Annual Return/Report of Employee Benefit Plan

2010 Instr for Form 5500

Annual Return/Report of Employee Benefit Plan

OMB: 1545-1610

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Department of the Treasury
Internal Revenue Service

Department of Labor
Employee Benefits
Security Administration

Pension Benefit
Guaranty Corporation

2010
Instructions for Form 5500
Annual Return/Report of Employee Benefit Plan

EFAST2 Processing System
Under the computerized ERISA Filing Acceptance System
(EFAST2), you must electronically file your 2010 Form 5500.
Your Form 5500 entries will be initially screened electronically.
For more information, see the instructions for Electronic Filing
Requirement and the EFAST2 website at www.efast.dol.gov.
You cannot file a paper Form 5500 by mail or other delivery
service.

About the Form 5500

The Form 5500, Annual Return/Report of Employee Benefit
Plan, including all required schedules and attachments (Form
5500 return/report), is used to report information concerning
employee benefit plans and Direct Filing Entities (DFEs). Any
administrator or sponsor of an employee benefit plan subject to
ERISA must file information about each benefit plan every year
(pursuant to Code section 6058 and ERISA sections 104 and
4065). Some plans participate in certain trusts, accounts, and
other investment arrangements that file a Form 5500 annual
return/report as DFEs. See Who Must File and When To File.
The Internal Revenue Service (IRS), Department of Labor
(DOL), and Pension Benefit Guaranty Corporation (PBGC)
have consolidated certain returns and report forms to reduce
the filing burden for plan administrators and employers.
Employers and administrators who comply with the instructions
for the Form 5500 generally will satisfy the annual reporting
requirements for the IRS and DOL.
Defined contribution and defined benefit pension plans may
have to file additional information with the IRS including Form
5330, Return of Excise Taxes Related to Employee Benefit
Plans, and Form 5310-A, Notice of Plan Mergers or
Consolidated, Spinoff, or Transfer of Plan Assets or Liabilities;
Notice of Qualified Separate Lines of Business. See www.irs.
gov for more information.
Plans covered by the PBGC have special additional
requirements, including premiums and reporting certain

and the EFAST2 website at www.efast.dol.gov. Your Form
5500 entries will be initially screened electronically. Your
entries must satisfy this screening for your filing to be received.
Once received, your form may be subject to further detailed
review, and your filing may be rejected based upon this further
review.
ERISA and the Code provide for the assessment or
imposition of penalties for not submitting the required
information when due. See Penalties.
Annual reports filed under Title I of ERISA must be made
available by plan administrators to plan participants and
beneficiaries and by the DOL to the public pursuant to ERISA
sections 104 and 106. Pursuant to Section 504 of the Pension
Protection Act of 2006 (PPA), this availability for defined
benefit pension plans must include the posting of identification
and basic plan information and actuarial information on any
plan sponsor intranet website (or website maintained by the
plan administrator on behalf of the plan sponsor) that is used
for the purpose of communicating with employees and not the
public. Section 504 also requires DOL to display such

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

(www.pbgc.gov/practitioners/) for information on premium
payments and reporting and disclosure.
Each Form 5500 must accurately reflect the characteristics
and operations of the plan or arrangement being reported. The
requirements for completing the Form 5500 will vary according
to the type of plan or arrangement. The section What To File
summarizes what information must be reported for different
types of plans and arrangements. The Quick Reference Chart
of Form 5500, Schedules and Attachments, gives a brief guide
to the annual return/report requirements of the 2010 Form
5500.
The Form 5500 must be filed electronically as noted above.
See How To File Electronic Filing Requirement instructions

including actuarial information, see www.dol.gov/ebsa. See
www.dol.gov/ebsa/actuarialsearch. html for 2008 and short
plan year 2009 actuarial information filed under the previous
paper-based system.

Changes to Note
Eligible Combined Plans. The Pension Protection Act of
new type of pension plan,
after December 31, 2009. An eligible combined plan consists
of a defined benefit plan and a defined contribution plan that
includes a qualified cash or deferred arrangement under Code
section 401(k), with the assets of the two plans held in a single
trust, but clearly identified and allocated between the plans.
The eligible combined plan design is available only to
employers that employed an average of at least 2 but not more
than 500 employees on each business day during the calendar
year preceding the plan year as of which the eligible combined
plan is established and that employs at least 2 employees on
the first day of the plan year. Because an eligible combined
plan includes both a defined benefit plan and a defined
contribution plan, the Form 5500 filed for the plan must include
all the information, schedules and attachments that would be
required for either a defined benefit plan (such as Schedule
SB) or a defined contribution plan.
2010 Short Plan Year Filings for Defined Benefit
Plans Required to File Actuarial Information. Based on
anticipated regulatory guidance related to the Pension
Protection Act of 2006 (PPA) that is to be finalized, availability
of Schedules SB and MB for the 2010 plan year will be
delayed. Short plan year filers for the 2010 plan year, other
than money purchase pension plan filers required to file
Schedule MB, must not use the 2009 Schedule SB (Single-

Cat. No. 13502B

Employer Defined Benefit Plan Actuarial Information) or
Schedule MB (Multiemployer Defined Benefit Plan and Certain
Money Purchase Plan Actuarial Information) for 2010 short
plan year filings.

How To Get Assistance
If you need help completing this form or have related
questions, call the EFAST2 Help Line at 1-866-GO-EFAST
(1-866-463-3278) (toll-free). The EFAST2 Help Line is
available Monday through Friday from 8:00 am to 8:00 pm,
Eastern Time.
You can access the EFAST2 website 24 hours a day, 7
days a week at www.efast.dol.gov to:
File the Form 5500-SF or 5500, and any needed schedules
or attachments.
Check on the status of a filing you submitted.
View filings posted by EFAST2.
Register for electronic credentials to sign or submit filings.
View forms and related instructions.
Get information regarding EFAST2, including approved
software vendors.
See answers to frequently asked questions about the Form
5500-SF, the Form 5500 and its schedules, and EFAST2.
Access the main EBSA and DOL websites for news,
regulations, and publications.

Short plan year filers who are required to file a Schedule SB or
MB with respect to a defined benefit plan cannot file their 2010
filings until the 2010 Schedule SB and MB become available
for filing. Only these filers are granted an automatic extension
of time for filing their complete Form 5500 until 90 days after
the 2010 Schedules SB and MB are made available for filing
through EFAST2.

You can access the IRS website 24 hours a day, 7 days a
week at www.irs.gov to:
View forms, instructions, and publications.
See answers to frequently asked tax questions.
Search publications on-line by topic or keyword.
Send comments or request help by e-mail.
Sign up to receive local and national tax news by e-mail.

Table of Contents
Page
Section 1: Who Must File ............................................... 2
Pension Benefit Plan ..................................................... 2
Welfare Benefit Plan ..................................................... 3
Direct Filing Entity (DFE) ............................................... 4
Section 2: When To File.................................................. 4
Extension of Time To File ............................................. 4
Section 3: Electronic Filing Requirement ..................... 5
Amended Return/Report................................................ 6
Final Return/Report ....................................................... 6
Signature and Date ....................................................... 6
Change in Plan Year ..................................................... 6
Penalties........................................................................ 6
Administrative Penalties .............................................. 6
Other Penalties ............................................................ 7
Section 4: What To File .................................................. 7
Form 5500 Schedules ................................................... 7
Pension Schedules ................................................... 7
General Schedules .................................................... 7
Pension Benefit Plan Filing Requirements .................... 8
Limited Pension Plan Reporting ................................. 8
Welfare Benefit Plan Filing Requirements ..................... 9
Direct Filing Entity (DFE) Filing Requirements .............. 9
Master Trust Investment Account (MTIA) .................. 9
Common/Collective Trust (CCT) and Pooled
Separate Account (PSA) .......................................... 10
103-12 Investment Entity (103-12 IE) .......................... 10
Group Insurance Arrangement (GIA) .......................... 11
Quick Reference Chart of Form 5500, Schedules, and
Attachments ............................................................. 12
Section 5: Line-by-Line Instructions for the 2010
Form 5500 and Schedules ........................................ 14
Part I (Form 5500) Annual Return/Report Identification
Information ............................................................... 14
Part II (Form 5500) Basic Plan Information .............. 15
Schedule A Insurance Information ........................... 21
Schedule C Service Provider Information ................. 24
Schedule D DFE/Participating Plan Information ....... 29
Schedule G Financial Transaction Schedules .......... 31
Schedule H Financial Information............................. 33
Schedule I Financial Information Small Plan ......... 43
Schedule MB Multiemployer Defined Benefit Plan and
Certain Money Purchase Plan Actuarial
Information ............................................................... 51
Schedule R Retirement Plan Information ................. 52
Schedule SB Single-Employer Defined Benefit Plan
Actuarial Information ................................................ 57
Paperwork Reduction Act Notice ............................... 58
Codes for Principal Business Activity ........................ 59
ERISA Compliance Quick Checklist ............................ 62
Index .............................................................................. 63

You can order related forms and IRS publications by calling
1-800-TAX-FORM (1-800-829-3676). You can order EBSA
publications by calling 1-866-444-EBSA (3272).

Section 1: Who Must File

A return/report must be filed every year for every pension
benefit plan, welfare benefit plan, and for every entity that files
as a DFE as specified below (pursuant to Code section 6058
and ERISA sections 104 and 4065).
If you are a small plan (generally under 100 participants at
the beginning of the plan year), you may be eligible to file the
Form 5500-SF instead of the Form 5500. For more information,
see the instructions to the Form 5500-SF.

Pension Benefit Plan
All pension benefit plans covered by ERISA must file an annual
return/report except as provided in this section. The return/
benefits no longer accrue, contributions were not made this
plan year, or contributions are no longer made. Pension benefit
plans required to file include both defined benefit plans and
defined contribution plans.
The following are among the pension benefit plans for
which a return/report must be filed.
1. Profit-sharing plans, stock bonus plans, money
purchase plans, 401(k) plans, etc.
2. Annuity arrangements under Code section 403(b)(1) and
custodial accounts established under Code section 403(b)(7)
for regulated investment company stock.
3. Individual retirement accounts (IRAs) established by an
employer under Code section 408(c).
4. Church pension plans electing coverage under Code
section 410(d).

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General Instructions to Form 5500

5. Pension benefit plans that cover residents of Puerto
Rico, the U.S. Virgin Islands, Guam, Wake Island, or American
Samoa. This includes a plan that elects to have the provisions
of section 1022(i)(2) of ERISA apply.
6. Plans that satisfy the Actual Deferral Percentage
requirements of Code section 401(k)(3)(A)(ii) by adopting the

Employer Welfare Arrangement (MEWA) as defined in ERISA
section 3(40) must file a Form 5500, unless otherwise exempt.

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

See What To File for more information about what must be
completed for pension plans.

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

1. An unfunded excess benefit plan. See ERISA section
4(b)(5).
2. An annuity or custodial account arrangement under
Code sections 403(b)(1) or (7) not established or maintained
by an employer as described in DOL Regulation 29 CFR
2510.3-2(f).
3. A Savings Incentive Match Plan for Employees of Small
Employers (SIMPLE) that involves SIMPLE IRAs under Code
section 408(p).
4. A simplified employee pension (SEP) or a salary
reduction SEP described in Code section 408(k) that conforms
to the alternative method of compliance in 29 CFR 2520.10448 or 2520.104-49.
5. A church plan not electing coverage under Code section
410(d).
6. A pension plan that is maintained outside the United
States primarily for the benefit of persons substantially all of
whom are nonresident aliens.
7. An unfunded pension plan for a select group of
management or highly compensated employees that meets the
requirements of 29 CFR 2520.104-23, including timely filing of
a registration statement with the DOL.
8. An unfunded dues financed pension benefit plan that
meets the alternative method of compliance provided by 29
CFR 2520.104-27.
9. An individual retirement account or annuity not
considered a pension plan under 29 CFR 2510.3-2(d).
10. A governmental plan.
11. One-Participant (Owners and Their Spouses)
Retirement Plan (generally referred to as a One-Participant
Plan). However, one-participant plans must file either the Form
5500-EZ, Annual Return of One-Participant (Owners and Their
Spouses) Retirement Plan, with the IRS or, if eligible, may file
the Form 5500-SF, Short Form Annual Return/Report of
Employee Benefit Plan, electronically with EFAST. For this
purpose, a one-participant plan is:
a. a pension benefit plan that covers only an individual or
an individual and his or her spouse who wholly own a trade or
business, whether incorporated or unincorporated; or
b. a pension benefit plan for a partnership that covers only
the partners or the

1. A welfare benefit plan that covered fewer than 100
participants as of the beginning of the plan year and is
unfunded, fully insured, or a combination of insured and
unfunded.
Note. To determine whether the plan covers fewer than 100
participants for purposes of these filing exemptions for insured
and unfunded welfare plans, see instructions for lines 5 and 6
on counting participants in a welfare plan. See also 29 CFR
2510.3-3(d).
a. An unfunded welfare benefit plan has its benefits paid as
needed directly from the general assets of the employer or
employee organization that sponsors the plan.
Note. Plans that are NOT unfunded include those plans that
received employee (or former employee) contributions during
the plan year and/or used a trust or separately maintained fund
(including a Code section 501(c)(9) trust) to hold plan assets or
act as a conduit for the transfer of plan assets during the year.
A welfare plan with employee contributions that is associated
with a cafeteria plan under Code section 125 may be treated
for annual reporting purposes as an unfunded welfare plan if it
meets the requirements of DOL Technical Release 92-01, 57
Fed. Reg. 23272 (June 2, 1992) and 58 Fed. Reg. 45359 (Aug.
27, 1993). The mere receipt of COBRA contributions or other
after-tax participant contributions (e.g., retiree contributions) by
a cafeteria plan would not by itself affect the availability of the
relief provided for cafeteria plans that otherwise meet the
requirements of DOL Technical Release 92-01. See 61 Fed.
Reg. 41220, 41222-23 (Aug. 7, 1996).

See the instructions to the Form 5500-EZ and the Form 5500SF for eligibility conditions and filing requirements. For more
information, go to www.irs.gov/ep or call 1-877-829-5500.

Welfare Benefit Plan
All welfare benefit plans covered by ERISA are required to file
a Form 5500 except as provided in this section. Welfare benefit
plans provide benefits such as medical, dental, life insurance,
apprenticeship and training, scholarship funds, severance pay,
disability, etc. See What To File for more information.
Reminder: The administrator of an employee welfare benefit
plan that provides benefits wholly or partially through a Multiple
General Instructions to Form 5500

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b. A fully insured welfare benefit plan has its benefits
provided exclusively through insurance contracts or policies,
the premiums of which must be paid directly to the insurance
carrier by the employer or employee organization from its
general assets or partly from its general assets and partly from
contributions by its employees or members (which the
employer or employee organization forwards within three (3)
months of receipt). The insurance contracts or policies
discussed above must be issued by an insurance company or
similar organization (such as Blue Cross, Blue Shield or a
health maintenance organization) that is qualified to do
business in any state.
c. A combination unfunded/insured welfare plan has its
benefits provided partially as an unfunded plan and partially as
a fully insured plan. An example of such a plan is a welfare
benefit plan that provides medical benefits as in a above and
life insurance benefits as in b above. See 29 CFR 2520.10420.
Note.
used in Code section 5
confused with the employer or employee organization that
sponsors the plan. See ERISA section 3(4).
2. A welfare benefit plan maintained outside the United
States primarily for persons substantially all of whom are
nonresident aliens.
3. A governmental plan.
4. An unfunded or insured welfare benefit plan maintained
for a select group of management or highly compensated
employees, which meets the requirements of 29 CFR
2520.104-24.

Notes. (1) If the filing due date falls on a Saturday, Sunday, or
Federal holiday, the return/report may be filed on the next day
that is not a Saturday, Sunday, or Federal holiday. (2) If the
2011 Form 5500 is not available before the plan or DFE filing
use the 2010 Form 5500 and enter the 2011 fiscal year
beginning and ending dates on the line provided at the top of
the form.

5. An employee benefit plan maintained only to comply
disability insurance laws.
6. A welfare benefit plan that participates in a group
insurance arrangement that files a Form 5500 on behalf of the
welfare benefit plan as specified in 29 CFR 2520.103-2. See
29 CFR 2520.104-43.
7. An apprenticeship or training plan meeting all of the
conditions specified in 29 CFR 2520.104-22.
8. An unfunded dues financed welfare benefit plan
exempted by 29 CFR 2520.104-26.
9. A church plan under ERISA section 3(33).
10. A welfare benefit plan maintained solely for (1) an
individual or an individual and his or her spouse, who wholly
own a trade or business, whether incorporated or
unincorporated, or (2) partners or the partners and the
-3(b).
pa

2010 Short Plan Year Filings. Based on anticipated
regulatory guidance related to the Pension Protection Act of
2006 (PPA) that is to be finalized, for the 2010 plan year,
defined benefit plan filers will not be able to use the 2009
Schedule SB (Single-Employer Defined Benefit Plan Actuarial
Information) or Schedule MB (Multiemployer Defined Benefit
Plan and Certain Money Purchase Plan Actuarial Information)
for 2010 short plan year filings.
Accordingly, short plan year filers who are required to file a
Schedule SB or Schedule MB, other than money purchase
pension plan filers who are required to file Schedule MB,
cannot file their 2010 filings until the 2010 Schedules SB and
MB become available for filing. These filers are granted an
automatic extension of time for filing their complete Form 5500
until 90 days after the 2010 Schedules SB and MB are made
available for filing through EFAST2.
Short plan year filers using this extension of time must
check Form 5500, Part I, box D, and enter into the space

Some plans participate in certain trusts, accounts, and other
investment arrangements that file the Form 5500 annual
return/report as a DFE in accordance with the Direct Filing
Entity (DFE) Filing Requirements. A Form 5500 must be filed
for a master trust investment account (MTIA). A Form 5500 is
not required but may be filed for a common/collective trust
(CCT), pooled separate account (PSA), 103-12 investment
entity (103-12 IE), or group insurance arrangement (GIA).
Plans that participate in CCTs, PSAs, 103-12 IEs, or GIAs that
file as DFEs, however, generally are eligible for certain annual
reporting relief. For reporting purposes, a CCT, PSA, 103-12
IE, or GIA is not considered a DFE unless a Form 5500 and all
required attachments are filed for it in accordance with the
Direct Filing Entity (DFE) Filing Requirements.
Note. Special requirements also apply to Schedules D and H
attached to the Form 5500 filed by plans participating in
MTIAs, CCTs, PSAs, and 103-12 IEs. See these schedules
and their instructions.

Direct Filing Entity (DFE)

Note: 2010 short plan year filers (other than defined benefit
plan filers required to file an actuarial schedule) must use the
2010 forms and schedules and are not granted an extension of
time.

Extension of Time To File
Using Form 5558
A plan or GIA may obtain a one-time extension of time to file a
Form 5500 annual return/report (up to 2½ months) by filing IRS
Form 5558, Application for Extension of Time To File Certain
Employee Plan Returns, on or before the normal due date (not
including any extensions) of the return/report. You MUST file
Form 5558 with the IRS. Approved copies of the Form 5558
will not be returned to the filer. A copy of the completed

Section 2: When To File

Plans and GIAs. File 2010 returns/reports for plan and GIA
years that began in 2010. All required forms, schedules,
statements, and attachments must be filed by the last day of
the 7th calendar month after the end of the plan or GIA year
(not to exceed 12 months in length) that began in 2010. If the
plan or GIA year differs from the 2010 calendar year, fill in the
fiscal year beginning and ending dates in the space provided.
DFEs other than GIAs. File 2010 returns/reports no later
than 9½ months after the end of the DFE year that ended in
2010. A Form 5500 filed for a DFE must report information for
the DFE year (not to exceed 12 months in length). If the DFE
year differs from the 2010 calendar year, fill in the fiscal year
beginning and ending dates in the space provided.
Short Years. For a plan year of less than 12 months (short
plan year), file the form and applicable schedules by the last
day of the 7th calendar month after the short plan year ends or
by the extended due date, if filing under an authorized
extension of time. Fill in the short plan year beginning and
ending dates in the space provided and check the appropriate
box in Part I, line B, of the Form 5500. For purposes of this
return/report, the short plan year ends on the date of the
change in accounting period or upon the complete distribution
of assets of the plan. Also see the instructions for Final Return/
Report to
should be checked.

records.
File Form 5558 with the Department of the Treasury,
Internal Revenue Service Center, Ogden, UT 84201-0027.
Using Extension of Time To File Federal Income Tax
Return
An automatic extension of time to file the Form 5500 annual
return/report until the due date of the federal income tax return
of the employer will be granted if all of the following conditions
are met: (1)
same; (2) the employer has been granted an extension of time
to file its federal income tax return to a date later than the
normal due date for filing the Form 5500; and (3) a copy of the
application for extension of time to file the federal income tax
granted by using this automatic extension procedure CANNOT
be extended further by filing a Form 5558, nor can it be
extended beyond a total of 9½ months beyond the close of the
plan year.

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General Instructions to Form 5500

Note. An extension of time to file the Form 5500 does not
operate as an extension of time to file a Form 5500 filed for a
DFE (other than a GIA) or to file PBGC premiums or annual
financial and actuarial reports (if required by section 4010 of
ERISA).

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

Delinquent Filer Voluntary Compliance (DFVC)
Program

forms and schedules cannot be left blank, unless specifically
oth.
All schedules and attachments to the Form 5500 must be
properly identified, and must include the name of the plan or
DFE, EIN, and plan number (PN) as found on the Form 5500,
lines, 1a, 2b, and 1b, respectively. At the top of each
attachment, indicate the schedule and line, if any (e.g.,
Schedule H, line 4i) to which the attachment relates.
You should check your return/report for errors before
signing or submitting it to EFAST2. Your filing software or, if
you are using it, the EFAST2 web-based filing system will allow
you to check your return/report for errors. If, after reasonable
attempts to correct your filing to eliminate any identified
problem or problems, you are unable to address them, or you
believe that you are receiving the message in error, call the
EFAST2 Help Line at 1-866-GO-EFAST (1-866-463-3278) or
contact the service provider you used to help prepare and file
your annual return/report.
Once you complete the return/report and finish the
electronic signature process, you can electronically submit it to
EFAST2. When you electronically submit your return/report,
EFAST2 is designed to immediately notify you if your
submission was received and whether the return/report is
ready to be processed by EFAST2. If EFAST2 does not notify
you that your submission was successfully received and is
ready to be processed, you will need to take steps to correct
the problem or you may be deemed a non-filer subject to
penalties from DOL, IRS, and/or PBGC.
Once EFAST2 receives your return/report, the EFAST2
system should be able to provide a filing status within 20
minutes. The person submitting the filing should check back
into the EFAST2 system to determine the filing status of your
return/report. The filing status message will include a list of any
filing errors or warnings that EFAST2 may have identified in
your filing. If EFAST2 did not identify any filing errors or
warnings, EFAST2 will show the filing status of your return/

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

answer all questions on the 2010 Form 5500 with respect to
the 2010 plan year unless otherwise explicitly stated in the
instructions or on the form itself.
Your entries must be in the proper format in order for the
EFAST2 system to process your filing. For example, if a
question requires you to enter a dollar amount, you cannot
enter a word. Your software will not let you submit your return/
report unless all entries are in the proper format. To reduce the
possibility of correspondence and penalties:
Complete all lines on the Form 5500 unless otherwise
specified. Also complete and electronically attach, as required,
applicable schedules and attachments.

Section 3: Electronic Filing Requirement
Under the computerized ERISA Filing Acceptance System
(EFAST2), you must file your 2010 Form 5500 annual return/
based filing system or you may file through an EFAST2approved vendor. Detailed information on electronic filing is
available at www.efast.dol.gov. For telephone assistance, call
the EFAST2 Help Line at 1-866-GO-EFAST (1-866-463-3278).
The EFAST2 Help Line is available Monday through Friday
from 8:00 am to 8:00 pm, Eastern Time.
Annual returns/reports filed under Title I of ERISA
must be made available by plan administrators to plan
participants and beneficiaries and by the DOL to the
public pursuant to ERISA sections 104 and 106. Even though
the Form 5500 must be filed electronically, the administrator
must keep a copy of the Form 5500, including schedules and
attachments, with all required signatures on file as part of the
request to participants, beneficiaries, and the DOL as required
by section 104 of ERISA and 29 CFR 2520.103-1. Filers may
use electronic media for record maintenance and retention, so
long as they meet the applicable requirements.
Generally, questions on the Form 5500 relate to the plan
year entered at the top of the first page of the form. Therefore,
General Instructions to Form 5500

-5-

can check whether the filing was received by calling the
EFAST2 Help Line at 1-866-GO-EFAST (1-866-463-3278) and
using the automated telephone system.
To reduce the possibility of correspondence and penalties
from the DOL, IRS, and/or PBGC, you should do the following:
(1) Before submitting your return/report to EFAST2, check it for
errors, and (2) after you have submitted it to EFAST2, verify
attempt to correct and resolve any errors or warnings listed in
the status report.
Note. Even after being received by the EFAST2 system, your
return/report filing may be subject to further detailed review by
DOL, IRS, and/or PBGC, and your filing may be deemed
deficient based upon this further review.

Do not enter social security numbers in response to
questions asking for an employer identification
number (EIN). Because of privacy concerns, the
inclusion of a social security number on the Form 5500 or on a
schedule or attachment that is open to public inspection may
result in the rejection of the filing. If you discover a filing
disclosed on the EFAST2 website that contains a social
security number, immediately call the EFAST2 Help Line at 1866-GO-EFAST (1-866-463-3278).
Do not attach a copy of the annual registration statement
identifying separated participants with deferred vested benefits,
-SSA or Schedule SSA (Form
5500) to your 2010 Form 5500 annual return/report. The
annual registration statement must be filed directly with the IRS
and cannot be attached to a Form 5500 submission with
EFAST2.
Employers without an EIN must apply for one as soon as
possible. The EBSA does not issue EINs. To apply for an EIN
from the IRS:
Mail or fax Form SS-4, Application for Employer
Identification Number, obtained by calling 1-800-TAX-FORM
(1-800-829-3676) or at the IRS website at www.irs.gov.
Call 1-800-829-4933 to receive your EIN by telephone.
Select the Online EIN Application link at www.irs.gov. The
EIN is issued immediately once the application information is
validated. (The online application process is not yet available
for corporations with addresses in foreign countries or Puerto
Rico.)

months or less) that ends when all plan assets were legally
transferred to the control of another plan.

Pension and Welfare Plans That Terminated Without
Distributing All Assets
If the plan was terminated, but all plan assets were not
distributed, a return/report must be filed for each year the plan
has assets. The return/report must be filed by the plan
administrator, if designated, or by the person or persons who

Welfare Plans Still Liable To Pay Benefits
A welfare plan cannot file a final return/report if the plan is still
liable to pay benefits for claims that were incurred prior to the
termination date, but not yet paid. See 29 CFR 2520.104b2(g)(2)(ii).

Signature and Date

Amended Return/Report

For purposes of Title I of ERISA, the plan administrator is
required to file the Form 5500. If the plan administrator does
not sign a filing, the filing status will indicate that there is an
error with your filing, and your filing will be subject to further
review, correspondence, rejection, and civil penalties. The
plan administrator or, if the plan administrator is an entity, a
person authorized to sign on behalf of the plan administrator
must electronically sign the Form 5500 submitted to EFAST2.
Note. The Code permit either the plan sponsor/employer or
the administrator to sign the filing. However, any Form 5500
that is not electronically signed by the plan administrator will be
subject to rejection and civil penalties under Title I of ERISA.
For DFE filings, a person authorized to sign on behalf of the
DFE must sign for the DFE.
The Form 5500 annual return/report must be filed
electronically and signed. To obtain an electronic signature, go
to www.efast. dol.gov and register in EFAST2 as a signer. You
will be provided with a UserID and PIN. Both the UserID and
PIN are needed to sign the Form 5500. The plan administrator
must keep a copy of the Form 5500, including schedules and
attachments with all required signatures on file as part of the
-1.

File an amended return/report to correct errors and/or
omissions in a previously filed annual return/report for the 2010
plan year. The amended Form 5500 and any amended
schedules and/or attachments must conform to the
requirements in these instructions. See the DOL website at
www.efast.dol.gov for information on filing amended returns/
reports for prior years.

you filed a previous 2010 annual return/report that

Electronic signatures on annual returns/reports filed under
EFAST2 are governed by the applicable statutory and
regulatory requirements.

submission attempts were not successfully received by EFAST2
because of problems with the transmission of your return/report.
For more information, go to the EFAST2 website at
www.efast.dol.gov or call the EFAST2 Help Line at 1-866-GOEFAST (1-866-463-3278).

Change in Plan Year
Generally, only defined benefit pension plans need to get
approval for a change in the plan year. (See Code section
412(c)(5).) However, under Rev. Proc. 87-27, 1987-1 C.B. 769,
these pension plans may be eligible for automatic approval of a
change in plan year.
If a change in plan year for a pension or a welfare plan creates
a short plan year, the appropriate box in Part I, line B, of the
Form 5500 must be checked, and a Form 5500, with all
required schedules and attachments, must be filed by the last
day of the 7th calendar month after the end of the short plan
year.

Final Return/Report
If all assets under the plan (including insurance/annuity
contracts) have been distributed to the participants and
beneficiaries or legally transferred to the control of another
plan, and when all liabilities for which benefits may be paid
under a welfare benefit plan have been satisfied, check the
final return/report box in Part I, line B at the top of the Form
5500. If a trustee is appointed for a terminated defined benefit
plan pursuant to ERISA section 4042, the last plan year for
which a return/report must be filed is the year in which the
trustee is appointed.

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

Examples:
Mergers/Consolidations
A final return/report should be filed for the plan year (12
-6-

General Instructions to Form 5500

administer the collection of the annual return/report data).
Others require a legal conviction.

return/report filed for a plan that covered 100 or more
participants as of the beginning of the plan year should be

Administrative Penalties

Other Penalties

Exceptions:
(1) 80-120 Participant Rule: If the number of participants
reported on line 5 is between 80 and 120, and a Form 5500
annual return/report was filed for the prior plan year, you may
led for the prior return/report.
Thus, if a Form 5500 annual return/report was filed for the
2009 plan year as a small plan, including the Schedule I if
applicable, and the number entered on line 5 of the 2010 Form
5500 is 120 or less, you may elect to complete the 2010 Form
5500 and schedules in accordance with the instructions for a
small plan, including for eligible filers, filing the Form 5500-SF
instead of the Form 5500.
(2) Short Plan Year Rule: If the plan had a short plan year
of seven (7) months or less for either the prior plan year or the
plan year being reported on the 2010 Form 5500, an election
accordance with 29 CFR 2520.104-50. If such an election was
made for the prior plan year, the 2010 Form 5500 must be
completed following the requirements for a large plan,
including the attachment of the Schedule H and the

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

Use the number of participants required to be entered in line
5 of the Form 5500 to

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

Section 4: What To File

The Form 5500 reporting requirements vary depending on

or DFE involved (e.g., welfare plan, pension plan,
common/collective trust (CCT), pooled separate account
(PSA), master trust investment account (MTIA), 103-12 IE, or
group insurance arrangement (GIA)).
The instructions below provide detailed information about
each of the Form 5500 schedules and which plans and DFEs
are required to file them.
The schedules are grouped in the instructions by type: (1)
Pension Benefit Schedules and (2) General Schedules. Each
schedule is listed separately with a description of the subject
matter covered by the schedule and the plans and DFEs that
are required to file the schedule.
Filing requirements also are listed by type of filer: (1)
Pension Benefit Plan Filing Requirements; (2) Welfare Benefit
Plan Filing Requirements; and (3) DFE Filing Requirements.
For each filer type there is a separate list of the schedules that
must be filed with the Form 5500 (including where applicable,
separate lists for large plan filers, small plan filers, and different
types of DFEs).
Quick
Reference Chart of Form 5500, Schedules, and Attachments
Generally, a return/report filed for a pension benefit plan or
welfare benefit plan that covered fewer than 100 participants
as of the beginning of the plan year should be completed
General Instructions to Form 5500

-7-

entered in Part II, line 5.

Form 5500 Schedules
Pension Schedules
Schedule R (Retirement Plan Information) is required for
a pension benefit plan that is a defined benefit plan or is
otherwise subject to Code section 412 or ERISA section 302.
Schedule R may also be required for certain other pension
benefit plans unless otherwise specified under Limited Pension
Plan Reporting. For additional information, see the Schedule R
instructions.

Schedule MB (Multiemployer Defined Benefit Plan and
Certain Money Purchase Plan Actuarial Information) is
required for most multiemployer defined benefit plans and for
defined contribution pension plans that currently amortize a
waiver of the minimum funding requirements specified in the
instructions for the Schedule MB. For additional information,
see the instructions for the Schedule MB and the Schedule R.
Schedule SB (Single-Employer Defined Benefit Plan
Actuarial Information) is required for most single-employer
defined benefit plans, including multiple-employer defined
benefit pension plans. For additional information, see the
instructions for the Schedule SB.

