Form 5500- Schedul Single-Employer Defined Benefit Plan Actuarial Informati

SCHEDULE SB

Single-Employer Defined Benefit Plan
Actuarial Information

(Form 5500)
Department of the Treasury
Internal Revenue Service

OMB No. 1210-0110

2011

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

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:

X

Single

X

Multiple-A

X

Multiple-B

F

Prior year plan size:

B

D

Three-digit
plan number (PN)

5
6

001

Employer Identification Number (EIN)

012345678
X

100 or fewer

X

101-500

Part I
Basic Information
1 Enter the valuation date:
Month _________ Day _________ Year _________
2 Assets:
a Market value .................................................................................................................................................... 2a
b Actuarial value ................................................................................................................................................. 2b
3 Funding target/participant count breakdown:
(1) Number of participants
12345678
a For retired participants and beneficiaries receiving payment ............ 3a
12345678
b For terminated vested participants .................................................... 3b
c For active participants:
(1) Non-vested benefits ................................................................... 3c(1)
(2) Vested benefits .......................................................................... 3c(2)
(3) Total active ................................................................................ 3c(3)
12345678
d Total ................................................................................................... 3d
4 If the plan is in at-risk status, check the box and complete lines (a) and (b) .............................. X
a
b



Funding target disregarding prescribed at-risk assumptions ..........................................................................

4a

Funding target reflecting at-risk assumptions, but disregarding transition rule for plans that have been in
at-risk status for fewer than five consecutive years and disregarding loading factor .....................................

4b

Effective interest rate ..............................................................................................................................................
Target normal cost ..................................................................................................................................................

5
6

X

More than 500

-123456789012345
-123456789012345
(2) Funding Target

-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
123.12%
-123456789012345

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

SIGN
HERE
Signature of actuary

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
Type or print name of actuary

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
Firm name

123456789 ABCDEFGHI ABCDEFGHI ABCDE
123456789 ABCDEFGHI ABCDEFGHI ABCDE
UK

Date

YYYY-MM-DD
Most recent enrollment number

1234567
Telephone number (including area code)

1234567890

Address of the firm
If the actuary has not fully reflected any regulation or ruling promulgated under the statute in completing this schedule, check the box and see
X
instructions
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500 or 5500-SF.
Schedule SB (Form 5500) 2011
v.012611

Page 2

Schedule SB (Form 5500) 2011

Part II

- 1 x

Beginning of year carryover and prefunding balances
(a) Carryover balance

7

Balance at beginning of prior year after applicable adjustments (line 13 from prior
year) ............................................................................................................................

8

Portion elected for use to offset prior year’s funding requirement (line 35 from
prior year) ...................................................................................................................

9
10
11

Amount remaining (line 7 minus line 8) .......................................................................
Interest on line 9 using prior year’s actual return of

-123456789012345

-123456789012345

-123456789012345
-123456789012345
-123456789012345

-123456789012345
-123456789012345
-123456789012345

Prior year’s excess contributions to be added to prefunding balance:

a
b
c
d
12
13

% ..............................

(b) Prefunding balance

-123456789012345

Present value of excess contributions (line 38 from prior year) .............................
Interest on (a) using prior year’s effective rate of
% except as
otherwise provided (see instructions) ....................................................................
Total available at beginning of current plan year to add to prefunding balance............
Portion of (c) to be added to prefunding balance ...................................................

-123456789012345
-123456789012345

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

-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345

Part III
Funding percentages
14 Funding target attainment percentage ................................................................................................................................................................. 14
15 Adjusted funding target attainment percentage ...................................................................................................................................... 15
16 Prior year’s funding percentage for purposes of determining whether carryover/prefunding balances may be used to reduce
16
current year’s funding requirement .........................................................................................................................................................
17

If the current value of the assets of the plan is less than 70 percent of the funding target, enter such percentage. ..............................

