2009 Forms and Schedules

2009 Form_5500_and_Schedules.pdf

Annual Information Return/Report

2009 Forms and Schedules

OMB: 1210-0110

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1210-0110 can be found here:
2024-04-02 - No material or nonsubstantive change to a currently approved collection
2023-12-18 - No material or nonsubstantive change to a currently approved collection
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Form 5500
Department of the Treasury
Internal Revenue Service

Annual Return/Report of Employee Benefit Plan
This form is required to be filed for employee benefit plans under sections 104
and 4065 of the Employee Retirement Income Security Act of 1974 (ERISA) and
sections 6047(e), 6057(b), and 6058(a) of the Internal Revenue Code (the Code).

Department of Labor
Employee Benefits Security
Administration

This Form is Open to Public
Inspection

Annual Report Identification Information

For calendar plan year 2009 or fiscal plan year beginning

A

B

2009

 Complete all entries in accordance with
the instructions to the Form 5500.

Pension Benefit Guaranty Corporation

Part I

OMB Nos. 1210-0110
1210-0089

This return/report is for:

This return/report is:

X
X

a multiemployer plan;

X
X

the first return/report;

,

a single-employer plan;

an amended return/report;

and ending

X
X

a multiple-employer plan; or

X
X

the final return/report;

a DFE (specify)

,

_C_

a short plan year return/report (less than 12 months).

C

If the plan is a collectively-bargained plan, check here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

D

Check box if filing under:

X
X

Form 5558;

X

X

automatic extension;

special extension (enter description) ABCDEFGHI

X the DFVC program;
ABCDEFGHI ABCDEFGHI ABCDE

Part II
Basic Plan Information—enter all requested information
1a Name of plan
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

1b
1c

Three-digit plan
001
number (PN) 
Effective date of plan

YYYY-MM-DD
2a

2b

Plan sponsor’s name and address (employer, if for a single-employer plan)
(Address should include room or suite no.)

Employer Identification
Number (EIN)

012345678
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
D/B/A ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
123456789 ABCDEFGHI ABCDEFGHI ABCDE
123456789 ABCDEFGHI ABCDEFGHI ABCDE
CITYEFGHI ABCDEFGHI AB, ST 012345678901
UK

2c

Sponsor’s telephone
number

0123456789
2d

Business code (see
instructions)

012345

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

SIGN
HERE

SIGN
HERE

YYYY-MM-DD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Signature of plan administrator

Date

Enter name of individual signing as plan administrator

YYYY-MM-DD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Signature of employer/plan sponsor

Date

Enter name of individual signing as employer or plan sponsor

YYYY-MM-DD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Signature of DFE
Date
Enter name of individual signing as DFE
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500.

Form 5500 (2009)
v.052407

Page 2

Form 5500 (2009)

3a Plan administrator’s name and address (if same as plan sponsor, enter “Same”)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
123456789 ABCDEFGHI ABCDEFGHI ABCDE
123456789 ABCDEFGHI ABCDEFGHI ABCDE
CITYEFGHI ABCDEFGHI AB, ST 012345678901
UK
4
a

3b

Administrator’s EIN

3c

Administrator’s telephone
number

012345678
0123456789

If the name and/or EIN of the plan sponsor has changed since the last return/report filed for this plan, enter the name, EIN and
the plan number from the last return/report:

4b

Sponsor’s name

4c

012345678

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
5
6

Total number of participants at the beginning of the plan year

EIN
PN

5

012
123456789012

Number of participants as of the end of the plan year (welfare plans complete only lines 6a, 6b, 6c, and 6d).

a

Active participants.....................................................................................................................................................................

6a

123456789012

b

Retired or separated participants receiving benefits.................................................................................................................

6b

123456789012

c

Other retired or separated participants entitled to future benefits.............................................................................................

6c

123456789012

d

Subtotal. Add lines 6a, 6b, and 6c...........................................................................................................................................

6d

123456789012

e

Deceased participants whose beneficiaries are receiving or are entitled to receive benefits...................................................

6e

123456789012

f

Total. Add lines 6d and 6e.......................................................................................................................................................

6f

123456789012

g

Number of participants with account balances as of the end of the plan year (only defined contribution plans
complete this item)....................................................................................................................................................................

6g

123456789012

Number of participants that terminated employment during the plan year with accrued benefits that were
less than 100% vested..............................................................................................................................................................
Enter the total number of employers obligated to contribute to the plan (only multiemployer plans complete this item) .........

6h
7

123456789012

h
7
8a

If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristic Codes in the instructions:

1x
b

1x

(3)
(4)

a

1x

1x

1x

1xx

1xx

1x

1x

1x

1x

1x

1x

1x

1xx

Plan funding arrangement (check all that apply)
(1)
X Insurance
(2)

10

1x

1xx

If the plan provides welfare benefits, enter the applicable welfare feature codes from the List of Plan Characteristic Codes in the instructions:

1x
9a

1x

X
X
X

1xx
9b

Plan benefit arrangement (check all that apply)
(1)
X Insurance

Code section 412(i) insurance contracts

(2)

Trust

(3)

General assets of the sponsor

(4)

X
X
X

Code section 412(i) insurance contracts
Trust
General assets of the sponsor

Check all applicable boxes in 10a and 10b to indicate which schedules are attached, and, where indicated, enter the number attached. (See instructions)
Pension Schedules
X R (Retirement Plan Information)
(1)
(2)

(3)

X

X

b

General Schedules
(1)
X
H (Financial Information)

MB (Multiemployer Defined Benefit Plan and Certain Money
Purchase Plan Actuarial Information) - signed by the plan
actuary

(2)

SB (Single-Employer Defined Benefit Plan Actuarial
Information) - signed by the plan actuary

(5)

(3)
(4)
(6)

X
X
X
X
X

I (Financial Information – Small Plan)
___ A (Insurance Information)
C (Service Provider Information)
D (DFE/Participating Plan Information)
G (Financial Transaction Schedules)

SCHEDULE A

Insurance Information

OMB No. 1210-0110

(Form 5500)
Department of the Treasury
Internal Revenue Service

This schedule is required to be filed under section 104 of the
Employee Retirement Income Security Act of 1974 (ERISA).

Department of Labor
Employee Benefits Security Administration

 File as an attachment to Form 5500.

Pension Benefit Guaranty Corporation

 Insurance companies are required to provide the information

2009
This Form is Open to Public
Inspection
,

pursuant to ERISA section 103(a)(2).
For calendar plan year 2009 or fiscal plan year beginning

,

and ending

A Name of plan
B Three-digit
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
001
plan number (PN)

FGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI
D Employer Identification Number (EIN)
C Plan sponsor’s name as shown on line 2a of Form 5500.
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
012345678
FGHI ABCDEFGHI
Information Concerning Insurance Contract Coverage, Fees, and Commissions Provide information for each contract
Part I
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 Information:

(a) Name of insurance carrier

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
(b) EIN

012345678
2

(c) NAIC
code

ABCDE

(e) Approximate number of
persons covered at end of
policy or contract year

(d) Contract or
identification number

ABCDE0123456789

1234567

Policy or contract year
(f) From

(g) To

YYYY-MM-DD

YYYY-MM-DD

Insurance fee and commission information. Enter the total fees and total commissions paid. List in item 3 the agents, brokers, and other persons in
descending order of the amount paid.
(a) Total amount of commissions paid

(b) Total amount of fees paid

123456789012345
3

123456789012345

Persons receiving commissions and fees. (Complete as many entries as needed to report all persons).
(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

ABCDEFGHI
123456789
123456789
CITY56789

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
AB, ST 021345678901
Fees and other commissions paid

(b) Amount of sales and base
commissions paid

(c) Amount

-123456789012345

-123456789012345

(e) Organization code

(d) Purpose

ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

1

(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

ABCDEFGHI
123456789
123456789
CITY56789

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
AB, ST 021345678901
Fees and other commissions paid

(b) Amount of sales and base
commissions paid

(c) Amount

-123456789012345

-123456789012345

(e) Organization code

(d) Purpose

ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500.

1

Schedule A (Form 5500) 2009
v.042407

Page 2

Schedule A (Form 5500) 2009

-X

(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

ABCDEFGHI
123456789
123456789
CITY56789

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
AB, ST 021345678901
Fees and other commissions paid

(b) Amount of sales and base
commissions paid

(c) Amount

-123456789012345

-123456789012345

(d) Purpose

ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

(e) Organization
code

1

(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

ABCDEFGHI
123456789
123456789
CITY56789

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
AB, ST 021345678901
Fees and other commissions paid

(b) Amount of sales and base
commissions paid

(c) Amount

-123456789012345

-123456789012345

(d) Purpose

ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

(e) Organization
code

1

(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

ABCDEFGHI
123456789
123456789
CITY56789

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
AB, ST 021345678901
Fees and other commissions paid

(b) Amount of sales and base
commissions paid

(c) Amount

-123456789012345

-123456789012345

(d) Purpose

ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

(e) Organization
code

1

(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

ABCDEFGHI
123456789
123456789
CITY56789

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
AB, ST 021345678901
Fees and other commissions paid

(b) Amount of sales and base
commissions paid

(c) Amount

-123456789012345

-123456789012345

(d) Purpose

ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

(e) Organization
code

1

(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

ABCDEFGHI
123456789
123456789
CITY56789

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
AB, ST 021345678901
Fees and other commissions paid

(b) Amount of sales and base
commissions paid

(c) Amount

-123456789012345

-123456789012345

(d) Purpose

ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

(e) Organization
code

1

Page 3

Schedule A (Form 5500) 2009

Investment and Annuity Contract Information

Part II
4
5
6

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.
-123456789012345
Current value of plan’s interest under this contract in the general account at year end ....................................................
4
Current value of plan’s interest under this contract in separate accounts at year end ......................................................

-123456789012345

6b
6c

-123456789012345
-123456789012345

6d

-123456789012345

Contracts With Allocated Funds:
a State the basis of premium rates 

b
c
d

e

Premiums paid to carrier ...........................................................................................................................................
Premiums due but unpaid at the end of the year ......................................................................................................
If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or
retention of the contract or policy, enter amount.......................................................................................................
Specify nature of costs 
Type of contract: (1)
(3)

f
7

5

X

X

other (specify)

individual policies

(2)

X

group deferred annuity



If contract purchased, in whole or in part, to distribute benefits from a terminating plan check here

 X

Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts)

a

Type of contract:

(1)
(3)

b
c

X
X

deposit administration

(2)

guaranteed investment

(4)

X
X

immediate participation guarantee
other 

7b
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345

-123456789012345

7c(6)
7d

-123456789012345
-123456789012345

Balance at the end of the previous year ...................................................................................................................
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 below)..................................................................................

7c(1)
7c(2)
7c(3)
7c(4)
7c(5)



d
e

(6)Total additions ......................................................................................................................................................
Total of balance and additions (add b and c(6)). .......................................................................................................
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 below)...................................................................................

7e(1)
7e(2)
7e(3)
7e(4)

-123456789012345
-123456789012345
-123456789012345
-123456789012345



f

(5) Total deductions ...................................................................................................................................................
Balance at the end of the current year (subtract e(5) from d) ...................................................................................

