Form Sch SB (Form 5500) Sch SB (Form 5500) Single-Employer Defined Benefit Plan Actuarial Informati

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
Pension Benefit Guaranty Corporation

This Form is Open to Public
Inspection

 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:

X

Single

X

Multiple-A

X

Multiple-B

F

Prior year plan size:

B

D

Three-digit
plan number (PN)

012345678
X

100 or fewer

X

101-500

T

AF

R

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 and disregarding loading factor ................................................

4b

D

5
6

001

Employer Identification Number (EIN)

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 the box and complete items (a) and (b) ........................................... X
a
b



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.092308.1

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...................................................

Reduction in balances due to elections or deemed elections......................................
Balance at beginning of current year (item 9 + item 10 + item 11d – item 12) ............

T

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

(b) Amount paid by
employer(s)

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

12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234

(a) Date
(MM-DD-YYYY)

(b) Amount paid by
employer(s)

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

D

19

(c) Amount paid by
employees

R

(a) Date
(MM-DD-YYYY)

AF

Part IV
Contributions and liquidity shortfalls
18 Contributions made to the plan for the plan year by employer(s) and employees:

Totals ►

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
employees

-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:
1st segment:
2nd segment:
3rd segment:
a Segment rates:
X N/A, full yield curve used
123.12_%
123.12_%
123.12 %
1
b Applicable month (enter code) .......................................................................................................................... 21b
12
22 Weighted average retirement age .......................................................................................................................... 22
23 Mortality table(s) (see instructions)
X Prescribed - combined
X Prescribed - separate
X Substitute
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 contributions from prior years

28

30

T

(item 19a)................................................................................................................................................................
Remaining amount of unpaid minimum required contributions (item 28 minus item 29) ........................................

29
30

AF

Part VIII Minimum required contribution for current year
31 Target normal cost, adjusted, if applicable (see instructions)................................................................................. 31
Outstanding Balance
32 Amortization installments:
-123456789012345
a Net shortfall amortization installment ..........................................................................
-123456789012345
b Waiver amortization installment ..................................................................................
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

R

33

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
Installment

-123456789012345
-123456789012345
-123456789012345
-123456789012345
Total balance

-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

Interest-adjusted excess contributions for current year (see instructions)..............................................................

38
39
40

-123456789012345
-123456789012345
-123456789012345

D

-123456789012345

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