Form 5500

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SCHEDULE R
(Form 5500)
Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security Administration
Pension Benefit Guaranty Corporation
Retirement Plan Information

This schedule is required to be filed under section 104 and 4065 of the Employee Retirement Income Security Act of 1974 (ERISA) and section 6058(a) of the Internal Revenue Code (the Code).
 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 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
  Distributions

1	Total value of distributions paid in property other than in cash or the forms of property specified in the instructions	
1
-123456789012345

Part II
Funding Information (If the plan is not subject to the minimum funding requirements of section of 412 of the Internal Revenue Code or ERISA section 302, skip this Part)

	If you completed line 5, complete lines 3, 9, and 10 of Schedule MB and do not complete the remainder of this schedule.

	If you completed line 6c, skip lines 8 and 9.

7	Will the minimum funding amount reported on line 6c be met by the funding deadline?		
  X   Yes 
  X   No 
X   N/A 

8	If a change in actuarial cost method was made for this plan year pursuant to a revenue procedure or other authority providing automatic approval for the change or a class ruling letter, does the plan sponsor or plan administrator agree with the change?	
  




X   Yes
  X   No
X   N/A 

Part III
  Amendments

9	If this is a defined benefit pension plan, were any amendments adopted during this plan year that increased or decreased the value of benefits? If yes, check the appropriate box. If no, check the “No” box.	





X  Increase
X Decrease
X  Both
X  No
Part IV   	
ESOPs (see instructions). If this is not a plan described under Section 409(a) or 4975(e)(7) of the Internal Revenue Code,
 skip this Part.
10	Were unallocated employer securities or proceeds from the sale of unallocated securities used to repay any exempt loan?	
X  Yes 
X   No 
11	a	Does the ESOP hold any preferred stock?	
X  Yes
X   No
	b	If the ESOP has an outstanding exempt loan with the employer as lender, is such loan part of a “back-to-back” loan? 
	(See instructions for definition of “back-to-back” loan.)	
X  Yes
X   No
12	Does the ESOP hold any stock that is not readily tradable on an established securities market?	
X  Yes
X   No
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. 
Schedule R (Form 5500) 2011
v.012611


 Part V 	
Additional Information for Multiemployer Defined Benefit Pension Plans
13	Enter the following information for each employer that contributed more than 5% of total contributions to the plan during the plan year (measured in dollars).  See instructions.  Complete as many entries as needed to report all applicable employers.
a	Name of contributing employer 
b	EIN  
c	Dollar amount contributed by employer 
d	Date collective bargaining agreement expires (If employer contributes under more than one collective bargaining agreement, check box X      and see instructions regarding required attachment.  Otherwise, enter the applicable date.)    Month _______    Day _______    Year _______
e	Contribution rate information (If more than one rate applies, check this box X and see instructions regarding required attachment.  Otherwise, complete items 13e(1) and 13e(2).)
(1) 	Contribution rate (in dollars and cents)  _____________
(2) 	Base unit measure: X   Hourly         X   Weekly         X   Unit of production         X   Other (specify): 

a	Name of contributing employer 
b	EIN  
c	Dollar amount contributed by employer
d	Date collective bargaining agreement expires (If employer contributes under more than one collective bargaining agreement, check box X      and see instructions regarding required attachment.  Otherwise, enter the applicable date.)    Month _______    Day _______    Year _______
e	Contribution rate information (If more than one rate applies, check this box X and see instructions regarding required attachment.  Otherwise, complete items 13e(1) and 13e(2).)
(1) 	Contribution rate (in dollars and cents)  _____________
(2) 	Base unit measure: X   Hourly         X   Weekly         X   Unit of production         X   Other (specify): _______________________________

a	Name of contributing employer 
b	EIN  
c	Dollar amount contributed by employer
d	Date collective bargaining agreement expires (If employer contributes under more than one collective bargaining agreement, check box X      and see instructions regarding required attachment.  Otherwise, enter the applicable date.)    Month _______    Day _______    Year _______
e	Contribution rate information (If more than one rate applies, check this box X and see instructions regarding required attachment.  Otherwise, complete items 13e(1) and 13e(2).)
(1) 	Contribution rate (in dollars and cents)  _____________
(2) 	Base unit measure: X   Hourly         X   Weekly         X   Unit of production         X   Other (specify): _______________________________