7e(5)
7f

-123456789012345
-123456789012345

Page 4

Schedule A (Form 5500) 2009

Part III

8

Welfare Benefit Contract Information
If more than one contract covers the same group of employees of the same employer(s) or members of the same employee 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.

Benefit and contract type (check all applicable boxes)

a X
e X
i X

Health (other than dental or vision)

mX

Other (specify)

Temporary disability (accident and sickness)
Stop loss (large deductible)

bX
f X
j X

cX
gX
kX

Dental
Long-term disability
HMO contract

Vision
Supplemental unemployment
PPO contract

dX
hX
lX

Life insurance
Prescription drug
Indemnity contract

 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCKEFGHI ABCDEFGHI ABCDEFGHI ABCDE

9

Experience-rated contracts:

a

Premiums: (1) Amount received.....................................................................

9a(1)

-123456789012345

b

-123456789012345
(2) Increase (decrease) in amount due but unpaid ....................................... 9a(2)
-123456789012345
(3) Increase (decrease) in unearned premium reserve................................. 9a(3)
(4) Earned ((1) + (2) - (3)) ...................................................................................................................................... 9a(4)
-123456789012345
Benefit charges (1) Claims paid ................................................................... 9b(1)

c

-123456789012345
(2) Increase (decrease) in claim reserves..................................................... 9b(2)
(3) Incurred claims (add (1) and (2)) ...................................................................................................................... 9b(3)
(4) Claims charged................................................................................................................................................. 9b(4)
-123456789012345
Remainder of premium: (1) Retention charges (on an accrual basis) --123456789012345
(A) Commissions .................................................................................... 9c(1)(A)
-123456789012345
(B) Administrative service or other fees ................................................. 9c(1)(B)
9c(1)(C)
-123456789012345
(C) Other specific acquisition costs ........................................................
9c(1)(D)
-123456789012345
(D) Other expenses ................................................................................
9c(1)(E)
-123456789012345
(E) Taxes................................................................................................
9c(1)(F)
-123456789012345
(F) Charges for risks or other contingencies ..........................................
9c(1)(G)
-123456789012345
(G) Other retention charges ...................................................................
(H) Total retention ........................................................................................................................................... 9c(1)(H)

123456789012345
123456789012345

9c(2)
9d(1)
9d(2)
9d(3)
9e

-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345

Total premiums or subscription charges paid to carrier ........................................................................................

10a

-123456789012345

If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or
retention of the contract or policy, other than reported in Part I, item 2 above, report amount. ............................
Specify nature of costs 

10b

-123456789012345

(2) Dividends or retroactive rate refunds. (These amounts were

10

-123456789012345

X

paid in cash, or

X

credited.) .....................

d

Status of policyholder reserves at end of year: (1) Amount held to provide benefits after retirement...................

e

(2) Claim reserves .................................................................................................................................................
(3) Other reserves .................................................................................................................................................
Dividends or retroactive rate refunds due. (Do not include amount entered in c(2).) ..........................................

Nonexperience-rated contracts:

a
b

Provision of Information
Part IV
X Yes
X No
11 Did the insurance company fail to provide any information necessary to complete Schedule A? .............
12 If the answer to line 11 is “Yes,” specify the information not provided.  ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

SCHEDULE MB

OMB No. 1210-0110

Multiemployer Defined Benefit Plan and Certain
Money Purchase Plan Actuarial Information

(Form 5500)
Department of the Treasury
Internal Revenue Service

This schedule is required to be filed under section 104 of the Employee
Retirement Income Security Act of 1974 (ERISA) and section 6059 of the
Internal Revenue Code (the Code).

Department of Labor
Employee Benefits Security Administration

2009
This Form is Open to Public
Inspection

Pension Benefit Guaranty Corporation

 File as an attachment to Form 5500 or 5500-SF.
For calendar plan year 2009 or fiscal plan year beginning
,
and ending

,

Round off amounts to nearest dollar.
Caution: A penalty of $1,000 will be assessed for late filing of this report unless reasonable cause is established.
A Name of plan
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
C Plan sponsor’s name as shown on line 2a of Form 5500 or 5500-SF
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
E

Type of plan:

1a

(1)

Enter the valuation date:

b

X

Multiemployer Defined Benefit
Month _________

(2)

Day _________

X

B

Three-digit
plan number (PN)

D

012345678

Money Purchase (see instructions)
Year _________
1b(1)
1b(2)
1c(1)

(a) Unfunded liability for methods with bases............................................................................................

1c(2)(a)

(b) Accrued liability under entry age normal method.................................................................................

1c(2)(b)

(c) Normal cost under entry age normal method.......................................................................................

1c(2)(c)
1c(3)

-123456789012345
-123456789012345
-123456789012345
-123456789012345

1d(1)

-123456789012345

(a) Current liability .....................................................................................................................................

1d(2)(a)

(b) Expected increase in current liability due to benefits accruing during the plan year ...........................

1d(2)(b)

(c) Expected release from “RPA ‘94” current liability for the plan year .....................................................

1d(2)(c)

-123456789012345
-123456789012345
-123456789012345
-123456789012345

(3) Accrued liability under unit credit cost method ...........................................................................................

d

001

Employer Identification Number (EIN)

Assets
(1) Current value of assets ........................................................................................................................
(2) Actuarial value of assets for funding standard account........................................................................
(1) Accrued liability for plan using immediate gain methods .....................................................................
(2) Information for plans using spread gain methods:

c



Information on current liabilities of the plan:
(1) Amount excluded from current liability attributable to pre-participation service (see instructions).............
(2) “RPA ‘94” information :

(3) Expected plan disbursements for the plan year .........................................................................................
Statement by Enrolled Actuary

1d(3)

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.

SIGN
HERE
Signature of actuary

Date

Type or print name of actuary

Most recent enrollment number

Firm name

Telephone number (including area code)

Address of the firm
If the actuary has not fully reflected any regulation or ruling promulgated under the statute in completing this schedule, check the box and see
instructions
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500 or Form 5500-SF.

X

Schedule MB (Form 5500) 2009
v.042407

Page 2

Schedule MB (Form 5500) 2009

2 Operational information as of beginning of this plan year:
a Current value of the assets (see instructions) ............................................................................................................ 2a
(1) Number of participants
b “RPA ‘94” current liability/participant count breakdown:
12345678
(1) For retired participants and beneficiaries receiving payment ....................................
12345678
(2) For terminated vested participants ............................................................................
(3)

-123456789012345
(2) Current liability

-123456789012345
-123456789012345

For active participants:
(a) Non-vested benefits ............................................................................................

-123456789012345
-123456789012345
-123456789012345
-123456789012345

(b) Vested benefits ...................................................................................................
(c) Total active ..........................................................................................................
(4)

c

Total...........................................................................................................................

12345678

If the percentage resulting from dividing line 2a by line 2b(4), column (2), is less than 70%, enter such
percentage................................................................................................................................................................

2c

123.12%

3 Contributions made to the plan for the plan year by employer(s) and employees:
(a) Date
(MM-DD-YYYY)

(b) Amount paid by
employer

(c) Amount paid by
employee

(a) Date
(MM-DD-YYYY)

Totals ►

(b) Amount paid by
employer

(c) Amount paid by employee

3(b)

3(c)

4 Information on plan status:
a Enter code to indicate plan’s status (see instructions for attachment of supporting evidence of plan’s status). If
code is “N,” go to item 5..............................................................................................................................................

4a

b
c

Is the plan making the scheduled progress with any applicable funding improvement or rehabilitation plan? ................................................................ X Yes

X

No

d

If the plan is in critical status, were any adjustable benefits reduced? .............................................................................................................. X Yes

X

No

e

If line d is “Yes,” enter the reduction in liability resulting from the reduction in adjustable benefits, measured as
of the valuation date ...................................................................................................................................................

Funded percentage for monitoring plan’s status (line 1b(2) divided by line 1c(3)) ....................................................

4b

123.1%

4e

-123456789012345

5 Actuarial cost method used as the basis for this plan year’s funding standard account computations (check all that apply):
a X Attained age normal
b X Entry age normal
c X Accrued benefit (unit credit)
d X Aggregate
e X Frozen initial liability
f
X Individual level premium
g X Individual aggregate
h X Shortfall
i
X Reorganization
j
X Other (specify): ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
YYYY-MM-DD
k If box h is checked, enter period of use of shortfall method ....................................................................................... 5k
l Has a change been made in funding method for this plan year? ...................................................................................................................... X Yes X No
m If line l is “Yes,” was the change made pursuant to Revenue Procedure 2000-40?.......................................................................................... X
n

If line l is “Yes,” and line m is “No,” enter the date (MM-DD-YYYY) of the ruling letter (individual or class)
approving the change in funding method....................................................................................................................

5n

Pre-retirement
Rates specified in insurance or annuity contracts ....................................

c

Mortality table code for valuation purposes:

X

Yes

X

No

X

X

No

YYYY-MM-DD

6 Checklist of certain actuarial assumptions:
a Interest rate for “RPA ‘94” current liability...........................................................................................................................................
b

Yes

6a

123.12%

Post-retirement
N/A

X

Yes

X

No

X

N/A

(1) Males ....................................................................................... 6c(1)
(2) Females................................................................................... 6c(2)

d

Valuation liability interest rate ........................................................

6d

123.12%

123.12%

e

Expense loading ............................................................................

6e

123.12%

123.12%

f

Salary scale ...................................................................................

6f

123.12%

g

Estimated investment return on actuarial value of assets for year ending on the valuation date....................... 6g

-123.1%

h

Estimated investment return on current value of assets for year ending on the valuation date ......................... 6h

-123.1%

Page 3

Schedule MB (Form 5500) 2009

7 New amortization bases established in the current plan year:
(1) Type of base

A
A
A

(2) Initial balance

(3) Amortization Charge/Credit

-123456789012345
-123456789012345
-123456789012345

-123456789012345
-123456789012345
-123456789012345

8 Miscellaneous information:
a

If a waiver of a funding deficiency has been approved for this plan year, enter the date (MM-DD-YYYY) of the
ruling letter granting the approval ...............................................................................................................................

8a

b
c

Is the plan required to provide a Schedule of Active Participant Data? (See the instructions.) If “Yes,” attach schedule.

d

If line c is “Yes,” provide the following additional information:

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)(1) of the Code? .............................................................................................................................. .

(1) Was an extension granted automatic approval under section 431(d)(1) of the Code? ........................................

YYYY-MM-DD
X Yes X No
X

Yes

X

No

X

Yes

X

No

(2) If line (1) is “Yes,” enter the number of years by which the amortization period was extended ........................... 8d(2)
(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? ...........................................................................................................................
(4) If line (3) is “Yes,” enter number of years by which the amortization period was extended (not including the
8d(4)
number of years in line (2))...................................................................................................................................
(5) If line (3) is “Yes,” enter the date of the ruling letter approving the extension...................................................... 8d(5)
(6) If line (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?......................................................................................................

e

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) ...................................................................................................................................................

