Form 5500 Schedule Financial Information—Small Plan

SCHEDULE I

OMB No. 1210-0110

Financial Information—Small Plan

(Form 5500)
Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security Administration

20121

This schedule is required to be filed under section 104 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.

This Form is Open to Public
Inspection

Pension Benefit Guaranty Corporation

For calendar plan year 20121 or fiscal plan year beginning

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
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI

and ending

B

Three-digit
plan number (PN)



001

D Employer Identification Number (EIN)
012345678

Complete Schedule I if the plan covered fewer than 100 participants as of the beginning of the plan year. You may also complete Schedule I if you are filing as a
small plan under the 80-120 participant rule (see instructions). Complete Schedule H if reporting as a large plan or DFE.

Part I

Small Plan Financial Information

Report below the current value of assets and liabilities, income, expenses, transfers and changes in net assets during the plan year. Combine the value of plan
assets held in more than one trust. Do not enter the value of the portion of an insurance contract that guarantees during this plan year to pay a specific dollar
benefit at a future date. Include all income and expenses of the plan including any trust(s) or separately maintained fund(s) and any payments/receipts to/from
insurance carriers. Round off amounts to the nearest dollar.

1 Plan Assets and Liabilities:
a Total plan assets ..............................................................................................
1a
b Total plan liabilities ..........................................................................................
1b
1c
c Net plan assets (subtract line 1b from line 1a) ...............................................
2 Income, Expenses, and Transfers for this Plan Year:
a Contributions received or receivable:
(1) Employers ................................................................................................
2a(1)
(2) Participants ..............................................................................................
2a(2)
(3) Others (including rollovers) .....................................................................
2a(3)

(a) Beginning of Year

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-123456789012345
-123456789012345
(a) Amount

-123456789012345
-123456789012345

e Benefits paid (including direct rollovers) .........................................................
2e
f Corrective distributions (see instructions) .......................................................
2f
g Certain deemed distributions of participant loans

-123456789012345
-123456789012345

2g
(see instructions) .............................................................................................
Administrative service providers (salaries, fees, and commissions) .............
2h
Other expenses................................................................................................
2i

-123456789012345
-123456789012345
-123456789012345
(b) Total

-123456789012345
-123456789012345
-123456789012345

b Noncash contributions .....................................................................................
2b
c Other income ...................................................................................................
2c
d Total income (add lines 2a(1), 2a(2), 2a(3), 2b, and 2c) ................................
2d

h
i
j
k
l
3

(b) End of Year

-123456789012345

-123456789012345
-123456789012345
-123456789012345

Total expenses (add lines 2e, 2f, 2g, 2h, and 2i) ...........................................
2j
Net income (loss) (subtract line 2j from line 2d) .............................................
2k
Transfers to (from) the plan (see instructions) ................................................
2l

-123456789012345
-123456789012345
-123456789012345

Specific Assets: If the plan held assets at anytime during the plan year in any of the following categories, check “Yes” and enter the current value of any assets
remaining in the plan as of the end of the plan year. Allocate the value of the plan’s interest in a commingled trust containing the assets of more than one plan on a lineby-line basis unless the trust meets one of the specific exceptions described in the instructions.
Yes
No
Amount

a Partnership/joint venture interests.........................................................................................................
3a

-123456789012345

b Employer real property ..........................................................................................................................
3b

-123456789012345

c Real estate (other than employer real property) ...................................................................................
3c

-123456789012345

d Employer securities ...............................................................................................................................
3d

-123456789012345

e Participant loans ....................................................................................................................................
3e
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500

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Schedule I (Form 5500) 20121
v. 120126012611

Schedule I (Form 5500) 20121 v. 120126

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Yes

No

Amount

-123456789012345

3f Loans (other than to participants) ............................................................................................................. 3f
g Tangible personal property........................................................................................................................ 3g
Part II Compliance Questions
4
During the plan year:
a Was there a failure to transmit to the plan any participant contributions within the time period
described in 29 CFR 2510.3-102? Continue to answer “Yes” for any prior year failures until fully
corrected. (See instructions and DOL’s Voluntary Fiduciary Correction Program.) ...............................

-123456789012345

Yes

No

Amount

4a

-123456789012345

4b

-123456789012345

4c

-123456789012345

b Were any loans by the plan or fixed income obligations due the plan in default as of the close of plan
year or classified during the year as uncollectible? Disregard participant loans secured by the
participant’s account balance. ...................................................................................................................

c Were any leases to which the plan was a party in default or classified during the year as
uncollectible? ............................................................................................................................................

d Were there any nonexempt transactions with any party-in-interest? (Do not include transactions
reported on line 4a.)...................................................................................................................................

4d

-123456789012345

e Was the plan covered by a fidelity bond? .................................................................................................

4e

-123456789012345

Did the plan have a loss, whether or not reimbursed by the plan’s fidelity bond, that was caused by
fraud or dishonesty? .................................................................................................................................

4f

-123456789012345

4g

-123456789012345

f

g Did the plan hold any assets whose current value was neither readily determinable on an established
market nor set by an independent third party appraiser? ........................................................................

h Did the plan receive any noncash contributions whose value was neither readily determinable on an
established market nor set by an independent third party appraiser? ...................................................

4h

-123456789012345

i

Did the plan at any time hold 20% or more of its assets in any single security, debt, mortgage, parcel
of real estate, or partnership/joint venture interest? ...............................................................................

4i

-123456789012345

j

Were all the plan assets either distributed to participants or beneficiaries, transferred to another plan,
or brought under the control of the PBGC? ............................................................................................

4j

k Are you claiming a waiver of the annual examination and report of an independent qualified public

l

accountant (IQPA) under 29 CFR 2520.104-46? If “No,” attach an IQPA’s report or 2520.104-50
statement. (See instructions on waiver eligibility and conditions.) .................................................................

4k

Has the plan failed to provide any benefit when due under the plan? ...................................................

4l

-123456789012345

m If this is an individual account plan, was there a blackout period? (See instructions and 29 CFR
2520.101-3.) .............................................................................................................................................

4m

n If 4m was answered “Yes,” check the “Yes” box if you either provided the required notice or one of
the exceptions to providing the notice applied under 29 CFR 2520.101-3 ...........................................

4n

5a Has a resolution to terminate the plan been adopted during the plan year or any prior plan year?
If “Yes,” enter the amount of any plan assets that reverted to the employer this year...........................

5b

X Yes X No

Amount:

-

If, during this plan year, any assets or liabilities were transferred from this plan to another plan(s), identify the plan(s) to which assets or liabilities were
transferred. (See instructions.)
5b(1) Name of plan(s)

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

5b(2) EIN(s)

5b(3) PN(s)

123456789

123

123456789

123
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123456789

123

Schedule I (Form 5500) 20121 v. 120126

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Part III Trust Information (optional)
6a Name of trust ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

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6b Trust’s EIN

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