General Schedules
Schedule H (Financial Information)

is required for

-12
IEs, and GIAs filing the Schedule H are generally required to
engage an independent qualified public accountant (IQPA) and
attach a report of the IQPA pursuant to ERISA section
103(a)(3)(A). These plans and DFEs are also generally
required to attach to the Form 5500 a
(Held At
Schedule of
Assets (Acquired an
a

and a
of Delinquent
For additional
information, see the Schedule H instructions.

Small Pension Plan
The following schedules (including any additional information
required by the instructions to the schedules) must be attached
to a Form 5500 filed for a small pension plan that is neither
exempt from filing nor is filing the Form 5500-SF:

Exceptions: Insured, unfunded, or combination
unfunded/insured welfare plans, as described in 29 CFR
2520.104-44(b)(1), and certain pension plans and
arrangements, as described in 29 CFR 2520.104-44(b)(2), and
in Limited Pension Plan Reporting, are exempt from
completing the Schedule H.

1. Schedule A (as many as needed), to report insurance,
annuity, and investment contracts held by the plan.
2. Schedule D, Part I, to list any CCTs, PSAs, MTIAs, and
103-12 IEs in which the plan participated at any time during the
plan year.
3. Schedule I, to report small plan financial information,
unless exempt.
4. Schedule MB or SB, to report actuarial information, if
applicable.
5. Schedule R, to report retirement plan information, if
applicable.

Schedule I (Financial Information - Small Plan) i s
required for all pension benefit plans and welfare benefit plans
filing the Form 5500 annual return/report, rather than the Form
pension benefit
5500plans and arrangements described in 29 CFR 2520.10444(b)(2) and Limited Pension Plan Reporting. For additional
information, see the Schedule I instructions.

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

Large Pension Plan

The following schedules (including any additional information
required by the instructions to the schedules) must be attached
to a Form 5500 filed for a large pension plan:

Note. Do not file Schedule A for Administrative Services Only
(ASO) contracts. Do not file Schedule A if a Schedule A is filed
for the contract as part of the Form 5500 filed directly by a
master trust investment account (MTIA) or 103-12 IE.

attach the report of the independent qualified public
accountant (IQPA) or a statement that the plan is

Schedule A (Insurance Information) is required if any
benefits under an employee benefit plan are provided by an
insurance company, insurance service or other similar
organization (such as Blue Cross, Blue Shield, or a health
maintenance organization). This includes investment contracts
with insurance companies, such as guaranteed investment
contracts and pooled separate accounts. For additional
information, see the Schedule A instructions.

1. Schedule A (as many as needed), to report insurance,
annuity, and investment contracts held by the plan.
2. Schedule C, if applicable, to report information on service
providers and, if applicable, any terminated accountants or
enrolled actuaries.
3. Schedule D, Part I, to list any CCTs, PSAs, MTIAs, and
103-12 IEs in which the plan invested at any time during the
plan year.
4. Schedule G, to report loans or fixed income obligations in
default or determined to be uncollectible as of the end of the
plan year, leases in default or classified as uncollectible, and
nonexempt transactions, i.e., file Schedule G if Schedule H

Schedule C (Service Provider Information) is required
for a large plan, MTIA, 103-12 IE, or GIA if (1) any service
provider who rendered services to the plan or DFE during the
plan or DFE year received $5,000 or more in compensation,
directly or indirectly from the plan or DFE, or (2) an accountant
and/or enrolled actuary has been terminated. For additional
information, see the Schedule C instructions.

Schedule D (DFE/Participating Plan Information) Part I
is required for a plan or DFE that invested or participated in
any MTIAs, 103-12 IEs, CCTs, and/or PSAs. Part II is required
when the Form 5500 is filed for a DFE. For additional
information, see the Schedule D instructions.

5. Schedule H, to report large plan financial information,
unless exempt.
6. Schedule MB or SB, to report actuarial information, if
applicable.
7. Schedule R, to report retirement plan information, if
applicable.

Schedule G (Financial Transaction Schedules) is
required for a large plan, MTIA, 103-12 IE, or GIA when
Schedule H (Financial Information) lines 4b, 4c, and/or 4d are
income obligations in default or classified as uncollectible. Part
II of the Schedule G reports leases in default or classified as
uncollectible. Part III of the Schedule G reports nonexempt
transactions. For additional information, see the Schedule G
instructions.

You must attach the report of the independent
qualified public accountant (IQPA) identified on
Schedule H, line 3c, unless line 3d(2) is checked.

Limited Pension Plan Reporting

An unfunded, fully insured, or combination unfunded/
insured welfare plan with 100 or more participants
exempt under 29 CFR 2520.104-44 from completing
Schedule H must still complete Schedule G, Part III, to report
nonexempt transactions.

The pension benefit plans or arrangements described below
are eligible for limited annual reporting:
1. IRA Plans: A pension plan using individual retirement
accounts or annuities (as described in Code section 408) as
the sole funding vehicle for providing pension benefits need
complete only Form 5500, Part I and Part II, lines 1 through 4,
and 8 (enter pension feature code 2N).
2. Fully Insured Pension Plan: A pension benefit plan
providing benefits exclusively through an insurance contract or
contracts that are fully guaranteed and that meet all of the
conditions of 29 CFR 2520.104-44(b)(2) during the entire plan

Pension Benefit Plan Filing
Requirements
Pension benefit plan filers must complete the Form 5500
annual return/report, including the signature block and, unless
otherwise specified, attach the following schedules and
information:
-8-

General Instructions to Form 5500

year must complete all the requirements listed under this
Pension Benefit Plan Filing Requirements section, except that
such a plan is exempt from attaching Schedule H, Schedule I,

nonexempt transactions.
5. Schedule H, to report financial information, unless
exempt.
Attach the report of the independent qualified public
accountant (IQPA) identified on Schedule H, line 3c,
unless line 3d(2) is checked.

from the requirement to engage an IQPA.
A pension benefit plan that has insurance contracts of the
type described in 29 CFR 2520.104-44 as well as other assets
must complete all requirements for a pension benefit plan,
acts (see
below) should not be reported in Part I of Schedule H or I. All
other assets should be reported on Schedule H or Schedule I,
and any other required schedules. If Schedule H is filed, attach

is generally not exempt from the requirement of engaging an
IQPA.

Direct Filing Entity (DFE) Filing
Requirements

Welfare Benefit Plan Filing Requirements

Welfare benefit plan filers must complete the Form 5500
annual return/report, including the signature block and, unless
otherwise specified, attach the following schedules and
information:

Small Welfare Plan

Some plans participate in certain trusts, accounts, and other
investment arrangements that file the Form 5500 annual
return/report as a DFE. A Form 5500 must be filed for a master
trust investment account (MTIA). A Form 5500 is not required
but may be filed for a common/collective trust (CCT), pooled
separate account (PSA), 103-12 investment entity (103-12 IE),
or group insurance arrangement (GIA). However, plans that
participate in CCTs, PSAs, 103-12 IEs, or GIAs that file as
DFEs generally are eligible for certain annual reporting relief.
For reporting purposes, a CCT, PSA, 103-12 IE, or GIA is
considered a DFE only when a Form 5500 and all required
schedules and attachments are filed for it in accordance with
the following instructions.
Only one Form 5500 should be filed for each DFE for all
plans participating in the DFE; however, the Form 5500 filed
for the DFE, including all required schedules and attachments,
must report information for the DFE year (not to exceed 12
months in length) that ends with or within the participating

instructions.
Note. For purposes of the annual return/report and the
alternative method of compliance set forth in 29 CFR
2520.104the insurance company or organization that issued the contract
unconditionally guarantees, upon receipt of the required
premium or consideration, to provide a retirement benefit of a
specified amount. This amount must be provided to each
participant without adjustment for fluctuations in the market
value of the underlying assets of the company or organization,
and each participant must have a legal right to such benefits,
which is legally enforceable directly against the insurance
company or organization. For example, deposit administration,
immediate participation guarantee, and guaranteed investment
contracts are NOT allocated contracts for Form 5500 annual
return/report purposes.

Neither Schedule H
attached to a Form 5500 filed for an unfunded, fully
insured or combination unfunded/insured welfare plan
that covered 100 or more participants as of the beginning of
the plan year that meets the requirements of 29 CFR
2520.104-44. However, Schedule G, Part III, must be attached
to the Form 5500 to report any nonexempt transactions. A

The following schedules (including any additional information
required by the instructions to the schedules) must be attached
to a Form 5500 filed for a small welfare plan that is neither
exempt from filing nor filing the Form 5500-SF:
1. Schedule A (as many as needed), to report insurance
contracts held by the plan.
2. Schedule D, Part I, to list any CCTs, PSAs, MTIAs, and
103-12 IEs in which the plan participated at any time during the
plan year.
3. Schedule I, to report small plan financial information.

Large Welfare Plan
The following schedules (including any additional information
required by the instructions to the schedules) must be attached
to a Form 5500 filed for a large welfare plan:
1. Schedule A (as many as needed), to report insurance
and investment contracts held by the plan.
2. Schedule C, if applicable, to report information on service
providers and any terminated accountants or actuaries.
3. Schedule D, Part I, to list any CCTs, PSAs, MTIAs, and
103-12 IEs in which the plan invested at any time during the
plan year.
4. Schedule G, to report loans or fixed income obligations in
default or determined to be uncollectible as of the end of the
plan year, leases in default or classified as uncollectible, and
nonexempt transactions, i.e., file Schedule G if Schedule H
large welfare plan that is not required to file a Schedule H has
General Instructions to Form 5500

-9-

Any Form 5500 filed for a DFE is an integral part of the
annual report of each participating plan, and the plan
administrator may be subject to penalties for failing to file a
complete annual report unless both the DFE Form 5500 and
required for a Form 5500 filed for a DFE varies according to
the type of DFE. The following paragraphs provide specific
guidance for the reporting requirements for each type of DFE.

Master Trust Investment Account (MTIA)
The administrator filing a Form 5500 for an employee benefit
plan is required to file or have a designee file a Form 5500 for
each MTIA in which the plan participated at any time during the
which a regulated financial institution (as defined below) serves
as trustee or custodian (regardless of whether such institution
exercises discretionary authority or control with respect to the
management of assets held in the trust), and in which assets of
more than one plan sponsored by a single employer or by a
group of employers under common control are held.
facts and circumstances (whether or not such employers are
incorporated).

company, or similar financial institution that is regulated,
supervised, and subject to periodic examination by a state or

However, the administrator of a large plan or DFE that
participates in a CCT or PSA that files as specified below is
entitled to reporting relief that is not available to plans or DFEs
participating in a CCT or PSA for which a Form 5500 is not
filed.

93-21A (available at www.dol.gov/ebsa).
The assets of a master trust are considered for reporting

(1) a trust
maintained by a bank, trust company, or similar institution or
(2) an account maintained by an insurance carrier, which are
regulated, supervised, and subject to periodic examination by a
state or federal agency in the case of a CCT, or by a state
agency in the case of a PSA, for the collective investment and
reinvestment of assets contributed thereto from employee
benefit plans maintained by more than one employer or
controlled group of corporations as that term is used in Code
section 1563. See 29 CFR 2520.103-3, 103-4, 103-5, and 1039.
Note. For reporting purposes, a separate account that is not
considered to be holding plan assets pursuant to 29 CFR
2510.3-101(h)(1)(iii) does not constitute a pooled separate
account.
The Form 5500 submitted for a CCT or PSA must comply
with the Form 5500 instructions for a Large Pension Plan,
unless otherwise specified in the forms and instructions.
The CCT or PSA must file:
1. Form 5500, except lines C, D, 1c, 2d, and 5 through 9.

assets or a single asset. Each pool of assets held in a master
trust must be treated as a separate MTIA if each plan that has
an interest in the pool has the same fractional interest in each
asset in the pool as its fractional interest in the pool, and if
each such plan may not dispose of its interest in any asset in
the pool without disposing of its interest in the pool. A master
trust may also contain assets that are not held in such a pool.
Each such asset must be treated as a separate MTIA.
set(s)
Notes. (1)
during the reporting period, the plan may report the asset(s)
either as an investment account on an MTIA Form 5500, or as
a plan asset(s) that is not part of the master trust (and
therefore subject to all instructions concerning assets not held
(2) If a master trust
in a
holds assets attributable to participant or beneficiary directed
transactions under an individual account plan and the assets
are interests in registered investment companies, interests in
contracts issued by an insurance company licensed to do
business in any state, interests in common/collective trusts
maintained by a bank, trust company or similar institution, or
the assets have a current value that is readily determinable on
an established market, those assets may be treated as a single
MTIA.
The Form 5500 submitted for the MTIA must comply with
the Form 5500 instructions for a Large Pension Plan, unless
otherwise specified in the forms and instructions. The MTIA
must file:
1. Form 5500, except lines C, D, 1c, 2d, and 5 through 9.
Be c
2. Schedule A (as many as needed) to report insurance,
annuity and investment contracts held by the MTIA.
3. Schedule C, if applicable, to report service provider
information. Part III is not required for an MTIA.
4. Schedule D, to list CCTs, PSAs, and 103-12 IEs in which
the MTIA invested at any time during the MTIA year and to list
all plans that participated in the MTIA during its year.
5. Schedule G, to report loans or fixed income obligations in
default or determined to be uncollectible as of the end of the
MTIA year, all leases in default or classified as uncollectible,
and nonexempt transactions.
6. Schedule H, except lines 1b(1), 1b(2), 1c(8), 1g, 1h, 1i,
2a, 2b(1)(E), 2e, 2f, 2g, 4a, 4e, 4f, 4g, 4h, 4k, 4l, 4m, 4n, and
5, to report financial information. An independent qualified

code.
2. Schedule D, to list all CCTs, PSAs, MTIAs, and 103-12
IEs in which the CCT or PSA invested at any time during the
CCT or PSA year and to list in Part II all plans that participated
in the CCT or PSA during its year.
3. Schedule H, except lines 1b(1), 1b(2), 1c(8), 1d, 1e, 1g,
1h, 1i, 2a, 2b(1)(E), 2e, 2f, and 2g, to report financial

not required for a CCT or PSA.

Different requirements apply to the Schedules D and
H attached to the Form 5500 filed by plans and DFEs
participating in CCTs and PSAs, depending upon
whether a DFE Form 5500 has been filed for the CCT or PSA.
See the instructions for these schedules.

103-12 Investment Entity (103-12 IE)
DOL Regulation 2520.103-12 provides an alternative method
of reporting for plans that invest in an entity (other than an
MTIA,
-101 of two or
employee benefit plans. Such an entity for which a Form 5500
103to be filed for such entities; however, filing a Form 5500 as a
103-12 IE provides certain reporting relief, including the
limitation of the examination and report of the independent
qualified public accountant (IQPA) provided by 29 CFR
2520.103-12(d), to participating plans and DFEs. For this

MTIA.
7. Additional information required by the instructions to the
above schedules, including, for example, the schedules of
assets held for investment and the schedule of reportable
transactions. For purposes of the schedule of reportable
transactions, the 5% figure shall be determined by comparing
the current value of the transaction at the transaction date with
the current value of the investment account assets at the
beginning of the applicable fiscal year of the MTIA. All
attachments must be properly labeled.

consists of each group of two or more employee benefit plans
(1) each of which receives 10% or more of its aggregate
contributions from the same employer or from a member of the
same controlled group of corporations (as determined under
Code section 1563(a), without regard to Code section
1563(a)(4) thereof); or (2) each of which is either maintained
by, or maintained pursuant to a collective-bargaining
agreement negotiated by, the same employee organization or
affiliated employee organizations. For purposes of this
tion means

Common/Collective Trust (CCT) and Pooled
Separate Account (PSA)
A Form 5500 is not required to be filed for a CCT or PSA.
-10-

General Instructions to Form 5500

any person controlling, controlled by, or under common control
with such organization. See 29 CFR 2520.103-12.
The Form 5500 submitted for a 103-12 IE must comply with
the Form 5500 instructions for a Large Pension Plan, unless
otherwise specified in the forms and instructions. The 103-12
IE must file:
1. Form 5500, except lines C, D, 1c, 2d, and 5 through 9.

5500 if a consolidated Form 5500 report for all the plans in the
arrangement was filed in accordance with 29 CFR 2520.104-

2. Schedule A (as many as needed), to report insurance,
annuity and investment contracts held by the 103-12 IE.
3. Schedule C, if applicable, to report service provider
information and any terminated accountants.
4. Schedule D, to list all CCTs, PSAs, and 103-12 IEs in
which the 103-12 IE invested at any time during the 103-12
and to list all plans that participated in the 103-12 IE
during its year.
5. Schedule G, to report loans or fixed income obligations in
default or determined to be uncollectible as of the end of the
103-12 IE year, leases in default or classified as uncollectible,
and nonexempt transactions.
6. Schedule H, except lines 1b(1), 1b(2), 1c(8), 1d, 1e, 1g,
1h, 1i, 2a, 2b(1)(E), 2e, 2f, 2g, 4a, 4e, 4f, 4g, 4h, 4j, 4k, 4l, 4m,
4n, and 5, to report financial information.
7. Additional information required by the instructions to the
above schedules, including, for example, the report of the
independent qualified public accountant (IQPA) identified on
Schedule H, line 3c, and the schedule(s) of assets held for
investment. All attachments must be properly labeled.

provides benefits to the employees of two or more unaffiliated
employers (not in connection with a multiemployer plan or a
collectively-bargained multiple-employer plan), fully insures
one or more welfare plans of each participating employer, uses
a trust or other entity as the holder of the insurance contracts,
and uses a trust as the conduit for payment of premiums to the
insurance company. The GIA must file:
1 . Form 5500, excep
line A, as the DFE code).
2. Schedule A (as many as needed), to report insurance,
annuity and investment contracts held by the GIA.
3. Schedule C, if applicable, to report service provider
information and any terminated accountants.
4. Schedule D, to list all CCTs, PSAs, and 103-12 IEs in
which the GIA invested at any time during the GIA year, and to
list all plans that participated in the GIA during its year.
5. Schedule G, to report loans or fixed income obligations in
default or determined to be uncollectible as of the end of the
GIA year, leases in default or classified as uncollectible, and
nonexempt transactions.
6. Schedule H, except lines 4a, 4e, 4f, 4g, 4h, 4k, 4m, 4n,
and 5, to report financial information.
7. Additional information required by the instructions to the
above schedules, including, for example, the report of the
independent qualified public accountant (IQPA) identified on
Schedule H, line 3c, the schedules of assets held for
investment and the schedule of reportable transactions. (All
attachments must be properly labeled.)

Group Insurance Arrangement (GIA)

Each welfare benefit plan that is part of a group insurance
arrangement is exempted from the requirement to file a Form

General Instructions to Form 5500

-11-

Quick Reference Chart of Form 5500, Schedules, and Attachments (Not
Applicable for Form 5500-SF Filers)1
Large
Pension Plan

Small
Pension Plan2

Large Welfare
Plan
3

Must complete.

Schedule A
(Insurance
Information)

Must complete if
plan has insurance
contracts.

Must complete if plan
has insurance
contracts.4

Must complete if
plan has insurance
contracts.

Not required.

Must complete Part I
if service provider
was paid $5,000 or
more, Part II if a
service provider
failed to provide
information
necessary for the
completion of Part I,
and Part III if an
accountant or
actuary was
terminated.

Schedule D
(DFE/Participating
Plan Information)

Must complete Part I
if plan participated in
a CCT, PSA, MTIA,
or 103-12 IE.

Must complete if
Schedule H, lines
4b, 4c, or 4d are

Must complete Part I
if plan participated in
a CCT, PSA, MTIA, or
103-12 IE.4

Must complete Part I
if plan participated in
a CCT, PSA, MTIA,
or 103-12 IE.

Must complete if
Schedule H, lines
4b, 4c, or 4d are

Schedule G
(Financial
Schedules)

Schedule C
(Service Provider
Information)

Must complete.

Not required.

DFE
Must complete.

Must complete if plan
has insurance
contracts.4

Must complete if
MTIA, 103-12 IE, or
GIA has insurance
contracts.

Not required.

MTIAs, GIAs, and
103-12 IEs must
complete Part I if
service provider paid
$5,000 or more, and
Part II if a service
provider failed to
provide information
necessary for the
completion of Part I.
GIAs and 103-12 IEs
must complete Part
III if accountant was
terminated.

Form 5500

Small Welfare
Plan2

Must complete Part I
if plan participated in
a CCT, PSA, MTIA,
or 103-12 IE.4

Not required.

All DFEs must
complete Part II, and
DFEs that invest in a
CCT, PSA, or 10312 IE must also
complete Part I.
Must complete if
Schedule H, lines
4b, 4c, or 4d for a
GIA, MTIA, or 103-

Must complete.5

Not required.

Must complete.3, 5

Not required.

All DFEs must
complete Parts I, II,
and III. MTIAs, 10312 IEs, and GIAs
must also complete
Part IV.5

Schedule I
(Financial
Information)

Not required.

Must complete.4

Not required.

Must complete.4

Not required.

Schedule MB
(Actuarial
Information)

Must complete if
multiemployer
defined benefit plan
or money purchase
plan subject to
minimum funding
standards.6

Must complete if
multiemployer defined
benefit plan or money
purchase plan subject
to minimum funding
standards.6

Not required.

Schedule R
(Pension Plan
Information)

Must complete.7

Must complete.4, 7

Not required.

Schedule SB
(Actuarial
Information)

Must complete if
single-employer or
multiple-employer
defined benefit plan,
including an eligible
combined plan.

Not required.

Schedule H
(Financial
Information)

-12-

General Instructions to Form 5500

Large
Pension Plan

Report

Must attach.

Small
Pension Plan2

Large Welfare
Plan

Not required unless
Schedule I, line 4k, is
checked

Must attach.3

Small Welfare
Plan2
Not required.

DFE
Must attach for a
GIA or 103-12 IE.

This chart provides only general guidance. Not all rules and requirements are reflected. Refer to specific Form 5500 instructions for complete
information on filing requirements (e.g., Who Must File and What To File). For example, a pension plan is exempt from filing any schedules if the plan
uses Code section 408 individual retirement accounts as the sole funding vehicle for providing benefits. See Limited Pension Plan Reporting.
2
Pension plans and welfare plans with fewer than 100 participants at the beginning of the plan year that are not exempt from filing an annual
return/report may be eligible to file the Form 5500-SF, a simplified report. In addition to the limitation on the number of participants, a Form 5500-SF
may only be filed for a plan that i
accountant (but not by reason of enhanced bonding), has 100 percent of its assets invested in certain secure investments with a readily determinable
fair market value, holds no employer securities, and is not a multiemployer plan. See Who Must File.
3

Unfunded, fully insured, or combination unfunded/fully insured welfare plans covering fewer than 100 participants at the beginning of the plan year
that meet the requirements of 29 CFR 2520.104-20 are exempt from filing an annual report. See Who Must File. Such a plan with 100 or more
t and completing Schedule
participants must file an annual report, but is exempt under 29 CFR 2520.104H, but MUST complete Schedule G, Part III, to report any nonexempt transactions. See What To File.
4
Do not complete if filing the Form 5500-SF instead of the Form 5500.
5
6

Money purchase defined contribution plans that are amortizing a funding waiver are required to complete lines 3, 9, and 10 of the Schedule MB in
accordance with the instructions. Also see instructions for line 5 of Schedule R and line 12a of Form 5500-SF.
7
A pension plan is exempt from filing Schedule R if all of the following conditions are met:

The plan is not a defined benefit plan or otherwise subject to the minimum funding standards of Code section 412 or ERISA section 302.
No plan benefits that would be reportable on line 1 of Part I of this Schedule R were distributed during the plan year. See the instructions for
Schedule R, Part I, line 1, below.
No benefits, as described in the instructions for Schedule R, Part I, line 2, below, were paid during the plan year other than by the plan
sponsor or plan administrator. (This condition is not met if benefits were paid by the trust or any other payor(s) which are reportable on IRS Form
1099-R, Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc., using an EIN other than
that of the plan sponsor or plan administrator reported on line 2b or 3b of Form 5500.)
Unless the plan is a profit-sharing, ESOP or stock bonus plan, no plan benefits of living or deceased participants were distributed during the
plan year in the form of a single-sum distribution. See the instructions for Schedule R, Part I, line 3, below.
The plan is not an ESOP.

General Instructions to Form 5500

-13-

and enter the correct letter from the following chart in the
space provided to indicate the type of entity.

Section 5: Line-by-Line
Instructions for the 2010
Form 5500 and Schedules
Part I - Annual Return/Report Identification
Information
File the 2010 Form 5500 annual return/report for a plan year
that began in 2010 or a DFE year that ended in 2010. If the
plan or DFE year is not the 2010 calendar year, enter the dates
in Part I. The 2010 Form 5500 annual return/report must be
filed electronically. Because of this, filings for 2010 plan years,
including short plan years, cannot use prior year paper forms.
One Form 5500 is generally filed for each plan or entity
described in the instructions to the boxes in line A. Do not
check more than one box.

Master Trust
Investment Account

Common/Collective Trust

Pooled Separate
Account

103-12 Investment
Entity

Group Insurance
Arrangement

Line B
Box for First Return/Report. Check this box if
an annual return/report has not been previously filed for this
plan or DFE. For the purpose of completing this box, the Form
5500-EZ is not considered an annual return/report.

Line B
Box for Amended Return/Report. Check this box
if this Form 5500 is being submitted as an amended
return/report to correct errors and/or omissions on a previously
filed Form 5500 for the 2010 plan year. See instructions on
page 5.

Enter the letter

Note.
code on Form 5500, line A, must be filed for each MTIA. See
instructions on page 9.

A separate Form 5500, with line A (single-employer plan)
checked, must be filed by each employer participating in a plan
or program of benefits in which the funds attributable to each
employees, even if the plan is maintained by a controlled
group.

Type of entity

controlled group of corporations under Code section 414(b), a
group of trades or businesses under common control under
Code section 414(c), or an affiliated service group under Code
section 414(m).

Line B
Box for Final Return/Report. Check this box if
this Form 5500 is the last annual return/report required to be
submitted for this plan. (See Final Return/Report.)

Line A
Box for Multiemployer Plan. Check this box if the
Form 5500 is filed for a multiemployer plan. A plan is a
multiemployer plan if: (a) more than one employer is required
to contribute, (b) the plan is maintained pursuant to one or
more collective bargaining agreements between one or more
employee organizations and more than one employer; (c) an
election under Code section 414(f)(5) and ERISA section
3(37)(E) has not been made; and (d) the plan meets any other
applicable conditions of 29 CFR 2510.3-37. A plan that has
made a proper election under ERISA section 3(37)(G) and
Code section 414(f)(6) on or before August 17, 2007, is also a
multiemployer plan. Participating employers do not file
individually for these plans.

Note.
entered on line 8b for a welfare plan that is not required to file
a Form 5500 for the next plan year because the welfare plan
has become eligible for an annual reporting exemption. For
example, certain unfunded and insured welfare plans may be
required to file the 2010 Form 5500 and be exempt from filing a
Form 5500 for the plan year 2011 if the number of participants
covered as of the beginning of the 2011 plan year drops below
100. See Who Must File. Should the number of participants
covered by such a plan increase to 100 or more in a future
-20.

Line A
Box for Single-Employer Plan. Check this box if
the Form 5500 is filed for a single-employer plan. A singleemployer plan for this Form 5500 reporting purpose is an
employee benefit plan maintained by one employer or one
employee organization.

Line B
Box for Short Plan Year Return/Report. Check
this box if this Form 5500 is being filed for a plan year of less
than 12 months. Provide the dates in Part I, Plan Year
Beginning and Ending.

Line A
Box for Multiple-Employer Plan. Check this box if
Form 5500 is being filed for a multiple-employer plan. A
multiple-employer plan is a plan that is maintained by more
than one employer and is not one of the plans already
described. A multiple-employer plan can be collectively
bargained and collectively funded, but if covered by PBGC
termination insurance, must have properly elected before
September 27, 1981, not to be treated as a multiemployer plan
under Code section 414(f)(5) or ERISA sections 3(37)(E) and
4001(a)(3). Participating employers do not file individually for
this type of plan. Do not check this box if the employers
maintaining the plan are members of the same controlled
group.
Line A

Line C
Box for Collectively-Bargained Plan. Check this
box when the contributions to the plan and/or the benefits paid
by the plan are subject to the collective bargaining process
(even if the plan is not established and administered by a joint
board of trustees and even if only some of the employees
covered by the plan are members of a collective bargaining
unit that negotiates contributions and/or benefits). The
contributions and/or benefits do not have to be identical for all
employees under the plan.
Line D
Box for Extension. Check the appropriate box
here if:
You filed for an extension of time to file this form with the
IRS using a completed Form 5558, Application for Extension
of Time To File Certain Employee Plan Returns (maintain a

Box for Direct Filing Entity (DFE). Check this box

Instructions for Part I and Part II of Form 5500

-14-

sponsoring employers). If the plan covers only the employees
You are filing using the automatic extension of time to file
Form 5500 until the due date of the federal income tax return

You are filing using a special extension of time to file the
Form 5500 that has been announced by the IRS, DOL, and
PBGC. If you checked that you are using a special extension of
time, enter a description of the extension of time in the space
provided.
Filer Voluntary
Compliance (DFVC) Program.

Note. In the case of a multiple-employer plan, if an
association or similar entity is not the sponsor, enter the name
of a participating employer as sponsor. A plan of a controlled
group of corporations should enter the name of one of the
sponsoring members. In either case, the same name must be
used in all subsequent filings of the Form 5500 for the multipleemployer plan or controlled group (see instructions to line 4
concerning change in sponsorship).

3. Enter the street address. A post office box number may
be entered if the Post Office does not deliver mail to the

Part II - Basic Plan Information

4. Enter the name of the city.
5. Enter the two-character abbreviation of the U.S. state or
possession and zip code.
6. Enter the foreign routing code, if applicable. Leave U.S.
state and zip code blank if entering a foreign routing code and
country name.
7. Enter the foreign country, if applicable.
8. Enter the D/B/A (the doing business as) or trade name of
the sponsor if differe
9. Enter any second address. Use only a street address
here, not a P.O. box.

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

The employer, for an employee benefit plan that a single
employer established or maintains;
The employee organization in the case of a plan of an
employee organization; or
The association, committee, joint board of trustees, or other
similar group of representatives of the parties who establish or
maintain the plan, if the plan is established or maintained
jointly by one or more employers and one or more employee
organizations, or by two or more employers.

Assign PN

For each Form 5500
with the same EIN
(line 2b), when
Part II, line 8a is completed,
or Part I, line A, for a DFE is
checked and an M, C, P, or
E is entered
Part II, line 8b is completed
and 8a is not checked, or
Part I, line A, for a DFE is
checked and a G is entered

001 to the first plan or DFE.
Consecutively number others

501 to the first plan or GIA.
Consecutively number others

Exception. If Part II, line 8a is completed and 333 (or a
higher number in a sequence beginning with 333) was
previously assigned to the plan, that number may be entered
on line 1b.
Line 1c. Enter the date the plan first became effective.
Line 2a. Limit your response to the information required in
each row as specified below:
1. Enter the name of the plan sponsor or, in the case of a
Form 5500 filed for a DFE, the name of the insurance
company, financial institution, or other sponsor of the DFE
(e.g., in the case of a GIA, the trust or other entity that holds
the insurance contract, or in the case of an MTIA, one of the

Line 2b. Enter the nine-digit employer identification number
(EIN) assigned to the plan sponsor/employer, for example, 001234567. In the case of a DFE, enter the employer
identification number (EIN) assigned to the CCT, PSA, MTIA,
103-12 IE, or GIA.
Do not use a social security number in lieu of an EIN. The
Form 5500 is open to public inspection, and the contents are
public information and are subject to publication on the
Internet. Because of privacy concerns, the inclusion of a social
security number on this line may result in the rejection of the
filing.
Employers without an EIN must apply for one as soon as
possible. The EBSA does not issue EINs. To apply for an EIN
from the IRS:
Mail or fax Form SS-4, Application for Employer
Identification Number, obtained by calling 1-800-TAX-FORM
(1-800-829-3676) or at the IRS website at www.irs.gov.
Call 1-800-829-4933 to receive your EIN by telephone.
Select the Online EIN Application link at www.irs.gov. The
EIN is issued immediately once the application information is
validated. (The online application process is not yet available
for corporations with addresses in foreign countries or Puerto
Rico.)
A multiple-employer plan or plan of a controlled group of
corporations should use the EIN of the sponsor identified in
line 2a. The EIN must be used in all subsequent filings of the
Form 5500 for these plans (see instructions to line 4

-15-

Instructions for Schedule A (Form 5500)

different employer identification number (EIN) could result in
correspondence from the DOL and the IRS.

concerning change in EIN).
If the plan sponsor is a group of individuals, get a single EIN
for the group. When you apply for the EIN, provide the name of

Lines 5 and 6. All filers must complete both lines 5 and 6
unless the Form 5500 is filed for an IRA Plan described in
Limited Pension Plan Reporting or for a DFE.