12
X

Yes

X

No

12
YYYY-MM-DD
X

Yes

X

No

8e

-123456789012345

9 Funding standard account statement for this plan year:
Charges to funding standard account:

a

Prior year funding deficiency, if any............................................................................................................................

9a

-123456789012345

b

Employer’s normal cost for plan year as of valuation date .........................................................................................

9b

-123456789012345

c

Amortization charges as of valuation date:
(1) All bases except funding waivers and certain bases for which the
amortization period has been extended.......................................................

d
e

Outstanding balance
9c(1)

-123456789012345

-123456789012345

(2) Funding waivers ...........................................................................................

9c(2)

-123456789012345

-123456789012345

(3) Certain bases for which the amortization period has been extended ..........

9c(3)

-123456789012345

-123456789012345

Interest as applicable on lines 9a, 9b, and 9c ............................................................................................................

9d

-123456789012345

Total charges. Add lines 9a through 9d......................................................................................................................

9e

-123456789012345

Credits to funding standard account:

f

Prior year credit balance, if any ..................................................................................................................................

9f

-123456789012345

g

Employer contributions. Total from column (b) of line 3 ............................................................................................

9g

-123456789012345

-123456789012345

-123456789012345

Outstanding balance

h

Amortization credits as of valuation date...........................................................

i

Interest as applicable to end of plan year on lines 9f, 9g, and 9h...............................................................................

j

Full funding limitation (FFL) and credits:

k
l

9h

9i

-123456789012345

(1)

ERISA FFL (accrued liability FFL) .............................................................

9j(1)

-123456789012345

(2)

“RPA ‘94” override (90% current liability FFL) ..........................................

9j(2)

-123456789012345

(3)

FFL credit............................................................................................................................................................

9j(3)

-123456789012345

(1)

Waived funding deficiency .................................................................................................................................. 9k(1)

-123456789012345

(2)

Other credits ....................................................................................................................................................... 9k(2)

-123456789012345

9l

-123456789012345

m Credit balance: If line 9l is greater than line 9e, enter the difference..........................................................................

9m

-123456789012345

n

9n

-123456789012345

Total credits. Add lines 9f through 9i, 9j(3), 9k(1), and 9k(2).....................................................................................

Funding deficiency: If line 9e is greater than 9l, enter the difference .........................................................................

Schedule MB (Form 5500) 2009

9o

Page 4

Current year’s accumulated reconciliation account:
(1)

Due to waived funding deficiency accumulated prior to the 2009 plan year...................................................

(2)

Due to amortization bases extended and amortized using the interest rate under section 6621(b) of the Code:

(3)

9o(1)

-123456789012345

(a) Reconciliation outstanding balance as of valuation date.......................................................................... 9o(2)(a)

-123456789012345

(b) Reconciliation amount (line 9c(3) balance minus line 9o(2)(a)) ............................................................... 9o(2)(b)

-123456789012345

Total as of valuation date................................................................................................................................

9o(3)

-123456789012345

10

-123456789012345
X Yes X No

10

Contribution necessary to avoid an accumulated funding deficiency. (See instructions.) ......................................

11

Has a change been made in the actuarial assumptions for the current plan year? If “Yes,” see instructions. ......................

SCHEDULE SB

OMB No. 1210-0110

Single-Employer Defined Benefit Plan
Actuarial Information

(Form 5500)
Department of the Treasury
Internal Revenue Service

2009

This schedule is required to be filed under section 104 of the Employee
Retirement Income Security Act of 1974 (ERISA) and section 6059 of the
Internal Revenue Code (the Code).

Department of Labor
Employee Benefits Security Administration

This Form is Open to Public
Inspection

Pension Benefit Guaranty Corporation

 File as an attachment to Form 5500 or 5500-SF.
For calendar plan year 2009 or fiscal plan year beginning
,
and ending

,

Round off amounts to nearest dollar.
Caution: A penalty of $1,000 will be assessed for late filing of this report unless reasonable cause is established.
A Name of plan
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
C Plan sponsor’s name as shown on line 2a of Form 5500 or 5500-SF
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
E

Type of plan: (1)

X

Single-employer (2)

X

Multiple-employer

F

Prior year plan size:

B

D

Three-digit
plan number (PN)

5
6

001

Employer Identification Number (EIN)

012345678
X

100 or fewer

X

101-500

Part I
Basic Information
1 Enter the valuation date:
Month _________ Day _________ Year _________
2 Assets:
a Market value.................................................................................................................................................... 2a
b Actuarial value................................................................................................................................................. 2b
3 Funding target/participant count breakdown
(1) Number of participants
12345678
a For retired participants and beneficiaries receiving payment ............ 3a
12345678
b For terminated vested participants .................................................... 3b
c For active participants:
(1) Non-vested benefits................................................................... 3c(1)
(2) Vested benefits.......................................................................... 3c(2)
(3) Total active ................................................................................ 3c(3)
12345678
d Total................................................................................................... 3d
4 If the plan is at-risk, check box X and complete items (a) and (b)
a
b



Funding target disregarding prescribed at-risk assumptions ..........................................................................

4a

Funding target reflecting at-risk assumptions, but disregarding transition rule for plans that have been
at-risk for fewer than five consecutive years ..................................................................................................

4b

Effective interest rate ..............................................................................................................................................
Target normal cost..................................................................................................................................................

5
6

X

More than 500

-123456789012345
-123456789012345
(2) Funding Target

-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
123.12%
-123456789012345

Statement by Enrolled Actuary
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.

SIGN
HERE
Signature of actuary

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
Type or print name of actuary

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
Firm name

123456789 ABCDEFGHI ABCDEFGHI ABCDE
123456789 ABCDEFGHI ABCDEFGHI ABCDE
UK

Date

YYYY-MM-DD
Most recent enrollment number

1234567
Telephone number (including area code)

1234567890

Address of the firm
If the actuary has not fully reflected any regulation or ruling promulgated under the statute in completing this schedule, check the box and see
X
instructions
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500 or 5500-SF.
Schedule SB (Form 5500) 2009
v.042407

Page 2

Schedule SB (Form 5500) 2009

Part II

Beginning of year carryover and prefunding balances
(a) Carryover balance

7
8
9
10
11

Balance at beginning of prior year after applicable adjustments (Item 13 from prior
year) ............................................................................................................................
Portion used to offset prior year’s funding requirement (Item 35 from prior year)
Amount remaining (Item 7 minus item 8).....................................................................
Interest on item 9 using prior year’s actual return of

-123456789012345

-123456789012345

-123456789012345
-123456789012345
-123456789012345

-123456789012345
-123456789012345
-123456789012345

-123456789012345
-123456789012345

-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345

Prior year’s excess contributions to be added to prefunding balance:

a
b
c
d
12
13

% .............................

(b) Prefunding balance

Excess contributions (Item 38 from prior year) ......................................................
Interest on (a) using prior year’s effective rate of

% ............................

Total available at beginning of current plan year to add to prefunding balance ...........
Portion of (c) to be added to prefunding balance...................................................

Voluntary reduction......................................................................................................
Balance at beginning of current year (item 9 + item 10 + item 11d – item 12) ............

Part III
Funding percentages
14 Funding target attainment percentage................................................................................................................................................................. 14
15 Adjusted funding target attainment percentage...................................................................................................................................... 15
16 Prior year’s funding percentage for purposes of determining whether carryover/prefunding balances may be used to reduce
16

123.12%
123.12%
123.12%
123.12%

current year’s funding requirement.........................................................................................................................................................

17

If the current value of the assets of the plan is less than 70 percent of the funding target, enter such percentage...............................

17

Part IV
Contributions and liquidity shortfalls
18 Contributions made to the plan for the plan year by employer(s) and employees:
(a) Date
(MM-DD-YYYY)

(b) Amount paid by
employer

(c) Amount paid by
employee

(a) Date
(MM-DD-YYYY)

(b) Amount paid by
employer

YYYY-MM-DD
YYYY-MM-DD
YYYY-MM-DD
YYYY-MM-DD
YYYY-MM-DD
YYYY-MM-DD

12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234

12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234

YYYY-MM-DD
YYYY-MM-DD
YYYY-MM-DD
YYYY-MM-DD
YYYY-MM-DD

12345678901234
12345678901234
12345678901234
12345678901234
12345678901234

Totals ►

19

18(b)

12345678901234512345678901234512345678901234512345678901234512345678901234518(c)

Discounted employer contributions – see instructions for small plan with a valuation date after the beginning of the year:

a Contributions allocated toward unpaid minimum required contribution from prior years........................................ 19a
b Contributions made to avoid restrictions adjusted to valuation date ...................................................................... 19b
c Contributions allocated toward minimum required contribution for current year adjusted to valuation date..................... 19c
20

(c) Amount paid by employee

-123456789012345
-123456789012345
-123456789012345

Quarterly contributions and liquidity shortfalls:

a

Did the plan have a “funding shortfall” for the prior year? ............................................................................................................................. X Yes

X

No

b

If 20a is “Yes,” were required quarterly installments for the current year made in a timely manner? ........................................................... X Yes

X

No

c

If 20a is “Yes,” see instructions and complete the following table as applicable:
(1) 1st

-123456789012345

Liquidity shortfall as of end of Quarter of this plan year
(2) 2nd
(3) 3rd

-123456789012345

-123456789012345

(4)

4th

-123456789012345

Page 3

Schedule SB (Form 5500) 2009

Part V Assumptions used to determine funding target and target normal cost
21 Discount rate:
2nd segment:
3rd segment:
1st segment:
a Segment rates:
123.12_%
123.12_%
123.12 %
b Applicable month (enter code) .......................................................................................................................... 21b
22 Weighted average retirement age .......................................................................................................................... 22
23 Mortality table (check box):
X Prescribed table(s)
X Substitute Table (see instructions)

X N/A, full yield curve used
1
12

Part VI Miscellaneous items
24 Has a change been made in the non-prescribed actuarial assumptions for the current plan year?

If “Yes,” see instructions regarding required
attachment. ........................................................................................................................................................................................................ X Yes

25
26
27

Has a method change been made for the current plan year? If “Yes,” see instructions regarding required attachment. ................................ X Yes
Is the plan required to provide a Schedule of Active Participants? If “Yes,” see instructions regarding required attachment.......................... X Yes
If the plan is eligible for (and is using) alternative funding rules, enter applicable code and see instructions
regarding attachment..............................................................................................................................................

27

Part VII Reconciliation of unpaid minimum required contributions for prior years
28 Unpaid minimum required contribution for all prior years .......................................................................................
29 Discounted employer contributions allocated toward unpaid minimum required contribution from prior years

28

(item 19a)................................................................................................................................................................

30

Remaining amount of unpaid minimum required contributions (item 28 minus item 29) ........................................

29
30

Part VIII Minimum required contribution for current year
31 Target normal cost (Item 6) .................................................................................................................................... 31
Outstanding Balance
32 Amortization charges:
-123456789012345
a Net shortfall amortization charge ................................................................................
-123456789012345
b Waiver amortization charge ........................................................................................
33

If a waiver has been approved for this plan year, enter the date of the ruling letter granting the approval
(Month _________ Day _________ Year _________ )_and the waived amount ...........................................

