rates for the 25-year period ending on September 30 of the 
calendar year preceding the first day of the plan year. Accordingly, 
if the funding target and target normal cost for a plan are 
determined using these segment rates, the segment rates used to 
determine the minimum required contribution and the adjusted funding 
target attainment percentage (``AFTAP'') used to apply funding-based 
benefit restrictions under Code section 436 and ERISA section 206(g) 
may be different from those used for other purposes (such as the 
segment rates used to determine the deductible limit under Code 
section 404(o)). In such cases, report all information on Schedule 
SB reflecting the assumptions used to determine the minimum required 
contribution and the AFTAP used to apply funding-based benefit 
restrictions.
    Note. (1) For a plan funded with insurance (other than a plan 
described in Code section 412(e)(3) or ERISA section 301(b)), refer 
to section 1.430(d)-1(c)(2) of the Income Tax Regulations regarding 
whether to include the liabilities for benefits covered under 
insurance contracts held by the plan and whether to include the 
value of the insurance contracts in plan assets. (2) For terminating 
plans, Rev. Rul. 79-237, 1979-2 C.B. 190, provides that minimum 
funding standards apply until the end of the plan year that includes 
the termination date. Accordingly, the Schedule SB is not required 
to be filed for any later plan year. However, if a termination fails 
to occur--whether because assets remain in the plan's related trust 
(see Rev. Rul. 89-87, 1989-2 C.B. 81) or for any other reason (e.g., 
the PBGC issues a notice of noncompliance pursuant to 29 CFR 4041.31 
for a standard termination)--there is no termination date, and 
therefore, minimum funding standards continue to apply and a 
Schedule SB continues to be required.

Statement by Enrolled Actuary

    An enrolled actuary must sign Schedule SB with either an 
electronic signature or a handwritten signature. The electronic 
signature of the enrolled actuary may be qualified to state that it 
is subject to attached qualifications. See Treasury Regulations 
section 301.6059-1(d) for permitted qualifications. If the actuary 
has not fully reflected any final or temporary regulation, revenue 
ruling, or notice promulgated under the statute in completing the 
Schedule SB, check the box on the last line of page 1. If this box 
is checked, indicate on this line whether any unpaid required 
contribution or a contribution that is not wholly deductible would 
result if the actuary had fully reflected such regulation, revenue 
ruling, or notice. In addition, the actuary may offer any other 
comments related to the information contained in Schedule SB. Except 
as otherwise provided in these instructions, a stamped or machine 
produced signature is not acceptable.
    The actuary must provide the completed and signed Schedule SB to 
the plan administrator to be retained with the plan records and 
included (in accordance with these instructions) with the Form 5500 
or Form 5500-SF that is submitted under EFAST2. The plan's actuary 
is permitted to electronically sign the Schedule SB, or sign on page 
one using the actuary's signature or by inserting the actuary's 
typed name in the signature line followed by the actuary's 
handwritten initials. The actuary's most recent enrollment number 
must be entered on the Schedule SB that is prepared and signed by 
the plan's actuary.

Attachments

    All attachments to the Schedule SB must be properly identified 
as attachments to the Schedule SB, and must include the name of the 
plan, plan sponsor's EIN, plan number, and line number to which the 
schedule relates.
    Do not include attachments that contain a visible social 
security number. Except for certain one-participant plans, the 
Schedule SB and its attachments are open to public inspection, and 
the contents are public information and are subject to publication 
on the Internet. Because of privacy concerns, the inclusion of a 
visible social security number or any portion thereof on an 
attachment may result in the rejection of the filing.

Part I--Basic Information

    Note. All entries in Part I must be reported as of the valuation 
date, reflecting the assumptions and amounts generally used to 
determine the minimum required contribution. In the case of a plan 
described in section 104 of PPA, the information should be reported 
as if PPA provisions were effective for all plan years beginning 
after December 31, 2007.
    Line 1. Valuation Date. The valuation date for a plan year must 
be the first day of the plan year unless the plan meets the small-
plan exception of Code section 430(g)(2)(B) and ERISA section 
303(g)(2)(B). For plans that qualify for the exception, the 
valuation date may be any date in the plan year, including the first 
or last day of the plan year. A plan qualifies for this small-plan 
exception if there were 100 or fewer participants on each day of the 
prior plan year. For the definition of participant as it applies in 
this case, see the instructions for Line F.
    Line 2a. Market Value of Assets. Enter the fair market value of 
assets as of the valuation date. Include contributions designated 
for any previous plan year that are made after the valuation date 
(but within the 8\1/2\-month period after the end of the immediately 
preceding plan year), adjusted for interest for the period between 
the date of payment and the valuation date as provided in the 
applicable regulations.
    Contributions made for the current plan year must be excluded 
from the amount reported in Line 2a. If these contributions were 
made prior to the valuation date (which can only occur for small 
plans with a valuation date other than the first day of the plan 
year), the asset value must be adjusted to exclude not only the 
contribution amounts, but interest on the contributions from the 
date of payment to the valuation date, using the current-year 
effective interest rate.
    Do not adjust for items such as the funding standard carryover 
balance, prefunding balance, any unpaid minimum required 
contributions, or the present value of remaining shortfall or waiver 
amortization installments. Rollover amounts or other assets held in 
individual accounts that are not available to provide defined 
benefits under the plan should not be included on Line 2a regardless 
of whether they are reported on the Schedule H (Form 5500) (line 1l, 
column (a)) or Form 5500-SF (Line 7c, column (a)). Additionally, 
asset and liability amounts must be determined in a consistent 
manner. Therefore, if the value of any insurance contracts has been 
excluded from the amount reported in Line 2a, liabilities satisfied 
by such contracts should also be excluded from the funding target 
values reported in Lines 3 and 4.
    Line 2b. Actuarial Value of Assets. Do not adjust the actuarial 
value of assets for items such as the funding standard carryover 
balance, the prefunding balance, any unpaid minimum required 
contributions, or the present value of any remaining shortfall or 
waiver amortization installments. Treat contributions designated for 
a current or prior plan year, rollover amounts, insurance contracts, 
and other items in the same manner as for Line 2a. If an averaging 
method is used to value plan assets (as permitted under Code section 
430(g)(3)(B) and ERISA section 303(g)(3)(B), as amended by WRERA), 
enter the value as of the valuation date taking into account the 
requirement that such value must be within 90% to 110% of the fair 
market value of assets.
    Note. Under Code section 430(g)(3)(B), the use of averaging 
methods in determining the value of plan assets is permitted only in 
accordance with methods prescribed in Treasury regulations. 
Accordingly, taxpayers cannot use asset valuation methods other than 
fair market value (as described in Code section 430(g)(3)(A)), 
except as provided under Notice 2009-22, 2009-14 I.R.B. 741, or 
Treasury regulations.
    Line 3. Funding Target/Participant Count Breakdown. All amounts 
should be reported as of the valuation date.
     Column (1)--Enter the number of participants, including 
beneficiaries of deceased participants, who are or who will be 
entitled to benefits under the plan.
     Column (2)--Enter the portion of the funding target 
attributable to vested benefits. For this purpose benefits 
considered to be vested for PBGC premium purposes must be included.
     Column (3)--Enter the funding target attributable to 
all benefits, both vested and nonvested.
    For columns (2) and (3), the funding target must be calculated 
using the methods and assumptions provided in Code sections 430(h) 
and (i), ERISA sections 303(h) and (i), and other related guidance.
    Unless the plan sponsor has received approval to use substitute 
mortality tables in accordance with Code section 430(h)(3)(C) and 
ERISA section 303(h)(3)(C), the funding target must be computed 
using the mortality tables for non-disabled lives, as described in 
section 1.430(h)(3)-1 of the regulations. If substitute mortality 
tables have been approved (or deemed to have been approved) by the 
IRS, such tables must be used instead of the mortality tables 
described in the previous sentence, subject to the rules of

[[Page 47649]]

Code section 430(h)(3) and ERISA section 303(h)(3). The funding 
target may be computed taking into account the mortality tables for 
disabled lives published in Rev. Rul. 96-7, 1996-1 C.B. 59, and as 
provided in Notice 2008-29, 2008-12 I.R.B. 637.
    Special rules for plans that are in at-risk status. If a plan is 
in at-risk status, report the amount reflecting the additional 
assumptions required in Code section 430(i)(1)(B) and ERISA section 
303(i)(1)(B).
    If the plan has been in at-risk status for any two or more of 
the preceding four plan years, also include the loading factor 
required in Code section 430(i)(1)(C) and ERISA section 
303(i)(1)(C). If the plan is in at-risk status and has been in at-
risk status for fewer than five consecutive years, report the 
funding target amounts after reflecting the transition rule provided 
in Code section 430(i)(5) and ERISA section 303(i)(5). For example, 
the funding target for a plan that is in at-risk status for 20XX and 
was in at-risk status for the 20XX-3, 20XX-2 and 20XX-1 plan years 
(but not the 20XX-4 plan year) will reflect 80% of the funding 
target using the special at-risk assumptions and 20% of the funding 
target determined without regard to the at-risk assumptions.
    Determining whether a plan is in at-risk status. Refer to Code 
section 430(i)(4) and ERISA section 303(i)(4) to determine whether 
the plan is in at-risk status. Generally, a plan is in at-risk 
status for a plan year if it had more than 500 participants on any 
day during the preceding plan year (see instructions for Line F for 
the definition of participants) and the plan's funding target 
attainment percentage (``FTAP'') for the preceding plan year fell 
below specified thresholds.
    A plan with over 500 participants is in at-risk status for 20XX 
if both:
    1. the FTAP for 20XX-1 (Line 17 of the for 20XX-1 Schedule SB) 
is less than 80%, and
    2. the at-risk funding target attainment percentage for 20XX-1 
is less than 70%.
    In general, the at-risk funding target attainment percentage is 
determined in the same manner as the FTAP (as described in the 
instructions for Line 17), except that the funding target is 
determined using the additional assumptions for plans in at-risk 
status. For this purpose, the at-risk funding target is determined 
by disregarding the transition rule of Code section 430(i)(5) and 
ERISA section 303(i)(5) for plans that have been in at-risk status 
for fewer than five consecutive years, and disregarding the loading 
factor in Code section 430(i)(1)(C) and ERISA section 303(i)(1)(C). 
For plans that were in at-risk status for the 20XX-1 plan year, the 
at-risk funding target used to determine whether the plan is in at-
risk status for the 20XX plan year is the amount reported in Line 4b 
of the 20XX-1 Schedule SB.
    Refer to the regulations under section 430(i) of the Code for 
rules pertaining to new plans and other special situations.
    Line 4. Additional Information for Plans in At-Risk Status. If 
the plan is in at-risk status as provided under Code section 
430(i)(4) and ERISA section 303(i)(4), check the box, complete Lines 
4a through 4d, and include as an attachment the information 
described below. Do not complete Line 4 if the plan is not in at-
risk status for the current plan year for purposes of determining 
the minimum required contribution.
     Column 1--Enter the amount of the funding target 
determined as if the plan were not in at-risk status.
     Column 2--Report the funding target disregarding the 
transition rule of Code section 430(i)(5) and ERISA section 
303(i)(5), and disregarding the loading factor in Code section 
430(i)(1)(C) and ERISA section 303(i)(1)(C).
    If the plan is in at-risk status for the current plan year, 
include a description of the at-risk assumptions for the assumed 
form of payment (e.g., specify the optional form resulting in the 
highest present value) in the attachment for Part V regarding the 
actuarial assumptions. Label this information in the attachment 
``Schedule SB, Line 4--Additional Information for Plans in At-Risk 
Status.''
    Line 5. Effective Interest Rate. Enter the single rate of 
interest which, if used instead of the interest rate(s) reported in 
Line 24 to determine the present value of the benefits that are 
taken into account in determining the plan's funding target for a 
plan year, would result in an amount equal to the plan's funding 
target determined for the plan year, without regard to calculations 
for plans in at-risk status. (This is the funding target reported in 
Line 3d, column (3) for plans not in at-risk status, or in Line 4a 
for plans in at-risk status.) However, if the funding target for the 
plan year is zero, the effective interest rate is determined as the 
single rate that would result in an amount equal to the plan's 
target normal cost determined for the plan year, without regard to 
calculations for plans in at-risk status. See the provisions of Code 
section 430(h)(2)(A), ERISA section 303(h)(2)(A), and the applicable 
regulations. Enter rate to the nearest .01% (e.g., 5.26%).
    Line 6a. Target Normal Cost. (Without Plan-Related Expenses). 
Report the present value of all benefits which have been accrued or 
have been earned (or that are expected to accrue or to be earned) 
under the plan during the plan year . Include any increase in 
benefits during the plan year that is a result of any actual or 
projected increase in compensation during the current plan year, 
even if that increase in benefits is with respect to benefits 
attributable to services performed in a preceding plan year. This 
amount must be calculated as of the valuation date and must 
generally be based on the same assumptions used to determine the 
funding target reported in Line 3c, column (3), reflecting the 
special assumptions and the loading factor for at-risk plans, if 
applicable. If the plan is in at-risk status for the current plan 
year and has been in at-risk status for fewer than five consecutive 
years, report the target normal cost after reflecting the transition 
rule provided in Code section 430(i)(5) and ERISA section 303(i)(5). 
Do not increase the amount by plan expenses and do not reduce the 
amount by mandatory employee contributions.
    Line 6b. Plan-Related Expenses. Report any plan-related expenses 
expected to be paid from plan assets during the plan year.
    Line 6c. Total Target Normal Cost. Report the total target 
normal cost (sum of Lines 6a and 6b minus mandatory employee 
contributions expected to be made during the plan year, but not less 
than zero).
    Special rule for airlines using 10-year amortization period 
under section 402(a)(2) of PPA. Section 402(a)(2) of PPA (as amended 
by section 6615 of the U.S. Troop Readiness, Veterans' Care, Katrina 
Recovery, and Iraq Accountability Appropriations Act, 2007, Pub. L. 
110-28 (121 Stat.112)) states that for plans electing the 10-year 
amortization period, the funding target during that period is 
determined using an interest rate of 8.25% rather than the interest 
rates or segment rates calculated on the basis of the corporate bond 
yield curve. However, this special 8.25% interest rate does not 
apply for other purposes, including the calculation of target normal 
cost or the amortization of the funding shortfall. Report the target 
normal cost using the interest rates or segment rates otherwise 
applicable under 430(h)(2) and ERISA section 303(h)(2).

Part II--Beginning of Year Carryover Prefunding Balances

    Line 7. Balance at Beginning of Prior Plan Year After Applicable 
Adjustments. In general, report the amount in the corresponding 
columns of Line 13 of the prior-year Schedule SB. See instructions 
for Line 14 if the balance from the prior year has been adjusted so 
that it does not match the corresponding amount in Line 13 of the 
prior-year Schedule SB. Note that elections to add excess 
contributions or reduce balances have specific deadlines, and 
generally cannot be changed once they have been made.
    If this is the first year for which the plan is subject to the 
minimum funding rules of Code section 430 or ERISA section 303, 
leave both columns blank.
    Line 8. Portion Elected for Use To Offset Prior Year's Funding 
Requirement. Report the amount for each column from the 
corresponding column of Line 39 of the prior-year Schedule SB. If 
the valuation date is not the first day of the plan year, report the 
amounts from Line 39 of the prior-year Schedule SB, discounted to 
the beginning of the prior plan year using the effective interest 
rate for the prior plan year.
    Reflect the full amount reported in Line 39 of the prior-year 
Schedule SB even if the amount is larger than the minimum required 
contribution reported for that year on Line 38 of the prior-year 
Schedule SB. This can occur under the special rule for elections to 
use balances in excess of the minimum required contribution under 
section 1.430(f)-1(f)(1)(ii) of the regulations, if no timely 
election is made to revoke the excess amount.
    If this is the first year for which the plan is subject to the 
minimum funding rules of Code section 430 or ERISA section 303, 
leave both columns blank.
    Special rule for late election to apply balances to quarterly 
installments. If an election was made to use the funding standard 
carryover balance or the prefunding balance to offset the amount of 
a required quarterly installment, but the election was made after 
the due date of the installment, the amount reported on Line 8 may 
not be

[[Page 47650]]

the same as the amount reported on Line 39 for the prior year. Refer 
to the regulations under section 430 of the Code for additional 
information. See instructions for Line 15 if a late election to 
apply the balances to quarterly installments was made.
    Line 9. Amount Remaining. Enter the amount equal to Line 7 minus 
Line 8 in each column. If this is the first year that the plan is 
subject to the minimum funding requirements of Code section 430 or 
ERISA section 303, enter the amount of any credit balance at the end 
of the prior year (the ``pre-effective plan year'') on Line 9, 
column (a) and leave Line 9, column (b) blank. The amount entered on 
Line 9, column (a) is generally the amount reported for the pre-
effective plan year on Line 9o of the 2007 version of the Schedule B 
form that was submitted as an attachment to the Schedule SB for that 
pre-effective plan year. See instructions for Line 16 if there has 
been any adjustment to this amount so that it does not match the 
amount so reported for the pre-effective plan year.
    Line 10. Interest on Line 9. Enter the actual rate of return on 
plan assets during the preceding plan year in the space provided. 
Enter the rate to the nearest .01% (e.g., 6.53%). If entering a 
negative number, enter a minus sign (``-'') to the left of the 
number. In each column, enter the product of this interest rate and 
the amount reported in the corresponding column of Line 9. If this 
is the first year for which the plan is subject to the minimum 
funding rules of Code section 430 or ERISA section 303, leave both 
columns blank.
    Line 11. Prior Year's Excess Contributions to be Added to 
Prefunding Balance.
    Line 11a. Enter the amount reported in Line 42a on the Schedule 
SB for the prior plan year.
    Line 11b(1). Enter the effective interest rate for the prior 
plan year, as reported on Line 5 of the Schedule SB for the prior 
plan year, in the space provided. Enter the rate to the nearest .01% 
(e.g., 6.35%).
    In column (b), enter the product of the prior year's effective 
interest rate in Line 11b(1) and the excess (if any) of the amount 
reported on Line 42a for the prior year over the amount reported on 
Line 42b for the prior year.
    However, if the valuation date for the prior plan year was not 
the first day of the plan year (permitted for small plans only), 
enter the result of the following calculation:
    Step 1: Determine the excess (if any) of the amount reported on 
Line 42a for the prior year over the amount reported on Line 42b for 
the prior year,
    Step 2: Adjust the result in Step 1 to the first day of the 
prior year using the effective interest rate for the prior year,
    Step 3: Multiply the result in Step 2 by the prior year's 
effective interest rate in Line 11(b)(1), and
    Step 4: Reduce the result in Step 3 by interest on the result in 
Step 2 of this paragraph for the period between the first day of the 
prior plan year and the prior-year valuation date using the 
effective interest rate for the prior year.
    The amount reported in Line 11(b)(1) is zero if the prior year's 
valuation date was the last day of the prior plan year.
    Line 11(b)(2). In column (b), enter the product of the prior 
year's actual rate of return (from Line 10) and the present value of 
excess contributions reported on Line 42b for the prior year. 
However, if the valuation date for the prior plan year was not the 
first day of the plan year (permitted for small plans only), enter 
the result of the following calculation:
    Step 1: Adjust the prior-year amount reported in Line 42b to the 
first day of the prior year, using the effective interest rate for 
the prior year,
    Step 2: Multiply the result in Step 1 by the prior year's actual 
rate of return (from Line 10), and
    Step 3: Reduce the result in Step 2 by interest on the result in 
Step 1 for the period between the first day of the prior plan year 
and the prior-year valuation date using the effective interest rate 
for the prior year.
    Line 11c. Enter the sum of Lines 11a, 11b(1) and 11(b)(2).
    Line 11d. Enter the amount of the excess contributions for the 
prior year (with interest) that the plan sponsor elected to use to 
increase the prefunding balance. This amount cannot be greater than 
the amount reported on Line 11c. If this is the first year for which 
the plan is subject to the minimum funding rules of Code section 430 
or ERISA section 303, leave Lines 11a-d blank.
    Line 12. Other Reductions in Balances Due to Elections or Deemed 
Elections. In each column, enter the amount by which the employer 
elects to reduce (or is deemed to elect to reduce, per Code section 
436(f)(3) and ERISA section 206(g)(5)(C)) the funding standard 
carryover balance or prefunding balance, as applicable, under Code 
section 430(f) and ERISA section 303(f), other than any amount 
reported in Line 8 that is treated as a reduction in these balances 
under the special rule in section 1.430(f)-1(f)(3)(ii) (relating to 
amounts elected for use to offset the minimum required contribution 
that exceed the minimum required contribution for the plan for the 
plan year, and which are not revoked by the plan sponsor). This 
amount cannot be greater than the sum of the amounts reported in the 
corresponding column of Lines 9, 10 and, if applicable, 11d. Note 
that an election (or deemed election) cannot be made to reduce the 
prefunding balance in column (b) until the funding standard 
carryover balance in column (a) has been reduced to zero.
    If the valuation date is not the first day of the plan year, 
adjust the amounts reported in Line 12 to the first day of the plan 
year, using the effective interest rate for the current plan year. 
If the plan did not exist in the prior year and is not a successor 
plan, leave both columns blank. If this is the first year for which 
the plan is subject to the minimum funding rules of Code section 430 
or ERISA section 303, leave column (b) blank.
    Line 13. Balance at Beginning of Current Year.
    Column (a)--Enter the sum of the amounts reported on Lines 9 and 
10 of column (a), minus the amount reported on Line 12 of column 
(a).
    Column (b)--Enter the sum of the amounts reported on Lines 9, 10 
and 11d of column (b), minus the amount reported on Line 12 of 
column (b).
    If this is the first year for which the plan is subject to the 
minimum funding rules of Code section 430 or ERISA section 303, 
leave column (b) blank.
    Line 14. Discrepancy in Prior Year Funding Standard Carryover 
Balance or Prefunding Balance. If the funding standard carryover 
balance or prefunding balance from the prior year reported on Line 7 
has been adjusted so that it does not match the corresponding amount 
in Line 13 of the prior-year Schedule SB, check the box in Line 14 
and provide an explanation. Note that elections to add excess 
contributions or reduce balances have specific deadlines, and 
generally cannot be changed once they have been made.
    Line 15. Late Election to Apply the Funding Standard Carryover 
Balance or Prefunding Balance to Quarterly Installments. If an 
election was made to use the funding standard carryover balance or 
the prefunding balance to offset the amount of a required quarterly 
installment, and the election was made after the due date of the 
installment, so that the amount reported on Line 8 is not the same 
as the amount reported on Line 39 for the prior year, check the box 
on Line 15 and provide an explanation.
    Line 16. Credit Balance Discrepancy. If there has been any 
adjustment to the credit balance amount reported in Line 9 so that 
it does not match the amount so reported for the pre-effective plan 
year, check the box on Line 16 and provide an explanation.

Part III--Funding Percentages

    Enter all percentages in this section by truncating at .01% 
(e.g., report 82.649% as 82.64%).
    Line 17. Funding Target Attainment Percentage. Enter the funding 
target attainment percentage (FTAP) determined in accordance with 
Code section 430(d)(2) and ERISA section 303(d)(2). The FTAP is the 
ratio (expressed as a percentage) which the actuarial value of plan 
assets (reduced by the funding standard carryover balance and 
prefunding balance) bears to the funding target determined without 
regard to the additional rules for plans in at-risk status. This 
percentage is determined by subtracting the sum of the amounts 
reported in Line 13 from Line 2b and dividing the result by the 
funding target. The funding target used for this purpose is the 
number reported in Line 3d, column (3) for plans that are not in at-
risk status and Line 4a for plans that are in at-risk status. If the 
plan's valuation date is not the first day of the plan year, 
subtract the sum of the amounts reported in Line 13, adjusted for 
interest between the beginning of the plan year and the valuation 
date using the effective interest rate for the current plan year, 
from the amount reported in Line 2b; and divide by the funding 
target.
    Line 18. Adjusted Funding Target Attainment Percentage. Enter 
the adjusted funding target attainment percentage (AFTAP) determined 
in accordance with Code section 436(j)(2) and ERISA section 
206(g)(9)(B). The AFTAP is calculated in the same manner as the FTAP 
reported in Line 17, except that both the assets and the funding 
target used to calculate the AFTAP are increased by the aggregate 
amount of

[[Page 47651]]

purchases of annuities for employees other than highly compensated 
employees (as defined in Code section 414(q)) which were made by the 
plan during the preceding two plan years.
    See Code section 436(j)(3) and ERISA section 206(g)(9)(C) for 
rules regarding circumstances in which the actuarial value of plan 
assets is not reduced by the funding standard carryover balance and 
prefunding balance for certain fully-funded plans when determining 
the AFTAP. Note that this special rule applies only to the 
calculation of the AFTAP and not to the FTAP reported in Line 17.
    Report the final certified AFTAP for the plan year, even if it 
does not correspond to the valuation results reported on this 
Schedule SB (for instance, if any adjustments pertaining to the plan 
year were made subsequent to the valuation or the AFTAP). If no 
AFTAP was certified for the plan year, check the box and attach an 
explanation and (1) report 100%, if the plan's adjusted funding 
target for the plan year is zero, as described in section 1.436-
1(j)(1)(iv) of the Treasury regulations, or (2) leave Line 18 blank 
if the plan's adjusted funding target for the plan year is not equal 
to zero. Label the attachment, ``Line 18, Reconciliation of 
differences between valuation results and amounts used to calculate 
AFTAP.'' For plans with valuation dates other than the first day of 
the plan year, report the AFTAP that is the final certified AFTAP 
based on the valuation results for the current plan year at the time 
that the Schedule SB is filed (reflecting contributions for the 
current plan year and reflecting other adjustments as described in 
applicable guidance), even if that AFTAP is not used to apply the 
restrictions under Code section 436 and ERISA section 206(g) until 
the following plan year.
    If the AFTAP reported on Line 18 does not correspond to the 
valuation results reported on this Schedule SB (for instance, if any 
adjustments pertaining to the plan year were made subsequent to the 
valuation), check the box and attach a schedule showing each AFTAP 
that was certified or recertified for the plan year, the date of the 
certification (or recertification), and a description and the amount 
of each adjustment to the funding target, actuarial value of assets, 
funding standard carryover balance and prefunding balance used to 
determine the corresponding AFTAP. Label the attachment, ``Line 18, 
Reconciliation of differences between valuation results and amounts 
used to calculate AFTAP.'' It is not necessary to include any 
information pertaining to a range certification in this attachment.
    Special rules for airlines using 10-year amortization period 
under section 402(a)(2) of PPA. Section 402(a)(2) of PPA (as 
amended) states that for plans electing the 10-year funding 
amortization period, the funding target during that period is 
determined using an interest rate of 8.25% rather than the interest 
rates or segment rates calculated on the basis of the corporate bond 
yield curve. Report the AFTAP for these plans based on the funding 
target determined using the special 8.25% interest rate.
    Line 19. Prior Year's Funding Percentage for Purposes of 
Determining Whether Carryover/Prefunding Balances May Be Used To 
Offset Current Year's Funding Requirement. Under Code section 
430(f)(3) and ERISA section 303(f)(3), the funding standard 
carryover balance and prefunding balance may not be applied toward 
minimum contribution requirements unless the ratio of plan assets 
for the preceding plan year to the funding target for the preceding 
plan year (as described in Code section 430(f)(3)(C) and ERISA 
section 303(f)(3)(C)) is 80% or more.
    Enter the applicable percentage as described below, truncated at 
.01% (e.g., report 81.239% as 81.23%). In general, the percentage is 
the ratio that the prior-year actuarial value of plan assets 
(reduced by the amount of any prefunding balance, but not the 
funding standard carryover balance) bears to the prior-year funding 
target determined without regard to the additional rules for plans 
in at-risk status. This percentage is determined as follows, with 
all amounts taken from the prior year's Schedule SB:
    1. For plans that are not in at-risk status, subtract the amount 
reported on Line 13, column (b) (adjusted for interest as described 
below, if the valuation date is not the first day of the plan year) 
from the amount reported on Line 2b, and divide the result by the 
funding target reported on Line 3d, column (3).
    2. For plans that are in at-risk status, subtract the amount 
reported on Line 13, column (b) (adjusted for interest as described 
below, if the valuation date is not the first day of the plan year) 
from the amount reported on Line 2b, and divide the result by the 
funding target reported on Line 4a.
    If the valuation date for the prior plan year was not the first 
day of that plan year, the amount subtracted from the assets for the 
purpose of the above calculations is the amount reported on Line 13, 
column(b), adjusted for interest between the beginning of the prior 
plan year and the prior year's valuation date, using the effective 
interest rate for the prior plan year.
    Line 20. Ratio of Current Value of Assets to Funding Target if 
Below 70%. This calculation is required under ERISA section 
103(d)(11). If Line 2a divided by the funding target reported in 
Line 3d, column (3), is less than 70%, enter such percentage. 
Otherwise, leave this line blank.

Part IV--Contributions and Liquidity Shortfalls

    Line 21. Contributions Made to the Plan. Show all employer and 
employee contributions either designated for this plan year or those 
allocated to unpaid minimum required contributions for a prior plan 
year. Do not adjust contributions to reflect interest in column (b). 
Show only employer contributions actually made to the plan within 
8\1/2\ months after the end of the plan year for which this Schedule 
SB is filed (or actually made before the Schedule SB is signed, if 
earlier).
    Certain employer contributions must be made in quarterly 
installments. See Code section 430(j) and ERISA section 303(j). 
Contributions made to meet the liquidity requirement of Code section 
430(j)(4) and ERISA section 303(j)(4) should be reported. Include 
contributions made to avoid benefit restrictions under Code section 
436 and ERISA section 206(g).
    Add the amounts in both columns 21(b) and 21(h) separately and 
enter each result in the corresponding column on the total line. All 
contributions except those made to avoid benefit restrictions under 
Code section 436 and ERISA section 206(g) must be credited toward 
minimum funding requirements for a particular plan year.
    Employer contributions reported in Line 21 that were made on a 
date other than the valuation date must be adjusted to reflect 
interest for the time period between the valuation date for the plan 
year to which the contribution is allocated and the date the 
contribution was made. In general, adjust each contribution using 
the effective interest rate reported on Line 5 for the plan year to 
which the contribution is allocated.
    Show the dates and amounts of individual contributions, the year 
to which the contributions (or the portion of individual 
contributions) are applied, the interest rate(s) used to adjust the 
contributions (i.e., the effective interest rate for timely 
contributions and the applicable effective interest rate plus 5% for 
late quarterly installments) and the periods during which each rate 
applies, and the interest-adjusted contribution. In Line 21(g), 
allocate the interest-adjusted employer contributions to Lines 22a, 
22b, and 22c to report the purpose for which they were made (as 
described below).
    Special note for small plans with valuation dates after the 
beginning of the plan year. If the valuation date is after the 
beginning of the plan year and contributions for the current year 
were made during the plan year but before the valuation date, such 
contributions are increased with interest to the valuation date 
using the effective interest rate for the current plan year. These 
contributions and the interest calculated as described in the 
preceding sentence are excluded from the value of assets reported in 
Lines 2a and 2b.
    Interest adjustment for contributions representing late required 
quarterly installments--installments due after the valuation date. 
If the full amount of a required installment due after the valuation 
date for the current plan year is not paid by the due date for that 
installment, increase the effective interest rate used to discount 
the contribution by 5 percentage points for the period between the 
due date for the required installment and the date on which the 
payment is made. If all or a portion of the late required quarterly 
installment is due to a liquidity shortfall, the increased interest 
rate is used for a period of time corresponding to the period 
between the due date for the installment and the end of that 
quarter, regardless of when the contribution is actually paid.
    Interest adjustment for contributions representing late required 
quarterly installments--small plans with valuation dates after the 
beginning of the plan year--installments due prior to the valuation 
date. See the regulations under section 430 for rules regarding 
interest adjustments for late quarterly contributions for quarterly 
contributions due before the valuation date.