-4, enter the
group name on line 1.)

only for purposes of these lines.

Note. EINs for funds (trusts or custodial accounts) associated
with plans (other than DFEs) are generally not required to be
furnished on the Form 5500; the IRS will issue EINs for such
funds for other reporting purposes. EINs may be obtained as
explained above. Plan sponsors should use the trust EIN
described above when opening a bank account or conducting
other transactions for a trust that require an EIN.

An individual becomes a participant covered under an
employee welfare benefit plan on the earliest of:
the date designated by the plan as the date on which the
individual begins participation in the plan;
the date on which the individual becomes eligible under the
plan for a benefit subject only to occurrence of the contingency
for which the benefit is provided; or
the date on which the individual makes a contribution to the
plan, whether voluntary or mandatory.

Line 2d. Enter the six-digit business code that best describes
the natu
business codes on pages 75, 76, and 77. If more than one
employer or employee organization is involved, enter the
business code for the main business activity of the employers
and/or employee organizations.

See 29 CFR 2510.3-3(d)(1). This includes former employees
who are receiving group health continuation coverage benefits
pursuant to Part 6 of ERISA and who are covered by the
employee welfare benefit plan. Covered dependents are not
counted as participants. A child who i
entitled to health benefits under a qualified medical child
support order (QMCSO) should not be counted as a participant
for lines 5 and 6. An individual is not a participant covered
under an employee welfare plan on the earliest date on which
the individual (a) is ineligible to receive any benefit under the
plan even if the contingency for which such benefit is provided
should occur, and (b) is not designated by the plan as a
participant. See 29 CFR 2510.3-3(d)(2).

remainder of line 3a, and all of lines 3b and 3c blank.

Line 3a. Please limit your response to the information
required:
1. Enter the name of the plan administrator unless the
administrator is the sponsor identified in line 2 or the Form
5500 is submitted for a DFE (Part I, line A, for a DFE should be
checked and the appropriate DFE code entered). If this is the

The person or group of persons specified as the
administrator by the instrument under which the plan is
operated;
The plan sponsor/employer if an administrator is not so
designated; or
Any other person prescribed by regulations if an
administrator is not designated and a plan sponsor cannot be
identified.
2. Enter
3. Enter the street address. A post office box number may
be entered if the Post Office does not deliver mail to the

Before counting the number of participants,
especially in a welfare benefit plan, it is important to
determine whether the plan sponsor has established
one or more plans for Form 5500/Form 5500-SF reporting
purposes. As a matter of plan design, plan sponsors can offer
benefits through various structures and combinations. For
example, a plan sponsor could create (i) one plan providing
major medical benefits, dental benefits, and vision benefits, (ii)
two plans with one providing major medical benefits and the
other providing self-insured dental and vision benefits; or (iii)
three separate plans. You must review the governing
documents and actual operations to determine whether welfare
benefits are being provided under a single plan or separate
plans.

4. Enter the name of the city.
5. Enter the two-character abbreviation of the U.S. state or
possession and zip code.
6. Enter the foreign routing code and foreign country, if
applicable. Leave U.S. state and zip code blank if entering
foreign routing code and country information.

The fact that you have separate insurance policies for each
different welfare benefit does not necessarily mean that you

Line 3b. Enter the plan adminis
-digit EIN. A plan
administrator must have an EIN for Form 5500 reporting
purposes. If the plan administrator does not have an EIN, apply
for one as explained in the instructions for line 2b. One EIN
should be entered for a group of individuals who are,
collectively, the plan administrator.
Note. Employees of the plan sponsor who perform
administrative functions for the plan are generally not the plan
administrator unless specifically designated in the plan
document. If an employee of the plan sponsor is designated as
the plan administrator, that employee must get an EIN.

document to incorporate various benefits and insurance
policies into one comprehensive plan. In addition, whether a
benefit arrangement is deemed to be a single plan may be
different for purposes other than Form 5500/Form 5500-SF
reporting. For example, special rules may apply for purposes of
HIPAA, COBRA, and Internal Revenue Code compliance. If
you need help determining whether you have a single welfare
benefit plan for Form 5500/Form 5500-SF reporting purposes,
you should consult a qualified benefits consultant or legal
counsel.
o
benefits under a qualified domestic relations order are not to
be counted as participants for this line.

Line 4.
changed since the last return/report was filed for this plan or
, and the
plan number as it appeared on the last return/report filed.

any individual who is included in one of the categories below:
1. Active participants (i.e., any individuals who are currently
in employment covered by the plan and who are earning or

The failure to indicate on line 4 that a plan sponsor
was previously identified by a different name or a
-16-

Instructions for Part I and Part II of Form 5500

the defined benefit pension features or the defined contribution
pension features of the plan.
For plan sponsors of Puerto Rico plans, enter
characteristic code 3C only in instances where there
was no election made under section 1022(i)(2) of
ERISA and, therefore, the plan does not intend to qualify under
section 401(a) of the Code. If an election was made under
section 1022(i)(2) of ERISA, do not enter characteristic code
3C.
Line 9 - Funding and Benefit Arrangements. Check all
boxes that apply to indicate the funding and benefit

investment, and transmittal of plan assets prior to the time the
plan actually provi
the method by which the plan provides benefits to participants.
For purposes of line 9:

means the plan has an account, contract, or
policy with an insurance company, insurance service, or other
similar organization (such as Blue Cross, Blue Shield, or a
health maintenance organization) during the plan or DFE year.
(This includes investments with insurance companies such as
guaranteed investment contracts (GICs).) An annuity account
arrangement under Code section 403(b)(1) that is required to
plan funding arrangement and plan benefit arrangement. Do

retaining credited service under the plan). This includes any
individuals who are eligible to elect to have the employer make
payments under a Code section 401(k) qualified cash or
deferred arrangement. Active participants also include any
nonvested individuals who are earning or retaining credited
service under the plan. This does not include (a) nonvested
former employees who have incurred the break in service
period specified in the plan or (b) former employees who have
their entire nonforfeitable accrued benefit.
2. Retired or separated participants receiving benefits (i.e.,
individuals who are retired or separated from employment
covered by the plan and who are receiving benefits under the
plan). This does not include any individual to whom an
insurance company has made an irrevocable commitment to
pay all the benefits to which the individual is entitled under the
plan.
3. Other retired or separated participants entitled to future
benefits (i.e., any individuals who are retired or separated from
employment covered by the plan and who are entitled to begin
receiving benefits under the plan in the future). This does not
include any individual to whom an insurance company has
made an irrevocable commitment to pay all the benefits to
which the individual is entitled under the plan.
4. Deceased individuals who had one or more beneficiaries
who are receiving or are entitled to receive benefits under the
plan. This does not include any individual to whom an
insurance company has made an irrevocable commitment to
pay all the benefits to which the beneficiaries of that individual
are entitled under the plan.

Line 6g. Enter the number of participants included on line 6f
(total participants at the end of the plan year) who have
account balances. For example, for a Code section 401(k) plan
the number entered on line 6g should be the number of
participants counted on line 6f who have made a contribution,
or for whom a contribution has been made, to the plan for this
plan year or any prior plan year. Defined benefit plans should
leave line 6g blank.
Line 6h. Include any individual who terminated employment
during this plan year, whether or not he or she (a) incurred a
break in service, (b) received an irrevocable commitment from
an insurance company to pay all the benefits to which he or
she is entitled under the plan, and/or (c) received a cash
distribution or deemed cash distribution of his or her
nonforfeitable accrued benefit. Multiemployer plans and
multiple-employer plans that are collectively bargained do not
have to complete line 6h.
Line 7. Only multiemployer plans should complete line 7.
Multiemployer plans should enter the total number of
employers obligated to contribute to the plan. For purposes of
line 7 of the Form 5500, an employer obligated to contribute is
defined as an employer who, during the 2010 plan year, is a
party to the collective bargaining agreement(s) pursuant to
which the plan is maintained or who may otherwise be subject
to withdrawal liability pursuant to ERISA section 4203. Any two
or more contributing entities (e.g., places of business with
separate collective bargaining agreements) that have the same
nine-digit employer identification number (EIN) must be
aggregated and counted as one employer for this purpose.
Line 8 - Benefits Provided Under the Plan. In line(s) 8a
and/or 8b, as appropriate, enter all applicable plan
characteristic codes from the List of Plan Characteristics
Codes in these instructions that describe the characteristics of
the plan being reported.
Note. In the case of an eligible combined plan, the codes
entered in line 8a must include any codes applicable for either

-17-

company was to provide administrative services.
are
contracts that provide retirement benefits under a plan that are
guaranteed by an insurance carrier. In general, such contracts
period of participation in the plan (to retirement age), premiums
must be timely paid as currently required under the contract,
no rights under the contract may be subject to a security
interest, and no policy loans may be outstanding. If a plan is
funded exclusively by the purchase of such contracts, the
otherwise applicable minimum funding requirements of section
412 of the Code and section 302 of ERISA do not apply for the
year and neither the Schedule MB nor the Schedule SB is
required to be filed.
includes any fund or account that receives, holds,
transmits, or invests plan assets other than an account or
policy of an insurance company. A custodial account
arrangement under Code section 403(b)(7) that is required to
complete the Form 5500 sho
funding arrangement and the plan benefit arrangement.
means either the plan
had no assets or some assets were commingled with the
general assets of the plan sponsor prior to the time the plan
actually provided the benefits promised.
Example. If the plan holds all its assets invested in
registered investment companies and other non-insurance
company investments until it purchases annuities to pay out
the benefits promised under the plan, box 9a(3) should be
checked as the funding arrangement and box 9b(1) should be
checked as the benefit arrangement.
Note. An employee benefit plan that checks boxes 9a(1),
9a(2), 9b(1), and/or 9b(2) must attach Schedule A (Form
5500), Insurance Information, to provide information
concerning each contract year ending with or within the plan
year. See the instructions to the Schedule A and enter the
number of Schedules A on line 10b(3), if applicable.
Instructions for Schedule A (Form 5500)

Line 10. Check the boxes on line 10 to indicate the
schedules being filed and, where applicable, count the
schedules and enter the number of attached schedules in the
space provided.

-18-

Instructions for Part I and Part II of Form 5500

LIST OF PLAN CHARACTERISTICS CODES FOR LINES 8a AND 8b

CODE

Defined Benefit Pension Features

Profit-sharing.

Benefits are primarily pay related.

Benefits are primarily flat dollar (includes dollars per year
of service).

ERISA section 404(c) plan This plan, or any part of it,
is intended to meet the conditions of 29 CFR 2550.404c1.

Cash balance or similar plan

Total participant-directed account plan Participants
have the opportunity to direct the investment of all the
assets allocated to their individual accounts, regardless
of whether 29 CFR 2550.404c-1 is intended to be met.

Partial participant-directed account plan Participants
have the opportunity to direct the investment of a portion
of the assets allocated to their individual accounts,
regardless of whether 29 CFR 2550.404c-1 is intended
to be met.

Stock bonus.

Code section 401(k) feature A cash or deferred
arrangement described in Code section 401(k) that is
part of a qualified defined contribution plan that provides
for an election by employees to defer part of their
compensation or receive these amounts in cash.

benefit formula in a defined benefit plan by whatever
name (for example, personal account plan, pension
equity plan, life cycle plan, cash account plan, etc.) that
rather than, or in addition to, expressing the accrued
benefit as a life annuity commencing at normal
retirement age, defines benefits for each employee in
terms more common to a defined contribution plan such
as a single sum distribution amount (for example, 10
percent of final average pay times years of service, or

Floor-offset plan to offset for retirement benefits
provided by an employer-sponsored defined contribution
plan.
Code section 401(h) arrangement Plan contains
separate accounts under Code section 401(h) to provide
employee health benefits.

Code section 414(k) arrangement Benefits are based
partly on the balance of the separate account of the
participant (also include appropriate defined contribution
pension feature codes).

Code section 403(b)(1) arrangement.

Covered by PBGC Plan is covered under the PBGC
insurance program (see ERISA section 4021).

Code section 403(b)(7) accounts.

Plan covered by PBGC that was terminated and closed
out for PBGC purposes Before the end of the plan year
(or a prior plan year), (1) the plan terminated in a
standard (or distress) termination and completed the
distribution of plan assets in satisfaction of all benefit
liabilities (or all ERISA Title IV benefits for distress
termination); or (2) a trustee was appointed for a
terminated plan pursuant to ERISA section 4042.

Code section 408 accounts and annuities See Limited
Pension Plan Reporting instructions for pension plan
utilizing Code section 408 individual retirement accounts
or annuities as the funding vehicle for providing benefits.

ESOP other than a leveraged ESOP.

Leveraged ESOP An ESOP that acquires employer
securities with borrowed money or other debt-financing
techniques.

The employer maintaining this ESOP is an S corporation.

Participant-directed brokerage accounts provided as an
investment option under the plan.

CODE
2A

Plan provides for automatic enrollment in plan that has
employee contributions deducted from payroll.

Total or partial participant-directed account plan plan
uses default investment account for participants who fail
to direct assets in their account.

Code section 401(m) arrangement Employee
contributions are allocated to separate accounts under
the plan or employer contributions are based, in whole or
in part, on employee deferrals or contributions to the
plan. Not applicable if plan is 401(k) with only QNECs
and/or QMACs. Also not applicable if Code sections
403(b)(1), 403(b)(7), or 408 arrangement/accounts
annuities.

balance).

Frozen plan As of the last day of the plan year, the plan
provides that no participant will get any new benefit
accrual (whether because of service or compensation).
Defined Contribution Pension Features
Age/service weighted or new comparability or similar
plan Age/service weighted plan: Allocations are based
on age, service, or age and service. New comparability
or similar plan: Allocations are based on participant
classifications and a classification(s) consists entirely or
predominantly of highly compensated employees; or the
plan provides an additional allocation rate on
compensation above a specified threshold, and the
threshold or additional rate exceeds the maximum
threshold or rate allowed under the permitted disparity
rules of Code section 401(l).

Target benefit plan.

Money purchase (other than target benefit).

Offset plan Plan benefits are subject to offset for
retirement benefits provided in another plan or
arrangement of the employer.

Instructions for Part I and Part II of Form 5500

CODE

-19-

Other Pension Benefit Features

Plan covering self-employed individuals.

Plan not intended to be qualified A plan not intended to
be qualified under Code sections 401, 403, or 408.

Pre-approved pension plan A master, prototype, or
volume submitter plan that is the subject of a favorable
opinion or advisory letter from the IRS.

Plan sponsor(s) received services of leased employees,
as defined in Code section 414(n), during the plan year.

LIST OF PLAN CHARACTERISTICS CODES FOR LINES 8a AND 8b (Continued)

Plan sponsor(s) is (are) a member(s) of a controlled
group (Code sections 414(b), (c), or (m)).

Plan requiring that all or part of employer contributions
be invested and held, at least for a limited period, in
employer securities.

CODE

U.S.-based plan that covers residents of Puerto Rico and
is qualified under both Code section 401 and section
1165 of Puerto Rico Code.

Scholarship (funded).

Death benefits (include travel accident but not life
insurance).

Taft-Hartley Financial Assistance for Employee Housing
Expenses.

Other.

Unfunded, fully insured, or combination unfunded/fully
insured welfare plan that will not file an annual report for
next plan year pursuant to 29 CFR 2520.104-20.

Unfunded, fully insured, or combination unfunded/fully
insured welfare plan that stopped filing annual reports in
an earlier plan year pursuant to 29 CFR 2520.104-20.

10 or more employer plan under Code section
419A(f)(6).

Welfare Benefit Features

Health (other than vision or dental).

Life insurance.

Supplemental unemployment.

Dental.

Vision.

Temporary disability (accident and sickness).

Prepaid legal.

Long-term disability.

Severance pay.

Apprenticeship and training.

Collectively-bargained welfare benefit arrangement
under Code section 419A(f)(5).

-20-

Instructions for Part I and Part II of Form 5500

inclusion of a social security number on this Schedule A or any
of its attachments may result in the rejection of the filing.
You can apply for an EIN from the IRS online, by
telephone, by fax, or by mail depending on how soon you need
to use the EIN. For more information, see Section 3: Electronic
Filing Requirement under General Instructions to Form 5500.
The EBSA does not issue EINs.

2010 Instructions for Schedule A
(Form 5500)
Insurance Information
General Instructions

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

Who Must File
Schedule A (Form 5500) must be attached to the Form 5500
filed for every defined benefit pension plan, defined
contribution pension plan, and welfare benefit plan required to
file a Form 5500 if any benefits under the plan are provided by
an insurance company, insurance service, or other similar
organization (such as Blue Cross, Blue Shield, or a health
maintenance organization). This includes investment contracts
with insurance companies such as guaranteed investment
(GICs). In addition, Schedules A must be attached to a Form
5500 filed for GIAs, MTIAs, and 103-12 IEs for each insurance
or annuity contract held in the MTIA, or 103-12 IE or by the
GIA.

If Form 5500 line 9a(1), 9a(2), 9b(1), or 9b(2) is
checked, indicating that either the plan funding
arrangement or plan benefit arrangement includes an
account, policy, or contract with an insurance company (or
similar organization), at least one Schedule A would be
required to be attached to the Form 5500 filed for a pension or
welfare plan to provide information concerning the contract
year ending with or within the plan year.

Line 1(c). Enter the code number assigned by the National
Association of Insurance Commissioners (NAIC) to the
insurance company. If none has been assigned, enter zeros
(-0-) in the spaces provided.
Line 1(d). If individual policies with the same carrier are
grouped as a unit for purposes of this report, and the group
does not have one identification number, you may use the
contract or identification number of one of the individual
contracts, provided this number is used consistently to report
these contracts as a group and the plan administrator
maintains the records necessary to disclose all the individual
contract numbers in the group upon request. Use separate
Schedules A to report individual contracts that cannot be
grouped as a unit.
Line 1(e). Since plan coverage may fluctuate during the year,
the administrator should estimate the number of persons that
were covered by the contract at the end of the policy or contract
year. Where contracts covering individual employees are
grouped, compute entries as of the end of the plan year.
Line 1(f) and (g). Enter the beginning and ending dates of
the policy year for the contract identified in 1(d). Leave 1(f)
blank if separate contracts covering individual employees are
grouped.
Line 2. Report on line 2 the total of all insurance fees and
commissions directly or indirectly attributable to the contract or
policy placed with or retained by the plan.
Totals. Enter on line 2 the total of all such commissions and
fees paid to agents, brokers, and other persons listed on line 3.
Complete a separate line 3 item (elements (a) through (e)) for
each person listed.
For purposes of lines 2 and 3, commissions and fees
include sales and base commissions and all other monetary
and non-

Do not file Schedule A for a contract that is an Administrative
Services Only (ASO) contract, a fidelity bond or policy, or a
fiduciary liability insurance policy. Also, if a Schedule A for a
contract or policy is filed as part of a Form 5500 for an MTIA or
103-12 IE that holds the contract, do not include a Schedule A
for the contract or policy on the Form 5500s filed for the plans
participating in the TIA or 103-12 IE.

Check the Schedule A box on the Form 5500 (Part II, line
10b(3)), and enter the number attached in the space provided
if one or more Schedules A are attached to the Form 5500.

Specific Instructions

Information entered on Schedule A should pertain to the
insurance contract or policy year ending with or within the plan
year (for reporting purposes, a year cannot exceed 12
months).
Example. If an insurance contract year begins on July 1
and ends on June 30, and the plan year begins on January 1
and ends on December 31, the information on the Schedule A
attached to the 2010 Form 5500 should be for the insurance
contract year ending on June 30, 2010.
Exception. If the insurance company maintains records on
the basis of a plan year rather than a policy or contract year,
the information entered on Schedule A may pertain to the plan
year instead of the policy or contract year.
Include only the contracts issued to or held by the plan,
GIA, MTIA, or 103-12 IE for which the Form 5500 is being filed.
Lines A, B, C, and D. This information must be the same as
reported in Part II of the Form 5500 to which this Schedule A is
attached.
Do not use a social security number in lieu of an EIN. The
Schedule A and its attachments are open to public inspection,
and the contents are public information and are subject to
publication on the Internet. Because of privacy concerns, the

amount of the payment is based, in whole or in part, on the
value (e.g., policy amounts, premiums) of contracts or policies
(or classes thereof) placed with or retained by an ERISA plan,
including, for example, persistency and profitability bonuses.
The amount (or pro rata share of the total) of such
commissions or fees attributable to the contract or policy
placed with or retained by the plan must be reported in line 2
and in line 3, element (b) and/or (c), as appropriate.
Insurers must provide plan administrators with a
proportionate allocation of commissions and fees attributable
to each contract. Any reasonable method of allocating
commissions and fees to policies or contracts is acceptable,
provided the method is disclosed to the plan administrator. A
reasonable allocation method could, in the Department of
cate fees and commissions to a Schedule A
based on a calendar year calculation even if the plan year or
policy year was not a calendar year. For additional information
on these Schedule A reporting requirements, see ERISA
Advisory Opinion 2005-02A, available on the Internet at
www.dol.gov/ebsa.

-21-

Instructions for Schedule A (Form 5500)

Line 3. Identify agents, brokers, and other persons
individually in descending order of the amount paid. Complete
as many entries as necessary to report all required information.
Complete elements (a) through (e) for each person as
specified below.
Element (a). Enter the name and address of the agents,
brokers, or other persons to whom commissions or fees were
paid.
Element (b). Report all sales and base commissions here. For
purposes of this element, sales and/or base commissions are
monetary amounts paid by an insurer that are charged directly
to the contract or policy and that are paid to a licensed agent or
broker for the sale or placement of the contract or policy. All
other payments should be reported in element (c) as fees.
Element (c). Fees to be reported here represent payments by
an insurer attributable directly or indirectly to a contract or
policy to agents, brokers, and other persons for items other
than sales and/or base commissions (e.g., service fees,
consulting fees, finders fees, profitability and persistency
bonuses, awards, prizes, and non-monetary forms of
compensation). Fees paid to persons other than agents and
brokers should be reported here, not in Parts II and III on
Schedule A as acquisition costs, administrative charges, etc.
Element (d). Enter the purpose(s) for which fees were paid.
Element (e). Enter the most appropriate organization code for
the broker, agent, or other person entered in element (a).

Where benefits under a plan are purchased from and
guaranteed by an insurance company, insurance service, or
other similar organization, and the contract or policy is reported
on a Schedule A, payments of reasonable monetary
compensation by the insurer out of its general assets to
affiliates or third parties for performing administrative activities
necessary for the insurer to fulfill its contractual obligation to
provide benefits, where there is no direct or indirect charge to
the plan for the administrative services other than the
insurance premium, then the payments for administrative
services by the insurer to the affiliates or third parties do not
need to be reported on lines 2 and 3 of Schedule A. This would
include compensation for services such as recordkeeping and
claims processing services provided by a third party pursuant
to a contract with the insurer to provide those services but
would not include compensation provided by the insurer
incidental to the sal
fees, insurance brokerage commissions and fees, or similar
fees.
Schedule A reporting also is not required for compensation

brokers representing insureds, and (2) payments would not be
treated as paid for managing an agency or performance of

payment or the amount of the payment is dependent or based
on the value (e.g., policy amounts, premiums) of contracts or
policies (or classes thereof) placed with or retained by ERISA
plan(s).
Schedule A reporting is not required for occasional nonmonetary gifts or meals of insubstantial value that are tax
deductible for federal income tax purposes by the person
providing the gift or meal and would not be taxable income to
the recipient. For exemption to be available, the gift or gratuity
must be both occasional and insubstantial. For this exemption
to apply, the gift must be valued at less than $50, the
aggregate value of gifts from one source in a calendar year
must be less than $100, but gifts with a value of less than $10
do not need to be counted toward the $100 annual limit. If the
$100 aggregate value limit is exceeded, then the aggregate
value of all the gifts will be reportable. For this purpose, nonmonetary gifts of less than $10 also do not need to be included
in calculating the aggregate value of all gifts required to be
reported if the $100 limit is exceeded.
Gifts from multiple employees of one service provider
should be treated as originating from a single source when
calculating whether the $100 threshold applies. On the other
hand, in applying the threshold to an occasional gift received
from one source by multiple employees of a single service
provider, the amount received by each employee should be
separately determined in applying the $50 and $100
thresholds. For example, if six employees of a broker attend a
business conference put on by an insurer designed to educate

performance of administrative functions for the insurer. For this

Type of Organization

Banking, Savings & Loan Association, Credit Union,
or other similar financial institution
Trust Company
Insurance Agent or Broker
Agent or Broker other than insurance
Third party administrator
Investment Company/Mutual Fund
Investment Manager/Adviser
Labor Union
Foreign entity (e.g., an agent or broker, bank,
insurance company, etc., not operating within the
jurisdictional boundaries of the United States)
Other

2
3
4
5
6
7
8
9

For plans, GIAs, MTIAs, and 103-12 IEs required to file Part
I of Schedule C, commissions and fees listed on the Schedule
A are not required to be reported again on Schedule C. The
amount of the compensation that must be reported on
Schedule A must, however, be taken into account in
direct or indirect compensation in relation to the plan or DFE is
$5,000 or more and, thus, requiring the compensation not
listed on the Schedule A to be reported on the Schedule C.
See FAQs about the Schedule C available on the EBSA
website at www.dol.gov/ebsa/faqs.

Part II - Investment and Annuity Contract Information

and the insurer provides, at no cost to the attendees,
refreshments valued at $20 per individual, the gratuities would
not be reportable on lines 2 and 3 of the Schedule A even
though the total cost of the refreshments for all the employees
would be $120.
These thresholds are for purposes of Schedule A reporting.
Filers are cautioned that the payment or receipt of gifts and
gratuities of any amount by plan fiduciaries may violate ERISA
and give rise to civil liabilities and criminal penalties.

Instructions for Schedule A (Form 5500)

Code

Line 4.
end in the contract reported on line 7, e.g., deposit
administration (DA), immediate participation guarantee (IPG),
or guaranteed investment contracts (GIC).
Exception. Contracts reported on line 7 need not be included
on line 4 if (1) the Schedule A is filed for a defined benefit
pension plan and the contract was entered into before March
20, 1992, or (2) the Schedule A is filed for a defined
contribution pension plan and the contract is a fully benefitresponsive contract, i.e., it provides a liquidity guarantee by a
-22-

financially responsible third party of principal and previously
accrued interest for liquidations, transfers, loans, or hardship
withdrawals initiated by plan participants exercising their rights
to withdraw, borrow, or transfer funds under the terms of a
defined contribution plan that does not include substantial
access to plan funds.

help the employer manage its risk associated with its liabilities
under the plan. These employer contracts with premiums paid

Important Reminder. Plans may treat multiple individual
annuity contracts, including Code section 403(b)(1) annuity
contracts, issued by the same insurance company as a single
group contract for reporting purposes on Schedule A.
Line 6a. The rate information called for here may be furnished
by attaching the appropriate schedules of current rates filed
with the appropriate state insurance department or by
providing a statement regarding the basis of the rates. Enter
if appropriate.
Lines 7a through 7f. Report contracts with unallocated funds.
Do not include portions of these contracts maintained in
separate accounts. Show deposit fund amounts rather than
experience credit records when both are maintained.

The insurance company, insurance service, or other similar
organization is required under ERISA section 103(a)(2) to
provide the plan administrator with the information needed to
complete this return/report. If you do not receive this
information in a timely manner, contact the insurance
company, insurance service, or other similar organization.
Lines 11 and 12. If information is missing on Schedule A due
to a refusal by the insurance company, insurance service, or

Part III - Welfare Benefit Contract Information

As noted above, the insurance company, insurance
service, or other similar organization is statutorily
required to provide you with all of the information
necessary to complete the Schedule A, but need not provide
the information on a Schedule A itself.

Part IV - Provision of Information

on line 11 and enter a description of the information not
provided on line 12. If you received all the information

line 12 blank.

Line 8i. Report a stop-loss insurance policy that is an asset of
the plan.
Note. Employers sponsoring welfare plans may purchase a
stop-loss insurance policy with the employer as the insured to

employee contributions generally are not plan assets and are
not reportable on Schedule A.

-23-

Instructions for Schedule A (Form 5500)

publication on the Internet. Because of privacy concerns, the
inclusion of a social security number on this Schedule C or any
of its attachments may result in the rejection of the filing.
You can apply for an EIN from the IRS online, by
telephone, by fax, or by mail depending on how soon you
need to use the EIN. For more information, see Section 3:
Electronic Filing Requirement under General Instructions to
Form 5500. The EBSA does not issue EINs.
Do not list the PBGC or the IRS on Schedule C as
service providers.
Either the cash or accrual basis may be used for the
recognition of transactions reported on the Schedule C as
long as you use one method consistently.
If service provider compensation is reported on a
Schedule C filed as a part of a Form 5500 filed for a MITIA
or a 103-12 IE, do not report the same compensation again
on the Schedule C filed for the plans that participate in the
MTIA or 103-12 IE.

2010 Instructions for Schedule C
(Form 5500)
Service Provider Information
General Instructions
Who Must File
Schedule C (Form 5500) must be attached to a Form 5500
filed for a large pension or welfare benefit plan, an MTIA, a
103-12 IE, or a GIA to report certain information concerning
service providers. Remember to check the Schedule C box on
the Form 5500 (Part II, line 10b(4)) if a Schedule C is attached
to the Form 5500.
Part I of the Schedule C must be completed to report
persons who rendered services to or who had transactions with
the plan (or with the DFE in the case of a Schedule C filed by a
DFE) during the reporting year if the person received, directly
or indirectly, $5,000 or more in reportable compensation in
connection with services rendered or their position with the
plan or DFE, except:
1. Employees of the plan whose only compensation in
relation to the plan was less than $25,000 for the plan year;
2. Employees of the plan sponsor or other business entity
where the plan sponsor or business entity is reported on the
Schedule C as a service provider, provided the employee did
not separately receive reportable direct or indirect
compensation in relation to the plan;
3. Persons who only compensation in relation to the plan
consists of insurance fees and commissions listed in a
Schedule A filed for the plan; and
4. Payments made directly by the plan sponsor that are not
reimbursed by the plan.

