Annual Information Return/Report

Department of the Treasury
Internal Revenue Service

Department of Labor
Employee Benefits
Security Administration

Pension Benefit
Guaranty Corporation

2014 2015
Instructions for Form 5500
Annual Return/Report of Employee Benefit Plan
Code section references are to the Internal Revenue Code
unless otherwise noted. ERISA refers to the Employee
Retirement Income Security Act of 1974.

EFAST2 Processing System
Under the computerized ERISA Filing Acceptance System
(EFAST2), you must electronically file your 2014 2015 Form
5500. Your Form 5500 entries will be initially screened
electronically. For more information, see the instructions for
Electronic Filing Requirement and the EFAST2 website at
www.efast.dol.gov. You cannot file a paper Form 5500 by mail
or other delivery service.

About the Form 5500
The Form 5500, Annual Return/Report of Employee Benefit
Plan, including all required schedules and attachments (Form
5500 return/report), is used to report information concerning
employee benefit plans and Direct Filing Entities (DFEs). Any
administrator or sponsor of an employee benefit plan subject to
ERISA must file information about each benefit plan every year
(pursuant to Code section 6058 and ERISA sections 104 and
4065). Some plans participate in certain trusts, accounts, and
other investment arrangements that file a Form 5500 annual
return/report as DFEs. See Who Must File and When To File.
The Internal Revenue Service (IRS), Department of Labor
(DOL), and Pension Benefit Guaranty Corporation (PBGC)
have consolidated certain returns and report forms to reduce
the filing burden for plan administrators and employers.
Employers and administrators who comply with the instructions
for the Form 5500 generally will satisfy the annual reporting
requirements for the IRS and DOL.
Defined contribution and defined benefit pension plans may
have to file additional information with the IRS including Form
5330, Return of Excise Taxes Related to Employee Benefit
Plans, Form 5310-A, Notice of Plan Merger or Consolidation,
Spinoff, or Transfer of Plan Assets or Liabilities; Notice of
Qualified Separate Lines of Business, and Form 8955-SSA,
Annual Registration Statement Identifying Separated
Participants with Deferred Vested Benefits. See www.irs.gov
for more information.
Plans covered by the PBGC have special additional
requirements, including premiums and reporting certain
transactions directly with that agency. See PBGC’s website
(www.pbgc.gov/practitioners/) for information on premium
payments and reporting and disclosure.
Each Form 5500 must accurately reflect the characteristics
and operations that applied during the reporting year of the
plan or arrangementof the plan or arrangement being reported.
The requirements for completing the Form 5500 will vary
according to the type of plan or arrangement. The section
What To File summarizes what information must be reported
for different types of plans and arrangements. The Quick
Reference Chart of Form 5500, Schedules and Attachments,
gives a brief guide to the annual return/report requirements of
the 2014 2015 Form 5500. See also the “Troubleshooters
Guide to Filing the ERISA Annual Reports” available on

www.dol.gov/ebsa, which is intended to help filers comply with
the Form 5500 and Form 5500-SF annual reporting
requirements and avoid common reporting errors.
The Form 5500 must be filed electronically as noted above.
See Section 3 – Electronic Filing Requirement and the
EFAST2 website at www.efast.dol.gov. Your Form 5500
entries will be initially screened electronically. Your entries
must satisfy this screening for your filing to be received. Once
received, your form may be subject to further detailed review,
and your filing may be rejected based upon this further review.
ERISA and the Code provide for the assessment or
imposition of penalties for not submitting the required
information when due. See Penalties.
Annual reports filed under Title I of ERISA must be made
available by plan administrators to plan participants and
beneficiaries and by the DOL to the public pursuant to ERISA
sections 104 and 106. Pursuant to Section 504 of the Pension
Protection Act of 2006 (PPA) Pub. L. 109-280, this availability
for defined benefit pension plans must include the posting of
identification and basic plan information and actuarial
information (Form 5500, Schedule SB or MB, and all of the
Schedule SB or MB attachments) on any plan sponsor intranet
website (or website maintained by the plan administrator on
behalf of the plan sponsor) that is used for the purpose of
communicating with employees and not the public. Section 504
also requires DOL to display such information on DOL’s
website within 90 days after the filing of the plan’s annual
return/report. To see plan year 2009 and later Forms 5500,
including actuarial information, see www.dol.gov/ebsa. See
www.dol.gov/ebsa/actuarialsearch.html for 2008 and short plan
year 2009 actuarial information filed under the previous paperbased system.

Changes to Note
IRS Electronic Filing Requirements. On September 29,
2014, the Treasury Department issued final regulations under
sections 6058 and 6059 of the Code providing that certain
filers must electronically file the Form 5500 series
returns/reports (including actuarial schedules). (See T.D. 9695,
79 FR 58256 at http://federalregister.gov/a/2014-23161).
Under the regulations you are required to file a Form 5500
series return/report electronically if you are required to file at
least 250 returns of all types during the calendar year that
includes the first day of the applicable plan year. Because the
IRS may now require certain filers to electronically file the
Form 5500 series returns/reports, the IRS is adding questions
to the Form 5500 and its Schedules relating solely to IRS
compliance issues.
IRS Compliance Questions.
 New Lines 4o and 4p, and Part V (Trust Information) were
added to Schedules H and I. Trust information is no longer
optional. You are required to answer these questions relating
to the name and EIN of the trust, and the trustee’s name and
telephone number.

 Preparer information on the Form 5500 is no longer
optional. You are required to answer these questions relating
to the preparer’s name, address, and telephone number.

Form 5500-Active Participants Information. A new question
“Total number of active participants at the beginning of the plan
year” has been added to Line 6a(1).
Form 5500-Multiple-Employer Plan Information. The check
box for “Multiple-Employer Plans” in Part I of the Form 5500
has been changed to indicate that multiple-employer pension
plans and multiple-employer welfare plans required to file a
Form 5500 must include an attachment that (1) lists each
participating employer in the plan during the plan year,
identified by name, employer identification number (EIN), and
(2) includes a good faith estimate of each employer's
percentage of the total contributions (including employer and
participant contributions) made by all participating employers
during the year.
Multiple-employer welfare plans that are exempt under 29 CFR
2520.104-44 from the obligation to file financial statements with
their annual report are required to include only a list of
participating employers with the corresponding EIN/PN
numbers in the “Multiple-Employer Plan Participating Employer
Information” attachment they will submit with their filing.
Filers will need to complete as many entries as needed to
report all applicable employers.
Schedule H. The instructions for line 1c(13) have been
enhanced to explain that a registered investment company is
an investment company registered under the Investment
Company Act of 1940. These are mutual funds (legally known
as open-end companies), closed-end funds (legally known as
closed-end companies), and UITs (legally known as unit
investment trusts).
Schedule MB. New Line 4f has been added to Line 4 to
require plans in critical status to provide information about the
plan year in which a plan is projected to emerge from critical
status or, if the rehabilitation plan is based on forestalling
possible insolvency, the plan year in which insolvency is
expected. The instructions for Line 4f have been updated to
reflect this change.
Schedule SB. Line 3 (and related instructions) has been
modified so that the funding target (vested and total) is
reported separately for each type of participant (active, retired,
terminated vested). Line 11b has been split into two parts; the
first providing the calculation based on the prior year’s effective
interest rate, and the second providing the calculation based
on the prior year’s actual return. See the instructions if the
valuation date for the prior plan year was not the first day of the
plan year. Line 15 instructions have been expanded to address
situations in which the AFTAP was not certified for the plan
year. Line 27 (and related instructions) has been modified to
reflect changes under the Cooperative and Small Employer
Charity Pension Flexibility Act of 2014.
Table of Contents
Page
Section 1: Who Must File ............................................. 23
Pension Benefit Plan ................................................... 23
Welfare Benefit Plan ..................................................... 3
Direct Filing Entity (DFE) ............................................... 4
Section 2: When To File .................................................. 4
Extension of Time To File ............................................. 4
Section 3: Electronic Filing Requirement ..................... 5
Amended Return/Report ................................................ 6
Final Return/Report ....................................................... 6
Signature and Date ........................................................ 6
Change in Plan Year...................................................... 7
Penalties ........................................................................ 7
Administrative Penalties ............................................... 7
Other Penalties ............................................................ 7
Section 4: What To File .................................................. 7
Form 5500 Schedules .................................................... 8
Pension Schedules ................................................... 8

 New Part VII (IRS Compliance Questions) was added to
Schedule R for purposes of satisfying the reporting
requirements of section 6058 of the Code.
 You are required to answer all these IRS Compliance
questions electronically through EFAST2 if you are required by
the Treasury regulations to file the Form 5500 series
return/report electronically. If you are not required to file these
returns/reports electronically, you may elect to answer the IRS
compliance questions electronically through EFAST2, or you
must answer these questions by filing paper Form 5500-SUP,
Annual Return of Employee Benefit Plan Supplemental
Information. These new IRS-only compliance questions must
be answered for plan years beginning on or after January 1,
2015, but only for returns/reports with a filing deadline after
December 31, 2015.
Schedule MB. The instructions are modified to add RP-2000
and RP-2000 (with Blue Collar Adjustment) to the list of
mortality tables for non-disabled lives that plans may report in
line 6c. The Schedule MB and instructions are also modified to
add a new question in line 8b that would require large
multiemployer plans (500 or more total participants as of the
valuation date) to provide in an attachment a projection of
expected benefit payments to be paid for the entire plan (not
including expected expenses) for each of the next ten plan
years starting with the plan year to which the filing relates. The
Schedule MB is modified to require all multiemployer plans to
report the funded percentage for monitoring the plan’s status in
line 4. Previously, only plans in critical or endangered status
were required to report this information. As a result of the
Multiemployer Pension Reform Act of 2014, the Schedule MB
and instructions are further modified to extend the reporting
requirements in line 4 for multiemployer plans in critical status
to plans in critical and declining status and require that
additional information to be reported by plans that have been
partitioned or have had benefits suspended.
Schedule SB. The instructions are modified to simplify the
alternative age/service scatters that cash balance plans with
1,000 or more active participants have an option to report on
an attachment to line 26.
Form 5500 Final Return/Report for Plans Trusteed by
PBGC. The instructions for “Final Return/Report” are modified
to add a statement that a filer for a terminated defined benefit
plan for which PBGC has been appointed trustee may contact
DOL at [email protected] for further information.
Form 5500-Form M-1 Compliance Information. The Form M1 (Report for Multiple-Employer Welfare Arrangements
(MEWAs) and Certain Entities Claiming Exception (ECEs))
compliance information that was required to be filed as an
attachment for 2013 now appears as three new questions on
the Form 5500. The instructions have also been updated to
reflect this change.
Form 5500-Signature and Date. The instructions for
“Signature and Date” have been updated to caution filers to
check the Filing Status and to advise that if the filing status is
"Processing Stopped" or “Unprocessable”, it is possible your
submission was not sent with a valid electronic signature as
required, and depending on the error, may be considered not
to have been filed. By looking closer at the Filing Status, you
can see specific error messages applicable to the transmitted
filing and determine whether it was sent with a valid electronic
signature and what other errors may need to be corrected.

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General Instructions to Form 5500

General Schedules .................................................... 8
Pension Benefit Plan Filing Requirements .................... 8
Limited Pension Plan Reporting ................................. 9
Welfare Benefit Plan Filing Requirements ..................... 9
Direct Filing Entity (DFE) Filing Requirements ............ 10
Master Trust Investment Account (MTIA) ................ 10
Common/Collective Trust (CCT) and Pooled
Separate Account (PSA) .......................................... 10
103-12 Investment Entity (103-12 IE) ...................... 11
Group Insurance Arrangement (GIA)....................... 11
Quick Reference Chart of Form 5500, Schedules, and
Attachments ............................................................. 12
Section 5: Line-by-Line Instructions for the 2014 2015
Form 5500 and Schedules ........................................ 14
Part I (Form 5500) – Annual Return/Report Identification
Information ............................................................... 14
Part II (Form 5500) – Basic Plan Information .............. 15
M-1 Compliance Information ....................................... 18
Schedule A – Insurance Information ........................... 21
Schedule C – Service Provider Information ................. 24
Schedule D – DFE/Participating Plan Information ....... 29
Schedule G – Financial Transaction Schedules .......... 31
Schedule H – Financial Information............................. 33
Schedule I – Financial Information – Small Plan ......... 43
Schedule MB – Multiemployer Defined Benefit Plan and
Certain Money Purchase Plan Actuarial
Information ............................................................... 51
Schedule R – Retirement Plan Information ................. 58
Schedule SB – Single-Employer Defined Benefit Plan
Actuarial Information ................................................ 63
Paperwork Reduction Act Notice ............................... 77
Codes for Principal Business Activity ........................ 78
ERISA Compliance Quick Checklist ............................ 81
Index .............................................................................. 82

Section 1: Who Must File
A return/report must be filed every year for every pension
benefit plan, welfare benefit plan, and for every entity that files
as a DFE as specified below (pursuant to Code section 6058
and ERISA sections 104 and 4065).
If you are a small plan (generally under 100 participants at
the beginning of the plan year), you may be eligible to file the
Form 5500-SF instead of the Form 5500. For more information,
see the instructions to the Form 5500-SF.

