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pdfSCHEDULE 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 Three-digit
C Plan sponsor’s name as shown on line 2a of Form 5500
ABCDEFGHI
D Employer Identification Number (EIN)
012345678
Part I
plan number (PN)
001
Service Provider Information (see instructions)
T
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
X Yes X No
AF
indirect compensation for which the plan received the required disclosures (see instructions for definitions and conditions).. . . . . . . . . . . . . . .
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).
R
(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation
D
(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.092308.1
Page 2-
Schedule C (Form 5500) 2009
(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
T
(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation
AF
(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation
D
R
(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
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)
(c)
(d)
ABCDEFGHI
ABCDEFGHI
ABCD
123456789012
345
(g)
(f)
(e)
Enter direct
Relationship to
Did service provider
employer, employee compensation paid
receive indirect
organization, or by the plan. If none, compensation? (sources
person known to be
other than plan or plan
enter -0-.
a party-in-interest
sponsor)
Did indirect compensation
include eligible indirect
compensation, for which the
plan received the required
disclosures?
(h)
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
T
(b)
Service
Code(s)
Yes
X No X
Yes
X No X
(c)
(d)
D
ABCDEFGHI
ABCDEFGHI
ABCD
(f)
(e)
Enter direct
Relationship to
Did service provider
employer, employee compensation paid
receive indirect
organization, or by the plan. If none, compensation? (sources
person known to be
other than plan or plan
enter -0-.
a party-in-interest
sponsor)
R
(b)
Service
Code(s)
AF
(a) Enter name and EIN or address (see instructions)
123456789012
345
Yes
Did indirect compensation
include eligible indirect
compensation, for which the
plan received the required
disclosures?
(g)
(h)
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
X No X
Yes
X No X
Yes
X No X
(a) Enter name and EIN or address (see instructions)
(b)
Service
Code(s)
(c)
(d)
ABCDEFGHI
ABCDEFGHI
ABCD
123456789012
345
(f)
(e)
Enter direct
Relationship to
Did service provider
employer, employee compensation paid
receive indirect
organization, or by the plan. If none, compensation? (sources
person known to be
other than plan or plan
enter -0-.
a party-in-interest
sponsor)
Yes
X No X
Did indirect compensation
include eligible indirect
compensation, for which the
plan received the required
disclosures?
Yes
X No X
(g)
(h)
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
(a) Enter name and EIN or address (see instructions)
(b)
Service
Code(s)
(c)
(e)
(d)
ABCDEFGHI
ABCDEFGHI
ABCD
123456789012
345
Yes
X No X
Did indirect compensation
include eligible indirect
compensation, for which the
plan received the required
disclosures?
Yes
(h)
(g)
(f)
Did service provider
Enter direct
Relationship to
receive indirect
employer, employee compensation paid
organization, or by the plan. If none, compensation? (sources
enter -0-.
person known to be
other than plan or plan
a party-in-interest
sponsor)
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-.
X No X
Yes
X No X
(c)
(d)
(e)
Did service provider
Enter direct
Relationship to
receive indirect
employer, employee compensation paid
organization, or by the plan. If none, compensation? (sources
enter -0-.
person known to be
other than plan or plan
a party-in-interest
sponsor)
123456789012
345
Yes
X No X
(f)
Did indirect compensation
include eligible indirect
compensation, for which the
plan received the required
disclosures?
Yes
(h)
(g)
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-.
X No X
Yes
X No X
D
ABCDEFGHI
ABCDEFGHI
ABCD
R
(b)
Service
Code(s)
AF
T
(a) Enter name and EIN or address (see instructions)
(a) Enter name and EIN or address (see instructions)
(b)
Service
Code(s)
(c)
(e)
(d)
Did service provider
Relationship to
Enter direct
receive indirect
employer, employee compensation paid
organization, or by the plan. If none, compensation? (sources
enter -0-.
other than plan or plan
person known to be
sponsor)
a party-in-interest
ABCDEFGHI
ABCDEFGHI
ABCD
123456789012
345
Yes
X No X
(f)
Did indirect compensation
include eligible indirect
compensation, for which the
plan received the required
disclosures?
Yes
X No X
(h)
(g)
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 No X
Page 5-
Schedule C (Form 5500) 2009
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 2
(b) Service Codes
(see instructions)
(b) Service Codes
AF
(a) Enter service provider name as it appears on line 2
D
R
(d) Enter name and EIN (address) of source of indirect compensation
(a) Enter service provider name as it appears on line 2
(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.
T
(d) Enter name and EIN (address) of source of indirect compensation
(c) Enter amount of indirect
(see instructions)
(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)
(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
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
ABCD
ABCD
ABCD
ABCD
ABCD
(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
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCD
ABCD
ABCD
ABCD
ABCD
ABCD
ABCD
ABCD
ABCD
ABCD
10 11
12 13
(b) Nature of
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
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDE
ABCDE
ABCDE
ABCDE
ABCDE
ABCDE
provide
(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
provide
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
D
(a) Enter name and EIN or address of service provider (see
ABCDE
ABCDE
ABCDE
ABCDE
ABCDE
ABCDE
(c) Describe the information that the service provider failed or refused to
Service
Code(s)
ABCD
ABCD
ABCD
ABCD
ABCD
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
10 11 12
13
R
instructions)
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
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
AF
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
instructions)
(c) Describe the information that the service provider failed or refused to
Service
Code(s)
T
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
Termination Information on Accountants and Enrolled Actuaries (see instructions)
(complete as many entries as needed)
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
ABCD
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
ABCD
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
ABCD
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
ABCD
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
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
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
T
a
c
d
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
AF
Explanation:
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
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
R
Name:
Position:
Address:
D
a
c
d
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
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
File Type | application/pdf |
File Title | Microsoft Word - DEL 22 Final PY 2009 and PY 2010 Form-Schedule Proofs Resubmission.doc |
Author | hickk2 |
File Modified | 2009-06-29 |
File Created | 2009-05-05 |