Specific Instructions
Part I - Service Provider Information

You must enter the information required for each person who
rendered services to or had transactions with the plan and
who received $5,000 or more in total direct or indirect
compensation in connection with services rendered to the
year.
Example. A plan had service providers, A, B, C, and D,
who received $12,000, $6,000, $4,500, and $430,
respectively, in direct and indirect compensation from the
plan. Service providers A and B must be identified
separately by name, EIN, etc. As service providers C and D
each received less than $5,000, they do not need to be
reported on the Schedule C.
For Schedule C purposes, reportable compensation
includes money and any other thing of value (for example,
gifts, awards, trips) received by a person, directly or
indirectly, from the plan (including fees charged as a
percentage of assets and deducted from investment returns)
in connection with services rendered to the plan, or the

Only line 1 of Part I of the Schedule C must be completed

as defined below.
Part II of the Schedule C must be completed to report
service providers who fail or refuse to provide information
necessary to complete Part I of this Schedule.
Part III of the Schedule C must be completed to report a
termination in the appointment of an accountant or enrolled
actuary during the 2010 plan year.
For plans, GIAs, MTIAs, and 103-12 IEs required to file Part
I of Schedule C, commissions and fees listed on the Schedule
A are not required to be reported again on Schedule C. The
amount of the compensation that must be reported on
Schedule A must, however, be taken into account in

purpose includes individuals, trades and businesses
(whether incorporated or unincorporated). See ERISA
section 3(9).
Direct Compensation: Payments made directly by the
plan for services rendered to the plan or because of a
compensation. Direct payments by the plan would include,
for example, direct payments by the plan out of a plan
account, charges to plan forfeiture accounts and fee

compensation in relation to the plan or DFE is $5,000 or more
and, thus, requiring the compensation not listed on the
Schedule A to be reported on the Schedule C. See FAQs
about the Schedule C available on the EBSA website at
www.dol.gov/ebsa/faqs.

allocations are made to individual participant accounts, and
direct charges to plan participant individual accounts.
Payments made by the plan sponsor, which are not
reimbursed by the plan, are not subject to Schedule C
reporting requirements even if the sponsor is paying for
services rendered to the plan.
Indirect Compensation: Compensation received from
sources other than directly from the plan or plan sponsor is
reportable on Schedule C as indirect compensation from the
plan if the compensation was received in connection with
services rendered to the plan during the plan year or the
rpose, compensation
is considered to have been received in connection with

Health and welfare plans that meet the conditions of
the limited exemption at 29 CFR 2520.104-44 or
Technical Release 92-01 are not required to
complete and file a Schedule C.
Lines A, B, C, and D. This information must be the same as
reported in Part II of the Form 5500 to which this Schedule C is
attached.
Do not use a social security number in line D in lieu of an
EIN. The Schedule C and its attachments are open to public
inspection, and the contents are public information subject to
-24-

Instructions for Schedule C (Form 5500)

Special rules for non-monetary compensation of
insubstantial value, guaranteed benefit insurance policies,
bundled service arrangements, and allocating
compensation among multiple plans:
Excludable Non-Monetary Compensation: You may
exclude non-monetary compensation of insubstantial value
(such as gifts or meals of insubstantial value) that is tax
deductible for federal income tax purposes by the person
providing the gift or meal and would not be taxable income to
the recipient. The gift or gratuity must be valued at less than
$50, and the aggregate value of gifts from one source in a
calendar year must be less than $100, but gifts with a value of
less than $10 do not need to be counted toward the $100 limit.
If the $100 aggregate value limit is exceeded, then the value of
all the gifts over $10 will be reportable. Gifts received by one
person from multiple employees of one entity must be treated
as originating from a single source when calculating whether
the $100 threshold applies. On the other hand, gifts received
from one person by multiple employees of one entity can be
treated as separate compensation when calculating the $50
and $100 thresholds. For more information, see FAQs about
the Schedule C, available on the EBSA website at
www.dol.gov/ebsa/faqs.
These thresholds are for purposes of Schedule C
reporting only. Filers are strongly cautioned that gifts
and gratuities of any amount paid to or received by
plan fiduciaries may violate ERISA and give rise to civil
liabilities and criminal penalties.

management fees paid by a mutual fund to its investment
adviser, sub-transfer agency fees, shareholder servicing fees,
account maintenance fees, and 12b-1 distribution fees). The
investment of plan assets and payment of premiums for
insurance contracts, however, are not in and of themselves
payments for services rendered to the plan for purposes of
Schedule C reporting and the investment and payment of
premiums themselves are not reportable compensation for
purposes of Part I of the Schedule C.
In the case of charges against an investment fund,
ensation
asset-based investment
management fee from the fund, brokerage commissions and
fees charged in connection with purchases and sales of
interests in the fund, fees related to purchases and sales of
interests in the fund (including 12b-1 fees), fees for providing
services to plan investors or plan participants such as
communication and other shareholder services, and fees
relating to the administration of the employee benefit plan such
as recordkeeping services, Form 5500 return/report filing and
other compliance services. Amounts charged against the fund

or in part, on services that were rendered to the plan or on a
transaction or series of transactions with the plan. Indirect
compensation would not include compensation that would
have been received had the service not been rendered or the
transaction had not taken place and that cannot be reasonably
allocated to the services performed or transaction(s) with the
plan.
Persons that provide investment management,
recordkeeping, claims processing, participant communication,
brokerage, and other services to the plan as part of an
investment contract or transaction are considered to be
providing services to the plan for purposes of Schedule C
reporting and would be required to be identified in Part I if they
received $5,000 or more in reportable compensation for
providing those services.
Examples of reportable indirect compensation include fees
and expense reimbursement payments received by a person
from mutual funds, bank commingled trusts, insurance
company pooled separate accounts, and other separately
managed accounts and pooled investment funds in which the
plan invests that are charged against the fund or account and

compensation for Schedule C purposes. Also, brokerage costs
associated with a broker-dealer effecting securities
transactions within the portfolio of a mutual fund or for the
ERISA purposes should be treated for Schedule C purposes
as an operating expense of the investment fund, not reportable
indirect compensation paid to a plan service provider or in
connection with a transaction with the plan.
Other examples of reportable indirect compensation are
(regardless of whether the broker is granted discretion),
research or other products or services, other than execution,
received from a broker-dealer or other third party in connection
with securities transactions (soft dollars), and other transaction
based fees received in connection with transactions or services
involving the plan whether or not they are capitalized as
investment costs.
For more information, see FAQs about the Schedule C,
available on the EBSA website at www.dol.gov/ebsa/faqs.
Instructions for Schedule C (Form 5500)

-25-

Fully Insured Group Health and Similarly Fully Insured
Benefits: Where benefits under a plan are purchased from
and guaranteed by an insurance company, insurance service,
or other similar organization, and the contract or policy is
reported on a Schedule A, payments of reasonable monetary
compensation by the insurer out of its general assets to
persons for performing administrative activities necessary for
the insurer to fulfill its contractual obligation to provide benefits,
where there is no direct or indirect charge to the plan for the
administrative services other than the insurance premium,
would not be treated as indirect compensation for services
provided to the plan for Schedule C reporting purposes. This
would include compensation for services such as
recordkeeping and claims processing services provided by a
third party pursuant to a contract with the insurer to provide
those services, but would not include compensation provided
by the insurer incidental to the sale or renewal of a policy, such
or similar fees. Insurance investment contracts are not eligible
for this exception.
Bundled Service Arrangements: For Schedule C
reporting purposes, a bundled service arrangement includes
any service arrangements where the plan hires one company
to provide a range of services either directly from the
company, through affiliates or subcontractors, or through a
combination, which are priced to the plan as a single package
rather than on a service-by-service basis. A bundled service
arrangement would also include an investment transaction in
which the plan receives a range of services either directly from
the investment provider, through affiliates or subcontractors, or
through a combination.
Direct payments by the plan to the bundled service provider
should be reported as direct compensation to the bundled
service provider. Such direct payments by the plan do not need
to be allocated among affiliates or subcontractors and do not
need to be reported as indirect compensation received by the
affiliates or subcontractors unless the amount paid to the

affiliate or subcontractor is set on a per transaction basis, e.g.,
brokerage fees and commissions.
eflected in the
net value of the investment, such as management fees paid by
mutual funds to their investment advisers, float revenue,
-1
distribution fees, account maintenance fees, and shareholder
servicing fees, must, subject to the alternative reporting option

rokerage
commissions or other transaction-based fees for transactions
or services involving the plan that were not paid directly by the
plan or plan sponsor (whether or not they are capitalized as
investment costs).
Investment funds or accounts for this purpose would
include mutual funds, bank commingled trusts, including
common and collective trusts, insurance company pooled
separate accounts, and other separately managed accounts
and pooled investment vehicles in which the plan invests.
Investment funds or accounts would also include separately
managed investment accounts that contain assets of individual
plans.
(2) Required Written Disclosures: For the types of
indirect compensation described above to be treated as eligible
indirect compensation for purposes of completing line 1, you
must have received written materials that disclosed and
described (a) the existence of the indirect compensation; (b)
the services provided for the indirect compensation or the
purpose for payment of the indirect compensation; (c) the
amount (or estimate) of the compensation or a description of
the formula used to calculate or determine the compensation;
and (d) the identity of the party or parties paying and receiving
the compensation. The written disclosures for a bundled
arrangement must separately disclose and describe each
element or indirect compensation that would be required to be
separately reported if you were not relying on this alternative
reporting option.

treated as separate reportable compensation by the person
receiving the fee for purposes of Schedule C reporting.
For each person who is a fiduciary to the plan or provides
contract
one or more of the following services to the plan
administrator, consulting, investment advisory (plan or
participants), investment management, securities brokerage, or
commissions and other transaction based
recordkeeping
monetary compensation, would also be required to be treated
as separate compensation for Schedule C purposes even if
those fees were paid from mutual fund management fees or

net value of the investment.
Other revenue sharing payments among members of a
bundled service arrangement do not need to be allocated
among affiliates or subcontractors and treated as indirect
compensation received by the affiliates or subcontractors in
determining whether the affiliate or subcontractor must be
separately identified on line 2 of the Schedule C.
For more information about bundled arrangements for
reporting purposes, see FAQs about the Schedule C,
available on the EBSA website at www.dol.gov/ ebsa/faqs.
Allocating Compensation Among Multiple Plans: Where
reportable compensation is received by a person in connection
with several plans or DFEs, any reasonable method of
allocating the compensation among the plans or DFEs may be
used provided that the allocation method is disclosed to the
plan administrator. In calculating the $5,000 threshold for
purposes of determining whether a person must be identified in
Part I, include the amount of compensation received by the
person that is attributable to the plan or DFE filing the Form
5500, not the aggregate amount received in connection with all
the plans or DFEs.
Affiliates: For purposes of Schedule C reporting, an

If any person received eligible indirect compensation
and either direct compensation and/or indirect
compensation that does not meet the requirements of
this line to be eligible indirect compensation, you cannot rely
on the alternative reporting option for that person and must
complete line 2 for each such person who received $5,000 or
more in direct and indirect compensation.
Line 2. Except for those persons and eligible indirect

complete as many entries as needed to list each person
receiving, directly or indirectly, $5,000 or more in total direct
and indirect compensation. Start with the most highly
compensated and list in descending order of compensation.
(a) through (h) as specified below. Use as many entries as
necessary to list all persons and information required to be
reported.
Element (a). Enter the EIN for the person identified in
element (a). If the name of an individual is entered in element
(a) and the individual does not have an EIN, enter the EIN of
-employed and

through one or more intermediaries, controlling, controlled by,
or under common control with the person applying principles
consistent with the regulations prescribed under section 414(c)
of the Code.
Line 1.
are relying on the alternative reporting option for a person or

and telephone number. Do not use a social security number in
lieu of an EIN. The Schedule C and its attachments are open
to public inspection and are subject to publication on the
Internet. Because of privacy concerns, the inclusion of a social
security number on this Schedule C or any of its attachments
may result in the rejection of the filing.
Element (b). Select from the list below all codes that
describe the services provided and compensation received.
Enter as many codes as apply:

as necessary to identify the person or persons who provided
you with the necessary disclosures regarding the eligible
indirect compensation. If any indirect compensation is either
not of the type described below or if the plan did not receive
the written disclosures described below, the indirect
purposes of Part 1.
(1) Eligible Indirect Compensation: The types of indirect
compensation that can be treated as eligible indirect
compensation are indirect compensation that is fees or
expense reimbursement payments charged to investment
funds and reflected in the value of the investment or return on

Code Service
10
11
12
13
14

-26-

Accounting (including auditing)
Actuarial
Claims processing
Contract Administrator
Plan Administrator

Instructions for Schedule C (Form 5500)

49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
70
71
72
73
99

Note. Do not leave element (d) blank. If no direct
Element (e).
(a), or any related person, received during the plan year
with the plan or services provided to the plan. (See instructions
above on definition of indirect compensation.) If the answer is
(f) through (h) for the person identified in
element (a).
pensation
Element (f).
was eligible indirect compensation for which the plan received
the necessary disclosures. See instructions for line 1 for
of the indirect compensation was eligible indirect
compensation.
Element (g). Enter the total of all indirect compensation that is
not eligible indirect compensation for which the plan received
the necessary disclosure. Do not leave blank. If none, enter
Element (h).
tead of an
amount or an estimated amount, gave the plan a formula or
other description of the method used to determine some or all
of the indirect compensation received.
Line 3. For each person identified in line 2 who is a fiduciary
to the plan or provides one or more of the following services to
the plan
contract administrator, consulting, investment
advisory (plan or participants), investment management,
securities brokerage, or recordkeeping
enter the requested
information for each source from whom the person received
indirect compensation if (1) the amount of the compensation
was $1,000 or more, or (2) the plan was given a formula or
other description of the method used to determine the indirect
compensation rather than an amount or estimated amount of
the indirect compensation.

Named fiduciary
Real estate brokerage
Securities brokerage
Valuation (appraisals, etc.)
Employee (plan sponsor)
Copying and duplicating
Participant loan processing
Participant communication
Foreign entity (e.g., an agent or broker, bank, insurance
company, etc. not operating within jurisdictional boundaries of
the United States)
Other services
Direction payment from the plan
Investment management fees paid directly by plan
Investment management fees paid indirectly by plan
Insurance brokerage commissions and fees
Sales loads (front end and deferred)
Other commissions
Non-monetary compensation
Redemption fees
Product termination fees (surrender charges, etc.)
Shareholder servicing fees
Sub-transfer agency fees

31
32
33
34
35
36
37
38
40

the plan after any revenue sharing offset should be entered in
element (d).

16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

Recordkeeping and information management (computing,
tabulating, data processing, etc.)
Consulting (general)
Consulting (pension)
Custodial (other than securities)
Custodial (securities)
Trustee (individual)
Trustee (bank, trust company, or similar financial institution)
Insurance agents and brokers
Insurance services
Trustee (discretionary)
Trustee (directed)
Investment advisory (participants)
Investment advisory (plan)
Investment management
Legal
Employee (plan)

Float revenue
Distribution (12b-1) fees
Recordkeeping fees
Account maintenance fees
Insurance mortality and expense charge
Other insurance wrap fees

Important Reminder. Before identifying a fiduciary or service
provider as a person who failed or refused to provide
information, you should contact the fiduciary or service
provider to request the necessary information and tell them
that you will list them on the Schedule C as a fiduciary or
service provider who failed or refused to provide information if
they do not provide the necessary information.

Consulting fees
Securities brokerage commissions and fees
Other investment fees and expenses
Other insurance fees and expenses
Other fees

Element (c). Enter any relationship of the person identified in
element (a) to the plan sponsor, to the participating employer
or employee organization, or to any person known to be a
party-in-interest, for example, employee of employer, vicepresident of employer, union officer, affiliate of plan
recordkeeper, etc.
Element (d). Enter the total amount of compensation
received directly from the plan for services rendered to the plan
during the plan year. If a service provider charges the plan a
fee or commission, but agrees to offset the fee or commission
with any revenue received from a party other than the plan or
plan sponsor, for example, as part of a commission recapture
or other offset arrangement, only the amount paid directly by
Instructions for Schedule C (Form 5500)

Part II - Service Providers Who Fail or Refuse To Provide
Information
Line 4. Provide the requested information for each plan
fiduciary or service provider who you believe failed or refused
to provide any of the information necessary to complete Part I
of this schedule.

-27-

Part III - Termination Information on Accountants and
Enrolled Actuaries
Complete Part III if there was a termination in the appointment
of an accountant or enrolled actuary during the 2010 plan year.
This information must be provided on the Form 5500 for the
plan year during which the termination occurred. For example,
if an accountant was terminated in the 2010 plan year after
completing work on an audit for the 2008 plan year, the
termination should be reported on the Schedule C filed with the
2010 plan year Form 5500. If the accountant is a firm (such as
a corporation, partnership, etc.), report when the service
provider (not an individual within the firm) was terminated. An
enrolled actuary is by definition an individual and not a firm,
and you must report when the individual is terminated.

and the contents are public information and are subject to
publication on the Internet. Because of privacy concerns, the
inclusion of a social security number on this Schedule C or any
of its attachments may result in the rejection of the filing.

Provide an explanation of the reasons for the termination of
an accountant or enrolled actuary. Include a description of any
material disputes or matters of disagreement concerning the
termination, even if resolved prior to the termination. If an
individual is listed, and the individual does not have an EIN,

The plan administrator must also provide the terminated
accountant or enrolled actuary with a copy of the explanation
for the termination provided in Part III of the Schedule C, along
with a completed copy of the notice below.

employer.
Do not use a social security number in lieu of an EIN. The
Schedule C and its attachments are open to public inspection,

Notice to Terminated Accountant
or Enrolled Actuary
I, as plan administrator, verify that the explanation that is reproduced below or attached to this notice is the explanation concerning
your termination reported on the Schedule C (Form 5500) attached to the 2010 Form 5500, Annual Return/Report of Employee
Benefit Plan, for the __________________________________________________________(enter name of plan). This Form 5500
-digit
is identified in line 2b by the nine-digit EIN
PN________(enter plan number).

AF
R
D

Signed
Dated

You have the opportunity to comment to the Department of Labor concerning any aspect of this explanation. Comments should
include the name, EIN, and PN of the plan and be submitted to: Office of Enforcement, Employee Benefits Security Administration,
U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, DC 20210.

-28-

Instructions for Schedule C (Form 5500)

Element (c). Enter the nine-digit employer identification
number (EIN) and three-digit plan/entity number (PN) for each
MTIA, CCT, PSA, or 103-12 IE named in element (a). This
must be the same DFE EIN/PN as reported on lines 2b and 1b
of the Form 5500 filed for the DFE. If a Form 5500 was not
filed for a CCT or PSA named in element (a), enter the EIN for
the CCT or PSA and enter 000 for the PN. Do not use a social
security number in lieu of an EIN. The Schedule D and its
attachments are open to public inspection, and the contents
are public information and are subject to publication on the
Internet. Because of privacy concerns, the inclusion of a social
security number on this Schedule D or any of its attachments
may result in the rejection of the filing.
Element (d). Enter an M, C, P, or E, as appropriate, (see
table below) to identify the type of entity (MTIA, CCT, PSA, or
103-12 IE).

2010 Instructions for Schedule D
(Form 5500)
DFE/Participating Plan Information
General Instructions
Purpose of Schedule
When the Form 5500 is filed for a plan or Direct Filing Entity
(DFE) that invested or participated in any master trust
investment accounts (MTIAs), 103-12 Investment Entities
(103-12 IEs), common/collective trusts (CCTs), and/or pooled
separate accounts (PSAs), Part I provides information about
these entities. When the Form 5500 is filed for a DFE, Part II
provides information about plans participating in the DFE.

Who Must File

Check the Schedule D box on the Form 5500 (Part II, line
10b(5)) if a Schedule D is attached to the Form 5500.
Complete as many repeating entries as necessary to report the
required information.

Specific Instructions

Enter in (d)

MTIA

CCT

PSA



103-12 IE



Element (e).
interest as of the end of the year. If the plan or DFE for which
this Schedule D is filed had no interest in the MTIA, CCT, PSA,
or 103Example for Part I: If a plan participates in an MTIA, the
MTIA is named in element (a)
element (b)
(c)
(such as: 12-3456789(d);

Form 5500). For more information, see instructions for Direct
Filing Entity (DFE) Filing Requirements.

Type of entity

Employee Benefit Plans: Schedule D (Form 5500) must be
attached to a Form 5500 filed for an employee benefit plan that
participated or invested in one or more CCTs, PSAs, MTIAs, or
103-12 IEs at anytime during the plan year.
Direct Filing Entities: Schedule D (Form 5500) must be
attached to a Form 5500 filed for a CCT, PSA, MTIA, 103-12
IE, or Group Insurance Arrangement (GIA), as a Direct Filing

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

Part I - Information on Interests in MTIAs, CCTs,
PSAs, and 103-12 IEs (To Be Completed by Plans
and DFEs)

If the plan also participates in a CCT for which a Form 5500
was not filed, the CCT is named in another element (a); the
name of the CCT sponsor is entered in element (b); the EIN for
the CCT, followed by 000 is entered in element (c) (such as:
99-8765432(d); and the
element (e).
If the plan also participates in a PSA for which a Form 5500
was filed, the PSA is named in a third element (a); the name of
the PSA sponsor is entered in element (b)
PN is entered in element (c) (such as: 98-7655555is entered in element (d); and
interest in the PSA is entered in element (e).

Part II - Information on Participating Plans
(To Be Completed Only by DFEs)

Complete as many repeating entries as necessary to enter the
information specified below for all MTIAs, CCTs, PSAs, and
103-12 IEs in which the plan or DFE filing the Form 5500
participated at anytime during the plan or DFE year.
Complete a separate item (elements (a) through (e)) for
each MTIA, CCT, PSA, or 103-12 IE.
Element (a). Enter the name of the MTIA, CCT, PSA, or10312 IE in which the plan or DFE filing the Form 5500
participated at any time during the plan or DFE year.
Element (b). Enter the name of the sponsor of the MTIA,
CCT, PSA, or 103-12 IE named in element (a).
Instructions for Schedule D (Form 5500)

end of plan year is entered in element (e).

-29-

Complete as many repeating entries as necessary to enter the
information specified below for all plans invested or
participated in the DFE at any time during the DFE year.
Complete a separate item (elements (a) through (c)) for each
plan.
Element (a). Enter the name of each plan that invested or
participated in the DFE at any time during the DFE year. GIAs
need not complete element (a).
Element (b). Enter the name of the sponsor of each and
every plan investing or participating in the DFE.
Element (c). Enter the nine-digit EIN and three-digit PN for
each plan named in element (a). This is the EIN and PN

subject to publication on the Internet. Because of privacy
concerns, the inclusion of a social security number on this
Schedule D or any of its attachments may result in the
rejection of the filing.

5500-SF. GIAs should enter the EIN of the sponsor listed in
element (b). Do not use a social security number in lieu of an
EIN. The Schedule D and its attachments are open to public
inspection, and the contents are public information and are

-30-

Instructions for Schedule D (Form 5500)

loan is in default when the borrower is unable to pay the
obligation upon maturity. Obligations that require periodic
repayment can default at any time. Generally loans and fixed
income obligations are considered uncollectible when payment
has not been made and there is little probability that payment
will be made. A fixed income obligation has a fixed maturity
date at a specified interest rate.
Do not report in Part I participant loans under an individual
account plan with investment experience segregated for each
account, that are made in accordance with 29 CFR 2550.408b-

2010 Instructions for Schedule G
(Form 5500)
Financial Transaction Schedules
General Instructions
Who Must File

Specific Instructions

vested accrued benefit. Report all other participant loans in
default or classified as uncollectible on Part I, and list each
such loan individually.

Part II - Leases in Default or Classified as
Uncollectible
List any leases in default or classified as uncollectible. A lease
is an agreement conveying the right to use property, plant, or
equipment for a stated period. A lease is in default when the
required payment(s) has not been made. An uncollectible
lease is one where the required payments have not been
made and for which there is little probability that payment will
be made. Provide, on a separate attachment, an explanation of
what steps have been taken or will be taken to collect overdue
amounts for each lease listed and label the attachment

Schedule G (Form 5500) must be attached to a Form 5500
filed for a plan, MTIA, 103-12 IE, or GIA to report loans or fixed
income obligations in default or determined to be uncollectible
as of the end of the plan year, leases in default or classified as
uncollectible, and nonexempt transactions. See Schedule H
(Form 5500) lines 4b, 4c, and/or 4d.
Check the Schedule G box on the Form 5500 (Part II, line
10b(6)) if a Schedule G is attached to the Form 5500.
Complete as many entries as necessary to report the required
information.
The Schedule G consists of three parts. Part I of the
Schedule G reports any loans or fixed income obligations in
default or determined to be uncollectible as of the end of the
plan year. Part II of the Schedule G reports any leases in
default or classified as uncollectible. Part III of the Schedule G
reports nonexempt transactions.

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

Part III - Nonexempt Transactions
All nonexempt party-in-interest transactions must be reported,

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

Part I - Loans or Fixed Income Obligations in Default
or Classified as Uncollectible
List all loans or fixed income obligations in default or
determined to be uncollectible as of the end of the plan year or
the fiscal year of the GIA, MTIA, or 103-12 IE. Include:
Obligations where the required payments have not been
made by the due date;
Fixed income obligations that have matured, but have not
been paid, for which it has been determined that payment will
not be made; and
Loans that were in default even if renegotiated later during
the year.
Note. Identify in element (a) each obligor known to be a
party-in-interest to the plan.
Provide, on a separate attachment, an explanation of what
steps have been taken or will be taken to collect overdue
amounts for each loan listed and label the attachment
The due date, payment amount, and conditions for
determining default in the case of a note or loan are usually
contained in the documents establishing the note or loan. A
Instructions for Schedule G (Form 5500)

-31-

An unfunded, fully insured, or combination
unfunded/insured welfare plan with 100 or more
participants exempt under 29 CFR 2520.104-44 from
completing Schedule H must still complete Schedule G, Part III,
to report nonexempt transactions.
If you are unsure whether a transaction is exempt or not, you

party dealing with the plan in connection with a transaction
involving the income or assets of the plan.

public accountant or legal counsel or both.
You may indicate that an application for an administrative
exemption is pending.
If the plan is a qualified pension plan and a nonexempt
prohibited transaction occurred with respect to a disqualified
person, an IRS Form 5330, Return of Excise Taxes Related to
Employee Benefit Plans, is required to be filed with the IRS to
pay the excise tax on the transaction.

The DOL Voluntary Fiduciary Correction Program (VFCP)
describes how to apply, the specific transactions covered
(which transactions include delinquent participation
contributions to pension and welfare plans), and
acceptable methods for correcting violations. In
addition, applicants that satisfy both the VFCP
requirements and the conditions of Prohibited Transaction
Exemption (PTE) 2002-51 are eligible for immediate relief from
payment of certain prohibited excise taxes for certain corrected
transactions, and are also relieved from the obligation to file
the Form 5330 with the IRS. For more information, see 71 Fed.
Reg. 20261 (Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19,
2006). If conditions of PTE 2002-51 are satisfied, corrected
transactions should be treated as exempt under Code section
4975(c) for the purposes of answering Schedule G, Part III.
Information about the VFCP is also available on the internet at
www.dol.gov/ebsa.

For purposes of this form, party-in-interest is deemed to
include a disqualified person. See Code section 4975(e)(2).
-inplan:
A. Any fiduciary (including, but not limited to, any
administrator, officer, trustee or custodian), counsel, or
employee of the plan;
B. A person providing services to the plan;
C. An employer, any of whose employees are covered by
the plan;
D. An employee organization, any of whose members are
covered by the plan;
E. An owner, direct or indirect, of 50% or more of: (1) the
combined voting power of all classes of stock entitled to vote
or the total value of shares of all classes of stock of a
corporation, (2) the capital interest or the profits interest of a
partnership, or (3) the beneficial interest of a trust or
unincorporated enterprise that is an employer or an
employee organization described in C or D;
F. A relative of any individual described in A, B, C, or E;
G. A corporation, partnership, or trust or estate of which (or
in which) 50% or more of: (1) the combined voting power of
all classes of stock entitled to vote or the total value of
shares of all classes of stock of such corporation, (2) the
capital interest or profits interest of such partnership, or (3)
the beneficial interest of such trust or estate is owned
directly or indirectly, or held by, persons described in A, B,
C, D, or E;
H. An employee, officer, director (or individual having
powers or responsibilities similar to those of officers or
directors), or a 10% or more shareholder, directly or
indirectly, of a person described in B, C, D, E, or G, or the
employee benefit plan; or
I. A 10% or more (directly or indirectly in capital or profits)
partner or joint venture of a person described in B, C, D, E,
or G.

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Instructions for Schedule G (Form 5500)

2010 Instructions for Schedule H
(Form 5500)
Financial Information
General Instructions
Who Must File

5500) may report investments in assets made through
participant-directed brokerage accounts either:
1. As individual investments on the applicable asset and
liability categories in Part I and the income and expense
categories in Part II, or
2. By including on line 1c(15) the total aggregate value of the
assets and on line 2c the total aggregate investment income
(loss) before expenses, provided the assets are not loans,
partnership or joint-venture interests, real property, employer
securities, or investments that could result in a loss in excess of
the account balance of the participant or beneficiary who
directed the transaction. Expenses charged to the accounts
must be reported on the applicable expense line items.
Participant-directed brokerage account assets reported in the
aggregate on line 1c(15) should be treated as one asset held for
investment for purposes of the line 4i schedules, except that
investments in tangible personal property must continue to be
reported as separate assets on the line 4i schedules.
In the event that investments made through a
participant-directed brokerage account are loans, partnership or
joint venture interests, real property, employer securities, or
investments that could result in a loss in excess of the account
balance of the participant or beneficiary who directed the
transaction, such assets must be broken out and treated as
separate assets on the applicable asset and liability categories
in Part I, income and expense categories in Part II, and on the
line 4i schedules. The remaining assets in the participantdirected brokerage account may be reported in the aggregate
as set forth in paragraph 2 above.
Columns (a) and (b). Enter the current value on each line as of
the beginning and end of the plan year.
Note. Amounts reported in column (a) must be the same as
reported for the end of the plan year for corresponding line
items of the return/report for the preceding plan year. Do not
include contributions designated for the 2010 plan year in
column (a).
Line 1a. Total noninterest bearing cash includes, among other
things, cash on hand or cash in a noninterest bearing checking
account.
Line 1b(1). Noncash basis filers must include contributions due
the plan by the employer but not yet paid. Do not include other
amounts due from the employer such as the reimbursement of
an expense or the repayment of a loan.
Line 1b(2). Noncash basis filers must include contributions
withheld by the employer from participants and amounts due
directly from participants that have not yet been received by the
plan. Do not include the repayment of participant loans.
Line 1b(3). Noncash basis filers must include amounts due to
the plan that are not includable in lines 1b(1) or 1b(2). These
amounts may include investment income earned but not yet
received by the plan and other amounts due to the plan such as
amounts due from the employer or another plan for expense

Specific Instructions

Schedule H (Form 5500) must be attached to a Form 5500 filed
for a pension benefit plan or a welfare benefit plan that covered
100 or more participants as of the beginning of the plan year
and a Form 5500 filed for an MTIA, CCT, PSA, 103-12 IE, or
GIA. See the instructions to the Form 5500 for Direct Filing
Entity (DFE) Filing Requirements.
Exceptions: (1) Insured, unfunded, or a combination of
unfunded/insured welfare plans and fully insured pension plans
that meet the requirements of 29 CFR 2520.104-44 are exempt
from completing the Schedule H. (2) If a Schedule I was filed for
the plan for the 2009 plan year and the plan covered fewer than
121 participants as of the beginning of the 2010 plan year, the
Schedule I may be completed instead of a Schedule H. See
What To File. If eligible, such a plan may file the Form 5500-SF
instead of the Form 5500 and its schedules, including the
Schedule I. See Instructions for Form 5500-SF. (3) Plans that
file a Form 5500-SF for the 2010 plan year are not required to
file a Schedule H for that year.
Check the Schedule H box on the Form 5500 (Part II, line
10b(1)) if a Schedule H is attached to the Form 5500. Do not
attach both a Schedule H and a Schedule I to the same Form
5500.

line 2b(6) or (7) in accordance with the instructions for these
lines.
If assets of one plan are maintained in two or more trust
funds, report the combined financial information in Parts I and II.
Current value means fair market value where available.
Otherwise, it means the fair value as determined in good faith
under the terms of the plan by a trustee or a named fiduciary,
assuming an orderly liquidation at time of the determination.
See ERISA section 3(26).
Note. For the 2010 plan year, plans that provide participantdirected brokerage accounts as an investment alternative (and

Lines A, B, C, and D. This information must be the same as
reported in Part II of the Form 5500 to which this Schedule H is
attached.
Do not use a social security number in line D in lieu of an
EIN. The Schedule H and its attachments are open to public
inspection, and the contents are public information and are
subject to publication on the Internet. Because of privacy
concerns, the inclusion of a social security number on this
Schedule H or any of its attachments may result in the rejection
of the filing.
You can apply for an EIN from the IRS online, by telephone,
by fax, or by mail depending on how soon you need to use the
EIN. For more information, see Section 3: Electronic Filing
Requirement under General Instructions to Form 5500. The
EBSA does not issue EINs.
Note. The cash, modified cash, or accrual basis may be used
for recognition of transactions in Parts I and II, as long as you
use one method consistently. Round off all amounts reported
on the Schedule H to the nearest dollar. Any other amounts are
subject to rejection. Check all subtotals and totals carefully.
If the assets of two or more plans are maintained in a fund or
account that is not a DFE, a registered investment company, or
the general account of an insurance company under an the
unallocated contract (see the instructions for lines 1c(9) through
1c(14)), complete Parts I and II of the Schedule H by entering
Exception. When completing Part II of the Schedule H for a
plan or DFE that participates in a CCT or PSA for which a Form
5500 has not been filed, do not allocate the income of the CCT
or PSA and expenses that were subtracted from the gross
income of the CCT or PSA in determining their net investment
gain (loss). Instead, enter the CCT or PSA net gain (loss) on

-33-

Instructions for Schedule H (Form 5500)

reimbursement or from a participant for the repayment of an
overpayment of benefits.
Line 1c(1). Include all assets that earn interest in a financial
institution account such as interest bearing checking accounts,
passbook savings accounts, or in money market accounts.
Line 1c(2). Include securities issued or guaranteed by the U.S.
Government or its designated agencies such as U.S. Savings
Bonds, Treasury Bonds, Treasury Bills, FNMA, and GNMA.
Line 1c(3). Include investment securities (other than employer
securities defined below in line 1d(1)) issued by a corporate
entity at a stated interest rate repayable on a particular future
date such as most bonds, debentures, convertible debentures,
commercial paper and zero coupon bonds. Do not include debt
securities of governmental units that should be reported on line
1c(2) or 1c(15).