Pension Benefit Plan
All pension benefit plans covered by ERISA must file an annual
return/report except as provided in this section. The return/
report must be filed whether or not the plan is “tax-qualified,”
benefits no longer accrue, contributions were not made this
plan year, or contributions are no longer made. Pension benefit
plans required to file include both defined benefit plans and
defined contribution plans.
The following are among the pension benefit plans for
which a return/report must be filed.
1. Profit-sharing plans, stock bonus plans, money purchase
plans, 401(k) plans, etc.
2. Annuity arrangements under Code section 403(b)(1) and
custodial accounts established under Code section 403(b)(7)
for regulated investment company stock. For more information
regarding filing requirements for 403(b) plans subject to Title I
of ERISA, see Field Assistance Bulletins 2009-02 and 201001.
3. Individual retirement accounts (IRAs) established by an
employer under Code section 408(c).
4. Church pension plans electing coverage under Code
section 410(d).
5. Pension benefit plans that cover residents of Puerto
Rico, the U.S. Virgin Islands, Guam, Wake Island, or American
Samoa. This includes a plan that elects to have the provisions
of section 1022(i)(2) of ERISA apply.
6. Plans that satisfy the Actual Deferral Percentage
requirements of Code section 401(k)(3)(A)(ii) by adopting the
‘‘SIMPLE’’ provisions of section 401(k)(11).
See What To File for more information about what must be
completed for pension plans.

How To Get Assistance
If you need help completing this form or have related
questions, call the EFAST2 Help Line at 1-866-GO-EFAST
(1-866-463-3278) (toll-free) or access the EFAST2 or IRS
websites. The EFAST2 Help Line is available Monday through
Friday from 8:00 am to 8:00 pm, Eastern Time.
You can access the EFAST2 website 24 hours a day, 7
days a week at www.efast.dol.gov to:

Do Not File a Form 5500 for a Pension Benefit
Plan That Is Any of the Following:

 File the Form 5500-SF or 5500, and any needed schedules
or attachments.
 Check on the status of a filing you submitted.
 View filings posted by EFAST2.
 Register for electronic credentials to sign or submit filings.
 View forms and related instructions.
 Get information regarding EFAST2, including approved
software vendors.
 See answers to frequently asked questions about the Form
5500-SF, the Form 5500 and its schedules, and EFAST2.
 Access the main EBSA and DOL websites for news,
regulations, and publications.
You can access the IRS website 24 hours a day, 7 days a
week at www.irs.gov to:

1. An unfunded excess benefit plan. See ERISA section
4(b)(5).
2. An annuity or custodial account arrangement under Code
sections 403(b)(1) or (7) not established or maintained by an
employer as described in DOL Regulation 29 CFR 2510.3-2(f).
3. A Savings Incentive Match Plan for Employees of Small
Employers (SIMPLE) that involves SIMPLE IRAs under Code
section 408(p).
4. A simplified employee pension (SEP) or a salary
reduction SEP described in Code section 408(k) that conforms
to the alternative method of compliance in 29 CFR 2520.10448 or 2520.104-49. A SEP is a pension plan that meets certain
minimum qualifications regarding eligibility and employer
contributions.
5. A church pension benefit plan not electing coverage
under Code section 410(d).
6. A pension plan that is maintained outside the United
States primarily for the benefit of persons substantially all of
whom are nonresident aliens. However, certain foreign plans
are required to file the Form 5500-EZ with the IRS or may file
the Form 5500-SF, Short Form Annual Return/Report of
Employee Benefit Plan, electronically with EFAST2. See the

 View forms, instructions, and publications.
 See answers to frequently asked tax questions.
 Search publications on-line by topic or keyword.
 Send comments or request help by e-mail.
 Sign up to receive local and national tax news by e-mail.
You can order other IRS forms and publications by calling
1-800-TAX-FORM (1-800-829-3676). You can order EBSA
publications by calling 1-866-444-EBSA (3272).
General Instructions to Form 5500

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instructions to the Form 5500-EZ for the filing requirements.
For more information, go to www.irs.gov/ep or call 1-877-8295500.
7. An unfunded pension plan for a select group of
management or highly compensated employees that meets the
requirements of 29 CFR 2520.104-23, including timely filing of
a registration statement with the DOL.
8. An unfunded dues financed pension benefit plan that
meets the alternative method of compliance provided by 29
CFR 2520.104-27.
9. An individual retirement account or annuity not
considered a pension plan under 29 CFR 2510.3-2(d).
10. A governmental plan.
11. A “one-participant plan,” as defined below. However,
certain one-participant plans are required to file the Form
5500-EZ, Annual Return of One-Participant (Owners and Their
Spouses) Retirement Plan with the IRS or, if eligible, may file
the Form 5500-SF, Short Form Annual Return/Report of
Employee Benefit Plan, electronically with EFAST2. For this
purpose, a “one-participant plan” is:
a. a pension benefit plan that covers only an individual or
an individual and his or her spouse who wholly own a trade or
business, whether incorporated or unincorporated; or
b. a pension benefit plan for a partnership that covers only
the partners or the partners and the partners’ spouses.
See the instructions to the Form 5500-EZ and the Form 5500SF for eligibility conditions and filing requirements. For more
information, go to www.irs.gov/ep or call 1-877-829-5500.

be treated for annual reporting purposes as an unfunded
welfare plan if it meets the requirements of DOL Technical
Release 92-01, 57 Fed. Reg. 23272 (June 2, 1992) and 58
Fed. Reg. 45359 (Aug. 27, 1993). The mere receipt of COBRA
contributions or other after-tax participant contributions (e.g.,
retiree contributions) by a cafeteria plan would not by itself
affect the availability of the relief provided for cafeteria plans
that otherwise meet the requirements of DOL Technical
Release 92-01. See 61 Fed. Reg. 41220, 41222-23 (Aug. 7,
1996).
b. A fully insured welfare benefit plan has its benefits
provided exclusively through insurance contracts or policies,
the premiums of which must be paid directly to the insurance
carrier by the employer or employee organization from its
general assets or partly from its general assets and partly from
contributions by its employees or members (which the
employer or employee organization forwards within three (3)
months of receipt). The insurance contracts or policies
discussed above must be issued by an insurance company or
similar organization (such as Blue Cross, Blue Shield or a
health maintenance organization) that is qualified to do
business in any state.
c. A combination unfunded/insured welfare benefit plan has
its benefits provided partially as an unfunded plan and partially
as a fully insured plan. An example of such a plan is a welfare
benefit plan that provides medical benefits as in a above and
life insurance benefits as in b above. See 29 CFR 2520.10420.
2. A welfare benefit plan maintained outside the United
States primarily for persons substantially all of whom are
nonresident aliens.
3. A governmental plan.
4. An unfunded or insured welfare benefit plan maintained
for a select group of management or highly compensated
employees, which meets the requirements of 29 CFR
2520.104-24.
5. An employee benefit plan maintained only to comply with
workers’ compensation, unemployment compensation, or
disability insurance laws.
6. A welfare benefit plan that participates in a group
insurance arrangement that files a Form 5500 on behalf of the
welfare benefit plan as specified in 29 CFR 2520.103-2. See
29 CFR 2520.104-43.
7. An apprenticeship or training plan meeting all of the
conditions specified in 29 CFR 2520.104-22.
8. An unfunded dues financed welfare benefit plan
exempted by 29 CFR 2520.104-26.
9. A church plan under ERISA section 3(33).
10. A welfare benefit plan maintained solely for (1) an
individual or an individual and his or her spouse, who wholly
own a trade or business, whether incorporated or
unincorporated, or (2) partners or the partners and the
partners’ spouses in a partnership. See 29 CFR 2510.3-3(b).

Welfare Benefit Plan
All welfare benefit plans covered by ERISA are required to file
a Form 5500 except as provided in this section. Welfare benefit
plans provide benefits such as medical, dental, life insurance,
apprenticeship and training, scholarship funds, severance pay,
disability, etc. See What To File for more information.
Reminder: The administrator of an employee welfare benefit
plan that provides benefits wholly or partially through a
Multiple-Employer Welfare Arrangement (MEWA) as defined in
ERISA section 3(40) must file a Form 5500, unless otherwise
exempt. Plans required to file a Form M-1, Report for MultipleEmployer Welfare Arrangements (MEWAs) and Certain
Entities Claiming Exception (ECEs), are not eligible for the
filing exemption in 29 CFR 2520.104-20 described below.
Such plans are required to file the Form 5500 regardless of the
plan size or type of funding.

Do Not File a Form 5500 for a Welfare Benefit
Plan That Is Any of the Following:
1. A welfare benefit plan that covered fewer than 100
participants as of the beginning of the plan year and is
unfunded, fully insured, or a combination of insured and
unfunded, as specified in 29 CFR 2520.104-20.
Note. To determine whether the plan covers fewer than 100
participants for purposes of these filing exemptions for insured
and unfunded welfare plans, see instructions for lines 5 and 6
on counting participants in a welfare plan. See also 29 CFR
2510.3-3(d).
a. An unfunded welfare benefit plan has its benefits paid as
needed directly from the general assets of the employer or
employee organization that sponsors the plan.
Note. Plans that are NOT unfunded include those plans that
received employee (or former employee) contributions during
the plan year and/or used a trust or separately maintained fund
(including a Code section 501(c)(9) trust) to hold plan assets or
act as a conduit for the transfer of plan assets during the year.
A welfare benefit plan with employee contributions that is
associated with a cafeteria plan under Code section 125 may

Direct Filing Entity (DFE)
Some plans participate in certain trusts, accounts, and other
investment arrangements that file the Form 5500 annual
return/report as a DFE in accordance with the Direct Filing
Entity (DFE) Filing Requirements. A Form 5500 must be filed
for a master trust investment account (MTIA). A Form 5500 is
not required but may be filed for a common/collective trust
(CCT), pooled separate account (PSA), 103-12 investment
entity (103-12 IE), or group insurance arrangement (GIA).
Plans that participate in CCTs, PSAs, 103-12 IEs, or GIAs that
file as DFEs, however, generally are eligible for certain annual
reporting relief. For reporting purposes, a CCT, PSA,
103-12 IE, or GIA is not considered a DFE unless a Form 5500
and all required attachments are filed for it in accordance with
the Direct Filing Entity (DFE) Filing Requirements.
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General Instructions to Form 5500

Note. Special requirements also apply to Schedules D and H
attached to the Form 5500 filed by plans participating in
MTIAs, CCTs, PSAs, and 103-12 IEs. See these schedules
and their instructions.

be extended further by filing a Form 5558, nor can it be
extended beyond a total of 9½ months beyond the close of the
plan year.
Note. An extension of time to file the Form 5500 does not
operate as an extension of time to file a Form 5500 filed for a
DFE (other than a GIA), to file PBGC premiums or annual
financial and actuarial reports (if required by section 4010 of
ERISA) or to file the Form 8955-SSA (Annual Registration
Statement Identifying Separated Participants with Deferred
Vested Benefits) (required to be filed with the IRS under Code
section 6057(a)).

Section 2: When To File
Plans and GIAs. File 2014 2015 returns/reports for plan and
GIA years that began in 20142015. All required forms,
schedules, statements, and attachments must be filed by the
last day of the 7th calendar month after the end of the plan or
GIA year (not to exceed 12 months in length) that began in
20142015. If the plan or GIA year differs from the 2014 2015
calendar year, fill in the fiscal year beginning and ending dates
in the space provided.
DFEs other than GIAs. File 2014 2015 returns/reports no later
than 9½ months after the end of the DFE year that ended in
20142015. A Form 5500 filed for a DFE must report
information for the DFE year (not to exceed 12 months in
length). If the DFE year differs from the 2014 2015 calendar
year, fill in the fiscal year beginning and ending dates in the
space provided.
Short Years. For a plan year of less than 12 months (short
plan year), file the form and applicable schedules by the last
day of the 7th calendar month after the short plan year ends or
by the extended due date, if filing under an authorized
extension of time. Fill in the short plan year beginning and
ending dates in the space provided and check the appropriate
box in Part I, line B, of the Form 5500. For purposes of this
return/report, the short plan year ends on the date of the
change in accounting period or upon the complete distribution
of assets of the plan. Also see the instructions for Final Return/
Report to determine if “the final return/report” box in line B
should be checked.
Notes. (1) If the filing due date falls on a Saturday, Sunday, or
Federal holiday, the return/report may be filed on the next day
that is not a Saturday, Sunday, or Federal holiday. (2) If the
2015 2016 Form 5500 is not available before the plan or DFE
filing is due, use the 2014 2015 Form 5500 and enter the 2015
2016 fiscal year beginning and ending dates on the line
provided at the top of the form.

Other Extensions of Time
The IRS, DOL, and PBGC may announce special extensions
of time under certain circumstances, such as extensions for
Presidentially-declared disasters or for service in, or in support
of, the Armed Forces of the United States in a combat zone.
See www.irs.gov, www.efast.dol.gov, and
www.pbgc.gov/practitioners for announcements regarding such
special extensions. If you are relying on one of these
announced special extensions, check the appropriate box on
Form 5500, Part I, line D, and enter a description of the
announced authority for the extension.

Delinquent Filer Voluntary Compliance (DFVC)
Program
The DFVC Program facilitates voluntary compliance by plan
administrators who are delinquent in filing annual reports under
Title I of ERISA by permitting administrators to pay reduced
civil penalties for voluntarily complying with their DOL annual
reporting obligations. If the Form 5500 is being filed under the
DFVC Program, check the appropriate box in Form 5500, Part
I, line D, to indicate that the Form 5500 is being filed under the
DFVC Program. See www.efast.dol.gov for additional
information.
Plan administrators are reminded that they can use the
online calculator available at
www.dol.gov/ebsa/calculator/dfvcpmain.html to compute the
penalties due under the program. Payments under the DFVC
Program also may be submitted electronically. For information
on how to pay DFVC Program payments online, go to
www.dol.gov/ebsa.
Filers who wish to participate in the DFVC Program for
plan years prior to 2011 2012 must use the 2014 2015
version of Form 5500 or, if applicable, Form 5500-SF.
Use the Form 5500 Version Selection Tool available at
www.efast.dol.gov for further information.