[[Page 47652]]

    Line 22. Discounted Employer Contributions.
    Line 22a. Contributions Allocated Toward Unpaid Minimum Required 
Contributions from Prior Plan Years. Code section 4971(c)(4)(B) 
provides that any payment to or under a plan for any plan year shall 
be allocated first to unpaid minimum required contributions for all 
preceding plan years on a first-in, first-out basis and then to the 
minimum required contribution for the current plan year. Report any 
contributions from Line 21 that are allocated toward unpaid minimum 
required contributions from prior plan years, discounted for 
interest from the date the contribution was made to the valuation 
date for the plan year for which the contribution was originally 
required as described above. Increase the effective interest rate 
for the applicable plan year by 5 percentage points for any portion 
of the unpaid minimum required contribution that represents a late 
quarterly installment, for the period between the due date for the 
installment and the date of payment. Reflect the increased interest 
rate for any portion of the unpaid minimum required contribution 
that represents a late liquidity shortfall installment, for the 
period corresponding to the time between the date the installment 
was due and the end of the quarter during which it was due. The 
amount reported in Line 22a cannot be larger than the amount 
reported in Line 32.
    For the purpose of allocating contribution amounts to unpaid 
minimum required contributions, any unpaid minimum required 
contribution attributable to an accumulated funding deficiency at 
the end of the last plan year before Code section 430 or ERISA 
section 303 applied to the plan (the ``pre-effective plan year'') is 
treated as a single contribution due on the last day of the pre-
effective plan year (without separately identifying any portion of 
the accumulated funding deficiency attributable to late quarterly 
installments or late liquidity shortfall installments), and the 
associated effective interest rate is deemed to be the valuation 
interest rate for the pre-effective plan year.
    Line 22b. Contributions Made To Avoid Benefit Restrictions. 
Include in this category current year contributions made to avoid or 
terminate benefit restrictions under Code section 436 and ERISA 
section 206(g). Adjust each contribution for interest from the date 
the contribution was made to the valuation date as described above.
    Line 22c. Contributions Allocated Toward Minimum Required 
Contribution for Current Year. Include in this category 
contributions (including any contributions made in excess of the 
minimum required contribution) that are not included in Line 22a or 
22b. Adjust each contribution for interest from the date the 
contribution was made to the valuation date as described above.
    Line 23. Quarterly Contributions and Liquidity Shortfalls.
    Line 23a. Did the Plan Have a Funding Shortfall for the Prior 
Plan Year? In accordance with Code section 430(j)(3) and ERISA 
section 303(j)(3), only plans that have a funding shortfall for the 
preceding plan year are subject to an accelerated quarterly 
contribution schedule. For this purpose, a plan is considered to 
have a funding shortfall for the prior year if the funding target 
reported on Line 3d, column (3) is greater than the actuarial value 
of assets reported on Line 2b, reduced by the sum of the funding 
standard carryover balance and prefunding balance reported on Line 
13, columns (a) and (b), with all figures taken from the prior 
year's Schedule SB.
    If the valuation date for the prior plan year was not the first 
day of that plan year, the amount subtracted from the actuarial 
value of assets for the above calculation is the sum of the amounts 
reported on Line 13, columns (a) and (b) of the prior-year Schedule 
SB, but adjusted for interest between the beginning of the prior 
plan year and the prior year's valuation date using the effective 
interest rate for the plan for the prior plan year.
    However, see Code section 430(f)(4)(B)(ii) and ERISA section 
303(f)(4)(B)(ii) for special rules in the case of a binding 
agreement with the PBGC providing that all or a portion of the 
funding standard carryover balance and/or prefunding balance is not 
available to offset the minimum required contribution for the prior 
plan year.
    Please note that a plan may be considered to have a funding 
shortfall for this purpose even if it is exempt from establishing a 
shortfall amortization base under the provisions of Code section 
430(c)(5) and ERISA section 303(c)(5).
    Line 23b. If Line 23a is ``No'' (i.e., if the plan did not have 
a funding shortfall in the prior plan year), the plan is not subject 
to the quarterly contribution rules, and this line should not be 
completed. If Line 23a is ``Yes,'' check the ``Yes'' box on Line 23b 
if required installments for the current plan year were made in a 
timely manner; otherwise, check ``No.''
    Line 23c. If Line 23a is ``No,'' or the plan had 100 or fewer 
participants on every day of the preceding plan year (as defined for 
line F), the plan is not subject to the liquidity requirement of 
Code section 430(j)(4) and ERISA section 303(j)(4) and this line 
should not be completed. Check the box and attach a certification by 
the enrolled actuary if the special rule for nonrecurring 
circumstances is used, and label the certification ``Schedule SB, 
Line 23c--Liquidity Requirement Certification.'' See Code section 
430(j)(4)(E)(ii)(II) and ERISA section 303(j)(4)(E)(ii)(II).
    If the plan is subject to the liquidity requirement and has a 
liquidity shortfall for any quarter of the plan year (see Code 
section 430(j)(4)(E) and ERISA section 303(j)(4)(E)), enter the 
amount of the liquidity shortfall for each such quarter. If the plan 
was subject to the liquidity requirement but did not have a 
liquidity shortfall, enter zero. File IRS Form 5330, Return of 
Excise Taxes Related to Employee Benefit Plans, with the IRS to pay 
the 10% excise tax(es) if there is a failure to pay any liquidity 
shortfall by the required due date, unless a waiver of the 10% tax 
has been granted under Code section 4971(f)(4).

Part V--Assumptions Used To Determine Funding Target and Target Normal 
Cost

    Attach a statement of actuarial assumptions and funding methods 
used to calculate the Schedule SB entries and label the statement 
``Schedule SB, Part V--Statement of Actuarial Assumptions/Methods.'' 
The statement must describe all non-prescribed actuarial assumptions 
(e.g., retirement, withdrawal rates) used to determine the funding 
target and target normal cost, including the assumption as to the 
frequency with which participants are assumed to elect each optional 
form of benefit (including lump sum distributions), whether 
mortality tables are applied on a static or generational basis, 
whether combined mortality tables are used instead of separate 
annuitant and nonannuitant mortality tables (for plans with 500 or 
fewer participants as of the valuation date), and (for target normal 
cost) expected plan-related expenses and increases in compensation. 
For applicable defined benefit pension plans under Code section 
411(a)(13)(C) and ERISA section 203(f)(3) (e.g., cash balance plans) 
the statement must include the assumptions used to convert balances 
to annuities. In addition, the statement must describe the method 
for determining the actuarial value of assets and any other aspects 
of the funding method for determining the Schedule SB entries that 
are not prescribed by law.
    Also attach a summary of the principal eligibility and benefit 
provisions on which the valuation was based, including the status of 
the plan (e.g., frozen eligibility, service/pay, or benefits), 
optional forms of benefits, special plan provisions, including those 
that apply only to a subgroup of employees (e.g., those with imputed 
service), supplemental benefits, and identification of benefits not 
included in the valuation, a description of any significant events 
that occurred during the year, a summary of any changes in principal 
eligibility or benefit provisions since the last valuation, and a 
description (or reasonably representative sample) of plan early 
retirement reduction factors and optional form conversion factors. 
Label the summary ``Schedule SB, Part V--Summary of Plan 
Provisions.''
    Also, include any other information needed to disclose the 
actuarial position of the plan fully and fairly.
    Line 24. Discount Rate. All discount rates are to be reported 
and used as published by the IRS, and are to be applied as annual 
rates without adjustment.
    Line 24a. Enter the three segment rates used to calculate the 
funding target and target normal cost as provided under Code section 
430(h)(2)(C) and ERISA section 303(h)(2)(C) and as published by the 
IRS, unless the plan sponsor has elected to use the full yield 
curve. If the sponsor has elected to use the full yield curve, check 
the ``N/A, full yield curve used'' box. Special rules for airlines 
using 10-year amortization period under section 402(a)(2) of PPA (as 
amended). Enter the information described above to reflect the 
discount rates used to determine the target normal cost in 
accordance with Code section 430(h)(2) and ERISA section 303(h)(2). 
Do not enter the special 8.25% interest rate used to determine the 
funding target under section 402(a)(2) of PPA.
    Line 24b. Code section 430(h)(2)(E) and ERISA section 
303(h)(2)(E) provide that the segment rate(s) used to measure the 
funding

[[Page 47653]]

target and target normal cost are those published by Treasury for 
the month that includes the valuation date (based on the average of 
the monthly corporate bond yield curves for the 24-month period 
ending with the month preceding that month). Alternatively, at the 
election of the plan sponsor, the segment rate(s) used to measure 
the funding target and target normal cost may be those published by 
Treasury for any of the four months that precede the month that 
includes the valuation date.
    Enter the applicable month to indicate which segment rates were 
used to determine the funding target and target normal cost. Enter 
``0'' if the rates used to determine the funding target and target 
normal cost were published for the month that includes the valuation 
date. Enter ``1'' if the rates were published for the month 
immediately preceding the month that includes the valuation date, 
``2'' for the second preceding month, and ``3'' or ``4,'' 
respectively, for the third or fourth preceding months. For example, 
if the valuation date is January 1 and the funding target and target 
normal cost were determined based on rates published for November, 
enter ``2.''
    Note. The plan sponsor's interest rate election under Code 
section 430(h)(2) or ERISA section 303(h)(2) (an election to use the 
yield curve or an election to use an applicable month other than the 
default month) generally may not be changed unless the plan sponsor 
obtains approval from the IRS. However, see the regulations under 
section 430(h)(2) for circumstances in which a change in interest 
rate may be made without obtaining approval from the IRS.
    Line 25. Weighted Average Retirement Age. Enter the weighted 
average retirement age for active participants. If the plan is in 
at-risk status, enter the weighted average retirement age as if the 
plan were not in at-risk status. If each participant is assumed to 
retire at his/her normal retirement age, enter the age specified in 
the plan as normal retirement age. If the normal retirement age 
differs for individual participants, enter the age that is the 
weighted average normal retirement age; do not enter ``NRA.'' 
Otherwise, enter the assumed retirement age. If the valuation uses 
rates of retirement at various ages, enter the nearest whole age 
that is the weighted average retirement age.
    On an attachment to Schedule SB, list the rate of retirement at 
each age and describe the methodology used to compute the weighted 
average retirement age, including a description of the weight 
applied at each potential retirement age, and label the attachment 
``Schedule SB, Line 25--Description of Weighted Average Retirement 
Age.''
    Line 26. Mortality Tables. Mortality tables described in Code 
section 430(h)(3), ERISA section 303(h)(3), and section 1.430(h)(3)-
1 of the regulations as published by the IRS must be used to 
determine the funding target and target normal cost for non-disabled 
participants and may be used to determine the funding target and 
target normal cost for disabled participants, unless the IRS has 
approved (or was deemed to have approved) the use of a substitute 
mortality table for the plan. Standard mortality tables must be 
either applied on a generational basis, or the tables must be 
updated to reflect the static tables published for the year in which 
the valuation date occurs. Substitute mortality tables must be 
applied in accordance with the terms of the IRS ruling letter.
    Separate standard mortality tables were published by the IRS for 
annuitants (rates applying for periods when a participant is assumed 
to receive a benefit under the plan) and nonannuitants (rates 
applying to periods before a participant is assumed to receive a 
benefit under the plan). If a plan has 500 or fewer participants as 
of the valuation date for the current plan year as reported in Line 
3d, column (1), the plan sponsor can elect to use the combined 
mortality tables published by the IRS, which reflect combined rates 
for both annuitants and nonannuitants.
    Line 26a. Mortality Tables Used. Check the applicable box to 
indicate which mortality table was used to determine the funding 
target and target normal cost. If one mortality table was used for 
certain populations within the plan and a different mortality table 
was used for other populations, check the box for the table that 
applied to the largest population.
    1. Check ``Prescribed--combined'' if the funding target and 
target normal cost are based on the prescribed tables with combined 
annuitant/nonannuitant mortality rates.
    2. Check ``Prescribed--separate'' if the funding target and 
target normal cost are based on the prescribed tables with separate 
mortality rates for nonannuitants and annuitants.
    3. Check ``Substitute'' if the funding target and target normal 
cost are based on substitute mortality tables.
    Line 26b. Use of More Than One Mortality Table. If more than one 
mortality table was used, check the box and provide an explanation 
describing the mortality table used for each population and the size 
of that population.
    Line 26c. Substitute Mortality Tables. If substitute mortality 
tables are used, check the box and provide a summary of plan 
populations for which substitute mortality tables are used, plan 
populations for which the prescribed tables are used, and the last 
plan year for which the IRS approval of the substitute mortality 
tables applies.

Part VI--Miscellaneous Items

    Line 27. Change in Non-Prescribed Actuarial Assumptions. Check 
the box if a change has been made in the non-prescribed actuarial 
assumptions for the current plan year. Provide a description of any 
change in non-prescribed actuarial assumptions and justifications 
for any such change. If the only assumption changes are statutorily 
required changes in the discount or mortality rates, or changes 
required for plans in at-risk status, do not check the box and do 
not provide a description of the changes. (See section 103(d) of 
ERISA.) If the non-prescribed assumptions have been changed in a way 
that decreases the funding shortfall for the current plan year, 
approval for such a change may be required.
    Line 28. Change in Method. Check the box if a change in the 
method has been made for the current plan year. For this purpose, a 
change in funding method refers to not only a change in the overall 
method used by the plan, but also each specific method of 
computation used in applying the overall method. Accordingly, 
funding method changes include modifications such as a change in the 
method for calculating the actuarial value of assets or a change in 
the valuation date (not an exclusive list). Also check the box if 
there has been a change in the method for determining the discount 
rates reported in Line 24. In general, any changes in a plan's 
method must be approved by the IRS. However, see the regulations 
under Code section 430 and Announcement 2010-3, 2010-4 I.R.B. 333, 
for circumstances in which a change in method may be made without 
obtaining approval from the IRS. Provide a description of the 
change.
    Note. The plan sponsor's agreement to certain changes in funding 
method should be reported on Line 9 of Schedule R (Form 5500).
    Line 29a. Schedule of Active Participant Data. Check ``Yes'' on 
Line 29a(i) only if (a) the plan is covered by Title IV of ERISA and 
(b) the plan has active participants. If Line 29a(i) is ``Yes,'' 
complete the schedule in Line 29a(ii) with the active plan 
participant data used in the valuation for this plan year and enter 
the average age and average credited service of the active 
participants on Lines 29a(iii) and 29a(iv), respectively. Include 
all active participants in the averages, even ones that are not 
required to be shown in the schedule under the instructions below. 
For each column, enter the number of active participants with the 
specified number of years of credited service divided according to 
age group. For participants with partial years of credited service, 
round the total number of years of credited service to the next 
lower whole number. Years of credited service are the years credited 
under the plan's benefit formula.
    Plans reporting 1,000 or more active participants on Line 3d, 
column (1), must also provide average compensation data. For each 
grouping, enter the average compensation of the active participants 
in that group. For this purpose, compensation is the compensation 
taken into account for each participant under the plan's benefit 
formula, limited to the amount defined under section 401(a)(17) of 
the Code. Do not enter the average compensation in any grouping that 
contains fewer than 20 participants.
    In the case of a plan under which benefits are primarily pay-
related and under which no future accruals are granted (i.e., a 
``frozen'' plan as defined in the instructions for Line 9a(4) of the 
Form 5500), check the box and report the average annual accrued 
benefit in lieu of average compensation.
    Cash balance plans (or any similar plans that check the box on 
Line 9a(1) of Form 5500) reporting 1,000 or more active participants 
on Line 3d, column (1), must also provide average cash balance 
account data, regardless of whether all active participants have 
cash balance accounts. For each age/service bin, enter the average 
cash balance account of the active participants in that bin. Do not 
enter the average cash

[[Page 47654]]

balance account in any age/service bin that contains fewer than 20 
active participants.
    General Rule. When all active participants in the plan have a 
cash balance account, data to be shown in each age/service bin 
includes:
    1. The number of active participants in the age/service bin,
    2. The average compensation of the active participants in the 
age/service bin, and
    3. The average cash balance account of the active participants 
in the age/service bin.
    If the accrued benefit is the greater of a cash balance benefit 
or some other benefit, average in only the cash balance account. If 
the accrued benefit is the sum of a cash balance account benefit and 
some other benefit, average in only the cash balance account. For 
both the average compensation and the average cash balance account, 
do not enter an amount for age/service bins with fewer than 20 
active participants.
    When some active participants do not have cash balance accounts, 
an alternative is provided for showing compensation and cash balance 
accounts, requiring two age/service scatters as follows:
     Scatter 1--Provide participant count and average 
compensation for all active participants, without account-based 
benefits.
     Scatter 2--Provide participant count and average cash 
balance account for only those active participants with account-
based benefits. If the number of participants with account-based 
benefits in a bin is fewer than 20, the average account should not 
be shown even if there are 20 or more active participants in this 
bin on Scatter 1.
    In general, information should be determined as of the valuation 
date. Average cash balance accounts may be determined as of either:
    1. The valuation date or
    2. The day immediately preceding the valuation date.
    Average cash balance accounts that are offset by amounts from 
another plan may be reported either as amounts prior to taking into 
account the offset or as amounts after taking into account the 
offset. Do not report the offset amount. For this or any other 
unusual or unique situation, the attachment should include an 
explanation of what is being provided.
    If the plan is a multiple-employer plan, complete one or more 
schedules of active participants in a manner consistent with the 
computations for the funding requirements reported in Part VIII. For 
example, if the funding requirements are computed as if each 
participating employer maintained a separate plan, complete a 
separate Schedule of Active Participant Data for each participating 
employer in the multiple-employer plan on the separate Schedule SB 
attached in accordance with the instructions for Line E.
    Line 29b. Schedule of Retired Participants and Beneficiaries 
Receiving Payment Data. Check ``Yes'' on Line 29b(i) only if (a) the 
plan is covered by Title IV of ERISA and (b) the plan has retired 
participants and beneficiaries receiving payment at the valuation 
date. If Line 29b(i) is ``Yes,'' complete the schedule in Line 
29b(ii) with the retired participant and beneficiary data used in 
the valuation for this plan year and enter the average age and 
average in-pay annual benefit of the retired participants and 
beneficiaries on Lines 29b(iii) and 29b(iv), respectively. Do not 
report average annual benefit information for age bins where there 
are 10 or less retired participants and beneficiaries receiving 
payment in the average.
    If the plan is a multiple-employer plan, complete one or more 
schedules of retired participant and beneficiary data in a manner 
consistent with the computations for the funding requirements 
reported in Part VIII. For example, if the funding requirements are 
computed as if each participating employer maintained a separate 
plan, complete a separate Schedule of Retired Participants and 
Beneficiaries Receiving Payment Data for each participating employer 
in the multiple-employer plan on the separate Schedule SB attached 
in accordance with the instructions for Line E.
    Line 29c. Schedule of Terminated Vested Participant Data. Check 
``Yes'' on Line 29c(i) only if (a) the plan is covered by Title IV 
of ERISA and (b) the plan has terminated vested participants at the 
valuation date. If Line 29c(i) is ``Yes,'' complete the schedule in 
Line 29c(ii) with the terminated vested participant data used in the 
valuation for this plan year and enter the average age and average 
annual benefit of the terminated vested participants on Lines 
29c(iii) and 29c(iv), respectively. Do not report average annual 
benefit information for age bins where there are 10 or less 
terminated vested participants in the average. Include the assumed 
form of payment and the assumed first age of payment in Lines 29c(v) 
and 29c(vi), respectively, for the benefit amounts shown in the 
schedule.
    If the plan is a multiple-employer plan, complete one or more 
schedules of terminated vested participant data in a manner 
consistent with the computations for the funding requirements 
reported in Part VIII. For example, if the funding requirements are 
computed as if each participating employer maintained a separate 
plan, complete a separate Schedule of Terminated Vested Participant 
Data for each participating employer in the multiple-employer plan 
on the separate Schedule SB attached in accordance with the 
instructions for Line E.
    Line 30. Projection of Expected Benefit Payments. Check ``Yes'' 
on Line 30a if this is a single-employer plan covered by Title IV of 
ERISA and is required to provide a projection of expected benefit 
payments. Do not report information if the plan has less than 500 
participants as of the valuation date.
    If Line 30a is ``Yes,'' in Line 30b provide a projection of 
benefits expected to be paid (not to include expected expenses) in 
each of the next ten years starting with the current plan year of 
this filing assuming (1) no additional accruals, (2) experience 
(e.g., termination, mortality, and retirement) are in line with 
valuation assumptions, and (3) no new entrants are covered by the 
plan.
    Line 31. Alternative Funding Rules. If one of the alternative 
funding rules was used for this plan year, enter the appropriate 
code from the table below and follow the special instructions 
applicable to that code, including completion of any required 
attachments.

Code Alternative Funding Rule

    1 A CSEC Act plan that is described in Code section 414(v). This 
includes certain multiple-employer plans maintained by rural 
cooperatives and other specified cooperative organizations and 
certain plans maintained by more than 1 employer (determined after 
application of Code section 414(b) and (c)), all of which are 
described in Code section 501(c (3). Do not use Code 1 for a plan 
that satisfies the definition of CSEC plan that has made the 
election not to be treated as a CSEC plan.
    2 This code, formerly used by certain plans maintained by PBGC 
settlements as described in section 105 of PPA, is no longer 
applicable and should not be used.
    3 Reserved.
    4 Plans with binding agreements with PBGC to maintain prefunding 
and/or funding standard carryover balances described in Code section 
430(f)(4)(B)(ii) and ERISA section 303(f)(4)(B)(ii).
    5 Airlines using 10-year amortization period for initial post-
PPA shortfall amortization base under section 402(a)(2) of PPA (as 
amended).
    6 Airlines with frozen plans using alternative 17-year funding 
schedule under section 402(a)(1) of PPA.
    7 Interstate transit company described in section 115 of PPA.
    8 A plan subject to 104 of PPA as amended that is not a CSEC 
plan. This includes plans that fit into the definition of a CSEC 
plan that elect out of CSEC plan status and become subject to 
section 104 of PPA as amended, and certain plans maintained by more 
than 1 employer (determined without regard to section 414(c)) where 
all of the employers are described in section 501(c)(3). Do not use 
Code 8 for a PPA section 104 plan that has made an election to not 
be treated as an eligible charity plan.

Special Instructions for Codes 1 through 8

    CSEC Plans, as described in Code section 414(y) and subject to 
Code section 433 (code 1).

Reserved

    Plans with binding agreements with the PBGC to maintain 
prefunding and/or carryover balances (code 4). Complete entire 
Schedule SB and attachments as outlined in these instructions. In 
addition, report on an attachment the amount subject to the binding 
agreement with the PBGC, reported separately for the funding 
standard carryover balance and prefunding balance. Label the 
attachment ``Schedule SB, Line 31--Balances Subject to Binding 
Agreement with PBGC.''
    Airlines using 10-year amortization period for initial post-PPA 
shortfall amortization base (code 5). Complete the entire Schedule 
SB and attachments as outlined in these instructions. Under section 
402(a)(2) of PPA (as amended), the funding target for plans funded 
using this alternative is determined using an interest rate of 8.25% 
for each of the 10 years during the amortization period instead of 
the interest

[[Page 47655]]

rates otherwise required under Code section 430(h)(2) and ERISA 
section 303(h)(2). However, this special 8.25% interest rate does 
not apply for other purposes, including the calculation of target 
normal cost or the amortization of the funding shortfall.
    Airlines with frozen plans using alternative 17-year funding 
schedule (code 6). Complete the following lines on Schedule SB and 
provide associated attachments:
     Lines A through F.
     Part I (including signature of enrolled actuary)--
complete all lines.
     Parts III through VII--complete all lines.
    For this purpose, disregard the special funding rules under 
section 402(e) of PPA except for the information reported on the 
following lines:
     Lines 21 and 22--Discount contributions to the 
applicable valuation date using the 8.85% discount rate provided 
under section 402(e)(4)(B) of PPA.
     Line 23--Reflect required quarterly installments based 
on the minimum required contribution determined under section 402(e) 
of PPA to the extent applicable (i.e., for purposes of calculating 
the required annual payment under Code section 430(j)(3)(D)(ii)(l) 
and ERISA section 303(j)(3)(D)(ii)(l)).
     Line 33--Reflect the minimum required contribution 
determined under section 402(e) of PPA when determining the unpaid 
minimum required contribution.
    Also, attach a worksheet showing the information below, 
determined in accordance with section 402(e) of PPA. Label this 
worksheet ``Schedule SB, Line 31--Alternative 17-Year Funding 
Schedule for Airlines.''
     Date as of which plan benefits were frozen as required 
under section 402(b)(2) of PPA.
     Date on which the first applicable plan year began.
     Accrued liability under the unit credit method 
calculated as of the first day of the plan year, using an interest 
rate of 8.85%.
     A summary of all other assumptions used to calculate 
the unit credit accrued liability.
     Fair market value of assets as of the first day of the 
plan year.
     Unfunded liability under section 402(e)(3)(A) of PPA.
     Alternative funding schedule:
    1. Contribution necessary to amortize the unfunded liability 
over the remaining number of years, assuming payments at the 
valuation date for each plan year and using an interest rate of 
8.85%;
    2. Employer contributions for the plan year, discounted for 
interest to the valuation date for the plan year, and using a rate 
of 8.85%; and
    3. Contribution shortfall, if any ((1)-(2) but not less than 
zero).
    Interstate transit company (code 7). Complete the entire 
Schedule SB, reflecting the modifications to the otherwise-required 
funding rules under section 115(b) of PPA, and disregarding the 
attachment required for plans reporting the use of the substitute 
mortality table in Line 26.
    Plans entitled to delayed effective dates for PPA funding rules 
(code 8).
    For plan years before Code section 430 and ERISA section 303 
apply to the plan, complete only the following lines on Schedule SB:
    Lines A through F.
    1. Part I (including signature of enrolled actuary), determined 
as if PPA provisions were effective for all plan years beginning 
after December 31, 2007.
    2. Part III, Line 17, determined as if PPA provisions were 
effective for all plan years beginning after December 31, 2007.
    3. Part V, determined as if PPA provisions were effective for 
all plan years beginning after December 31, 2007.
    4. If the minimum required contribution for any year was 
determined using pension funding relief under section 107 of PPA 
'06, as added by PRA 2010, complete Part IX, Lines 45a and 45b.
    Also, report other information for the current plan year using a 
2007 Schedule B (Form 5500). Label this attachment ``20XX Schedule 
SB, Line 31--Actuarial Information Based on Pre-PPA Funding Rules.'' 
Complete all items, and attach the form and all applicable 
attachments to the Schedule SB. Note that under PPA, the third 
segment rate determined under Code section 430(h)(2)(C)(iii) and 
ERISA section 303(h)(2)(C)(iii) is substituted for the current 
liability interest rate under Code section 412(b)(5)(B) and ERISA 
section 302(b)(5)(B) (as in effect before PPA).

Part VII--Reconciliation of Unpaid Minimum Required Contributions for 
Prior Years

    Line 32. Unpaid Minimum Required Contributions for Prior Years. 
Enter the total amount of any unpaid minimum required contributions 
for all years from Line 44 of the Schedule SB for the prior plan 
year.
    If this is the first year that the plan is subject to the 
minimum funding requirements of Code section 430 or ERISA section 
303, enter the amount of any accumulated funding deficiency at the 
end of the prior year (the pre-effective plan year). This is the 
amount reported on Line 9p of the 2007 Schedule B form that was 
submitted as an attachment to the Schedule SB for the pre-effective 
plan year.
    Line 33. Discounted Employer Contributions Allocated Toward 
Unpaid Minimum Required Contributions from Prior Years. Enter the 
total amount of discounted contributions made for the current plan 
year allocated toward unpaid minimum required contributions from 
prior years as reported in Line 22a.
    Line 34. Remaining Unpaid Minimum Required Contributions. Enter 
the amount in Line 32 minus the amount in Line 33.