a	Name of contributing employer
b	EIN  
c	Dollar amount contributed by employer
d	Date collective bargaining agreement expires (If employer contributes under more than one collective bargaining agreement, check box X      and see instructions regarding required attachment.  Otherwise, enter the applicable date.)    Month _______    Day _______    Year _______
e	Contribution rate information (If more than one rate applies, check this box X and see instructions regarding required attachment.  Otherwise, complete items 13e(1) and 13e(2).)
(1) 	Contribution rate (in dollars and cents)  _____________
(2) 	Base unit measure: X   Hourly         X   Weekly         X   Unit of production         X   Other (specify): _______________________________

a	Name of contributing employer
b	EIN  
c	Dollar amount contributed by employer
d	Date collective bargaining agreement expires (If employer contributes under more than one collective bargaining agreement, check box X      and see instructions regarding required attachment.  Otherwise, enter the applicable date.)    Month _______    Day _______    Year _______
e	Contribution rate information (If more than one rate applies, check this box X and see instructions regarding required attachment.  Otherwise, complete items 13e(1) and 13e(2).)
(1) 	Contribution rate (in dollars and cents)  _____________
(2) 	Base unit measure: X   Hourly         X   Weekly         X   Unit of production         X   Other (specify): _______________________________

a	Name of contributing employer
b	EIN  
c	Dollar amount contributed by employer
d	Date collective bargaining agreement expires (If employer contributes under more than one collective bargaining agreement, check box X      and see instructions regarding required attachment.  Otherwise, enter the applicable date.)    Month _______    Day _______    Year _______
e	Contribution rate information (If more than one rate applies, check this box X and see instructions regarding required attachment.  Otherwise, complete items 13e(1) and 13e(2).)
(1) 	Contribution rate (in dollars and cents)  _____________
(2) 	Base unit measure: X   Hourly         X   Weekly         X   Unit of production         X   Other (specify): _______________________________



14	Enter the number of participants on whose behalf no contributions were made by an employer as an employer of the participant for: 

	a	The current year	 
14a
123456789012345
	b	The plan year immediately preceding the current plan year	 
14b
123456789012345
	c	The second preceding plan year	 
14c
123456789012345
15	Enter the ratio of the number of participants under the plan on whose behalf no employer had an obligation to make an employer contribution during the current plan year to:

	a	The corresponding number for the plan year immediately preceding the current plan year	 
15a
123456789012345
	b	The corresponding number for the second preceding plan year	 
15b
123456789012345
16	Information with respect to any employers who withdrew from the plan during the preceding plan year:

	a	Enter the number of employers who withdrew during the preceding plan year  	 
16a
123456789012345
	b	If item 16a is greater than 0, enter the aggregate amount of withdrawal liability assessed or estimated to be assessed against such withdrawn employers	 
16b
123456789012345
17	If assets and liabilities from another plan have been transferred to or merged with this plan during the plan year, check box and see instructions regarding supplemental information to be included as an attachment.	X

Part VI
Additional Information for Single-Employer and Multiemployer Defined Benefit Pension Plans
18	If any liabilities to participants or their beneficiaries under the plan as of the end of the plan year consist (in whole or in part) of liabilities to such participants and beneficiaries under two or more pension plans as of immediately before such plan year, check box and see instructions regarding supplemental information to be included as an attachment	X
19	If the total number of participants is 1,000 or more, complete items (a) through (c)

	a	Enter the percentage of plan assets held as: 
 Stock: _____%   Investment-Grade Debt: _____%    High-Yield Debt: _____%    Real Estate: _____%   Other: _____% 
	b	Provide the average duration of the combined investment-grade and high-yield debt:  
      X  0-3 years     X  3-6 years     X  6-9 years     X  9-12 years     X  12-15 years     X  15-18 years     X  18-21 years     X  21 years or more 
	c	What duration measure was used to calculate item 19(b)?
X Effective duration     X Macaulay duration     X Modified duration     X Other (specify):