33

34

Total funding requirement before reflecting carryover/prefunding balances (item 31 + item 32a + item 32b –
item 33)...................................................................................................................................................................

34

Carryover balance

35
36
37

Balances used to offset funding requirement ........

38
39
40

Prefunding balance

X
X
X

No
No
No

-123456789012345
-123456789012345
-123456789012345
-123456789012345
Amount

-123456789012345
-123456789012345
-123456789012345
-123456789012345
Amount

-123456789012345

-123456789012345
36
Additional cash requirement (item 34 minus item 35).............................................................................................

-123456789012345
-123456789012345

Contributions allocated toward minimum required contribution for current year adjusted to valuation date
(Item 19c)................................................................................................................................................................

37

-123456789012345

Excess contributions for current year (excess, if any, of item 37 over item 36) .....................................................

38
39
40

-123456789012345
-123456789012345
-123456789012345

Unpaid minimum required contribution for current year (excess, if any, of item 36 over item 37)..........................
Unpaid minimum required contribution for all years ...............................................................................................

SCHEDULE C

OMB No. 1210-0110

Service Provider Information

(Form 5500)
Department of the Treasury
Internal Revenue Service

This schedule is required to be filed under section 104 of the Employee
Retirement Income Security Act of 1974 (ERISA).

Department of Labor
Employee Benefits Security Administration

 File as an attachment to Form 5500.

This Form is Open to Public
Inspection.

Pension Benefit Guaranty Corporation

For calendar plan year 2009 or fiscal plan year beginning

,

2009

and ending

,

A Name of plan
ABCDEFGHI

B

C Plan sponsor’s name as shown on line 2a of Form 5500
ABCDEFGHI

D Employer Identification Number (EIN)
012345678

Part I

Three-digit
plan number (PN)



001

Service Provider Information (see instructions)

You must complete this Part, in accordance with the instructions, to report the information required for each person who received, directly or indirectly, $5,000
or more in total 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. If a person received only eligible indirect compensation for which the plan received the required disclosures, you are required to
answer line 1 but are not required to include that person when completing the remainder of this Part.

1 Information on Persons Receiving Only Eligible Indirect Compensation
a Check "Yes" or "No" to indicate whether you are excluding a person from the remainder of this Part because they received only eligible
indirect compensation for which the plan received the required disclosures (see instructions for definitions and conditions).. . . . . . . . . . . . . . .

X Yes X No

b If you answered line 1a “Yes,” enter the name and EIN or address of each person providing the required disclosures for the service providers who
received only eligible indirect compensation. Complete as many entries as needed (see instructions).
(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

(b) Enter name and EIN or address of person who provided you disclosure on eligible indirect compensation

(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500

Schedule C (Form 5500) 2009
v.042407

Schedule C (Form 5500) 2009

Page 2-

X

(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

Page 3-

Schedule C (Form 5500) 2009

X

2. Information on Other Service Providers Receiving Direct or Indirect Compensation.

Except for those persons for whom you
answered “yes” to line 1a above, complete as many entries as needed to list each person receiving, directly or indirectly, $5,000 or more in total compensation
(i.e., money or anything else of value) in connection with services rendered to the plan or their position with the plan during the plan year. (See instructions).

(a) Enter name and EIN or address (see instructions)

(b)
Service
Code(s)

(c)

(e)

(d)

(f)

Did service provider
Relationship to
Enter direct
receive indirect
employer, employee compensation paid
organization, or
by the plan. If none, compensation? (sources
other than plan or plan
person known to be
enter -0-.
sponsor)
a party-in-interest

ABCDEFGHI
ABCDEFGHI
ABCD

123456789012
345

(h)

(g)

Did indirect compensation
include eligible indirect
compensation, for which the
plan received the required
disclosures?

Enter total indirect
Did the service
compensation received by provider give you a
service provider excluding formula instead of
eligible indirect
an amount or
compensation for which you estimated amount?
answered “Yes” to element
(f). If none, enter -0-.

123456789012345
Yes

X

No

X

Yes

X

No

Yes

X

X

No

X

(a) Enter name and EIN or address (see instructions)

(b)
Service
Code(s)

(c)

(e)

(d)

(f)

Relationship to
Enter direct
Did service provider
employer, employee compensation paid
receive indirect
organization, or
by the plan. If none, compensation? (sources
person known to be
enter -0-.
other than plan or plan
a party-in-interest
sponsor)

ABCDEFGHI
ABCDEFGHI
ABCD

123456789012
345

(h)

(g)

Did indirect compensation
include eligible indirect
compensation, for which the
plan received the required
disclosures?

Did the service
Enter total indirect
compensation received by provider give you a
service provider excluding formula instead of
an amount or
eligible indirect
compensation for which you estimated amount?
answered “Yes” to element
(f). If none, enter -0-.

123456789012345
Yes

X

No

X

Yes

X

No

Yes

X

X

No

X

(a) Enter name and EIN or address (see instructions)

(b)
Service
Code(s)

(c)

(e)

(d)

(f)

Did service provider
Relationship to
Enter direct
receive indirect
employer, employee compensation paid
organization, or
by the plan. If none, compensation? (sources
other than plan or plan
person known to be
enter -0-.
sponsor)
a party-in-interest

ABCDEFGHI
ABCDEFGHI
ABCD

123456789012
345

Yes

X

No

X

Yes

X

(h)

(g)

Did indirect compensation
include eligible indirect
compensation, for which the
plan received the required
disclosures?

No

X

Enter total indirect
Did the service
compensation received by provider give you a
service provider excluding formula instead of
eligible indirect
an amount or
compensation for which you estimated amount?
answered “Yes” to element
(f). If none, enter -0-.

Yes

X

No

X

Page 4-

Schedule C (Form 5500) 2009

X

(a) Enter name and EIN or address (see instructions)

(b)
Service
Code(s)

(c)

(e)

(d)

(f)

Relationship to
Enter direct
Did service provider
employer, employee compensation paid
receive indirect
organization, or
by the plan. If none, compensation? (sources
person known to be
enter -0-.
other than plan or plan
a party-in-interest
sponsor)

ABCDEFGHI
ABCDEFGHI
ABCD

123456789012
345

Yes

X

No

X

Yes

X

(h)

(g)

Did indirect compensation
include eligible indirect
compensation, for which the
plan received the required
disclosures?

No

Did the service
Enter total indirect
compensation received by provider give you a
service provider excluding formula instead of
an amount or
eligible indirect
compensation for which you estimated amount?
answered “Yes” to element
(f). If none, enter -0-.

Yes

X

X

No

X

(a) Enter name and EIN or address (see instructions)

(b)
Service
Code(s)

(c)

(e)

(d)

(f)

Relationship to
Enter direct
Did service provider
employer, employee compensation paid
receive indirect
organization, or
by the plan. If none, compensation? (sources
person known to be
enter -0-.
other than plan or plan
a party-in-interest
sponsor)

ABCDEFGHI
ABCDEFGHI
ABCD

123456789012
345

Yes

X

No

X

Yes

X

(h)

(g)

Did indirect compensation
include eligible indirect
compensation, for which the
plan received the required
disclosures?

No

Did the service
Enter total indirect
compensation received by provider give you a
service provider excluding formula instead of
an amount or
eligible indirect
compensation for which you estimated amount?
answered “Yes” to element
(f). If none, enter -0-.

Yes

X

X

No

X

(a) Enter name and EIN or address (see instructions)

(b)
Service
Code(s)

(c)

(e)

(d)

(f)

Did service provider
Relationship to
Enter direct
receive indirect
employer, employee compensation paid
organization, or
by the plan. If none, compensation? (sources
other than plan or plan
person known to be
enter -0-.
sponsor)
a party-in-interest

ABCDEFGHI
ABCDEFGHI
ABCD

123456789012
345

Yes

X

No

X

Yes

X

(h)

(g)

Did indirect compensation
include eligible indirect
compensation, for which the
plan received the required
disclosures?

No

X

Enter total indirect
Did the service
compensation received by provider give you a
service provider excluding formula instead of
eligible indirect
an amount or
compensation for which you estimated amount?
answered “Yes” to element
(f). If none, enter -0-.
Yes

X

No

X

Schedule C (Form 5500) 2009

Page 5-

X

Part I Service Provider Information (continued)
3 If you reported on line 2 receipt of indirect compensation, other than eligible indirect compensation, by a service provider, and the service provider is a fiduciary
or provides contract administrator, consulting, custodial, investment advisory, investment management, broker, or recordkeeping services, answer the following
questions for (a) each source from whom the service provider received $1,000 or more in indirect compensation and (b) each source for whom the service
provider gave you a formula used to determine the indirect compensation instead of an amount or estimated amount of the indirect compensation. Complete as
many entries as needed to report the required information for each source.

(a) Enter service provider name as it appears on line 1

(b) Service Codes
(see instructions)

(d) Enter name and EIN (address) of source of indirect compensation

(a) Enter service provider name as it appears on line 1

(a) Enter service provider name as it appears on line 1

(b) Service Codes

(c) Enter amount of indirect
compensation

(e) Describe the indirect compensation, including any
formula used to determine the service provider’s eligibility
for or the amount of the indirect compensation.

(b) Service Codes
(see instructions)

(d) Enter name and EIN (address) of source of indirect compensation

compensation

(e) Describe the indirect compensation, including any
formula used to determine the service provider’s eligibility
for or the amount of the indirect compensation.

(see instructions)

(d) Enter name and EIN (address) of source of indirect compensation

(c) Enter amount of indirect

(c) Enter amount of indirect
compensation

(e) Describe the indirect compensation, including any
formula used to determine the service provider’s eligibility
for or the amount of the indirect compensation.

Page 6-

Schedule C (Form 5500) 2009

X

Part II Service Providers Who Fail or Refuse to Provide Information
4 Provide, to the extent possible, the following information for each service provider who failed or refused to provide the information necessary to complete
this Schedule.