Extension of Time To File
Using Form 5558
A plan or GIA may obtain a one-time extension of time to file a
Form 5500 annual return/report (up to 2½ months) by filing IRS
Form 5558, Application for Extension of Time To File Certain
Employee Plan Returns, on or before the normal due date (not
including any extensions) of the return/report. You MUST file
Form 5558 with the IRS. Approved copies of the Form 5558
will not be returned to the filer. A copy of the completed
extension request must, however, be retained with the filer’s
records.
File Form 5558 with the Department of the Treasury,
Internal Revenue Service Center, Ogden, UT 84201-0045.

Section 3: Electronic Filing Requirement
Under the computerized ERISA Filing Acceptance System
(EFAST2), you must file your 2014 2015 Form 5500 annual
return/ report electronically. You may file online using
EFAST2’s web-based filing system or you may file through an
EFAST2-approved vendor. Detailed information on electronic
filing is available at www.efast.dol.gov. For telephone
assistance, call the EFAST2 Help Line at 1-866-GO-EFAST (1866-463-3278). The EFAST2 Help Line is available Monday
through Friday from 8:00 am to 8:00 pm, Eastern Time.
Annual returns/reports filed under Title I of ERISA
must be made available by plan administrators to plan
participants and beneficiaries and by the DOL to the
public pursuant to ERISA sections 104 and 106. Even
though the Form 5500 must be filed electronically, the
administrator must keep a copy of the Form 5500, including
schedules and attachments, with all required signatures on file
as part of the plan’s records and must make a paper copy
available upon request to participants, beneficiaries, and the

Using Extension of Time To File Federal Income Tax
Return
An automatic extension of time to file the Form 5500 annual
return/report until the due date of the federal income tax return
of the employer will be granted if all of the following conditions
are met: (1) the plan year and the employer’s tax year are the
same; (2) the employer has been granted an extension of time
to file its federal income tax return to a date later than the
normal due date for filing the Form 5500; and (3) a copy of the
application for extension of time to file the federal income tax
return is maintained with the filer’s records. An extension
granted by using this automatic extension procedure CANNOT
General Instructions to Form 5500

-5-

DOL as required by section 104 of ERISA and 29 CFR
2520.103-1. Filers may use electronic media for record
maintenance and retention, so long as they meet the
applicable requirements.
Generally, questions on the Form 5500 relate to the plan
year entered at the top of the first page of the form. Therefore,
answer all questions on the 2014 2015 Form 5500 with respect
to the 2014 2015 plan year unless otherwise explicitly stated in
the instructions or on the form itself.
Your entries must be in the proper format in order for the
EFAST2 system to process your filing. For example, if a
question requires you to enter a dollar amount, you cannot
enter a word. Your software will not let you submit your return/
report unless all entries are in the proper format. To reduce the
possibility of correspondence and penalties:

attempt to correct and resolve any errors or warnings listed in
the status report.
Note. Even after being received by the EFAST2 system, your
return/report filing may be subject to further detailed review by
DOL, IRS, and/or PBGC, and your filing may be deemed
deficient based upon this further review. See Penalties on
Page 6.
Do not enter social security numbers in response to
questions asking for an employer identification
number (EIN). Because of privacy concerns, the
inclusion of a social security number or any portion thereof on
the Form 5500 or on a schedule or attachment that is open to
public inspection may result in the rejection of the filing. If you
discover a filing disclosed on the EFAST2 website that
contains a social security number, immediately call the
EFAST2 Help Line at 1-866-GO-EFAST (1-866-463-3278).
Employers without an EIN must apply for one as soon as
possible. The EBSA does not issue EINs. To apply for an EIN
from the IRS:

 Complete all lines on the Form 5500 unless otherwise
specified. Also complete and electronically attach, as required,
applicable schedules and attachments.
 Do not enter “N/A” or “Not Applicable” on the Form 5500
unless specifically permitted. “Yes” or “No” questions on the
forms and schedules cannot be left blank, unless specifically
permitted. Answer either “Yes” or “No,” but not both.
All schedules and attachments to the Form 5500 must be
properly identified, and must include the name of the plan or
DFE, EIN, and plan number (PN) as found on the Form 5500,
lines, 1a, 2b, and 1b, respectively. At the top of each
attachment, indicate the schedule and line, if any (e.g.,
Schedule H, line 4i) to which the attachment relates.
Check your return/report for errors before signing or
submitting it to EFAST2. Your filing software or, if you are
using it, the EFAST2 web-based filing system will allow you to
check your return/report for errors. If, after reasonable attempts
to correct your filing to eliminate any identified problem or
problems, you are unable to address them, or you believe that
you are receiving the message in error, call the EFAST2 Help
Line at 1-866-GO-EFAST (1-866-463-3278) or contact the
service provider you used to help prepare and file your annual
return/report.
Once you complete the return/report and finish the
electronic signature process, you can electronically submit it to
EFAST2. When you electronically submit your return/report,
EFAST2 is designed to immediately notify you if your
submission was received and whether the return/report is
ready to be processed by EFAST2. If EFAST2 does not notify
you that your submission was successfully received and is
ready to be processed, you will need to take steps to correct
the problem or you may be deemed a non-filer subject to
penalties from DOL, IRS, and/or PBGC.
Once EFAST2 receives your return/report, the EFAST2
system should be able to provide a filing status within 20
minutes. The person submitting the filing should check back
into the EFAST2 system to determine the filing status of your
return/report. The filing status message will include a list of any
filing errors or warnings that EFAST2 may have identified in
your filing. If EFAST2 did not identify any filing errors or
warnings, EFAST2 will show the filing status of your return/
report as “Filing_Received.” Persons other than the submitter
can check whether the filing was received by the system by
calling the EFAST2 Help Line at 1-866-GO-EFAST (1-866-4633278) and using the automated telephone system.
To reduce the possibility of correspondence and penalties
from the DOL, IRS, and/or PBGC, you should do the following:
(1) Before submitting your return/report to EFAST2, check it for
errors, and (2) after you have submitted it to EFAST2, verify
that you have received a filing status of “Filing Received” and

 Mail or fax Form SS-4, Application for Employer Identification
Number, obtained by calling 1-800-TAX-FORM (1-800-8293676) or at the IRS website at www.irs.gov.
 Call 1-800-829-4933 to receive your EIN by telephone.
 Select the Online EIN Application link at www.irs.gov. The
EIN is issued immediately once the application information is
validated. (The online application process is not yet available
for corporations with addresses in foreign countries).
Do not attach a copy of the annual registration statement (IRS
Form 8955-SSA) identifying separated participants with
deferred vested benefits, or a previous year’s Schedule SSA
(Form 5500) to your 2014 2015 Form 5500 annual
return/report. The annual registration statement must be filed
directly with the IRS and cannot be attached to a Form 5500
submission with EFAST2.

Amended Return/Report
File an amended return/report to correct errors and/or
omissions in a previously filed annual return/report for the 2014
2015 plan year. The amended Form 5500 and any amended
schedules and/or attachments must conform to the
requirements in these instructions. See the DOL website at
www.efast.dol.gov for information on filing amended returns/
reports for prior years.
Check the line B box for “an amended return/report” if
you filed a previous 2014 2015 annual return/report
that was given a “Filing_Received,” “Filing_Error,” or
“Filing_Stopped” status by EFAST2. Do not check the line B box
for “an amended return/report” if your previous submission
attempts were not successfully received by EFAST2 because of
problems with the transmission of your return/report. For more
information, go to the EFAST2 website at www.efast.dol.gov or
call the EFAST2 Help Line at 1-866-GO-EFAST (1-866-4633278).

Final Return/Report
If all assets under the plan (including insurance/annuity
contracts) have been distributed to the participants and
beneficiaries or legally transferred to the control of another
plan, and when all liabilities for which benefits may be paid
under a welfare benefit plan have been satisfied, check the
final return/report box in Part I, line B at the top of the Form
5500. Do not mark the final return/report box if you are
reporting participants and/or assets at the end of the plan year.
If a trustee is appointed for a terminated defined benefit plan
pursuant to ERISA section 4042, the last plan year for which a
return/report must be filed is the year in which the trustee is

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General Instructions to Form 5500

Note. The Code permits either the plan sponsor/employer or
the administrator to sign the filing. However, any Form 5500
that is not electronically signed by the plan administrator will be
subject to rejection and civil penalties under Title I of ERISA.
For DFE filings, a person authorized to sign on behalf of the
DFE must sign for the DFE.
The Form 5500 annual return/report must be filed
electronically and signed. To obtain an electronic signature, go
to www.efast.dol.gov and register in EFAST2 as a signer. You
will be provided with a UserID and PIN. Both the UserID and
PIN are needed to sign the Form 5500. The plan administrator
must keep a copy of the Form 5500, including schedules and
attachments with all required signatures on file as part of the
plan’s records. See 29 CFR 2520.103-1.
Electronic signatures on annual returns/reports filed under
EFAST2 are governed by the applicable statutory and
regulatory requirements.
Preparer Information (optional)

appointed. If you are in this situation you may contact
[email protected] for further information.

Examples:
Mergers/Consolidations
A final return/report should be filed for the plan year (12
months or less) that ends when all plan assets were legally
transferred to the control of another plan.

Pension and Welfare Plans That Terminated Without
Distributing All Assets
If the plan was terminated, but all plan assets were not
distributed, a return/report must be filed for each year the plan
has assets. The return/report must be filed by the plan
administrator, if designated, or by the person or persons who
actually control the plan’s assets/property.

Welfare Plans Still Liable To Pay Benefits
A welfare plan cannot file a final return/report if the plan is still
liable to pay benefits for claims that were incurred prior to the
termination date, but not yet paid. See 29 CFR 2520.104b2(g)(2)(ii).

You may optionallymust enter the “Preparer’s name (including
firm’s name, if applicable), address, and telephone number” at
the bottom of the first page of Form 5500. A preparer is any
person who prepares an annual return/report for
compensation, or who employs one or more persons to
prepare for compensation. If the person who prepared the
annual return/report is not the employer named in line 2a or the
plan administrator named in line 3a, you may name the person
on this line. If there are several people who prepare Form 5500
and applicable schedules, please name the person who is
primarily responsible for the preparation of the annual
return/report.
Note. Although preparer’s name, address, and phone number
are optional, the IRS encourages filers to provide preparer
information on these lines. Treasury regulations require all paid
tax return preparers to obtain the Paid Preparer Tax
Identification Numbers (PTINs) and put the PTIN on all tax
forms. However, the Form 5500 series, at this time, is not
subject to the PTIN requirements of section 1.6109-2 of the
Treasury regulations.

Signature and Date
For purposes of Title I of ERISA, the plan administrator is
required to file the Form 5500. If the plan administrator does
not sign a filing, the filing status will indicate that there is an
error with your filing, and your filing will be subject to further
review, correspondence, rejection, and civil penalties.
The plan administrator must electronically sign the Form 5500
or 5500-SF submitted to EFAST2.
After submitting your filing, you must check the Filing
Status. If the filing status is "Processing Stopped" or
“Unprocessable”, it is possible your submission was
not sent with a valid electronic signature as required, and
depending on the error, may be considered not to have been
filed. By looking closer at the Filing Status, you can see
specific error messages applicable to the transmitted filing and
determine whether it was sent with a valid electronic signature
and what other errors may need to be corrected.
Note. If the plan administrator is an entity, the electronic
signature must be in the name of a person authorized to sign
on behalf of the plan administrator.
Authorized Service Provider Signatures. If the plan
administrator elects to have a service provider who manages
the filing process for the plan get EFAST2 signing credentials
and submit the electronic Form 5500 for the plan: 1) the
service provider must receive specific written authorization
from the plan administrator to submit the plan’s electronic filing;
2) the plan administrator must manually sign a paper copy of
the electronically completed Form 5500, and the service
provider must include a PDF copy of the first two pages of the
manually signed Form 5500 as an attachment to the electronic
Form 5500 submitted to EFAST2; 3) the service provider must
communicate to the plan administrator any inquiries received
from EFAST2, DOL, IRS or PBGC regarding the filing; 4) the
service provider must communicate to the plan administrator
that, by electing to use this option, the image of the plan
administrator’s manual signature will be included with the rest
of the return/report posted by the Labor Department on the
Internet for public disclosure; and 5) the plan administrator
must keep the manually signed copy of the Form 5500, with all
required schedules and attachments, as part of the plan’s
records. For more information on the electronic signature
option, see the EFAST2 All-Electronic Filing System FAQs at
www.dol.gov/ebsa/faqs/faq-EFAST2.html.
Service providers should consider implications of IRS
tax return preparer rules.
General Instructions to Form 5500

Change in Plan Year
Generally, only defined benefit pension plans need to get
approval for a change in the plan year. See Code section
412(d)(1). However, under Rev. Proc. 87-27, 1987-1 C.B. 769,
these pension plans may be eligible for automatic approval of a
change in plan year.
If a change in plan year for a pension or welfare benefit plan
creates a short plan year, file the form and applicable
schedules by the last day of the 7th calendar month after the
short plan year ends or by the extended due date, if filing
under an authorized extension of time. Fill in the short plan
year beginning and ending dates in the space provided in Part
I and check the appropriate box in Part I, line B of the Form
5500. For purposes of this return/report, the short plan year
ends on the date of the change in accounting period or upon
the complete distribution of assets of the plan. Also, see the
instructions for the Final Return/Report to determine if “final
return/report” in line B should be checked.

