Form 5500 -- Sched Multiemployer Defined Benefit Plan and Certain Money Pur

SCHEDULE MB

Multiemployer Defined Benefit Plan and Certain
Money Purchase Plan Actuarial 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) and section 6059 of the
Internal Revenue Code (the Code).

Department of Labor
Employee Benefits Security Administration

OMB No. 1210-0110

2011
This Form is Open to Public
Inspection

Pension Benefit Guaranty Corporation

 File as an attachment to Form 5500 or 5500-SF.
For calendar plan year 2011 or fiscal plan year beginning
and ending

Round off amounts to nearest dollar.
Caution: A penalty of $1,000 will be assessed for late filing of this report unless reasonable cause is established.
A Name of plan
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
C Plan sponsor’s name as shown on line 2a of Form 5500 or 5500-SF
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
E

Type of plan:

1a
b
c

(1)

Enter the valuation date:

X

Multiemployer Defined Benefit
Month _________

(2)

Day _________

X

B

Three-digit
plan number (PN)

D

001

Employer Identification Number (EIN)

012345678

Money Purchase (see instructions)
Year _________

Assets
(1) Current value of assets ........................................................................................................................
(2) Actuarial value of assets for funding standard account ........................................................................

1b(1)
1b(2)
1c(1)

(1) Accrued liability for plan using immediate gain methods .....................................................................
(2) Information for plans using spread gain methods:
(a) Unfunded liability for methods with bases............................................................................................

1c(2)(a)

(b) Accrued liability under entry age normal method .................................................................................

1c(2)(b)

(c) Normal cost under entry age normal method.......................................................................................

1c(2)(c)
1c(3)

-123456789012345
-123456789012345
-123456789012345
-123456789012345

1d(1)

-123456789012345

(a) Current liability .....................................................................................................................................

1d(2)(a)

(b) Expected increase in current liability due to benefits accruing during the plan year ...........................

1d(2)(b)

(c) Expected release from “RPA ‘94” current liability for the plan year .....................................................

1d(2)(c)

-123456789012345
-123456789012345
-123456789012345
-123456789012345

(3) Accrued liability under unit credit cost method ...........................................................................................

d



Information on current liabilities of the plan:
(1) Amount excluded from current liability attributable to pre-participation service (see instructions) .............
(2) “RPA ‘94” information :

(3) Expected plan disbursements for the plan year .........................................................................................
Statement by Enrolled Actuary

1d(3)

To the best of my knowledge, the information supplied in this schedule and accompanying schedules, statements and attachments, if any, is complete and accurate. Each prescribed assumption was applied in
accordance with applicable law and regulations. In my opinion, each other assumption is reasonable (taking into account the experience of the plan and reasonable expectations) and such other assumptions, in
combination, offer my best estimate of anticipated experience under the plan.

SIGN
HERE
Signature of actuary

Date

Type or print name of actuary

Most recent enrollment number

Firm name

Telephone number (including area code)

Address of the firm
If the actuary has not fully reflected any regulation or ruling promulgated under the statute in completing this schedule, check the box and see
instructions
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500 or Form 5500-SF.

X

Schedule MB (Form 5500) 2011
v.012611

Page 2

Schedule MB (Form 5500) 2011

-1 x

2 Operational information as of beginning of this plan year:
a Current value of assets (see instructions) ...................................................................................................………… 2a
(1) Number of participants
b “RPA ‘94” current liability/participant count breakdown:
12345678
(1) For retired participants and beneficiaries receiving payment ....................................
12345678
(2) For terminated vested participants ............................................................................
(3)

-123456789012345
(2) Current liability

-123456789012345
-123456789012345

For active participants:
(a) Non-vested benefits ............................................................................................

-123456789012345
-123456789012345
-123456789012345
-123456789012345

(b) Vested benefits ...................................................................................................
(c) Total active ..........................................................................................................
(4)

c

12345678

Total ...........................................................................................................................

If the percentage resulting from dividing line 2a by line 2b(4), column (2), is less than 70%, enter such
percentage ................................................................................................................................................................