(a) Enter name and EIN or address of service provider (see
instructions)

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
1234567890

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

instructions)

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

instructions)

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

instructions)

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

instructions)

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

instructions)

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

10 11
12 13

(b) Nature of

ABCDE
ABCDE
ABCDE
ABCDE
ABCDE
ABCDE

provide

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDE
ABCDE
ABCDE
ABCDE
ABCDE
ABCDE

(c) Describe the information that the service provider failed or refused to
provide

10 11 12
13

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(b) Nature of

(c) Describe the information that the service provider failed or refused to

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDE
ABCDE
ABCDE
ABCDE
ABCDE
ABCDE

provide

10 11 12
13

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(b) Nature of

(c) Describe the information that the service provider failed or refused to

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDE
ABCDE
ABCDE
ABCDE
ABCDE
ABCDE

provide

10 11 12
13

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(b) Nature of

(c) Describe the information that the service provider failed or refused to

Service
Code(s)

ABCD
ABCD
ABCD
ABCD

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(c) Describe the information that the service provider failed or refused to

Service
Code(s)

(a) Enter name and EIN or address of service provider (see

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
1234567890

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

Service
Code(s)

(a) Enter name and EIN or address of service provider (see
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
1234567890

(b) Nature of

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

Service
Code(s)

(a) Enter name and EIN or address of service provider (see
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
1234567890

10 11
12 13

provide

Service
Code(s)

(a) Enter name and EIN or address of service provider (see
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
1234567890

(c) Describe the information that the service provider failed or refused to

Service
Code(s)

(a) Enter name and EIN or address of service provider (see
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
1234567890

(b) Nature of

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
provide

ABCDE
ABCDE
ABCDE
ABCDE
ABCDE
ABCDE

Page 7-

Schedule C (Form 5500) 2009

Part III

X

Termination Information on Accountants and Enrolled Actuaries (see instructions)
(complete as many entries as needed)

a
c
d

Name:
Position:
Address:

Explanation:

a
c
d

Name:
Position:
Address:

Explanation:

a
c
d

Name:
Position:
Address:

Explanation:

a
c
d

Name:
Position:
Address:

Explanation:

a
c
d

Name:
Position:
Address:

Explanation:

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCD
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCD
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCD
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCD
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCD
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD

b

EIN:

123456789

ABCD
1234567890
e Telephone:
ABCD
ABCD
ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCD

b

EIN:

123456789

ABCD
1234567890
e Telephone:
ABCD
ABCD
ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCD

b

EIN:

123456789

ABCD
1234567890
e Telephone:
ABCD
ABCD
ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCD

b

EIN;

123456789

ABCD
1234567890
e Telephone:
ABCD
ABCD
ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCD

b

EIN;

123456789

ABCD
1234567890
e Telephone:
ABCD
ABCD
ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

SCHEDULE D

DFE/Participating Plan Information

(Form 5500)
This schedule is required to be filed under section 104 of the Employee
Retirement Income Security Act of 1974 (ERISA).

Department of the Treasury
Internal Revenue Service

OMB No. 1210-0110

2009

 File as an attachment to Form 5500.

Department of Labor
Employee Benefits Security Administration

This Form is Open to Public
Inspection.

For calendar plan year 2009 or fiscal plan year beginning

,

and ending

,

A Name of plan
B Three-digit
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
001

plan number (PN)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
D Employer Identification Number (EIN)
C Plan or DFE sponsor’s name as shown on line 2a of Form 5500
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
012345678
ABCDEFGHI
Part I Information on interests in MTIAs, CCTs, PSAs, and 103-12 IEs (to be completed by plans and DFEs)
(Complete as many entries as needed to report all interests in DFEs)
a Name of MTIA, CCT, PSA, or 103-12 IE:
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
b Name of sponsor of entity listed in (a):
ABCDEFGHI
d
e Dollar value of interest in MTIA, CCT, PSA, or
Entity
c EIN-PN 123456789-123
1
-123456789012345
code
103-12 IE at end of year (see instructions)
a

Name of MTIA, CCT, PSA, or 103-12 IE:

b

Name of sponsor of entity listed in (a):

c

EIN-PN

a

Name of MTIA, CCT, PSA, or 103-12 IE:

b

Name of sponsor of entity listed in (a):

c

EIN-PN

a

Name of MTIA, CCT, PSA, or 103-12 IE:

b

Name of sponsor of entity listed in (a):

c

EIN-PN

a

Name of MTIA, CCT, PSA, or 103-12 IE:

b

Name of sponsor of entity listed in (a):

c

EIN-PN

a

Name of MTIA, CCT, PSA, or 103-12 IE:

b

Name of sponsor of entity listed in (a):

c

EIN-PN

a

Name of MTIA, CCT, PSA, or 103-12 IE:

b

Name of sponsor of entity listed in (a):

c

EIN-PN

d
123456789-123

d
123456789-123

d
123456789-123

d
123456789-123

d
123456789-123

d
123456789-123

Entity
code

Entity
code

Entity
code

Entity
code

Entity
code

Entity
code

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)

For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500.

Schedule D (Form 5500) 2009
v.042407

Page 2

Schedule D (Form 5500) 2009

a

Name of MTIA, CCT, PSA, or 103-12 IE:

b

Name of sponsor of entity listed in (a):

c

EIN-PN

a

Name of MTIA, CCT, PSA, or 103-12 IE:

b

Name of sponsor of entity listed in (a):

c

EIN-PN

a

Name of MTIA, CCT, PSA, or 103-12 IE:

b

Name of sponsor of entity listed in (a):

c

EIN-PN

a

Name of MTIA, CCT, PSA, or 103-12 IE:

b

Name of sponsor of entity listed in (a):

c

EIN-PN

a

Name of MTIA, CCT, PSA, or 103-12 IE:

b

Name of sponsor of entity listed in (a):

c

EIN-PN

a

Name of MTIA, CCT, PSA, or 103-12 IE:

b

Name of sponsor of entity listed in (a):

c

EIN-PN

a

Name of MTIA, CCT, PSA, or 103-12 IE:

b

Name of sponsor of entity listed in (a):

c

EIN-PN

a

Name of MTIA, CCT, PSA, or 103-12 IE:

b

Name of sponsor of entity listed in (a):

c

EIN-PN

a

Name of MTIA, CCT, PSA, or 103-12 IE:

b

Name of sponsor of entity listed in (a):

c

EIN-PN

a

Name of MTIA, CCT, PSA, or 103-12 IE:

b

Name of sponsor of entity listed in (a):

c

EIN-PN

d
123456789-123

d
123456789-123

d
123456789-123

d
123456789-123

d
123456789-123

d
123456789-123

d
123456789-123

d
123456789-123

d
123456789-123

d
123456789-123

Entity
code

Entity
code

Entity
code

Entity
code

Entity
code

Entity
code

Entity
code

Entity
code

Entity
code

Entity
code

-X

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)

Schedule D (Form 5500) 2009

Page 3

-X

6

Part II

Information on Participating Plans (to be completed by DFEs)
(Complete as many entries as needed to report all participating plans)

a

Plan name

b

Name of
plan sponsor

a

Plan name

b

Name of
plan sponsor

a

Plan name

b

Name of
plan sponsor

a

Plan name

b

Name of
plan sponsor

a

Plan name

b

Name of
plan sponsor

a

Plan name

b

Name of
plan sponsor

a

Plan name

b

Name of
plan sponsor

a

Plan name

b

Name of
plan sponsor

a

Plan name

b

Name of
plan sponsor

a

Plan name

b

Name of
plan sponsor

a

Plan name

b

Name of
plan sponsor

a

Plan name

b

Name of
plan sponsor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI ABCDEFGHI
123456789-123
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123

SCHEDULE G

OMB No. 1210-0110

Financial Transaction Schedules

(Form 5500)
Department of Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security Administation

This Form is Open to Public
Inspection.

 File as an attachment to Form 5500.

For calendar plan year 2009 or fiscal plan year beginning

,

and ending

A Name of plan:
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
C Plan sponsor’s name as shown on line 2a of Form 5500
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
Part I

2009

This schedule is required to be filed under section 104 of the Employee Retirement
Income Security Act of 1974 (ERISA) and section 6058(a) of the Internal Revenue
Code (the Code).

B

D

,
Three-digit
plan number (PN)



001

Employer Identification Number (EIN):

012345678

Schedule of Loans or Fixed Income Obligations in Default or Classified as Uncollectible
Complete as many entries as needed to report all loans or fixed income obligations in default or classified as uncollectible. Check box (a) if obligor
is known to be a party in interest. Attach Overdue Loan Explanation for each loan listed. See Instructions.

(a)

X

(c) Detailed description of loan including dates of making and maturity, interest rate, the
type and value of collateral, any renegotiation of the loan and the terms of the
renegotiation, and other material items

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

Amount received during reporting year
(d) Original amount of
loan

(e) Principal

(f) Interest

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345 123456789012345
(a)

X

(c) Detailed description of loan including dates of making and maturity, interest rate, the
type and value of collateral, any renegotiation of the loan and the terms of the
renegotiation, and other material items

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

Amount received during reporting year
(d) Original amount of
loan

(e) Principal

(f) Interest

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345
(a)

X

(c) Detailed description of loan including dates of making and maturity, interest rate, the
type and value of collateral, any renegotiation of the loan and the terms of the
renegotiation, and other material items

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

Amount received during reporting year
(d) Original amount of
loan

(e) Principal

(f) Interest

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345 123456789012345
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500.

Schedule G (Form 5500) 2009
v.042407

Page 2

Schedule G (Form 5500) 2009

(a)

X

(c) Detailed description of loan including dates of making and maturity, interest rate, the
type and value of collateral, any renegotiation of the loan and the terms of the
renegotiation, and other material items

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

-X

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

Amount received during reporting year
(d) Original amount of
loan

(e) Principal

(f) Interest

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345 123456789012345
(a)

X

(c) Detailed description of loan including dates of making and maturity, interest rate, the
type and value of collateral, any renegotiation of the loan and the terms of the
renegotiation, and other material items

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

Amount received during reporting year
(d) Original amount of
loan

(e) Principal

(f) Interest

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345 123456789012345
(a)

X

(c) Detailed description of loan including dates of making and maturity, interest rate, the
type and value of collateral, any renegotiation of the loan and the terms of the
renegotiation, and other material items

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

Amount received during reporting year
(d) Original amount of
loan

(e) Principal

(f) Interest

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345 123456789012345
(a)

X

(c) Detailed description of loan including dates of making and maturity, interest rate, the
type and value of collateral, any renegotiation of the loan and the terms of the
renegotiation, and other material items

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

Amount received during reporting year
(d) Original amount of
loan

(e) Principal

(f) Interest

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345 123456789012345
(a)

X

(c) Detailed description of loan including dates of making and maturity, interest rate, the
type and value of collateral, any renegotiation of the loan and the terms of the
renegotiation, and other material items

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

Amount received during reporting year
(d) Original amount of
loan

(e) Principal

(f) Interest

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345 123456789012345

Page 3

Schedule G (Form 5500) 2009

Part II

(a)

X

Schedule of Leases in Default or Classified as Uncollectible
Complete as many entries as needed to report all leases in default or classified as uncollectible. Check box (a) if lessor or lessee is known to be a
party in interest. Attach Overdue Lease Explanation for each lease listed. (See instructions)
(c) Relationship to plan, employer,
(d) Terms and description (type of property, location and date it was
(b) Identity of lessor/lessee
employee organization or other
purchased, terms regarding rent, taxes, insurance, repairs,
party-in-interest
expenses, renewal options, date property was leased)

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

(e) Original cost

123456789012345
(a)

X

X

(a)

X

(a)

X

(a)

X

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

(c) Relationship to plan, employer,
employee organization or other
party-in-interest

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

(i) Net receipts

(j) Amount in arrears

123456789012345 123456789012345

(i) Net receipts

(j) Amount in arrears

123456789012345 123456789012345

(d) Terms and description (type of property, location and date it was
purchased, terms regarding rent, taxes, insurance, repairs,
expenses, renewal options, date property was leased)

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCD

123456789012345 123456789012345 123456789012345

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

123456789012345

(c) Relationship to plan, employer,
employee organization or other
party-in-interest

123456789012345 123456789012345

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCD

(g) Gross rental
(f) Current value at time of
(h) Expenses paid during
receipts during the plan
lease
the plan year
year