Part VIII--Minimum Required Contribution for Current Year

    Line 35. Target Normal Cost and Excess Assets.
    Line 35a. Target Normal Cost (Line 6c). Enter the target normal 
cost as reported in Line 6c.
    Line 35b. Excess Assets. Enter the excess, if any, of the value 
of assets reported on Line 2b reduced by any funding standard 
carryover balance and prefunding balance on Line 13, columns (a) and 
(b), over the funding target reported on Line 3d, column (3). If the 
valuation date is not the first day of the plan year, excess assets 
are determined as the value of assets reported on Line 2b reduced by 
any funding standard carryover balance and prefunding balance 
reported on Line 13, columns (a) and (b), adjusted for interest at 
the effective interest rate for the period between the beginning of 
the plan year and the valuation date, minus the funding target 
reported on Line 3d, column (3) (but not less than zero). Limit the 
amount reported in Line 35b so that it is not greater than the 
target normal cost reported in Line 35a.
    Line 36. Amortization Installments.
    Line 36a. Shortfall Amortization Bases and Amortization 
Installments.
    Outstanding balance. If the plan's funding shortfall (determined 
under Code section 430(c)(4) and ERISA section 303(c)(4)) is zero, 
all amortization bases and related installments are considered fully 
amortized. In this case, enter zero. Otherwise, enter the sum (but 
not less than zero) of the outstanding balances of all shortfall 
amortization bases (including any new shortfall amortization base 
established for the current plan year). The outstanding balance for 
each amortization base established in past years is equal to the 
present value as of the valuation date of any remaining amortization 
installments for each base (including the amortization installment 
for the current plan year), using the interest rates reported on 
Line 24.
    A plan is generally exempt from the requirement to establish a 
new shortfall amortization base for the current plan year if the 
funding target reported on Line 3d, column (3), is less than or 
equal to the reduced value of assets as described below.
    For the purpose of determining whether a plan is exempt from the 
requirement to establish a new shortfall amortization base for the 
current plan year, the reduced value of assets is the amount 
reported on Line 2b, reduced by the full value of the prefunding 
balance reported on Line 13, column (b), adjusted for interest for 
the period between the beginning of the plan year and the valuation 
date using the effective interest rate for the current plan year, if 
the valuation date is not the first day of the plan year. However, 
the assets are reduced by the prefunding balance if and only if the 
plan sponsor has elected to use any portion of the prefunding 
balance to offset the minimum required contribution for the current 
plan year, as reported on Line 39. The assets are not reduced by the 
amount of any funding standard carryover balance for this 
calculation regardless of whether any portion of the funding 
standard carryover balance is used to offset the minimum required 
contribution for the plan year.
    If the plan is not exempt from the requirement to establish a 
new shortfall amortization base for the current plan year, the 
amount of that base is generally equal to the difference between the 
funding shortfall as of the valuation date (determined under Code 
section 430(c)(4) and ERISA section 303(c)(4)) and the sum of any 
outstanding balances of any previously established

[[Page 47656]]

shortfall and waiver amortization bases. The new shortfall 
amortization base may be either greater than or less than zero.
    For the purpose of determining the amount of any new shortfall 
amortization base, the funding shortfall is equal to the amount of 
the funding target reported on Line 3d, column (3), minus the 
reduced value of assets, but not less than zero.
    If the plan's valuation date is the first day of the plan year, 
then the reduced value of assets for the purpose of determining the 
amount of any new shortfall amortization base is the amount reported 
on Line 2b, reduced by the sum of the funding standard carryover 
balance and the prefunding balance reported on Line 13, columns (a) 
and (b). However, if the plan's valuation date is not the first day 
of the plan year, then the reduced value of assets for the purpose 
of determining the amount of any new shortfall amortization base is 
the amount reported on Line 2b, reduced by the sum of the funding 
standard carryover balance and the prefunding balance reported on 
Line 13, columns (a) and (b), adjusted for interest for the period 
between the beginning of the plan year and the valuation date (using 
the effective interest rate for the current plan year). See Code 
section 430(f)(4)(B)(ii) and ERISA section 303(f)(4)(B)(ii) for 
special rules in the case of a binding agreement with the PBGC 
providing that all or a portion of the funding standard carryover 
balance and/or prefunding balance is not available to offset the 
minimum required contribution for the plan year.
    Shortfall amortization installment--Enter the sum (but not less 
than zero) of:
    1. Any shortfall amortization installments that were established 
to amortize shortfall amortization bases established in prior years, 
excluding amortization installments for bases that have been or are 
deemed to be fully amortized, and
    2. The shortfall amortization installment that corresponds to 
any new shortfall amortization base established for the current plan 
year. This amount is the level amortization payment that will 
amortize the new shortfall amortization base over 7 annual payments, 
using the interest rates reported in Line 21 for the current plan 
year.
    Note. (1) Shortfall amortization installments for a given 
shortfall amortization base are not re-determined from year to year 
regardless of any changes in interest rates or valuation dates. (2) 
If an election was made to use an alternative shortfall amortization 
schedule under Code section 430(c)(2)(D) and ERISA section 
303(c)(2)(D) added by PRA 2010, the shortfall amortization 
installment is the amount determined in accordance with the 
shortfall amortization schedule chosen and guidance issued by 
Treasury and the IRS. Include any increase to the shortfall 
amortization installment for this year due to the installment 
acceleration amount, as provided in Code section 430(c)(7) and ERISA 
section 303(c)(7).
    Line 36b. Waiver Amortization Bases and Amortization 
Installments.
    Outstanding balance--If the plan's funding shortfall (determined 
under Code section 430(c)(4) and ERISA section 303(c)(4)) is zero, 
all waiver amortization bases and related installments are 
considered fully amortized. In this case, enter zero. Otherwise, 
enter the present value as of the valuation date of all remaining 
waiver amortization installments (including any installment for the 
current plan year), using the interest rates reported on Line 24. Do 
not include any new waiver amortization base established for a 
waiver of minimum funding requirements for the current plan year.
    Waiver amortization installments--Enter the sum of any remaining 
waiver amortization installments that were established to amortize 
any waiver amortization bases for prior plan years, unless such 
bases have been or are deemed to be fully amortized. Do not include 
an amortization installment for any new waiver amortization base 
established for a waiver of minimum funding requirements for the 
current plan year.
    Note. If a waiver of minimum funding requirements has been 
granted for the current plan year, a waiver amortization base is 
established as of the valuation date for the current plan year equal 
to the amount of the funding waiver reported in Line 37. The waiver 
amortization installment that corresponds to any waiver amortization 
base established for the current year is the level amortization 
payment that will amortize the new waiver amortization base over 5 
annual payments, using the same segment interest rates or rates from 
the full yield curve reported on Line 24 for the current plan year, 
but with the first payment due on the valuation date for the 
following plan year. The amount of the waiver amortization base and 
the waiver amortization installments for this base are not reported 
in Line 36b for the year in which they are established. Rather, 
these are included in the entries for Line 36b on the Schedule SB 
for the following plan year.
    Note. Waiver amortization installments (including the waiver 
amortization installments of any waiver amortization base 
established for the prior plan year) are not re-determined from year 
to year regardless of any changes in interest rates or valuation 
dates.
    Required Schedule of Amortization Bases. If there are any 
shortfall or waiver amortization bases, complete the schedule 
listing all bases (other than a base established for a funding 
waiver for the current plan year) showing for each base:
    1. The type of base (shortfall or waiver),
    2. The present value of any remaining installments (including 
the installment for the current plan year),
    3. The valuation date as of which the base was established,
    4. The number of years remaining in the amortization period, and
    5. The amortization installment.
    If a base is negative (i.e., a ``gain base''), show amounts in 
parentheses or with a negative sign in front of them. All amounts 
must be calculated as of the valuation date for the plan year.
    If any of the shortfall amortization bases shown on this 
schedule are being amortized using an alternative amortization 
schedule in accordance with Code section 430(c)(2)(D) or ERISA 
section 303(c)(2)(D), identify the amortization schedule being used 
and show separately the amount of any installment acceleration 
amount added to the shortfall amortization installment for the 
current plan year under Code section 430(c)(7) or ERISA section 
303(c)(7).
    Line 37. Funding Waiver. If a waiver of minimum funding 
requirements has been approved for the current plan year, enter the 
date of the ruling letter granting the approval and the waived 
amount (reported as of the valuation date) in the spaces provided. 
If a waiver is pending, do not complete this line. If a pending 
waiver is granted after Form 5500 Annual Return/Report is filed, 
file an amended Form 5500 with an amended Schedule SB.
    Line 38. Total Funding Requirement Before Reflecting Carryover/
Prefunding Balances. Enter the target normal cost in Line 35a, minus 
the excess assets in Line 35b, plus the amortization installments 
reported in Lines 36a and 36b, reduced by any waived amounts 
reported in Line 37.
    Line 39. Balances Elected for Use to Offset Funding Requirement. 
If the percentage reported on Line 19 is at least 80%, and the plan 
has a funding standard carryover balance and/or prefunding balance 
(as reported on Line 13, columns (a) and (b)), the plan sponsor may 
elect to credit all or a portion of such balances against the 
minimum required contribution. Enter the amount of any balance 
elected for use for this purpose in the applicable column of Line 
39, and enter the total in the column headed ``Total Balance.'' No 
portion of the prefunding balance can be used for this purpose 
unless the full amount of any remaining funding standard carryover 
balance (Line 13, column (a)) is used. The amounts entered on Line 
39 cannot be larger than the corresponding amounts on Line 13 
(unless the plan's valuation date is not the first day of the plan 
year, as discussed below).
    If the plan's valuation date is not the first day of the plan 
year, adjust the portion of the funding standard carryover balance 
and prefunding balance used to offset the minimum required 
contribution for interest between the beginning of the plan year and 
the valuation date using the effective interest rate for the current 
plan year.
    Special rule for late election to apply balances to quarterly 
installments. If an election was made to use the funding standard 
carryover balance or the prefunding balance to offset the amount of 
a required quarterly installment, but the election was made after 
the due date of the installment, the amount reported on Line 39 may 
not be the same amount that is subtracted from the plan's balances 
in the following plan year (to be reported in Line 8 of Schedule SB 
for the following plan year). Refer to the regulations under Section 
430 of the Code for additional information.
    Special rule for elections to use balances in excess of the 
minimum required contribution. Section 1.430(f)-1(f)(3)(ii) of the 
regulations provides an exception to the general rule requiring that 
any elections to use the funding standard carryover balance and/or 
prefunding balance to offset the minimum required contribution

[[Page 47657]]

are irrevocable. Under this exception, such an election may be 
revoked to the extent that the amount of the election exceeds the 
minimum required contribution for the plan year as reported in Line 
38. If a timely election is made to revoke the excess amount, report 
only the amount of the election used to offset the minimum required 
contribution on Line 39. If the excess amount is not revoked by 
means of a timely election, report the full amount of the election 
on Line 39 even if it exceeds the minimum required contribution 
reported on Line 38.
    Line 40. Additional Cash Requirement. Enter the amount in Line 
38 minus the amount in the ``Total Balance'' column in Line 39. (The 
result cannot be less than zero.) This represents the contribution 
needed to satisfy the minimum funding requirement for the current 
year, adjusted for interest to the valuation date.
    Line 41. Contributions Allocated Toward Minimum Required 
Contribution for Current Year, Adjusted to Valuation Date. Enter the 
amount reported in Line 22c.
    Line 42. Present Value of Excess Contributions for Current Year.
    Line 42a. If Line 41 is greater than Line 40, enter the amount 
by which Line 41 exceeds line 40. Otherwise, enter ``0.'' This 
amount (plus interest, if applicable) is the maximum amount by which 
the plan sponsor may elect to increase the prefunding balance.
    Line 42b. Enter the amount of any portion of the amount shown on 
Line 42a that results solely from the use of the funding standard 
carryover balance and/or prefunding balance to offset the minimum 
required contribution.
    Line 43. Unpaid Minimum Required Contribution for Current Year. 
If Line 41 is less than Line 40, enter the amount by which Line 40 
exceeds Line 41. Otherwise, enter ``0''.
    Line 44. Unpaid Minimum Required Contributions for All Years. 
Enter the sum of the remaining unpaid minimum required contributions 
from Line 34 and the unpaid minimum required contribution for the 
current year from Line 43. If this amount is greater than zero, file 
Form 5330, Return of Excise Taxes Related to Employee Benefit Plans 
and pay the 10% excise tax on the unpaid minimum required 
contributions.

Part IX--Election to Use Pension Funding Relief under PRA 2010

    Note. This section is completed only if:
    (1) an election was made to use an alternative shortfall 
amortization schedule for any election year under Code section 
430(c)(2)(D) or ERISA section 303(c)(2)(D), or
    (2) in the case of a plan subject to a delayed effective date 
for PPA funding rules under section 104 of PPA, an election was made 
to determine the minimum required contribution for any election year 
using the extended amortization periods under section 107 of PPA 
'06, as added by PRA 2010 (complete Lines 45a and 45b only).
    Line 45a. Schedule elected. Check the applicable box to indicate 
which alternative shortfall amortization schedule is being used, the 
2 plus 7-year schedule or the 15-year being used, the 2 plus 7-year 
schedule or the 15-year schedule.
    Line 45b. Eligible plan year(s) for which the election in Line 
45a was made. Check the box(es) to indicate the eligible plan years 
for which the election was made to use an alternative amortization 
schedule under Code section 430(c)(2)(D) or ERISA section 
303(c)(2)(D) or the relief under section 107 of PPA '06 as added by 
PRA 2010. Note that an election to use an alternative amortization 
schedule may only be made with respect to one or two eligible plan 
years. Refer to Code section 430(c)(2)(D)(v) or ERISA section 
303(c)(2)(D)(v) for the definition of eligible plan years.
    Line 46. Amount of acceleration adjustment. Enter the total 
amount included in the shortfall amortization installments reported 
for the current year on Line 36a as a result of increases due to any 
installment acceleration amount under Code section 430(c)(7) or 
ERISA section 303(c)(7), taking into account any amounts carried 
over from previous years and the annual limitation in Code section 
430(c)(7)(C)(ii) or ERISA section 303(c)(7)(C)(ii).
    Line 47. Excess installment acceleration amount to be carried 
over to future plan years. Enter the amount of any excess 
installment acceleration amount for the current year (including any 
amounts carried to the current year from prior years) that will be 
carried over to future plan years in accordance with Code section 
430(c)(7)(C)(iii) or ERISA section 303(c)(7)(C)(iii).

Quick Reference Charts

    Note. The following series of quick reference charts set forth a 
general summary of filing requirements for pension plans, welfare 
plans that provide group health benefits, welfare plans other than 
group health, and direct filing entities. Not all rules and 
requirements are reflected for the various types of filers.
    CAUTION: Refer to specific Form 5500 Annual Return/Report 
instructions for complete information on filing requirements (e.g., 
Who Must File and What To File). These charts do not include filing 
requirements for small plans eligible to file the Form 5500-SF or 
the new registration alternative for small fully insured group 
health plans.
    Make sure you are reading the right chart for your type of plan 
or filing entity:
    1. Pension Plans Required to File the Form 5500
    2. Direct Filing Entities Other Than Group Insurance 
Arrangements (GIAs)
    3. Welfare Plans and GIAs That Provide Group Health Benefits
    4. Welfare Plans Other Than Group Health

Pension Plans Required to File the Form 5500

    (Does not include filing requirements for small plans eligible 
to file the Form 5500-SF). This chart provides only general 
guidance. Not all rules and requirements are reflected. Refer to 
specific Form 5500 Annual Return/Report instructions for complete 
information on filing requirements (e.g., Who Must File and What To 
File).

------------------------------------------------------------------------
                               Large Pension Plan    Small Pension Plan
------------------------------------------------------------------------
Form 5500...................  Must complete.......  Must complete unless
                                                     eligible to File
                                                     Form 5500-SF.
                                                     Pension plans and
                                                     welfare plans with
                                                     fewer than 100
                                                     participants at the
                                                     beginning of the
                                                     plan year that are
                                                     not exempt from
                                                     filing an annual
                                                     return/report may
                                                     be eligible to file
                                                     the Form 5500-SF, a
                                                     simplified report.
                                                     In addition to the
                                                     limitation on the
                                                     number of
                                                     participants, a
                                                     Form 5500-SF may
                                                     only be filed for a
                                                     plan that is exempt
                                                     from the
                                                     requirement that
                                                     the plan's books
                                                     and records be
                                                     audited by an
                                                     independent
                                                     qualified public
                                                     accountant (but not
                                                     by reason of
                                                     enhanced bonding),
                                                     has 100 percent of
                                                     its assets invested
                                                     in certain secure
                                                     investments with a
                                                     readily
                                                     determinable fair
                                                     market value, holds
                                                     no employer
                                                     securities, and is
                                                     not a multiemployer
                                                     plan. See Who Must
                                                     File. Defined
                                                     contribution
                                                     pension plans
                                                     (other than those
                                                     that check the
                                                     ``first plan year''
                                                     box, which use Line
                                                     6) that otherwise
                                                     meet the conditions
                                                     for filing the Form
                                                     5500-SF use the
                                                     count on Line
                                                     7g(1)--number of
                                                     participants with
                                                     account balances at
                                                     the beginning of
                                                     the year--to
                                                     determine whether
                                                     they are a small
                                                     plan.
Schedule A (Insurance         Must complete if      Must complete if
 Information).                 plan has insurance    plan has insurance
                               contracts.            contracts.

[[Page 47658]]

 
Schedule C (Service Provider  Must complete Part I  Must complete Part I
 Information).                 if (1) each covered   if (1) each covered
                               service provider      service provider
                               who received $1,000   who received $1,000
                               or more in total      or more in total
                               direct and indirect   direct and indirect
                               compensation (i.e.,   compensation (i.e.,
                               money or anything     money or anything
                               else of monetary      else of monetary
                               value in connection   value in connection
                               with services         with services
                               rendered to the       rendered to the
                               plan or the           plan or the
                               person's position     person's position
                               with the plan         with the plan
                               during the plan       during the plan
                               year, including       year, including
                               payments from         payments from
                               participants'         participants'
                               accounts and (2)      accounts and (2)
                               other persons who     other persons who
                               received $5,000 or    received $5,000 or
                               more in direct        more in direct
                               compensation in       compensation in
                               connection with       connection with
                               services rendered     services rendered
                               to the plan or the    to the plan or the
                               person's position     person's position
                               with the plan         with the plan
                               during the plan       during the plan
                               year, including       year, including
                               payments from         payments from
                               participants'         participants'
                               accounts; and Part    accounts; and Part
                               II if a service       II if a service
                               provider failed to    provider failed to
                               provide information   provide information
                               necessary for the     necessary for the
                               completion of Part    completion of Part
                               I.                    I.
Schedule D (DFE/              Not required........  Not required
 Participating Plan
 Information).
Schedule G (Financial         Must complete if      Must complete if
 Schedules).                   Schedule H, Lines     Schedule H, Lines
                               4b, 4c, or 4d are     4b, 4c, or 4d are
                               answered ``Yes.''.    answered ``Yes''
                                                     and plan is not
                                                     eligible for the
                                                     audit waiver under
                                                     29 CFR 2520.104-46.
Schedule H (Financial         Must complete.......  Must complete
 Information).
Line 4a Schedule of           Must check ``yes''    Must check ``yes''
 Delinquent Participant        to Schedule H, Line   to Schedule H, Line
 Contributions.                4a and complete if    4a and complete if
                               plan had delinquent   plan had delinquent
                               contributions (see    contributions (see
                               instructions).        instructions).
Line 4i(1) Schedule of        Must check ``yes''    Must check ``yes''
 Assets Held for Investment    to Schedule H, Line   to Schedule H, Line
 at EOY.                       4i(1) and complete    4i(1) and complete
                               if plan held assets   if plan held assets
                               at end of year (all   at end of year (all
                               plans except those    plans except those
                               that are filing       that are filing
                               final return/report   final return/report
                               with -0- assets at    with -0- assets at
                               year end)). If        year end)). If
                               invested in a CCT     invested in a CCT
                               or PSA that has not   or PSA that has not
                               filed a Form 5500,    filed a Form 5500,
                               must break out the    must break out the
                               underlying            underlying
                               investments of the    investments of the
                               CCT and PSA,          CCT and PSA,
                               indicating assets     indicating assets
                               held through a CCT    held through a CCT
                               or PSA. If invested   or PSA. If invested
                               in a CCT or PSA       in a CCT or PSA
                               that has filed the    that has filed the
                               Form 5500, may        Form 5500, may
                               report individual     report individual
                               CCTs and PSAs at      CCTs and PSAs at
                               the CCT/PSA level,    the CCT/PSA level,
                               indicating the Line   indicating the Line
                               1b category for       1b category for
                               type of CCT/PSA       type of CCT/PSA
                               investment.           investment.
Line 4i(2) Schedule of        Must check ``yes''    Must check ``yes''
 Assets Disposed of During     to Schedule H, Line   to Schedule H, Line
 the Plan Year.                4i(2) and complete    4i(2) and complete
                               if plan disposed of   if plan disposed of
                               assets during the     assets during the
                               plan year. Certain    plan year. Certain
                               readily tradable      readily tradable
                               assets not required   assets not required
                               to be reported (see   to be reported (see
                               instructions).        instructions).
Line 4j Schedule of           Must check ``yes''    Must check ``yes''
 Reportable Transactions.      to Schedule H, Line   to Schedule H, Line
                               4j and complete if    4j and complete if
                               plan had              plan had
                               transactions          transactions
                               involving 5% or       involving 5% or
                               more of plan assets.  more of plan
                                                     assets.
Schedule J..................  Pension plans do NOT  Pension plans do NOT
                               need to complete      need to complete
                               unless providing      unless providing
                               retiree health        retiree health
                               benefits or           benefits or
                               otherwise providing   otherwise providing
                               ``group health        ``group health
                               benefits''.           benefits''.
Schedule MB (Actuarial        Must complete if      Must complete if
 Information).                 multiemployer         multiemployer
                               defined benefit       defined benefit
                               pension plan or       pension plan or
                               money purchase plan   money purchase plan
                               subject to minimum    subject to minimum
                               funding standards.    funding standards.
Schedule R (Pension Plan      Must complete.......  Must complete.
 Information).                Money purchase        Money purchase
                               defined               defined
                               contribution          contribution
                               pension plans that    pension plans that
                               are amortizing a      are amortizing a
                               funding waiver are    funding waiver are
                               required to           required to
                               complete Lines 3,     complete Lines 3,
                               9, and 10 of the      9, and 10 of the
                               Schedule MB in        Schedule MB in
                               accordance with the   accordance with the
                               instructions. Also    instructions. Also
                               see instructions      see instructions
                               for Line 6 and 7a     for Line 6 and 7a
                               of Schedule R.        of Schedule R.
                              Schedule R should     Schedule R should
                               not be completed      not be completed
                               when the Form 5500    when the Form 5500
                               Annual Return/        Annual Return/
                               Report is filed for   Report is filed for
                               a pension plan that   a pension plan that
                               uses, as the sole     uses, as the sole
                               funding vehicle for   funding vehicle for
                               providing benefits,   providing benefits,
                               individual            individual
                               retirement accounts   retirement accounts
                               or annuities (as      or annuities (as
                               described in Code     described in Code
                               section 408). See     section 408). See
                               the Form 5500         the Form 5500
                               instructions for      instructions for
                               Limited Pension       Limited Pension
                               Plan Reporting for    Plan Reporting for
                               more information.     more information.
Schedule SB (Actuarial        Must complete if      Must complete if
 Information).                 single-employer or    single-employer or
                               multiple-employer     multiple-employer
                               defined benefit       defined benefit
                               pension plan,         pension plan,
                               including an          including an
                               eligible combined     eligible combined
                               plan and subject to   plan and subject to
                               minimum funding       minimum funding
                               standards.            standards.
Accountant's Opinion (IQPA    Must attach.........  Required unless
 Report).                                            Schedule H, Line
                                                     3h(4) is checked to
                                                     indicate that the
                                                     plan is a small
                                                     plan that meets the
                                                     requirements of 29
                                                     CFR 2520.104-46.
------------------------------------------------------------------------

    Direct Filing Entities Other Than Group Insurance Arrangements 
(GIAs)). This chart provides only general guidance. Not all rules 
and requirements are reflected. Refer to specific Form 5500 Annual 
Return/Report instructions for complete information on filing 
requirements (e.g., Who Must File and What To File).

[[Page 47659]]



----------------------------------------------------------------------------------------------------------------
                                            Master Trusts              CCTs/PSAs                103-12 IEs
----------------------------------------------------------------------------------------------------------------
Form 5500............................  Must complete..........  CCTs and PSAs are not    Certain collective
                                                                 required to file a       investment vehicles
                                                                 Form 5500, but filing    that hold plan assets
                                                                 by the CCT/PSA           are permitted to elect
                                                                 relieves investing       to file a Form 5500,
                                                                 plans of certain         which filing relieves
                                                                 reporting obligations.   investing plans of
                                                                                          certain reporting
                                                                                          obligations.
Schedule of Participating Employers..  Not required...........  Not required...........  Not required
Schedule A (Insurance Information)...  Must complete if plan    Not required...........  Must complete if plan
                                        has insurance                                     has insurance
                                        contracts.                                        contracts.
Schedule C (Service Provider           Must complete Part I if  Not required...........  Must complete Part I if
 Information).                          (1) each covered                                  (1) each covered
                                        service provider who                              service provider who
                                        received $1,000 or                                received $1,000 or
                                        more in total direct                              more in total direct
                                        and indirect                                      and indirect
                                        compensation (i.e.,                               compensation (i.e.,
                                        money or anything else                            money or anything else
                                        of monetary value in                              of monetary value in
                                        connection with                                   connection with
                                        services rendered to                              services rendered to
                                        the plan or the                                   the plan or the
                                        person's position with                            person's position with
                                        the plan during the                               the plan during the
                                        plan year, including                              plan year, including
                                        payments from                                     payments from
                                        participants' accounts                            participants' accounts
                                        and (2) other persons                             and (2) other persons
                                        who received $5,000 or                            who received $5,000 or
                                        more in direct                                    more in direct
                                        compensation in                                   compensation in
                                        connection with                                   connection with
                                        services rendered to                              services rendered to
                                        the plan or the                                   the plan or the
                                        person's position with                            person's position with
                                        the plan during the                               the plan during the
                                        plan year, including                              plan year , including
                                        payments from                                     payments from
                                        participants'                                     participants'
                                        accounts; and Part II                             accounts; and Part II
                                        if a service provider                             if a service provider
                                        failed to provide                                 failed to provide
                                        information necessary                             information necessary
                                        for the completion of                             for the completion of
                                        Part I.                                           Part I.
Schedule D (DFE/Participating Plan     Must complete..........  Must complete..........  Must complete
 Information).
Schedule G (Financial Schedules).....  Must complete if         Not required...........  Must complete if
                                        Schedule H, Lines 4b,                             Schedule H, Lines 4b,
                                        4c, or 4d are answered                            4c, or 4d are answered
                                        ``Yes.''.                                         ``Yes.''.
Schedule H (Financial Information)...  Must complete..........  Must complete..........  Must complete
Line 4a Schedule of Delinquent         Not required...........  Not required...........  Not required
 Participant Contributions.
Line 4i(1) Schedule of Assets Held     Must check ``yes'' to    Must check ``yes'' to    Must check ``yes'' to
 for Investment at EOY.                 Schedule H, Line 4i(1)   Schedule H, Line 4i(1)   Schedule H, Line 4i(1)
                                        and complete if master   and complete if plan     and complete if 103-12
                                        trust held assets at     held assets at end of    IE held assets at end
                                        end of year (all plans   year (all plans except   of year (all plans
                                        except those that are    those that are filing    except those that are
                                        filing final return/     final return/report      filing final return/
                                        report with -0- assets   with -0- assets at       report with -0- assets
                                        at year end).            year end).               at year end)
Line 4i(2) Schedule of Assets          Must check ``yes'' to    Not required...........  Must check ``yes'' to
 Disposed of During the Plan Year.      Schedule H, Line 4i(2)                            Schedule H, Line 4i(2)
                                        and complete if master                            and complete if 103-12
                                        trust disposed of                                 IE disposed of assets
                                        assets during the plan                            during the plan year.
                                        year. Certain readily                             Certain readily
                                        tradable assets not                               tradable assets not
                                        required to be                                    required to be
                                        reported (see                                     reported (see
                                        instructions).                                    instructions)
Line 4j Schedule of Reportable         Must check ``yes'' to    Not required...........  Not required
 Transactions.                          Schedule H, Line 4j
                                        and complete if master
                                        trust had transactions
                                        involving 5% or more
                                        of assets.
Schedule J...........................  Not required...........  Not required...........  Not required
Schedule MB (Actuarial Information)..  Not required...........  Not required...........  Not required
Schedule R (Pension Plan Information)  Not required...........  Not required...........  Not required
Schedule SB (Actuarial Information)..  Not required...........  Not required...........  Not required
Accountant's Opinion (IQPA Report)...  Not required...........  Not required...........  Must attach
----------------------------------------------------------------------------------------------------------------

    Welfare Plans and Group Insurance Arrangements (GIAs) That 
Provide Health Benefits \44\ This chart provides only general 
guidance. Not all rules and requirements are reflected. Refer to 
specific Form 5500 Annual Return/Report instructions for complete 
information on filing requirements (e.g., Who Must File and What To 
File).