2c

123.12%

3 Contributions made to the plan for the plan year by employer(s) and employees:
(a) Date
(MM-DD-YYYY)

(b) Amount paid by
employer(s)

(c) Amount paid by
employees

(a) Date
(MM-DD-YYYY)

Totals ►

(b) Amount paid by
employer(s)

(c) Amount paid by
employees

3(b)

3(c)

4 Information on plan status:
a Enter code to indicate plan’s status (see instructions for attachment of supporting evidence of plan’s status). If
code is “N,” go to item 5. .............................................................................................................................................

4a

b
c

Is the plan making the scheduled progress under any applicable funding improvement or rehabilitation plan? ............................................................. X Yes

X

No

d

If the plan is in critical status, were any adjustable benefits reduced? .............................................................................................................. X Yes

X

No

e

If line d is “Yes,” enter the reduction in liability resulting from the reduction in adjustable benefits, measured as
of the valuation date ...................................................................................................................................................

Funded percentage for monitoring plan’s status (line 1b(2) divided by line 1c(3)) ....................................................

4b

123.1%

4e

-123456789012345

5 Actuarial cost method used as the basis for this plan year’s funding standard account computations (check all that apply):
a X Attained age normal
b X Entry age normal
c X Accrued benefit (unit credit)
d X Aggregate
e X Frozen initial liability
f
X Individual level premium
g X Individual aggregate
h X Shortfall
i
X Reorganization
j
X Other (specify): ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
YYYY-MM-DD
k If box h is checked, enter period of use of shortfall method ....................................................................................... 5k
l Has a change been made in funding method for this plan year? ...................................................................................................................... X Yes X No
m If line l is “Yes,” was the change made pursuant to Revenue Procedure 2000-40 or other automatic approval? ............................................. X
n

If line l is “Yes,” and line m is “No,” enter the date (MM-DD-YYYY) of the ruling letter (individual or class)
approving the change in funding method....................................................................................................................

5n

Pre-retirement
Rates specified in insurance or annuity contracts ....................................

c

Mortality table code for valuation purposes:

X

Yes

X

No

X

X

No

YYYY-MM-DD

6 Checklist of certain actuarial assumptions:
a Interest rate for “RPA ‘94” current liability. ..........................................................................................................................................
b

Yes

6a

123.12%

Post-retirement

X

N/A

Yes

X

No

X

N/A

(1) Males ....................................................................................... 6c(1)
(2) Females ................................................................................... 6c(2)

d

Valuation liability interest rate ........................................................

6d

e

Expense loading ............................................................................

6e

123.12%

X

N/A

f

Salary scale ...................................................................................

6f

123.12%

X

N/A

g

Estimated investment return on actuarial value of assets for year ending on the valuation date ......................

6g

-123.1%

h

Estimated investment return on current value of assets for year ending on the valuation date ........................

6h

-123.1%

123.12%

123.12%
123.12%

X

N/A

Page 3

Schedule MB (Form 5500) 2011

-1 x

7 New amortization bases established in the current plan year:
(1) Type of base

A
A
A

(2) Initial balance

(3) Amortization Charge/Credit

-123456789012345
-123456789012345
-123456789012345

-123456789012345
-123456789012345
-123456789012345

8 Miscellaneous information:
a

If a waiver of a funding deficiency has been approved for this plan year, enter the date (MM-DD-YYYY) of the
ruling letter granting the approval ...............................................................................................................................

8a

b
c

Is the plan required to provide a Schedule of Active Participant Data? (See the instructions.) If “Yes,” attach schedule.

d

If line c is “Yes,” provide the following additional information:

Are any of the plan’s amortization bases operating under an extension of time under section 412(e) (as in effect prior to
2008) or section 431(d) of the Code? ................................................................................................................................... .

(1) Was an extension granted automatic approval under section 431(d)(1) of the Code? ........................................