(b) Identity of lessor/lessee

(e) Original cost

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

(j) Amount in arrears

(d) Terms and description (type of property, location and date it was
purchased, terms regarding rent, taxes, insurance, repairs,
expenses, renewal options, date property was leased)

123456789012345 123456789012345 123456789012345

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

123456789012345

(c) Relationship to plan, employer,
employee organization or other
party-in-interest

(i) Net receipts

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCD

(g) Gross rental
(f) Current value at time of
(h) Expenses paid during
receipts during the plan
lease
the plan year
year

(b) Identity of lessor/lessee

(e) Original cost

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

123456789012345 123456789012345

(d) Terms and description (type of property, location and date it was
purchased, terms regarding rent, taxes, insurance, repairs,
expenses, renewal options, date property was leased)

123456789012345 123456789012345 123456789012345

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

123456789012345

(c) Relationship to plan, employer,
employee organization or other
party-in-interest

(j) Amount in arrears

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCD

(g) Gross rental
(f) Current value at time of
(h) Expenses paid during
receipts during the plan
lease
the plan year
year

(b) Identity of lessor/lessee

(e) Original cost

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

(i) Net receipts

(d) Terms and description (type of property, location and date it was
purchased, terms regarding rent, taxes, insurance, repairs,
expenses, renewal options, date property was leased)

123456789012345 123456789012345 123456789012345

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

123456789012345

(c) Relationship to plan, employer,
employee organization or other
party-in-interest

(g) Gross rental
(f) Current value at time of
(h) Expenses paid during
receipts during the plan
lease
the plan year
year

(b) Identity of lessor/lessee

(e) Original cost

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCD

123456789012345 123456789012345 123456789012345

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

123456789012345

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

(g) Gross rental
(f) Current value at time of
(h) Expenses paid during
receipts during the plan
lease
the plan year
year

(b) Identity of lessor/lessee

(e) Original cost

(a)

-X

(i) Net receipts

(j) Amount in arrears

123456789012345 123456789012345

(d) Terms and description (type of property, location and date it was
purchased, terms regarding rent, taxes, insurance, repairs,
expenses, renewal options, date property was leased)

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCD

(g) Gross rental
(f) Current value at time of
(h) Expenses paid during
receipts during the plan
lease
the plan year
year

123456789012345 123456789012345 123456789012345

(i) Net receipts

(j) Amount in arrears

123456789012345 123456789012345

Page 4

Schedule G (Form 5500) 2009

Part III

-X

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, file Form 5330 with the IRS to pay the excise tax on the transaction.
(b) Relationship to plan, employer, (c) Description of transaction including maturity date, rate
(a) Identity of party involved
(d) Purchase price
or other party-in-interest
of interest, collateral, par or maturity value

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI ABCD
(e) Selling price

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

(f) Lease rental

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(g) Transaction
expenses

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCD

(h) Cost of asset

(i) Current value of
asset

123456789012345

(j) Net gain (or loss) on
each transaction

123456789012345 123456789012345 123456789012345 123456789012345 12345678901235 -123456789012345
(a) Identity of party involved

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI ABCD
(e) Selling price

(a) Identity of party involved

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI ABCD
(e) Selling price

(b) Relationship to plan, employer,
or other party-in-interest

(c) Description of transactions including maturity date,
rate of interest, collateral, par or maturity value

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(f) Lease rental

(g) Transaction
expenses

(b) Relationship to plan, employer,
or other party-in-interest

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

(f) Lease rental

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCD

(h) Cost of asset

(i) Current value of
asset

(c) Description of transactions including maturity date,
rate of interest, collateral, par or maturity value

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(g) Transaction
expenses

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCD

(h) Cost of asset

(i) Current value of
asset

(d) Purchase price

123456789012345

(j) Net gain (or loss) on
each transaction

(d) Purchase price

123456789012345

(j) Net gain (or loss) on
each transaction

123456789012345 123456789012345 123456789012345 123456789012345 12345678901235 -123456789012345
(a) Identity of party involved

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI ABCD
(e) Selling price

(a) Identity of party involved

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI ABCD
(e) Selling price

(b) Relationship to plan, employer,
or other party-in-interest

(c) Description of transactions including maturity date,
rate of interest, collateral, par or maturity value

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(f) Lease rental

(g) Transaction
expenses

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCD

(h) Cost of asset

(i) Current value of
asset

(b) Relationship to plan, employer,
or other party-in-interest

(c) Description of transactions including maturity date,
rate of interest, collateral, par or maturity value

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(f) Lease rental

(g) Transaction
expenses

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCD

(h) Cost of asset

(i) Current value of
asset

(d) Purchase price

123456789012345

(j) Net gain (or loss) on
each transaction

(d) Purchase price

123456789012345

(j) Net gain (or loss) on
each transaction

123456789012345 123456789012345 123456789012345 123456789012345 12345678901235 -123456789012345
(a) Identity of party involved

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI ABCD
(e) Selling price

(b) Relationship to plan, employer,
or other party-in-interest

(c) Description of transactions including maturity date,
rate of interest, collateral, par or maturity value

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(f) Lease rental

(g) Transaction
expenses

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCD

(h) Cost of asset

(i) Current value of
asset

(d) Purchase price

123456789012345

(j) Net gain (or loss) on
each transaction

123456789012345 123456789012345 123456789012345 123456789012345 12345678901235 -123456789012345

SCHEDULE H

OMB No. 1210-0110

Financial Information

(Form 5500)
Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security Administration

2009

This schedule is required to be filed under section 104 of the Employee
Retirement Income Security Act of 1974 (ERISA), and section 6058(a) of the
Internal Revenue Code (the Code).

 File as an attachment to Form 5500.

Pension Benefit Guaranty Corporation

For calendar plan year 2009 or fiscal plan year beginning
A Name of plan

,

and ending

B

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
C Plan sponsor’s name as shown on line 2a of Form 5500
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI

D

This Form is Open to Public
Inspection
,

Three-digit
plan number (PN)



001

Employer Identification Number (EIN)

012345678

Part I
Asset and Liability Statement
1 Current value of plan assets and liabilities at the beginning and end of the plan year. Combine the value of plan assets held in more than 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 1c(9) through 1c(14). 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. MTIAs, CCTs, PSAs, and 103-12 IEs do not complete lines 1b(1), 1b(2), 1c(8), 1g, 1h,
and 1i. CCTs, PSAs, and 103-12 IEs also do not complete lines 1d and 1e. See instructions.

Assets
a
b

c

Total noninterest-bearing cash .......................................................................

(a) Beginning of Year

(b) End of Year

1a

-123456789012345

-123456789012345

(1) Employer contributions ...........................................................................

1b(1)

(2) Participant contributions .........................................................................

1b(2)

(3) Other.......................................................................................................

1b(3)

-123456789012345
-123456789012345
-123456789012345

-123456789012345
-123456789012345
-123456789012345

-123456789012345
-123456789012345

-123456789012345
-123456789012345

-123456789012345
-123456789012345

-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345

Receivables (less allowance for doubtful accounts):

General investments:
(1) Interest-bearing cash (include money market accounts & certificates
of deposit) .............................................................................................
(2) U.S. Government securities....................................................................

1c(1)
1c(2)

(3) Corporate debt instruments (other than employer securities):
(A) Preferred ..........................................................................................

1c(3)(A)

(B) All other............................................................................................

1c(3)(B)

(4) Corporate stocks (other than employer securities):
(A) Preferred ..........................................................................................

1c(4)(A)

(B) Common ..........................................................................................

1c(4)(B)

(5) Partnership/joint venture interests ..........................................................

1c(5)

(6) Real estate (other than employer real property) .....................................

1c(6)

(7) Loans (other than to participants) ...........................................................

1c(7)

(8) Participant loans .....................................................................................

1c(8)

(9) Value of interest in common/collective trusts..........................................

1c(9)

(10) Value of interest in pooled separate accounts ........................................

1c(10)

(11) Value of interest in master trust investment accounts ............................

1c(11)

(12) Value of interest in 103-12 investment entities .......................................
(13) Value of interest in registered investment companies (e.g., mutual
funds)......................................................................................
(14) Value of funds held in insurance company general account (unallocated
contracts)................................................................................................

1c(12)

-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345

1c(13)

-123456789012345

-123456789012345

1c(14)

-123456789012345

-123456789012345

1c(15)

-123456789012345

-123456789012345

(15) Other .......................................................................................................

For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500

Schedule H (Form 5500) 2009
v.042407

Page 2

Schedule H (Form 5500) 2009

1d

1e
1f

Employer-related investments:

(a) Beginning of Year

(1) Employer securities ....................................................................................

1d(1)

(2) Employer real property ...............................................................................

1d(2)

Buildings and other property used in plan operation.........................................

1e

Total assets (add all amounts in lines 1a through 1e) ......................................

1f

(b) End of Year

-123456789012345
-123456789012345
-123456789012345
-123456789012345

-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345

Liabilities
1g
1h
1i
1j
1k

Benefit claims payable ......................................................................................

1g

Operating payables ...........................................................................................

1h

Acquisition indebtedness ..................................................................................

1i

Other liabilities...................................................................................................

1j

Total liabilities (add all amounts in lines 1g through1j) .....................................

1k

-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345

1l

-123456789012345

Net Assets
1l

Net assets (subtract line 1k from line 1f)...........................................................

Part II Income and Expense Statement
2 Plan income, expenses, and changes in net assets for the year. Include all income and expenses of the plan, including any trust(s) or separately maintained
fund(s) and any payments/receipts to/from insurance carriers. Round off amounts to the nearest dollar. MTIAs, CCTs, PSAs, and 103-12 IEs do not complete
lines 2a, 2b(1)(E), 2e, 2f, and 2g.

Income
a

b

(a) Amount

(b) Total

Contributions:
(1) Received or receivable in cash from: (A) Employers..................................

2a(1)(A)

(B) Participants .........................................................................................

2a(1)(B)

(C) Others (including rollovers).................................................................

2a(1)(C)

(2) Noncash contributions ................................................................................

2a(2)

(3) Total contributions. Add lines 2a(1)(A), (B), (C), and line 2a(2) .................

2a(3)

-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345

Earnings on investments:
(1) Interest:
(A) Interest-bearing cash (including money market accounts and
certificates of deposit).........................................................................

2b(1)(A)

-123456789012345

(B) U.S. Government securities ................................................................

2b(1)(B)

(C) Corporate debt instruments ................................................................

2b(1)(C)

(D) Loans (other than to participants) .......................................................

2b(1)(D)

(E) Participant loans .................................................................................

2b(1)(E)

-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345

(F) Other ...................................................................................................

2b(1)(F)

(G) Total interest. Add lines 2b(1)(A) through (F) .....................................

2b(1)(G)

(2) Dividends: (A) Preferred stock....................................................................

2b(2)(A)

(B) Common stock ....................................................................................

2b(2)(B)

(C) Registered investment company shares (e.g. mutual funds)..............

2b(2)(C)

(D) Total dividends. Add lines 2b(2)(A), (B), and (C)

2b(2)(D)

(3) Rents...........................................................................................................