Penalties
Plan administrators and plan sponsors must provide complete
and accurate information and must otherwise comply fully with
the filing requirements. ERISA and the Code provide for the
DOL and the IRS, respectively, to assess or impose penalties
for not giving complete and accurate information and for not
filing complete and accurate statements and returns/reports.
Certain penalties are administrative (i.e., they may be imposed
or assessed by one of the governmental agencies delegated to
-7-

following the requirements below for a “small plan,” and a
return/report filed for a plan that covered 100 or more
participants as of the beginning of the plan year should be
completed following the requirements below for a “large plan.”
Use the number of participants required to be entered in line
5 of the Form 5500 to determine whether a plan is a “small
plan” or “large plan.”

administer the collection of the annual return/report data).
Others require a legal conviction.

Administrative Penalties
Listed below are various penalties under ERISA and the Code
that may be assessed or imposed for not meeting the annual
return/report filing requirements. Generally, whether the
penalty is under ERISA or the Code, or both, depends upon
the agency for which the information is required to be filed.
One or more of the following administrative penalties may be
assessed or imposed in the event of incomplete filings or filings
received after the due date unless it is determined that your
failure to file properly is for reasonable cause:
1. A penalty of up to $1,100 a day (or higher amount if
adjusted pursuant to the Federal Civil Penalties Inflation
Adjustment Act of 1990, as amended) for each day a plan
administrator fails or refuses to file a complete and accurate
report. See ERISA section 502(c)(2) and 29 CFR 2560.502c-2.
2. A penalty of $25 a day (up to $15,000) for not filing
returns for certain plans of deferred compensation, trusts and
annuities, and bond purchase plans by the due date(s). See
Code section 6652(e).
3. A penalty of $1,000 for each failure to file an actuarial
statement (Schedule MB (Form 5500) or Schedule SB (Form
5500)) required by the applicable instructions. See Code
section 6692.

Exceptions:
(1) 80-120 Participant Rule: If the number of participants
reported on line 5 is between 80 and 120, and a Form 5500
annual return/report was filed for the prior plan year, you may
elect to complete the return/report in the same category (‘‘large
plan’’ or ‘‘small plan’’) as was filed for the prior return/report.
Thus, if a Form 5500-SF or a Form 5500 annual return/report
was filed for the 2013 2014 plan year as a small plan, including
the Schedule I if applicable, and the number entered on line 5
of the 2014 2015 Form 5500 is 120 or less, you may elect to
complete the 2014 2015 Form 5500 and schedules in
accordance with the instructions for a small plan, including for
eligible filers, filing the Form 5500-SF instead of the Form
5500.
(2) Short Plan Year Rule: If the plan had a short plan year
of seven (7) months or less for either the prior plan year or the
plan year being reported on the 2014 2015 Form 5500, an
election can be made to defer filing the accountant’s report in
accordance with 29 CFR 2520.104-50. If such an election was
made for the prior plan year, the 2014 2015 Form 5500 must
be completed following the requirements for a large plan,
including the attachment of the Schedule H and the
accountant’s reports, regardless of the number of participants
entered in Part II, line 5.

Other Penalties
1. Any individual who willfully violates any provision of Part
1 of Title I of ERISA shall on conviction be fined not more than
$100,000 or imprisoned not more than 10 years, or both. See
ERISA section 501.
2. A penalty up to $10,000, five (5) years imprisonment, or
both, may be imposed for making any false statement or
representation of fact, knowing it to be false, or for knowingly
concealing or not disclosing any fact required by ERISA. See
section 1027, Title 18, U.S. Code, as amended by section 111
of ERISA.

Form 5500 Schedules
Pension Schedules
Schedule R (Retirement Plan Information) – is required for a
pension benefit plan that is a defined benefit plan or is
otherwise subject to Code section 412 or ERISA section 302.
Schedule R may also be required for certain other pension
benefit plans unless otherwise specified under limited Pension
Plan Reporting. For additional information, see the Schedule R
instructions.
Schedule MB (Multiemployer Defined Benefit Plan and
Certain Money Purchase Plan Actuarial Information) – is
required for most multiemployer defined benefit plans and for
defined contribution pension plans that currently amortize a
waiver of the minimum funding requirements specified in the
instructions for the Schedule MB. For additional information,
see the instructions for the Schedule MB and the Schedule R.
Schedule SB (Single-Employer Defined Benefit Plan
Actuarial Information) – is required for most single-employer
defined benefit plans, including multiple-employer defined
benefit pension plans. For additional information, see the
instructions for the Schedule SB.

Section 4: What To File
The Form 5500 reporting requirements vary depending on
whether the Form 5500 is being filed for a ‘‘large plan,’’ a
‘‘small plan,’’ and/or a DFE, and on the particular type of plan
or DFE involved (e.g., welfare plan, pension plan,
common/collective trust (CCT), pooled separate account
(PSA), master trust investment account (MTIA), 103-12 IE, or
group insurance arrangement (GIA)).
The instructions below provide detailed information about
each of the Form 5500 schedules and which plans and DFEs
are required to file them.
The schedules are grouped in the instructions by type:
(1) Pension Benefit Schedules and (2) General Schedules.
Each schedule is listed separately with a description of the
subject matter covered by the schedule and the plans and
DFEs that are required to file the schedule.
Filing requirements also are listed by type of filer:
(1) Pension Benefit Plan Filing Requirements; (2) Welfare
Benefit Plan Filing Requirements; and (3) DFE Filing
Requirements. For each filer type there is a separate list of the
schedules that must be filed with the Form 5500 (including
where applicable, separate lists for large plan filers, small plan
filers, and different types of DFEs).
The filing requirements also are summarized in a “Quick
Reference Chart of Form 5500, Schedules, and Attachments.”

General Schedules
Schedule H (Financial Information) – is required for pension
benefit plans and welfare benefit plans filing as “large plans”
and for all DFE filings. Employee benefit plans, 103-12 IEs,
and GIAs filing the Schedule H are generally required to
engage an independent qualified public accountant (IQPA) and
attach a report of the IQPA pursuant to ERISA section
103(a)(3)(A). These plans and DFEs are also generally
required to attach to the Form 5500 a “Schedule of Assets
(Held At End of Year),” and, if applicable, a “Schedule of
Assets (Acquired and Disposed of Within Year),” a
“Schedule of Reportable Transactions,” and a “Schedule
of Delinquent Participant Contributions.” For additional

Generally, a return/report filed for a pension benefit plan or
welfare benefit plan that covered fewer than 100 participants
as of the beginning of the plan year should be completed
-8-

General Instructions to Form 5500

information, see the Schedule H instructions.
Exceptions: Insured, unfunded, or combination
unfunded/insured welfare plans, as described in 29 CFR
2520.104-44(b)(1) and certain pension plans and
arrangements, as described in 29 CFR 2520.104-44(b)(2) and
in Limited Pension Plan Reporting, are exempt from
completing the Schedule H.
Schedule I (Financial Information - Small Plan) – i s
required for all pension benefit plans and welfare benefit plans
filing the Form 5500 annual return/report, rather than the Form
5500-SF, as ‘‘small plans,’’ except for certain pension benefit
plans and arrangements described in 29 CFR 2520.10444(b)(2) and Limited Pension Plan Reporting. For additional
information, see the Schedule I instructions.
Note. A welfare plan that would have been eligible for the filing
exemption under 29 CFR 2520.104-20, but for the fact that it is
required to file a Form M-1, is exempt from completing a
Schedule I if it meets the requirements of 29 CFR 2520.10444(b)(1).
Schedule A (Insurance Information) – is required if any
benefits under an employee benefit plan are provided by an
insurance company, insurance service or other similar
organization (such as Blue Cross, Blue Shield, or a health
maintenance organization). This includes investment contracts
with insurance companies, such as guaranteed investment
contracts and pooled separate accounts. For additional
information, see the Schedule A instructions.
Note. Do not file Schedule A for Administrative Services Only
(ASO) contracts. Do not file Schedule A if a Schedule A is filed
for the contract as part of the Form 5500 filed directly by a
master trust investment account (MTIA) or 103-12 IE.
Schedule C (Service Provider Information) – is required for
a large plan, MTIA, 103-12 IE, or GIA if (1) any service
provider who rendered services to the plan or DFE during the
plan or DFE year received $5,000 or more in compensation,
directly or indirectly from the plan or DFE, or (2) an accountant
and/or enrolled actuary has been terminated. For additional
information, see the Schedule C instructions.
Schedule D (DFE/Participating Plan Information) – Part I is
required for a plan or DFE that invested or participated in any
MTIAs, 103-12 IEs, CCTs, and/or PSAs. Part II is required
when the Form 5500 is filed for a DFE. For additional
information, see the Schedule D instructions.
Schedule G (Financial Transaction Schedules) – is
required for a large plan, MTIA, 103-12 IE, or GIA when
Schedule H (Financial Information) lines 4b, 4c, and/or 4d are
checked ‘‘Yes.’’ Part I of the Schedule G reports loans or fixed
income obligations in default or classified as uncollectible. Part
II of the Schedule G reports leases in default or classified as
uncollectible. Part III of the Schedule G reports nonexempt
transactions. For additional information, see the Schedule G
instructions.

The following schedules (including any additional information
required by the instructions to the schedules) must be attached
to a Form 5500 filed for a small pension plan that is neither
exempt from filing nor is filing the Form 5500-SF:
1. Schedule A (as many as needed), to report insurance,
annuity, and investment contracts held by the plan.
2. Schedule D, Part I, to list any CCTs, PSAs, MTIAs, and
103-12 IEs in which the plan participated at any time during the
plan year.
3. Schedule I, to report small plan financial information,
unless exempt.
4. Schedule MB or SB, to report actuarial information, if
applicable.
5. Schedule R, to report retirement plan information, if
applicable.
If Schedule I, line 4k, is checked “No,” you must
attach the report of the independent qualified public
accountant (IQPA) or a statement that the plan is
eligible and elects to defer attaching the IQPA’s opinion
pursuant to 29 CFR 2520.104-50 in connection with a short
plan year of seven months or less.

Large Pension Plan
The following schedules (including any additional information
required by the instructions to the schedules) must be attached
to a Form 5500 filed for a large pension plan:
1. Schedule A (as many as needed), to report insurance,
annuity, and investment contracts held by the plan.
2. Schedule C, if applicable, to report information on service
providers and, if applicable, any terminated accountants or
enrolled actuaries.
3. Schedule D, Part I, to list any CCTs, PSAs, MTIAs, and
103-12 IEs in which the plan invested at any time during the
plan year.
4. Schedule G, to report loans or fixed income obligations in
default or determined to be uncollectible as of the end of the
plan year, leases in default or classified as uncollectible, and
nonexempt transactions, i.e., file Schedule G if Schedule H
(Form 5500) lines 4b, 4c, and/or 4d are checked ‘‘Yes.’’
5. Schedule H, to report large plan financial information,
unless exempt.
6. Schedule MB or SB, to report actuarial information, if
applicable.
7. Schedule R, to report retirement plan information, if
applicable.

Eligible Combined Plans

Pension benefit plan filers must complete the Form 5500
annual return/report, including the signature block and, unless
otherwise specified, attach the following schedules and
information:

Section 903 of PPA established rules for a new type of pension
plan, an “eligible combined plan,” effective for plan years
beginning after December 31, 2009. See Code section 414(x)
and ERISA section 210(e). An eligible combined plan consists
of a defined benefit plan and a defined contribution plan that
includes a qualified cash or deferred arrangement under Code
section 401(k), with the assets of the two plans held in a single
trust, but clearly identified and allocated between the plans.
The eligible combined plan design is available only to
employers that employed an average of at least two, but not
more than 500 employees, on business days during the
calendar year preceding the plan year as of which the eligible
combined plan is established and that employs at least two
employees on the first day of the plan year that the plan is
established. Because an eligible combined plan includes both
a defined benefit plan and a defined contribution plan, the
Form 5500 filed for the plan must include all the information,
schedules, and attachments that would be required for either a
defined benefit plan (such as a Schedule SB) or a defined
contribution plan.

Small Pension Plan

Limited Pension Plan Reporting

An unfunded, fully insured, or combination unfunded/
insured welfare plan with 100 or more participants
exempt under 29 CFR 2520.104-44 from completing
Schedule H must still complete Schedule G, Part III, to report
nonexempt transactions.

Pension Benefit Plan Filing
Requirements

General Instructions to Form 5500

-9-

The pension benefit plans or arrangements described below
are eligible for limited annual reporting:
1. IRA Plans: A pension plan using individual retirement
accounts or annuities (as described in Code section 408) as
the sole funding vehicle for providing pension benefits need
complete only Form 5500, Part I and Part II, lines 1 through 4,
and 8 (enter pension feature code 2N).
2. Fully Insured Pension Plan: A pension benefit plan
providing benefits exclusively through an insurance contract or
contracts that are fully guaranteed and that meet all of the
conditions of 29 CFR 2520.104-44(b)(2) during the entire plan
year must complete all the requirements listed under this
Pension Benefit Plan Filing Requirements section, except that
such a plan is exempt from attaching Schedule H, Schedule I,
and an independent qualified public accountant’s opinion, and
from the requirement to engage an IQPA.
A pension benefit plan that has insurance contracts of the
type described in 29 CFR 2520.104-44 as well as other assets
must complete all requirements for a pension benefit plan,
except that the value of the plan’s allocated contracts (see
below) should not be reported in Part I of Schedule H or I. All
other assets should be reported on Schedule H or Schedule I,
and any other required schedules. If Schedule H is filed, attach
an accountant’s report in accordance with the Schedule H
instructions.
Note. For purposes of the annual return/report and the
alternative method of compliance set forth in 29 CFR
2520.104-44, a contract is considered to be ‘‘allocated’’ only if
the insurance company or organization that issued the contract
unconditionally guarantees, upon receipt of the required
premium or consideration, to provide a retirement benefit of a
specified amount. This amount must be provided to each
participant without adjustment for fluctuations in the market
value of the underlying assets of the company or organization,
and each participant must have a legal right to such benefits,
which is legally enforceable directly against the insurance
company or organization. For example, deposit administration,
immediate participation guarantee, and guaranteed investment
contracts are NOT allocated contracts for Form 5500 annual
return/report purposes.

