Form 5500 Schedule Retirement Plan Information

SCHEDULE R

OMB No. 1210-0110

Retirement Plan Information

(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 and 4065 of the
Employee Retirement Income Security Act of 1974 (ERISA) and section
6058(a) of the Internal Revenue Code (the Code).

This Form is Open to Public
Inspection.

 File as an attachment to Form 5500.

Pension Benefit Guaranty Corporation

For calendar plan year 20121 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
C Plan sponsor’s name as shown on line 2a of Form 5500
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
Part I

B Three-digit
plan number
(PN)


001

D Employer Identification Number (EIN)
012345678

Distributions

All references to distributions relate only to payments of benefits during the plan year.

1
2

Total value of distributions paid in property other than in cash or the forms of property specified in the
instructions..................................................................................................................................................................

-123456789012345

1

Enter the EIN(s) of payor(s) who paid benefits on behalf of the plan to participants or beneficiaries during the year (if more than two, enter EINs of the two
payors who paid the greatest dollar amounts of benefits):
EIN(s):

_______________________________

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______________________________

Profit-sharing plans, ESOPs, and stock bonus plans, skip line 3.

3

Number of participants (living or deceased) whose benefits were distributed in a single sum, during the plan
year. ..............................................................................................................................................................................

Part II

12345678

3

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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)

4

X Yes

Is the plan administrator making an election under Code section 412(d)(2) or ERISA section 302(d)(2)? ..........................

X No

X N/A

If the plan is a defined benefit plan, go to line 8.

5

If a waiver of the minimum funding standard for a prior year is being amortized in this
plan year, see instructions and enter the date of the ruling letter granting the waiver.

Date:

Month _________

Day _________

Year _________

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

6

a Enter the minimum required contribution for this plan year (include any prior year accumulated funding
deficiency not waived)...........................................................................................................................................

-123456789012345

6a

6b
-123456789012345
b Enter the amount contributed by the employer to the plan for this plan year ...................................................... ...........................

c Subtract the amount in line 6b from the amount in line 6a. Enter the result
(enter a minus sign to the left of a negative amount) ............................................................................................

-123456789012345

6c

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? ........................................

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? .......................................................................................................................

Part III
9

X No

X N/A

X Yes

X No

X N/A

Amendments

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

Part IV

X Yes

X Increase

X Decrease

X Both

X No

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? ..............
11 a Does the ESOP hold any preferred stock? ........................................................................................................................................
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.) .....................................................................................................................

12 Does the ESOP hold any stock that is not readily tradable on an established securities market? ..........................................................
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500.

X Yes
X Yes

X No
X No

X Yes

X No

X Yes

X No

Schedule R (Form 5500) 20121
v. 120126012611

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Schedule R (Form 5500) 20121v.120126

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1 x
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

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dollars). See instructions. Complete as many entries as needed to report all applicable employers.

a
b

Name of contributing 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 lines 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
b

Name of contributing 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 lines 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
b

Name of contributing 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 lines 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
b

Name of contributing 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 lines 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
b

Name of contributing 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 lines 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
b

Name of contributing 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 lines 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): _______________________________

EIN

EIN

EIN

EIN

EIN

EIN

c

Dollar amount contributed by employer
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c

Dollar amount contributed by employer
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c

Dollar amount contributed by employer
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c

Dollar amount contributed by employer
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c

Dollar amount contributed by employer
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c

Dollar amount contributed by employer
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Schedule R (Form 5500) 20121 v. 120126

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

14a
a The current year ..............................................................................................................................................................
14b
b The plan year immediately preceding the current plan year .........................................................................................

123456789012345

14c
c The second preceding plan year ....................................................................................................................................

123456789012345

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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:

15a
a The corresponding number for the plan year immediately preceding the current plan year ........................................
15b
b The corresponding number for the second preceding plan year ...................................................................................

123456789012345
123456789012345

16 Information with respect to any employers who withdrew from the plan during the preceding plan year :
16a
a Enter the number of employers who withdrew during the preceding plan year .........................................................
b If item line 16a is greater than 0, enter the aggregate amount of withdrawal liability assessed or estimated

16b

to be assessed against such withdrawn employers ......................................................................................................

123456789012345
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

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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 lines (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 line 19(b)?
X Effective duration X Macaulay duration X Modified duration X Other (specify):

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