2b(3)

(4) Net gain (loss) on sale of assets: (A) Aggregate proceeds .......................

2b(4)(A)

(B) Aggregate carrying amount (see instructions) ....................................

2b(4)(B)

(C) Subtract line 2b(4)(B) from line 2b(4)(A) and enter result ..................

2b(4)(C)

-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345

Page 3

Schedule H (Form 5500) 2009

(a) Amount

2b

c
d

(5) Unrealized appreciation (depreciation) of assets: (A) Real estate.........................

2b(5)(A)

(B) Other ...................................................................................................
(C) Total unrealized appreciation of assets.
Add lines 2b(5)(A) and (B)..................................................................

2b(5)(B)

(b) Total

-123456789012345
-123456789012345

2b(5)(C)

-123456789012345

(6) Net investment gain (loss) from common/collective trusts ..........................

2b(6)

(7) Net investment gain (loss) from pooled separate accounts ........................

2b(7)

(8) Net investment gain (loss) from master trust investment accounts ............

2b(8)

(9) Net investment gain (loss) from 103-12 investment entities .......................
(10) Net investment gain (loss) from registered investment
companies (e.g., mutual funds)...................................................................

2b(9)

-123456789012345
-123456789012345
-123456789012345
-123456789012345

2b(10)

-123456789012345

Other income.....................................................................................................

2c

Total income. Add all income amounts in column (b) and enter total......................

2d

-123456789012345
-123456789012345

Expenses
e

f
g
h
i

j

Benefit payment and payments to provide benefits:
(1) Directly to participants or beneficiaries, including direct rollovers ..............

2e(1)

(2) To insurance carriers for the provision of benefits ......................................

2e(2)

(3) Other ...........................................................................................................

2e(3)

(4) Total benefit payments. Add lines 2e(1) through (3)...................................

2e(4)

Corrective distributions (see instructions) .........................................................

2f

Certain deemed distributions of participant loans (see instructions).................

2g

Interest expense................................................................................................

2h

Administrative expenses: (1) Professional fees ...............................................

2i(1)

(2) Contract administrator fees.........................................................................

2i(2)

(3) Investment advisory and management fees ...............................................

2i(3)

-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345

(4) Other ...........................................................................................................

2i(4)

(5) Total administrative expenses. Add lines 2i(1) through (4).........................

2i(5)

Total expenses. Add all expense amounts in column (b) and enter total.........

2j

-123456789012345
-123456789012345

2k

-123456789012345

(1) To this plan..................................................................................................

2l(1)

(2) From this plan .............................................................................................

2l(2)

-123456789012345
-123456789012345

Net Income and Reconciliation
k
l

Net income (loss). Subtract line 2j from line 2d.............................................................
Transfers of assets:

Part III Accountant’s Opinion
3 Complete lines 3a through 3c if the opinion of an independent qualified public accountant is attached to this Form 5500. Complete line 3d if an opinion is not
attached.

a

The attached opinion of an independent qualified public accountant for this plan is (see instructions):
(1)

X

Unqualified

(2)

X

Qualified

(3)

X

Disclaimer

(4)

X

Adverse

X Yes
b Did the accountant perform a limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)?
c Enter the name and EIN of the accountant (or accounting firm) below:
(1) Name: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
(2) EIN: 123456789
d The opinion of an independent qualified public accountant is not attached because:
(1) X This form is filed for a CCT, PSA, or MTIA.
(2) X It will be attached to the next Form 5500 pursuant to 29 CFR 2520.104-50.

X

No

Page 4

Schedule H (Form 5500) 2009

Part IV Compliance Questions
4
CCTs and PSAs do not complete Part IV. MTIAs, 103-12 IEs, and GIAs do not complete 4a, 4e, 4f, 4g, 4h, 4k, 4m, 4n, or 5.
103-12 IEs also do not complete 4j and 4l. MTIAs also do not complete 4l.
During the plan year:

a

Yes

No

Amount

Was there a failure to transmit to the plan any participant contributions within the time
period 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.) ......

4a

-123456789012345

b

Were any loans by the plan or fixed income obligations due the plan in default as of the
close of the plan year or classified during the year as uncollectible? Disregard participant loans
secured by participant’s account balance. (Attach Schedule G (Form 5500) Part I if “Yes” is
checked.)......................................................................................................................................

4b

-123456789012345

c

Were any leases to which the plan was a party in default or classified during the year as
uncollectible? (Attach Schedule G (Form 5500) Part II if “Yes” is checked.) ..............................

4c

-123456789012345

Were there any nonexempt transactions with any party-in-interest? (Do not include transactions
reported on line 4a. Attach Schedule G (Form 5500) Part III if “Yes” is
checked.)......................................................................................................................................

4d

-123456789012345

Was this plan covered by a fidelity bond?....................................................................................

4e

-123456789012345

Did the plan have a loss, whether or not reimbursed by the plan’s fidelity bond, that was caused
by fraud or dishonesty? ...............................................................................................................

4f

-123456789012345

Did the plan hold any assets whose current value was neither readily determinable on an
established market nor set by an independent third party appraiser? .........................................

4g

-123456789012345

4h

-123456789012345

d

e
f
g
h

Did the plan receive any noncash contributions whose value was neither readily
determinable on an established market nor set by an independent third party appraiser? .........

i

Did the plan have assets held for investment? (Attach schedule(s) of assets if “Yes” is checked,
and see instructions for format requirements.).............................................................................

4i

j

Were any plan transactions or series of transactions in excess of 5% of the current
value of plan assets? (Attach schedule of transactions if “Yes” is checked, and
see instructions for format requirements.)....................................................................................

4j

k

Were all the plan assets either distributed to participants or beneficiaries, transferred to another
plan, or brought under the control of the PBGC?.........................................................................

4k

l
m

Has the plan failed to provide any benefit when due under the plan? .........................................

4l

If this is an individual account plan, was there a blackout period? (See instructions and 29 CFR
2520.101-3.).................................................................................................................................

4m

n

If 4m was answered “Yes,” check the “Yes” box if you either provided the required notice or one
of the exceptions to providing the notice applied under 29 CFR 2520.101-3. .............................

4n

5a
5b

Has a resolution to terminate the plan been adopted during the plan year or any prior plan year?
If yes, enter the amount of any plan assets that reverted to the employer this year .............................

X

Yes

-123456789012345

X No

Amount:

-123456789012345

If, during this plan year, any assets or liabilities were transferred from this plan to another plan(s), identify the plan(s) to which assets or liabilities were
transferred. (See instructions.)
5b(1) Name of plan(s)

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

5b(2) EIN(s)

5b(3) PN(s)

ABCDEFGHI
ABCDEFGHI

123456789

123

ABCDEFGHI
ABCDEFGHI

123456789

123

ABCDEFGHI
ABCDEFGHI

123456789

123

ABCDEFGHI
ABCDEFGHI

123456789

123

SCHEDULE I

OMB No. 1210-0110

Financial Information—Small Plan

(Form 5500)
Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security Administration

2009

This schedule is required to be filed under section 104 of the Employee
Retirement Income Security Act of 1974 (ERISA), and section 6058(a) of the
Internal Revenue Code (the Code).

Pension Benefit Guaranty Corporation

 File as an attachment to Form 5500.

For calendar plan year 2009 or fiscal plan year beginning

,

and ending

A Name of plan
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
C Plan sponsor’s name as shown on line 2a of Form 5500
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI

B

D

Three-digit
plan number (PN)

This Form is Open to Public
Inspection
,



001

Employer Identification Number (EIN)

012345678

Complete Schedule I if the plan covered fewer than 100 participants as of the beginning of the plan year. You may also complete Schedule I if you are filing as a
small plan under the 80-120 participant rule (see instructions). Complete Schedule H if reporting as a large plan or DFE.

Part I

Small Plan Financial Information

Report below the current value of assets and liabilities, income, expenses, transfers and changes in net assets during the plan year. Combine the value of plan
assets held in more than one trust. Do not enter the value of the portion of an insurance contract that guarantees during this plan year to pay a specific dollar
benefit at a future date. Include all income and expenses of the plan including any trust(s) or separately maintained fund(s) and any payments/receipts to/from
insurance carriers. Round off amounts to the nearest dollar.

1
a
b
c
2
a

Plan Assets and Liabilities:

(a) Beginning of Year

Total plan assets ...............................................................................

1a

Total plan liabilities............................................................................

1b

Net plan assets (subtract line 1b from line 1a)..................................

1c

Income, Expenses, and Transfers for this Plan Year:

(a) Amount

(2) Participants................................................................................ 2a(2)
(3) Others (including rollovers) ....................................................... 2a(3)

h
i
j
k
l
3

(b) End of Year

-123456789012345
-123456789012345
-123456789012345
(b) Total

Contributions received or receivable:
(1) Employers ................................................................................. 2a(1)

b
c
d
e
f
g

-123456789012345
-123456789012345
-123456789012345

Noncash contributions.......................................................................

2b

Other income.....................................................................................

2c

Total income (add lines 2a(1), 2a(2), 2a(3), 2b, and 2c)...................

2d

Benefits paid (including direct rollovers) ...........................................

2e

Corrective distributions (see instructions) .........................................

2f

Certain deemed distributions of participant loans
(see instructions) ..............................................................................

2g

Administrative service providers (salaries, fees, and commissions).

2h

Other expenses.................................................................................

2i

Total expenses (add lines 2e, 2f, 2g, 2h, and 2i) ..............................

2j

Net income (loss) (subtract line 2j from line 2d)................................

2k

Transfers to (from) the plan (see instructions) ..................................

2l

-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345

Specific Assets: If the plan held assets at anytime during the plan year in any of the following categories, check “Yes” and enter the current value of any assets
remaining in the plan as of the end of the plan year. Allocate the value of the plan’s interest in a commingled trust containing the assets of more than one plan on a lineby-line basis unless the trust meets one of the specific exceptions described in the instructions.
Yes
No
Amount

a

Partnership/joint venture interests..........................................................................................

3a

-123456789012345

b

Employer real property...........................................................................................................

3b

-123456789012345

c

Real estate (other than employer real property) ....................................................................

3c

-123456789012345

d

Employer securities................................................................................................................

3d

-123456789012345

e

Participant loans.....................................................................................................................

3e

For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500

-123456789012345
Schedule I (Form 5500) 2009
v.042407

Schedule I (Form 5500) 2009

Page 2
Yes

No

Amount

3f

Loans (other than to participants) ..........................................................................................................

3f

-123456789012345

g

Tangible personal property ....................................................................................................................

3g

-123456789012345

Part II Compliance Questions
4
During the plan year:
a Was there a failure to transmit to the plan any participant contributions within the time period

Yes

No

Amount

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.)..............................

4a

-123456789012345

Were any loans by the plan or fixed income obligations due the plan in default as of the close of plan
year or classified during the year as uncollectible? Disregard participant loans secured by the
participant’s account balance.................................................................................................................

4b

-123456789012345

Were any leases to which the plan was a party in default or classified during the year as
uncollectible? ........................................................................................................................................

