Schedule G Financial Transaction Schedules

Annual Return/Report of Employee Benefit Plan

2009 Form 5500 SchG EFAST

Annual Return/Report of Employee Benefit Plan

OMB: 1545-1610

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1545-1610 can be found here:
2024-04-15 - No material or nonsubstantive change to a currently approved collection
2023-08-31 - No material or nonsubstantive change to a currently approved collection
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SCHEDULE G

OMB No. 1210-0110

Financial Transaction Schedules

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

This Form is Open to Public
Inspection.

 File as an attachment to Form 5500.

For calendar plan year 2009 or fiscal plan year beginning

and ending

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

2009

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

B

D

Three-digit
plan number (PN)



001

Employer Identification Number (EIN):

012345678

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

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

T

X

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

(b) Identity and address of obligor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

AF

(a)

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

(e) Principal

(f) Interest

(g) Unpaid balance at end
of year

Amount overdue
(h) Principal

(i) Interest

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345 123456789012345

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

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

R

X

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

D

(a)

Amount received during reporting year

(d) Original amount of
loan

(e) Principal

(f) Interest

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345

(a)

X

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

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

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

(e) Principal

(f) Interest

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

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

Schedule G (Form 5500) 2009
v.092308.1

Page 2-

Schedule G (Form 5500) 2009

(a)

X

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

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

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

(f) Interest

(e) Principal

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345 123456789012345

X

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

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

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

(f) Interest

(e) Principal

T

(a)

(g) Unpaid balance at end
of year

Amount overdue

(h) Principal

(i) Interest

X

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

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

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

R

(a)

AF

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345 123456789012345

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

(e) Principal

(f) Interest

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

(a)

X

D

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345 123456789012345
(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

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

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

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

(e) Principal

(f) Interest

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345 123456789012345
(a)

X

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

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

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

(e) Principal

(f) Interest

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345 123456789012345

Page 3-

Schedule G (Form 5500) 2009

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

123456789012345
(a)

X

X

X

123456789012345
(a)

X

123456789012345
(a)

X

123456789012345

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

(j) Amount in arrears

123456789012345 123456789012345

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

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

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

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

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

(i) Net receipts

(j) Amount in arrears

123456789012345 123456789012345

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

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCD
(i) Net receipts

(j) Amount in arrears

123456789012345 123456789012345

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

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCD

123456789012345 123456789012345 123456789012345

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

(i) Net receipts

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCD

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

(b) Identity of lessor/lessee

(e) Original cost

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

123456789012345 123456789012345 123456789012345

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

123456789012345 123456789012345

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

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

(b) Identity of lessor/lessee

(e) Original cost

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

123456789012345 123456789012345 123456789012345

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

(j) Amount in arrears

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCD

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

(b) Identity of lessor/lessee

(e) Original cost

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

(i) Net receipts

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

123456789012345 123456789012345 123456789012345

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

123456789012345

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

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

(b) Identity of lessor/lessee

(e) Original cost

(a)

123456789012345 123456789012345 123456789012345

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

123456789012345
(a)

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

(b) Identity of lessor/lessee

(e) Original cost

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCD

T

(e) Original cost

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

AF

X

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

R

(a)

Schedule of Leases in Default or Classified as Uncollectible

D

Part II

(i) Net receipts

(j) Amount in arrears

123456789012345 123456789012345

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

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCD

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

123456789012345 123456789012345 123456789012345

(i) Net receipts

(j) Amount in arrears

123456789012345 123456789012345

Page 4-

Schedule G (Form 5500) 2009

Part III

Nonexempt Transactions

Complete as many entries as needed to report all nonexempt transactions. Caution: If a nonexempt prohibited transaction occurred with respect
to a disqualified person, file Form 5330 with the IRS to pay the excise tax on the transaction.
(b) Relationship to plan, employer, (c) Description of transaction including maturity date, rate
(a) Identity of party involved
(d) Purchase price
or other party-in-interest
of interest, collateral, par or maturity value

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

(e) Selling price

(f) Lease rental

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(g) Transaction
expenses

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCD

(h) Cost of asset

(i) Current value of
asset

123456789012345

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

123456789012345 123456789012345 123456789012345 123456789012345 12345678901235 -123456789012345

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI ABCD
(e) Selling price

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

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

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(f) Lease rental

(a) Identity of party involved

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

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

(e) Selling price

(f) Lease rental

(h) Cost of asset

(i) Current value of
asset

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

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCD

AF

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI ABCD

(g) Transaction
expenses

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCD

T

(a) Identity of party involved

(g) Transaction
expenses

(h) Cost of asset

(i) Current value of
asset

(d) Purchase price

123456789012345

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

(d) Purchase price

123456789012345

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

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

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(f) Lease rental

(g) Transaction
expenses

D

(e) Selling price

(a) Identity of party involved

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI ABCD

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

R

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI ABCD

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

(e) Selling price

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCD

(h) Cost of asset

(i) Current value of
asset

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

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

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(f) Lease rental

(g) Transaction
expenses

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCD

(h) Cost of asset

(i) Current value of
asset

(d) Purchase price

123456789012345

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

(d) Purchase price

123456789012345

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

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

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI ABCD
(e) Selling price

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

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

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(f) Lease rental

(g) Transaction
expenses

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCD

(h) Cost of asset

(i) Current value of
asset

(d) Purchase price

123456789012345

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

123456789012345 123456789012345 123456789012345 123456789012345 12345678901235 -123456789012345
File Type	application/pdf
File Title	Microsoft Word - DEL 22 Final PY 2009 and PY 2010 Form-Schedule Proofs Resubmission.doc
Author	hickk2
File Modified	2009-06-29
File Created	2009-05-05