Annual Information Return/Report

Forms and Documents

Document Name	Status
Form 2015 Schedule A (F Annual Information Return/Report Form	Modified
Form 5500 EBSA Supporting Statement 5-6-15.docx Supplementary Document	2015-06-16
PBGC_2015_5500 Draft SS 3_15 Rev 5_15.docx Supporting Statement A	2015-06-16

IC Document Collections

IC ID	Document Title	Status
13607	Annual Information Return/Report Form	Modified

ICR Details

OMB Control No: 1212-0057	ICR Reference No: 201412-1212-001
Status: Historical Active	Previous ICR Reference No: 201402-1212-012
Agency/Subagency: PBGC	Agency Tracking No:
Title: Annual Information Return/Report
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/22/2015
	Date Received in OIRA: 03/03/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2017	36 Months From Approved	06/30/2017
Responses	24,000	0	25,000
Time Burden (Hours)	1,200	0	1,200
Cost Burden (Dollars)	1,407,000	0	1,357,000

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Abstract: Sections 104 and 4065 of ERISA require plan administrators to file an annual report. The report must contain the information described in section 103 of ERISA. The Form 5500 Series provides a standard format for fulfilling that requirement.

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Authorizing Statute(s): US Code: 29 USC 1302(b)(3), 1365 Name of Law: ERISA
  

Citations for New Statutory Requirements: Statute at Large: 120 Stat. 780 Name of Statute: Pension Protection Act of 2006

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 62681	10/20/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 11501	03/03/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Annual Information Return/Report	2015 Schedule MB (Form 5500) PBGC Revisions, 2015 Schedule D (Form 5500), 2015 Form 5500-SF, 2015 Form 5500-SF, 2015 Schedule G (Form 5500), 2015 Schedule H (Form 5500), 2015 Schedule I (Form 5500), 2015 Schedule MB (Form 5500), 2015 Schedule MB (Form 5500), 2015 Schedule R (Form 5500), 2015 Form 5500, 2015 Form 5500, 2015 Schedule C (Form 5500), 2015 Schedule A (Form 5500), 2015 Schedule A (Form 5500), 2015 Schedule C (Form 5500), 2015 Schedule D (Form 5500), 2015 Schedule G (Form 5500), 2015 Schedule H (Form 5500), 2015 Schedule I (Form 5500), 2015 Schedule R (Form 5500), 2015 Schedule SB (Form 5500), 2015 Schedule SB (Form 5500)	2015 Schedule A (Form 5500) - Insurance Information (RLSO) ,   2015 Schedule C (Form 5500) - Service Provider Information ,   2015 Schedule C (Form 5500) Service Provider Information (RLSO) ,   2015 Schedule D (Form 5500) - DFE/Participating Provider Information ,   2015 Schedule G (Form 5500) - Financial Transaction Schedules (RLSO) ,   2015 Schedule H (Form 5500) - Financial Information ,   2015 Schedule I (Form 5500) - Financial Information - Small Plan ,   2015 Schedule R (Form 5500) - Retirement Plan Information ,   2015 Schedule SB (Form 5500) - Single-Employer Defined Benefit Plan Actuarial Information ,   2015 Schedule SB (Form 5500) - Single-Employer Defined Benefit Plan Actuarial Information (RLSO) ,   2015 Annual Return/Report of Employee Benefit Plan ,   2015 Annual Return/Report of Employee Benefit Plan (RLSO) ,   2015 Schedule A (Form 5500) - Insurance Information ,   2015 Schedule MB (Form 5500) - Multiemployer Defined Benefit Plan and Certain Money Purchase Plan Actuarial Information (RLSO) - PBGC Revisions ,   2015 Short Form Annual Return/Report of Small Employee Benefit Plan ,   2015 Short Form Annual Return/Report of Small Employee Benefit Plan (RLSO) ,   2015 Schedule D (Form 5500) - DFE/Participating Provider Information (RLSO) ,   2015 Schedule G (Form 5500) - Financial Transation Schedules ,   2015 Schedule H (Form 5500) - Financial Information (RLSO) ,   2015 Schedule I (Form 5500) - Financial Information - Small Plan (RLSO) ,   2015 Schedule MB (Form 5500) - Multiemployer Defined Benefit Plan and Certain Money Purchase Plan Actuarial Information ,   2015 Schedule MB (Form 5500) - Multiemployer Defined Benefit Plan and Certain Money Purchase Plan Actuarial Information (RLSO) ,   2015 Schedule R (Form 5500) - Retirement Plan Information (RLSO)

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	24,000	25,000	0	0	-1,000	0
Annual Time Burden (Hours)	1,200	1,200	0	0	0	0
Annual Cost Burden (Dollars)	1,407,000	1,357,000	0	0	50,000	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $822,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/03/2015

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