YYYY-MM-DD
X Yes X No
X

Yes

X

No

X

Yes

X

No

(2) If line (1) is “Yes,” enter the number of years by which the amortization period was extended ........................... 8d(2)
(3) Was an extension approved by the Internal Revenue Service under section 412(e) (as in effect prior to
2008) or 431(d)(2) of the Code? ...........................................................................................................................
(4) If line (3) is “Yes,” enter number of years by which the amortization period was extended (not including the
8d(4)
number of years in line (2)) ...................................................................................................................................
(5) If line (3) is “Yes,” enter the date of the ruling letter approving the extension ...................................................... 8d(5)
(6) If line (3) is “Yes,” is the amortization base eligible for amortization using interest rates applicable under section
6621(b) of the Code for years beginning after 2007? ......................................................................................................

e

If box 5h is checked or line 8c is “Yes,” enter the difference between the minimum required contribution for the
year and the minimum that would have been required without using the shortfall method or extending the
amortization base(s) ...................................................................................................................................................

12
X

Yes

X

No

12
YYYY-MM-DD
X

Yes

X

No

8e

-123456789012345

9 Funding standard account statement for this plan year:
Charges to funding standard account:

a

Prior year funding deficiency, if any............................................................................................................................

9a

-123456789012345

b

Employer’s normal cost for plan year as of valuation date .........................................................................................

9b

-123456789012345

c

Amortization charges as of valuation date:
(1) All bases except funding waivers and certain bases for which the
amortization period has been extended .......................................................

d
e

Outstanding balance
9c(1)

-123456789012345

-123456789012345

(2) Funding waivers ...........................................................................................

9c(2)

-123456789012345

-123456789012345

(3) Certain bases for which the amortization period has been extended ..........

9c(3)

-123456789012345

-123456789012345

Interest as applicable on lines 9a, 9b, and 9c ............................................................................................................

9d

-123456789012345

Total charges. Add lines 9a through 9d ......................................................................................................................

9e

-123456789012345

Credits to funding standard account:

f

Prior year credit balance, if any ..................................................................................................................................

9f

-123456789012345

g

Employer contributions. Total from column (b) of line 3 ............................................................................................

9g

-123456789012345

-123456789012345

-123456789012345

Outstanding balance

h

Amortization credits as of valuation date ...........................................................

i

Interest as applicable to end of plan year on lines 9f, 9g, and 9h...............................................................................

j

Full funding limitation (FFL) and credits:

k
l

9h

9i

-123456789012345

(1)

ERISA FFL (accrued liability FFL) .............................................................

9j(1)

-123456789012345

(2)

“RPA ‘94” override (90% current liability FFL) ..........................................

9j(2)

-123456789012345

(3)

FFL credit............................................................................................................................................................

9j(3)

-123456789012345

(1)

Waived funding deficiency .................................................................................................................................. 9k(1)

-123456789012345

(2)

Other credits ....................................................................................................................................................... 9k(2)

-123456789012345

9l

-123456789012345

m Credit balance: If line 9l is greater than line 9e, enter the difference..........................................................................

9m

-123456789012345

n

9n

-123456789012345

Total credits. Add lines 9f through 9i, 9j(3), 9k(1), and 9k(2) .....................................................................................

Funding deficiency: If line 9e is greater than line 9l, enter the difference ...................................................................

Schedule MB (Form 5500) 2011

9o

Page 4

Current year’s accumulated reconciliation account:
(1)

Due to waived funding deficiency accumulated prior to the 2011 plan year ..................................................

(2)

Due to amortization bases extended and amortized using the interest rate under section 6621(b) of the Code:

(3)

9o(1)

-123456789012345

(a) Reconciliation outstanding balance as of valuation date ......................................................................... 9o(2)(a)

-123456789012345

(b) Reconciliation amount (line 9c(3) balance minus line 9o(2)(a)) ............................................................... 9o(2)(b)

-123456789012345

Total as of valuation date................................................................................................................................

9o(3)

-123456789012345

10

-123456789012345
X Yes X No

10

Contribution necessary to avoid an accumulated funding deficiency. (See instructions.) ......................................

11

Has a change been made in the actuarial assumptions for the current plan year? If “Yes,” see instructions. ......................