The following schedules (including any additional information
required by the instructions to the schedules) must be attached
to a Form 5500 filed for a large welfare plan:
1. Schedule A (as many as needed), to report insurance
and investment contracts held by the plan.
2. Schedule C, if applicable, to report information on service
providers and any terminated accountants or actuaries.
3. Schedule D, Part I, to list any CCTs, PSAs, MTIAs, and
103-12 IEs in which the plan invested at any time during the
plan year.
4. Schedule G, to report loans or fixed income obligations in
default or determined to be uncollectible as of the end of the
plan year, leases in default or classified as uncollectible, and
nonexempt transactions, i.e., file Schedule G if Schedule H
(Form 5500) lines 4b, 4c, and/or 4d are checked ‘‘Yes’’ or if a
large welfare plan that is not required to file a Schedule H has
nonexempt transactions.
5. Schedule H, to report financial information, unless exempt.
Attach the report of the independent qualified public
accountant (IQPA) identified on Schedule H, line 3c,
unless line 3d(2) is checked.
Neither Schedule H nor an IQPA’s opinion should be
attached to a Form 5500 filed for an unfunded, fully
insured or combination unfunded/insured welfare plan
that covered 100 or more participants as of the beginning of
the plan year that meets the requirements of 29 CFR
2520.104-44. However, Schedule G, Part III, must be attached
to the Form 5500 to report any nonexempt transactions. A
welfare benefit plan that uses a ‘‘voluntary employees’
beneficiary association’’ (VEBA) under Code section 501(c)(9)
is generally not exempt from the requirement of engaging an
IQPA.

Direct Filing Entity (DFE) Filing
Requirements
Some plans participate in certain trusts, accounts, and other
investment arrangements that file the Form 5500 annual
return/report as a DFE. A Form 5500 must be filed for a master
trust investment account (MTIA). A Form 5500 is not required
but may be filed for a common/collective trust (CCT), pooled
separate account (PSA), 103-12 investment entity (103-12 IE),
or group insurance arrangement (GIA). However, plans that
participate in CCTs, PSAs, 103-12 IEs, or GIAs that file as
DFEs generally are eligible for certain annual reporting relief.
For reporting purposes, a CCT, PSA, 103-12 IE, or GIA is
considered a DFE only when a Form 5500 and all required
schedules and attachments are filed for it in accordance with
the following instructions.
Only one Form 5500 should be filed for each DFE for all
plans participating in the DFE; however, the Form 5500 filed
for the DFE, including all required schedules and attachments,
must report information for the DFE year (not to exceed 12
months in length) that ends with or within the participating
plan’s year.
Any Form 5500 filed for a DFE is an integral part of the
annual report of each participating plan, and the plan
administrator may be subject to penalties for failing to file a
complete annual report unless both the DFE Form 5500 and
the plan’s Form 5500 are properly filed. The information
required for a Form 5500 filed for a DFE varies according to
the type of DFE. The following paragraphs provide specific
guidance for the reporting requirements for each type of DFE.

Welfare Benefit Plan Filing Requirements
Welfare benefit plan filers must complete the Form 5500
annual return/report, including the signature block and, unless
otherwise specified, attach the following schedules and
information:

Small Welfare Plan
The following schedules (including any additional information
required by the instructions to the schedules) must be attached
to a Form 5500 filed for a small welfare plan that is neither
exempt from filing nor filing the Form 5500-SF:
1. Schedule A (as many as needed), to report insurance
contracts held by the plan.
2. Schedule D, Part I, to list any CCTs, PSAs, MTIAs, and
103-12 IEs in which the plan participated at any time during the
plan year.
3. Schedule I, to report small plan financial information.
A welfare plan that covered fewer than 100
participants as of the beginning of the plan year and
is required to file a Form M-1, Report for MultipleEmployer Welfare Arrangements (MEWAs) and Certain
Entities Claiming Exception (ECEs), is exempt from attaching
Schedule I if the plan meets the requirements of 29 CFR
2520.104-44. However, Schedule G, Part III, must be attached
to the Form 5500 to report any nonexempt transactions.

Master Trust Investment Account (MTIA)
The administrator filing a Form 5500 for an employee benefit
plan is required to file or have a designee file a Form 5500 for
each MTIA in which the plan participated at any time during the

Large Welfare Plan
-10-

General Instructions to Form 5500

plan year. For reporting purposes, a ‘‘master trust’’ is a trust for
which a regulated financial institution (as defined below) serves
as trustee or custodian (regardless of whether such institution
exercises discretionary authority or control with respect to the
management of assets held in the trust), and in which assets of
more than one plan sponsored by a single employer or by a
group of employers under common control are held.
‘‘Common control’’ is determined on the basis of all relevant
facts and circumstances (whether or not such employers are
incorporated).
A ‘‘regulated financial institution’’ means a bank, trust
company, or similar financial institution that is regulated,
supervised, and subject to periodic examination by a state or
federal agency. A securities brokerage firm is not a ‘‘similar
financial institution’’ as used here. See DOL Advisory Opinion
93-21A (available at www.dol.gov/ebsa).
The assets of a master trust are considered for reporting
purposes to be held in one or more ‘‘investment accounts.’’ A
‘‘master trust investment account’’ may consist of a pool of
assets or a single asset. Each pool of assets held in a master
trust must be treated as a separate MTIA if each plan that has
an interest in the pool has the same fractional interest in each
asset in the pool as its fractional interest in the pool, and if
each such plan may not dispose of its interest in any asset in
the pool without disposing of its interest in the pool. A master
trust may also contain assets that are not held in such a pool.
Each such asset must be treated as a separate MTIA.
Notes. (1) If an MTIA consists solely of one plan’s asset(s)
during the reporting period, the plan may report the asset(s)
either as an investment account on an MTIA Form 5500, or as
a plan asset(s) that is not part of the master trust (and
therefore subject to all instructions concerning assets not held
in a master trust) on the plan’s Form 5500. (2) If a master trust
holds assets attributable to participant or beneficiary directed
transactions under an individual account plan and the assets
are interests in registered investment companies, interests in
contracts issued by an insurance company licensed to do
business in any state, interests in common/collective trusts
maintained by a bank, trust company or similar institution, or
the assets have a current value that is readily determinable on
an established market, those assets may be treated as a single
MTIA.
The Form 5500 submitted for the MTIA must comply with
the Form 5500 instructions for a Large Pension Plan, unless
otherwise specified in the forms and instructions. The MTIA
must file:
1. Form 5500, except lines C, D, 1c, 2d, and 5 through 9.
Be certain to enter ‘‘M’’ in Part I, line A, as the DFE code.
2. Schedule A (as many as needed) to report insurance,
annuity and investment contracts held by the MTIA.
3. Schedule C, if applicable, to report service provider
information. Part III is not required for an MTIA.
4. Schedule D, to list CCTs, PSAs, and 103-12 IEs in which
the MTIA invested at any time during the MTIA year and to list
all plans that participated in the MTIA during its year.
5. Schedule G, to report loans or fixed income obligations in
default or determined to be uncollectible as of the end of the
MTIA year, all leases in default or classified as uncollectible,
and nonexempt transactions.
6. Schedule H, except lines 1b(1), 1b(2), 1c(8), 1g, 1h, 1i,
2a, 2b(1)(E), 2e, 2f, 2g, 4a, 4e, 4f, 4g, 4h, 4k, 4l, 4m, 4n, and
5, to report financial information. An independent qualified
public accountant’s (IQPA’s) opinion is not required for an
MTIA.
7. Additional information required by the instructions to the
above schedules, including, for example, the schedules of
assets held for investment and the schedule of reportable
transactions. For purposes of the schedule of reportable
General Instructions to Form 5500

transactions, the 5% figure shall be determined by comparing
the current value of the transaction at the transaction date with
the current value of the investment account assets at the
beginning of the applicable fiscal year of the MTIA. All
attachments must be properly labeled.

Common/Collective Trust (CCT) and Pooled
Separate Account (PSA)
A Form 5500 is not required to be filed for a CCT or PSA.
However, the administrator of a large plan or DFE that
participates in a CCT or PSA that files as specified below is
entitled to reporting relief that is not available to plans or DFEs
participating in a CCT or PSA for which a Form 5500 is not
filed.
For reporting purposes, ‘‘common/collective trust’’ and
‘‘pooled separate account’’ are, respectively: (1) a trust
maintained by a bank, trust company, or similar institution or
(2) an account maintained by an insurance carrier, which is
regulated, supervised, and subject to periodic examination by a
state or federal agency in the case of a CCT, or by a state
agency in the case of a PSA, for the collective investment and
reinvestment of assets contributed thereto from employee
benefit plans maintained by more than one employer or
controlled group of corporations as that term is used in Code
section 1563. See 29 CFR 2520.103-3, 103-4, 103-5, and
103-9.
Note. For reporting purposes, a separate account that is not
considered to be holding plan assets pursuant to 29 CFR
2510.3-101(h)(1)(iii) does not constitute a pooled separate
account.
The Form 5500 submitted for a CCT or PSA must comply
with the Form 5500 instructions for a Large Pension Plan,
unless otherwise specified in the forms and instructions.
The CCT or PSA must file:
1. Form 5500, except lines C, D, 1c, 2d, and 5 through 9.
Enter ‘‘C’’ or ‘‘P,’’ as appropriate, in Part I, line A, as the DFE
code.
2. Schedule D, to list all CCTs, PSAs, MTIAs, and
103-12 IEs in which the CCT or PSA invested at any time
during the CCT or PSA year and to list in Part II all plans that
participated in the CCT or PSA during its year.
3. Schedule H, except lines 1b(1), 1b(2), 1c(8), 1d, 1e, 1g,
1h, 1i, 2a, 2b(1)(E), 2e, 2f, and 2g, to report financial
information. Part IV and an accountant’s (IQPA’s) opinion are
not required for a CCT or PSA.
Different requirements apply to the Schedules D and H
attached to the Form 5500 filed by plans and DFEs
participating in CCTs and PSAs, depending upon
whether a DFE Form 5500 has been filed for the CCT or PSA.
See the instructions for these schedules.

103-12 Investment Entity (103-12 IE)
DOL Regulation 2520.103-12 provides an alternative method
of reporting for plans that invest in an entity (other than an
MTIA, CCT, or PSA), whose underlying assets include ‘‘plan
assets’’ within the meaning of 29 CFR 2510.3-101 of two or
more plans that are not members of a ‘‘related group’’ of
employee benefit plans. Such an entity for which a Form 5500
is filed constitutes a ‘‘103-12 IE.’’ A Form 5500 is not required
to be filed for such entities; however, filing a Form 5500 as a
103-12 IE provides certain reporting relief, including the
limitation of the examination and report of the independent
qualified public accountant (IQPA) provided by 29 CFR
2520.103-12(d), to participating plans and DFEs. For this
reporting purpose, a ‘‘related group’’ of employee benefit plans
consists of each group of two or more employee benefit plans
-11-

(1) each of which receives 10% or more of its aggregate
contributions from the same employer or from a member of the
same controlled group of corporations (as determined under
Code section 1563(a), without regard to Code section
1563(a)(4) thereof); or (2) each of which is either maintained
by, or maintained pursuant to a collective-bargaining
agreement negotiated by, the same employee organization or
affiliated employee organizations. For purposes of this
paragraph, an ‘‘affiliate’’ of an employee organization means
any person controlling, controlled by, or under common control
with such organization. See 29 CFR 2520.103-12.
The Form 5500 submitted for a 103-12 IE must comply with
the Form 5500 instructions for a Large Pension Plan, unless
otherwise specified in the forms and instructions. The
103-12 IE must file:
1. Form 5500, except lines C, D, 1c, 2d, and 5 through 9.
Enter ‘‘E’’ in part I, line A, as the DFE code.
2. Schedule A (as many as needed), to report insurance,
annuity and investment contracts held by the 103-12 IE.
3. Schedule C, if applicable, to report service provider
information and any terminated accountants.
4. Schedule D, to list all CCTs, PSAs, and 103-12 IEs in
which the 103-12 IE invested at any time during the
103-12 IE’s year, and to list all plans that participated in the
103-12 IE during its year.
5. Schedule G, to report loans or fixed income obligations in
default or determined to be uncollectible as of the end of the
103-12 IE year, leases in default or classified as uncollectible,
and nonexempt transactions.
6. Schedule H, except lines 1b(1), 1b(2), 1c(8), 1d, 1e, 1g,
1h, 1i, 2a, 2b(1)(E), 2e, 2f, 2g, 4a, 4e, 4f, 4g, 4h, 4j, 4k, 4l, 4m,
4n, and 5, to report financial information.
7. Additional information required by the instructions to the
above schedules, including, for example, the report of the
independent qualified public accountant (IQPA) identified on
Schedule H, line 3c, and the schedule(s) of assets held for

investment. All attachments must be properly labeled.