123.12%
123.12%
123.12%
123.12%

17

Part IV
Contributions and liquidity shortfalls
18 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)

(b) Amount paid by
employer(s)

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

12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234

12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234

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

12345678901234
12345678901234
12345678901234
12345678901234
12345678901234

Totals ►

19

18(b)

12345678901234512345678901234512345678901234512345678901234512345678901234518(c)

Discounted employer contributions – see instructions for small plan with a valuation date after the beginning of the year:

a Contributions allocated toward unpaid minimum required contributions from prior years. ..................................... 19a
b Contributions made to avoid restrictions adjusted to valuation date ...................................................................... 19b
c Contributions allocated toward minimum required contribution for current year adjusted to valuation date ..................... 19c
20

(c) Amount paid by
employees

-123456789012345
-123456789012345
-123456789012345

Quarterly contributions and liquidity shortfalls:

a

Did the plan have a “funding shortfall” for the prior year? ............................................................................................................................. X Yes

X

No

b

If 20a is “Yes,” were required quarterly installments for the current year made in a timely manner? ........................................................... X Yes

X

No

c

If 20a is “Yes,” see instructions and complete the following table as applicable:
Liquidity shortfall as of end of quarter of this plan year
(1) 1st
(2) 2nd
(3) 3rd

-123456789012345

-123456789012345

-123456789012345

(4)

4th

-123456789012345

Page 3

Schedule SB (Form 5500) 2011

Part V Assumptions used to determine funding target and target normal cost
21 Discount rate:
1st segment:
2nd segment:
3rd segment:
a Segment rates:
123.12_%
123.12_%
123.12 %
b
22
23

Applicable month (enter code) .........................................................................................................................

Weighted average retirement age .........................................................................................................................
Mortality table(s) (see instructions)

X

Prescribed - combined

X

Prescribed - separate

X

X N/A, full yield curve used
21b
22

1
12

Substitute

Part VI Miscellaneous items
24 Has a change been made in the non-prescribed actuarial assumptions for the current plan year?

If “Yes,” see instructions regarding required
attachment. ........................................................................................................................................................................................................ X Yes

25

Has a method change been made for the current plan year? If “Yes,” see instructions regarding required attachment. ................................ X Yes

X
X

26
27

Is the plan required to provide a Schedule of Active Participants? If “Yes,” see instructions regarding required attachment.......................... X Yes

X

If the plan is eligible for (and is using) alternative funding rules, enter applicable code and see instructions
regarding attachment .............................................................................................................................................

27

Part VII Reconciliation of unpaid minimum required contributions for prior years
28 Unpaid minimum required contributions for all prior years ....................................................................................
29 Discounted employer contributions allocated toward unpaid minimum required contributions from prior years

28
29

(line 19a) ................................................................................................................................................................

30

30

Remaining amount of unpaid minimum required contributions (line 28 minus line 29) .........................................

Part VIII Minimum required contribution for current year
31 Target normal cost and excess assets (see instructions):
a Target normal cost (line 6) ................................................................................................................................. 31a
b Excess assets, if applicable, but not greater than 31a ..................................................................................... 31b
Outstanding Balance
32 Amortization installments:
-123456789012345
a Net shortfall amortization installment .........................................................................
-123456789012345
b Waiver amortization installment .................................................................................
33
34

If a waiver has been approved for this plan year, enter the date of the ruling letter granting the approval
(Month _________ Day _________ Year _________ )_and the waived amount ..........................................

33

Total funding requirement before reflecting carryover/prefunding balances (lines 31a - 31b + 32a + 32b - 33) ...

34

Carryover balance

Prefunding balance

35

Balances elected for use to offset funding
requirement ............................................................

36
37

Additional cash requirement (line 34 minus line 35) ..............................................................................................

38

Present value of excess contributions for current year (see instructions)

-123456789012345

a
b

Total (excess, if any, of line 37 over line 36) ....................................................................................................
Portion included in line 38a attributable to use of prefunding and funding standard carryover balances ........

39 Unpaid minimum required contribution for current year (excess, if any, of line 36 over line 37) ...........................
40 Unpaid minimum required contributions for all years.............................................................................................
Part IX
Pension funding relief under Pension Relief Act of 2010 (see instructions)
41

No

No

-123456789012345
-123456789012345
-123456789012345

-123456789012345
Installment

-123456789012345
-123456789012345
-123456789012345
-123456789012345
Total balance

-123456789012345
36

Contributions allocated toward minimum required contribution for current year adjusted to valuation date
(line 19c) ................................................................................................................................................................

No

-123456789012345
-123456789012345

37

-123456789012345

38a
38b
39
40

-123456789012345
-123456789012345

If a shortfall amortization base is being amortized pursuant to an alternative amortization schedule:

a Schedule elected

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

b Eligible plan year(s) for which the election in line 41a was made

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

2 plus 7 years

X 15 years

X 2008 X 2009 X 2010 X

42

Amount of acceleration adjustment .......................................................................................................................

42

43

Excess installment acceleration amount to be carried over to future plan years ...................................................

43

2011