[[Page 47660]]



----------------------------------------------------------------------------------------------------------------
                                                                                             Group insurance
                                      Large welfare plans        Small welfare plans        arrangements that
                                   providing health benefits      providing health       provide health benefits
                                                                      benefits                   (GIAs)
----------------------------------------------------------------------------------------------------------------
Form 5500........................  Must complete............  Must complete.            Must complete.
                                                               Exception: Small fully
                                                               insured group health
                                                               plans complete only
                                                               certain questions.
Schedule of Participating          Multiple employer plans    Multiple employer plans   Must complete
 Employers.                         and plans covering         and plans covering
                                    members of a controlled    members of a controlled
                                    group must complete.       group must complete.
Schedule A (Insurance              Must complete if plan has  Must complete if plan     Must complete
 Information).                      insurance contracts.       has insurance
                                                               contracts. Exception:
                                                               Small fully insured
                                                               group health plans do
                                                               not complete.
Schedule C (Service Provider       Must complete Part I for   Must complete Part I for  Must complete Part I for
 Information).                      (1) each covered service   (1) each covered          (1) each covered
                                    provider who received      service provider who      service provider who
                                    $1,000 or more in total    received $1,000 or more   received $1,000 or more
                                    direct and indirect        in total direct and       in total direct and
                                    compensation (i.e.,        indirect compensation     indirect compensation
                                    money or anything else     (i.e., money or           (i.e., money or
                                    of monetary value in       anything else of          anything else of
                                    connection with services   monetary value in         monetary value in
                                    rendered to the plan or    connection with           connection with
                                    the person's position      services rendered to      services rendered to
                                    with the plan during the   the plan or the           the plan or the
                                    plan year, including       person's position with    person's position with
                                    payments from              the plan during the       the plan during the
                                    participants' accounts)    plan year, including      plan year, including
                                    and (2) other persons      payments from             payments from
                                    who received $5,000 or     participants' accounts)   participants' accounts
                                    more in direct             and (2) other persons     and (2) other persons
                                    compensation in            who received $5,000 or    who received $5,000 or
                                    connection with services   more in direct            more in direct
                                    rendered to the plan or    compensation in           compensation in
                                    the person's position      connection with           connection with
                                    with the plan during the   services rendered to      services rendered to
                                    plan year, including       the plan or the           the plan or the
                                    payments from              person's position with    person's position with
                                    participants' accounts;    the plan during the       the plan during the
                                    and Part II if a service   plan year, including      plan year, including
                                    provider failed to         payments from             payments from
                                    provide information        participants' accounts;   participants' accounts;
                                    necessary for the          and Part II if a          and Part II if a
                                    completion of Part I.      service provider failed   service provider failed
                                    Exception: Unfunded,       to provide information    to provide information
                                    fully insured, or          necessary for the         necessary for the
                                    combination unfunded/      completion of Part I.     completion of Part I.
                                    fully insured group        Exception: Unfunded,
                                    health plans are exempt    fully insured, or
                                    under 29 CFR 2520.104-44   combination unfunded/
                                    from completing Schedule   fully insured group
                                    C.                         health plans are exempt
                                                               under 29 CFR 2520.104-
                                                               44 from completing
                                                               Schedule C.
Schedule D (DFE/Participating      Not required for plans...  Not required for plans..  Must complete to report
 Plan Information).                                                                      participating plans.
Schedule G (Financial Schedules).  Must complete if Schedule  Not required............  Must complete if
                                    H, Lines 4b, 4c, or 4d                               Schedule H, Lines 4b,
                                    are answered ``Yes.''.                               4c, or 4d for a GIA,
                                   Unfunded, fully insured,                              are answered ``Yes.''
                                    or combination unfunded/                            Unfunded, fully insured,
                                    fully insured welfare                                or combination unfunded/
                                    plans are exempt under                               fully insured welfare
                                    29 CFR 2520.104-44 from                              plans are exempt under
                                    completing Parts I and                               29 CFR 2520.104-44 from
                                    II but must still                                    completing Parts I and
                                    complete Schedule G,                                 II but GIA's must still
                                    Part III to report                                   complete Schedule G,
                                    nonexempt transactions.                              Part III to report
                                                                                         nonexempt transactions
                                                                                         for participating
                                                                                         plans.
Schedule H (Financial              Must complete if plan is   Must complete if plan is  Must complete
 Information).                      partly or fully funded     partly or fully funded
                                    with a trust (including    with a trust (including
                                    a VEBA). Unfunded, fully   a VEBA). Unfunded,
                                    insured, or combination    fully insured, or
                                    unfunded/fully insured     combination unfunded/
                                    group health plans are     fully insured group
                                    exempt under 29 CFR        health plans are exempt
                                    2520.104-44 from           under 29 CFR 2520.104-
                                    completing Schedule H.     44 from completing
                                                               Schedule H.
Line 4a Schedule of Delinquent     Must complete if required  Not required............  Not required
 Participant Contributions.         to complete Schedule H.
Line 4i(1) Schedule of Assets      If required to complete    Not required............  Must complete
 Held for Investment at EOY.        Schedule H, must check
                                    ``yes'' to Schedule H,
                                    Line 4i(1) and complete
                                    if plan held assets at
                                    end of year (all plans
                                    except those that are
                                    filing final return/
                                    report with -0- assets
                                    at year end).
Line 4i(2) Schedule of Assets      If required to complete    Not required............  Must complete
 Disposed of During the Plan Year.  Schedule H, must check
                                    ``yes'' to Schedule H,
                                    Line 4i(2) and complete
                                    if plan disposed of
                                    assets during the plan
                                    year. Certain readily
                                    tradable assets not
                                    required to be reported
                                    (see instructions).

[[Page 47661]]

 
Line 4j Schedule of Reportable     If required to complete    Not required............  Must complete
 Transactions.                      Schedule H, must check
                                    ``yes'' to Schedule H,
                                    Line 4j and complete if
                                    plan had transactions
                                    involving 5% or more of
                                    plan assets.
Schedule J.......................  Must complete............  Must complete entire      Must complete a separate
                                                               Schedule J if not fully   Schedule J for each
                                                               insured. If fully         participating employer.
                                                               insured, must complete
                                                               Lines 1-8.
Schedule MB (Actuarial             Not required.............  Not required............  Not required
 Information).
Schedule R (Pension Plan           Not required.............  Not required............  Not required
 Information).
Schedule SB (Actuarial             Not required.............  Not required............  Not required
 Information).
Accountant's Opinion (IQPA         Must complete if plan is   Not required............  Must attach.
 Report).                           partly or fully funded
                                    with a trust (including
                                    a VEBA). Unfunded, fully
                                    insured, or combination
                                    unfunded/fully insured
                                    group health plans are
                                    exempt under 29 CFR
                                    2520.104-44 from the
                                    IQPA report.
----------------------------------------------------------------------------------------------------------------

    Welfare Plans Other Than Group Health This chart provides only 
general guidance. Not all rules and requirements are reflected. 
Refer to specific Form 5500 Annual Return/Report instructions for 
complete information on filing requirements (e.g., Who Must File and 
What To File).
---------------------------------------------------------------------------

    \44\ Pension plans that also provide health benefits must follow 
the rules for pension plan filings and must also attach a Schedule J 
to report on health benefits.

----------------------------------------------------------------------------------------------------------------
                                                                                             Group insurance
                                    Large welfare plans NOT    Small welfare plans NOT   arrangements (GIAs) NOT
                                     providing health plan      providing health plan       providing health
                                            benefits                  benefits                  benefits
----------------------------------------------------------------------------------------------------------------
Form 5500........................  Must complete............  Must complete, except     Must complete
                                                               (1) unfunded, fully
                                                               insured, or combination
                                                               unfunded/fully insured
                                                               welfare plans covering
                                                               fewer than 100
                                                               participants at the
                                                               beginning of the plan
                                                               year that meet the
                                                               requirements of 29 CFR
                                                               2520.104-20 are exempt
                                                               from filing an annual
                                                               report.
                                                              (2) Welfare plans with
                                                               fewer than 100
                                                               participants at the
                                                               beginning of the plan
                                                               year that are not
                                                               exempt from filing an
                                                               annual return/report
                                                               may be eligible to file
                                                               the Form 5500-SF, a
                                                               simplified report.
                                                              Note: If plan provides
                                                               group health benefits,
                                                               follow the filing
                                                               instructions for group
                                                               health plans.
Schedule of Participating          Multiple employer plans    Multiple employer plans   Must complete
 Employers.                         and plans covering         and plans covering
                                    members of a controlled    members of a controlled
                                    group must complete.       group must complete.
Schedule A (Insurance              Must complete if plan has  Must complete if plan     Must complete
 Information).                      insurance contracts.       has insurance contracts.

[[Page 47662]]

 
Schedule C (Service Provider       Must complete Part I for   Must complete Part I for  Must complete Part I for
 Information).                      (1) each covered service   (1) each covered          (1) each covered
                                    provider who received      service provider who      service provider who
                                    $1,000 or more in total    received $1,000 or more   received $1,000 or more
                                    direct and indirect        in total direct and       in total direct and
                                    compensation (i.e.,        indirect compensation     indirect compensation
                                    money or anything else     (i.e., money or           (i.e., money or
                                    of monetary value in       anything else of          anything else of
                                    connection with services   monetary value in         monetary value in
                                    rendered to the plan or    connection with           connection with
                                    the person's position      services rendered to      services rendered to
                                    with the plan during the   the plan or the           the plan or the
                                    plan year, including       person's position with    person's position with
                                    payments from              the plan during the       the plan during the
                                    participants' accounts)    plan year, including      plan year, including
                                    and (2) other persons      payments from             payments from
                                    who received $5,000 or     participants' accounts)   participants' accounts
                                    more in direct             and (2) other persons     and (2) other persons
                                    compensation in            who received $5,000 or    who received $5,000 or
                                    connection with services   more in direct            more in direct
                                    rendered to the plan or    compensation in           compensation in
                                    the person's position      connection with           connection with
                                    with the plan during the   services rendered to      services rendered to
                                    plan year, including       the plan or the           the plan or the
                                    payments from              person's position with    person's position with
                                    participants' accounts;    the plan during the       the plan during the
                                    and Part II if a service   plan year, including      plan year, including
                                    provider failed to         payments from             payments from
                                    provide information        participants' accounts;   participants' accounts;
                                    necessary for the          and Part II if a          and Part II if a
                                    completion of Part I.      service provider failed   service provider failed
                                    Unfunded, fully insured,   to provide information    to provide information
                                    or combination unfunded/   necessary for the         necessary for the
                                    fully insured welfare      completion of Part I.     completion of Part I.
                                    plans are exempt under     Exception: Unfunded,
                                    29 CFR 2520.104-44 from    fully insured, or
                                    completing Schedule C.     combination unfunded/
                                                               fully insured welfare
                                                               benefit plans are
                                                               exempt under 29 CFR
                                                               2520.104-44 from
                                                               completing Schedule C.
Schedule D (DFE/Participating      Not required.............  Not required............  Must complete to report
 Plan Information).                                                                      participating plans.
Schedule G (Financial Schedules).  Must complete if Schedule  Not required............  Must complete if
                                    H, Lines 4b, 4c, or 4d                               Schedule H, Lines 4b,
                                    are ``Yes.'' Unfunded,                               4c, or 4d are answered
                                    fully insured, or                                    ``Yes.''
                                    combination unfunded/
                                    fully insured welfare
                                    plans are exempt under
                                    29 CFR 2520.104-44 from
                                    completing Parts I and
                                    II but must still
                                    complete Schedule G,
                                    Part III to report
                                    nonexempt transactions.
Schedule H (Financial              Must complete if plan is   Not required............  Must complete
 Information).                      partly or fully funded
                                    with a trust (including
                                    a VEBA). Unfunded, fully
                                    insured, or combination
                                    unfunded/fully insured
                                    welfare plans are exempt
                                    under 29 CFR 2520.104-44
                                    from completing Schedule
                                    H.
Line 4a Schedule of Delinquent     Must complete if required  Not required............  Not required
 Participant Contributions          to complete Schedule H.
Line 4i(1) Schedule of Assets      Must check ``Yes'' to      Not required............  Must complete
 Held for Investment at EOY         Schedule H, Line 4i(1)
                                    and complete if plan
                                    held assets at end of
                                    year (all plans except
                                    those that are filing
                                    final return/report with
                                    -0- assets at year end).
Line 4i(2) Schedule of Assets      Must check ``Yes'' to      Not required............  Must complete
 Disposed of During the Plan Year   Schedule H, Line 4i(2)
                                    and complete if plan
                                    disposed of assets
                                    during the plan year.
                                    Certain readily tradable
                                    assets not required to
                                    be reported (see
                                    instructions).
Line 4j Schedule of Reportable     Must check ``Yes'' to      Not required............  Must complete
 Transactions                       Schedule H, Line 4j and
                                    complete if plan had
                                    transactions involving
                                    5% or more of plan
                                    assets.
Schedule J.......................  Not required.............  Not required............  Not required
Schedule MB (Actuarial             Not required.............  Not required............  Not required
 Information).
Schedule R (Pension Plan           Not required.............  Not required............  Not required
 Information).
Schedule SB (Actuarial             Not required.............  Not required............  Not required
 Information).

[[Page 47663]]

 
Accountant's Opinion (IQPA         Large welfare plans must   Not required............  Must attach.
 Report).                           complete if plan is
                                    partly or fully funded
                                    with a trust (including
                                    a VEBA). Unfunded, fully
                                    insured, or combination
                                    unfunded/fully insured
                                    welfare plans are exempt
                                    under 29 CFR 2520.104-44
                                    from the IQPA report.
----------------------------------------------------------------------------------------------------------------

ERISA Compliance Quick Checklist

    Compliance with the Employee Retirement Income Security Act 
(ERISA) begins with knowing the rules. Plan administrators and other 
plan officials can use this checklist as a quick diagnostic tool for 
assessing a plan's compliance with certain important ERISA rules; it 
is not a complete description of all ERISA's rules and it is not a 
substitute for a comprehensive compliance review. Use of this 
checklist is voluntary. Do not file it with your Form 5500.
    If you answer ``No'' to any of the questions below, you should 
review your plan's operations because you may not be in full 
compliance with ERISA's requirements.
    1. Have you provided plan participants with a summary plan 
description, summaries of any material modifications of the plan, 
and annual summary financial reports or annual pension funding 
reports?
    2. Do you maintain copies of plan documents at the principal 
office of the plan administrator for examination by participants and 
beneficiaries?
    3. Do you respond to written participant inquires for copies of 
plan documents and information within 30 days?
    4. Does your plan include written procedures for making benefit 
claims and appealing denied claims, and are you complying with those 
procedures?
    5. Is your plan covered by fidelity bonds protecting the plan 
against losses due to fraud or dishonesty by persons who handle plan 
funds or other property?
    6. Are the plan's investments diversified so as to minimize the 
risk of large losses?
    7. If the plan permits participants to select the investments in 
their plan accounts, has the plan provided them with enough 
information to make informed decisions?
    8. Has a plan official determined that the investments are 
prudent and solely in the interest of the plan's participants and 
beneficiaries, and evaluated the risks associated with plan 
investments before making the investments?
    9. Did the employer or other plan sponsor send participant 
contributions to the plan on a timely basis?
    10. Did the plan pay participant benefits on time and in the 
correct amounts?
    11. Did the plan give participants and beneficiaries 30 days 
advance notice before imposing a ``blackout period'' of at least 
three consecutive business days during which participants or 
beneficiaries of a 401(k) or other individual account pension plan 
were unable to change their plan investments, obtain loans from the 
plan, or obtain distributions from the plan?
    If you answer ``Yes'' to any of the questions below, you should 
review your plan's operations because you may not be in full 
compliance with ERISA's requirements.
    1. Has the plan engaged in any financial transactions with 
persons related to the plan or any plan official? (For example, has 
the plan made a loan to or participated in an investment with the 
employer?)
    2. Has the plan official used the assets of the plan for his/her 
own interest?
    3. Have plan assets been used to pay expenses that were not 
authorized in the plan document, were not necessary to the proper 
administration of the plan, or were more than reasonable in amount?
    If you need help answering these questions or want additional 
guidance about ERISA requirements, a plan official should contact 
the U.S. Department of Labor Employee Benefits Security 
Administration office in your region or consult with the plan's 
legal counsel or professional employee benefit advisor.

APPENDIX C

Form 5500-SF Instructions

20XX Instructions for Form 5500-SF (Short Form Annual Return/Report of 
Small Employee Benefit Plan)

    Code section references are to the Internal Revenue Code unless 
otherwise noted. ERISA refers to the Employee Retirement Income 
Security Act of 1974.
    Changes to Note [The instructions for the year in which the 
revisions are implemented will include such items in the ``Changes 
to Note'' section.]
    Table of Contents [The final version of the Instructions for 
20XX will include a Table of Contents in substantially the same 
format as the existing Table of Contents]

EFAST2 Processing System

    Under the computerized ERISA Filing Acceptance System (EFAST), 
you must electronically file your 20XX Form 5500-SF, Short Form 
Annual Return/Report of Small Employee Benefit Plan. You may file 
your 20XX Form 5500-SF online using EFAST2's web-based filing system 
or you may file through an EFAST2-approved vendor. You cannot file a 
paper Form 5500-SF by mail or other delivery service. For more 
information, see the instructions for How To File--Electronic Filing 
Requirement on page xx and the EFAST2 Web site at www.efast.dol.gov.

How To Get Assistance

    If you need help completing this form, or have other questions, 
call the EFAST2 Help Line at 1-866-GO-EFAST (1-866-463-3278) (toll 
free) or access the EFAST2 or IRS Web sites. The EFAST2 Help Line is 
available Monday through Friday from 8:00 a.m. to 8:00 p.m., Eastern 
Time.
    You can access the EFAST2 Web site 24 hours a day, 7 days a week 
at www.efast.dol.gov to:
     File the Form 5500-SF or 5500 and any needed schedules 
or attachments.
     Check on the status of a filing you submitted.
     View filings posted by EFAST2.
     Register for electronic credentials to sign or submit 
filings.
     View forms and related instructions.
     Get information regarding EFAST2, including approved 
software vendors.
     See answers to frequently asked questions about the 
Form 5500-SF, the Form 5500 and its schedules, and EFAST2.
     Access the main Employee Benefits Security 
Administration (EBSA) and DOL Web sites for news, regulations, and 
publications.
    You can access the IRS Web site 24 hours a day, 7 days a week at 
www.irs.gov to:
     View forms, instructions, and publications.
     See answers to frequently asked tax questions.
     Search publications online by topic or keyword.
     Send comments or request help by email.
     Sign up to receive local and national tax news by 
email.
    You can order other IRS forms and publications at the IRS Web 
site at www.irs.gov/orderforms. You can order EBSA publications by 
calling 1-866-444-EBSA (3272).

General Instructions

    The Form 5500-SF, Short Form Annual Return/Report of Small 
Employee Benefit Plan, is a simplified annual reporting form for use 
by certain small pension and welfare benefit plans. To be eligible 
to use the Form 5500-SF, the plan must:
     Be a small plan (i.e., generally have fewer than 100 
participants at the beginning of the plan year);
     Meet the conditions for being exempt from the 
requirement that the plan's books and records be audited by an 
independent qualified public accountant (IQPA);
     Have 100% of its assets invested in certain secure 
investments with a readily determinable fair value;
     Hold no employer securities;
     Not be a multiemployer plan; and
     Not provide health benefits.
    Plans required to file an annual return/report that are not 
eligible to file the Form 5500-SF, must file a Form 5500, Annual 
Return/Report of Employee Benefit Plan, with all required schedules 
and attachments

[[Page 47664]]

(Form 5500), or Form 5500-EZ, Annual Return of One-Participant 
(Owners and Their Spouses) Retirement Plan.
    To reduce the possibility of correspondence and penalties, we 
remind filers that the Internal Revenue Service (IRS), Department of 
Labor (DOL), and Pension Benefit Guaranty Corporation (PBGC) have 
consolidated their annual return/report forms to minimize the filing 
burden for employee benefit plans. Administrators and sponsors of 
employee benefit plans generally will satisfy their IRS and DOL 
annual reporting requirements for the plan under ERISA sections 104 
and 4065 and Code sections 6058 and 6059 by filing either the Form 
5500, Form 5500-SF, or Form 5500-EZ. Defined contribution and 
defined benefit pension plans may have to file additional 
information with the IRS including: Form 8955-SSA, Annual 
Registration Statement Identifying Separated Participants with 
Deferred Vested Benefits.; Form 5330, Return of Excise Taxes Related 
to Employee Benefit Plans; Form 5310-A, Notice of Plan Merger or 
Consolidation, Spinoff, or Transfer of Plan Assets or Liabilities; 
Notice of Qualified Separate Lines of Business. See www.irs.gov for 
more information. Defined benefit pension plans covered by the PBGC 
have special additional requirements, including filing premiums and 
reporting certain transactions directly with that agency. See the 
PBGC's Web site at www.pbgc.gov/practitioners for information on 
premium filings and reporting and disclosure requirements.
    Note. The Form 5500-EZ generally is used by ``one-participant 
plans or certain foreign plans'' (as defined under Specific 
Instructions Only for ``One-Participant Plans and certain foreign 
plans'') that are not subject to the requirements of section 104(a) 
of ERISA to satisfy certain annual reporting and filing obligations 
imposed by the Code. A ``one-participant plan and certain foreign 
plan'' may also be eligible to file Form 5500-SF. See Specific 
Instructions Only for ``One-Participant Plans and certain foreign 
plans.'' A ``one-participant plan or certain foreign plan'' that is 
eligible to file Form 5500-SF may elect to file Form 5500-SF 
electronically with EFAST2 rather than filing a Form 5500-EZ on 
paper with the IRS. A ``one-participant plan or certain foreign 
plan'' that is not eligible to file Form 5500-SF must file Form 
5500-EZ on paper with the IRS. For more information on filing with 
the IRS, go to www.irs.gov or call 1-877-829-5500.
    [CAUTION] Abbreviated filing requirements apply for one-
participant plan filers who are eligible to file Form 5500-SF. See 
Specific Instructions Only for ``One-Participant Plans'' on page XX.
    The Form 5500-SF must be filed electronically. See How To File--
Electronic Filing Requirement instructions and the EFAST2 Web site 
at www.efast.dol.gov. Your Form 5500-SF entries will be initially 
screened electronically. Your entries must satisfy this screening 
for your filing to be received. Once received, your form may be 
subject to further detailed review, and your filing may be rejected 
based upon this further review.
    ERISA and the Code provide for the assessment or imposition of 
penalties for not submitting the required information when due. See 
Penalties.
    Annual returns/reports filed under Title I of ERISA must be made 
available by plan administrators to plan participants and 
beneficiaries and by the DOL to the public pursuant to ERISA 
sections 104 and 106. Pursuant to Section 504 of the Pension 
Protection Act of 2006 (PPA), this availability for defined benefit 
pension plans must include the posting of identification and basic 
plan information and actuarial information (Form 5500-SF, Schedule 
SB or MB, and all of the Schedule SB or MB attachments) on any plan 
sponsor intranet Web site (or Web site maintained by the plan 
administrator on behalf of the plan sponsor) that is used for the 
purpose of communicating with employees and not the public. Section 
504 also requires DOL to display such information on DOL's Web site 
within 90 days after the filing of the plan's annual return/report. 
To see 2009 and later Forms 5500-SF, including actuarial 
information, see www.dol.gov/ebsa. See www.dol.gov/ebsa/actuarialsearch.html for 2008 and short plan year 2009 actuarial 
information filed under the previous paper-based system.

Pension and Welfare Plans Required To File Annual Return/Report

    All pension benefit plans and welfare benefit plans covered by 
ERISA must file a Form 5500 or Form 5500-SF for a plan year unless 
they are eligible for a filing exemption. (See Code sections 6058 
and 6059 and ERISA sections 104 and 4065). An annual return/report 
must be filed even if the plan is not ``tax qualified,'' benefits no 
longer accrue, contributions were not made during this plan year, or 
contributions are no longer made. Pension benefit plans required to 
file include both defined benefit pension plans and defined 
contribution pension plans. Profit-sharing plans, stock bonus plans, 
money purchase plans, 401(k) plans, Code section 403(b) plans 
covered by Title I of ERISA, and IRA plans established by an 
employer are among the pension benefit plans for which an annual 
return/report must be filed. Welfare benefit plans provide benefits 
such as medical, dental, life insurance, apprenticeship and 
training, scholarship funds, severance pay, disability, etc. Plans 
that cover residents of Puerto Rico, the U.S. Virgin Islands, Guam, 
Wake Island, or American Samoa also must file unless they are 
eligible for a filing exemption. This includes a plan that elects to 
have the provisions of section 1022(i)(2) of ERISA apply.
    For more information about annual return/report filings for Code 
section 403(b) plans covered by Title I of ERISA, see Field 
Assistance Bulletins 2009-02 and 2010-01, available on the DOL Web 
site at www.dol.gov.

Plans Exempt From Filing

    Under regulations and applicable guidance, some pension benefit 
plans and many welfare benefit plans with fewer than 100 
participants are exempt from filing an annual return/report. Do not 
file a Form 5500-SF for an employee benefit plan that is any of the 
following:
    1. An unfunded excess benefit plan. See ERISA section 4(b)(5).
    2. A pension benefit plan maintained outside the United States 
primarily for the benefit of persons substantially all of whom are 
nonresident aliens. However, certain foreign plans are required to 
file the Form 5500-EZ with the IRS. See the instructions to the Form 
5500-EZ for the filing requirements. For more information, go to 
www.irs.gov/ep or call 1-877-829-5500.
    3. An annuity or custodial account arrangement under Code 
section 403(b)(1) or (7) not established or maintained by an 
employer as described in DOL Regulations 29 CFR 2510.3-2(f).
    4. A simplified employee pension (SEP) described in Code section 
408(k) that conforms to the alternative method of compliance 
described in 29 CFR 2520.104-48 or 29 CFR 104-49. A SEP is a pension 
plan that meets certain minimum qualifications regarding eligibility 
and employer contributions.
    5. A Savings Incentive Match Plan for Employees of Small 
Employers (SIMPLE) that involves SIMPLE IRAs under Code section 
408(p).
    6. A church pension benefit plan not electing coverage under 
Code section 410(d).
    7. An unfunded dues financed pension benefit plan that meets the 
alternative method of compliance provided by 29 CFR 2520.104-27.
    8. An individual retirement account or annuity not considered a 
pension plan under 29 CFR 2510.3-2(d).
    9. A ``one-participant plan,'' as defined on page 7. However, 
certain one-participant plans are required to file the Form 5500-EZ, 
Annual Return of One-Participant (Owners and Their Spouses) 
Retirement Plan, with the IRS or, if eligible, may file the Form 
5500-SF, Short Form Annual Return/Report of Employee Benefit Plan, 
electronically with EFAST2. See page 7.
    10. A governmental plan.
    11. An unfunded pension benefit plan or an unfunded or insured 
welfare benefit plan: (a) whose benefits go only to a select group 
of management or highly compensated employees, and (b) which meets 
the terms of 29 CFR 2520.104-23 (including the requirement that a 
registration statement be timely filed with DOL) or 29 CFR 2520.104-
24.
    12. A welfare benefit plan that covers fewer than 100 
participants as of the beginning of the plan year and is unfunded, 
fully insured, or a combination of insured and unfunded, and does 
not provide group health benefits. Plans that provide group health 
benefits, regardless of size or funding method must file the Form 
5500 and the Schedule J (Group Health Plan Information) and other 
schedules as applicable and cannot file the Form 5500-SF. See Form 
5500 Annual Return/Report Instructions. For this purpose:
    a. An unfunded welfare benefit plan has its benefits paid as 
needed directly from the general assets of the employer or the 
employee organization that sponsors the plan.
    Note. Plans that are NOT unfunded include those plans that 
received employee (or former employee) contributions during the

[[Page 47665]]

plan year and/or used a trust or separately maintained fund 
(including a Code section 501(c)(9) trust) to hold plan assets or 
act as a conduit for the transfer of plan assets during the plan 
year. A welfare benefit plan with employee contributions that is 
associated with a cafeteria plan under Code section 125 may be 
treated for annual reporting purposes as an unfunded welfare benefit 
plan if it meets the requirements of DOL Technical Release 92-01, 57 
FR 23272 (June 2, 1992) and 58 FR 45359 (Aug. 27, 1993). The mere 
receipt of COBRA contributions or other after-tax participant 
contributions (e.g., retiree contributions) by a cafeteria plan 
would not by itself affect the availability of the relief provided 
for cafeteria plans that otherwise meet the requirements of DOL 
Technical Release 92-01. See 61 FR 41220, 41222-23 (Aug. 7, 1996).
    b. A fully insured welfare benefit plan has its benefits 
provided exclusively through insurance contracts or policies, the 
premiums of which must be paid directly to the insurance carrier by 
the employer or employee organization from its general assets or 
partly from its general assets and partly from contributions by its 
employees or members (which the employer or employee organization 
forwards within 3 months of receipt). The insurance contracts or 
policies discussed above must be issued by an insurance company or 
similar organization that is qualified to do business in any state.
    c. A combination unfunded/insured welfare benefit plan has its 
benefits provided partially as an unfunded plan and partially as a 
fully insured plan. An example of such a plan is a welfare benefit 
plan that provides medical benefits as in ``a'' above and life 
insurance benefits as in ``b'' above. See 29 CFR 2520.104-20.
    Note. A voluntary employees' beneficiary association, as used in 
Code section 501(c)(9) (VEBA), should not be confused with the 
employer or employee organization that sponsors the plan. See ERISA 
section 3(4).
    13. Plans maintained only to comply with workers' compensation, 
unemployment compensation, or disability insurance laws.
    14. A welfare benefit plan maintained outside the United States 
primarily for persons substantially all of whom are nonresident 
aliens.
    15. A church welfare benefit plan under ERISA section 3(33).
    16. An unfunded dues financed welfare benefit plan that meets 
the alternative method of compliance provided by 29 CFR 2520.104-26.
    17. A welfare benefit plan that participates in a group 
insurance arrangement that files a return/report on its behalf under 
29 CFR 2520.104-43. A group insurance arrangement generally is an 
arrangement that provides benefits to the employees of two or more 
unaffiliated employers (not in connection with a multiemployer plan 
or a collectively bargained multiple-employer plan), fully insures 
one or more welfare benefit plans of each participating employer, 
uses a trust (or other entity such as a trade association) as the 
holder of the insurance contracts, and uses a trust as the conduit 
for payment of premiums to the insurance company.
    18. An apprenticeship or training plan meeting all of the 
conditions specified in 29 CFR 2520.104-22.
    For more information on plans that are exempt from filing an 
annual return/report, call the EFAST2 Help Line at 1-866-GO-EFAST 
(1-866-463-3278). For one-participant plan filers, see the 
Instructions for Form 5500-EZ or call the IRS Help Line at 1-877-
829-5500.

Who May File Form 5500-SF

    If your plan is required to file an annual return/report, you 
may file the Form 5500-SF instead of the Form 5500 only if you meet 
all of the eligibility conditions listed below.
    1. The plan (a) covered fewer than 100 participants at the 
beginning of the plan year 20XX, or (b) under 29 CFR 2520.103-1(d) 
was eligible to and filed as a small plan for plan year 20XX-1 and 
did not cover more than 120 participants at the beginning of plan 
year 20XX. (See instructions for Lines 6 and 7, on counting the 
number of participants.);
    2. The plan did not hold any employer securities at any time 
during the plan year;
    3. At all times during the plan year, the plan was 100% invested 
in certain secure, easy to value assets that meet the definition of 
``eligible plan assets'' (see the instructions for Line 8a), such as 
mutual fund shares, investment contracts with insurance companies 
and banks valued at least annually, publicly traded securities held 
by a registered broker dealer, cash and cash equivalents, and plan 
loans to participants;
    4. The plan is eligible for the waiver of the annual examination 
and report of an independent qualified public accountant (IQPA) 
under 29 CFR 2520.104-46 (but not by reason of enhanced bonding), 
which requirement includes, among others, giving certain disclosures 
and supporting documents to participants and beneficiaries regarding 
the plan's investments (see instructions for Line 8b);
    5. The plan is not a multiemployer plan; and
    6. The plan does not provide group health benefits.
    Notes. (1) Employee Stock Ownership Plans (ESOPs) and Direct 
Filing Entities (DFEs) may not file the Form 5500-SF. (2) One-
participant plans and certain foreign plans should follow the 
Specific Instructions Only for ``One-Participant Plans and Certain 
Foreign Plans'' in place of the instructions 1-5 above to see if 
Form 5500-SF may be filed instead of Form 5500-EZ.