1. Under the plan, the participant loan is treated as a
and
2. As of the end of the plan year, the participant is not
continuing repayment under the loan.
If both of these circumstances apply, report the loan as a
deemed distribution on line 2g. However, if either of these
circumstances does not apply, the current value of the
participant loan (including interest accruing thereon after the
deemed distribution) must be included in column (b) without
regard to the occurrence of a deemed distribution.
Note. After a participant loan that has been deemed distributed
is reported on line 2g, it is no longer to be reported as an asset
on Schedule H or Schedule I unless, in a later year, the
participant resumes repayment under the loan. However, such a
loan (including interest accruing thereon after the deemed
distribution) that has not been repaid is still considered
outstanding for purposes of applying Code section 72(p)(2)(A)
to determine the maximum amount of subsequent loans. Also,
the deemed distribution is not treated as an actual distribution
for other purposes, such as the qualification requirements of
Code section 401, including, for example, the determination of
top-heavy status under Code section 416 and the vesting
requirements of Treasury Regulations section 1.411(a)-7(d)(5).
See Q&As 12 and 19 of Treasury Regulations section 1.72(p)-1.
The entry on line 1c(8), column (b), of Schedule H
(participant loans - end of year) or on line 1a, column (b), of
Schedule I (plan assets - end of year) must include the current
value of any participant loan that was reported as a deemed
distribution on line 2g for any earlier year if the participant
resumes repayment under the loan during the plan year. In
addition, the amount to be entered on line 2g must be reduced
by the amount of the participant loan that was reported as a
deemed distribution on line 2g for the earlier year.
Lines 1c(9), (10), (11), and (12). Enter the total current value of

publicly traded on a recognized securities exchange and the

Line 1c(4)(A). Include stock issued by corporations (other than
employer securities defined in line 1d(1) below) which is
accompanied by preferential rights such as the right to share in
distributions of earnings at a higher rate or which has general
priority over the common stock of the same entity. Include the
value of warrants convertible into preferred stock.
Line 1c(4)(B). Include any stock (other than employer securities
defined in line 1d(1)) that represents regular ownership of the
corporation and is not accompanied by preferential rights.
Include the value of warrants convertible into common stock.
Line 1c(5).
partnership or joint venture if the underlying assets of the
partnership or joint venture are not considered to be plan assets
under 29 CFR 2510.3-101. Do not include the v
interest in a partnership or joint venture that is a 103-12
Investment Entity (103-12 IE). Include the value of a 103-12 IE
in line 1c(12).
Line 1c(6). Include the current value of both income and nonincome producing real property owned by the plan. Do not
include the value of property that is employer real property or
property used in plan operations that must be reported on lines
1d and 1e, respectively.
Line 1c(7). Enter the current value of all loans made by the
plan, except participant loans reportable on line 1c(8). Include
the sum of the value of loans for construction, securities loans,
commercial and/or residential mortgage loans that are not
subject to Code section 72(p) (either by making or participating
in the loans directly or by purchasing loans originated by a third
party), and other miscellaneous loans.
Line 1c(8). Enter the current value of all loans to participants
including residential mortgage loans that are subject to Code
section 72(p). Include the sum of the value of the unpaid
principal balances, plus accrued but unpaid interest, if any, for
participant loans made under an individual account plan with
investment experience segregated for each account, that are
made in accordance with 29 CFR 2550.408b-1 and secured

of the beginning and end of the plan or DFE year. The value of

or DFE year must be reported on the Schedule D (Form 5500).
trusts (CCTs) and pooled separate accounts (PSAs)
for which a DFE Form 5500 has not been filed may not
interest in the underlying assets of such CCTs and PSAs must
be allocated and reported in the appropriate categories on a
line-by-line basis on Part I of the Schedule H.
Note. For reporting purposes, a separate account that is not
considered to be holding plan assets pursuant to 29 CFR
2510.3-101(h)(1)(iii) does not constitute a PSA.
Line 1c(14). Use the same method for determining the value of
the insurance contracts reported here as you used for line 4 of
Schedule A, or, if line 4 is not required, line 7 of Schedule A.
Line 1c(15). Include all other investments not includable in lines
1c(1) through (14), such as options, index futures, state and
municipal securities, collectibles, and other personal property.
Line 1d(1). An employer security is any security issued by an
employer (including affiliates) of employees covered by the plan.
These may include common stocks, preferred stocks, bonds,
zero coupon bonds, debentures, convertible debenturees, notes
and commercial paper.
Line 1d(2).
property (and related personal property) that is leased to an
employer of employees covered by the plan, or to an affiliate of
such employer. For purposes of determining the time at which a

When applicable, combine this amount with the current value of
any other participant loans. Do not include in column (b) a
participant loan that has been deemed distributed during the
plan year under the provisions of Code section 72(p) and
Treasury Regulations section 1.72(p)-1, if both of the following
circumstances apply:

Instructions for Schedule H (Form 5500)

-34-

Line 2b(3). Generally, rents represent the income earned on the
real property that is reported in lines 1c(6) and 1d(2). Enter

plan acquires employer real property for purposes of this line,
such property shall be deemed to be acquired by the plan on
the date on which the plan acquires the property or on the date
on which the lease to the employer (or affiliate) is entered into,
whichever is later.
Line 1e. Include the current (not book) value of the buildings
and other property used in the operation of the plan. Buildings
or other property held as plan investments should be reported in
1c(6) and 1d(2).
Do not include the value of future pension payments on lines
1g, h, i, j, or k.
Line 1g. Noncash basis plans must include the total amount of
benefit claims that have been processed and approved for

total rent received and subtracting all expenses directly
associated with the property. If the real property is jointly used
as income producing property and for the operation of the plan,
net that portion of the expenses attributable to the income
producing portion of the property against the total rents
received.
Line 2b(4). Enter in column (b), the total of net gain (loss) on
sale of assets. This equals the sum of the net realized gain (or
loss) on each asset held at the beginning of the plan year which
was sold or exchanged during the plan year, and on each asset
that was both acquired and disposed of within the plan year.
Note. As current value reporting is required for the Form 5500,
assets are revalued to current value at the end of the plan year.
For purposes of this form, the increase or decrease in the value
of assets since the beginning of the plan year (if held on the first
day of the plan year) or their acquisition date (if purchased
during the plan year) is reported in line 2b(5) below, with two
exceptions: (1) the realized gain (or loss) on each asset that
was disposed of during the plan year is reported in line 2b(4)
(NOT on line 2b(5)), and (2) the net investment gain (or loss)
from CCTs, PSAs, MTIAs, 103-12 IEs, and registered
investment companies is reported in lines 2b(6) through (10).
The sum of the realized gain (or loss) of assets sold or
exchanged during the plan year is to be calculated as follows:
1. Enter in line 2b(4)(A), column (a), the sum of the amount
received for these former assets;
2. Enter in line 2b(4)(B), column (a), the sum of the current
value of these former assets as of the beginning of the plan year
and the purchase price for assets both acquired and disposed of
during the plan year; and
3. Enter in 2b(4) (C), column (b), the result obtained when
2b(4)(B) is subtracted from 2b(4)(A). If entering a negative

Line 1h. Noncash basis plans must include the total amount of
obligations owed by the plan which were incurred in the normal
operations of the plan and have been approved for payment by
the plan but have not been paid.
-financed
Line 1i.
property other than real property, means the outstanding
amount of the principal debt incurred:
1. By the organization in acquiring or improving the
property;
2. Before the acquisition or improvement of the property if
the debt was incurred only to acquire or improve the property; or
3. After the acquisition or improvement of the property if the
debt was incurred only to acquire or improve the property and
was reasonably foreseeable at the time of such acquisition or
improvement. For further explanation, see Code section 514(c).
Line 1j. Noncash basis plans must include amounts owed for
any liabilities that would not be classified as benefit claims
payable, operating payables, or acquisition indebtedness.
Line 1l. The entry in column (b) must equal the sum of the entry
in column (a) plus lines 2k, 2l(1), and 2l(2).
Line 2a. Include the total cash contributions received and/or (for
accrual basis plans) due to be received.
Note. Plans using the accrual basis of accounting should not
include contributions designated for years before the 2010 plan
year on line 2a.
Line 2a(1)(B). For welfare plans, report all employee
contributions, including all elective contributions under a
cafeteria plan (Code section 125). For pension benefit plans,
participant contributions, for purposes of this item, also include
elective contributions under a qualified cash or deferred entities
arrangement (Code section 401(k)).
Line 2a(2). Use the current value, at date contributed, of
securities or other noncash property.
Line 2b(1)(A). Enter interest earned on interest-bearing cash,
including earnings from sweep accounts, STIF accounts, money
market accounts, certificates of deposit, etc. This is the interest
earned on the investments reported on line 1c(1).
Line 2b(1)(B). Enter interest earned on U.S. Government
Securities. This is the interest earned on the investments
reported on line 1c(2).
Line 2b(1)(C). Generally, this is the interest earned on
securities that are reported on lines 1c(3)(A) and (B) and 1d(1).
Line 2b(2). Generally, the dividends are for investments
reported on lines 1c(4)(A) and (B), 1c(13), and 1d(1). For
accrual basis plans, include any dividends declared for stock
held on the date of record, but not yet received as of the end of
the plan year.

Note. Bond write-offs should be reported as realized losses.
Line 2b(5). Subtract the current value of assets at the beginning
of the year plus the cost of any assets acquired during the plan
year from the current value of assets at the end of the year to
obtain this figure. If entering a negative number, enter a minus
assets reportable in lines 2b(4) and 2b(6) through 2b(10).
Lines 2b(6), (7), (8), and (9). Report all earnings, expenses,
gains or losses, and unrealized appreciation or depreciation
included in computing the net investment gain (or loss) from all
CCTs, PSAs, MTIAs, and 103-12 IEs here. If some plan funds
are held in any of these entities and other plan funds are held in
other funding media, complete all applicable subitems of line 2
to report plan earnings and expenses relating to the other
funding media. The net investment gain (or loss) allocated to the
entities is equal to:
entity at the end of the plan year,
entity
at the beginning of the plan year,
3. Plus any amounts transferred out of each entity by the
plan during the plan year, and
4. Minus any amounts transferred into each entity by the
plan during the plan year.
Enter the net gain as a positive number or the net loss as a
negative number.

-35-

Instructions for Schedule H (Form 5500)

Note. Enter the combined net investment gain or loss from all
CCTs and PSAs, regardless of whether a DFE Form 5500 was
filed for the CCTs and PSAs.
Line 2b(10). Enter net investment gain (loss) from registered
investment companies here. Compute in the same manner as
discussed above for lines 2b(6) through (9).
Line 2c. Include all other plan income earned that is not
included in line 2a or 2b. Do not include transfers from other
plans that should be reported in line 2l.
Line 2e(1). Include the current value of all cash, securities, or
other property at the date of distribution. Include all eligible
rollover distributions as defined in Code section 401(a)(31)(D)
ent plan
(including an IRA within the meaning of section 401(a)(31)(E)).
Line 2e(2). Include payments to insurance companies and
similar organizations such as Blue Cross, Blue Shield, and
health maintenance organizations for the provision of plan
benefits (e.g., paid-up annuities, accident insurance, health
insurance, vision care, dental coverage, stop-loss insurance
whose claims are paid to the plan (or which is otherwise an
asset of the plan )), etc.
Line 2e(3). Include all payments made to other organizations
or individuals providing benefits. Generally, these are individual
providers of welfare benefits such as legal services, day care
services, training, and apprenticeship services.
Line 2f. Include on this line all distributions paid during the
plan year of excess deferrals under Code section
402(g)(2)(A)(ii), excess contributions under Code section
401(k)(8), and excess aggregate contributions under Code
section 401(m)(6). Include allocable income distributed. Also
include on this line any elective deferrals and employee
contributions distributed or returned to employees during the
plan year in accordance with Code section 415, as well as any
attributable gains that were also distributed.
Line 2g. Report on line 2g a participant loan that has been
deemed distributed during the plan year under the provisions of
Code section 72(p) and Treasury Regulations section 1.72(p)-1
only if both of the following circumstances apply:
1. Under the plan, the participant loan is treated as a
directed investment so
and
2. As of the end of the plan year, the participant is not
continuing repayment under the loan.

loan in a later year), they are still considered outstanding loans
and are not treated as actual distributions for certain purposes.
See Q&As 12 and 19 of Treasury Regulations section 1.72(p)-1.
Line 2h. Interest expense is a monetary charge for the use of
money borrowed by the plan. This amount should include the
total of interest paid or to be paid (for accrual basis plans)
during the plan year.
Line 2i. Report all administrative expenses (by specified
category) paid by or charged to the plan, including those that
were not subtracted from the gross income of CCTs, PSAs,
MTIAs, and 103-12 IEs in determining their net investment
gain(s) or loss(es). Expenses incurred in the general operations
of the plan are classified as administrative expenses.
Line 2i(1). Include the total fees paid (or in the case of accrual
basis plans, costs incurred during the plan year but not paid as
of the end of the plan year) by the plan for outside accounting,
actuarial, legal, and valuation/appraisal services. Include fees
for the annual audit of the plan by an independent qualified
public accountant (IQPA); for payroll audits; for
accounting/bookkeeping services; for actuarial services
rendered to the plan; and to a lawyer for rendering legal
opinions, litigation, and advice (but not for providing legal
services as a benefit to plan participants). Report here fees and
expenses for corporate trustees and individual plan trustees,
including reimbursement of expenses associated with trustees,
such as lost time, seminars, travel, meetings, etc. Include the
fee(s) for valuations or appraisals to determine the cost, quality,
or value of an item such as real property, personal property
(gemstones, coins, etc.), and for valuations of closely held
securities for which there is no ready market. Do not include
amounts paid to plan employees to perform bookkeeping/
accounting functions that should be included in line 2i(4).
Line 2i(2). Enter the total fees paid (or in the case of accrual
basis plans, costs incurred during the plan year but not paid as
of the end of the plan year) to a contract administrator for
performing administrative services for the plan. For purposes of
the return/report, a contract administrator is any individual,
partnership, or corporation, responsible for managing the
clerical operations (e.g., handling membership rosters, claims
payments, maintaining books and records) of the plan on a
contractual basis. Do not include salaried staff or employees of
the plan or banks or insurance carriers.
Line 2i(3). Enter the total fees paid (or in the case of accrual
basis plans, costs incurred during the plan year but not paid as
of the end of the plan year) to an individual, partnership or
corporation (or other person) for advice to the plan relating to its
investment portfolio. These may include fees paid to manage

performance.
Line 2i(4). Other expenses are those that cannot be included in
2i(1) through 2i(3). These may include plan expenditures such
as salaries and other compensation and allowances (e.g.,
payment of premiums to provide health insurance benefits to
plan employees), expenses for office supplies and equipment,
cars, telephone, postage, rent, expenses associated with the
ownership of a building used in the operation of the plan, and all
miscellaneous expenses.
Line 2l. Include in these reconciliation figures the value of all
transfers of assets or liabilities into or out of the plan resulting
from, among other things, mergers and consolidations. A
transfer of assets or liabilities occurs when there is a reduction
of assets or liabilities with respect to one plan and the receipt of
these assets or the assumption of these liabilities by another

the left of the number. The current value of the participant loan
must then be included in line 1c(8), column (b), of Schedule H
(participant loans - end of year) or in line 1a, column (b), of
Schedule I (plan assets - end of year).
Although certain participant loans deemed distributed are to
be reported on line 2g of the Schedule H or Schedule I, and are
not to be reported on the Schedule H or Schedule I as an asset
thereafter (unless the participant resumes repayment under the
Instructions for Schedule H (Form 5500)

-36-

from one investment to another. A transfer is not a distribution of

for the period under audit in conformity with generally accepted
accounting principles (GAAP) or an other comprehensive basis
of accounting (OCBOA), e.g., cash basis.
Line 3a(2). Check if a qualified opinion was issued. Generally,

reportable on IRS Form 1099-R, Distributions From Pensions,
Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance
Contracts, etc., (see the instructions for line 2e). Transfers out
at the end of the year should be reported as occurring during
the plan year. Include premium payments to the PBGC when
paid from plan assets.
Note. If this Schedule H is filed for a CCT, PSA, MTIA, or 10312 IE, report the value of all asset transfers to the CCT, PSA,
MTIA, or 103-12 IE, including those resulting from contributions
to participating plans on line 2l(1), and report the total value of
all assets transferred out of the CCT, PSA, MTIA, or 103-12 IE,
including assets withdrawn for disbursement as benefit
payments by participating plans, on line 2l(2). Contributions and
benefit payments are considered to be made to/by the plan (not
to/by a CCT, PSA, MTIA, or 103-12 IE).
Line 3. The administrator of an employee benefit plan who
files a Schedule H generally must engage an IQPA pursuant to
ERISA section 103(a)(3)(A) and 29 CFR 2520.103-1(b). This
requirement also applies to a Form 5500 filed for a 103-12 IE
and for a GIA (see 29 CFR 2520.103-12 and 29 CFR 2520.103-

fairly, in all material respects, the financial status of the plan as
of the end of the audit period and the changes in its financial
status for the period under audit in conformity with GAAP or
OCBOA.
Line 3b.

a Schedule H is attached unless line 3d(1) or 3d(2) on the
Schedule H is checked.

financial statements present fairly, in all material respects, the
financial status of the plan as of the end of the audit period and
the changes in its financial status for the period under audit in
conformity with GAAP or OCBOA, except for the effects of one
or more matters described in the opinion.
Line 3a(3). Check if a disclaimer of opinion was issued. A
disclaimer of opinion is issued when the IQPA does not express
an opinion on the financial statements because he or she has
not performed an audit sufficient in scope to enable him or her
to form an opinion on the financial statements.
Line 3a(4). Check if the plan received an adverse
accounta

DOL regulations 29 CFR 2520.103-8 and 2520.103-12(d)
because the examination and report of an IQPA did not extend
to: (a) statements or information regarding assets held by a
bank, similar institution, or insurance carrier that is regulated
and supervised and subject to periodic examination by a state
or federal agency provided that the statements or information
are prepared by and certified to by the bank or similar institution
or an insurance carrier, or (b) information included with the
Form 5500 filed for a 103used here does not extend to securities brokerage firms (see
DOL Advisory Opinion 93-21A). See 29 CFR 2520.103-8 and
2520.103-12(d).

29 CFR 2520.103-1(b) requires that any separate financial
statements prepared in order for the IQPA to form the opinion
and notes to these financial statements must be attached to the
Form 5500. Any separate statements must include the
information required to be disclosed in Parts I and II of the
Schedule H; however, they may be aggregated into categories
in a manner other than that used on the Schedule H. The
separate statements must consist of reproductions of Parts I
and II or statements incorporating by reference Parts I and II.
See ERISA section 103(a)(3)(A), and the DOL regulations 29
CFR 2520.103-1(a)(2) and (b), 2520.103-2, and 2520.104-50.
Note. Delinquent participant contributions reported on line 4a
should be treated as part of the separate schedules referenced
in ERISA section 103(a)(3)(A) and 29 CFR 2520.103-1(b) and
2520.103described on line 3 even though they are no longer required to
be listed on Part III of the Schedule G. If the information
contained on line 4a is not presented in accordance with
regulatory requirements, i.e., when the IQPA concludes that the
scheduled information required by line 4a does not contain all
the required information or contains information that is
inaccurate or i
the IQPA report must make the appropriate disclosures in
accordance with generally accepted auditing standards.
Delinquent participant contributions that are exempt because
they satisfy the DOL voluntary fiduciary correction program
(VFCP) requirements and the conditions of prohibited
transaction exemption (PTE) 2002-51 do not need to be treated
as part of the schedule of nonexempt party-in-interest
transactions.
ched to the Form
5500, the filing is subject to rejection as incomplete and
penalties may be assessed.
Lines 3a(1) through 3a(4). These boxes identify the type of
opinion offered by the accountant.
Line 3a(1). Check if an unqualified opinion was issued.
Generally, an unqualified opinion is issued when the IQPA

for any reason in addition to that pursuant to DOL
regulations 29 CFR 2520.103-8 and 2520.103-12.
Note. These regulations do not exempt the plan administrator
the Form 5500. If you check line 3b, you must also check the
appropriate box on line 3a to identify the type of opinion offered
by the IQPA.
Line 3c. Enter the name and EIN of the accountant (or
accounting firm) in the space provided on line 3c. Do not use a
social security number in lieu of an EIN. The Schedule H is
open to public inspection, and the contents are public
information and are subject to publication on the Internet.
Because of privacy concerns, the inclusion of a social security
number on this Schedule H may result in the rejection of the
filing.
Line 3d(1). Check this box only if the Schedule H is being filed
for a CCT, PSA, or MTIA.
Line 3d(2). Check this box if the plan has elected to defer
plan years, one of which is a short plan year of seven (7)
months or fewer. The Form 5500 for the first of the two (2) years
must be complete and accurate, with all required attachments,
why one of the two (2) plan years is of seven (7) or fewer
months duration and stating that the annual report for the
immediately following plan year will include a report of an IQPA
with respect to the financial statements and accompanying
schedules for both of the two (2) plan years. The Form 5500 for

all material respects, the financial status of the plan as of the
end of the period audited and the changes in its financial status
-37-

Instructions for Schedule H (Form 5500)

the second year must include: (a) financial schedules and
statements for both plan years; (b) a report of an IQPA with
respect to the financial schedules and statements for each of
the two (2) plan years (regardless of the number of participants
covered at the beginning of each plan year); and (c) a statement
identifying any material differences between the unaudited
financial information submitted with the first Form 5500 and the
audited financial information submitted with the second Form
5500. See 29 CFR 2520.104-50.
Note. Do not check the box on line 3d(2) if the Form 5500 is
filed for a 103not permitted for a 103-12 IE or a GIA. If an E or G is entered

with regulatory requirements, i.e., when the IQPA concludes
that the scheduled information required by line 4a does not
contain all the required information or contains information that
inancial
statements, the IQPA report must make the appropriate
disclosures in accordance with generally accepted auditing
Questions About Reporting Delinquent Contributions on the
Form 5500, available on the Internet at www.dol.gov/ebsa.
These Frequently Asked Questions clarify that plans have an
obligation to include delinquent participant contributions on their
financial statements and supplemental schedules and that the
h delinquent contributions even though
they are not required to be included on Part III of the Schedule
G. Although all delinquent participant contributions must be
reported on line 4a, delinquent contributions for which the DOL
VFCP requirements and the conditions of PTE 2002-51 have
been satisfied do not need to be treated as nonexempt party-ininterest transactions.
The VFCP describes how to apply, the specific transactions
covered (which transactions include delinquent participant
contributions to pension and welfare plans), and acceptable
methods for correcting violations. In addition, applicants that
satisfy both the VFCP requirements and the conditions of PTE
2002-51 are eligible for immediate relief from payment of certain
prohibited transaction excise taxes for certain corrected
transactions, and are also relieved from the obligation to file the
IRS Form 5330 with the IRS. For more information, see 71 Fed.
Reg. 20261 (Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19,
2006). Information about the VFCP is also available on the
Internet at www.dol.gov/ebsa.

attached to the Form 5500 and the type of opinion must be
reported on Schedule H, line 3a.
Lines 4a through 4n. Plans completing Schedule H must

answer blank, unless otherwise directed. For lines 4a through
amount must be
entered.
Report investments in CCTs, PSAs, MTIAs, and 103-12 IEs,
but not the investments made by these entities. Plans with all of

4c, 4i, and 4j. CCTs and PSAs do not complete Part IV. MTIAs,
103-12 IEs, and GIAs do not complete lines 4a, 4e, 4f, 4g, 4h,
4k, 4m, or 4n. 103-12 IEs also do not complete line 4j and 4l.
MTIAs also do not complete line 4l.
Line 4a. Amounts paid by a participant or beneficiary to an
employer and/or withheld by an employer for contribution to the
plan are participant contributions that become plan assets as of
the earliest date on which such contributions can reasonably be

All delinquent participant contributions must be reported on
line 4a even if violations have been corrected.
Line 4a Schedule. Attach a Schedule of Delinquent
Participant Contributions using the format below if you entered

2510.3-102). An employer holding these assets after that date
commingled with its general assets will have engaged in a
prohibited use of plan assets (see ERISA section 406). If such a
nonexempt prohibited transaction occurred with respect to a
disqualified person (see Code section 4975(e)(2)), file IRS
Form 5330, Return of Excise Taxes Related to Employee
Benefit Plans, with the IRS to pay any applicable excise tax on
the transaction.

line 4a, you must apply the same supplemental schedule and
IQPA disclosure requirements to the loan repayments as
applied to delinquent transmittals of participant contributions.

Schedule H Line 4a
Schedule of Delinquent
Participant Contributions

all late contributions for the year. The total amount of the
delinquent contributions should be included on line 4a of the
Schedule H or I, as applicable, for the year in which the
contributions were delinquent and should be carried over and
reported again on line 4a of the Schedule H or I, as applicable,
for each subsequent year until the year after the violation has
been fully corrected, which correction includes payment of the
late contributions and reimbursement of the plan for lost
earnings or profits. If no participant contributions were received

Participant
Contributions
Transferred
Late to Plan

Total Fully
Corrected
Under
VFCP and
Check here if Contributions Contributions Contributions PTE 200251
Late
Not
Corrected
Pending
Participant
Corrected
Outside
Correction in
Loan
VFCP
VFCP
Repayments
are included:

Line 4b.
complete Part I of Schedule G. The due date, payment amount
and conditions for determining default of a note or loan are
usually contained in the documents establishing the note or
loan. A loan by the plan is in default when the borrower is
unable to pay the obligation upon maturity. Obligations that
require periodic repayment can default at any time. Generally,
loans and fixed income obligations are considered uncollectible
when payment has not been made and there is little probability
that payment will be made. A fixed income obligation has a fixed
maturity date at a specified interest rate. Do not include
participant loans made under an individual account plan with
investment experience segregated for each account that were

Delinquent participant contributions reported on line 4a
should be treated as part of the separate schedules
referenced in ERISA section 103(a)(3)(A) and 29 CFR
2520.103-1(b) and 2520.103-2(b) for purposes of preparing the
longer required to be listed on Part III of the Schedule G. If the
information contained on line 4a is not presented in accordance
Instructions for Schedule H (Form 5500)

Total that Constitute Nonexempt
Prohibited Transactions

-38-

made in accordance with 29 CFR 2550.408b-1 and secured

information on the fidelity bonding requirements, see Field
Assistance Bulletin 2008-04, available on the Internet at www.
dol.gov/ebsa.
Note. Plans are permitted under certain conditions to purchase
fiduciary liability insurance. These fiduciary liability insurance
policies are not written specifically to protect the plan from
losses due to dishonest acts and cannot be reported as fidelity
bonds on line 4c.
Line 4f.
loss as a result of any dishonest or fraudulent act(s) even if the

Line 4c.
complete Part II of Schedule G. A lease is an agreement
conveying the right to use property, plant, or equipment for a
stated period. A lease is in default when the required
payment(s) has not been made. An uncollectible lease is one
where the required payments have not been made and for
which there is little probability that payment will be made.
Line 4d.
transaction with a party-in-interest occurred regardless of
whether the transaction is disclosed

not
to
transactions that are: (1) statutorily exempt under Part 4 of Title
I of ERISA; (2) administratively exempt under ERISA section
408(a); (3) exempt under Code sections 4975(c) or 4975(d); (4)
the holding of participant contributions in the
assets for a welfare plan that meets the conditions of ERISA
Technical Release 92-01; (5) a transaction of a 103-12 IE with
parties other than the plan; or (6) delinquent participant
contributions or delinquent participant loan repayments reported
on line 4a.
Note. See the instructions for Part III of the Schedule G (Form
5500) concerning nonexempt transactions and party-in-interest.
You may indicate that an application for an administrative
exemption is pending. If you are unsure as to whether a
transaction is exempt or not, you should consult with either the

loss. If the full amount of the loss has not yet been determined,
provide an estimate and disclose that the figure is an estimate
as determined in good faith by a plan fiduciary. You must keep,
in accordance with ERISA section 107, records showing how
the estimate was determined.
Willful failure to report is a criminal offense. See ERISA
section 501.

Applicants that satisfy the VFCP requirements and the
conditions of PTE 2002-51 (see the instructions for line
4a) are eligible for immediate relief from payment of
certain prohibited transaction excise taxes for certain corrected
transactions, and are also relieved from the obligation to file the
IRS Form 5330 with the IRS. For more information, see 71 Fed.
Reg. 20261 (Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19,
2006). When the conditions of PTE 2002-51 have been
satisfied, the corrected transactions should be treated as
exempt under Code section 4975(c) for the purposes of
answering line 4d.
Line 4e.

investment contracts for which the plan receives valuation
information at least annually.
4g if the plan is a defined contribution plan and the only assets
the plan holds, that do not have a readily determinable value on
an established market, are: (1) participant loans not in default,
or (2) assets over which the participant exercises control within
the meaning of section 404(c) of ERISA.
Although the current value of plan assets must be determined
each year, there is no requirement that the assets (other than
certain nonpublicly traded employer securities held in ESOPs)
be valued every year by independent third-party appraisers.
Enter in the amount column the fair market value of the
assets referred to on line 4g whose value was not readily
determinable on an established market and which were not
valued by an independent third-party appraiser in the plan year.
Generally, as it relates to these questions, an appraisal by an
independent third party is an evaluation of the value of an asset
prepared by an individual or firm who knows how to judge the
value of such assets and does not have an ongoing relationship
with the plan or plan fiduciaries except for preparing the
appraisals.
Line 4i.
investment purposes, and attach a schedule of assets held for
investment purposes at end of year, a schedule of assets held
for investment purposes that were both acquired and disposed
of within the plan year, or both, as applicable. The schedules
must use the format set forth below or a similar format. See 29
CFR 2520.103-11.

only if the plan itself (as opposed to the plan sponsor or
administrator) is a named insured under a fidelity bond from an
approved surety covering plan officials and that protects the
plan as described in 29 CFR Part 2580. Generally, every plan
other property of such plan must be bonded. Generally, a
property of a plan, so as to require bonding, whenever his or her
duties or activities with respect to given funds are such that
there is a risk that such funds could be lost in the event of fraud
or dishonesty on the part of such person, acting either alone or
in collusion with others. Section 412 of ERISA and 29 CFR Part
2580 describe the bonding requirements, including the definition
-6), the permissible forms of
bonds (29 CFR 2580.412-10), the amount of the bond (29 CFR
Part 2580, subpart C), and certain exemptions such as the
exemption for unfunded plans, certain banks and insurance
companies (ERISA section 412), and the exemption allowing
plan officials to purchase bonds from surety companies
authorized by the Secretary of the Treasury as acceptable
reinsurers on federal bonds (29 CFR 2580.412-23). Information
concerning the list of approved sureties and reinsures is
available on the Internet at www.fms.treas/gov/c570. For more

Assets held for investment purposes shall include:
-39-

Instructions for Schedule H (Form 5500)

7. Securities purchased from a broker-dealer
registered under the Securities Exchange Act of 1934 and
either: (1) listed on a national securities exchange and
registered under section 6 of the Securities Exchange Act
of 1934 or (2) quoted on NASDAQ.

Any investment asset held by the plan on the last day of the
plan year; and
Any investment asset purchased during the plan year and
sold before the end of the plan year except:
1. Debt obligations of the U.S. or any U.S. agency.
2. Interests issued by a company registered under the
Investment Company Act of 1940 (e.g., a mutual fund).
3. Bank certificates of deposit with a maturity of one
year or less.
4. Commercial paper with a maturity of 9 months or
less if it is valued in the highest rating category by at least
two nationally recognized statistical rating services and is
issued by a company required to file reports with the
Securities and Exchange Commission under section 13 of
the Securities Exchange Act of 1934.
5. Participations in a bank common or collective trust.
6. Participations in an insurance company pooled
separate account.

Assets held for investment purposes shall not include any
investment that was not held by the plan on the last day of the
plan year if that investment is reported in the annual report for
that plan year in any of the following:
1. The schedule of loans or fixed income obligations in
default required by Schedule G, Part I;
2. The schedule of leases in default or classified as
uncollectible required by Schedule G, Part II;
3. The schedule of nonexempt transactions required by
Schedule G, Part III; or
4. The schedule of reportable transactions required by
Schedule H, line 4j.