Group Insurance Arrangement (GIA)
Each welfare benefit plan that is part of a group insurance
arrangement is exempt from the requirement to file a Form
5500 if a consolidated Form 5500 report for all the plans in the
arrangement was filed in accordance with 29 CFR 2520.10443. For reporting purposes, a ‘‘group insurance arrangement’’
provides benefits to the employees of two or more unaffiliated
employers (not in connection with a multiemployer plan or a
collectively-bargained multiple-employer plan), fully insures
one or more welfare plans of each participating employer, uses
a trust or other entity as the holder of the insurance contracts,
and uses a trust as the conduit for payment of premiums to the
insurance company. The GIA must file:
1 . Form 5500, except lines C and 2d. (Enter ‘‘G’’ in Part I,
line A, as the DFE code).
2. Schedule A (as many as needed), to report insurance,
annuity and investment contracts held by the GIA.
3. Schedule C, if applicable, to report service provider
information and any terminated accountants.
4. Schedule D, to list all CCTs, PSAs, and 103-12 IEs in
which the GIA invested at any time during the GIA year, and to
list all plans that participated in the GIA during its year.
5. Schedule G, to report loans or fixed income obligations in
default or determined to be uncollectible as of the end of the
GIA year, leases in default or classified as uncollectible, and
nonexempt transactions.
6. Schedule H, except lines 4a, 4e, 4f, 4g, 4h, 4k, 4m, 4n,
and 5, to report financial information.
7. Additional information required by the instructions to the
above schedules, including, for example, the report of the
independent qualified public accountant (IQPA) identified on
Schedule H, line 3c, the schedules of assets held for
investment and the schedule of reportable transactions. (All
attachments must be properly labeled.)

Quick Reference Chart of Form 5500, Schedules, and Attachments (Not
Applicable for Form 5500-SF Filers)1
Large
Pension Plan

Small
Pension Plan2

Large Welfare
Plan
3

Form 5500

Must complete.

Must complete.

Must complete.

Schedule A
(Insurance
Information)

Must complete if
plan has insurance
contracts.

Must complete if plan
has insurance
contracts.4

Must complete if
plan has insurance
contracts.

Not required.

Must complete Part I
if service provider
was paid $5,000 or
more, Part II if a
service provider
failed to provide
information
necessary for the
completion of Part I,
and Part III if an
accountant or
actuary was
terminated.

Schedule C
(Service Provider
Information)

Must complete Part I
if service provider
was paid $5,000 or
more, Part II if a
service provider
failed to provide
information
necessary for the
completion of Part I,
and Part III if an
accountant or
actuary was
terminated.

-12-

Small Welfare
Plan2
Must complete.

3

DFE
Must complete.

Must complete if plan
has insurance
contracts.4

Must complete if
MTIA, 103-12 IE, or
GIA has insurance
contracts.

Not required.

MTIAs, GIAs, and
103-12 IEs must
complete Part I if
service provider paid
$5,000 or more, and
Part II if a service
provider failed to
provide information
necessary for the
completion of Part I.
GIAs and 103-12 IEs
must complete Part
III if accountant was
terminated.

General Instructions to Form 5500

Schedule D
(DFE/Participating
Plan Information)

Schedule G
(Financial
Schedules)

Must complete Part I
if plan participated in
a CCT, PSA, MTIA,
or 103-12 IE.

Must complete if
Schedule H, lines
4b, 4c, or 4d are
“Yes.”

Must complete Part I
if plan participated in
a CCT, PSA, MTIA, or
103-12 IE.4

Must complete Part I
if plan participated in
a CCT, PSA, MTIA,
or 103-12 IE.

Not required.

Must complete if
Schedule H, lines
4b, 4c, or 4d are
“Yes.”3

Must complete Part I
if plan participated in
a CCT, PSA, MTIA,
or 103-12 IE.4

All DFEs must
complete Part II, and
DFEs that invest in a
CCT, PSA, or
103-12 IE must also
complete Part I.

Not required 3.

Must complete if
Schedule H, lines
4b, 4c, or 4d for a
GIA, MTIA, or
103-12 IE are “Yes.”

Schedule H
(Financial
Information)

Must complete.5

Not required.

Must complete.3, 5

Not required.

All DFEs must
complete Parts I, II,
and III. MTIAs,
103-12 IEs, and
GIAs must also
complete Part IV.5

Schedule I
(Financial
Information)

Not required.

Must complete.4

Not required.

Must complete.4

Not required.

Schedule MB
(Actuarial
Information)

Must complete if
multiemployer
defined benefit plan
or money purchase
plan subject to
minimum funding
standards.6

Must complete if
multiemployer defined
benefit plan or money
purchase plan subject
to minimum funding
standards.6

Not required.

Not required.

Not required.

Schedule R
(Pension Plan
Information)

Must complete.7

Must complete.4, 7

Not required.

Not required.

Not required.

Schedule SB
(Actuarial
Information)

Must complete if
single-employer or
multiple-employer
defined benefit plan,
including an eligible
combined plan and
subject to minimum
funding standards.

Must complete if
single-employer or
multiple-employer
defined benefit plan,
including an eligible
combined plan and
subject to minimum
funding standards.

Not required.

Not required.

Not required.

Large
Pension Plan
Accountant’s
Report

Must attach.

Small
Pension Plan2

Large Welfare
Plan

Not required unless
Schedule I, line 4k, is
checked “No.”

Must attach.3

Small Welfare
Plan2
Not required.

DFE
Must attach for a
GIA or 103-12 IE.

1

This chart provides only general guidance. Not all rules and requirements are reflected. Refer to specific Form 5500 instructions for complete
information on filing requirements (e.g., Who Must File and What To File). For example, a pension plan is exempt from filing any schedules if the plan
uses Code section 408 individual retirement accounts as the sole funding vehicle for providing benefits. See Limited Pension Plan Reporting.
2
Pension plans and welfare plans with fewer than 100 participants at the beginning of the plan year that are not exempt from filing an annual
return/report may be eligible to file the Form 5500-SF, a simplified report. In addition to the limitation on the number of participants, a Form 5500-SF
may only be filed for a plan that is exempt from the requirement that the plan’s books and records be audited by an independent qualified public
accountant (but not by reason of enhanced bonding), has 100 percent of its assets invested in certain secure investments with a readily determinable
fair market value, holds no employer securities, and is not a multiemployer plan. See Who Must File.
3

Unfunded, fully insured, or combination unfunded/fully insured welfare plans covering fewer than 100 participants at the beginning of the plan year
that meet the requirements of 29 CFR 2520.104-20 are exempt from filing an annual report. See Who Must File. Such a plan with 100 or more
participants must file an annual report, but is exempt under 29 CFR 2520.104-44 from the accountant’s report requirement and completing Schedule
H, but MUST complete Schedule G, Part III, to report any nonexempt transactions. See What To File. All Plans required to file Form M-1 (Report for
Multiple-Employer Welfare Arrangements (MEWAs) and Certain Entities Claiming Exception (ECEs)) must file a Form 5500 regardless of plan size or
type of funding.
4

Do not complete if filing the Form 5500-SF instead of the Form 5500.

5

Schedules of assets and reportable (5%) transactions also must be filed with the Form 5500 if Schedule H, line 4i or 4j is “Yes.”

6

Money purchase defined contribution plans that are amortizing a funding waiver are required to complete lines 3, 9, and 10 of the Schedule MB in
accordance with the instructions. Also see instructions for line 5 of Schedule R and line 12a of Form 5500-SF.

General Instructions to Form 5500

-13-

7

Schedule R should not be completed when the Form 5500 annual return/report is filed for a pension plan that uses, as the sole funding vehicle for
providing benefits, individual retirement accounts or annuities (as described in Code section 408). See the Form 5500 instructions for Limited Pension
Plan Reporting for more information. A pension plan is exempt from filing Schedule R if all of the following conditions are met:
The plan is not a defined benefit plan or otherwise subject to the minimum funding standards of Code section 412 or ERISA section 302.
No plan benefits that would be reportable on line 1 of Part I of this Schedule R were distributed during the plan year. See the instructions for Schedule
R, Part I, line 1, below.
No benefits, as described in the instructions for Schedule R, Part I, line 2, below, were paid during the plan year other than by the plan sponsor or
plan administrator. (This condition is not met if benefits were paid by the trust or any other payor(s) which are reportable on IRS Form 1099-R,
Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc., using an EIN other than that of the plan
sponsor or plan administrator reported on line 2b or 3b of Form 5500.)
Unless the plan is a profit-sharing, ESOP or stock bonus plan, no plan benefits of living or deceased participants were distributed during the plan year
in the form of a single-sum distribution. See the instructions for Schedule R, Part I, line 3, below.
The plan is not an ESOP.
The plan is not a multiemployer defined benefit plan.

-14-

General Instructions to Form 5500

and multiple-employer welfare plans required to file a Form
5500 must include an attachment using the format below that
(1) lists each participating employer in the plan during the plan
year, identified by name and employer identification number
(EIN), and (2) includes a good faith estimate of each
employer’s percentage of the total contributions (including
employer and participant contributions) made by all
participating employers during the year. Any employer who
was obligated to make contributions to the plan for the plan
year, made contributions to the plan for the plan year, or
whose employees were covered under the plan is a
“participating employer” for this purpose. If a participating
employer made no contributions, enter “-0-” in element (c).
The attachment must be properly identified at the top with
the label “Multiple-Employer Plan Participating Employer
Information,” and the name of the plan, EIN, and plan number
(PN) as found on the plan’s Form 5500.
Multiple-employer welfare plans that are exempt under
29 CFR 2520.104-44 from the obligation to file financial
statements with their annual report are required to include only
a list of participating employers with the corresponding EIN/PN
numbers in elements (a) and (b) of the “Multiple-Employer Plan
Participating Employer Information” attachment included with
their Form 5500.
Complete as many entries as needed to report the required
information for all participating employers.

Section 5: Line-by-Line
Instructions for the 20142015
Form 5500 and Schedules
Part I – Annual Return/Report Identification
Information
File the 2014 2015 Form 5500 annual return/report for a plan
year that began in 2014 2015 or a DFE year that ended in
20142015. Enter the beginning and ending dates in Part I. The
2014 2015 Form 5500 annual return/report must be filed
electronically.
One Form 5500 is generally filed for each plan or entity
described in the instructions to the boxes in line A. Do not
check more than one box.
A separate Form 5500, with line A (single-employer plan)
checked, must be filed by each employer participating in a plan
or program of benefits in which the funds attributable to each
employer are available to pay benefits only for that employer’s
employees, even if the plan is maintained by a controlled
group.
A “controlled group” is generally considered one employer
for Form 5500 reporting purposes. A “controlled group” is a
controlled group of corporations under Code section 414(b), a
group of trades or businesses under common control under
Code section 414(c), or an affiliated service group under Code
section 414(m).
Line A –B o x for Multiemployer Plan. Check this box if the
Form 5500 is filed for a multiemployer plan. A plan is a
multiemployer plan if: (a) more than one employer is required
to contribute, (b) the plan is maintained pursuant to one or
more collective bargaining agreements between one or more
employee organizations and more than one employer; (c) an
election under Code section 414(f)(5) and ERISA section
3(37)(E) has not been made; and (d) the plan meets any other
applicable conditions of 29 CFR 2510.3-37. A plan that has
made a proper election under ERISA section 3(37)(G) and
Code section 414(f)(6) on or before August 17, 2007, is also a
multiemployer plan. Participating employers do not file
individually for these plans.
Line A –B o x for Single-Employer Plan. Check this box if
the Form 5500 is filed for a single-employer plan. A singleemployer plan for this Form 5500 reporting purpose is an
employee benefit plan maintained by one employer or one
employee organization.
Line A –B o x for Multiple-Employer Plan. Check this box if
the Form 5500 is being filed for a multiple-employer plan. A
multiple-employer plan is a plan that is maintained by more
than one employer and is not one of the plans already
described. A multiple-employer plan can be collectively
bargained and collectively funded, but if covered by PBGC
termination insurance, must have properly elected before
September 27, 1981, not to be treated as a multiemployer plan
under Code section 414(f)(5) or ERISA sections 3(37)(E) and
4001(a)(3), and have not revoked that election or made an
election to be treated as a multiemployer plan under Code
section 414(f)(6) or ERISA section 3(37)(G). Participating
employers do not file individually for this type of plan.
Note. Do not check this box if all of the employers maintaining
the plan are members of the same controlled group or affiliated
service group under Code sections 414(b), (c), or (m).
Except as provided below, multiple-employer pension plans

Multiple-Employer Plan Participating Employer Information
(Insert Name of Plan and EIN/PN as shown on the Form 5500 )

(a) Name of participating employer

(b) EIN

(a) Name of participating employer

(b) EIN

(c) Percent of
Total
Contributions
(c) Percent of
Total
Contributions

Line A –Box for Direct Filing Entity (DFE). Check this box
and enter the correct letter from the following chart in the
space provided to indicate the type of entity.
Type of entity

Enter the letter

Master Trust
Investment Account

M

Common/Collective Trust

C

Pooled Separate
Account

P

103-12 Investment
Entity

E

Group Insurance
Arrangement

G

Note. A separate annual report with “M” entered as the DFE
code on Form 5500, line A, must be filed for each MTIA. See
instructions on page 9.
Line B –B o x for First Return/Report. Check this box if an
annual return/report has not been previously filed for this plan
or DFE. For the purpose of completing this box, the Form
5500-EZ is not considered an annual return/report.
Line B –B o x for Amended Return/Report. Check this box if
you have already filed for the 2014 2015 plan year and are
now filing an amended return/report to correct errors and/or
omissions on the previously filed return/report. See instructions
on page 6.
Check the line B box for an “amended return/report” if
you filed a previous 2014 2015 annual return/report
-14-