What To File

    Plans required to file an annual return/report that meet all of 
the conditions for filing the Form 5500-SF may complete and file the 
Form 5500-SF in accordance with its instructions. Single-employer 
defined benefit pension plans using the Form 5500-SF must also file 
the Schedule SB (Form 5500), Single-Employer Defined Benefit Plan 
Actuarial Information, and its required attachments. Money purchase 
plans amortizing a funding waiver using the Form 5500-SF must also 
file the Schedule MB (Form 5500), Multiemployer Defined Benefit Plan 
and Certain Money Purchase Plan Actuarial Information, and its 
required attachments. For information about Schedule SB and Schedule 
MB, see the 20XX Instructions for Form 5500, Annual Return/Report of 
Employee Benefit Plan. One-participant plans see Specific 
Instructions Only for ``One-Participant Plans and Certain Foreign 
Plans.''
    Eligible Combined Plans. The Pension Protection Act of 2006 
(PPA) established rules for a new type of pension plan, an 
``eligible combined plan,'' effective for plan years beginning after 
December 31, 2009. See Code section 414(x) and ERISA section 210(e). 
An eligible combined plan consists of a defined benefit pension plan 
and a defined contribution pension plan that includes a qualified 
cash or deferred arrangement under Code section 401(k), with the 
assets of the two plans held in a single trust, but clearly 
identified and allocated between the plans. The eligible combined 
plan design is available only to employers that employed an average 
of at least two, but not more than 500 employees, on business days 
during the calendar year preceding the plan year as of which the 
eligible combined plan is established and that employs at least two 
employees on the first day of the plan year that the plan is 
established. Because an eligible combined plan includes both a 
defined benefit pension plan and a defined contribution pension 
plan, the Form 5500-SF filed for the plan must include all the 
information, schedules, and attachments that would be required for 
either a defined benefit pension plan (such as a Schedule SB) or a 
defined contribution pension plan.

When to File

    File the 20XX Form 5500-SF for plan years that began in 20XX. 
The form, and any required schedules and attachments, must be filed 
by the last day of the 7th calendar month after the end of the plan 
year (not to exceed 12 months in length) that began in 20XX.
    Short Years. For a plan year of less than 12 months (short plan 
year), file the form and applicable schedules by the last day of the 
7th calendar month after the short plan year ends or by the extended 
due date, if filing under an authorized extension of time. 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-
SF. For purposes of this return/report, a short plan year ends on 
the date of the change in accounting period or upon the complete 
distribution of assets of the plan. Also see the instructions for 
Final Return/Report to determine if ``the final return/report'' box 
in Line B should be checked.

Extension of Time To File

Using Form 5558

    If filing under an extension of time based on the filing of an 
IRS Form 5558, Application for Extension of Time To File Certain 
Employee Plan Returns, check the appropriate box on the Form 5500-
SF, Part I, Line C. A one-time extension of time to file the Form 
5500-SF (up to 2\1/2\ months) may be obtained by filing Form 5558 on 
or before the normal due date (not including any extensions) of the 
return/report. [The language on how to file the Form 5558 will

[[Page 47666]]

be changed if filers will be able, as proposed, to file the Form 
5558 through EFAST2]. You must file the Form 5558 with the 
Department of Treasury, Internal Revenue Service Center, Ogden, UT 
84201-0045. Approved copies of the Form 5558 will not be returned to 
the filer. A copy of the completed extension request must be 
retained with the plan's records.

Using Extension of Time To File Federal Income Tax Return

    An automatic extension of time to file Form 5500-SF until the 
due date of the federal income tax return of the employer will be 
granted if all of the following conditions are met: (1) the plan 
year and the employer's tax year are the same; (2) the employer has 
been granted an extension of time to file its federal income tax 
return to a date later than the normal due date for filing the Form 
5500-SF; and (3) a copy of the application for extension of time to 
file the federal income tax return is maintained with the filer's 
records. An extension of time granted by using this automatic 
extension procedure CANNOT be extended further by filing an IRS Form 
5558, nor can it be extended beyond a total of 9 \1/2\ months beyond 
the close of the plan year.
    Notes. (1) If the filing due date falls on a Saturday, Sunday, 
or Federal holiday, the return/report may be filed on the next day 
that is not a Saturday, Sunday, or Federal holiday. (2) If the 20XX 
Form 5500 is not available before the plan filing, use the 20XX-1 
Form 5500 and enter the 20XX fiscal year beginning and ending dates 
on the line provided at the top of the form.

Other Extensions of Time

    The IRS, DOL, and PBGC may announce special extensions of time 
under certain circumstances, such as extensions for Presidentially-
declared disasters or for service in, or in support of, the Armed 
Forces of the United States in a combat zone. See www.irs.gov, 
www.efast.dol.gov, and www.pbgc.gov/practitioners for announcements 
regarding such special extensions. If you are relying on one of 
these announced special extensions, check the appropriate box on the 
Form 5500-SF, Part I, line C, and enter a description of the 
announced authority for the extension.

Delinquent Filer Voluntary Compliance (DFVC) Program

    The DFVC Program facilitates voluntary compliance by plan 
administrators who are delinquent in filing annual return/report 
forms under Title I of ERISA by permitting administrators to pay 
reduced civil penalties for voluntarily complying with their DOL 
annual reporting obligations. If the Form 5500-SF is being filed 
under the DFVC Program, check the appropriate box on Form 5500-SF, 
Part I, line C to indicate that the Form 5500-SF is being filed 
under the DFVC Program. See www.efast.dol.gov for additional 
information.
    Plan administrators are reminded that they can use the online 
calculator available at www.dol.gov/ebsa/calculator/dfvcpmain.html 
to compute the penalties due under the program. Payments under the 
DFVC Program also may be submitted electronically. For information 
on how to pay DFVC Program payments online, go to www.dol.gov/ebsa.

Change in Plan Year

    Generally, only defined benefit pension plans need to get 
approval for a change in plan year. See Code section 412(d)(1). 
However, under Rev. Proc. 87-27, 1987-1 C.B. 769, these pension 
plans may be eligible for automatic approval of a change in plan 
year.
    If a change in plan year for a pension or a welfare benefit plan 
creates a short plan year, file the form and applicable schedules by 
the last day of the 7th calendar month after the short plan year 
ends or by the extended due date, if filing under an authorized 
extension of time. Fill in the short plan year beginning and ending 
dates in the space provided in Part I and check the appropriate box 
in Part I, line B of the Form 5500-SF. For purposes of this return/
report, the short plan year ends on the date of the change in 
accounting period or upon the complete distribution of assets of the 
plan. Also, see the instructions for Final Return/Report to 
determine if ``final return/report'' in line B should be checked.

Penalties

    Plan administrators and plan sponsors must provide complete and 
accurate information and must otherwise comply fully with the filing 
requirements. ERISA and the Code provide for the DOL and the IRS, 
respectively, to assess or impose penalties for not giving complete 
and accurate information and for not filing complete and accurate 
statements and returns/reports. Certain penalties are administrative 
(that is, they may be imposed or assessed in an administrative 
proceeding by one of the governmental agencies delegated to 
administer the collection of the Form 5500-SF data). Others require 
a legal conviction.

Administrative Penalties

    Listed below are various penalties under ERISA and the Code that 
may be assessed or imposed for not meeting the annual return/report 
filing requirements. Generally, whether the penalty is under ERISA 
or the Code, or both, depends upon the agency for which the 
information is required to be filed. One or more of the following 
administrative penalties may be assessed or imposed in the event of 
incomplete filings or filings received after the due date unless it 
is determined that your failure to file properly is for reasonable 
cause.
    1. A penalty of up to $1,100 a day (or higher amount if adjusted 
pursuant to the Federal Civil Penalties Inflation Adjustment Act of 
1990, as amended) for each day a plan administrator fails or refuses 
to file a complete and accurate annual return/report. See ERISA 
section 502(c)(2) and 29 CFR 2560.502c-2.
    2. A penalty of $25 a day (up to $15,000) for not filing the 
annual return/report for certain plans of deferred compensation, 
trusts and annuities, and bond purchase plans by the due date(s). 
See Code section 6652(e).
    3. A penalty of $1,000 for not filing an actuarial statement 
(Schedule MB (Form 5500) or Schedule SB (Form 5500)) required by the 
applicable instructions. See Code section 6692.

Other Penalties

    1. Any individual who willfully violates any provision of Part 1 
of Title I of ERISA shall on conviction be fined not more than 
$100,000 or imprisoned not more than 10 years, or both. See ERISA 
section 501.
    2. A penalty up to $10,000, five (5) years imprisonment, or 
both, may be imposed for making any false statement or 
representation of fact, knowing it to be false, or for knowingly 
concealing or not disclosing any fact required by ERISA. See section 
1027, Title 18, U.S. Code, as amended by section 111 of ERISA.

How to File--Electronic Filing Requirement

    Under the computerized ERISA Filing Acceptance System (EFAST2), 
you must file your 20XX Form 5500-SF electronically. You may file 
your 20XX Form 5500-SF online using EFAST2's web-based filing system 
or you may file through an EFAST2-approved vendor. Detailed 
information on electronic filing is available at www.efast.dol.gov. 
For telephone assistance, call the EFAST2 Help Line at 1-866-GO-
EFAST (1-866-463-3278). The EFAST2 Help Line is available Monday 
through Friday from 8:00 a.m. to 8:00 p.m., Eastern Time.
    [CAUTION] Annual returns/reports filed under Title I of ERISA, 
including those filed using the Form 5500-SF, must be made available 
by the plan administrators to plan participants and beneficiaries 
and by the DOL to the public pursuant to ERISA sections 104 and 106. 
Even though the Form 5500-SF must be filed electronically, the plan 
administrator must keep a copy of the Form 5500-SF, including 
schedules and attachments, with all required signatures on file as 
part of the plan's records, and must make a paper copy available on 
request to participants, beneficiaries, and the DOL as required by 
section 104 of ERISA and 29 CFR 2520.103-1. Filers may use 
electronic media for record maintenance and retention, so long as 
they meet the applicable requirements.
    Generally, questions on the Form 5500-SF relate to the plan year 
entered at the top of the first page of the form. Therefore, answer 
all questions on the 20XX Form 5500-SF with respect to the 20XX plan 
year unless otherwise explicitly stated in the instructions or on 
the form itself.
    Your entries must be in the proper format in order for the 
EFAST2 system to process your filing. For example, if a question 
requires you to enter a dollar amount, you cannot enter a word. Your 
software will not let you submit your return/report unless all 
entries are in the proper format. To reduce the possibility of 
correspondence and penalties:
     Complete all lines on the Form 5500-SF unless otherwise 
specified. Also complete and electronically attach, as required, any 
applicable schedules and attachments.
     Do not enter ``N/A'' or ``Not Applicable'' on the Form 
5500-SF or Schedules SB (Form 5500) and MB (Form 5500) unless 
specifically permitted. ``Yes'' or ``No''

[[Page 47667]]

questions on the form and schedules cannot be left blank, unless 
specifically permitted. Answer ``Yes'' or ``No,'' but not both.
     Use the correct employer identification number (EIN) 
and plan number (PN) for the plan.
    You should check your return/report for errors before signing or 
submitting it to EFAST2. Your filing software or, if you are using 
it, the EFAST2 web-based filing system will allow you to check your 
return/report for errors. If, after reasonable attempts to correct 
your filing to eliminate any identified problem or problems, you are 
unable to address them, or you believe that you are receiving the 
message in error, call the EFAST2 Help Line at 1-866-GO-EFAST (1-
866-463-3278) or contact the service provider you used to help 
prepare and file your annual return/report.
    Once you complete the return/report and finish the electronic 
signature process, you can electronically submit it to EFAST2. When 
you electronically submit your return/report, EFAST2 is designed to 
immediately notify you if your submission was received and whether 
the return/report is ready to be processed by EFAST2. If EFAST2 does 
not notify you that your submission was successfully received and is 
ready to be processed, you will need to take steps to correct the 
problem or you may be deemed a non-filer subject to penalties from 
DOL, IRS, and/or PBGC.
    Once EFAST2 receives your return/report, the EFAST2 system 
should be able to provide a filing status within 20 minutes. Check 
back into the EFAST2 system to determine the filing status of your 
return/report. The filing status message will include a list of any 
filing errors or warnings that EFAST2 may have identified in your 
filing. If EFAST2 did not identify any filing errors or warnings, 
EFAST2 will show the filing status of your return/report as 
``Filing_Received.'' Persons other than the submitter can check 
whether the filing was received by the system by calling the EFAST2 
Help Line at 1-866-GO-EFAST (1-866-463-3278) and using the automated 
telephone system.
    To reduce the possibility of correspondence and penalties from 
the DOL, IRS, and/or PBGC, you should do the following: (1) Before 
submitting your return/report to EFAST2, check it for errors, and 
(2) after you have submitted it to EFAST2, verify that you have 
received a filing status of ``Filing_Received'' and attempt to 
correct and resolve any errors or warnings listed in the status 
report.
    Note. Even after being received by the EFAST2 system, your 
return/report filing may be subject to further detailed review by 
DOL, IRS, and/or PBGC, and your filing may be deemed deficient based 
upon this further review. See Penalties on page 5.
    The Form 5500-SF, Schedules SB (Form 5500) and MB (Form 5500), 
and any attachments that are filed under ERISA are open to public 
inspection, and the contents are public information subject to 
publication on the Internet.
    [CAUTION] Do not enter social security numbers in response to 
questions asking for an employer identification number (EIN). 
Because of privacy concerns, the inclusion of a social security 
number or any portion thereof on the Form 5500-SF or on a schedule 
or attachment that is open to public inspection may result in the 
rejection of the filing. If you discover a filing disclosed on the 
EFAST2 Web site that contains a social security number, immediately 
call the EFAST2 Help Line at 1-866-GO-EFAST (1-866-463-3278).
    Do not attach a copy of the annual registration statement 
identifying separated participants with deferred vested benefits or 
a previous year's Schedule SSA (Form 5500) to your 20XX Form 5500-SF 
annual return/report. The annual registration statement must be 
filed directly with the IRS and cannot be attached to a Form 5500-SF 
submission with EFAST2.
    Employers without an employer identification number (EIN) must 
apply to the IRS for one as soon as possible. The EBSA does not 
issue EINs. To apply for an EIN from the IRS:
     Mail or fax Form SS-4, Application for Employer 
Identification Number, obtained at the IRS Web site at www.irs.gov.
     Call 1-800-829-4933 to receive your EIN by telephone.
     Select the Online EIN Application link at www.irs.gov.
    The EIN is issued immediately once the application information 
is validated. (The online application process is not yet available 
for corporations with addresses in foreign countries or Puerto 
Rico.)

Signature and Date

    For purposes of Title I of ERISA, the plan administrator is 
required to file the Form 5500 or 5500-SF. The plan administrator 
must electronically sign the Form 5500 or 5500-SF submitted to 
EFAST2.
    [CAUTION] After submitting your filing, you must check the 
Filing Status. If the filing status is ``Processing Stopped'', it is 
possible your submission was not sent with a valid electronic 
signature as required, and depending on the error, may be considered 
not to have been filed. By looking closer at the Filing Status, you 
can see specific error messages applicable to the transmitted filing 
and determine whether it was sent with a valid electronic signature 
and what other errors may need to be corrected.
    Note. If the plan administrator is an entity, the electronic 
signature must be in the name of a person authorized to sign on 
behalf of the plan administrator.
    If the plan administrator does not sign a filing, the filing 
status will indicate that there is an error with your filing, and 
your filing will be subject to further review, correspondence, 
rejection, and civil penalties.
    Authorized Service Provider Signatures. If the plan 
administrator elects to have a service provider who manages the 
filing process for the plan get EFAST2 signing credentials and 
submit the electronic Form 5500-SF for the plan:
    (1) the service provider must receive specific written 
authorization from the plan administrator to submit the plan's 
electronic filing;
    (2) the plan administrator must manually sign a paper copy of 
the electronically completed Form 5500-SF, and the service provider 
must include a PDF copy of the entire three-page Form 5500-SF, 
excluding any attachments and associated schedules, submitted to 
EFAST2;
    (3) the service provider must communicate to the plan 
administrator any inquiries received from EFAST2, DOL, IRS or PBGC 
regarding the filing;
    (4) the service provider must communicate to the plan 
administrator that, by electing to use this option, the image of the 
plan administrator's manual signature will be included with the rest 
of the return/report posted by the Labor Department on the Internet 
for public disclosure; and
    (5) the plan administrator must keep the manually signed copy of 
the Form 5500-SF, with all required schedules, as part of the plan's 
records. For more information on the electronic signature option, 
see EFAST2 All-Electronic Filing System FAQs at www.dol.gov/ebsa/faqs/faq-EFAST2.html.
    [CAUTION] Service providers should consider implications of IRS 
tax return preparer rules.
    Note. The Code permits either the plan sponsor/employer or the 
administrator to sign the filing. Therefore, in the case of a Form 
5500-SF filed for a ``one-participant plan'' not subject to Title I 
of ERISA that is filing a Form 5500-SF with EFAST2 in lieu of filing 
a Form 5500-EZ on paper with the IRS (see Specific Instructions Only 
for ``One-Participant Plans and certain foreign plans''), either may 
sign. However, any other Form 5500-SF that is not electronically 
signed by the plan administrator will be subject to rejection and 
civil penalties under Title I of ERISA.
    The Form 5500-SF annual return/report must be filed 
electronically and signed. To obtain an electronic signature, go to 
www.efast.dol.gov and register in EFAST2 as a signer. You will be 
provided with a UserID and a PIN. Both the UserID and PIN are needed 
to sign the Form 5500-SF. The plan administrator must keep a copy of 
the Form 5500-SF, including schedules and attachments, with all 
required signatures on file as part of the plan's records. See 29 
CFR 2520.103-1. Electronic signatures on annual returns/reports 
filed under EFAST2 are governed by the applicable statutory and 
regulatory requirements.

Trustee/Custodian Signature

    The plan trustee or custodian may electronically sign this 
schedule or attach to the Form 5500 an electronic reproduction of 
the Schedule H signed by the plan's trustee. This electronic 
reproduction must be labeled ``Trustee Signature'' and must be 
included as a Portable Document Format (PDF) attachment or any 
alternative electronic attachment allowable under EFAST2 if this is 
not electronically signed. If there is more than one trustee or 
custodian, the trustee or custodian authorized by the others may 
sign. If the plan trustee or custodian is an entity, the signature 
must be the name of a person authorized to sign on behalf of the 
plan trustee or custodian.
    Note. Trust information reported in this Form is for purpose of 
satisfying the requirements under Code section 6033(a) for

[[Page 47668]]

an annual information return from every section 401(a) organization 
exempt from tax under section 501(a). The statute of limitations 
under Code section 6501(a) for any trust described in section 
401(a), which is exempt from tax under section 501(a), will not 
start to run until you timely file with the appropriate trust 
information on this Form.

Preparer Information

    Enter the ``Preparer's name (including firm's name, if 
applicable), address, and telephone number'' at the bottom of the 
first page of Form 5500-SF. A preparer is any person who prepares an 
annual return/report for compensation, or who employs one or more 
persons to prepare for compensation. If the person who prepared the 
annual return/report is not the employer named in line 2a or the 
plan administrator named in line 3a, you must name the person on 
this line. If there are several people who prepare Form 5500-SF and 
applicable schedules, please name the person who is primarily 
responsible for the preparation of the annual return/report.
    Note. You must complete preparer information if you are required 
to file at least 250 returns of any type with the IRS during the 
calendar year. However, if you are a small filer (files fewer than 
250 returns of any type with the IRS during the calendar year), and 
you do not enter preparer information on the Form 5500, then you 
must file the paper Form 5500-SUP with the IRS. See the Treasury 
regulations on ``Employee Retirement Benefit Plan Returns Required 
on Magnetic Media'' (See 79 FR 58256 at http://federalregister.gov/a/2014-23161) and Instructions for Form 5500-SUP for more 
information.

Specific Instructions Only for ``One-Participant Plans and Certain 
Foreign Plans''

    A ``one-participant plan'' is: (1) A pension benefit plan that 
covers only an individual or an individual and his or her spouse who 
wholly own a trade or business, whether incorporated or 
unincorporated; or (2) a pension benefit plan for a partnership that 
covers only the partners or the partners and the partners' spouses. 
Thus, a ``one-participant plan'' can cover more than one 
participant. On the other hand, merely covering only one participant 
does not make you eligible to file as a ``one-participant plan'' 
unless you are one of the types of plans described above.
    A foreign plan is maintained outside the United States primarily 
for nonresident aliens, if (1) a plan is maintained by a domestic 
employer; or (2) a plan is maintained by a foreign employer with 
income derived from sources within the United States (including 
foreign subsidiaries of domestic employers) if contributions to the 
plan are deducted on its U.S. income tax return.
    The Form 5500-EZ generally is used by one-participant plans and 
certain foreign plans that are not subject to the requirements of 
section 104(a) of ERISA to satisfy certain annual reporting and 
filing obligations imposed by the Code. One-participant plans and 
certain foreign plans may file the Form 5500-SF electronically in 
place of a Form 5500-EZ (on paper) to satisfy the filing obligations 
under the Code. One-participant plans and foreign plans that file 
the Form 5500-SF electronically complete only certain questions on 
the Form 5500-SF. These are the questions that would be completed if 
the filer filed Form 5500-EZ on paper. For more information on 
filing with the IRS, go to www.irs.gov or call 1-877-829-5500.
    Notes. (1) A Form 5500-SF may be filed for one-participant plans 
and certain foreign plans that are either defined contribution 
pension plans (which include profit-sharing and money purchase 
pension plans, but not an ESOP or stock bonus plan) or defined 
benefit pension plans. (2) The filer of a one-participant plan or a 
foreign plan that is required by the Code or regulations to file at 
least 250 returns of any type, including information returns (for 
example, Forms W-2 and Forms 1099), income tax returns, employment 
tax returns, and excise tax returns, with the IRS during the 
calendar year, must use the Form 5500-SF to file the information 
required on the Form 5500-EZ, but will not be required to attach to 
the filing a Schedules SB or MB. For more information, see IRS 
regulations on ``Employee Retirement Benefit Plan Returns Required 
on Magnetic Media'' (See T.D. 9695, 79 FR 58256 at http://federalregister.gov/a/2014-23161). (3) Information filed on Form 
5500-EZ is required to be made available to the public. Form 5500-SF 
is open to public inspection and the contents are public information 
subject to publication on the Internet. However, the information on 
Form 5500-SF will not be subject to publication on the internet for 
a ``one-participant plan or a foreign plan'' that is electronically 
filed using a Form 5500-SF with EFAST2 in lieu of filing a Form 
5500-EZ on paper with the IRS.
    Eligible one-participant plans and certain foreign plans need 
complete only the following questions on the Form 5500-SF:
    1. Part I, Lines A, B, and C;
    2. Part II, Lines 1a-5b; 5d(1), 5d(2), and 5(e);
    3. Part III, Lines 7a-c, and 8a;
    4. Part IV, Line 9a;
    5. Part V, Lines 10g; and 10l
    6. Part VI, Lines 11-12e.
    7. Part VIII, Lines 14a-14d; and
    8. Part IX, Lines 18 a, b, c, d, Line 19, and Line 20.
    Note. For Lines 7a through 7c, an eligible one-participant plan 
or certain foreign plan need complete only for total plan assets, 
total plan liabilities, and net plan assets for beginning of year 
and end of year, and is not required to complete Line 7a(1) through 
7a(8).
    Schedule MB (Form 5500). If a money purchase defined 
contribution pension plan (including a target benefit plan) has 
received a waiver of the minimum funding standard, and the waiver is 
currently being amortized, complete Lines 3, 9, and 10 of Schedule 
MB (Form 5500). See the Instructions for Schedule MB in the 
Instructions for Form 5500 Annual Return/Report. One-participant 
plans and foreign plans, however, do not attach Schedule MB to the 
Form 5500-SF. Instead, these plans must keep the completed Schedule 
MB in accordance with the applicable records retention requirements.
    Schedule SB (Form 5500). One-participant plans and foreign plans 
do not attach Schedule SB (Form 5500) to the Form 5500-SF. Instead, 
these plans must keep the completed Schedule SB that is signed by 
the plan actuary in accordance with the applicable records retention 
requirements. Actuaries of one-participant plans and foreign plans 
that are defined benefit pension plans subject to the minimum 
funding standards for this plan year, must complete Schedule SB 
(Form 5500) and forward the completed and signed Schedule SB to the 
plan administrator no later than the filing due date. See the 
Instructions for Schedule SB in the Instructions for Form 5500.
    Filing Form 5500-EZ with the IRS. If you are filing a paper 
form, you must file the Form 5500-EZ with the IRS using the 
following address: Department of the Treasury, Internal Revenue 
Service Center, Ogden, UT 84201-0027. You may order the paper Form 
5500-EZ and its instructions by visiting the IRS Web site at 
www.irs.gov/formspubs/.
    Filing an amendment. If you are filing an amendment for a ``one-
participant plan'' or a ``foreign plan'' that filed a Form 5500-SF 
electronically, you may submit the amendment either electronically 
using the Form 5500-SF with EFAST2 or on paper using the Form 5500-
EZ with the IRS. If you are filing an amendment for a ``one-
participant plan'' that previously filed on a paper Form 5500-EZ, 
you must submit the amendment using the paper Form 5500-EZ with the 
IRS. However, if you are filing an amendment for a one-participant 
plan or a foreign plan that is required by the Treasury regulations 
(See T.D. 9695, 79 FR 58256 at http://federalregister.gov/a/2014-23161 to file electronically using the Form 5500-SF, you must submit 
the amendment electronically using the Form 5500-SF with EFAST2.

Specific Line-by-Line Instructions (Form 5500-SF)

Part I--Annual Report Identification Information

    File the 20XX Form 5500-SF annual report for a plan year that 
began in 20XX. Enter the beginning and ending dates in Part I. The 
20 XX Form 5500-SF annual report must be filed electronically.

Check only one of the Line A box choices.

    Line A(1)--Box for Single-Employer Plan. Check this box if the 
Form 5500-SF is filed for a single-employer plan. A single-employer 
plan for purposes of the Form 5500-SF is an employee benefit plan 
maintained by one employer or one employee organization.
    Note. Do not check this box even if all of the employers 
maintaining the plan are members of the same controlled group or 
affiliated service group under Code sections 414(b), (c), or (m). 
Check Box A(3).
    Line A(2)--Box for Multiple-Employer Plan. Check this box if the 
Form 5500-SF is being filed for a multiple-employer plan. A 
multiple-employer plan is a plan that is maintained by more than one 
employer and is not the type of plan described in A(3). For purposes 
of the Form 5500-SF, a multiple-employer plan is a plan that is 
maintained by

[[Page 47669]]

more than one employer and is not a single-employer plan or a 
multiemployer plan. Multiple-employer plans can be collectively 
bargained and collectively funded, but if covered by PBGC 
termination insurance, they must have properly elected before 
September 27, 1981, not to be treated as a multiemployer plan under 
Code section 414(f)(5) or ERISA sections 3(37)(E) and 4001(a)(3), 
and have not revoked that election or made an election to be treated 
as a multiemployer plan under Code section 414(f)(6) or ERISA 
section 3(37)(G). Participating employers do not file individually 
for multiple-employer plans.
    Note. Do not check this box if all of the employers maintaining 
the plan are members of the same controlled group or affiliated 
service group under Code sections 414(b), (c), or (m).
    Except as provided below, multiple-employer pension plans 
required to file a Form 5500-SF must include an attachment using the 
format below that (1) lists each participating employer in the plan 
during the plan year, identified by name and employer identification 
number (EIN), and (2) includes a good faith estimate of each 
employer's percentage of the total contributions (including employer 
and participant contributions) made by all participating employers 
during the year. Any employer who was obligated to make 
contributions to the plan for the plan year, made contributions to 
the plan for the plan year, or whose employees were covered under 
the plan is a ``participating employer'' for this purpose. If a 
participating employer made no contributions, enter ``-0-'' in 
element (c).
    The attachment must be properly identified at the top with the 
label ``Multiple-employer Plan Participating Employer Information,'' 
and the name of the plan, EIN, and plan number (PN) as found on the 
plan's Form 5500-SF.
    Complete as many entries as needed to report the required 
information for all participating employers.

------------------------------------------------------------------------
 
------------------------------------------------------------------------
        Multiple-Employer Plan Participating Employer Information
(Insert Name of Plan, and EIN/
 PN as shown on the Form 5500-
              SF)
------------------------------------------------------------------------
   (a) Name of participating         (b) EIN        (c) Percent of Total
           employer                                     Contributions
------------------------------------------------------------------------

    [CAUTION]Multiemployer plans cannot use the Form 5500-SF to 
satisfy their annual reporting obligations. They must file the Form 
5500. For these purposes, a plan is a multiemployer plan if: (a) 
More than one employer is required to contribute; (b) the plan is 
maintained pursuant to one or more collective bargaining agreements 
between one or more employee organizations and more than one 
employer; (c) an election under Code section 414(f)(5) and ERISA 
section 3(37)(E) has not been made; and (d) the plan meets any other 
applicable conditions of 29 CFR 2510.3-37. A plan that made a proper 
election under ERISA section 3(37)(G) and Code section 414(f)(6) on 
or before Aug. 17, 2007, is also a multiemployer plan.
    Line A(3)--Box for Controlled Group. Check this box for a 
``controlled group'' of corporations that is filing a single Form 
5500-SF for reporting purposes. A ``controlled group'' is a 
controlled group of corporations under Code section 414(b), a group 
of trades or businesses under common control under Code section 
414(c), or an affiliated service group under Code section 414(m).
    Plans sponsored by controlled groups required to file a Form 
5500-SF must include an attachment using the format below that (1) 
lists each controlled group member in the plan during the plan year, 
identified by name and employer identification number (EIN), and (2) 
includes a good faith estimate of each employer's percentage of the 
total contributions (including employer and participant 
contributions) made by all members during the year. Any employer who 
was obligated to make contributions to the plan for the plan year, 
made contributions to the plan for the plan year, or whose employees 
were covered under the plan is a ``controlled group member'' for 
this purpose. If a controlled group member made no contributions, 
enter ``-0-'' in element (c).
    ``Controlled Group Plan Member Information'' Attachment. If you 
checked box A(3) for ``Controlled Group Plan,'' you must complete 
the ``Controlled Group Member Information'' attachment. Enter the 
name of the plan, EIN, and plan number (PN) as found on the plan's 
Form 5500-SF. Complete as many entries as needed to report the 
required information for all participating employers.