(b) Identity of issue, borrower, lessor, or similar party

(d) Cost

(a)

Line 4i schedules. The first schedule required to be attached is a schedule of all assets held for investment purposes at the end
of the plan year, aggregated and identified by issue, maturity date, rate of interest, collateral, par or maturity value, cost and current
value, and, in the case of a loan, the payment schedule.
In column (a), place an asterisk (*) on the line of each identified person known to be a party-in-interest to the plan. In column
(c), include any restriction on transferability of corporate securities. (Include lending of securities permitted under Prohibited
Transactions Exemption 81-6.)
This schedule must be clearly labeled
H, line 4i Schedule of Assets (Held At End of Y
(e) Current
value

The second schedule required to be attached is a schedule of investment assets that were both acquired and disposed of
within the plan year. This schedule must be clearly labeled
H, line 4i Schedule of Assets (Acquired and Disposed of
Within Y
(a) Identity of issue, borrower, lessor, or similar party

(b) Description of investment including maturity date, rate of
interest, collateral, par, or maturity value

(d) Proceeds
of
dispositions

Notes: (1) Participant loans under an individual account plan with investment experience segregated for each account, that are
made in accordance with 29 CFR 2550.408b-1 and that are secured solely by a portion of the
vested accrued benefit,
may be aggregated for reporting purposes in line 4i. Under identity of borrower enter
under rate of interest
enter the lowest rate and the highest rate charged during the plan year (e.g., 8% 10%), under the cost and proceeds columns enter
zero, and under current value enter the total amount of these loans. (2) Column (d) cost information for the Schedule of Assets
(Held At End of Year) and the column (c) cost of acquisitions information for the Schedule of Assets (Acquired and Disposed
of Within Year) may be omitted when reporting investments of an individual account plan that a participant or beneficiary directed
with respect to assets allocated to his or her account (including a negative election authorized under the terms of the plan). Likewise,
cost information for investments in Code sections 403(b)(1) annuity contracts and 403(b)(7) custodial accounts may also be omitted.
(3) Participant-directed brokerage account assets reported in the aggregate on line 1c(15) must be treated as one asset held for
investment for purposes of the line 4i schedules, except investments in tangible personal property must continue to be reported
as separate assets on the line 4i schedules. Investments in Code section 403(b) annuity contracts and Code section 403(b)(7)
custodial accounts should also be treated as one asset held for investment for purposes on the line 4i schedules.

Instructions for Schedule H (Form 5500)

-40-

Line 4j.
schedule if the plan had any reportable transactions (see 29
CFR 2520.103-6 and the examples provided in the regulation).
The schedule must use the format set forth below or a similar
format. See 29 CFR 2520.103-11.
A reportable transaction includes:
1. A single transaction within the plan year in excess of 5%
of the current value of the plan assets;
2. Any series of transactions with or in conjunction with the
same person, involving property other than securities, which
amount in the aggregate within the plan year (regardless of the
category of asset and the gain or loss on any transaction) to
more than 5% of the current value of plan assets;
3. Any transaction within the plan year involving securities of
the same issue if within the plan year any series of transactions
with respect to such securities amount in the aggregate to more
than 5% of the current value of the plan assets; and
4. Any transaction within the plan year with respect to
securities with, or in conjunction with, a person if any prior or
subsequent single transaction within the plan year with such
person, with respect to securities, exceeds 5% of the current
value of plan assets.

benefits for claims incurred before the termination date, but not
yet paid. See 29 CFR 2520.104b-2(g)(2)(ii).
Line 4l.
plan were not timely paid or not paid in full. Include in this
amount the total of any outstanding amounts that were not paid
when due in previous years that have continued to remain
unpaid.
Line 4m.
blackout period is a temporary suspension of more than three
(3) consecutive business days during which participants or
beneficiaries of a 401(k) or other individual account pension
plan were unable to, or were limited or restricted in their ability
to, direct or diversify assets credited to their accounts, obtain
loans from the plan, or obtain distributions from the plan. A
not include a temporary
suspension of the right of participants and beneficiaries to direct
or diversity assets credited to their accounts, obtain loans from
the plan, or obtain distributions from the plan if the temporary
suspension is: (1) part of the regularly scheduled operations of
the plan that has been disclosed to participants and
beneficiaries; (2) due to a qualified domestic relations order
(QDRO) or because of a pending determination as to whether a
domestic relations order is a QDRO; (3) due to an action or a
failure to take action by an individual participant or because of
an action or claim by someone other than the plan regarding a

The 5% figure is determined by comparing the current value
of the transaction at the transaction date with the current value
of the plan assets at the beginning of the plan year. If this is the
initial plan year, you may use the current value of the plan
assets at the end of the plan year to determine the 5% figure.
If the assets of two or more plans are maintained in one trust,
except as p
transactions of the trust shall be combined with the other
transactions of the plan, if any, to determine which transactions
(or series of transactions) are reportable (5%) transactions.
For investments in common/collective trusts (CCTs), pooled
separate accounts (PSAs), 103-12 IEs, and registered
investment companies, determine the 5% figure by comparing
the transaction date value of the acquisition and/or disposition of
units of participation or shares in the entity with the current
value of the plan assets at the beginning of the plan year. If the
Schedule H is attached to a Form 5500 filed for a plan with all

Special rule for certain participant-directed transactions.
Transactions under an individual account plan that a participant
or beneficiary directed with respect to assets allocated to his or
her account (including a negative election authorized under the
terms of the plan) should not be treated for purposes of line 4j
as reportable transactions. The current value of all assets of the
plan, including these participant-directed transactions, should be
included in determining the 5% figure for all other transactions.
Line 4k.
insurance/annuity contracts) were distributed to the participants
and beneficiaries, legally transferred to the control of another
plan, or brought under the control of the PBGC.

securities laws. For more information, see 29 CFR 2520.101-3
(available at www.dol/gov/ebsa).

with assets in a master trust that have other transactions should
determine the 5% figure by subtracting the current value of plan
assets held in the master trust from the current value of all plan
ot include individual transactions of
(CCTs), (PSAs), master trust investment accounts (MTIAs),
103-12 IEs, and registered investment companies in which this
plan or DFE invests.
In the case of a purchase or sale of a security on the market,
do not identify the person from whom purchased or to whom
sold.
_____________________________________________________________________________________________________________________
Line 4j schedule. The schedule required to be attached is a schedule of reportable transactions that must be clearly labeled
(a) Identity of
party
involved

(b) Description of
asset (include
interest rate and
maturity in case of
a loan)

(d) Selling
price

(e) Lease
rental

-41-

(f) Expense
incurred with
transaction

(g) Cost
of asset

(h) Current value
of asset on
transaction date

(i) Net
gain or
(loss)

Instructions for Schedule H (Form 5500)

Line 4n. If there was a blackout period, did you provide the
required notice not less than 30 days nor more than 60 days in
advance of restricting the rights of participants and beneficiaries
to change their plan investments, obtain loans from the plan, or
CFR 2520.101-3 for specific notice requirements and for
one of the exceptions to the notice requirement under 29 CFR
2520.101-3 applies.
Line 5a.
adopted during this or any prior plan year, unless the
termination was revoked and no assets reverted to the

for the transferee plan(s) involved on lines 5b(1), (2), and (3).
Do not use a social security number in lieu of an EIN or
include an attachment that contains visible social security
numbers. The Schedule H is open to public inspection, and the
contents are public information and are subject to publication on
the Internet. Because of privacy concerns, the inclusion of a
social security number on this Schedule H or the inclusion of a
visible social security number on an attachment may result in
the rejection of the filing.
Note.
account balance that is reportable on Form 1099-R should not
be included on line 5b. Do not submit Form 1099-R with the
Form 5500.

that reverted to the employer during the plan year in connection
reversion occurred during the current plan year.

IRS Form 5310-A, Notice of Plan Merger or
Consolidation, Spinoff, or Transfer of Plan Assets or
Liabilities; Notice of Qualified Separate Lines of
Business, must be filed at least 30 days before any plan merger
or consolidation or any transfer of plan assets or liabilities to
another plan. There is a penalty for not filing IRS Form 5310-A
on time. In addition, a transfer of benefit liabilities involving a
plan covered by PBGC insurance may be reportable to the
PBGC. See PBGC Form 10, Post-Event Notice of Reportable
Events, and PBGC Form 10-Advance, Advance Notice of
Reportable Events.

A Form 5500 must be filed for each year the plan has
assets, and, for a welfare benefit plan, if the plan is still
liable to pay benefits for claims incurred before the
termination date, but not yet paid. See 29 CFR 2520.104b2(g)(2)(ii).

-42-

Instructions for Schedule H (Form 5500)

plan year for corresponding lines on the return/report for the
preceding plan year.
Do not include contributions designated for the 2009 plan
year in column (a).
Line 1a. A plan with assets held in common/collective trusts
(CCTs), pooled separate accounts (PSAs), master trust
investment accounts (MTIAs), and/or 103-12 IEs must also
attach Schedule D.

2010 Instructions for Schedule I
(Form 5500)
Financial Information Small Plan
General Instructions
Who Must File

Specific Instructions

account; and
2. As of the end of the plan year, the participant is not
continuing repayment under the loan.
If the deemed distributed participant loan is included in
column (a) and both of these circumstances apply, report the
loan as a deemed distribution on line 2g. However, if either of
these circumstances does not apply, the current value of the
participant loan (including interest accruing thereon after the
deemed distribution) should be included in column (b) without
regard to the occurrence of a deemed distribution.
After a participant loan that has been deemed distributed is
reported on line 2g, it is no longer to be reported as an asset
on Schedule H or Schedule I unless, in a later year, the
participant resumes repayment under the loan. However, such
a loan (including interest accruing thereon after the deemed
distribution) that has not been repaid is still considered
outstanding for purposes of applying Code section 72(p)(2)(A)
to determine the maximum amount of subsequent loans. Also,
the deemed distribution is not treated as an actual distribution
for other purposes, such as the qualification requirements of
Code section 401, including, for example, the determination of
top-heavy status under Code section 416 and the vesting
requirements of Treasury Regulations section 1.411(a)-7(d)(5).
See Q&As 12 and 19 of Treasury Regulations section 1.72(p)1.
The entry on line 1a, column (b), of Schedule I (plan assets
- end of year) or on line 1c(8), column (b), of Schedule H
(participant loans - end of year) must include the current value
of any participant loan reported as a deemed distribution on
line 2g for any earlier year if, during the plan year, the
participant resumes repayment under the loan. In addition, the
amount to be entered on line 2g must be reduced by the
amount of the participant loan reported as a deemed
distribution on line 2g for the earlier year.
Line 1b. Enter the total liabilities at the beginning and end of
the plan year. Liabilities to be entered here do not include the
value of future pension payments to plan participants.
However, the amount to be entered in line 1b for accrual basis
filers includes, among other things:
1. Benefit claims that have been processed and approved
for payment by the plan but have not been paid (including all
incurred but not reported welfare benefit claims);
2. Accounts payable obligations owed by the plan that were
incurred in the normal operations of the plan but have not been
paid; and
3. Other liabilities such as acquisition indebtedness and
any other amount owed by the plan.

Check the Schedule I box on the Form 5500 (Part II, line
10b(2)) if a Schedule I is attached to the Form 5500. Do not
attach both a Schedule I and a Schedule H to the same Form
5500.

interest in an insurance company general account (unallocated
contracts) that you used for line 4 of Schedule A, or, if line 4 is
not required, line 7 of Schedule A.
Note. Do not include in column (b) a participant loan that has
been deemed distributed during the plan year under the
provisions of Code section 72(p) and Treasury Regulations
section 1.72(p)-1, if both of the following circumstances apply:
1. Under the plan, the participant loan is treated as a

Schedule I (Form 5500) must be attached to a Form 5500 filed
for pension benefit plans and welfare benefit plans that
covered fewer than 100 participants as of the beginning of the
plan year and that are not eligible to file Form 5500-SF.
Note. If a Schedule I was filed for the plan for the 2009 plan
year and the plan covered fewer than 121 participants as of
the beginning of the 2010 plan year, the Schedule I may be
completed instead of a Schedule H.
Exception. Certain insured, unfunded or combination
unfunded/insured welfare plans are exempt from filing the
Form 5500 and the Schedule I. In addition, certain fully insured
pension benefit plans are exempt from completing the
Schedule I. See the Form 5500 instructions for Who Must File
and Limited Pension Plan Reporting for more information.

Lines A, B, C, and D. This information must be the same as
reported in Part II of the Form 5500 to which this Schedule I is
attached.
Do not use a social security number in Line D in lieu of an
EIN. The Schedule I and its attachments are open to public
inspection, and the contents are public information and are
subject to publication on the Internet. Because of privacy
concerns, the inclusion of a social security number on this
Schedule I or any of its attachments may result in the rejection
of the filing.
You can apply for and EIN from the IRS online, by
telephone, by fax, or by mail depending on how soon you need
to use the EIN. For more information, see Section 3: Electronic
Filing Requirement under General Instructions to Form 5500.
The EBSA does not issue EINs.
Note. Use the cash, modified cash, or accrual basis for
recognition of transactions, as long as you use one method
consistently. Round off all amounts reported on the Schedule I
to the nearest dollar. Any other amounts are subject to
rejection. Check all subtotals and totals carefully.
If the assets of two or more plans are maintained in one
fund, such as when an employer has two plans funded through
a single trust (except a DFE), complete Parts I and II by
If assets of one plan are maintained in two or more trust
funds, report the combined financial information in Part I.
Current value means fair market value where available.
Otherwise, it means the fair value as determined in good faith
under the terms of the plan by a trustee or a named fiduciary,
assuming an orderly liquidation at time of the determination.
See ERISA section 3(26).

Part I - Small Plan Financial Information
Amounts reported on lines 1a, 1b, and 1c for the beginning of
the plan year must be the same as reported for the end of the
-43-

Instructions for Schedule I (Form 5500)

plan year in accordance with Code section 415, as well as any
attributable gains that were also distributed.
Line 2g. Report on line 2g a participant loan included in line
1a, column (a) (participant loans - beginning of year) and that
has been deemed distributed during the plan year under the
provisions of Code section 72(p) and Treasury Regulations
section 1.72(p)-1 only if both of the following circumstances
apply:
1. Under the plan, the participant loan is treated as a
account; and
2. As of the end of the plan year, the participant is not
continuing repayment under the loan.

If either of these circumstances does not apply, a deemed
distribution of a participant loan should not be reported on line
2g. Instead, the current value of the participant loan (including
interest accruing thereon after the deemed distribution) should
be included on line 1a, column (b) (plan assets end of year),
without regard to the occurrence of a deemed distribution.
Note. The amount to be reported on line 2g of Schedule H or
Schedule I must be reduced if, during the plan year, a
participant resumes repayment under a participant loan
reported as a deemed distribution on line 2g for any earlier
year. The amount of the required reduction is the amount of
the participant loan reported as a deemed distribution on line
2g for the earlier year. If entering a negative number, enter a
the participant loan must then be included in line 1c(8), column
(b), of Schedule H (participant loans end of year) or in line
1a, column (b), of Schedule I (plan assets end of year).
Although certain participant loans deemed distributed are to
be reported on line 2g of the Schedule H or Schedule I, and
are not to be reported on the Schedule H or Schedule I as an
asset thereafter (unless the participant resumes repayment
under the loan in a later year), they are still considered
outstanding loans and are not treated as actual distributions for
certain purposes. See Q&As 12 and 19 of Treasury
Regulations section 1.72(p)-1.
Line 2h. The amount to be reported for expenses involving
administrative service providers (salaries, fees, and
commissions) includes the total fees paid (or in the case of
accrual basis plans, costs incurred during the plan year but not
paid as of the end of the plan year) by the plan for, among
others:
1. Salaries to employees of the plan;
2. Fees and expenses for accounting, actuarial, legal,
investment management, investment advice, and securities
brokerage services;
3. Contract administrator fees;
4. Fees and expenses for individual plan trustees, including
reimbursement for travel, seminars, and meeting expenses;
and
5. Fees and expenses paid for valuations and appraisals of
real estate and closely held securities.

Line 1c. Enter the net assets as of the beginning and end of
the plan year. (Subtract line 1b from 1a.) Line 1c, column (b)
must equal the sum of line 1c, column (a) plus lines 2j and 2k.
Line 2a. Include the total cash contributions received and/or
(for accrual basis plans) due to be received.
Line 2a(1). Plans using the accrual basis of accounting must
not include contributions designated for years before the 2010
plan year on line 2a(1).
Line 2a(2). For welfare plans, report all employee
contributions, including all elective contributions under a
cafeteria plan (Code section 125). For pension benefit plans,
participant contributions, for purposes of this item, also include
elective contributions under a qualified cash or deferred
arrangement (Code section 401(k)).
Line 2b. Use the current value, at date contributed, of
securities or other noncash property.
Line 2c. Enter all other plan income for the plan year. Do not
include transfers from other plans that are reported on line 2l.
Other income received and/or receivable would include:
1. Interest on investments (including money market
accounts, sweep accounts, STIF accounts, etc.).
2. Dividends. (Accrual basis plans should include dividends
declared for all stock held by the plan even if the dividends
have not been received as of the end of the plan year.)
3. Rents from income-producing property owned by the
plan.
4. Royalties.
5. Net gain or loss from the sale of assets.
6. Other income, such as unrealized appreciation
(depreciation) in plan assets. To compute this amount subtract
the current value of all assets at the beginning of the year plus
the cost of any assets acquired during the plan year from the
current value of all assets at the end of the year minus assets
disposed of during the plan year.

Line 2d. Enter the total of all cash contributions (lines 2a(1)
through (3)), noncash contributions (line 2b), and other plan
income (line 2c) during the plan year. If entering a negative
Line 2e. Include: (1) payments made (and for accrual basis
filers payments due) to or on behalf of participants or
beneficiaries in cash, securities, or other property (including
Include all eligible rollover distributions as defined in Code

eligible retirement plan (including an IRA within the meaning of
Code section 401(a)(31)(E)); (2) payments to insurance
companies and similar organizations such as Blue Cross, Blue
Shield, and health maintenance organizations for the provision
of plan benefits (e.g., paid-up annuities, accident insurance,
health insurance, vision care, dental coverage, etc.); and (3)
payments made to other organizations or individuals providing
benefits. Generally, these payments discussed in (3) are made
to individual providers of welfare benefits such as legal
services, day care services, and training and apprenticeship
services. If securities or other property are distributed to plan
participants or beneficiaries, include the current value on the
date of distribution.
Line 2f. Include on this line all distributions paid during the
plan year of excess deferrals under Code section
402(g)(2)(A)(ii), excess contributions under Code section
401(k)(8), and excess aggregate contributions under Code
section 401(m)(6). Include allocable income distributed. Also
include on this line any elective deferrals and employee
contributions distributed or returned to employees during the
Instructions for Schedule I (Form 5500)

Line 2i. Other expenses (paid and/or payable) include other
administrative and miscellaneous expenses paid by or charged
to the plan, including among others, office supplies and
equipment, telephone, postage, rent and expenses associated
with the ownership of a building used in operation of the plan.
Line 2j. Enter the total of all benefits paid or due as reported
on lines 2e, 2f, and 2g and all other plan expenses (lines 2h
and 2i) during the year.
Line 2l. Enter the net value of all assets transferred to and
from the plan during the plan year including those resulting
-44-

deemed distribution) should be included on line 3e without
regard to the occurrence of a deemed distribution.
Note. After participant loans have been deemed distributed
and reported on line 2g of the Schedule I or H, they are no
longer required to be reported as assets on the Schedule I or
H. However, such loans (including interest accruing thereon
after the deemed distribution) that have not been repaid are
still considered outstanding for purposes of applying Code
section 72(p)(2)(A) to determine the maximum amount of
subsequent loans. Also, the deemed distribution is not treated
as an actual distribution for other purposes, such as the
qualification requirements of Code section 401, including, for
example, the determination of top-heavy status under Code
section 416 and the vesting requirements of Treasury
Regulations section 1.411(a)-7(d)(5). See Q&As 12 and 19 of
Treasury Regulations section 1.72(p)-1.

checked on any line, enter in the amount column for that line
the current value of the assets held at the end of the plan year

Line 3f. Enter the current value of all loans made by the plan,
except participant loans reportable on line 3e. Include the sum
of the value of loans for construction, securities loans,
commercial and/or residential mortgage loans that are not
subject to Code section 72(p) (either by making or participating
in the loans directly or by purchasing loans originated by a
third party), and other miscellaneous loans.
Line 3g. Include all property that has concrete existence and
is capable of being processed, such as goods, wares,
merchandise, furniture, machines, equipment, animals,
automobiles, etc. This includes collectibles, such as works of
art, rugs, antiques, metals, gems, stamps, coins, alcoholic
beverages, musical instruments, and historical objects

commingled trust containing the assets of more than one plan
on a line-by-line basis, except do not include on lines 3a
thro
MTIA, or 103-12 IE (see instructions definitions of CCT, PSA,
MTIA, and 103-12 IE).
Line 3a.
partnership or joint venture, unless the partnership or joint
venture is a 103-12 IE.
Line 3b.
property (and related personal property) that is leased to an
employer of employees covered by the plan, or to an affiliate of
such employer. For purposes of determining the time at which
a plan acquires employer real property for purposes of this
line, such property shall be deemed to be acquired by the plan
on the date on which the plan acquires the property or on the
date on which the lease to the employer (or affiliate) is entered
into, whichever is later.

from mergers and spinoffs. A transfer of assets or liabilities
occurs when there is a reduction of assets or liabilities with
respect to one plan and the receipt of these assets or the
assumption of these liabilities by another plan. Transfers out at
the end of the year should be reported as occurring during the
plan year.
Note. A distribution of all or part of an
account balance that is reportable on Form 1099-R,
Distributions From Pensions, Annuities, Retirement or ProfitSharing Plans, IRAs, Insurance Contracts, etc., should not be
included on line 2l but must be included in benefit payments
reported on line 2e. Do not submit IRS Form 1099-R with Form
5500.
Lines 3a through 3g.
each line to report whether the plan held any assets in the

interest in property reported on lines 3a through 3f, or
intangible property, such as patents, copyrights, goodwill,
franchises, notes, mortgages, stocks, claims, interests, or other
property that embodies intellectual or legal rights.

Part II - Compliance Questions
blank, unless otherwise directed. For lines 4a through 4i and

Line 3d. An employer security is any security issued by an
employer (including affiliates) of employees covered by the
plan. These may include common stocks, preferred stocks,
bonds, zero coupon bonds, debentures, convertible
debentures, notes and commercial paper.

independent qualified public accountant (IQPA) or a statement
s
opinion pursuant to 29 CFR 2520.104-50 in connection with a
short plan year of seven months or less. Plans with all of their

Line 3e. Enter the current value of all loans to participants
including residential mortgage loans that are subject to Code
section 72(p). Include the sum of the value of the unpaid
principal balances, plus accrued but unpaid interest, if any, for
participant loans made under an individual account plan with
investment experience segregated for each account, that are
made in accordance with 29 CFR 2550.408b-1 and secured
solely by a portion of the partici
When applicable, combine this amount with the current value
of any other participant loans. Do not include any amount of a
participant loan deemed distributed during the plan year under
the provisions of Code section 72(p) and Treasury Regulations
section 1.72(p)-1, if both of the following circumstances apply:
1. Under the plan, the participant loan is treated as a

lines 4b, c, and i.
Line 4a. Amounts paid by a participant or beneficiary to an
employer and/or withheld by an employer for contribution to
the plan are participant contributions that become plan assets
as of the earliest date on which such contributions can
(see 29 CFR 2510.3-102). An employer holding these assets
after that date commingled with its general assets will have
engaged in a prohibited use of plan assets (see ERISA section
406). If such a nonexempt prohibited transaction occurred with
respect to a disqualified person (see Code section 4975(e)(2)),
file IRS Form 5330, Return of Excise Taxes Related to
Employee Benefit Plans, with the IRS to pay any applicable
excise tax on the transaction.

account; and
2. As of the end of the plan year, the participant is not
continuing repayment under the loan,
If both of these circumstances apply, report the loan as a
deemed distribution on line 2g. However, if either of these
circumstances does not apply, the current value of the
participant loan (including interest accruing thereon after the

all late contributions for the year. The total amount of the
delinquent contributions must be included on line 4a of the
Schedule H or I, as applicable, for the year in which the
contributions were delinquent and must be carried over and
reported again on line 4a of the Schedule H or I, as applicable,
-45-

Instructions for Schedule I (Form 5500)

for each subsequent year until the year after the violation has
been fully corrected, which correction includes payment of the
late contributions and reimbursement of the plan for lost
earnings or profits. If no participant contributions were received

Schedule I Line 4a
Schedule of Delinquent
Participant Contributions
Participant
Total that Constitute Nonexempt Prohibited
Contributions
Transactions
Transferred
Late to Plan

Total
Fully
Corrected
Under
Check here if Contributions Contributions Contributions VFCP
and PTE
Late
Not
Corrected
Pending
Participant
Corrected
Outside
Correction in 2002-51
Loan
VFCP
VFCP
Repayments
are included:

Participant loan repayments paid to and/or withheld by an
employer for purposes of transmittal to the plan that were not
transmitted to the plan in a timely fashion must be reported
either on line 4a in accordance with the reporting requirements
that apply to delinquent participant contributions or on line 4d.
See Advisory Opinion 2002-02A, available at
www.dol.gov/ebsa.
For those Schedule I filers required to submit an IQPA
report, delinquent participant contributions reported on
line 4a must be treated as part of the separate
schedules referenced in ERISA section 103(a)(3)(A) and 29
CFR 2520.103-1(b) and 2520.103-2(b) for purposes of
s opinion even though they are not
required to be listed on Part III of the Schedule G. If the
information contained on line 4a is not presented in
accordance with regulatory requirements, i.e., when the IQPA
concludes that the scheduled information required by line 4a
does not contain all the required information or contains

financial statements, the IQPA report must make the
appropriate disclosures in accordance with generally accepted
audi
Frequently Asked Questions about Reporting Delinquent
Contributions on the Form 5500, available on the Internet at
www.dol.gov/ebsa. These Frequently Asked Questions clarify
that plans have an obligation to include delinquent participant
contributions on their financial statements and supplemental

Line 4b.
due date, payment amount and conditions for determining
default of a note or loan are usually contained in the
documents establishing the note or loan. A loan by the plan is
in default when the borrower is unable to pay the obligation
upon maturity. Obligations that require periodic repayment can
default at any time. Generally, loans and fixed income
obligations are considered uncollectible when payment has not
been made and there is little probability that payment will be
made. A fixed income obligation has a fixed maturity date at a
specified interest rate. Do not include participant loans made
under and individual account plan with investment experience
segregated for each account that were made in accordance
with 29 CFR 2550.408b-1 and secured solely by a portion of
Line 4c.
lease is an agreement conveying the right to use property,
plant or equipment for a stated period. A lease is in default
when the required payment(s) has not been made. An
uncollectible lease is one where the required payments have
not been made and for which there is little probability that
payment will be made.
Line 4d.
st enter the amount. Check
-in-interest
occurred regardless of whether the transaction is disclosed in

contributions even though they are no longer required to be
included on Part III of the Schedule G. Although all delinquent
participant contributions must be reported on line 4a,
delinquent contributions for which the DOL Voluntary Fiduciary
Correction Program (VFCP) requirements and the conditions
of the Prohibited Transaction Exemption (PTE) 2002-51 have
been satisfied do not need to be treated as nonexempt partyin-interest transactions.
The VFCP describes how to apply, the specific transactions
covered (which transactions include delinquent participant
contributions to pension and welfare plans), and acceptable
methods for correcting violations. In addition, applicants that
satisfy both the VFCP requirements and the conditions of
Prohibited Transaction Exemption (PTE) 2002-51 are eligible
for immediate relief from payment of certain prohibited
transaction excise taxes for certain corrected transactions, and
are also relieved from the obligation to file the IRS Form 5330
with the IRS. For more information, see 71 Fed. Reg. 20261
(Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19, 2006). All
delinquent participant contributions must be reported on line 4a
even if violations have been corrected. Information about the
VFCP is also available on the Internet at www.dol.gov/ebsa.
Line 4a Schedule. Attach a Schedule of Delinquent
Participant Contributions using the format below if you entered

transactions that are: (1) statutorily exempt under Part 4 of
Title I of ERISA; (2) administratively exempt under ERISA
section 408(a); (3) exempt under Code sections 4975(c) or
4975(d); (4) the holding of participant contributions in the
n that meets the
conditions of ERISA Technical Release 92-01; (5) a
transaction of a 103-12 IE with parties other than the plan; or
(6) delinquent participant contributions or delinquent participant
loan repayments reported on line 4a. You may indicate that an
application for an administrative exemption is pending. If you
are unsure whether a transaction is exempt or not, you should
consult with either a qualified public accountant, legal counsel
or both. If the plan is a qualified pension plan and a nonexempt
prohibited transaction occurred with respect to a disqualified
person, an IRS Form 5330 should be filed with the IRS to pay
the excise tax on the transaction.
Applicants that satisfy the VFCP requirements and the
conditions of PTE 2002-51 (see the instructions for
line 4a) are eligible for immediate relief from payment
of certain prohibited transaction excise taxes for certain
corrected transactions, and are also relieved from the
obligation to file the Form 5330 with the IRS. For more
information, see 71 Fed. Reg. 20261 (Apr. 19, 2006) and 71
Fed. Reg. 20135 (Apr. 19, 2006). When the conditions of PTE
2002-51 have been satisfied, the corrected transactions should
be treated as exempt under Code section 4975(c) for the
purposes of answering line 4d.

you are not claiming the audit waiver for the plan. If you
choose to include participant loan repayments on line 4a, you
must apply the same supplemental schedule and IQPA
disclosure requirements to the loan repayments as apply to
delinquent transmittals of participant contributions.

Instructions for Schedule I (Form 5500)

-46-

Party-in-Interest. For purposes of this form, party-ininterest is deemed to include a disqualified person. See Code
-inan employee benefit plan:

other property of such plan must be bonded. Generally, a

property of a plan, so as to require bonding, whenever his or
her duties or activities with respect to given funds are such that
there is a risk that such funds could be lost in the event of
fraud or dishonesty on the part of such person, acting either
alone or in collusion with others. Section 412 of ERISA and 29
CFR Part 2580 describe the bonding requirements, including
-6), the
the
permissible forms of bonds (29 CFR 2580.412-10), the amount
of the bond (29 CFR Part 2580, subpart C), and certain
exemptions such as the exemption for unfunded plans, certain
banks and insurance companies (ERISA section 412), and the
exemption allowing plan officials to purchase bonds from
surety companies authorized by the Secretary of the Treasury
as acceptable reinsurers on federal bonds (29 CFR 2580.41223). Information concerning the list of approved sureties and
reinsurers is available on the Internet at
www.fms.treas.gov/c570. For more information on the fidelity
bonding requirements, see Field Assistance Bulletin 2008-04,
available on the Internet at www.dol.gov/ebsa.
Note. Plans are permitted under certain conditions to
purchase fiduciary liability insurance. These fiduciary liability
insurance policies are not written specifically to protect the
plan from losses due to dishonest acts and cannot be reported
as fidelity bonds on line 4e.
Line 4f.
any loss as a result of any dishonest or fraudulent act(s) even

A. Any fiduciary (including, but not limited to, any
administrator, officer, trustee, or custodian), counsel, or
employee of the plan;
B. A person providing services to the plan;
C. An employer, any of whose employees are covered by
the plan;
D. An employee organization, any of whose members are
covered by the plan;
E. An owner, direct or indirect, of 50% or more of: (1) the
combined voting power of all classes of stock entitled to vote
or the total value of shares of all classes of stock of a
corporation, (2) the capital interest or the profits interest of a
partnership, or (3) the beneficial interest of a trust or
unincorporated enterprise that is an employer or an
employee organization described in C or D;
F. A relative of any individual described in A, B, C, or E;
G. A corporation, partnership, or trust or estate of which (or
in which) 50% or more of: (1) the combined voting power of
all classes of stock entitled to vote or the total value of
shares of all classes of stock of such corporation, (2) the
capital interest or profits interest of such partnership, or (3)
the beneficial interest of such trust or estate is owned
directly or indirectly, or held by, persons described in A, B,
C, D, or E;
H. An employee, officer, director (or an individual having
powers or responsibilities similar to those of officers or
directors), or a 10% or more shareholder, directly or
indirectly, of a person described in B, C, D, E, or G, or of the
employee benefit plan; or
I. A 10% or more (directly or indirectly in capital or profits)
partner or joint venturer of a person described in B, C, D, E,
or G.
Nonexempt transactions with a party-in-interest include
any direct or indirect:

plan as described in 29 CFR Part 2580. Generally, every plan

full amount of
the loss. If the full amount of the loss has not yet been
determined, provide an estimate as determined in good faith
by a plan fiduciary. You must keep, in accordance with ERISA
section 107, records showing how the estimate was
determined.
Willful failure to report is a criminal offense. See ERISA
section 501.

A. Sale or exchange, or lease, of any property between the
plan and a party-in-interest.
B. Lending of money or other extension of credit between
the plan and a party-in-interest.
C. Furnishing of goods, services, or facilities between the
plan and a party-in-interest.
D. Transfer to, or use by or for the benefit of, a party-ininterest, of any income or assets of the plan.
E. Acquisition, on behalf of the plan, of any employer
security or employer real property in violation of ERISA
section 407(a).
F.
interest or own account.
G.
any transaction involving the plan on behalf of a party (or
represent a party) whose interests are adverse to the
interests of the plan or the interests of its participants or
beneficiaries.
H. Receipt of any consideration for his or her own personal
account by a party-in-interest who is a fiduciary from any
party dealing with the plan in connection with a transaction
involving the income or assets of the plan.
Line 4e.

