Schedule D DFE/Participating Plan Information

Annual Return/Report of Employee Benefit Plan

SchD

Annual Return/Report of Employee Benefit Plan

OMB: 1545-1610

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Schedule D (Form 5500) 2008 Page 2

SCHEDULE D

(Form 5500)


Department of the Treasury

Internal Revenue Service


Department of Labor

Employee Benefits Security Administration

DFE/Participating Plan Information


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

File as an attachment to Form 5500.



OMB No. 1210-0110


2011


This Form is Open to Public Inspection.

For calendar plan year 2011 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

B Three-digit
plan number (PN)

001


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

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

D Employer Identification Number (EIN)
012345678

Part I

Information on interests in MTIAs, CCTs, PSAs, and 103-12 IEs (to be completed by plans and DFEs)
(Complete as many entries as needed to report all interests in DFEs)

a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103 12 IE at end of year (see instructions)

-123456789012345




a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103 12 IE at end of year (see instructions)

-123456789012345




a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345




a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345

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

Schedule D (Form 5500) 2011

v.012611


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345



6

Part II

Information on Participating Plans (to be completed by DFEs)
(Complete as many entries as needed to report all participating plans)

a Plan name

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123


a Plan name

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

a Plan name

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123


a Plan name

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123


a Plan name

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123


a Plan name

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123


a Plan name

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123


a Plan name

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123


a Plan name

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123


a Plan name

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123


a Plan name

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123


a Plan name

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123


File Typeapplication/msword
File TitleForm 5500
AuthorBruce Silver
Last Modified Bythornton.emily
File Modified2011-01-26
File Created2010-09-14
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