Schedule SB (Form 2012 Schedule SB (Form 5500) - Single-Employer Defined B

Schedule SB (Form 5500) 20121 v. 110923 Page 3 - 1 x

SCHEDULE SB (Form 5500) Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation		Single-Employer Defined Benefit Plan Actuarial Information 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).  File as an attachment to Form 5500 or 5500-SF.				OMB No. 1210-0110 20121 This Form is Open to Public Inspection
For calendar plan year 20121 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					B Three-digit plan number (PN) 		001
C Plan sponsor’s name as shown on line 2a of Form 5500 or 5500-SF ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI					D Employer Identification Number (EIN) 012345678
E Type of plan: X Single X Multiple-A X Multiple-B				F Prior year plan size: X 100 or fewer X 101-500 X More than 500
Part I	Basic Information

1 Enter the valuation date: Month _________ Day _________ Year _________
2 Assets:
a Market value	2a	-123456789012345
b Actuarial value	2b	-123456789012345

3 Funding target/participant count breakdown:			(1) Number of participants					(2) Funding Target
a For retired participants and beneficiaries receiving payment		3a	12345678					-123456789012345
b For terminated vested participants		3b	12345678					-123456789012345
c For active participants:
(1) Non-vested benefits		3c(1)						-123456789012345
(2) Vested benefits		3c(2)						-123456789012345
(3) Total active		3c(3)						-123456789012345
d Total		3d	12345678					-123456789012345
4 If the plan is in at-risk status, check the box and complete lines (a) and (b) X
a Funding target disregarding prescribed at-risk assumptions						4a		-123456789012345
b 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		-123456789012345
5 Effective interest rate						5		123.12%
6 Target normal cost						6		-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					Date
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE					YYYY-MM-DD
Type or print name of actuary					Most recent enrollment number
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE					1234567
Firm name					Telephone number (including area code)
123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE UK					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 instructions									X
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500 or 5500-SF.							Schedule SB (Form 5500) 20112 v. 110923012611

Part II	Beginning of year carryover and prefunding balances
			(a) Carryover balance	(b) Prefunding balance
7 Balance at beginning of prior year after applicable adjustments (line 13 from prior year)			-123456789012345	-123456789012345
8 Portion elected for use to offset prior year’s funding requirement (line 35 from prior year)			-123456789012345	-123456789012345
9 Amount remaining (line 7 minus line 8)			-123456789012345	-123456789012345
10 Interest on line 9 using prior year’s actual return of %			-123456789012345	-123456789012345
11 Prior year’s excess contributions to be added to prefunding balance:
a Present value of excess contributions (line 38a from prior year)				-123456789012345
b Interest on (a) using prior year’s effective interest rate of % except as otherwise provided (see instructions)				-123456789012345
c Total available at beginning of current plan year to add to prefunding balance				-123456789012345
d Portion of (cc) to be added to prefunding balance				-123456789012345
12 Other reductions in balances due to elections or deemed elections			-123456789012345	-123456789012345
13 Balance at beginning of current year (line 9 + line 10 + line 11d – line 12)			-123456789012345	-123456789012345
Part III		Funding percentages
14 Funding target attainment percentage					14	123.12%
15 Adjusted funding target attainment percentage					15	123.12%
16 Prior year’s funding percentage for purposes of determining whether carryover/prefunding balances may be used to reduce current year’s funding requirement					16	123.12%
17 If the current value of the assets of the plan is less than 70 percent of the funding target, enter such percentage.					17	123.12%
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)

(c) Amount paid by employees

YYYY-MM-DD	123456789012345 YYYY-MM-DD YYYY-MM-DD YYYY-MM-DD YYYY-MM-DD Totals	123456789012345-123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345	YYYY-MM-DD -123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345		123456789012345-123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345	123456789012345-123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345
YYYY-MM-DD	123456789012345	123456789012345	YYYY-MM-DD		123456789012345-123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345	123456789012345-123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345
YYYY-MM-DD	123456789012345	123456789012345	YYYY-MM-DD		123456789012345-123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345	123456789012345-123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345
YYYY-MM-DD	123456789012345	123456789012345	YYYY-MM-DD		123456789012345-123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345	123456789012345-123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345
YYYY-MM-DD	123456789012345	123456789012345	YYYY-MM-DD		123456789012345-123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345	123456789012345-123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345 -123456789012345
YYYY-MM-DD	123456789012345	123456789012345
			Totals ►	18(b)		18(c)

19 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	-123456789012345
b Contributions made to avoid restrictions adjusted to valuation date	19b	-123456789012345
c Contributions allocated toward minimum required contribution for current year adjusted to valuation date	19c	-123456789012345
20 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	(4) 4th
-123456789012345	-123456789012345	-123456789012345	-123456789012345

Part V	Assumptions used to determine funding target and target normal cost
21 Discount rate:
a Segment rates:			1st segment: 123.12_%		2nd segment: 123.12_%	3rd segment: 123.12 %				X N/A, full yield curve used
b Applicable month (enter code)									21b	1
22 Weighted average retirement age									22	12
23 Mortality table(s) (see instructions) X Prescribed - combined X Prescribed - separate X 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 X No
25 Has a method change been made for the current plan year? If “Yes,” see instructions regarding required attachment. X Yes X No
26 Is the plan required to provide a Schedule of Active Participants? If “Yes,” see instructions regarding required attachment. X Yes X No
27 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									28	-123456789012345
29 Discounted employer contributions allocated toward unpaid minimum required contributions from prior years (line 19a)									29	-123456789012345
30 Remaining amount of unpaid minimum required contributions (line 28 minus line 29)									30	-123456789012345
Part VIII		Minimum required contribution for current year
31 Target normal cost and excess assets (see instructions):
a Target normal cost (line 6)									31a	-123456789012345
b Excess assets, if applicable, but not greater than 31a									31b
32 Amortization installments:							Outstanding Balance			Installment
a Net shortfall amortization installment							-123456789012345			-123456789012345
b Waiver amortization installment							-123456789012345			-123456789012345
33 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	-123456789012345
34 Total funding requirement before reflecting carryover/prefunding balances (lines 31a - 31b + 32a + 32b - 33)									34	-123456789012345
				Carryover balance				Prefunding balance		Total balance
35 Balances elected for use to offset funding requirement				-123456789012345				-123456789012345		-123456789012345
36 Additional cash requirement (line 34 minus line 35)									36	-123456789012345
37 Contributions allocated toward minimum required contribution for current year adjusted to valuation date (line 19c)									37	-123456789012345
38 Present value of excess contributions for current year (see instructions) -123456789012345
a Total (excess, if any, of line 37 over line 36)									38a
b Portion included in line 38a attributable to use of prefunding and funding standard carryover balances									38b
39 Unpaid minimum required contribution for current year (excess, if any, of line 36 over line 37)									39	-123456789012345
40 Unpaid minimum required contributions for all years									40	-123456789012345
Part IX		Pension funding relief under Pension Relief Act of 2010 (see instructions)
41 If a shortfall amortization base is being amortized pursuant to an alternative amortization schedule:If an election was made to use PRA 2010 funding relief for this plan:
a Schedule elected 2 plus 7 years X 15 years
b Eligible plan year(s) for which the election in line 41a was made X 2008 X 2009 X 2010 X 2011
42 Amount of acceleration adjustment									42
43 Excess installment acceleration amount to be carried over to future plan years									43