CAUTION

Lines 4g and 4h. Current value means fair market value
where available. Otherwise, it means the fair value as
determined in good faith under the terms of the plan by a
trustee or a named fiduciary, assuming an orderly liquidation at
time of the determination. See ERISA section 3(26).
An accurate assessment of fair market value is essential to
forth in the Code (e.g., the exclusive benefit rule of Code
section 401(a)(2), the limitations on benefits and contributions
under Code section 415, and the minimum funding
requirements under Code section 412) and must be
determined annually.
Examples of assets that may not have a readily
determinable value on an established market (e.g., NYSE,
AMEX, over the counter, etc.) include real estate, nonpublicly
traded securities, shares in a limited partnership, and
shares or insurance company investment contracts for which
the plan receives valuation information at least annually. Also
contribution plan and the only assets the plan holds, that do
not have a readily determinable value on an established
market, are: (1) participant loans not in default, or (2) assets
over which the participant exercises control within the meaning
of section 404(c) of ERISA.

only if the plan itself (as opposed to the plan sponsor or
administrator) is a named insured under a fidelity bond from an
approved surety covering plan officials and that protects the
-47-

Instructions for Schedule I (Form 5500)

Although the current value of plan assets must be
determined each year, there is no requirement that the assets
(other than certain nonpublicly traded employer securities held
in ESOPs) be valued every year by independent third-party
appraisers.
Enter in the amount column the fair market value of the
assets referred to on line 4g whose value was not readily
determinable on an established market and which were not
valued by an independent third-party appraiser in the plan
year. Generally, as it relates to these questions, an appraisal
by an independent third party is an evaluation of the value of
an asset prepared by an individual or firm who knows how to
judge the value of such assets and does not have an ongoing
relationship with the plan or plan fiduciaries except for
preparing the appraisals.
Line 4i. Include as a single security all securities of the same
issue. An example of a single issue is a certificate of deposit
issued by the XYZ Bank on July 1, 2009, which matures on
June 30, 2010, and yields 5.5%. For the purposes of line 4i, do

Condition 1: At least 95 percent of plan assets are
year, or any person who handles assets of the plan that do not
constitute qualifying plan assets is bonded in accordance with
the requirements of ERISA section 412 (see the instructions
for line 4e), except that the amount of the bond shall not be
less than the value of such non-qualifying assets.
end of the preceding plan year and the amount of any required

year for which the waiver is being claimed. For purposes of this
line, you will have satisfied the requirement to make these
determinations at the beginning of the plan reporting year for
which the waiver is being claimed if they are made as soon
after the date when such year begins as the necessary
information from the preceding reporting year can practically
be ascertained. See 29 CFR 2580.412-11, 14 and 19 for
additional guidance on these determinations, and 29 CFR
2580.412-15 for procedures to be used for estimating these
amounts if there is no preceding plan year.
means:
1. Any assets held by any of the following regulated financial
institutions:
a. A bank or similar financial institution as defined in 29
CFR 2550.408b-4(c);
b. An insurance company qualified to do business under the
laws of a state;
c. An organization registered as a broker-dealer under the
Securities Exchange Act of 1934; or
d. Any other organization authorized to act as a trustee for
individual retirement accounts under Code section 408.
2. Shares issued by an investment company registered
under the Investment Company Act of 1940 (e.g., mutual
funds);
3. Investment and annuity contracts issued by any
insurance company qualified to do business under the laws of
a state;
4. In the case of an individual account plan, any assets in
the individual account of a participant or beneficiary over which
the participant or beneficiary has the opportunity to exercise
control and with respect to which the participant or beneficiary
is furnished, at least annually, a statement from a regulated
financial institution referred to above describing the assets held
or issued by the institution and the amount of such assets;
5. Qualifying employer securities, as defined in ERISA
section 407(d)(5); and
6. Participant loans meeting the requirements of ERISA
section 408(b)(1).

a result of participant-directed transactions.
Line 4j.
insurance/annuity contracts) were distributed to the
participants and beneficiaries, legally transferred to the control
of another plan, or brought under the control of the PBGC.

the EFAST2 Help Line at 1-866-GO-EFAST (1-866-463-3278)
(toll-free)

benefits for claims that were incurred before the termination
date, but not yet paid. See 29 CFR 2520.104b-2(g)(2)(ii).
Line 4k.
the
annual examination and report of an independent qualified
public accountant (IQPA) under 29 CFR 2520.104-46. You are
eligible to claim the waiver if the Schedule I is being filed for:
1. A small welfare plan, or
2. A small pension plan for a plan year that began on or
after April 18, 2001, that complies with the conditions of 29
CFR 2520.104-46 summarized below.

requirements of 29 CFR 2520.103-1(b) if you are not claiming
the waiver. Also check
reports or the required explanatory statement if you are relying
on 29 CFR 2520.104-50 in connection with a short plan year of
seven months or less. At the top of any attached 2520.104-50
statement, enter
-50 Statement, Schedule I, Line
For more information on the requirements for deferring an
IQPA report pursuant to 29 CFR 2520.104-50 in connection
with a short plan year of seven months or less and the
contents of the required explanatory statement, see the
instructions for Schedule H, line 3d(2) or call the EFAST2 Help
Line at 1-866-GO-EFAST (1-866-463-3278) (toll-free).
Note.
the appropriate disclosures in accordance with generally
accepted auditing standards if the information reported on line
4a is not presented in accordance with regulatory
requirements.
The following summarizes the conditions of 29 CFR
2520.104-46 that must be met for a small pension plan with a
plan year beginning on or after April 18, 2001, to be eligible for
the waiver. For more information regarding these
d Questions on
the Small Pension Plan Audit Waiver Regulation and 29 CFR
2520.104-46, which are available at www.dol.gov/ebsa, or call

Instructions for Schedule I (Form 5500)

Condition 2: The administrator must disclose the following
information in the summary annual report (SAR) furnished to
participants and beneficiaries, in accordance with 29 CFR
2520.104b-10. For defined benefit pension plans that are
required pursuant to section 101(f) of ERISA to furnish an
Annual Funding Notice (AFN), the administrator must instead
either provide the information to participants and beneficiaries
with the AFN or as a stand-alone notification at the time a SAR
would have been due and in accordance with the rules for
furnishing a SAR, although such plans do not have to furnish a
SAR.
1. The name of each regulated financial institution holding
or issuing qualifying plan assets and the amount of such
assets reported by the institution as of the end of the plan year
-48-

(this SAR disclosure requirement does not apply to qualifying
employer securities, participant loans and individual account
assets described in paragraphs 4,5 and 6 above);
2. The name of the surety company issuing the fidelity bond,
if the plan has more than 5% of its assets in non-qualifying
plan assets;
3. A notice that participants and beneficiaries may, upon
request and without charge, examine or receive from the plan
evidence of the required bond and copies of statements from
the regulated financial institutions describing the qualifying
plan assets; and
4. A notice that participants and beneficiaries should contact
the EBSA Regional Office if they are unable to examine or
obtain copies of the regulated financial institution statements or
evidence of the required bond, if applicable.
A Model Notice that plans can use to satisfy the enhanced
SAR (or Annual Funding Notice) disclosure requirements to be
eligible for the audit waiver is available as an Appendix to 29
CFR 2520.104-46.
Condition 3: In addition, in response to a request from any
participant or beneficiary, the administrator, without charge to
the participant or beneficiary, must make available for
examination, or upon request furnish copies of, each regulated
financial institution statement and evidence of any required
bond.
Examples. Plan A, which has a plan year that began on or
after April 18, 2001, had total assets of $600,000 as of the end
of the 2000 plan year that included: investments in various
bank, insurance company and mutual fund products of
$520,000; investments in qualifying employer securities of
$40,000; participant loans (meeting the requirements of ERISA
section 408(b)(1)), totaling $20,000; and a $20,000 investment
in a real estate limited partnership. Because the only asset of

paid when due in previous years that have continued to remain
unpaid.
Line 4m.
blackout period is a temporary suspension of more than three
(3) consecutive business days during which participants or
beneficiaries of a 401(k) or other individual account pension
plan were unable to, or were limited or restricted in their ability
to, direct or diversify assets credited to their accounts, obtain
loans from the plan, or obtain distributions from the plan. A

suspension of the right of participants and beneficiaries to
direct or diversity assets credited to their accounts, obtain
loans from the plan, or obtain distributions from the plan if the
temporary suspension is: (1) part of the regularly scheduled
operations of the plan that has been disclosed to participants
and beneficiaries; (2) due to a qualified domestic relations
order (QDRO) or because of a pending determination as to
whether a domestic relations order is a QDRO; (3) due to an
action or a failure to take action by an individual participant or
because of an action or claim by someone other than the plan
application
of federal securities laws. For more information, see 29 CFR
2520.101-3 (available at www.dol.gov/ebsa).
Line 4n. If there was a blackout period, did you provide the
required notice not less than 30 days nor more than 60 days in
advance of restricting the rights of participants and
beneficiaries to change their plan investments, obtain loans
from the plan, or obtain distributions from the plan? If so, check
-3 for specific notice requirements
and for exceptions from the notice requirement. Also, answer
29 CFR 2520.101-3 applies.
Line 5a.
adopted during this or any prior plan year, unless the
termination was revoked and no assets reverted to the

$20,000 real estate limited partnership investment and that

that reverted to the employer during the plan year in
connection with the implementation of such termination. Enter

assets of $600,000 as of the end of the 2000 plan year,

A Form 5500 must be filed for each year the plan has
assets, and, for a welfare benefit plan, if the plan is
still liable to pay benefits for claims that were incurred
before the termination date, but not yet paid. See 29 CFR
2520.104b-2(g)(2)(ii).

no fidelity bond is required as a condition for the plan to be
eligible for the waiver for the 2001 plan year.

constitutes non-qualifying plan assets. Because 7%
than 5%

the 2001 plan year, must ensure that it has a fidelity bond in an
amount equal to at least $42,000 covering persons handling its
non-qualifying plan assets. Inasmuch as compliance with
ERISA section 412 generally requires the amount of the bond

Line 5b. Enter information concerning assets and/or liabilities
transferred from this plan to another plan(s) (including spinoffs)
during the plan year. A transfer of assets or liabilities occurs
when there is a reduction of assets or liabilities with respect to
one plan and the receipt of these assets or the assumption of
these liabilities by another plan. Enter the name, EIN, and PN
for the transferee plan(s).
Do not use a social security number in lieu of an EIN or
include an attachment that contains visible social security
numbers. The Schedule I and its attachments are open to
public inspection, and the contents are public information and
are subject to publication on the Internet. Because of privacy
concerns, the inclusion of a social security number on this
Schedule I or the inclusion of a visible social security number
on an attachment may result in the rejection of the filing.
Note.
account balance that is reportable on IRS Form 1099-R should
not be included on line 5b. Do not submit IRS Form 1099-R
with the Form 5500.

other property handled, the bond acquired for ERISA section
412 purposes may be adequate to cover the non-qualifying
plan assets without an increase (i.e., if the amount of the bond
determined to be needed for the relevant persons for ERISA
section 412 purposes is at least $42,000). As demonstrated by
the foregoing example, where a plan has more than 5% of its
assets in non-qualifying plan assets, the required bond is for
the total amount of the non-qualifying plan assets, not just the
amount in excess of 5%.
If you need further information regarding these
requirements, see 29 CFR 2520.104-46 which is available at
www.dol.gov/ebsa or call the EFAST2 Help Line at 1-866-GOEFAST (1-866-463-3278) (toll-free)
Line 4l.
plan were not timely paid or not paid in full. Include in this
amount the total of any outstanding amounts that were not
-49-

Instructions for Schedule I (Form 5500)

Form 5310-A on time. In addition, a transfer of benefit liabilities
involving a plan covered by PBGC insurance may be
reportable to the PBGC. See PBGC Form 10, Post-Event
Notice of Reportable Events, and PBGC Form 10-Advance,
Advance Notice of Reportable Events.

Instructions for Schedule I (Form 5500)

-50-

2010 Instructions for Schedule MB
(Form 5500)
Multiemployer Defined Benefit Plan and
Certain Money Purchase Plan Actuarial
Information

The 2010 Schedule MB will be available for filing after the
issuance of additional regulatory guidance related to PPA. Do
not file the 2010 Form 5500 for a multiemployer defined benefit
plan until the 2010 Schedule MB and instructions are available
to use for filing.

-51-

Instructions for Schedule MB (Form 5500)

Check the Schedule R box on the Form 5500 (Part II, line
10a(1)) if a Schedule R is attached to the Form 5500.

2010 Instructions for Schedule R
(Form 5500)
Retirement Plan Information

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

General Instructions
Purpose of Schedule

Who Must File

Part I

Distributions

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

Schedule R line number at the top of each attachment to
identify the information to which the attachment relates. Do not
include attachments that contain a visible social security
number. The Schedule R and its attachments are open to
public inspection, and the contents are subject to publication
on the Internet. Because of privacy concerns, the inclusion of a
visible social security number on an attachment may result in
the rejection of the filing.

Schedule R (Form 5500) reports certain information on plan
distributions, funding, and the adoption of amendments
increasing or decreasing the value of benefits in a defined
benefit pension plan, as well as certain information on
employee stock ownership plans (ESOPs), and multiemployer
defined benefit plans.
Electronic Attachments. All attachments to Schedule R must
be properly identified, must include the name of the plan, plan

Schedule R must be attached to a Form 5500 filed for both taxqualified and nonqualified pension benefit plans. The parts of
Schedule R that must be completed depend on whether the
plan is subject to the minimum funding standards of Code
section 412 or ERISA section 302 and the type of plan. See
line item requirements under Specific Instructions for more
details.
Exceptions: (1) Schedule R should not be completed when
the Form 5500 annual return/report is filed for a pension plan
that uses, as the sole funding vehicle for providing benefits,
individual retirement accounts or annuities (as described in
Code section 408). See the Form 5500 instructions for Limited
Pension Plan Reporting for more information.
(2) Schedule R also should not be completed if all of the
following conditions are met:
The plan is not a defined benefit plan or otherwise
subject to the minimum funding standards of Code section
412 or ERISA section 302.
No plan benefits that would be reportable on line 1 of
Part I of this Schedule R were distributed during the plan
year. See the instructions for Part I, line 1, below.
No benefits, as described in the instructions for Part I,
line 2, below, were paid during the plan year other than by
the plan sponsor or plan administrator. (This condition is
not met if benefits were paid by the trust or any other
payor(s) which are reportable on IRS Form 1099-R,
Distributions From Pensions, Annuities, Retirement or
Profit-Sharing Plans, IRAs, Insurance Contracts, etc.,
using an EIN other than that of the plan sponsor or plan
administrator reported on line 2b or 3b of Form 5500.)
Unless the plan is a profit-sharing, ESOP, or stock
bonus plan, no plan benefits of living or deceased
participants were distributed during the plan year in the
form of a single-sum distribution. See the instructions for
Part I, line 3, below.
The plan is not an ESOP.
The plan is not a multiemployer defined benefit plan.
Instructions for Schedule R (Form 5500)

Line 1. Enter the total value of all distributions made during
the year (regardless of when the distribution began) in any
form other than cash, annuity contracts issued by an insurance
company, distribution of life insurance contracts, marketable
securities within the meaning of Code section 731(c)(2), or
plan loan offset amounts. Do not include eligible rollover
distributions paid directly to eligible retirement plans in a direct
rollover under Code section 401(a)(31) unless such direct
rollovers include property other than that enumerated in the
preceding sentence.
Line 2. Enter the EIN(s) of any payor(s) (other than the plan
sponsor or plan administrator on line 2b or 3b of the Form
5500) who paid benefits reportable on IRS Form 1099-R on
behalf of the plan to participants or beneficiaries during the
plan year. This is the EIN that appears on the IRS Forms
1099-R that are issued to report the payments. Include the EIN
of the trust if different than that of the sponsor or plan
administrator. If more than two payors made such payments
during the year, enter the EINs of the two payors who paid the
greatest dollar amounts during the year. For purposes of this
line 2, take into account all payments made during the plan
year, in cash or in kind, that are reportable on IRS Form 1099-52-

must be filed with the Form 5500 annual return/report.
Line 5. If a money purchase defined contribution plan
(including a target benefit plan) has received a waiver of the
minimum funding standard, and the waiver is currently being
amortized, complete lines 3, 9, and 10 of Schedule MB. See
instructions for Schedule MB. Attach Schedule MB to Form
5500. The Schedule MB for a money purchase defined
contribution plan does not need to be signed by an enrolled
actuary.
Line 6a. The minimum required contribution for a money
purchase defined contribution plan (including a target benefit
plan) for a plan year is the amount required to be contributed
for the year under the formula set forth in the plan document. If
there is an accumulated funding deficiency for a prior year that
has not been waived, that amount should also be included as
part of the contribution required for the current year.
Line 6b. Include all contributions for the plan year made not
later than 81/2 months after the end of the plan year. Show
only contributions actually made to the plan by the date the
form is filed. For example, do not include receivable
contributions for this purpose.
Line 6c. If the minimum required contribution exceeds the
contributions for the plan year made not later than 81/2 months
after the end of the plan year, the excess is an accumulated
funding deficiency for the plan year. File IRS Form 5330,
Return of Excise Taxes Related to Employee Benefit Plans,
with the IRS to pay the excise tax on the deficiency. There is a
penalty for not filing IRS Form 5330 on time.
Line 7. Will the minimum required contribution remaining in
6c be made not later than 81/2 months after the end of the plan
e by this
date, then there will be no reportable deficiency and IRS Form
5330 will not need to be filed.
Line 8. Revenue Procedure 2000-40, 2002-2 C.B. 357,
providing for automatic approval for a change in funding
method for a plan year, generally does not apply unless the
plan administrator or an authorized representative of the plan
sponsor explicitly agrees to the change. If a change in funding
method made pursuant to such a revenue procedure (or a
class ruling letter) is to be applicable for the current plan year,

R, regardless of when the payments began, but take into
account payments from an insurance company under an
annuity only in the year the contract was purchased.
Line 3. Enter the number of living or deceased participants
whose benefits under the plan were distributed during the plan
year in the form of a single-sum distribution. For this purpose,
a dis
single-sum distribution merely because, after the date of the
distribution, the plan makes a supplemental distribution as a
result of earnings or other adjustments made after the date of
the single-sum distribution. Also include any participants
whose benefits were distributed in the form of a direct rollover
to the trustee or custodian of a qualified plan or individual
retirement account.

Part II

Funding Information

Complete Part II only if the plan is subject to the minimum
funding requirements of Code section 412 or ERISA section
302.
All qualified defined benefit and defined contribution plans
are subject to the minimum funding requirements of Code
section 412 unless they are described in the exceptions listed
under Code section 412(e)(2). These exceptions include profitsharing or stock bonus plans, insurance contract plans
described in Code section 412(e)(3), and certain plans to
which no employer contributions are made.
Nonqualified employee pension benefit plans are subject to
the minimum funding requirements of ERISA section 302
unless specifically exempted under ERISA sections 4(a) or
301(a).
The sponsor or plan administrator of a single-employer or
multiple-employer defined benefit plan that is subject to the
minimum funding requirements must file Schedule SB as an
attachment to Form 5500. Schedule MB is filed for
multiemployer defined benefit plans and certain money
purchase defined contribution plans (whether they are singleemployer or multiemployer plans). However, Schedule MB is
not required to be filed for a money purchase defined
contribution plan that is subject to the minimum funding
requirements unless the plan is currently amortizing a waiver
of the minimum funding requirements.
Line 4
minimum funding requirements for the plan year, the plan
administrator is making an election intended to satisfy the
requirements of Code section 412(d)(2) or ERISA section
302(d)(2). Under Code section 412(d)(2) and ERISA section
302(d)(2), a plan administrator may elect to have any
amendment, adopted after the close of the plan year for which
it applies, treated as having been made on the first day of the
plan year if all of the following requirements are met:
1. The amendment is adopted no later than two and onehalf months (two years for a multiemployer plan) after the close
of such plan year;
2. The amendment does not reduce the accrued benefit of
any participant determined as of the beginning of such plan
year; and
3. The amendment does not reduce the accrued benefit of
any participant determined as of the adoption of the
amendment unless the plan administrator notified the
Secretary of the Treasury of the amendment and the Secretary
either approved the amendment or failed to disapprove the
amendment within 90 days after the date the notice was filed.

however, the requirement that the plan administrator or an
authorized representative of the plan sponsor agree to the
change in funding method will be satisfied if the plan
administrator or an authorized representative of the plan
sponsor is made aware of the change. In these situations, this
2000pursuant to a revenue procedure providing automatic approval
or a class ruling letter (e.g., it is pursuant to a regulation or
Notice 2009-

Part III

Amendments

Line 9.
plan year that increased or decreased the value of
benefits.
the plan year that increased the value of benefits in any
way. This includes an amendment providing for an
increase in the amount of benefits or rate of accrual, more
generous lump sum factors, COLAs, more rapid vesting,
additional payment forms, or earlier eligibility for some
benefits.

See Treasury Temporary Regulations section 11.412(c)7(b) for details on when and how to make the election and
what information to include on the statement of election, which

the plan year that decreased the value of benefits in any
-53-

Instructions for Schedule R (Form 5500)

assumptions and upon exhaustion of all reasonable measures,
the plan cannot emerge from Critical Status by the end of the
Rehabilitation Period as described in Code section
432(e)(3)(A)(ii), the summary must include an explanation of
the alternatives considered, why the plan is not reasonably
expected to emerge from Critical Status by the end of the
Rehabilitation Period, and when, if ever, it is expected to
emerge from Critical Status under the Rehabilitation Plan.
Unless an election was made under section 204 of
WRERA, the plan sponsor is required to annually update a
Funding Improvement Plan or Rehabilitation Plan that was
adopted in a prior year. The update must be filed as an
attachment to the Schedule R. The update attachment must
identify the modifications made to the Funding Improvement
Plan or Rehabilitation Plan during the plan year, including
contribution increases, benefit reductions, or other actions. If
an update of the Funding Improvement Plan or Rehabilitation
Plan is not required because of an election under section 204
of WRERA, the update attachment must include a statement to
that effect and the date that the election was filed with the IRS.
The attachment described above must be labeled
Schedule R, Summary of Funding Improvement Plan
Schedule R, Summary of Rehabilitation Plan
Schedule R, Explanation of Status
Schedule R, Update of Funding Improvement
Plan or Rehabilitation Plan
d EIN, and
the plan number.
Line 13. This line should be completed only by multiemployer
defined benefit pension plans that are subject to the minimum
funding standards (see Code section 412 and Part 3 of Title I
of ERISA). Enter the information on lines 13a through 13e for
any employer that contributed more than five (5) percent of the

way. This includes a decrease in future accruals, closure
of the plan to new employees, or accruals being frozen for
some or all participants.
If the amendments that were adopted increased the
value of some benefits but decreased the value of others,

Part IV

ESOP Information

Line 11b.
-torequirements are satisfied:
1. The loan from the employer corporation to the ESOP
qualifies as an exempt loan under DOL regulations at 29 CFR
2550.408b-3 and under Treasury Regulations sections
54.4975-7 and 54.4975-11; and
2. The repayment terms of the loan from the sponsoring
corporation to the ESOP are substantially similar to the
repayment terms of the loan from the commercial lender to the
sponsoring employer.

Required Attachments. Multiemployer defined benefit plans
that are in Endangered Status or Critical Status must attach a
summary of their Funding Improvement Plan or Rehabilitation
Plan (as updated, if applicable) and also any update to a
Funding Improvement Plan or Rehabilitation Plan. For this
purpose, whether a plan is in Endangered Status or Critical
Status is determined by taking into account any election under
section 204 of the Worker, Retiree, and Employer Recovery

Additional Employer Information for
Part V
Multiemployer Defined Benefit Pension Plans

Schedule MB provide that the Plan Status Code entered on
line 4a of Schedule MB must be based on the actuarial

under section 204 of WRERA. In certain cases, as a result of
the WRERA election, the plan status for purposes of attaching
Funding Improvement
Plan or Rehabilitation Plan to the Schedule R may not be the
same as shown by the Plan Status Code entered on line 4a of

in descending order according to the dollar amount of their
contributions to the plan. Complete as many entries as are
necessary to list all employers that contributed more than five
Line 13a. Enter the name of the employer contributing to the
plan.
Line 13b. Enter the EIN of the employer contributing to the
plan. Do not enter a social security number in lieu of an EIN;

status is different must be included either with the summary of
as a separate attachment to the Schedule R (if the plan is
neither in Endangered Status nor Critical Status, taking into
account the election). The explanation must include the date
that the WRERA election was filed with the IRS.
The summary of any Funding Improvement Plan or
Rehabilitation Plan must reflect the plan in effect at the end of
the plan year (whether the original Funding Improvement Plan
or Rehabilitation Plan or as updated) and must include a
description of the various contribution and benefit schedules
that are being provided to the bargaining parties and any other
actions taken in connection with the Funding Improvement
Plan or Rehabilitation Plan, such as use of the shortfall funding
method or extension of an amortization period. The summary
must also identify the first year and the last year of the Funding
Improvement Period or the Rehabilitation Period. If an
extended Funding Improvement Period (of 13 or 18 years) or
Rehabilitation Period (of 13 years) applies because of an
election under section 205 of WRERA, the summary must
include a statement to that effect and the date that the election
was filed with the IRS.
The summary must also include a schedule of the expected
annual progress for the funded percentage or other relevant
factors under the Funding Improvement Plan or Rehabilitation
Plan. If the sponsor of a multiemployer plan in Critical Status
has determined that, based on reasonable actuarial
Instructions for Schedule R (Form 5500)

social security number. The Form 5500 is open to public
inspection, and the contents are public information and are
subject to publication on the Internet. Because of privacy
concerns, the inclusion of a social security number on this line
may result in the rejection of the filing.
EINs can be obtained from the IRS online, by telephone, by
fax, or by mail depending on when you need to use the EIN.
For more information, see Section 3: Electronic Filing
Requirement. The EBSA does not issue EINs.
Line 13c. Dollar Amount Contributed. Enter the total dollar
amount contributed to the plan by the employer for all covered
workers in all locations for the plan year. Do not include the
portion of an aggregated contribution that is for another plan,
such as a welfare benefit plan, a defined contribution pension
plan or another defined benefit pension plan.
Line 13d. Collective Bargaining Agreement Expiration
Date. Enter the date on which the
bargaining agreement expires. If the employer has more than
one collective bargaining agreement requiring contributions to
the plan, check the box and include, as an attachment, the
expiration date of each collective bargaining agreement
(regardless of the amount of contributions arising from such
-54-

Schedule R, line 13d
Collective Bargaining Agreement Expiration Date

employers. If the withdrawal liability for one or more
withdrawing employers has not yet been determined, include
the amounts estimated to be assessed against them in the
aggregate amount.
The definitions of withdrawal are those contained in Section
4203 of ERISA. If the plan is in the building and construction,
entertainment, or another industry that has special withdrawal
rules, withdrawing employers should only be counted if the
withdrawal adheres to the special rules applying to its specific
industry.
Line 17. If assets and liabilities from another plan were
transferred to or merged with the assets and liabilities of this
plan during the 2010 plan year, check the box and provide the
following information as an attachment. The attachment should
include the names and employer identification numbers of all
plans that transferred assets and liabilities to, or merged with,
this plan. For each plan, including this plan, the attachment
should also include the actuarial valuation of the total assets
and total liabilities for the year preceding the transfer or
merger, based on the most recent data available as of the day
before the first day of the 2010 plan year. Label the attachment
Information on Assets and
and

Line 13e. Contribution Rate Information. Enter the
contribution rate (in dollars and cents) per contribution base
unit in line 13e(1) and the base unit measure in line 13e(2).
Indicate whether the base unit is measured on an hourly,
weekly, unit-ofbase unit measure used. If the contribution rate changed
during the plan year, enter the last contribution rate in effect for
the plan year.
If the employer has different contribution rates for different
classifications of employees or different places of business,
check the box in the first line of line 13e and list in an
attachment each contribution rate and corresponding base unit
measure under which the employer made contributions
(regardless of the amount of contributions resulting from each
Schedule R, line 13e
Information on Contribution Rates and Base Units

Line 14. Enter the number of participants on whose behalf no
contributions were made by an employer as an employer of the
participant. For purposes of line 14, count only those
participants whose employers or former employers had
withdrawn from the plan by the beginning of the relevant plan
year. Disregard any participants whose employers had not
withdrawn from the plan, even if, in the relevant year, no
contributions were made by the employer on behalf of those
participants. Thus, for the limited purposes of line 14 and
notwithstanding any contrary definition of such participants
applicable elsewhere, the deferred vested and retired
participants of employers who have not withdrawn from the
plan should not be included in these numbers.
Note. Withdrawal liability payments are not to be treated as
contributions for the purpose of determining the number of
participants for line 14.
Line 14a. Enter the number of participants for the 2010 plan
year described in the line 14 instructions.
Line 14b. Enter the number of participants for the 2009 plan
year described in the line 14 instructions.
Line 14c. Enter the number of participants for the 2008 plan
year described in the line 14 instructions.
Line 15. Enter the ratio of number of participants on whose
behalf no employer had an obligation to make a contribution
for the 2010 plan year to the corresponding number for each of
the two preceding plan years. For the purpose of these ratios,
count all participants whose employers have withdrawn from
the plan as well as all deferred vested and retired participants
of employers still active in the plan (unless the collective
bargaining agreement specifically requires the employer to
make contributions for such participants.)
Line 15a. Enter the ratio of the number of participants as
described in the line 15 instructions for the 2010 plan year to
the number for the 2009 plan year.
Line 15b. Enter the ratio of the number of participants as
described on the line 15 instructions for the 2010 plan year to
the number for the 2008 plan year.
Note. Withdrawal liability payments are not to be treated as
contributions for determining the number of participants on line
15.
Line 16a. Enter the number of employers that withdrew from
the plan during the 2009 plan year.
Line 16b. If line 16a is greater than zero, enter the aggregate
amount of withdrawal liability assessed against these

Part VI
Additional Information for SingleEmployer and Multiemployer Defined Benefit
Pension Plans

Line 18. If any liabilities to participants or their beneficiaries
under the plan at the end of the plan year consist of liabilities
under two (2) or more plans as of immediately before the 2010
plan year, check the box and provide the following information
as an attachment. The attachment should include the names,
employer identification numbers, and plan numbers of all
plans, including the current plan, that provided a portion of
liabilities of the participants and beneficiaries in question. The
attachment should also include the funding percentage of each
plan as of the last day of the 2009 plan year. For singleemployer plans, the funding percentage is the funding target
attainment percentage, where the numerator is the value of
plan assets reduced by the sum of the amount of the
prefunding balance and the funding standard carryover
balance, and the denominator is the funding target for the plan
(without regard to the at-risk status of the plan). For
multiemployer plans, the funding percentage is the ratio where
the denominator is the accrued liability of the plan. If a plan
whose funding percentage is required to be reported has
funding percentage would otherwise have been reported.
Label the attachment
18 Funded
Percentage of Plans Contributing to the Liabilities of Plan
and include the plan name and the plan
nd EIN.
Line 19. This line must be completed by all defined benefit
pension plans (except DFEs) with 1,000 or more participants at
the beginning of the plan year. To determine if the plan has
1,000 or more participants, use the participant count shown on
line 3d(1) of the Schedule SB for single-employer plans or on
line 2b(4)(1) of the Schedule MB for multiemployer plans.
Line 19a. Show the beginning-of-year distribution of assets
for the categories shown. Use the market value of assets and
do not include the value of any receivables. These
percentages, expressed to the nearest whole percent, should
reflect the total assets held in stocks, investment-grade debt
instruments, high-yield debt instruments, real estate, or other

-55-

Instructions for Schedule R (Form 5500)

levels. If the debt does not have a rating, it should be included
government entity. Unrated debt with the backing of a
government entity would generally be included in the
vestmentratings in effect as of the beginning of the plan year.
Line 19b. Check the box that shows the average duration of
tment-grade and high-yield debt
portfolio. If the average duration falls exactly on the boundary
of two boxes, check the box with the lower duration. To

asset classes, regardless of how they are listed on the
Schedule H. The percentages in the five categories should
sum to 100 percent. Assets held in trusts, accounts, and other
investment arrangements should be disaggregated and
properly distributed among the five asset components. The
assets in these trusts, accounts and investment arrangements
investments contain no stocks, bonds, or real estate holdings.
The same methodology should be used in disaggregating trust
assets as is used when disclosing the allocation of plan assets
-K filings to the Securities and Exchange
Commission. Real estate investment trusts (REITs) should be
listed with stocks, while real estate limited partnerships should
be included in the Real Estate category.
Investment-grade debt-instruments are those with an S&P
rating of BBB
or an equivalent rating from another rating agency. High-yield
debt instruments are those that have ratings below these rating

any other generally accepted measure of duration. Report the
duration measure used in line 19c. If debt instruments are held
in multiple debt portfolios, report the weighted average of the
average durations of the various portfolios where the weights
are the dollar values of the individual portfolios.