Instructions for Part I and Part II of Form 5500

that was given a “Filing_Received,” “Filing_Error,” or
“Filing_Stopped” status by EFAST2. Do not check the line B box
for an “amended return/report” if your previous submission
attempts were not successfully received by EFAST2 because of
problems with the transmission of your return/report. For more
information, go to the EFAST2 website at www.efast.dol.gov or
call the EFAST2 Help Line at 1-866-GO-EFAST (1-866-4633278).
Line B –B o x for Final Return/Report. Check this box if this
Form 5500 is the last annual return/report required to be
submitted for this plan. (See Final Return/Report.)
Note. Do not check box B (Final Return/Report) if “4R” is
entered on line 8b for a welfare plan that is not required to file
a Form 5500 for the next plan year because the welfare plan
has become eligible for an annual reporting exemption. For
example, certain unfunded and insured welfare plans may be
required to file the 2014 2015 Form 5500 and be exempt from
filing a Form 5500 for the plan year 2014 2016 if the number of
participants covered as of the beginning of the 2014 2016 plan
year drops below 100. See Who Must File. Should the number
of participants covered by such a plan increase to 100 or more
in a future year, the plan must resume filing Form 5500 and
enter ‘‘4S’’ on line 8b on that year’s Form 5500. See 29 CFR
2520.104-20.
Line B –B o x for Short Plan Year Return/Report. Check
this box if this Form 5500 is being filed for a plan year period of
less than 12 months. Provide the dates in Part I, Plan Year
Beginning and Ending.
Line C –B o x for Collectively-Bargained Plan. Check this
box when the contributions to the plan and/or the benefits paid
by the plan are subject to the collective bargaining process
(even if the plan is not established and administered by a joint
board of trustees and even if only some of the employees
covered by the plan are members of a collective bargaining
unit that negotiates contributions and/or benefits). The
contributions and/or benefits do not have to be identical for all
employees under the plan.
Line D –B o x for Extension and DFVC Program. Check the
appropriate box here if:
 You filed for an extension of time to file this form with the
IRS using a completed Form 5558, Application for Extension
of Time To File Certain Employee Plan Returns (maintain a
copy of the Form 5558 with the filer’s records);
 You are filing using the automatic extension of time to file
Form 5500 until the due date of the federal income tax return
of the employer (maintain a copy of the employer’s extension
of time to file the income tax return with the filer’s records);
 You are filing using a special extension of time to file the
Form 5500 that has been announced by the IRS, DOL, and
PBGC. If you checked that you are using a special extension of
time, enter a description of the extension of time in the space
provided.
 You are filing under DOL’s Delinquent Filer Voluntary
Compliance (DFVC) Program.

Line 1b. Enter the three-digit plan or entity number (PN) the
employer or plan administrator assigned to the plan or DFE.
This three-digit number, in conjunction with the employer
identification number (EIN) entered on line 2b, is used by the
IRS, DOL, and PBGC as a unique 12-digit number to identify
the plan or DFE.
Start at 001 for plans providing pension benefits, plans
providing pension and welfare benefits, or DFEs as illustrated
in the table below. Start at 501 for plans providing only welfare
benefits and GIAs. Do not use 888 or 999.
Once you use a plan or DFE number, continue to use it for
that plan or DFE on all future filings with the IRS, DOL, and
PBGC. Do not use it for any other plan or DFE, even if the first
plan or DFE is terminated.
For each Form 5500
with the same EIN
(line 2b), when
Part II, line 8a is completed,
or Part I, line A, for a DFE is
checked and an M, C, P, or
E is entered
Part II, line 8b is completed
and 8a is not checked, or
Part I, line A, for a DFE is
checked and a G is entered

Assign PN

001 to the first plan or DFE.
Consecutively number others
as 002, 003…
501 to the first plan or GIA.
Consecutively number others
as 502, 503…

Exception. If Part II, line 8a is completed and 333 (or a higher
number in a sequence beginning with 333) was previously
assigned to the plan, that number may be entered on line 1b.
Line 1c. Enter the date the plan first became effective.
Line 2a. Limit your response to the information required in
each row as specified below:
1. Enter the name of the plan sponsor or, in the case of a
Form 5500 filed for a DFE, the name of the insurance
company, financial institution, or other sponsor of the DFE
(e.g., in the case of a GIA, the trust or other entity that holds
the insurance contract, or in the case of an MTIA, one of the
sponsoring employers). If the plan covers only the employees
of one employer, enter the employer’s name.
The term ‘‘plan sponsor’’ means:
 The employer, for an employee benefit plan that a single
employer established or maintains;
 The employee organization in the case of a plan of an
employee organization; or
 The association, committee, joint board of trustees, or other
similar group of representatives of the parties who establish or
maintain the plan, if the plan is established or maintained
jointly by one or more employers and one or more employee
organizations, or by two or more employers.
Note. In the case of a multiple-employer plan, file only one
annual return/report for the plan. If an association or other
entity is not the sponsor, enter the name of a participating
employer as sponsor. A plan of a controlled group of
corporations should enter the name of one of the sponsoring
members. In either case, the same name must be used in all
subsequent filings of the Form 5500 for the multiple-employer
plan or controlled group (see instructions to line 4 concerning
change in sponsorship).
2. Enter any ‘‘in care of’’ (C/O) name.
3. Enter the current street address. A post office box
number may be entered if the Post Office does not deliver mail
to the sponsor’s street address.
4. Enter the name of the city.

Part II – Basic Plan Information
Line 1a. Enter the formal name of the plan or DFE or enough
information to identify the plan or DFE. Abbreviate if
necessary. If an annual return/report has previously been filed
on behalf of the plan, regardless of the type of form that was
filed (Form 5500, Form 5500-EZ, or Form 5500-SF) use the
same name or abbreviation as was used on the prior filings.
Once you use an abbreviation, continue to use it for that plan
on all future annual return/report filings with the IRS, DOL, and
PBGC. Do not use the same name or abbreviation for any
other plan, even if the first plan is terminated.
-16-

Instructions for Part I and Part II of Form 5500

5. Enter the two-character abbreviation of the U.S. state or
possession and zip code.
6. Enter the foreign routing code, if applicable. Leave U.S.
state and zip code blank if entering a foreign routing code and
country name.
7. Enter the foreign country, if applicable. Do not abbreviate
the country name.
8. Enter the D/B/A (the doing business as) or trade name of
the sponsor if different from the plan sponsor’s name.
9. Enter any second address. Use only a street address
here, not a P.O. box.
Note. You can also use the IRS Form 8822-B, Change of
Address – Business, to notify the IRS if the address provided
here is a change in your business mailing address or your
business location.
Line 2b. Enter the nine-digit employer identification number
(EIN) assigned to the plan sponsor/employer, for example, 001234567. In the case of a DFE, enter the employer
identification number (EIN) assigned to the CCT, PSA, MTIA,
103-12 IE, or GIA.
Do not use a social security number in lieu of an EIN. The
Form 5500 is open to public inspection, and the contents are
public information and are subject to publication on the
Internet. Because of privacy concerns, the inclusion of a social
security number or any portion thereof on this line may result in
the rejection of the filing.
Employers without an EIN must apply for one as soon as
possible. The EBSA does not issue EINs. To apply for an EIN
from the IRS:

unless the administrator is the sponsor identified in line 2. If
both the plan administrator name and address are the same as
the plan sponsor name and address, check the “Same as Plan
Sponsor” box and disregard items 2 through 6 below. If the
Form 5500 is submitted for a DFE, check the appropriate box
in Part I, line A, and enter the appropriate DFE code.
The term “plan administrator” means:
 The person or group of persons specified as the
administrator by the instrument under which the plan is
operated;
 The plan sponsor/employer if an administrator is not so
designated; or
 Any other person prescribed by regulations if an
administrator is not designated and a plan sponsor cannot
be identified.
2. Enter any “in care of” (C/O) name.
3. Enter the current street address. A post office box
number may be entered if the Post Office does not deliver mail
to the administrator’s street address.
4. Enter the name of the city.
5. Enter the two-character abbreviation of the U.S. state or
possession and zip code.
6. Enter the foreign routing code and foreign country, if
applicable. Leave U.S. state and zip code blank if entering
foreign routing code and country information.
Line 3b. Enter the plan administrator’s nine-digit EIN. A plan
administrator must have an EIN for Form 5500 reporting
purposes. If the plan administrator does not have an EIN, apply
for one as explained in the instructions for line 2b. One EIN
should be entered for a group of individuals who are,
collectively, the plan administrator.
Note. Employees of the plan sponsor who perform
administrative functions for the plan are generally not the plan
administrator unless specifically designated in the plan
document. If an employee of the plan sponsor is designated as
the plan administrator, that employee must get an EIN.
Line 4. If the plan sponsor’s or DFE’s name and/or EIN have
changed since the last return/report was filed for this plan or
DFE, enter the plan sponsor’s or DFE’s name, EIN, and the
plan number as it appeared on the last return/report filed.
The failure to indicate on line 4 that a plan sponsor
was previously identified by a different name or a
different employer identification number (EIN) could
result in correspondence from the DOL and the IRS.
Lines 5 and 6. All filers must complete both lines 5 and 6
unless the Form 5500 is filed for an IRA Plan described in
Limited Pension Plan Reporting or for a DFE.


Mail or fax Form SS-4, Application for Employer
Identification Number, obtained by calling 1-800-TAX-FORM
(1-800-829-3676) or at the IRS website at www.irs.gov.

Call 1-800-829-4933 to receive your EIN by telephone.

Select the Online EIN Application link at www.irs.gov. The
EIN is issued immediately once the application information is
validated. (The online application process is not yet available
for corporations with addresses in foreign countries or Puerto
Rico.)
A multiple-employer plan or plan of a controlled group of
corporations should use the EIN of the sponsor identified in
line 2a. The EIN must be used in all subsequent filings of the
Form 5500 for these plans (see instructions to line 4
concerning change in EIN).
If the plan sponsor is a group of individuals, get a single EIN
for the group. When you apply for the EIN, provide the name of
the group, such as ‘‘Joint Board of Trustees of the Local 187
Machinists’ Retirement Plan.’’ (If filing Form SS-4, enter the
group name on line 1.)
Note. EINs for funds (trusts or custodial accounts) associated
with plans (other than DFEs) are generally not required to be
furnished on the Form 5500; the IRS will issue EINs for such
funds for other reporting purposes. EINs may be obtained as
explained above. Plan sponsors should use the trust EIN
described above when opening a bank account or conducting
other transactions for a trust that require an EIN.
Line 2d. Enter the six-digit business code that best describes
the nature of the plan sponsor’s business from the list of
business codes on pages 78, 79, and 80. If more than one
employer or employee organization is involved, enter the
business code for the main business activity of the employers
and/or employee organizations.
Line 3a. Please limit your response to the information
required:
1. Enter the name and address of the plan administrator
Instructions for Part I and Part II of Form 5500

The description of ‘‘participant’’ in the instructions below is
only for purposes of these lines.
An individual becomes a participant covered under an
employee welfare benefit plan on the earliest of:
 the date designated by the plan as the date on which the
individual begins participation in the plan;
 the date on which the individual becomes eligible under the
plan for a benefit subject only to occurrence of the contingency
for which the benefit is provided; or
 the date on which the individual makes a contribution to the
plan, whether voluntary or mandatory.
See 29 CFR 2510.3-3(d)(1). This includes former employees
who are receiving group health continuation coverage benefits
pursuant to Part 6 of ERISA and who are covered by the
employee welfare benefit plan. Covered dependents are not
counted as participants. A child who is an “alternate recipient”
entitled to health benefits under a qualified medical child
-17-

support order (QMCSO) should not be counted as a participant
for lines 5 and 6. An individual is not a participant covered
under an employee welfare plan on the earliest date on which
the individual (a) is ineligible to receive any benefit under the
plan even if the contingency for which such benefit is provided
should occur, and (b) is not designated by the plan as a
participant. See 29 CFR 2510.3-3(d)(2).
Before counting the number of participants, especially
in a welfare benefit plan, it is important to determine
whether the plan sponsor has established one or more
plans for Form 5500/Form 5500-SF reporting purposes. As a
matter of plan design, plan sponsors can offer benefits through
various structures and combinations. For example, a plan
sponsor could create (i) one plan providing major medical
benefits, dental benefits, and vision benefits, (ii) two plans with
one providing major medical benefits and the other providing
self-insured dental and vision benefits; or (iii) three separate
plans. You must review the governing documents and actual
operations to determine whether welfare benefits are being
provided under a single plan or separate plans.
The fact that you have separate insurance policies for each
different welfare benefit does not necessarily mean that you
have separate plans. Some plan sponsors use a “wrap”
document to incorporate various benefits and insurance
policies into one comprehensive plan. In addition, whether a
benefit arrangement is deemed to be a single plan may be
different for purposes other than Form 5500/Form 5500-SF
reporting. For example, special rules may apply for purposes of
HIPAA, COBRA, and Internal Revenue Code compliance. If
you need help determining whether you have a single welfare
benefit plan for Form 5500/Form 5500-SF reporting purposes,
you should consult a qualified benefits consultant or legal
counsel.
For pension benefit plans, “alternate payees” entitled to
benefits under a qualified domestic relations order are not to
be counted as participants for this line.
For pension benefit plans, “participant” for this line means
any individual who is included in one of the categories below:
1. Active participants (i.e., any individuals who are currently
in employment covered by the plan and who are earning or
retaining credited service under the plan). This includes any
individuals who are eligible to elect to have the employer make
payments under a Code section 401(k) qualified cash or
deferred arrangement. Active participants also include any
nonvested individuals who are earning or retaining credited
service under the plan. This does not include (a) nonvested
former employees who have incurred the break in service
period specified in the plan or (b) former employees who have
received a “cash-out” distribution or deemed distribution of
their entire nonforfeitable accrued benefit.
2. Retired or separated participants receiving benefits (i.e.,
individuals who are retired or separated from employment
covered by the plan and who are receiving benefits under the
plan). This does not include any individual to whom an
insurance company has made an irrevocable commitment to
pay all the benefits to which the individual is entitled under the
plan.
3. Other retired or separated participants entitled to future
benefits (i.e., any individuals who are retired or separated from
employment covered by the plan and who are entitled to begin
receiving benefits under the plan in the future). This does not
include any individual to whom an insurance company has
made an irrevocable commitment to pay all the benefits to
which the individual is entitled under the plan.
4. Deceased individuals who had one or more beneficiaries
who are receiving or are entitled to receive benefits under the

