Form 5500 -- Sched Service Provider Information

Annual Information Return/Report

SchC_mockup

Annual Information Return/Report

OMB: 1210-0110

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1210-0110 can be found here:
2024-04-02 - No material or nonsubstantive change to a currently approved collection
2023-12-18 - No material or nonsubstantive change to a currently approved collection
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Page 1

Schedule C (Form 5500) 2011

SCHEDULE C

OMB No. 1210-0110

Service Provider Information

(Form 5500)
Department of the Treasury
Internal Revenue Service

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

Department of Labor
Employee Benefits Security Administration

 File as an attachment to Form 5500.

Pension Benefit Guaranty Corporation

For calendar plan year 2011 or fiscal plan year beginning

2011
This Form is Open to Public
Inspection.

and ending

A Name of plan
ABCDEFGHI

B

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

D Employer Identification Number (EIN)
012345678

Part I

Three-digit
plan number (PN)



001

Service Provider Information (see instructions)

You must complete this Part, in accordance with the instructions, to report the information required for each person who received, directly or indirectly, $5,000
or more in total compensation (i.e., money or anything else of monetary value) in connection with services rendered to the plan or the person's position with the
plan during the plan year. If a person received only eligible indirect compensation for which the plan received the required disclosures, you are required to
answer line 1 but are not required to include that person when completing the remainder of this Part.

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

b

X Yes X No

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

(b)

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

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

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

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

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

Schedule C (Form 5500) 2011
v.012611

Schedule C (Form 5500) 2011

Page 2-

1 x

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

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

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

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

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

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

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

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

Page 3

Schedule C (Form 5500) 2011

-1 x

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

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

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

(b)
Service
Code(s)

(c)

(e)

(d)

(f)

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

ABCDEFGHI
ABCDEFGHI
ABCD

123456789012
345

(h)

(g)

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

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

123456789012345
Yes

X

No

X

Yes

X

No

X

Yes

X

No

X

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

(b)
Service
Code(s)

(c)

(e)

(d)

(f)

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

ABCDEFGHI
ABCDEFGHI
ABCD

123456789012
345

(h)

(g)

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

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

123456789012345
Yes

X

No

X

Yes

X

No

X

Yes

X

No

X

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

(b)
Service
Code(s)

(c)

(d)

(f)

(e)

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

ABCDEFGHI
ABCDEFGHI
ABCD

123456789012
345

Yes

X

No

X

(g)

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

Yes

X

No

X

(h)

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

Yes

X

No

X

Schedule C (Form 5500) 2011

Page 4-

1 x

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

(a) Enter service provider name as it appears on line 2

(b) Service Codes
(see instructions)

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

(a) Enter service provider name as it appears on line 2

(a) Enter service provider name as it appears on line 2

(b) Service Codes

(c) Enter amount of indirect
compensation

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

(b) Service Codes
(see instructions)

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

compensation

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

(see instructions)

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

(c) Enter amount of indirect

(c) Enter amount of indirect
compensation

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

Page 5-

Schedule C (Form 5500) 2011

1 x

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

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

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
1234567890

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

instructions)

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

instructions)

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

instructions)

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

instructions)

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

instructions)

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

10 11
12 13

(b) Nature of

ABCDE
ABCDE
ABCDE
ABCDE
ABCDE
ABCDE

provide

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDE
ABCDE
ABCDE
ABCDE
ABCDE
ABCDE

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

10 11 12
13

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(b) Nature of

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

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDE
ABCDE
ABCDE
ABCDE
ABCDE
ABCDE

provide

10 11 12
13

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(b) Nature of

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

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDE
ABCDE
ABCDE
ABCDE
ABCDE
ABCDE

provide

10 11 12
13

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(b) Nature of

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

Service
Code(s)

ABCD
ABCD
ABCD
ABCD

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

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

Service
Code(s)

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

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
1234567890

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

Service
Code(s)

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

(b) Nature of

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

Service
Code(s)

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

10 11
12 13

provide

Service
Code(s)

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

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

Service
Code(s)

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

(b) Nature of

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
provide

ABCDE
ABCDE
ABCDE
ABCDE
ABCDE
ABCDE

Page 6-

Schedule C (Form 5500) 2011

Part III

1 x

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

a
c
d

Name:
Position:
Address:

Explanation:

a
c
d

Name:
Position:
Address:

Explanation:

a
c
d

Name:
Position:
Address:

Explanation:

a
c
d

Name:
Position:
Address:

Explanation:

a
c
d

Name:
Position:
Address:

Explanation:

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCD
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCD
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCD
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCD
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCD
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD

b

EIN:

123456789

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

b

EIN:

123456789

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

b

EIN:

123456789

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

b

EIN:

123456789

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

b

EIN:

123456789

ABCD
1234567890
e Telephone:
ABCD
ABCD
ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
File Type	application/pdf
File Title	Microsoft Word - SchC_mockup
Author	st.onge.emily
File Modified	2011-05-13
File Created	2011-05-13