Instructions for Schedule R (Form 5500)

-56-

2010 Instructions for Schedule SB
(Form 5500)
Single-Employer Defined Benefit Plan
Actuarial Information

The 2010 Schedule SB will be available for filing after the
issuance of additional regulatory guidance related to PPA. Do
not file the 2010 Form 5500 for a defined benefit plan until the
2010 Schedule SB and instructions are available to use for
filing.

-57-

Instructions for Schedule SB (Form 5500)

OMB Control Numbers
Agency

OMB Number

Employee Benefits Security Administration...............................................1210-0110 and 1210-0089
Pension Benefit Guaranty Corporation .....................................................1212 0057
Internal Revenue Service ..........................................................................1545 - 1610
Paperwork Reduction Act Notice
We ask for the information on this form to carry out the law as specified in ERISA and in Code sections 6047(e), 6058(a), and
6059(a). You are required to give us the information. We need it to determine whether the plan is operating according to the law. You
are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form
displays a valid OMB control number. Books and records relating to a form or its instructions must be retained as long as their
contents may become material in the administration of the Internal Revenue Code or are required to be maintained pursuant to Title I
or IV of ERISA. Generally, the Form 5500 return/reports are open to public inspection and are subject to publication on the Internet.
The time needed to complete and file the forms listed below reflects the combined requirements of the Internal Revenue Service,
Department of Labor, and Pension Benefit Guaranty Corporation. These times will vary depending on individual circumstances. The
estimated average times are:

Large

1 hr., 19 min.
2 hr., 51 min.
N/A
20 min.
N/A
N/A
2 hr., 5 min.
4 hr., 14 min.
1 hr., 5 min.
6 hr., 49 min.

1 hr., 54 min.
2 hr., 52 min.
3 hr., 4 min
1 hr., 39 min.
11 hr., 29 min.
7 hr., 42 min.
N/A
7 hr., 52 min.
1 hr., 43 min.
6 hr., 38 min.

Small

Form 5500
Schedule A
Schedule C
Schedule D
Schedule G
Schedule H
Schedule I
Schedule MB
Schedule R
Schedule SB

Welfare Plans

Pension Plans
Large

1 hr., 45 min.
3 hr., 39 min.
3 hr., 38 min.
1 hr., 52 min.
11 hr.
8 hr., 35 min.
N/A
N/A
N/A
N/A

Small
1 hr., 14 min.
2 hr., 43 min.
N/A
20 min.
N/A
N/A
1 hr., 55 min.
N/A
N/A
N/A

If you have comments concerning the accuracy of these time estimates or suggestions for making these forms simpler, we
would be happy to hear from you. You can write to the Internal Revenue Service, Tax Products Coordinating Committee,
SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave NW, IR-6526, Washington, DC 20224. Do not send any of these forms or schedules to
this address. The forms and schedules must be filed electronically. See How To File Electronic Filing Requirement.

-58-

Mining

212390
213110

Oil & Gas Extraction
Coal Mining
Metal Ore Mining
Stone Mining & Quarrying
Sand, Gravel, Clay, &
Ceramic, & Refractory
Minerals Mining, & Quarrying
Other Nonmetalic Mineral
Mining & Quarrying
Support Activities for Mining

Utilities
221100
221210
221300
221500

Food Manufacturing
311110 Animal Food Mfg
311200 Grain & Oilseed Milling
311300 Sugar & Confectionary
Product Mfg
311400 Fruit & Vegetable Preserving
& Specialty Food Mfg
311500 Dairy Product Mfg
311610 Animal Slaughtering and
Processing
311710 Seafood Product Preparation
& Packaging
311800 Bakeries & Tortilla Mfg
311900 Other Food Mfg (including
coffee, tea, flavorings &
seasonings)
Beverage and Tobacco Product
Manufacturing
312110 Soft Drink & Ice Mfg
312120 Breweries
312130 Wineries
312140 Distilleries
312200 Tobacco Manufacturing
Textile Mills and Textile Product
Mills
313000 Textile Mills
314000 Textile Product Mills
Apparel Manufacturing
315100 Apparel Knitting Mills
315210 Cut & Sew Apparel
Contractors
315220
Apparel Mfg.
315230
Apparel Mfg.
315290 Other Cut & Sew Apparel Mfg
315990 Apparel Accessories & Other
Apparel Mfg
Leather and Allied Product
Manufacturing
316110 Leather, & Hide Tanning, &
Finishing
316210 Footwear Mfg (including
rubber & plastics)
316990 Other Leather & Allied
Product Mfg
Wood Product Manufacturing
321110 Sawmills & Wood
Preservation
321210 Veneer, Plywood, &
Engineered Wood Product
Mfg
321900 Other Wood Product Mfg
Paper Manufacturing
322100 Pulp, Paper, & Paperboard
Mills
322200 Converted Paper Product Mfg

211110
212110
212200
212310
212320

Manufacturing

Electric Power Generation,
Transmission & Distribution
Natural Gas Distribution
Water, Sewage, & Other
Systems
Combination Gas & Electric

Construction
Construction of Buildings
236110 Residential Building
Construction
236200 Nonresidential Building
Construction
Heavy and Civil Engineering
Construction
237100 Utility System Construction
237210 Land Subdivision
237310 Highway, Street, & Bridge
Construction
237990 Other Heavy & Civil
Engineering Construction

Code
Printing and Related Support
Activities
323100 Printing & Related Support
Activities
Petroleum and Coal Products
Manufacturing
324110 Petroleum Refineries
(including integrated)
324120 Asphalt Paving, Roofing, &
Saturated Materials Mfg
324190 Other Petroleum & Coal
Products Mfg
Chemical Manufacturing
325100 Basic Chemical Mfg
325200 Resin, Synthetic Rubber, &
Artificial & Synthetic Fibers, &
Filaments Mfg
325300 Pesticide, Fertilizer, & Other
Agricultural Chemical Mfg
325410 Pharmaceutical & Medicine Mfg
325500 Paint, Coating & Adhesive Mfg
325600 Soap, Cleaning Compound &
Toilet Preparation Mfg
325900 Other Chemical Product &
Preparation Mfg
Plastics and Rubber Products
Manufacturing
326100 Plastics Product Mfg
326200 Rubber Product Mfg
Nonmetallic Mineral Product
Manufacturing
327100 Clay Product & Refractory Mfg
327210 Glass & Glass Product Mfg
327300 Cement & Concrete Product Mfg
327400 Lime & Gypsum Product Mfg
327900 Other Nonmetallic Mineral
Product Mfg
Primary Metal Manufacturing
331110 Iron & Steel Mills & Ferroalloy
Mfg
331200 Steel Product Mfg from
Purchased Steel
331310 Alumina & Aluminum
Production & Processing
331400 Nonferrous Metal (except
Aluminum) Production &
Processing
331500 Foundries
Fabricated Metal Product
Manufacturing
332110 Forging & Stamping
332210 Cutlery & Handtool Mfg
332300 Architectural & Structural
Metals Mfg
332400 Boiler, Tank, & Shipping
Container Mfg
332510 Hardware Mfg
332610 Spring & Wire Product Mfg
332700 Machine Shops; Turned
Product; & Screw, Nut, & Bolt
Mfg
332810 Coating, Engraving, Heat
Treating, & Allied Activities
332900 Other Fabricated Metal
Product Mfg
Machinery Manufacturing
333100 Agriculture, Construction, &
Mining Machinery Mfg
333200 Industrial Machinery Mfg
333310 Commercial & Service
Industry Machinery Mfg
333410 Ventilation, Heating,
Air-Conditioning, &
Commercial Refrigeration
Equipment Mfg
333510 Metalworking Machinery Mfg
333610 Engine, Turbine, & Power
Transmission Equipment Mfg
333900 Other General Purpose
Machinery Mfg

Crop Production
111100 Oilseed & Grain Farming
111210 Vegetable & Melon Farming
(including potatoes & yams)
111300 Fruit & Tree Nut Farming
111400 Greenhouse, Nursery, &
Floriculture Production
111900 Other Crop Farming
(including tobacco, cotton,
sugarcane, hay, peanut
sugar beet, & all other crop
farming)
Animal Production
112111 Beef cattle Ranching &
Farming
112112 Cattle Feedlots
112120 Dairy Cattle & Milk
Production
112210 Hog & Pig Farming
112300 Poultry & Egg Production
112400 Sheep & Goat Farming
112510 Aquaculture (including
Shellfish, & finfish farms, &
hatcheries)
112900 Other Animal Production
Forestry and Logging
113110 Timber Tract Operations
113210 Forest Nurseries & Gathering
of Forest Products
113310 Logging
Fishing, Hunting, and Trapping
114110 Fishing
114210 Hunting & Trapping
Support Activities for Agriculture
and Forestry
115110 Support Activities for Crop
Production (including cotton,
ginning, soil preparation,
planting, & cultivating)
115210 Support Activities for Animal
Production
115310 Support Activities for
Forestry

Code
Specialty Trade Contractors
238100 Foundation, Structure, &
Building Exterior Contractors
(including framing carpentry,
masonry, glass, roofing, &
siding)
238210 Electrical Contractors
238220 Plumbing, Heating, &
Air-Conditioning Contractors
238290 Other Building Equipment
Contractors
238300 Building Finishing
Contractors (including
drywall, insulation, painting,
wallcovering, flooring, tile, &
finish carpentry)
238900 Other Specialty Trade
Contractors (including site
preparation)

These principal activity codes are based on the North American
Industry Classification System.

Code

Agriculture, Forestry, Fishing
and Hunting

This list of principal business activities and their associated
codes is designed to classify an enterprise by the type of activity
in which it is engaged.

Forms 5500, 5500-SF, and
5500-EZ Codes for Principal
Business Activity

-59-

Code
Computer and Electronic Product
Manufacturing
334110 Computer & Peripheral
Equipment Mfg
334200 Communications Equipment
Mfg
334310 Audio & Video Equipment Mfg
334410 Semiconductor & Other
Electronic Component Mfg
334500 Navigational, Measuring,
Electromedical, & Control
Instruments Mfg
334610 Manufacturing & Reproducing
Magnetic & Optical Media
Electrical Equipment, Appliance, and
Component Manufacturing
335100 Electric Lighting Equipment
Mfg
335200 Household Appliance Mfg
335310 Electrical Equipment Mfg
335900 Other Electrical Equipment &
Component Mfg
Transportation Equipment
Manufacturing
336100 Motor Vehicle Mfg
336210 Motor Vehicle Body & Trailer
Mfg
336300 Motor Vehicle Parts Mfg
336410 Aerospace Product & Parts
Mfg
336510 Railroad Rolling Stock Mfg
336610 Ship & Boat Building
336990 Other Transportation
Equipment Mfg
Furniture and Related Product
Manufacturing
337000 Furniture & Related Product
Manufacturing
Miscellaneous Manufacturing
339110 Medical Equipment &
Supplies Mfg
339900 Other Miscellaneous Mfg

Wholesale Trade
Merchant Wholesalers, Durable
Goods
423100 Motor Vehicle, & Motor
Vehicle Parts & Supplies
423200 Furniture & Home Furnishings
423300 Lumber & Other Construction
Materials
423400 Professional & Commercial
Equipment & Supplies
423500 Metals & Minerals (except
Petroleum)
423600 Electrical & Electronic Goods
423700 Hardware, Plumbing, &
Heating Equipment &
Supplies
423800 Machinery, Equipment, &
Supplies
423910 Sporting & Recreational
Goods & Supplies
423920 Toy, & Hobby Goods, &
Supplies
423930 Recyclable Materials
423940 Jewelry, Watches, Precious
Stones, & Precious Metals
423990 Other Miscellaneous Durable
Goods
Merchant Wholesalers, Nondurable
Goods
424100 Paper & Paper Products
424210
424300 Apparel, Piece Goods, &
Notions
424400 Grocery & Related Products
424500 Farm Product Raw Materials
424600 Chemical & Allied Products

Forms 5500, 5500-SF, and 5500-EZ Codes for Principal Business Activity (continued)

424930
424940
424950
424990

Tobacco & Tobacco Products
Paint, Varnish, & Supplies
Other Miscellaneous
Nondurable Goods
Wholesale Electronic Markets and
Agents and Brokers
425110 Business to Business
Electronic Markets
425120 Wholesale Trade Agents &
Brokers

Retail Trade

Transportation and
Warehousing

Air, Rail, and Water Transportation
481000 Air Transportation
482110 Rail Transportation
483000 Water Transportation
Truck Transportation
484110 General Freight Trucking,
Local
484120 General Freight Trucking,
Long-distance
484200 Specialized Freight Trucking
Transit and Ground Passenger
Transportation
485110 Urban Transit Systems
485210 Interurban & Rural Bus
Transportation
485310 Taxi Service
485320 Limousine Service
485410 School & Employee Bus
Transportation
485510 Charter Bus Industry
485990 Other Transit & Ground
Passenger Transportation
Pipeline Transportation
486000 Pipeline Transportation
Scenic & Sightseeing Transportation
487000 Scenic & Sightseeing
Transportation

Motor Vehicle and Parts Dealers
441110 New Car Dealers
441120 Used Car Dealers
441210 Recreational Vehicle Dealers
441221 Motorcycle Dealers
441222 Boat Dealers
441229 All Other Motor Vehicle
Dealers
441300 Automotive Parts,
Accessories, & Tire Stores
Furniture and Home Furnishings
Stores
442110 Furniture Stores
442210 Floor Covering Stores
442291 Window Treatment Stores
442299 All Other Home Furnishings
Stores
Electronics and Appliance Stores
443111 Household Appliance Stores
443112 Radio, Television, & Other
Electronics Stores
443120 Computer & Software Stores
443130 Camera & Photographic
Supplies Stores
Building Material and Garden
Equipment and Supplies Dealers
444110 Home Centers
444120 Paint & Wallpaper Stores
444130 Hardware Stores
444190 Other Building Material
Dealers
444200 Lawn & Garden Equipment &
Supplies Stores
Food and Beverage Stores
445110 Supermarkets and Other
Grocery (except
Convenience) Stores
445120 Convenience Stores
445210 Meat Markets
445220 Fish & Seafood Markets
445230 Fruit & Vegetable Markets
445291 Baked Goods Stores
445292 Confectionery & Nut Stores
445299 All Other Specialty Food
Stores
445310 Beer, Wine, & Liquor Stores
Health and Personal Care Stores
446110 Pharmacies & Drug Stores
446120 Cosmetics, Beauty Supplies,
& Perfume Stores
446130 Optical Goods Stores
446190 Other Health & Personal
Care Stores
Gasoline Stations
447100 Gasoline Stations (including
convenience stores with gas)
Clothing and Clothing Accessories
Stores
448110
448120
448130

Family Clothing Stores
Clothing Accessories Stores
Other Clothing Stores
Shoe Stores
Jewelry Stores
Luggage & Leather Goods
Stores
Sporting Goods, Hobby, Book, and
Music Stores
451110 Sporting Goods Stores
451120 Hobby, Toy, & Game Stores
451130 Sewing, Needlework, & Piece
Goods Stores
451140 Musical Instrument &
Supplies Stores
451211 Book Stores
451212 News Dealers & Newsstands
451220 Prerecorded Tape, Compact
Disc, & Record Stores
General Merchandise Stores
452110 Department Stores
452900 Other General Merchandise
Stores
Miscellaneous Store Retailers
453110 Florists
453210 Office Supplies & Stationery
Stores
453220 Gift, Novelty, & Souvenir
Stores
453310 Used Merchandise Stores
453910 Pet & Pet Supplies Stores
453920 Art Dealers
453930 Manufactured (Mobile) Home
Dealers
453990 All Other Miscellaneous Store
Retailers (including tobacco,
candle, & trophy shops)
Nonstore Retailers
454110 Electronic Shopping &
Mail-Order Houses
454210 Vending Machine Operators
454311 Heating Oil Dealers
454312 Liquefied Petroleum Gas
(bottled gas) Dealers
454319 Other Fuel Dealers
454390 Other Direct Selling
Establishments (including
door-to-door retailing, frozen
food plan providers, party
plan merchandisers, &
coffee-break service providers)

Code
Support Activities for Transportation
488100 Support Activities for Air
Transportation
488210 Support Activities for Rail
Transportation
488300 Support Activities for Water
Transportation
488410 Motor Vehicle Towing
488490 Other Support Activities for
Road Transportation
488510 Freight Transportation
Arrangement
488990 Other Support Activities for
Transportation
Couriers and Messengers
492110 Couriers
492210 Local Messengers & Local
Delivery
Warehousing and Storage
493100 Warehousing & Storage
(except lessors of
miniwarehouses & self-storage
units)

Information
Publishing Industries (except Internet)
511110 Newspaper Publishers
511120 Periodical Publishers
511130 Book Publishers
511140 Directory & Mailing List
Publishers
511190 Other Publishers
511210 Software Publishers
Motion Picture and Sound Recording
Industries
512100 Motion Picture & Video
Industries (except video rental)
512200 Sound Recording Industries
Broadcasting (except Internet)
515100 Radio & Television
Broadcasting
515210 Cable & Other Subscription
Programming
Telecommunications
517000 Telecommunications
(including paging, cellular,
satellite, cable & other program
distribution, resellers, other
telecommunications, &
internet service providers)
Data Processing Services
518210 Data Processing, Hosting, &
Related Services
Other Information Services
519100 Other Information Services
(including news syndicates,
libraries, internet publishing &
broadcasting)

424910
424920

Code
448140
448150
448190
448210
448310
448320

424800

Petroleum & Petroleum
Products
Beer, Wine, & Distilled
Alcoholic Beverages
Farm Supplies
Books, Periodicals, &
Newspapers
Flower, Nursery Stock, &

Code
424700

Instructions for Schedule SB (Form 5500)

Finance and Insurance
Depository Credit Intermediation
522110 Commercial Banking
522120 Savings Institutions
522130 Credit Unions
522190 Other Depository Credit
Intermediation
Nondepository Credit Intermediation
522210 Credit Card Issuing
522220 Sales Financing
522291 Consumer Lending
522292 Real Estate Credit
(including mortgage bankers &
originators)
522293 International Trade Financing
522294 Secondary Market Financing
522298 All Other Nondepository
Credit Intermediation
Activities Related to Credit
Intermediation
522300 Activities Related to Credit
Intermediation (including loan
brokers, check clearing, &
money transmitting)

-60-

Code
Securities, Commodity Contracts,
and Other Financial Investments and
Related Activities
523110 Investment Banking &
Securities Dealing
523120 Securities Brokerage
523130 Commodity Contracts Dealing
523140 Commodity Contracts
Brokerage
523210 Securities & Commodity
Exchanges
523900 Other Financial Investment
Activities (including portfolio
management & investment
advice)
Insurance Carriers and Related
Activities
524140 Direct Life, Health, & Medical
Insurance & Reinsurance
Carriers
524150 Direct Insurance &
Reinsurance (except Life,
Health & Medical) Carriers
524210 Insurance Agencies &
Brokerages
524290 Other Insurance Related
Activities (including thirdparty administration of
Insurance and pension funds)
Funds, Trusts, and Other Financial
Vehicles
525100 Insurance & Employee
Benefit Funds
525910 Open-End Investment Funds
(Form 1120-RIC)
525920 Trusts, Estates, & Agency
Accounts
525990 Other Financial Vehicles
(including mortgage REITs &
closed-end investment funds)

are located under Management
of Companies (Holding Companies).

Real Estate and Rental and Leasing
Real Estate
531110 Lessors of Residential
Buildings & Dwellings
(including equity REITs)
531114 Cooperative Housing
(including equity REITs)
531120 Lessors of Nonresidential
Buildings (except
Miniwarehouses) (including
equity REITs)
531130 Lessors of Miniwarehouses &
Self-Storage Units (including
equity REITs)
531190 Lessors of Other Real Estate
Property (including equity
REITs)
531210 Offices of Real Estate Agents
& Brokers
531310 Real Estate Property
Managers
531320 Offices of Real Estate
Appraisers
531390 Other Activities Related to
Real Estate
Rental and Leasing Services
532100 Automotive Equipment Rental &
Leasing
532210 Consumer Electronics &
Appliances Rental
532220 Formal Wear & Costume Rental
532230 Video Tape & Disc Rental

Forms 5500, 5500-SF, and 5500-EZ Codes for Principal Business Activity (continued)

Educational Services
611000

Educational Services
(including Schools, Colleges,
& Universities)

Health Care and Social Assistance

Offices of Physicians and Dentists
621111 Offices of Physicians (except
Mental Health Specialists)
621112 Offices of Physicians, Mental
Health Specialists
621210 Offices of Dentists
Offices of Other Health Practitioners
621310 Offices of Chiropractors
621320 Offices of Optometrists
621330 Offices of Mental Health
Practitioners (except
Physicians)
621340 Offices of Physical,
Occupational & Speech
Therapists, & Audiologists
621391 Offices of Podiatrists
621399 Offices of all Other
Miscellaneous Health
Practitioners
Outpatient Care Centers
621410 Family Planning Centers
621420 Outpatient Mental Health &
Substance Abuse Centers
621491 HMO Medical Centers
621492 Kidney Dialysis Centers
621493 Freestanding Ambulatory
Surgical & Emergency Centers
621498 All Other Outpatient Care
Centers

Legal Services
541110 Offices of Lawyers
541190 Other Legal Services
Accounting, Tax Preparation,
Bookkeeping, and Payroll Services
541211 Offices of Certified Public
Accountants
541213 Tax Preparation Services
541214 Payroll Services
541219 Other Accounting Services
Architectural, Engineering, and
Related Services
541310 Architectural Services
541320 Landscape Architecture
Services
541330 Engineering Services
541340 Drafting Services
541350 Building Inspection Services
541360 Geophysical Surveying &
Mapping Services
541370 Surveying & Mapping (except
Geophysical) Services
541380 Testing Laboratories
Specialized Design Services
541400 Specialized Design Services
(including interior, industrial,
graphic, & fashion design)
Computer System Design and
Related Services
541511 Custom Computer
Programming Services
541512 Computer Systems Design
Services
541513 Computer Facilities
Management Services
541519 Other Computer Related
Services
Other Professional, Scientific, and
Technical Services
541600 Management, Scientific, &
Technical Consulting Services
541700 Scientific Research &
Development Services
541800 Advertising & Related
Services
541910 Marketing Research & Public
Opinion Polling
541920 Photographic Services
541930 Translation & Interpretation
Services
541940 Veterinary Services
541990 All Other Professional,
Scientific, & Technical
Services

Administration and Support Services
561110 Office Administrative Services
561210 Facilities Support Services
561300 Employment Services
561410 Document Preparation Services
561420 Telephone Call Centers
561430 Business Service Centers
(including private mail centers
& copy shops)
561440 Collection Agencies
561450 Credit Bureaus
561490 Other Business Support
Services (including
repossession services, court
reporting, & stenotype
services)
561500 Travel Arrangement &
Reservation Services
561600 Investigation & Security
Services
561710 Exterminating & Pest Control
Services
561720 Janitorial Services
561730 Landscaping Services
561740 Carpet & Upholstery Cleaning
Services
561790 Other Services to Buildings &
Dwellings
561900 Other Support Services
(including packaging &
labeling services, & convention
& trade show organizers)
Waste Management and
Remediation Services
562000 Waste Management and
Remediation Services

Management of Companies
(Holding Companies)
551111
551112

Offices of Bank Holding
Companies
Offices of Other Holding
Companies

Code
Medical and Diagnostic Laboratories
621510 Medical & Diagnostic
Laboratories
Home Health Care Services
621610 Home Health Care Services
Other Ambulatory Health Care Services
621900 Other Ambulatory Health Care
Services (including ambulance
services & blood & organ banks)
Hospitals
622000 Hospitals
Nursing and Residential Care
Facilities
623000 Nursing & Residential Care
Facilities
Social Assistance
624100 Individual & Family Services
624200 Community Food & Housing, &
Emergency & Other Relief
Services
624310 Vocational Rehabilitation
Services
624410 Child Day Care Services

Arts, Entertainment, and
Recreation
Performing Arts, Spectator Sports,
and Related Industries
711100 Performing Arts Companies
711210 Spectator Sports (including
sports clubs & racetracks)
711300 Promoters of Performing Arts,
Sports, & Similar Events
711410 Agents & Managers for
Artists, Athletes, Entertainers, &
Other Public Figures
711510 Independent Artists, Writers, &
Performers
Museums, Historical Sites, and Similar
Institutions
712100 Museums, Historical Sites, &
Similar Institutions
Amusements, Gambling, and
Recreation Industries
713100 Amusement Parks & Arcades
713200 Gambling Industries
713900 Other Amusement &
Recreation Industries
(including golf courses, skiing
facilities, marinas, fitness
centers, & bowling centers)

Professional, Scientific, and
Technical Services

Administrative and Support and
Waste Management and
Remediation Services

Code

Other Consumer Goods
Rental
532310 General Rental Centers
532400 Commercial & Industrial
Machinery & Equipment
Rental & Leasing
Lessors of Nonfinancial Intangible
Assets (except copyrighted works)
533110 Lessors of Nonfinancial
Intangible Assets (except
copyrighted works)

Code
532290

Accommodation and Food Services
Accommodation
721110 Hotels (except Casino Hotels) &
Motels
721120 Casino Hotels
721191 Bed & Breakfast Inns
721199 All other Traveler
Accommodation
721210 RV (Recreational Vehicle)
Parks & Recreational Camps
721310 Rooming & Boarding Houses
Food Services and Drinking Places
722110 Full-Service Restaurants
722210 Limited-Service Eating Places
722300 Special Food Services
(including food service
contractors & caterers)
722410 Drinking Places (Alcoholic
Beverages)

-61-

Code

Other Services
Repair and Maintenance
811110 Automotive Mechanical, &
Electrical Repair &
Maintenance
811120 Automotive Body, Paint,
Interior, & Glass Repair
811190 Other Automotive Repair &
Maintenance (including oil
change & lubrication shops &
car washes)
811210 Electronic & Precision
Equipment Repair &
Maintenance
811310 Commercial & Industrial
Machinery & Equipment
(except Automotive &
Electronic) Repair &
Maintenance
811410 Home & Garden Equipment &
Appliance Repair &
Maintenance
811420 Reupholstery & Furniture
Repair
811430 Footwear & Leather Goods
Repair
811490 Other Personal & Household
Goods Repair & Maintenance
Personal and Laundry Services
812111 Barber Shops
812112 Beauty Salons
812113 Nail Salons
812190 Other Personal Care
Services (including diet &
weight reducing centers)
812210 Funeral Homes & Funeral
Services
812220 Cemeteries & Crematories
812310 Coin-Operated Laundries &
Drycleaners
812320 Drycleaning & Laundry
Services (except
Coin-Operated)
812330 Linen & Uniform Supply
812910 Pet Care (except Veterinary)
Services
812920 Photofinishing
812930 Parking Lots & Garages
812990 All Other Personal Services
Religious, Grantmaking, Civic,
Professional, and Similar
Organizations
813000 Religious, Grantmaking,
Civic, Professional, & Similar
Organizations (including
condominium and
homeowners associations)
813930 Labor Unions and Similar
Labor Organizations
921000 Governmental Instrumentality
or Agency

Instructions for Schedule SB (Form 5500)

ERISA COMPLIANCE QUICK CHECKLIST
Compliance with the Employee Retirement Income Security Act (ERISA) begins with knowing the rules. Plan administrators and
other plan officials
review. Use of this checklist is voluntary, and it is not be filed with your Form 5500-SF.

Have you provided plan participants with a summary plan description, summaries of any material modifications of the
plan, and annual summary financial reports or annual pension funding reports?

Do you maintain copies of plan documents at the principal office of the plan administrator for examination by
participants and beneficiaries?

Do you respond to written participant inquires for copies of plan documents and information within 30 days?

Does your plan include written procedures for making benefit claims and appealing denied claims, and are you
complying with those procedures?

Is your plan covered by fidelity bonds protecting the plan against losses due to fraud or dishonesty by persons who
handle plan funds or other property?

ts diversified so as to minimize the risk of large losses?

6.
7.

If the plan permits participants to select the investments in their plan accounts, has the plan provided them with
enough information to make informed decisions?

Has a plan official deter
beneficiaries, and evaluated the risks associated with plan investments before making the investments?

Did the employer or other plan sponsor send participant contributions to the plan on a timely basis?

10. Did the plan pay participant benefits on time and in the correct amounts?
11.

If you answer

three consecutive business days during which participants or beneficiaries of a 401(k) or other individual account
pension plan were unable to change their plan investments, obtain loans from the plan, or obtain distributions from
the plan?

Has the plan engaged in any financial transactions with persons related to the plan or any plan official? (For example,
has the plan made a loan to or participated in an investment with the employer?)

Has the plan official used the assets of the plan for his/her own interest?

Have plan assets been used to pay expenses that were not authorized in the plan document, were not necessary to
the proper administration of the plan, or were more than reasonable in amount?

If you need help answering these questions or want additional guidance about ERISA requirements, a plan official
should contact the U.S. Department of Labor Employee Benefits Security Administration office in your region or consult

Instructions for Schedule SB (Form 5500)

-62-

Index

C
Change in Plan Year ..................... 6
Changes to Note ........................... 1
Combination unfunded/insured
Welfare plan .............................. 3
Common/Collective Trust ............ 10
D
Direct Filing Entity (DFE) Who
Must File .................................... 4
Direct Filing Entity (DFE) Filing
Requirements ............................ 9
Distributions ................................ 52

L
Limited Pension Plan Reporting .... 8
Loans or Fixed Income
Obligations in Default Classified
As Uncollectible........................ 31
M
Master Trust Investment
Account (MTIA) .............................. 9

E
EFAST2 Processing System ......... 1
Electronic Filing Requirement ....... 5
ESOP Information ....................... 54
Extension of Time to File............... 4

N
Nonexempt Transactions ....... 31, 47
Notice to Terminated Accountant
or Enrolled Actuary................... 28

F
Final Return/Report:
Mergers/Consolidations ............. 6
Pension and Welfare Plans That
Terminated Without Distributing
All Assets ............................... 6
Welfare Plans Still Liable to Pay
Benefits .................................. 6
Form 5500 Schedules ................... 7
Fully insured welfare benefit
plan ........................................... 3
Funding Information .................... 53

G
General Schedules ....................... 7
Group Insurance Arrangement
(GIA) ........................................ 11

Pension Schedules ........................ 7
Plan Sponsor ............................... 15
Pooled Separate Account (PSA) . 10
Provision of Information ............... 23
R
Reportable Transaction ............... 41
S
Schedule of Reportable
Transactions ........................... 41
Service Provider Information ....... 24
Service Providers Who Fail or
Refuse To Provide
Information ............................... 27
Short Plan Year Rule .................... 7
Signature and Date ....................... 6
Small Plan Financial
Information ............................... 43
Special rule for certain
participant-directed
transactions ............................. 41
Statement by Enrolled
Actuary.................................. TBD

A
About the From 5500 .................... 1
Additional Employer Information
for Multiemployer Defined
Benefit Pension Plans .......... 54
Additional Information for
Single-Employer and
Multiemployer Defined
Benefit Pension Plans ......... 55
Amended Return/Report ............... 5
Amendments .............................. 53

80...... 7
103-12 Investment Entity
(103-12 IE) ............................... 10

I
Information Concerning Insurance
Contract Coverage, Fees, and
Commissions............................ 21
Instructions for Schedule A:
Who Must File .......................... 21
Instructions for Schedule C:
Who Must File .......................... 24
Instructions for Schedule D:
Who Must File .......................... 29
Instructions for Schedule G:
Who Must File .......................... 31
Instructions for Schedule H:
Who Must File .......................... 33
Instructions for Schedule I:
Who Must File .......................... 43
Instructions for Schedule MB:
Statement by Enrolled
Actuary ..............................TBD
Who Must File .......................... 51
Instructions for Schedule R:
Who Must File .......................... 52
Instructions for Schedule SB:
Statement by Enrolled
Actuary ..............................TBD
Who Must File .......................... 57
Investment and Annuity
Contract Information................. 22

P
Party-In-Interest .................... 31, 47
Penalties:
Administrative ........................... 6
Other.......................................... 7
Pension Benefit Plan - Who
Must File ................................... 2
Pension Benefit Plan Filing
Requirements ............................ 8

-63-

T
Telephone Assistance ................... 2
Termination Information on
Accountants and Enrolled
Actuaries .................................. 27
Transactions During Plan Year .... 45
U
Unfunded welfare benefit plan ....... 3
W
Welfare Benefit Contract
Information ............................... 22
Welfare Benefit Plan Who
Must File .................................... 3
Welfare benefit Plan Filing
Requirements ........................... 9
What To File .................................. 7
When To File:
DFEs other than GIAs ................ 4
Extensions ................................ 4
Plans and GIAs .......................... 4
Short Years ................................ 4
Who Must File ............................... 2

-64-

File Type	application/pdf
File Title	2010
Author	Dawn Patterson
File Modified	2009-09-15
File Created	2009-09-15