------------------------------------------------------------------------
 
------------------------------------------------------------------------
                   Controlled Group Member Information
 (Heading for this chart must
 include Insert Name of Plan,
  and EIN/PN as shown on the
    Form 5500-SF)(Complete
 elements (a), (b), and (c) to
  provide the name, EIN, and
percent of total contributions
   of each controlled group
           member.)
------------------------------------------------------------------------
 (a) Name of controlled group        (b) EIN        (c) Percent of Total
            member                                      Contributions
------------------------------------------------------------------------

    Line A(4)--Box for One-Participant Plan. Check this box if the 
Form 5500-SF is being filed for a plan that is a ``one-participant 
plan'' (see page 7). Check the one-participant plan box only for 
those plans that are submitting the Form 5500-SF in place of a Form 
5500-EZ (on paper) to satisfy the annual return/report filing 
obligations under the Code. Plans checking the box for one-
participant plan should not check either the box for single-employer 
plan or the box for multiple-employer plan. See Specific 
Instructions Only for ``One-Participant Plans and Certain Foreign 
Plans.''
    Line A(5)--Box for Foreign Plans. Check this box if the Form 
5500-SF is being filed for a plan that is a ``foreign plan''(see 
page XX). Check the foreign plan box only for those plans that are 
submitting the Form 5500-SF in place of a Form 5500-EZ (on paper) to 
satisfy the annual return/report filing obligations under the Code. 
Plans checking the box for foreign plan should not check either the 
box for single-employer plan or the box for multiple-employer plan. 
See Specific Instructions Only for ``One-Participant Plans and 
Certain Foreign Plans.''
    Line B(1)--Box for First Return/Report. Check this box if an 
annual return/report has not been previously filed for this plan. 
For the purpose of completing this box, the Form 5500-EZ is not 
considered an annual return/report.
    Line B(2)--Box for Final Return/Report. Check this box if this 
is the final report for the plan. Only check this box if all assets 
under the plan (including insurance/annuity contracts) have been 
distributed to the participants and beneficiaries or legally 
transferred to the control of another plan, and when all liabilities 
for which benefits may be paid under a welfare benefit plan have 
been satisfied. Do not mark the final return/report box if you are 
reporting participants and/or assets at the end of the plan year. If 
a trustee is appointed for a terminated defined benefit pension plan 
pursuant to ERISA section 4042, the last plan year for which a 
return/report must be filed is the year in which the trustee is 
appointed. See Box B(5) for the simplified filing requirements for 
PBGC-trusteed plans.

Examples:

    Mergers/Consolidations. A final return/report should be filed 
for the plan year (12 months or less) that ends when all plan assets 
were legally transferred to the control of another plan.
    Pension and Welfare Plans That Terminated Without Distributing 
All Assets. If the plan was terminated but all plan assets

[[Page 47670]]

were not distributed, a return/report must be filed for each year 
the plan has assets. The return/report must be filed by the plan 
administrator, if designated, or by the person or persons who 
actually control the plan's assets/property.
    Welfare Plans Still Liable To Pay Benefits. A welfare plan 
cannot file a final return/report if the plan is still liable to pay 
benefits for claims that were incurred prior to the termination 
date, but not yet paid. See 29 CFR 2520.104b-2(g)(2)(ii).
    Line B(3)--Box for Amended Return/Report. Check this box if you 
have already filed for the 20XX plan year and are now filing an 
amended return/report to correct errors and/or omissions on the 
previously filed return/report.
    [TIP] Check the Line B box for an ``amended return/report'' if 
you filed a previous 20XX annual return/report that was given a 
``Filing_Received,'' ``Filing_Error,'' or ``Filing_Stopped'' status 
by EFAST2. Do not check the Line B box for an ``amended return/
report'' if your previous submission attempts were not successfully 
received by EFAST2 because of problems with the transmission of your 
return/report. For more information, go to the EFAST2 Web site at 
www.efast.dol.gov or call the EFAST2 Help line at 1-866-GO-EFAST (1-
866-463-3278).
    If you need to file an amended return/report to correct errors 
and/or omissions in a previously filed annual return/report for the 
20XX plan year AND you are eligible to file the Form 5500-SF, you 
may use the Form 5500-SF even if the original filing was a Form 
5500. If you filed a Form 5500-SF, but determine that you were not 
eligible to file the Form 5500-SF, you must use the Form 5500 or 
Form 5500-EZ to amend your return/report.
    Line B(4)--Box for Short Plan Year Return/Report. Check this box 
if this Form 5500-SF is being filed for a plan year period of less 
than 12 months. Provide the dates in Part I, Plan Year Beginning and 
Ending.
    Line B(5)--Box for Plan Trusteed by PBGC. Plans that, as of the 
due date of this return, have been trusteed by PBGC under section 
4041(c) or 4042 of ERISA, must check this box and enter the date of 
trusteeship in the space provided. Plans that check this box must 
complete all of Part I, Lines 1, 2, 3, 5 of Part II, and Lines 
11a(3) and 11a(4) of Part IV.
    Line C--Box for Extensions and DFVC Program. Check the 
appropriate box here if:
    1. You filed for an extension of time to file this form with the 
IRS using Form 5558, Application for Extension of Time To File 
Certain Employee Plan Returns, and maintain a copy of the Form 5558 
with the filer's records;
    2. You are filing using the automatic extension of time to file 
the Form 5500-SF return/report until the due date of the federal 
income tax return of the employer and maintain a copy of the 
employer's extension of time to file the income tax return with the 
plan's records;
    3. You are filing using a special extension of time to file the 
Form 5500-SF annual return/report that has been announced by the 
IRS, DOL, or PBGC. If you checked that you are using a special 
extension of time, enter a description of the extension of time in 
the space provided.; or
    4. You are filing under the DFVC Program.

Part II--Basic Plan Information

    Line 1a. Enter the formal name of the plan or enough information 
to identify the plan. Abbreviate if necessary. If an annual return/
report has previously been filed on behalf of the plan, regardless 
of the type of Form that was filed (Form 5500, Form 5500-EZ, or Form 
5500-SF), use the same name or abbreviations that were used on the 
prior filings. Once you use an abbreviation, continue to use it for 
that plan on all future annual return/report filings with the IRS, 
DOL, and PBGC. Do not use the same name or abbreviation for any 
other plan, even if the first plan is terminated.
    Line 1b. Enter the three-digit plan or entity number (PN) that 
the employer or plan administrator assigned to the plan. This three-
digit number, in conjunction with the employer identification number 
(EIN) entered on Line 2b, is used by the IRS, DOL, and PBGC as a 
unique 12-digit number to identify the plan.
    Start at 001 for plans providing pension benefits. Start at 501 
for welfare plans. Do not use 888 or 999.
    Once you use a plan number, continue to use it for that plan on 
all future filings with the IRS, DOL, and PBGC. Failure to use the 
same three-digit plan/DFE number may result in correspondence from 
DOL or IRS. Do not use this unique three-digit number for any other 
plan, even if the first plan is terminated.

------------------------------------------------------------------------
 
------------------------------------------------------------------------
  You should assign a plan number (PN) as described below for each Form
5500 (and Form 5500-SF) with the same EIN of plan or DFE sponsor entered
                              into Line 2b
------------------------------------------------------------------------
Pension benefit plans........  001 to the first plan. Consecutively
                                number other plans providing pension
                                benefits with the same plan sponsor as
                                002, 003 . . .
Welfare benefit plans........  501 to the first plan or GIA.
                                Consecutively number others as 502, 503
                                . . .
------------------------------------------------------------------------

    Exception. If Part II, elements of Line 11a are completed and 
333 (or a higher number in a sequence beginning with 333) was 
previously assigned to the plan, that number may be entered on Line 
1b.
    Line 1c. Enter the date the plan first became effective.
    Line 2a. Limit your response to the information required in each 
row as specified below:
    1. Enter the plan sponsor's (employer, if for a single-employer 
plan) name, current postal address (only use a P.O. Box number if 
the Post Office does not deliver mail to the employer's street 
address), foreign routing code where applicable, and ``D/B/A'' 
(doing business as) or trade name of the employer if different from 
the employer's name.
    2. Enter any ``in care of'' (C/O) name.
    3. Enter the current street address. A post office box number 
may be entered, in addition to the street address, if the Post 
Office does not deliver mail to the sponsor's street address.
    4. Enter the name of the city.
    5. Enter the two-character abbreviation of the U.S. state or 
possession and zip code.
    6. Enter the foreign routing code, if applicable. Leave U.S. 
state and zip code blank if entering a foreign routing code and 
country name.
    7. Enter the foreign country, if applicable. Do not abbreviate 
the country name after ``Enter foreign country.''
    8. Enter the D/B/A (the doing business as) or trade name of the 
sponsor if different from the plan sponsor's name.
    9. Enter any second address. Use only a street address here, not 
a P.O. box.
    Notes. (1) In the case of a multiple-employer plan, file only 
one annual return/report for the plan. If an association or other 
entity is not the sponsor, enter the name of a participating 
employer as sponsor. For a plan of a controlled group of 
corporations, the name of one of the sponsoring members should be 
entered. In either case, the same name must be used in all 
subsequent filings of the Form 5500 return/report or Form 5500-SF 
for the multiple-employer plan or controlled group. (See 
instructions for Line 5 concerning change in sponsorship). (2) You 
can also use the IRS Form 8822-B to notify the IRS if the address 
provided here is a change in your business mailing address or your 
business location.
    Line 2b. Enter the employer's nine-digit employer identification 
number (EIN).
    [CAUTION] Do not use a social security number in lieu of an EIN. 
The Form 5500-SF is open to public inspection, and the contents are 
public information and are subject to publication on the Internet. 
Because of privacy concerns, the inclusion of a social security 
number or any portion thereof on this line may result in the 
rejection of the filing.
    Employers without an EIN number must apply to the IRS for one as 
soon as possible. The EBSA does not issue EINs. To apply for an EIN 
from the IRS:
     Mail or fax Form SS-4, Application for Employer 
Identification Number, obtained at the IRS Web site at www.irs.gov.
     Call 1-800-829-4933 to receive your EIN by telephone.
     Select the Online EIN Application link at www.irs.gov.
    The EIN is issued immediately once the application information 
is validated. (The online application process is not yet

[[Page 47671]]

available for corporations with addresses in foreign countries).
    A multiple-employer plan or plan of a controlled group of 
corporations should use the EIN number of the sponsor identified in 
Line 2b(1). The EIN must be used in all subsequent filings of the 
Form 5500-SF (or any subsequent Form 5500 or Form 5500-EZ in a year 
where the plan is not eligible to file the Form 5500-SF) for these 
plans. (See instructions to Line 4 concerning change in EIN).
    Note. EINs for funds (trusts or custodial accounts) associated 
with plans are generally not required to be furnished on the Form 
5500-SF. The IRS, however, will issue EINs for such funds for other 
reporting purposes. EINs may be obtained as explained above. Plan 
sponsors should use the trust EIN described above when opening a 
bank account or conducting other transactions for a trust that 
requires an EIN.
    Line 2b(2). If available, enter the global legal entity 
identification number (LEI). With respect to any company, the LEI is 
the ``legal entity identifier'' assigned by or on behalf of an 
internationally recognized standards setting body and required for 
reporting purposes by the U.S. Department of the Treasury's Office 
of Financial Research or a financial regulator. In the case of a 
financial institution, if a ``legal entity identifier'' has not been 
assigned, then provide the RSSD ID assigned by the National 
Information Center of the Board of Governors of the Federal Reserve 
System, if any.
    Line 2c. Enter the telephone number for the plan sponsor. Use 
numbers only, including area code, and do not include any special 
characters.
    Line 2d. Enter the six-digit business code that best describes 
the nature of the plan sponsor's business from the list of business 
codes on pages XX-XY. If more than one employer or employee 
organization is involved, enter the business code for the main 
business activity of the employers and/or employee organizations.
    Line 3a. Limit your response to the information required in each 
row as specified below:
    1. Enter the name and address of the plan administrator unless 
the administrator is the sponsor identified in Line 2. If both the 
plan administrator name and address are the same as the plan sponsor 
name and address, check the ``Same as Plan Sponsor'' box and 
disregard items 2 through 6 below.
    2. Enter any ``in care of'' (C/O) name.
    3. Enter the current street address. A post office box number 
may be entered, in addition to the street address, if the Post 
Office does not deliver mail to the administrator's street address.
    4. Enter the name of the city.
    5. Enter the two-character abbreviation of the U.S. state or 
possession and zip code.
    6. Enter the foreign routing code and foreign country, if 
applicable. Leave U.S. state and zip code blank if entering foreign 
routing code and country information.
    Plan administrator for this purpose means:
     The person or group of persons specified as the 
administrator by the instrument under which the plan is operated;
     The plan sponsor/employer if an administrator is not so 
designated; or
     Any other person prescribed by applicable regulations 
if an administrator is not designated and a plan sponsor cannot be 
identified.
    Line 3b. Enter the plan administrator's nine-digit EIN. A plan 
administrator must have an EIN for Form 5500-SF reporting. If the 
plan administrator does not have an EIN, it must apply to the IRS 
for one as explained in the instructions for Line 2b. One EIN should 
be entered for a group of individuals who are, collectively, the 
plan administrator.
    Note. Employees of the plan sponsor who perform administrative 
functions for the plan are generally not the plan administrator 
unless specifically designated in the plan document. If an employee 
of the plan sponsor is designated as the plan administrator, that 
employee must obtain an EIN.
    Do not use a social security number in lieu of an EIN. The Form 
5500-SF and its schedules and attachments are open to public 
inspection, and the contents are public information and are subject 
to publication on the Internet. Because of privacy concerns, the 
inclusion of a social security number or any portion thereof on this 
Form 5500-SF or any of it schedules or attachments may result in the 
rejection of the filing.
    Line 3c. Enter the telephone number for the plan administrator.
    Line 4. Enter the name and identifying information of the 
``named fiduciary.'' A plan must have at least one fiduciary (a 
person or entity) named in the written plan, or through a process 
described in the plan, as having control over the plan's operation. 
The named fiduciary can be identified by office or by name. For some 
plans, it may be an administrative committee or a company's board of 
directors. If the named fiduciary is an entity such as a committee 
or board, include the name and contact information for a specific 
individual, as well as the name of the entity. If you are unable to 
determine who is the ``named fiduciary,'' enter the name and 
identifying information of the person who appointed the plan 
trustee.
    Line 5. If the plan sponsor's name, EIN, or LEI have changed 
since the last annual return/report was filed for this plan, enter 
the plan sponsor's name, EIN, LEI, and the plan number as it 
appeared on the last annual return/report filed.
    [CAUTION] Failure to indicate on Line 5 that a plan or plan 
sponsor was previously identified by a different name, employer 
identification number (EIN), LEI, or plan number could result in 
correspondence from the DOL and the IRS.
    Line 5a. Enter the plan sponsor's name as it appeared on the 
last return/report filed.
    Line 5b(1). Enter the plan sponsor's EIN as it appeared on the 
last return/report filed.
    Line 5b(2). Enter the plan sponsor's LEI (if available) as it 
appeared on the last return/report filed.
    Line 5c. Enter the plan sponsor's plan number as it appeared on 
the last return/report filed.
    Line 6. Enter in element (a) the total number of participants at 
the beginning of the plan year. Enter in element (b) the total 
number of participants at the end of the plan year.
    Line 7. Enter in element (a) the total number of participants 
with account balances as of the end of the plan year. Welfare 
benefit plans and defined benefit pension plans do not complete 
element (c). Enter in element (a)(1) the total number of active 
participants at the beginning of the plan year. Enter in element 
(a)(2) the total number of active participants at the end of the 
plan year.
    The description of ``participant'' in the following instructions 
is only for purposes of these lines.
    An individual becomes a participant covered under an employee 
welfare benefit plan on the earliest of:
     The date designated by the plan as the date on which 
the individual begins participation in the plan;
     The date on which the individual becomes eligible under 
the plan for a benefit subject only to occurrence of the contingency 
for which the benefit is provided; or
     The date on which the individual makes a contribution 
to the plan, whether voluntary or mandatory.
    See 29 CFR 2510.3-3(d)(1). Covered dependents are not counted as 
participants. A child who is an ``alternate recipient'' entitled to 
health benefits under a qualified medical child support order 
(QMCSO) should not be counted as a participant for Line 6. An 
individual is not a participant covered under an employee welfare 
plan on the earliest date on which the individual (a) is ineligible 
to receive any benefit under the plan even if the contingency for 
which such benefit is provided should occur, and (b) is not 
designated by the plan as a participant. See 29 CFR 2510.3-3(d)(2).
    [TIP] Before counting the number of participants, especially in 
a welfare benefit plan, it is important to determine whether the 
plan sponsor has established one or more plans for Form 5500/Form 
5500-SF reporting purposes. As a matter of plan design, plan 
sponsors can offer benefits through various structures or 
combinations.
    The fact that you have separate insurance policies for each 
different welfare benefit does not necessarily mean that you have 
separate plans. Some plan sponsors use a ``wrap'' document to 
incorporate various benefits and insurance policies into one 
comprehensive plan. In addition, whether a benefit arrangement is 
deemed to be a single plan may be different for purposes other than 
Form 5500/Form 5500-SF reporting. For example, special rules may 
apply for purposes of Internal Revenue Code compliance. If you need 
help determining whether you have a single welfare benefit plan for 
Form 5500/Form 5500-SF reporting purposes, you should consult a 
qualified benefits consultant or legal counsel.
    [CAUTION] Plans that provide health benefits cannot file the 
Form 5500-SF regardless of size and must file the Form 5500.
    For pension benefit plans, ``alternate payees'' entitled to 
benefits under a qualified domestic relations order (QDRO) are not 
to be counted as participants for this line.
    For pension benefit plans, ``participant'' for this line means 
any individual who is included in one of the categories below.
    1. Active participants (i.e., any individuals who are currently 
in employment covered by

[[Page 47672]]

the plan and who are earning or retaining credited service under the 
plan). This includes any individuals who are eligible to elect to 
have the employer make payments under a Code section 401(k) 
qualified cash or deferred arrangement. Active participants also 
include any nonvested individuals who are earning or retaining 
credited service under the plan. This does not include (a) nonvested 
former employees who have incurred the break in service period 
specified in the plan or (b) former employees who have received a 
``cash-out'' distribution or deemed distribution of their entire 
nonforfeitable accrued benefit.
    2. Retired or separated participants receiving benefits (i.e., 
individuals who are retired or separated from employment covered by 
the plan and who are receiving benefits under the plan). This does 
not include any individual to whom an insurance company has made an 
irrevocable commitment to pay all the benefits to which the 
individual is entitled under the plan.
    3. Other retired or separated participants entitled to future 
benefits (i.e., any individuals who are retired or separated from 
employment covered by the plan and who are entitled to begin 
receiving benefits under the plan in the future). This does not 
include any individual to whom an insurance company has made an 
irrevocable commitment to pay all the benefits to which the 
individual is entitled under the plan.
    4. Deceased individuals who had one or more beneficiaries who 
are receiving or are entitled to receive benefits under the plan. 
This does not include any individual to whom an insurance company 
has made an irrevocable commitment to pay all the benefits to which 
the beneficiaries of that individual are entitled under the plan.
    Line 7g. Enter in element (1) the number of participants who 
have an account balances at the beginning of the year. Enter in 
element (2) the number of participants included on Line 7f (total 
participants at the end of the plan year) who have account balances 
at the end of the plan year. For example, for a Code section 401(k) 
plan the number entered on Line 7g should be the number of 
participants counted on Line 7f who have made a contribution, or for 
whom a contribution has been made, to the plan for this plan year or 
any prior plan year. Enter in element (3) the number of participants 
that made contributions to the plan (regardless of whether the 
employer made contributions) during the plan year. Both defined 
contribution pension plans and welfare plans complete element (3). 
Enter in element (4) the number of participants that terminated 
employment during the plan year that had their entire account 
balance distributed as of the end of the plan year. Only defined 
contribution pension plans complete element (4).
    Defined contribution plans must complete all of Lines 7g(1)-(4). 
Welfare plans must complete Line 7g(3) and should leave Line 7g(1), 
(2), and (4) blank. Defined benefit pension plans should skip Line 
7g and should leave it blank.
    Line 7h. Include any individual who terminated employment during 
this plan year, whether or not he or she (a) incurred a break in 
service, (b) received an irrevocable commitment from an insurance 
company to pay all the benefits to which he or she is entitled under 
the plan, and/or (c) received a cash distribution or deemed cash 
distribution of his or her nonforfeitable accrued benefit.

Part III--Form 5500-SF Eligibility Information.

    If your plan is required to file an annual return/report, you 
may file the Form 5500-SF instead of the Form 5500 only if you meet 
all of the eligibility conditions listed below.
    1. The plan (a) covered fewer than 100 participants at the 
beginning of the plan year 20XX, or (b) under 29 CFR 2520.103-1(d) 
was eligible to and filed as a small plan for plan year 20XX-1and 
covered 120 or fewer participants at the beginning of plan year 20XX 
(see instructions; defined benefit pension plans, welfare plans, and 
defined contribution pension plans that check the ``first plan 
year'' box use the number on Line 6; defined contribution pension 
plans use the number on Line 7g(1);
    2. The plan did not hold any employer securities at any time 
during the plan year;
    3. At all times during the plan year, the plan was 100% invested 
in certain secure, easy to value assets such as mutual fund shares, 
investment contracts with insurance companies and banks valued at 
least annually and that are not invested in ``hard-to-value'' 
assets, publicly traded securities held by a registered broker 
dealer, cash and cash equivalents, and plan loans to participants 
that meet the definition of ``eligible plan assets'' (see the 
instructions for Line 8a);
    4. The plan is eligible for the waiver of the annual examination 
and report of an independent qualified public accountant (IQPA) 
under 29 CFR 2520.104-46 (but not by reason of enhanced bonding), 
which requirement includes, among others, giving certain disclosures 
and supporting documents to participants and beneficiaries regarding 
the plan's investments (see instructions for Line 8b);
    5. The plan is not a multiemployer plan; and
    6. The plan did not provide group health benefits.
    Special conditions for filing the Form 5500-SF apply to ``one-
participant plans.'' See Specific Instructions for ``One-Participant 
Plans'' on page 7.
    Line 8a. Eligible Plan Assets. To be eligible to file the Form 
5500-SF, all of the plan's assets must be ``eligible plan assets.'' 
Answer Line 8a ``Yes'' or ``No.'' Do not leave this question blank. 
If the answer to Line 8a is ``No'' you CANNOT file the Form 5500-SF 
and must file the Form 5500. See discussion under Who May File Form 
5500-SF.
    For the purposes of this line, ``eligible plan assets'' are 
assets that have a readily determinable fair market value for 
purposes of this annual reporting requirement as described in 29 CFR 
2520.103-1(c)(2)(ii)(C), are not employer securities, and are held 
or issued by one of the following regulated financial institutions: 
a bank or similar financial institution as defined in 29 CFR 
2550.408b-4(c) (for example, banks, trust companies, savings and 
loan associations, domestic building and loan associations, and 
credit unions); an insurance company qualified to do business under 
the laws of a state; organizations registered as broker-dealers 
under the Securities Exchange Act of 1934; investment companies 
registered under the Investment Company Act of 1940; or any other 
organization authorized to act as a trustee for individual 
retirement accounts under Code section 408. Examples of assets that 
would qualify as eligible plan assets for this annual reporting 
purpose are mutual fund shares, investment contracts with insurance 
companies or banks that provide the plan with valuation information 
at least annually, publicly traded stock held by a registered broker 
dealer, cash and cash equivalents held by a bank. Participant loans 
meeting the requirements of ERISA section 408(b)(1) are also 
``eligible plan assets'' for this purpose whether or not they have 
been deemed distributed. ``Eligible plan assets'' do not include 
leveraged investments. Small plans that have such investments must 
file the Form 5500.
    Line 8b. In addition to all of the plan's assets being eligible 
plan assets as defined in Line 8a, to be eligible to file the Form 
5500-SF the plan also must meet the conditions for the exemption 
from the requirement to be audited annually by an independent 
qualified public accountant (IQPA) in 29 CFR 2520.104-46 and covered 
fewer than 100 participants as of the beginning of 20XX or, under 29 
CFR 2520.103-1(d), was eligible to and filed as a small plan for 
plan year 20XX-1 and did not cover more than 120 participants at the 
beginning of plan year 20XX. For these purposes, defined benefit 
pension plans, welfare plans, and defined contribution pension plans 
that check the ``first plan'' year box use the participant count on 
Line 6, and defined contribution pension plans can use the 
participant count on Line 7g(1).
    To be able to file the Form 5500-SF, the filer must meet the 
following three requirements for the audit waiver under 29 CFR 
2520.104-46:
    (1) as the last day of the preceding plan year, at least 95% of 
a small pension plan's assets were ``qualifying plan assets;''
    (2) the plan includes the required audit waiver disclosure in 
the Summary Annual Report (SAR) furnished to participants and 
beneficiaries, in accordance with 29 CFR 2520.104b-10. For defined 
benefit pension plans that are required pursuant to section 101(f) 
of ERISA to furnish an Annual Funding Notice (AFN), the 
administrator must instead either provide the information to 
participants and beneficiaries with the AFN or as a stand-alone 
notification at the time an SAR would have been due and in 
accordance with the rules for furnishing an SAR, although such plans 
do not have to furnish an SAR; and
    (3) in response to a request from any participant or 
beneficiary, the plan administrator must furnish without charge 
copies of statements from the regulated financial institutions 
holding or issuing the plan's ``qualifying plan assets.''
    [CAUTION] In order to be eligible to file the Form 5500-SF, a 
small pension plan

[[Page 47673]]

must meet the audit waiver conditions by virtue of having 95% or 
more of its assets as ``qualifying plan assets'' in accordance with 
29 CFR 2520.104-46(b)(1)(i)(A)(1). If the small plan satisfies the 
conditions of the audit waiver by virtue of having an enhanced 
fidelity bond under 29 CFR 2520.104-46(b)(1)(i)(A)(2), the plan does 
not satisfy the conditions for filing the Form 5500-SF and must file 
the Form 5500, along with the appropriate schedules and attachments. 
Also, although many ``qualifying plan assets'' for audit waiver 
purposes will also be ``eligible plan assets'' as described in the 
instructions for Line 6a, the definitions are not the same. If, as 
of the last day of the preceding plan year, the plan was 100% 
invested in ``eligible plan assets,'' the plan would satisfy the 
``qualifying plan asset'' prong of the audit waiver conditions. 
Holding all the plan's investments in ``qualifying plan assets,'' 
however, would not necessarily satisfy the conditions for filing the 
Form 5500-SF. For example, real estate held by a bank as trustee for 
a plan could be a qualifying plan asset for purposes of the small 
pension plan audit waiver conditions but it would not be an 
``eligible plan asset'' for purposes of the plan being eligible to 
file the Form 5500-SF because real estate would not have a readily 
determinable fair market value as described in 29 CFR 2520.103-
1(c)(2)(ii)(C).
    Line 8c. If you answer ``yes'' because the plan provided health 
benefits, whether through insurance or otherwise, you must file the 
Form 5500 and cannot file the Form 5500-SF regardless of plan size 
or, if any, investment type.