4c

-123456789012345

Were there any nonexempt transactions with any party-in-interest? (Do not include transactions
reported on line 4a.) ...............................................................................................................................

4d

-123456789012345

Was the plan covered by a fidelity bond? ..............................................................................................

4e

-123456789012345

Did the plan have a loss, whether or not reimbursed by the plan’s fidelity bond, that was caused by
fraud or dishonesty? ..............................................................................................................................

4f

-123456789012345

Did the plan hold any assets whose current value was neither readily determinable on an established
market nor set by an independent third party appraiser? ......................................................................

4g

-123456789012345

Did the plan receive any noncash contributions whose value was neither readily determinable on an
established market nor set by an independent third party appraiser? .................................................

4h

-123456789012345

Did the plan at any time hold 20% or more of its assets in any single security, debt, mortgage, parcel
of real estate, or partnership/joint venture interest?.............................................................................

4i

-123456789012345

j

Were all the plan assets either distributed to participants or beneficiaries, transferred to another plan,
or brought under the control of the PBGC? .........................................................................................

4j

k

Are you claiming a waiver of the annual examination and report of an independent qualified public
accountant (IQPA) under 29 CFR 2520.104-46? If “No,” attach an IQPA’s report or 2520.104-50
statement. (See instructions on waiver eligibility and conditions.) .................................................................

4k

Has the plan failed to provide any benefit when due under the plan? .................................................

4l

If this is an individual account plan, was there a blackout period? (See instructions and 29 CFR
2520.101-3.).........................................................................................................................................

4m

If 4m was answered “Yes,” check the “Yes” box if you either provided the required notice or one of
the exceptions to providing the notice applied under 29 CFR 2520.101-3 ..........................................

4n

b
c
d
e
f
g
h
i

l
m
n
5a

Has a resolution to terminate the plan been adopted during the plan year or any prior plan year?
If “Yes,” enter the amount of any plan assets that reverted to the employer this year...........................

X

Yes

-123456789012345

X No

Amount:

-

12345678901234
5b

If, during this plan year, any assets or liabilities were transferred from this plan to another plan(s), identify the plan(s) to which assets or liabilities were
transferred. (See instructions.)
5b(1) Name of plan(s)

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

5b(2) EIN(s)

5b(3) PN(s)

123456789

123

123456789

123

123456789

123

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

SCHEDULE R

OMB No. 1210-0110

Retirement Plan Information

(Form 5500)
Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security Administration
Pension Benefit Guaranty Corporation

This Form is Open to Public
Inspection.

 File as an attachment to Form 5500.

For calendar plan year 2009 or fiscal plan year beginning

,

and ending

A Name of plan
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
C Plan sponsor’s name as shown on line 2a of Form 5500
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
Part I

2009

This schedule is required to be filed under section 104 and 4065 of the
Employee Retirement Income Security Act of 1974 (ERISA) and section
6058(a) of the Internal Revenue Code (the Code).

B

D

,
Three-digit
plan number

(PN)

001

Employer Identification Number (EIN)

012345678

Distributions

All references to distributions relate only to payments of benefits during the plan year.

1

Total value of distributions paid in property other than in cash or the forms of property specified in the
instructions..............................................................................................................................................................

2

Enter the EIN(s) of payor(s) who paid benefits on behalf of the plan to participants or beneficiaries during the year (if more than two, enter EINs of the two
payors who paid the greatest dollar amounts of benefits):
EIN(s):

_______________________________

-123456789012345

1

_______________________________

Profit-sharing plans, ESOPs, and stock bonus plans, skip line 3.

3

Number of participants (living or deceased) whose benefits were distributed in a single sum, during the plan
year. ..........................................................................................................................................................................

Part II
4

12345678

3

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)

X

Is the plan administrator making an election under Code section 412(d)(2) or ERISA section 302(d)(2)?.........................

Yes

X

No

N/A

X

If the plan is a defined benefit plan, go to line 8.

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.

Date:

Month _________

Day _________

Year _________

If you completed line 5, complete lines 3, 9, and 10 of Schedule MB and do not complete the remainder of this schedule.

6

a
b

Enter the minimum required contribution for this plan year ................................................................................

6a

Enter the amount contributed by the employer to the plan for this plan year .....................................................

6b

-123456789012345
-123456789012345

c

Subtract the amount in line 6b from the amount in line 6a. Enter the result
(enter a minus sign to the left of a negative amount)..........................................................................................

6c

-123456789012345

If you completed line 6c, skip lines 8 and 9.

7

Will the minimum funding amount reported on line 6c be met by the funding deadline? ......................................

X

Yes

X

No

X

N/A

8

If a change in actuarial cost method was made for this plan year pursuant to a revenue procedure providing
automatic approval for the change or a class ruling letter, does the plan sponsor or plan administrator agree
with the change?....................................................................................................................................................

X

Yes

X

No

X

N/A

Part III
9

Amendments

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(es). If no, check the “No” box......................................................................................

Part IV

X

Increase

X Decrease

X

X

No

ESOPs

(see instructions). If this is not a plan described under Section 409(a) or 4975(e)(7) of the Internal Revenue Code,
skip this Part.

10 Were unallocated employer securities or proceeds from the sale of unallocated securities used to repay any exempt loan?..............
11 a Does the ESOP hold any preferred stock? ....................................................................................................................................
b If the ESOP has an outstanding exempt loan with the employer as lender, is such loan part of a “back-to-back” loan?
(See instructions for definition of “back-to-back” loan.) ..................................................................................................................

12

Both

Does the ESOP hold any stock that is not readily tradable on an established securities market? ........................................................

For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500.

X
X

Yes

X
X

No

Yes

X

Yes

X

No

X

Yes

X

No

No

Schedule R (Form 5500) 2009
v.042407

Page 2

Schedule R (Form 5500) 2009

Part V
Additional Information for Multiemployer Defined Benefit Pension Plans
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.
Name of contributing employer

a

b

EIN

d

Date collective bargaining agreement expires (If employer contributes under more than one collective bargaining agreement, check box X
and see instructions regarding required attachment. Otherwise, enter the applicable date.) Month _______ Day _______ Year _______

e

Contribution rate information (If more than one rate applies, check this box X and see instructions regarding required attachment. Otherwise,
complete items 13e(1) and 13e(2).)
(1) Contribution rate (in dollars and cents) _____________
(2) Base unit measure: X Hourly
X Weekly
X Unit of production
X Other (specify): _______________________________

a
b
d
e

a
b
d

c

Dollar amount contributed by employer

Name of contributing employer
EIN

c

Dollar amount contributed by employer

Date collective bargaining agreement expires (If employer contributes under more than one collective bargaining agreement, check box X
and see instructions regarding required attachment. Otherwise, enter the applicable date.) Month _______ Day _______ Year _______
Contribution rate information (If more than one rate applies, check this box X and see instructions regarding required attachment. Otherwise,
complete items 13e(1) and 13e(2).)
(1) Contribution rate (in dollars and cents) _____________
(2) Base unit measure: X Hourly
X Weekly
X Unit of production
X Other (specify): _______________________________
Name of contributing employer
EIN

c

Dollar amount contributed by employer

Date collective bargaining agreement expires (If employer contributes under more than one collective bargaining agreement, check box X
and see instructions regarding required attachment. Otherwise, enter the applicable date.) Month _______ Day _______ Year _______

e

Contribution rate information (If more than one rate applies, check this box X and see instructions regarding required attachment. Otherwise,
complete items 13e(1) and 13e(2).)
(1) Contribution rate (in dollars and cents) _____________
(2) Base unit measure: X Hourly
X Weekly
X Unit of production
X Other (specify): _______________________________

a
b
d

Name of contributing employer

e

Contribution rate information (If more than one rate applies, check this box X and see instructions regarding required attachment. Otherwise,
complete items 13e(1) and 13e(2).)
(1) Contribution rate (in dollars and cents) _____________
(2) Base unit measure: X Hourly
X Weekly
X Unit of production
X Other (specify): _______________________________

a
b

Name of contributing employer

d

Date collective bargaining agreement expires (If employer contributes under more than one collective bargaining agreement, check box X
and see instructions regarding required attachment. Otherwise, enter the applicable date.) Month _______ Day _______ Year _______

e

Contribution rate information (If more than one rate applies, check this box X and see instructions regarding required attachment. Otherwise,
complete items 13e(1) and 13e(2).)
(1) Contribution rate (in dollars and cents) _____________
(2) Base unit measure: X Hourly
X Weekly
X Unit of production
X Other (specify): _______________________________

a
b
d

Name of contributing employer

e

Contribution rate information (If more than one rate applies, check this box X and see instructions regarding required attachment. Otherwise,
complete items 13e(1) and 13e(2).)
(1) Contribution rate (in dollars and cents) _____________
(2) Base unit measure: X Hourly
X Weekly
X Unit of production
X Other (specify): _______________________________

EIN

c

Dollar amount contributed by employer

Date collective bargaining agreement expires (If employer contributes under more than one collective bargaining agreement, check box X
and see instructions regarding required attachment. Otherwise, enter the applicable date.) Month _______ Day _______ Year _______

EIN

EIN

c

c

Dollar amount contributed by employer

Dollar amount contributed by employer

Date collective bargaining agreement expires (If employer contributes under more than one collective bargaining agreement, check box X
and see instructions regarding required attachment. Otherwise, enter the applicable date.) Month _______ Day _______ Year _______

Page 3

Schedule R (Form 5500) 2009

14

Enter the number of participants on whose behalf no contributions were made by an employer as an employer of the
participant for:

a
b
c
15

The second preceding plan year ..........................................................................................................................

123456789012345
123456789012345
123456789012345

15a
15b

123456789012345
123456789012345

Enter the number of employers who withdrew during the preceding plan year .................................................

16a

123456789012345

If item 16a is greater than 0, enter the aggregate amount of withdrawal liability assessed or estimated to be
assessed against such withdrawn employers ......................................................................................................

16b

The corresponding number for the plan year immediately preceding the current plan year ................................
The corresponding number for the second preceding plan year ..........................................................................

Information with respect to any employers who withdrew from the plan during the preceding plan year:

a
b
17

The plan year immediately preceding the current plan year.................................................................................

14a
14b
14c

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
b
16

The current year ...................................................................................................................................................

123456789012345

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. ....................................................................................................................... X

Part VI
Additional Information for Single-Employer and Multiemployer Defined Benefit Pension Plans
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 ............................................................................................................................................................................ X

19

If the total number of participants is 1,000 or more, complete items (a) through (c)

a

Enter the percentage of plan assets held as:
Stock: _____% Investment-Grade Debt: _____%

b

Provide the average duration of the combined investment-grade and high-yield debt:
X 0-3 years X 3-6 years X 6-9 years X 9-12 years X 12-15 years X 15-18 years

c

High-Yield Debt: _____%

What duration measure was used to calculate item 19(b)?
X Macaulay duration X Modified duration

X Effective duration

Real Estate: _____% Other: _____%

X

18-21 years

X

21 years or more

X Other (specify) _________________________________

_____
File Type	application/pdf
File Title	Microsoft Word - Form_5500.doc
Author	LKosar
File Modified	2007-06-08
File Created	2007-05-24