Part IV--Financial Information

    Note. The cash, modified cash, or accrual basis may be used for 
recognition of transactions in Parts I and II, as long as you use 
one method consistently. Round off all amounts reported on the Form 
5500-SF to the nearest dollar. Any other amounts are subject to 
rejection. Check all subtotals and totals carefully.
    Current value means fair market value where available. 
Otherwise, it means the fair value as determined in good faith under 
the terms of the plan by a trustee or named fiduciary, assuming an 
orderly liquidation at the time of the determination. See ERISA 
section 3(26).
    Line 9. Plan Assets and Liabilities. Amounts reported on the 
Form 5500-SF for the beginning of the plan year must be the same as 
reported for the end of the plan year for the corresponding lines on 
the return/report for the preceding plan year.
    Line 9a. Enter the total amount of plan assets at the beginning 
of the plan year in column (a). Do not include contributions 
designated for the 20XX plan year in column (a).
    Enter the total amount of plan assets at the end of the plan 
year in column (b). Do not include in column (b) a participant loan 
that has been deemed distributed during the plan year under the 
provisions of Code section 72(p) and Treasury Regulations section 
1.72(p)-1 if both the following circumstances apply: (1) Under the 
plan, the participant loan is treated as a directed investment 
solely of the participant's individual account; and (2) As of the 
end of the plan year, the participant is not continuing repayment 
under the loan.
    If the deemed distributed participant loan is included in column 
(a) and both of these circumstances apply, include the value of the 
loan as a deemed distribution on Line 8e. However, if either of 
these two circumstances does not apply, the current value of the 
participant loan (including interest accruing thereon after the 
deemed distribution) should be included in column (b) without regard 
to the occurrence of a deemed distribution.
    After a participant loan that has been deemed distributed it is 
included in the amount reported on Line 10e, it is no longer to be 
reported as an asset on Line 9a unless, in a later year, the 
participant resumes repayment under the loan. However, such a loan 
(including interest accruing thereon after the deemed distribution) 
that has not been repaid is still considered outstanding for 
purposes of applying Code section 72(p)(2)(A) to determine the 
maximum amount of subsequent loans. Also, the deemed distribution is 
not treated as an actual distribution for other purposes, such as 
the qualification requirements of Code section 401, including, for 
example, the determination of top-heavy status under Code section 
416 and the vesting requirements of Treasury Regulations section 
1.411(a)-7(d)(5). See Q&As 12 and 19 of Treasury Regulations section 
1.72(p)-1.
    The entry on Line 9a, column (b) (plan assets at end of year) 
must include the current value of any participant loan included as a 
deemed distribution in the amount reported for any earlier year if, 
during the plan year, the participant resumes repayment under the 
loan. In addition, the amount to be entered on Line 10e must be 
reduced by the amount of the participant loan reported as a deemed 
distribution for the earlier year.
    Line 9b. Enter the total liabilities at the beginning and end of 
the plan year. Liabilities to be entered here do not include the 
value of future pension payments to participants. The amount to be 
entered in Line 9b for accrual basis filers includes, among other 
things:
    1. Benefit claims that have been processed and approved for 
payment by the plan but have not been paid (including all incurred 
but not reported (IBNR) welfare benefit claims);
    2. Accounts payable obligations owed by the plan that were 
incurred in the normal operations of the plan but have not been 
paid; and
    3. Other liabilities such as acquisition indebtedness and any 
other amount owed by the plan.
    Line 9c. Enter the net assets as of the beginning and end of the 
plan year. (Subtract Line 9b from Line 9a). Line 9c, column (b), 
must equal the sum of Line 9c, column (a), plus Line 10j (net income 
(loss)) and Line 10k (transfers to (from) the plan).
    Line 10--Income, Expenses, and Transfers for this Plan Year.
    Line 10a. Receivables. Include the total cash contributions 
received and/or (for accrual basis plans) due to be received.
    Line 10a(1). Contributions--Employer and Employee. Plans using 
the accrual basis of accounting must not include contributions 
designated for years before the 20XX plan year on Line 10a(1). For 
welfare plans, report all employee contributions, including all 
elective contributions under a cafeteria plan (Code section 125). 
For pension plans, participant contributions, for purposes of this 
line item, also include elective contributions under a qualified 
cash or deferred arrangement (Code section 401(k)).
    Line 10a(2). Enter the current value, at date contributed, of 
all other contributions, including rollovers from other plans.
    Line 10b. Enter all other plan income for the plan year. Do not 
include transfers from other plans that are reported on Line 10k. 
Examples of other income received and/or receivable include:
    1. Interest on investments (including money market accounts, 
sweep accounts, etc.)
    2. Dividends. (Accrual basis plans should include dividends 
declared for all stock held by the plan even if the dividends have 
not been received as of the end of the plan year.)
    3. Net gain or loss from the sale of assets.
    4. Other income such as unrealized appreciation (depreciation) 
in plan assets.
    To compute this amount, subtract the current value of all assets 
at the beginning of the year plus the cost of any assets acquired 
during the plan year from the current value of all assets at the end 
of the year minus assets disposed of during the plan year.
    Line 10c. Enter the total of all cash contributions (Line 10a(1) 
through Line 10a(3)) and other plan income (Line 10b) during the 
plan year. If entering a negative number, enter a minus sign (``-'') 
to the left of the number.
    Line 10d. Include: (1) payments made (and, for accrual basis 
filers, payments due) to or on behalf of participants or 
beneficiaries in cash, securities, or other property (including 
rollovers of an individual's accrued benefit or account balance). 
Include all eligible rollover distributions as defined in Code 
section 401(a)(31)(D) paid at the participant's election to an 
eligible retirement plan (including an IRA within the meaning of 
Code section 401(a)(31)(E)); (2) payments to insurance companies and 
similar organizations for the provision of plan benefits (e.g., 
paid-up annuities, accident insurance, etc.); and (3) payments made 
to other organizations or individuals providing benefits. Generally, 
these payments discussed in (3) are made to individual providers of 
welfare benefits such as legal services, day care services, and 
training and apprenticeship services. If securities or other 
property are distributed to plan participants or beneficiaries, 
include the current value as of the date of distribution.
    Line 10e. Include on this line all distributions paid during the 
plan year of excess deferrals under Code section 402(g)(2)(A)(ii), 
excess contributions under Code section 401(k)(8), and excess 
aggregate contributions under Code section 401(m)(6). Include 
allocable income distributed. Also include on this line any elective 
deferrals and employee contributions distributed or returned to 
employees during the plan year

[[Page 47674]]

as well as any attributable income that was also distributed.
    For Line 10e, also include in the total amount a participant 
loan included in Line 10b, column (a) that has been deemed 
distributed during the plan year under the provisions of Code 
section 72(p) and Treasury Regulations section 1.72(p)-1 only if 
both of the following circumstances apply:
    1. Under the plan, the participant loan is treated as a directed 
investment solely of the participant's individual account; and
    2. As of the end of the plan year, the participant is not 
continuing repayment under the loan.
    If either of these circumstances does not apply, a deemed 
distribution of a participant loan should not be included in the 
total on Line 10e. Instead, the current value of the participant 
loan (including interest accruing thereon after the deemed 
distribution) should be included on Lines 9a, column (b) (plan 
assets--end of year), and 10b (participant loans--end of year), 
without regard to the occurrence of a deemed distribution.
    Note. The amount to be reported on Line 10d must be reduced if, 
during the plan year, a participant resumes repayment under a 
participant loan reported as a deemed distribution on Line 2g of 
Schedule H of a prior Form 5500 Annual Return/Report or Line 10e of 
a prior Form 5500-SF for any earlier year. The amount of the 
required reduction is the amount of the participant loan that was 
reported as a deemed distribution on such line for any earlier year. 
If entering a negative number, enter a minus sign (``-'') to the 
left of the number. The current value of the participant loan must 
then be included on line 9a, column (b) (plan assets--end of year).
    Although certain participant loans deemed distributed are to be 
reported on Line 10e, and are not to be reported on the Form 5500-SF 
or on the Schedule H of the Form 5500 Annual Return/Report as an 
asset thereafter (unless the participant resumes repayment under the 
loan in a later year), they are still considered outstanding loans 
and are not treated as actual distributions for certain purposes. 
See Q&As 12 and 19 of Treasury Regulations section 1.72(p)-1.
    Line 10f. The amount to be reported for expenses involving 
administrative service providers (salaries, fees, and commissions) 
includes the total fees paid (or in the case of accrual basis plans, 
costs incurred during the plan year but not paid as of the end of 
the plan year) by the plan for, among others:
    1. Salaries to employees of the plan;
    2. Fees and expenses for accounting, actuarial, legal, 
investment management, investment advice, and securities brokerage 
services;
    3. Contract administrator fees; and
    4. Fees and expenses for individual plan trustees, including 
reimbursement for travel, seminars, and meeting expenses.
    Line 10g. Other expenses (paid and/or payable) include other 
administrative and miscellaneous expenses paid by or charged to the 
plan, including among others office supplies and equipment, 
telephone, and postage.
    Line 10h. Enter the total of all benefits paid or due reported 
on Lines 10d and 10e and all other plan expenses reported on Lines 
10f and 10g during the year.
    Line 10i. Subtract Line 10i from Line 10b.
    Line 10j. Enter the net value of all assets transferred to and 
from the plan during the plan year including those resulting from 
mergers and spinoffs. A transfer of assets or liabilities occurs 
when there is a reduction of assets or liabilities with respect to 
one plan and the receipt of these assets or the assumption of these 
liabilities by another plan. Transfers out at the end of the year 
should be reported as occurring during the plan year.
    Note. A distribution of all or part of an individual 
participant's account balance that is reportable on Form 1099-R, 
Distributions From Pensions, Annuities, Retirement or Profit-Sharing 
Plans, IRAs, Insurance Contracts, etc., should not be included on 
Line 8j but must be included in benefit payments reported on Line 
10d. Do not submit IRS Form 1099-R with the Form 5500-SF.
    Lines 11(a)-(i). Enter the totals for the various categories as 
appropriate.
    [CAUTION] Filers that have assets that do not fit into any of 
these breakout categories must file the Form 5500. If, the plan is 
invested in any assets other than eligible plan assets, which 
includes the requirement of being readily marketable, you must file 
the Form 5500 and required schedules. For example, if the plan holds 
real estate, nonpublicly traded securities, shares in a limited 
partnership, derivatives, notes and stock not traded on an exchange, 
private equity, and collectibles, or other alternative or hard-to-
value assets, then the plan is required to file a Form 5500.
    For reporting purposes, ``common/collective trust'' and ``pooled 
separate account'' are, respectively: (1) a trust maintained by a 
bank, trust company, or similar institution; or (2) an account 
maintained by an insurance carrier, which is regulated, supervised, 
and subject to periodic examination by a state or federal agency in 
the case of a CCT, or by a state agency in the case of a PSA, for 
the collective investment and reinvestment of assets contributed 
thereto from employee benefit plans maintained by more than one 
employer or controlled group of corporations as that term is used in 
Code section 1563. See 29 CFR 2520.103-3, 103-4, 103-5, and 103-9. 
To be eligible plan assets for Form 5500-SF reporting purposes, a 
bank or insurance company contract, including a CCT or PSA must not 
only be valued at least annually, but must itself be invested 
primarily in readily marketable assets.
    Note. For reporting purposes, a separate account that is not 
considered to be holding plan assets pursuant to 29 CFR 2510.3-
101(h)(1)(iii) does not constitute a pooled separate account.

Part IV--Plan Characteristics

    Line 12. Benefits Provided Under the Plan. Pension plans must 
answer all applicable questions in Line 11a that applied during the 
reporting year of the plan or arrangement. Defined benefit pension 
plans must complete Lines 12(1)-(3), 12a(4) and 12a(9)-(11). Defined 
contribution pension plans must complete Lines 12a(4)-12a(11). 
Welfare benefit plans must complete Lines 11b(1)-(3).
    Line 12a(1). Defined Benefit Pension Plans; How Benefits Are 
Calculated. If benefits are based primarily on pay, check the box 
``Benefits are primarily pay related.'' If benefits are primarily 
flat dollar, including dollars per year of service, check the box 
``Benefits are primarily flat dollar.''
    Check the box for ``Cash balance plan'' if the plan has a ``cash 
balance'' formula under which the accumulated benefit provided under 
the formula is expressed as the current balance of a hypothetical 
account maintained for the participant. For this purpose, a ``cash 
balance'' formula is a lump sum based benefit formula in a defined 
benefit pension plan by whatever name (for example, personal account 
plan, life cycle plan, cash account plan, etc.).
    Check the box for ``Pension equity plan (PEP)'' if the plan has 
a ``pension equity plan formula under which the accumulated benefit 
provided under the formula is expressed as the current value of an 
accumulated percentage of the participant's final average 
compensation or is expressed as a current single-sum dollar amount 
equal to a percentage of the participant's highest average 
compensation (with a permitted lookback period for determining 
highest average compensation, such as highest 5 out of the last 10 
years).
    Check the box for ``Other hybrid plan'' if the plan provides a 
lump sum based benefit formula that is different from the cash 
balance or pension equity plan formula.
    Note that a benefit formula does not constitute a lump sum based 
benefit formula unless a distribution of the benefits under that 
formula in the form of a single-sum payment equals the accumulated 
benefit under that formula (except to the extent the single-sum 
payment is greater to satisfy the requirements of Code section 
411(d)(6)).
    Line 12a(2). Code Section Arrangements for Defined Benefit 
Pension Plans. Check the box for ``Code section 414(k) arrangement'' 
if benefits are based partly on the balance of the separate account 
of the participant (also include appropriate defined contribution 
pension feature codes).
    Line 12a(3). Terminated Defined Benefit Pension Plan. Check 
``Yes'' if the plan is covered by PBGC and was terminated and closed 
out for PBGC purposes before the end of the plan year (or a prior 
plan year), and either (1) the plan terminated in a standard (or 
distress) termination and completed the distribution of plan assets 
in satisfaction of all benefit liabilities (or all ERISA Title IV 
benefits for distress termination); or (2) a trustee was appointed 
for a terminated plan pursuant to ERISA section 4042.
    Line 12a(4). PBGC Covered Defined Benefit Pension Plan. If you 
are uncertain whether the plan is covered under the PBGC termination 
insurance program, check the box ``Not determined'' and contact the 
PBGC either by phone at 1-800-736-2444, by Email at 
[email protected], or in writing to Pension Benefit Guaranty 
Corporation, Standard Termination Compliance Division, Suite 930, 
Processing and Technical Assistance Branch, 1200 K Street, NW., 
Washington, DC 20005-4026. If you checked

[[Page 47675]]

the box ``Yes,'' enter the My PAA generated confirmation number for 
the premium filing for this plan year (see filing receipt). If you 
amended your premium filing for this plan year, enter the 
confirmation number for that filing and not for the previous 
filing(s). Defined contribution pension plans and welfare plans do 
not need to complete this item.
    Line 12a(5). Frozen Plans. Check ``Yes'' if the plan is frozen.
    Line 12a(6). Offset Arrangement. Both defined benefit and 
contribution plans that are part of an offset arrangement must 
answer this question. Check ``Yes'' if plan benefits are subject to 
offset for retirement benefits provided in another plan or 
arrangement of the employer. If you have checked ``Yes,'' enter the 
name, EIN of sponsor, and PN of the other plan or arrangement.
    Line 12a(7). Defined Contribution Pension Plan Type(s). Defined 
contribution pension plans only complete this line. Check all 
type(s) that apply.
    Line 12a(8). Defined Contribution Pension Plan Arrangements. If 
this is a defined contribution pension plan, check the type(s) of 
arrangements under which the plan operates. (Check all that apply.)
    Line 12a(9). Defined Contribution Pension Plan Features. If this 
is a defined contribution pension plan, check all that apply to 
indicate features of the plan.
    Check automatic enrollment feature if the plan has elective 
contributions from payroll and provides for automatic enrollment in 
the plan.
    A designated Roth account is a feature in new or existing 
401(k), 403(b), or governmental 457(b) plans that permit such plans 
to accept designated Roth contributions and certain rollovers. If a 
plan adopts this feature, employees can designate some or all of 
their elective contributions (also referred to as elective 
deferrals) as designated Roth contributions (which are included in 
gross income), rather than traditional, pre-tax elective 
contributions.
    Check the box for ``Age/service weighted plan'' if allocations 
are based on age, service, or age and service.
    New comparability or similar plan: Allocations are based on 
participant classifications and a classification(s) consists 
entirely or predominantly of highly compensated employees; or the 
plan provides an additional allocation rate on compensation above a 
specified threshold, and the threshold or additional rate exceeds 
the maximum threshold or rate allowed under the permitted disparity 
rules of Code section 401(l).
    Check ``other'' if the plan has any other particularized 
features for defined contribution pension plans that are not listed 
above and enter a short description in the space provided.
    Line 12a(10). Participant-Directed Defined Contribution Pension 
Plan. Check the box for ERISA section 404(c) plan if the plan, or 
any part of it, is intended to meet the conditions of 29 CFR 
2550.404c-1.
    Check the box for total participant-directed account plan if 
participants have the opportunity to direct the investment of all 
the assets allocated to their individual accounts, regardless of 
whether 29 CFR is intended to be met.
    Check partial participant-directed account if participants have 
the opportunity to direct the investment of a portion of the assets 
allocated to their individual accounts, regardless of whether 29 CFR 
is intended to be met. Do not check both ``total'' and ``partial'' 
participant-directed account.
    Check the box for participant-directed brokerage accounts if the 
plan provides such accounts as an investment option under the plan. 
If you check this box, enter the number of participants using the 
participant-directed brokerage account(s).
    Line 12a(11). Qualified Default Investment Alternatives (QDIAs). 
Regardless of whether the plan is total or partial participant-
directed, if the plan uses default investment alternative(s) (DIA) 
that are intended to be QDIA(s) for participants who fail to direct 
assets in their account, also check the box to so indicate. If the 
plan uses a QDIA for participants who fail to direct assets in their 
account, indicate type of default investment alternative: target 
date/life fund; fixed income; money market or equivalent; balanced 
fund; professionally managed account; or other. If other, specify 
the type of account. If you checked the box for ``Other,'' you may 
be using an investment alternative that does not satisfy the QDIA 
requirements in the Department of Labor's regulation at 29 CFR 
2550.404c-5.
    Line 12a(12) Eligible Combined Plan Under Code section 414(x). 
If the plan is an eligible combined plan under Code section 414(x), 
check ``Yes.''
    Note. In the case of an eligible combined plan under Code 
section 414(x) and ERISA section 210(e), you must answer all 
applicable for both the defined benefit pension features and the 
defined contribution pension features of the plan.
    Line 12a(13). Check this box if a rollover from a plan was used 
to start up the business (ROBS) sponsoring this plan.
    Line 12a(14). Other Pension Benefit Features. Check all that 
apply.
    Notes: (1) If a plan sponsor or an employer adopted a pre-
approved plan that includes a master & prototype plan or a volume 
submitter plan, enter the most recent adoption date and the IRS 
favorable opinion or advisory letter's serial number. (2) Sponsors 
of Puerto Rico plans, check the box to indicate that the plan is not 
intended to be qualified under Code sections 401, 403, or 408 only 
if:
    i. only Puerto Rico residents participate,
    ii. the trust is exempt from income tax under the laws of Puerto 
Rico, and
    iii. the plan administrator has not made the election under 
ERISA section 1022(i)(2), and, therefore, the plan is not intended 
to qualify under section 401(a) of the Internal Revenue Code (U.S).
    Line. 12b Welfare Benefit Plan Characteristics. Welfare plans 
must answer all applicable questions in Line 12b. Plans that provide 
group health benefits cannot file the Form 5500-SF; they must file 
the Form 5500. Pension plans skip to Line 13.
    Line 12b(1). Disability Benefits. If the plan provides 
disability benefits, answer ``Yes'' and check all that apply.
    Line 12b(2). Other Welfare Benefits. If the plan provides 
welfare benefits other than disability, answer ``Yes'' and check all 
that apply. If the type of benefits is not listed, check ``other'' 
and enter a description.
    Line 13. Funding and Benefit Arrangements. Check all boxes that 
apply to indicate the funding and benefit arrangements used during 
the plan year. The ``funding arrangement'' is the method for the 
receipt, holding, investment, and transmittal of plan assets prior 
to the time the plan actually provides benefits. ``The benefit 
arrangement'' is the method by which the plan provides benefits to 
participants. For purposes of Line 13:
    ``Insurance'' means the plan has an account, contract, or policy 
with an insurance company, insurance service, or other similar 
organization during the plan or DFE year. (This includes investments 
with insurance companies such as guaranteed investment contracts 
(GICs).) An annuity account arrangement under Code section 403(b)(1) 
that is required to complete the Form 5500 should mark ``insurance'' 
for both the plan funding arrangement and plan benefit arrangement. 
Do not check ``insurance'' if the sole function of the insurance 
company was to provide administrative services.
    ``Code section 412(e)(3) insurance contract'' are contracts that 
provide retirement benefits under a plan that are guaranteed by an 
insurance carrier. In general, such contracts must provide for level 
premium payments over the individual's period of participation in 
the plan (to retirement age), premiums must be timely paid as 
currently required under the contract, no rights under the contract 
may be subject to a security interest, and no policy loans may be 
outstanding. If a plan is funded exclusively by the purchase of such 
contracts, the otherwise applicable minimum funding requirements of 
section 412 of the Code and section 302 of ERISA do not apply for 
the year and neither the Schedule MB nor the Schedule SB is required 
to be filed.
    ``Trust'' includes any fund or account that receives, holds, 
transmits, or invests plan assets other than an account or policy of 
an insurance company. A custodial account arrangement under Code 
section 403(b)(7) that is required to complete the Form 5500 should 
mark ``trust'' for both the plan funding arrangement and the plan 
benefit arrangement.
    ``General assets of the sponsor'' means either the plan had no 
assets or some assets were commingled with the general assets of the 
plan sponsor prior to the time the plan actually provided the 
benefits promised.
    Example. If the plan holds all its assets invested in registered 
investment companies and other non-insurance company investments 
until it purchases annuities to pay out the benefits promised under 
the plan, box 13a(3) should be checked as the funding arrangement 
and box 12b(1) should be checked as the benefit arrangement.
    Note. An employee benefit plan that checks boxes 13a(1), 13a(2), 
13b(1), and/or 13b(2) must answer line 14e to report insurance fee 
and commission information.

[[Page 47676]]

Part VI--Plan Operations Compliance Questions

    Line 14. Answer all lines either ``Yes'' or ``No.'' Do not leave 
any answer blank unless otherwise directed. For Lines 14a, b, c, d, 
e, f, and n, if the answer is ``Yes,'' an amount must be entered.
    Note. ``One-participant plans'' should complete only Line 14g.
    Line 14a. Amounts paid by a participant or beneficiary to an 
employer and/or withheld by an employer for contribution to the plan 
are participant contributions that become plan assets as of the 
earliest date on which such contributions can reasonably be 
segregated from the employer's general assets. See 29 CFR 2510.3-
102. In the case of a plan with fewer than 100 participants at the 
beginning of the plan year, any amount deposited with such plan not 
later than the 7th business day following the day on which such 
amount is received by the employer (in the case of amounts that a 
participant or beneficiary pays to an employer), or the 7th business 
day following the day on which such amount would otherwise have been 
payable to the participant in cash (in the case of amounts withheld 
by an employer from a participant's wages), shall be deemed to be 
contributed or repaid to such plan on the earliest date on which 
such contributions or participant loan repayments can reasonably be 
segregated from the employer's general assets. See 29 CFR 2510.3-
102(a)(2). Plans that check ``Yes,'' must enter the aggregate amount 
of all late contributions for the year. The total amount of the 
delinquent contributions must be included on Line 14a for the year 
in which the contributions were delinquent and must be carried over 
and reported again on Line 14a for each subsequent year (or on Line 
4a of Schedule H of the Form 5500 if not eligible to file the Form 
5500-SF in the subsequent year) until the year after the violation 
has been fully corrected by payment of the late contributions and 
reimbursement of the plan for lost earnings or profits. If no 
participant contributions were received or withheld by the employer 
during the plan year, answer ``No.''
    An employer holding participant contributions commingled with 
its general assets after the earliest date on which such 
contributions can reasonably be segregated from the employer's 
general assets will have engaged in a prohibited use of plan assets 
(see ERISA section 406). If such a nonexempt prohibited transaction 
occurred with respect to a disqualified person (see Code section 
4975(e)(2)), file IRS Form 5330, Return of Excise Taxes Related to 
Employee Benefit Plans, with the IRS to pay any applicable excise 
tax on the transaction.
    Participant loan repayments paid to and/or withheld by an 
employer for purposes of transmittal to the plan that were not 
transmitted to the plan in a timely fashion must be reported either 
on Line 14a in accordance with the reporting requirements that apply 
to delinquent participant contributions or on Line 14b. See Advisory 
Opinion 2002-02A, available at www.dol.gov/ebsa.
    Applicants that satisfy both the DOL Voluntary Fiduciary 
Correction Program (VFCP) and the conditions of Prohibited 
Transaction Exemption (PTE) 2002-51 are eligible for immediate 
relief from payment of certain prohibited transaction excise taxes 
for certain corrected transactions, and are also relieved from the 
requirement to file the IRS Form 5330 with the IRS. For more 
information on how to apply under the VFCP, the specific 
transactions covered (which transactions include delinquent 
participant contributions to pension and welfare plans), and 
acceptable methods for correcting violations. See 71 FR 20261 (Apr. 
19, 2006) and 71 FR 20135 (Apr. 19, 2006). All delinquent 
participant contributions must be reported on Line 14a at least for 
the year in which they were delinquent even if violations have been 
fully corrected by the close of the plan year. Information about the 
VFCP is also available on the Internet at www.dol.gov/ebsa.
    Line 14b. Plans that check ``Yes'' must enter the amount. Check 
``Yes'' if any nonexempt transaction with a party-in-interest 
occurred. Do not check ``Yes'' with respect to transactions that 
are: (1) statutorily exempt under Part 4 of Title I of ERISA; (2) 
administratively exempt under ERISA section 408(a); (3) exempt under 
Code sections 4975(c) or 4975(d); (4) the holding of participant 
contributions in the employer's general assets for a welfare plan 
that meets the conditions of ERISA Technical Release 92-01; or (5) 
delinquent participant contributions or delinquent loan repayments 
reported on Line 14a. You may indicate that an application for an 
administrative exemption is pending. If you are unsure whether a 
transaction is exempt or not, you should consult either with a 
qualified public accountant, legal counsel, or both. If the plan is 
a qualified pension plan and a nonexempt prohibited transaction 
occurred with respect to a disqualified person, an IRS Form 5330 is 
required to be filed with the IRS to pay the excise tax on the 
transaction.
    Nonexempt transactions. Nonexempt transactions with a party-in-
interest include any direct or indirect:
    A. Sale or exchange, or lease, of any property between the plan 
and a party-in-interest.
    B. Lending of money or other extension of credit between the 
plan and a party-in-interest.
    C. Furnishing of goods, services, or facilities between the plan 
and a party-in-interest.
    D. Transfer to, or use by or for the benefit of, a party-in-
interest, of any income or assets of the plan.
    E. Acquisition, on behalf of the plan, of any employer security 
or employer real property in violation of ERISA section 407(a).
    F. Dealing with the assets of the plan for a fiduciary's own 
interest or own account.
    G. Acting in a fiduciary's individual or any other capacity in 
any transaction involving the plan on behalf of a party (or 
represent a party) whose interests are adverse to the interests of 
the plan or the interests of its participants or beneficiaries.
    H. Receipt of any consideration for his or her own personal 
account by a party-in-interest who is a fiduciary from any party 
dealing with the plan in connection with a transaction involving the 
income or assets of the plan.
    Party-in-Interest. For purposes of this form, party-in-interest 
is deemed to include a disqualified person. See Code section 
4975(e)(2). The term ``party-in-interest'' means, as to an employee 
benefit plan:
    A. Any fiduciary (including, but not limited to, any 
administrator, officer, trustee, or custodian), counsel, or employee 
of the plan;
    B. A person providing services to the plan;
    C. An employer, any of whose employees are covered by the plan;
    D. An employee organization, any of whose members are covered by 
the plan;
    E. An owner, direct or indirect, of 50% or more of:
    1. the combined voting power of all classes of stock entitled to 
vote or the total value of shares of all classes of stock of a 
corporation;
    2. the capital interest or the profits interest of a 
partnership; or
    3. the beneficial interest of a trust or unincorporated 
enterprise which is an employer or an employee organization 
described in C or D;
    F. A relative of any individual described in A, B, C, or E;
    G. A corporation, partnership, or trust or estate of which (or 
in which) 50% or more of:
    1. the combined voting power of all classes of stock entitled to 
vote or the total value of shares of all classes of stock of such 
corporation,
    2. the capital interest or profits interest of such partnership, 
or
    3. the beneficial interest of such trust or estate, is owned 
directly or indirectly, or held by persons described in A, B, C, D, 
or E;
    H. An employee, officer, director (or an individual having 
powers or responsibilities similar to those of officers or 
directors), or a 10% or more shareholder directly or indirectly, of 
a person described in B, C, D, E, or G, or of the employee benefit 
plan; or
    I. A 10% or more (directly or indirectly in capital or profits) 
partner or joint venturer of a person described in B, C, D, E, or G.
    [TIP] Applicants that satisfy the VFCP requirements and the 
conditions of PTE 2002-51 (see the instructions for Line 12a) are 
eligible for immediate relief from payment of certain prohibited 
transaction excise taxes for certain corrected transactions and the 
requirement to file the Form 5330 with the IRS. For more 
information, see 71 FR 20261 (Apr. 19, 2006) and 71 FR 20135 (Apr. 
19, 2006). When the conditions of PTE 2002-51 have been satisfied, 
the corrected transactions should be treated as exempt under Code 
section 4975(c) for the purposes of answering Line 14b.
    Line 14c. Plans that check ``Yes'' must enter the aggregate 
amount of fidelity bond coverage for all claims. Check ``Yes'' only 
if the plan itself (as opposed to the plan sponsor or administrator) 
is a named insured under a fidelity bond that is from an approved 
surety covering plan officials and that protects the plan from 
losses due to fraud or dishonesty as described in 29 CFR part 2580. 
Generally, every plan official of an employee benefit plan who 
``handles'' funds or other property of such plan must be

[[Page 47677]]

bonded. Generally, a person shall be deemed to be ``handling'' funds 
or other property of a plan, so as to require bonding, whenever his 
or her duties or activities with respect to given funds are such 
that there is a risk that such funds could be lost in the event of 
fraud or dishonesty on the part of such person, acting either alone 
or in collusion with others. Section 412 of ERISA and 29 CFR part 
2580 describe the bonding requirements, including the definition of 
``handling'' (29 CFR 2580.412-6), the permissible forms of bonds (29 
CFR 2580.412-10), the amount of the bond (29 CFR part 2580, subpart 
C), and certain exemptions such as the exemption for unfunded plans, 
certain banks and insurance companies (ERISA section 412), and the 
exemption allowing plan officials to purchase bonds from surety 
companies authorized by the Secretary of the Treasury as acceptable 
reinsurers on federal bonds (29 CFR 2580.412-23). Information 
concerning the list of approved sureties and reinsurers is available 
on the Internet at www.fms.treas.gov/c570. For more information on 
the fidelity bonding requirements, see Field Assistance Bulletin 
2008-04, available at www.dol.gov/ebsa.
    Note. Plans are permitted under certain conditions to purchase 
fiduciary liability insurance. These fiduciary liability insurance 
policies are not written specifically to protect the plan from 
losses due to dishonest acts and cannot be reported as fidelity 
bonds on Line 13c.
    Line 14d. Check ``Yes'' if the plan had suffered or discovered 
any loss as a result of any dishonest or fraudulent act(s) even if 
the loss was reimbursed by the plan's fidelity bond or from any 
other source. If ``Yes'' is checked enter the full amount of the 
loss. If the full amount of the loss has not yet been determined, 
provide an estimate as determined in good faith by a plan fiduciary. 
You must keep, in accordance with ERISA section 107, records showing 
how the estimate was determined.
    [CAUTION] Willful failure to report is a criminal offense. See 
ERISA section 501.
    Line 14e. If any benefits under the plan are provided by an 
insurance company, insurance service, or other similar organization 
or if the plan has investments with insurance companies such as 
guaranteed investment contracts (GICs), report the total of all 
insurance fees and commissions paid to agents, brokers and/or other 
persons directly or indirectly attributable to the contract(s) 
placed with or retained by the plan.
    For purposes of Line 14e, commissions and fees include sales or 
base commissions and all other monetary and non-monetary forms of 
compensation where the broker's, agent's, or other person's 
eligibility for the payment or the amount of the payment is based, 
in whole or in part, on the value (e.g., policy amounts, premiums) 
of contracts or policies (or classes thereof) placed with or 
retained by an ERISA plan, including, for example, persistency and 
profitability bonuses. The amount (or pro rata share of the total) 
of such commissions or fees attributable to the contract or policy 
placed with or retained by the plan must be reported. Insurers must 
provide plan administrators with a proportionate allocation of 
commissions and fees attributable to each contract. Any reasonable 
method of allocating commissions and fees to policies or contracts 
is acceptable, provided the method is disclosed to the plan 
administrator. A reasonable allocation method could allocate fees 
and commissions based on a calendar year calculation even if the 
plan year or policy year was not a calendar year. For additional 
information on these reporting requirements, see ERISA Advisory 
opinion 2005-02A, available on the Internet at www.dol.gov/ebsa.
    Where benefits under a plan are purchased from and guaranteed by 
an insurance company, insurance service, or other similar 
organization, and the total fees and commissions are reported on the 
Form 5500-SF, payments of reasonable monetary compensation by the 
insurer out of its general assets to affiliates or third parties for 
performing administrative activities necessary for the insurer to 
fulfill its contractual obligation to provide benefits, where there 
is no direct or indirect charge to the plan for administrative 
services other than the insurance premium, then the payments for 
administrative services by the insurer to the affiliates or third 
parties do not need to be reported on Line 14e. This would include 
compensation for services such as recordkeeping and claims 
processing services provided by a third party pursuant to a contract 
with the insurer to provide those services but would not include 
compensation provided by the insurer incidental to the sale or 
renewal of a policy, such as finders' fees, insurance brokerage 
commissions and fees, or similar fees.
    Reporting also is not required for compensation paid by the 
insurer to a ``general agent'' or ``manager'' for that general 
agent's or manager's management of an agency or performance of 
administrative functions for the insurer. For this purpose, (1) a 
``general agent'' or ``manager'' does not include brokers 
representing insureds, and (2) payments would not be treated as paid 
for managing an agency or performance of administrative functions 
where the recipient's eligibility for the payment or the amount of 
the payment is dependent or based on the value (e.g., policy 
amounts, premiums) of contracts or policies (or classes thereof) 
placed with or retained by ERISA plan(s).
    Reporting is not required for occasional gifts or meals of 
insubstantial value which are tax deductible for federal income tax 
purposes by the person providing the gift or meal and would not be 
taxable income to the recipient. For this exemption to be available, 
the gift or gratuity must be both occasional and insubstantial. For 
this exemption to apply, the gift must be valued at less than $50, 
the aggregate value of gifts from one source in a calendar year must 
be less than $250, but gifts with a value of less than $10 do not 
need to be counted toward the $250 annual limit. If the $250 
aggregate value limit is exceeded, then the aggregate value of all 
the gifts will be reportable. For this purpose, non-monetary gifts 
of less than $10 also do not need to be included in calculating the 
aggregate value of all gifts required to be reported if the $250 
limit is exceeded.
    Gifts from multiple employees of one service provider should be 
treated as originating from a single source when calculating whether 
the $50 or $250 thresholds apply. On the other hand, in applying the 
threshold to an occasional gift received from one source by multiple 
employees of a single service provider, the amount received by each 
employee should be separately determined in applying the $50 and 
$250 thresholds. For example, if 11 employees of a broker attend a 
business conference put on by an insurer designed to educate and 
explain the insurer's products for employee benefit plans, and the 
insurer provides, at no cost to the attendees, refreshments valued 
at $25 per individual, the gratuities would not be reportable on 
this line even though the total cost of the refreshments for all the 
employees would be $275.
    These thresholds are for purposes of Line 13e reporting. Filers 
are cautioned that the payment or receipt of gifts and gratuities of 
any amount by plan fiduciaries may violate ERISA and give rise to 
civil liabilities and criminal penalties.
    Important Reminder. The insurance company, insurance service, or 
other similar organization is required under ERISA section 103(a)(2) 
to provide the plan administrator with the information needed to 
complete this return/report. Your insurance company must provide you 
with the information you need to answer this question. If your 
insurance company, insurance service, or other similar organization 
does not automatically send you this information, you should make a 
written request for the information. If you have difficulty getting 
the information from your insurance company, contact the nearest 
office of the DOL's Employee Benefits Security Administration.
    Line 14f. You must check ``Yes'' if any benefits due under the 
plan were not timely paid or not paid in full. Include in this 
amount the total of any outstanding amounts that were not paid when 
due in previous years that have continued to remain unpaid.
    Line 14g. Code section 401(k) and other individual account 
pension plans must complete Line 10h. Other filers should leave Line 
10h blank. Check ``Yes'' if there was a ``blackout period.'' A 
blackout period is a temporary suspension of more than three 
consecutive business days during which participants or beneficiaries 
of a 401(k) or other individual account pension plan were unable, or 
were limited or restricted in their ability, to direct or diversify 
assets credited to their accounts, obtain loans from the plan, or 
obtain distributions from the plan. A ``blackout period'' generally 
does not include a temporary suspension of the right of participants 
and beneficiaries to direct or diversify assets credited to their 
accounts, obtain loans from the plan, or obtain distributions from 
the plan if the temporary suspension is: (1) part of the regularly 
scheduled operations of the plan that has been disclosed to 
participants and beneficiaries; (2) due to a qualified domestic 
relations order (QDRO) or because of a pending determination as to 
whether a domestic relations order is a QDRO; (3) due to an action 
or a failure to take action by an

[[Page 47678]]

individual participant or because of an action or claim by someone 
other than the plan regarding a participant's individual account; or 
(4) by application of federal securities laws. For more information, 
see the DOL's regulation at 29 CFR 2520.101-3 (available at 
www.dol.gov/ebsa).
    Line 14h. Code section 401(k) and other individual account 
pension plans who answered ``Yes'' to Line 14h must complete Line 
14i. Other filers should leave Line 14i blank. If there was a 
blackout period, did you provide the required notice not less than 
30 days nor more than 60 days in advance of restricting the rights 
of participants and beneficiaries to change their plan investments, 
obtain loans from the plan, or obtain distributions from the plan? 
If so, check ``Yes.'' See 29 CFR 2520.101-3 for specific notice 
requirements and for exceptions from the notice requirement. Also, 
answer ``Yes'' if one of the exceptions to the notice requirement 
under 29 CFR 2520.101-3 applies.
    Line 14i. Disclosures for Participant-Directed Accounts. All 
individual account plans that provide for participant-direction must 
provide specified disclosures under 29 CFR 2550.404a-5 with respect 
to each participant or beneficiary that, pursuant to the terms of 
the plan, has the right to direct the investment of assets held in, 
or contributed to, his or her individual account. Included in the 
required disclosures is a comparison chart. If subject to the 
disclosure requirements under 29 CFR 2550.404a-5, answer ``Yes'' and 
attach to your Form 5500-SF, a copy of the comparison chart for the 
plan year.
    Line 14j. If you answered ``Yes'' to Line 14j, check the box to 
indicate whether the plan provide participants and beneficiaries the 
plan and investment disclosures required under 29 CFR 2550.404a-
5(d)(2) and, if you answered ``Yes,'' attach the comparison chart(s) 
provided to participants and beneficiaries.
    Line 14k. If you answered ``Yes,'' to Line 14j, enter the number 
of designated investment alternatives (DIAs) available under the 
plan and indicate the number of DIAs that are index funds.
    Line 14l. If you answered ``Yes,'' to Line 14j, check the 
appropriate box to indicate whether the plan made available to 
participants and beneficiaries a designated investment manager 
(DIM). If you answered ``Yes,'' enter name of DIM.
    Line 14m. Check ``Yes,'' if the plan make available to 
participants and beneficiaries any brokerage window, self-directed 
brokerage account or similar plan arrangements that enabled 
participants to select investments beyond those designated by the 
plan. If you answered ``Yes'' to Line 14n, enter the number of 
participants that utilized the account or arrangement.
    Line 14n. Unrelated Business Taxable Income. Unrelated business 
taxable income generally means the gross income derived from any 
unrelated trade or business (as defined in Code section 513) 
regularly conducted and not substantially related to the plan's 
exempt purpose under Code section 512, less the deductions directly 
connected with carrying on the trade or business. See IRS 
Publication 598 for more information. Check ``N/A'' if this plan 
does not have a trust, such as 412(e)(3) fully insured plans or 
certain 403(b) annuity plans.
    Plans that check ``Yes'' must enter any amount of unrelated 
business taxable income. Form 990-T, Exempt Organization Business 
Income Tax Return, is required to be filed for any gross income of 
$1000 or more generated by an employer's trust by the 15th day of 
the 4th month following the end of the trust's tax year. See 
Instructions to Form 990-T for more details.
    Line 14o. Check ``Yes'' if an employer sponsoring the plan pays 
any of the administrative expenses of the plan that were not 
reported on Line 10g.
    Line 14p. Check ``Yes'' if any person who is disqualified under 
ERISA Section 411, served or was permitted to serve the plan in any 
capacity. Section 411 of ERISA establishes a bar against certain 
persons serving as employee benefit plan fiduciaries or service 
providers because they have been convicted of any of a broad range 
of specified crimes. Prohibited positions and activities include 
consultants and advisers to plans and any entity whose activities 
are in whole or substantial part devoted to providing goods or 
services to employee benefit plans. As amended by the Comprehensive 
Crime Control Act of 1984, section 411 of ERISA prohibits such 
persons from serving plans for a period of thirteen years after such 
judgment or the end of imprisonment resulting from a disqualifying 
conviction, whichever is later, unless the sentencing court, under 
appropriate circumstances, has reduced the period of prohibition to 
not less than three years or has determined that service in any of 
the prohibited capacities would not be contrary to the purposes of 
ERISA. The prohibition takes effect upon the date of conviction (the 
date of entry of judgment by the trial court) or the end of 
imprisonment, whichever is later.
    Line 14q. Check ``Yes'' if the plan sponsor or its affiliates 
provide any services to the plan in exchange for direct or indirect 
compensation.
    Line 14r. Termination of Service Providers. Identify any service 
providers that have been terminated for a material failure to meet 
the terms of a service arrangement or failure to comply with Title I 
of ERISA, including the failure to provide required disclosures 
under 29 CFR 2550.408b-2. If the reason for termination was the 
failure to provide required disclosures under 29 CFR 2550.408b-2, in 
addition to providing an explanation in (6), check the box in 
element (7).
    Line 14s. See 29 CFR 2520.102-2 and 2520.102-3 for style, 
format, and content requirements for summary plan descriptions. For 
distribution requirements see 29 CFR 2520.104b.
    Line 14t. Defined contribution pension plans must complete Line 
14t. For purposes of Line 14t, an uncashed check is one that is no 
longer negotiable or is subject to limited payability. Check 
``Yes,'' if there were any uncashed checks as of the end of the plan 
year. If ``Yes,'' indicate the number of checks that were uncashed 
at the end of the plan year and the total value of the checks. 
Briefly describe the procedures followed by the plan to verify a 
participant's or beneficiary's address before a check was mailed. 
Plans must ensure that they use measures reasonably calculated to 
ensure actual receipt of materials by plan participants and 
beneficiaries, which would include procedures to keep track of 
participants' and beneficiaries' current mailing addresses so that 
information is less likely to be mailed to a bad address. See CFR 
2520.104b-1(b). Also, briefly describe the procedures followed by 
the plan to address the uncashed checks, including steps to locate 
``lost participants.''
    Plans should have procedures to keep track of uncashed checks. 
The procedures for ongoing plans should include procedures for 
locating ``missing'' participants. Plans may use the steps described 
in FAB 2014-01 to search for missing participants or beneficiaries, 
which may be helpful in particular where a check was returned as 
``undeliverable.'' The procedures should also include a method by 
which plan fiduciaries keep track or are made aware of the number of 
uncashed checks and the amount involved. Such procedures could 
include contractually requiring any third party administrators to 
keep the plan administrator regularly informed of uncashed checks. 
For missing participant and beneficiary searches and distributions 
from terminating defined contribution pension plans, see 29 CFR 
2550.404a-3; DOL Field Assistance Bulletin 2014-01 (Aug. 14, 2014).

Part VI--Pension Funding Compliance

    Complete Part VI only if the plan is subject to the minimum 
funding requirements of Code section 412 or ERISA section 302.
    All qualified defined benefit and defined contribution pension 
plans are subject to the minimum funding requirements of Code 
section 412 unless they are described in the exceptions listed under 
Code section 412(e)(2). These exceptions include profit-sharing or 
stock bonus plans, insurance contract plans described in Code 
section 412(e)(3), and certain plans to which no employer 
contributions are made.
    Nonqualified employee pension benefit plans are subject to the 
minimum funding requirements of ERISA section 302 unless 
specifically exempted under ERISA sections 4(a) or 301(a).
    The employer or plan administrator of a single-employer or 
multiple-employer defined benefit pension plan that is subject to 
the minimum funding requirements must file the Schedule SB (Form 
5500) as an attachment to the Form 5500-SF. The employer or plan 
administrator of a money purchase plan that is currently amortizing 
a waiver of the minimum funding requirements must complete Lines 3, 
9, and 10 of the Schedule MB (Form 5500) and file it as an 
attachment to the Form 5500-SF.
    Line 15. If ``Yes'' is checked, attach a completed and signed 
Schedule SB (Form 5500), and complete Line 15a. See the instructions 
for the Schedule SB in the Instructions for Form 5500. If this is a 
defined contribution pension plan, leave blank.
    Line 15a. Enter the amount from Line 40 of Schedule SB (Form 
5500).

[[Page 47679]]

    Line 16. Check the ``Yes'' box if the plan is a defined 
contribution pension plan subject to the minimum funding 
requirements of Code section 412 and ERISA section 302. Those money 
purchase plans (including target benefit plans) that are amortizing 
a waiver of the minimum funding standard for a prior year should 
fill out Line 16a and then skip to Line 17. Those defined 
contribution pension plans answering ``Yes'' to the Line 15 question 
that do not fill out Line 16a should fill out Lines 16b-16e.
    Line 16a. If a money purchase defined contribution pension plan 
(including a target benefit plan) has received a waiver of the 
minimum funding standard, and the waiver is currently being 
amortized, complete Lines 3, 9, and 10 of Schedule MB (Form 5500). 
See instructions for Schedule MB in the Instructions for Form 5500 
Annual Return/Report. The Schedule MB for a money purchase defined 
contribution pension plan does not need to be signed by an enrolled 
actuary.
    Line 16b. The minimum required contribution for a money purchase 
defined contribution pension plan (including a target benefit plan) 
for a plan year is the amount required to be contributed for the 
year under the formula set forth in the plan document. If there is 
an accumulated funding deficiency for a prior year that has not been 
waived, that amount should also be included as part of the 
contribution required for the current year.
    Line 16c. Include all contributions for the plan year made not 
later than 8\1/2\ months after the end of the plan year. Show only 
contributions actually made to the plan by the date the form is 
filed. For example, do not include receivable contributions for this 
purpose
    Line 16d. If the minimum required contribution exceeds the 
contributions for the plan year made not later than 8\1/2\ months 
after the end of the plan year, the excess is an accumulated funding 
deficiency for the plan year. File IRS Form 5330, Return of Excise 
Taxes Related to Employee Benefit Plans, with the IRS to pay the 
excise tax on the deficiency. There is a penalty for not filing Form 
5330 on time.
    Line 16e. Check ``Yes'' if the minimum required contribution 
remaining in Line 15d will be made not later than 8\1/2\ months 
after the end of the plan year. If ``Yes,'' and contributions are 
actually made by this date, then there will be no reportable 
deficiency and IRS Form 5330 will not need to be filed.

Part VII--Plan Terminations and Transfers of Assets

    Line 17a. Check ``Yes'' if a resolution to terminate the plan 
was adopted during this or any prior plan year, unless the 
termination was revoked and no assets reverted to the employer. If 
``Yes'' is checked, enter in Line 17a(1) the effective date of plan 
termination, enter in Line 18a(2) the plan year in which assets were 
distributed to participants and beneficiaries (including insurance/
annuity contracts) and enter in Line 17a(3) the amount of plan 
assets that reverted to the employer during the plan year in 
connection with the implementation of such termination. Enter ``0'' 
if no reversion occurred during the current plan year.
    Line 17b. Transfer to other plans. If the plan transferred 
assets or liabilities to another plan since the date of the most 
recent filing, report the EIN and PN of the plan to which the assets 
and liabilities were transferred (i.e., the ``transferee plan''). In 
addition, report the date of the transfer and check the box that 
best describes the type of transfer (see Definitions below). Do not 
use a social security number in lieu of an EIN or include an 
attachment that contains visible social security numbers. The Form 
5500-SF is open to public inspection, and the contents are public 
information and are subject to publication on the Internet. Because 
of privacy concerns, the inclusion of a social security number or 
any portion thereof on this Schedule H or the inclusion of a visible 
social security number or any portion thereof on an attachment may 
result in the rejection of the filing.
    Note. A distribution of all or part of an individual 
participant's account balance that is reportable on Form 1099-R 
should not be included on Line 17b. Do not submit Form 1099-R with 
the Form 5500 Annual Return/Report.
    IRS Form 5310-A, Notice of Plan Merger or Consolidation, 
Spinoff, or Transfer of Plan Assets or Liabilities; Notice of 
Qualified Separate Lines of Business, may be required to be filed at 
least 30 days before any plan merger or consolidation or any 
transfer of plan assets or liabilities to another plan. There is a 
penalty for not filing IRS Form 5310-A on time. In addition, a 
transfer of benefit liabilities involving a plan covered by PBGC 
insurance may be reportable to the PBGC. See PBGC Form 10, Post-
Event Notice of Reportable Events, and PBGC Form 10-Advance, Advance 
Notice of Reportable Events.
    Line 17c. Transfer from other plans. If another plan transferred 
assets or liabilities to this plan since the date of the most recent 
filing, report the EIN and PN of sponsor of the plan from which the 
assets and liabilities were transferred (i.e., the ``transferor 
plan''), the date of the transfer, and the box that best describes 
tot type of transfer.
    ``Consolidation'' means a transaction in which two or more plans 
transfer all of their assets and liabilities to a new plan and, as a 
result, cease to exist (because the transferor plans become part of 
the new transferee plan). It differs from a Merger because in a 
Merger, the transferee plan existed before the transaction. In a 
consolidation, the transferee plan is a new plan that is created in 
the Consolidation. Thus, the plan that exists after the 
Consolidation follows the PBGC premium filing rules for new plans.
    ``Merger'' means a transaction I which one or more plans 
transfer all of their assets and liabilities to an existing plan 
and, as a result, cease to exist (because the transferor plan(s) 
become part of the transferee plan). It differs from a Consolidation 
because in a Consolidation, the transferee plan did not exist before 
the transaction. In a Merger, the transferee plan is an existing 
plan and follows the rules for a preexisting, ongoing plan.
    ``Spinoff'' means a transaction in which the transferor plan 
transfers only part of its assets and/or liabilities to the 
transferee plan. The transferee plan may be a new plan that is 
created in the Spinoff, or it may be a preexisting plan that simply 
receives part of the assets or liabilities of the transferor plan.
    Note: If Final Return/Report is checked on the Form 5500 or Form 
5500-SF, information should be entered an at least one of Lines 17a, 
17b, or 17c. Participant-directed transfers do not need to be 
reported on Line 17c. If you reported transfers of assets and 
liabilities to this plan on Line 10k, information should be entered 
in Line 17d.
    Line 17d. Defined Contribution Pension Plan--Transfers to 
financial institution. If the filer is a defined contribution 
pension plan, indicate whether, as part of the procedures for 
terminating the plan, transferred plan assets to a financial 
institution(s), establishing interest bearing federally insured bank 
accounts in the name of missing participants in connection with 
terminating the plan. If ``Yes,'' complete elements (1)-(5). List 
each financial institution where plan assets were transferred and 
continue reporting until the plan terminates and the final return/
report is filed. For more information on making provisions for lost 
or missing participants, see DOL Field Assistance Bulletin 2014-01.

Part VIII--Trust Information

    Line 18a. Enter the ``Name of trust.'' If a plan uses more than 
one trust or custodial account for its fund, you should enter the 
primary trust or custodial account in which the greatest dollar 
amount or largest percentage of the plan assets as of the end of the 
plan year is held on this line. For example, if a plan uses three 
different trusts, X, Y, Z, with the percentages of plan assets, 35%, 
45%, and 20%, respectively, trust Y that held the 45% of plan assets 
would be entered in Line 18a.
    Line 18b. Enter the ``Trust's Employer Identification Number 
(EIN)'' assigned to the employee benefit trust or custodial account, 
if one has been issued to you. The trust EIN should be used for 
transactions conducted for the trust. If you do not have a trust 
EIN, enter the EIN you would use on Form 1099-R, Distributions From 
Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, 
Insurance Contracts, etc., to report distributions from employee 
benefit plans and on Form 945, Annual Return of Withheld Federal 
Income Tax, to report withheld amounts of income tax from those 
payments.
    Do not use a social security number in lieu of an EIN. Form 5500 
and its attachments are open to public inspection, and the contents 
are public information and are subject to publication on the 
Internet. Because of privacy concerns, the inclusion of a social 
security number or any portion thereof may result in the rejection 
of the filing.
    Trust EINs can be obtained from the IRS by applying for one on 
Form SS-4, Application for Employer Identification Number. See 
Instructions to Line 2b (Form 5500) for applying for an EIN. Also 
see IRS EIN application link page for further information.
    Line 18c. Enter the name of the plan trustee or custodian.
    Line 18d. Enter the telephone number for the plan trustee or 
custodian.

[[Page 47680]]

Part IX--IRS Compliance Questions [New]

    Note. If you are required to file an annual return of employee 
benefit plans under Code section 6058, you must complete this part 
from Lines 18 through 24, unless you are required to file fewer than 
250 returns of any type with the IRS, including information returns 
(for example, Forms W-2 and Forms 1099), income tax returns, 
employment tax returns, and excise tax returns during the calendar 
year, then you can alternatively file Form 5500-SUP with the IRS on 
paper. See the Treasury regulations on ``Employee Retirement Benefit 
Plan Returns Required on Magnetic Media'' (See T.D. 9695, 79 FR 
58256 at http://federalregister.gov/a/2014-23161) and Instructions 
for Form 5500-SUP for more information.
    Line 19a. Check ``Yes'' if the plan includes a cash or deferred 
arrangement (CODA), under which a covered employee may elect to have 
the employer either contribute an amount to the plan's trust on 
behalf of the employee or to pay the employee directly in cash or 
some other taxable benefit. The contributions go into an individual 
account, with the employee often choosing the investments based on 
options provided under the plan. In some plans, the employer also 
makes contributions, such as contributions that match the employee's 
contributions up to a certain percentage.
    Line 19b.
    If Line 19a is ``Yes,'' check the applicable method used to 
satisfy the nondiscrimination requirements of Code section 401(k). A 
safe harbor 401(k) plan is similar to a traditional 401(k) plan but, 
among other things, it must provide for employer contributions. 
These contributions may be employer matching contributions, limited 
to employees who defer, or employer contributions made on behalf of 
all eligible employees, regardless of whether they make elective 
deferrals. The safe harbor 401(k) plan is not subject to the complex 
annual nondiscrimination tests that apply to traditional 401(k) 
plans. Check ``Design-based safe harbor method'' if this is a safe 
harbor 401(k) plan that is a SIMPLE 401(k) plan under Code section 
401(k)(11), a safe harbor 401(k) plan under Code section 401(k)(12), 
or a qualified automatic contribution arrangement under Code section 
401(k)(13).
    If the plan, by its terms, does not satisfy the safe harbor 
method, it generally must satisfy the regular nondiscrimination 
test, known as the actual deferral percentage (ADP) test. Check the 
appropriate box to indicate if the plan uses the ``current year'' 
ADP test or the ``prior year'' ADP test. Check ``current year'' ADP 
test if the plan uses the current year testing method under which 
the ADP test is performed by comparing the current plan year's ADP 
for HCEs with the current plan year's (rather than the prior plan 
year's) ADP for NHCEs. Check all boxes that apply for a plan that 
tests different groups of employees on a disaggregated basis. Check 
``N/A'' if the plan is not required to test for nondiscrimination 
under Code section 401(k)(3), such as a plan in which no HCE is 
benefitting.
    Line 20a. Check the applicable testing method used to satisfy 
the minimum coverage requirements under Code section 410(b). Check 
``N/A'' if the plan is deemed to satisfy section 410(b) 
automatically, such as a plan in which no HCE is benefitting. Check 
all boxes that apply for a plan that tests different groups of 
employees on a disaggregated basis.
    Line 20b. Check ``Yes'' if this plan was permissively aggregated 
with another plan to satisfy requirements under Code sections 410(b) 
and 401(a)(4). Generally, each single plan must separately satisfy 
the coverage and nondiscrimination requirements. However, an 
employer may designate two or more separate plans as a single plan 
for purposes of applying the ratio percentage test of Treasury 
Regulations section 1.410(b)-2(b)(2) or the nondiscretionary 
classification test of Treasury Regulations section 1.401(b)-4. Two 
or more plans that are permissively aggregated and treated as a 
single plan for purposes of the minimum coverage test of Code 
section 410(b) must also be treated as a single plan for purpose of 
the nondiscrimination test under Code section 401(a)(4). See 
Treasury Regulations sections 1.410(b)-7 and 1.401(a)(4)-(9) for 
more information.
    Line 21. Check ``Yes'' if the plan does not satisfy any 
exceptions under Treasury Regulation section 1.401(a)26)-1(b) if it 
benefitted at least the lesser of: 50 employees of the employer, or 
the greater of: 40 percent of all employees of the employer, or 2 
employees (or if there is only 1 employee, such employer). The 
definition of employer includes all related employers under Code 
sections 414(b), (c) or (m). In performing the participation tests, 
the employees who are excludable are generally the same as those who 
are excludable for purposes of performing coverage tests under Code 
section 410(b), see Treasury Regulation section 1.401(a)(26)-6. In 
addition, for most plans the definition of who is benefiting under 
the plan for the purposes of the participation tests is the same as 
the definition of benefiting employees for purposes of coverage 
tests under Code section 410(b), see Treasury Regulation section 
1.401(a)(26)-5.
    Line 22a. If a plan sponsor or an employer adopted a pre-
approved plan that includes a master & prototype plan (a 
standardized or nonstandardized M&P) or a volume submitter plan, 
enter the date of the most recent favorable opinion or advisory 
letter issued by the IRS and the serial number listed on that 
favorable letter.
    Line 22b. If it is an individually-designed plan and received a 
favorable determination letter from the IRS, enter the date of the 
most recent determination letter. Leave it blank if this 
individually-designed plan has never received a favorable 
determination letter.
    Line 23a. A section 401(k) plan may (in accordance with the plan 
document) allow participants to receive hardship distributions under 
Code section 401(k)(2)(B)(i)(IV). A distribution from a 
participant's elective deferral account can only be made if the 
distribution is because of an immediate and heavy financial need, 
and the amount should be limited to what is necessary to satisfy 
that financial need. Hardship withdrawals are subject to income 
taxes and a 10% additional tax on distributions before age 59\1/
2\''. Employees who take a hardship distribution cannot repay it to 
the plan.
    Line 23b. This is for a defined benefit plan or a money purchase 
pension plan only. Check ``Yes'' if the plan made any distributions 
during the plan year to employees who have attained age 62 and who 
were not separated from service when the distributions were made, as 
permitted under Code section 401(a)(36).
    Note. Any distribution above made prior to age 59\1/2\ would be 
subject to an additional 10% tax under Code section 72(t).
    Line 24. Check ``Yes'' if required minimum distributions were 
made to 5% owners who attained age 70\1/2\ and older. Required 
Minimum Distributions (RMDs) generally are minimum amounts that a 
retirement plan account owner must withdraw annually starting with 
the year that he or she reaches 70\1/2\ years of age or, if later, 
the year in which he or she retires. However, if the account owner 
is a 5% owner of the business sponsoring the retirement plan, the 
RMDs must begin once the account holder is age 70\1/2\, regardless 
of whether he or she is retired.
    Line 25. Check ``Yes'' if the plan has ceased employer and/or 
employee contributions and prohibited entry by new participants.

ERISA Compliance Quick Checklist

    Compliance with the Employee Retirement Income Security Act 
(ERISA) begins with knowing the rules. Plan administrators and other 
plan officials can use this checklist as a quick diagnostic tool for 
assessing a plan's compliance with certain important ERISA rules; it 
is not a complete description of all ERISA's rules and it is not a 
substitute for a comprehensive compliance review. Use of this 
checklist is voluntary, and it is not be filed with your Form 5500-
SF.
    If you answer ``No'' to any of the questions below, you should 
review your plan's operations because you may not be in full 
compliance with ERISA's requirements.
    1. Have you provided plan participants with a summary plan 
description, summaries of any material modifications of the plan, 
and annual summary financial reports or annual pension funding 
reports?
    2. Do you maintain copies of plan documents at the principal 
office of the plan administrator for examination by participants and 
beneficiaries?
    3. Do you respond to written participant inquires for copies of 
plan documents and information within 30 days?
    4. Does your plan include written procedures for making benefit 
claims and appealing denied claims, and are you complying with those 
procedures?
    5. Is your plan covered by fidelity bonds protecting the plan 
against losses due to fraud or dishonesty by persons who handle plan 
funds or other property?
    6. Are the plan's investments diversified so as to minimize the 
risk of large losses?
    7. I f the plan permits participants to select the investments 
in their plan accounts, has the plan provided them with enough 
information to make informed decisions?
    8. Has a plan official determined that the investments are 
prudent and solely in the interest of the plan's participants and 
beneficiaries, and evaluated the risks

[[Page 47681]]

associated with plan investments before making the investments?
    9. Did the employer or other plan sponsor send participant 
contributions to the plan on a timely basis?
    10. Did the plan pay participant benefits on time and in the 
correct amounts?
    11. Did the plan give participants and beneficiaries 30 days 
advance notice before imposing a ``blackout period'' of at least 
three consecutive business days during which participants or 
beneficiaries of a 401(k) or other individual account pension plan 
were unable to change their plan investments, obtain loans from the 
plan, or obtain distributions from the plan?
    If you answer ``Yes'' to any of the questions below, you should 
review your plan's operations because you may not be in full 
compliance with ERISA's requirements.
    1. Has the plan engaged in any financial transactions with 
persons related to the plan or any plan official? (For example, has 
the plan made a loan to or participated in an investment with the 
employer?)
    2. Has the plan official used the assets of the plan for his/her 
own interest?
    3. Have plan assets been used to pay expenses that were not 
authorized in the plan document, were not necessary to the proper 
administration of the plan, or were more than reasonable in amount?
    If you need help answering these questions or want additional 
guidance about ERISA requirements, a plan official should contact 
the U.S. Department of Labor Employee Benefits Security 
Administration office in your region or consult with the plan's 
legal counsel or professional employee benefit advisor.

Statutory Authority

    Accordingly, pursuant to the authority in sections 101, 103, 
104, 109, 110 and 4065 of ERISA and sections 6058 and 6059 of the 
Code, the Form 5500 Annual Return/Report and the instructions 
thereto are proposed to be amended as set forth herein.

    Signed at Washington, DC, this 20th day of June 2016.
Phyllis C. Borzi,
Assistant Secretary, Employee Benefits Security Administration, U.S. 
Department of Labor.

Signed at Washington, DC, this 20th day of June 2016.

Robert S. Choi, Director,
Employee Plans, Tax Exempt and Government Entities Division, Internal 
Revenue Service.
    Signed at Washington, DC, this 20th day of June 2016.
W. Thomas Reeder,
Director, Pension Benefit Guaranty Corporation.
[FR Doc. 2016-14893 Filed 7-11-16; 4:15 pm]
 BILLING CODE 4510-29-P