plan. This does not include any individual to whom an
insurance company has made an irrevocable commitment to
pay all the benefits to which the beneficiaries of that individual
are entitled under the plan.
Line 6g. Enter the number of participants included on line 6f
(total participants at the end of the plan year) who have
account balances. For example, for a Code section 401(k) plan
the number entered on line 6g should be the number of
participants counted on line 6f who have made a contribution,
or for whom a contribution has been made, to the plan for this
plan year or any prior plan year. Defined benefit plans should
leave line 6g blank.
Line 6h. Include any individual who terminated employment
during this plan year, whether or not he or she (a) incurred a
break in service, (b) received an irrevocable commitment from
an insurance company to pay all the benefits to which he or
she is entitled under the plan, and/or (c) received a cash
distribution or deemed cash distribution of his or her
nonforfeitable accrued benefit. Multiemployer plans and
multiple-employer plans that are collectively bargained do not
have to complete line 6h.
Line 7. Only multiemployer plans should complete line 7.
Multiemployer plans must enter the total number of employers
obligated to contribute to the plan. For purposes of line 7 of the
Form 5500, an employer obligated to contribute is defined as
an employer who, during the 2014 2015 plan year, is a party to
the collective bargaining agreement(s) pursuant to which the
plan is maintained or who may otherwise be subject to
withdrawal liability pursuant to ERISA section 4203. Any two or
more contributing entities (e.g., places of business with
separate collective bargaining agreements) that have the same
nine-digit employer identification number (EIN) must be
aggregated and counted as one employer for this purpose.
Line 8 - Benefits Provided Under the Plan. In the boxes for
line 8a and 8b, as appropriate, enter all applicable plan
characteristics codes that applied during the reporting year
from the List of Plan Characteristics Codes on pages 19 and
20 that describe the characteristics of the plan being reported.
Note. In the case of an eligible combined plan under Code
section 414(x) and ERISA section 210(e), the codes entered in
line 8a must include any codes applicable for either the defined
benefit pension features or the defined contribution pension
features of the plan.
For plan sponsors of Puerto Rico plans, enter
characteristic code 3C only if:
i. only Puerto Rico residents participate,
ii. the trust is exempt from income tax under the laws of
Puerto Rico, and
iii. the plan administrator has not made the election under
ERISA section 1022(i)(2), and, therefore, the plan is not
intended to qualify under section 401(a) of the Internal
Revenue Code (U.S).
Line 9 - Funding and Benefit Arrangements. Check all
boxes that apply to indicate the funding and benefit
arrangements used during the plan year. The ‘‘funding
arrangement’’ is the method for the receipt, holding,
investment, and transmittal of plan assets prior to the time the
plan actually provides benefits. The ‘‘benefit arrangement’’ is
the method by which the plan provides benefits to participants.
For purposes of line 9:
‘‘Insurance’’ means the plan has an account, contract, or
policy with an insurance company, insurance service, or other
similar organization (such as Blue Cross, Blue Shield, or a
health maintenance organization) during the plan or DFE year.
-18-

Instructions for Part I and Part II of Form 5500

(This includes investments with insurance companies such as
guaranteed investment contracts (GICs).) An annuity account
arrangement under Code section 403(b)(1) that is required to
complete the Form 5500 should mark “insurance” for both the
plan funding arrangement and plan benefit arrangement. Do
not check ‘‘insurance’’ if the sole function of the insurance
company was to provide administrative services.
‘‘Code section 412(e)(3) insurance contracts’’ are
contracts that provide retirement benefits under a plan that are
guaranteed by an insurance carrier. In general, such contracts
must provide for level premium payments over the individual’s
period of participation in the plan (to retirement age), premiums
must be timely paid as currently required under the contract,
no rights under the contract may be subject to a security
interest, and no policy loans may be outstanding. If a plan is
funded exclusively by the purchase of such contracts, the
otherwise applicable minimum funding requirements of section
412 of the Code and section 302 of ERISA do not apply for the
year and neither the Schedule MB nor the Schedule SB is
required to be filed.
‘‘Trust’’ includes any fund or account that receives, holds,
transmits, or invests plan assets other than an account or
policy of an insurance company. A custodial account
arrangement under Code section 403(b)(7) that is required to
complete the Form 5500 should mark “trust” for both the plan
funding arrangement and the plan benefit arrangement.
‘‘General assets of the sponsor’’ means either the plan
had no assets or some assets were commingled with the
general assets of the plan sponsor prior to the time the plan
actually provided the benefits promised.
Example. If the plan holds all its assets invested in registered
investment companies and other non-insurance company
investments until it purchases annuities to pay out the benefits
promised under the plan, box 9a(3) should be checked as the
funding arrangement and box 9b(1) should be checked as the
benefit arrangement.
Note. An employee benefit plan that checks boxes 9a(1),
9a(2), 9b(1), and/or 9b(2) must attach Schedule A (Form
5500), Insurance Information, to provide information
concerning each contract year ending with or within the plan
year. See the instructions to the Schedule A and enter the
number of Schedules A on line 10b(3), if applicable.
Line 10. Check the boxes on line 10 to indicate the schedules
being filed and, where applicable, count the schedules and
enter the number of attached schedules in the space provided.

filings are necessary in the case of certain registration,
origination, or special events. See the instructions for Form M1 at http://www.askebsa.dol.gov/mewa, and 29 CFR 2520.1012 for more information regarding the Form M-1 filing
requirements for plan MEWAs and ECEs.
Line 11b. All plans that answered ‘‘Yes’’ in line 11a must
complete line 11b by answering either ‘‘Yes’’ or ‘‘No.’’ Do not
leave the answer blank.
Line 11c. All plans that answered ‘‘Yes’’ in line 11a must enter
a Receipt Confirmation Code for the 2014 2015 Form M–1
annual report that was required to be filed with the Department
of Labor under the Form M–1 filing requirements. The Receipt
Confirmation Code is a unique code generated by the Form M–
1 electronic filing system. You can find this code under the
‘‘completed filings’’ area when you log into your Form M–1
electronic filing system at http://www.askebsa.dol.gov/mewa. If
a plan was not required to file a 2014 2015 Form M–1 annual
report, enter the Receipt Confirmation Code for the most
recent Form M–1 that was required to be filed under the Form
M–1 filing requirements on or before the date of filing the 2014
2015 Form 5500. (For example, if a plan was not required to
file a 2014 2015 Form M–1 annual report by March 1, 2015
2016 for the 2014 2015 calendar year because it experienced
a registration event between October 1 and December 31,
20142015, and made a timely Form M–1 registration filing, the
plan must enter on line 11c of the 2014 2015 Form 5500 the
Receipt Confirmation Code issued for the Form M–1
registration filing.)
If a plan that is subject to the Form M-1 filing requirements was
not required to file a 2014 2015 Form M-1 annual report, enter
the Receipt Confirmation Code for the most recent Form M-1
that was required to be filed under the Form M-1 filing
requirements on or before the date of filing the 2014 2015
Form 5500. (For example, if a plan was not required to file a
2014 2015 Form M-1 annual report by March 1, 2014 2015 for
the 2014 2015 calendar year because it experienced a
registration event between October 1 and December 31,
20142015, and made a timely Form M-1 registration
filing, the plan must provide the Receipt Confirmation
Code for the Form M-1 registration filing.)
A welfare benefit plan’s failure to answer line 11a, and if
applicable, lines 11b and 11c, or enter a valid Receipt
Confirmation Code in line 11c, will subject the Form 5500 filing
to rejection as incomplete and civil penalties may be assessed
pursuant to ERISA Section 502(c)(2) and 29 CFR 2560.502c2.

Form M-1 Compliance Information (to be
provided by all welfare plans).
Line 11a. All plans providing welfare benefits must complete
Part III, line 11a by answering either “Yes” or “No”. Do not
leave the answer blank. If the plan is a multiple-employer
welfare arrangement or an Entity Claiming Exception (ECE)
subject to the Form M-1, Report for Multiple-Employer Welfare
Arrangements (MEWAs) and Certain Entities Claiming
Exception (ECEs) filing requirements, check “Yes” and
complete line 11, elements 11b and 11c. If the answer is “No,”
skip elements 11b and 11c of line 11.
st
Generally, a Form M-1 must be filed each year by March 1
following the calendar year in which a plan operates subject to
the Form M-1 filing requirement. (For example, a plan MEWA
that was operating in 2014 2015 must file the 2014 2015 Form
M-1 annual report by March 1, 2015.) In addition, Form M-1

LIST OF PLAN CHARACTERISTICS CODES FOR LINES 8a AND 8b
Instructions for Part I and Part II of Form 5500

-19-

CODE

Defined Benefit Pension Features

1A

Benefits are primarily pay related.

1B

Benefits are primarily flat dollar (includes dollars per year
of service).

1C

Cash balance or similar plan – Plan has a “cash balance”
formula. For this purpose, a “cash balance” formula is a
benefit formula in a defined benefit plan by whatever
name (for example, personal account plan, pension
equity plan, life cycle plan, cash account plan, etc.) that
rather than, or in addition to, expressing the accrued
benefit as a life annuity commencing at normal
retirement age, defines benefits for each employee in
terms more common to a defined contribution plan such
as a single sum distribution amount (for example, 10
percent of final average pay times years of service, or
the amount of the employee’s hypothetical account
balance).

1D

Floor-offset plan – to offset for retirement benefits
provided by an employer-sponsored defined contribution
plan.

1E

Code section 401(h) arrangement – Plan contains
separate accounts under Code section 401(h) to provide
employee health benefits.

1F

Code section 414(k) arrangement – Benefits are based
partly on the balance of the separate account of the
participant (also include appropriate defined contribution
pension feature codes).

1H

1I

CODE
2A

2F

ERISA section 404(c) plan – This plan, or any part of it,
is intended to meet the conditions of 29 CFR 2550.404c1.

2G

Total participant-directed account plan – Participants
have the opportunity to direct the investment of all the
assets allocated to their individual accounts, regardless
of whether 29 CFR 2550.404c-1 is intended to be met.

2H

Partial participant-directed account plan – Participants
have the opportunity to direct the investment of a portion
of the assets allocated to their individual accounts,
regardless of whether 29 CFR 2550.404c-1 is intended
to be met.

2I

Stock bonus.

2J

Code section 401(k) feature – A cash or deferred
arrangement described in Code section 401(k) that is
part of a qualified defined contribution plan that provides
for an election by employees to defer part of their
compensation or receive these amounts in cash.

2K

Code section 401(m) arrangement – Employee
contributions are allocated to separate accounts under
the plan or employer contributions are based, in whole or
in part, on employee deferrals or contributions to the
plan. Not applicable if plan is 401(k) with only QNECs
and/or QMACs. Also not applicable if Code sections
403(b)(1), 403(b)(7), or 408 arrangement/accounts
annuities.
An annuity contract purchased by Code section 501(c)(3)
organization or public school as described in Code
section 403(b)(1) arrangement.”
Custodial accounts for regulated investment company
stock as described in Code section 403(b)(7).
Code section 408 accounts and annuities – See Limited
Pension Plan Reporting instructions for pension plan
utilizing Code section 408 individual retirement accounts
or annuities as the funding vehicle for providing benefits.

2L
2M

Plan covered by PBGC that was terminated and closed
out for PBGC purposes – Before the end of the plan year
(or a prior plan year), (1) the plan terminated in a
standard (or distress) termination and completed the
distribution of plan assets in satisfaction of all benefit
liabilities (or all ERISA Title IV benefits for distress
termination); or (2) a trustee was appointed for a
terminated plan pursuant to ERISA section 4042.

2N
2O

ESOP other than a leveraged ESOP.

2P

Frozen plan – As of the last day of the plan year, the plan
provides that no participant will get any new benefit
accrual (whether because of service or compensation).

Leveraged ESOP – An ESOP that acquires employer
securities with borrowed money or other debt-financing
techniques.

2Q

The employer maintaining this ESOP is an S corporation.

Defined Contribution Pension Features

2R

Participant-directed brokerage accounts provided as an
investment option under the plan.

2S

401(k) plan or 403(b) plan that provides for automatic
enrollment in plan that has elective contributions
deducted from payroll

2T

Total or partial participant-directed account plan – plan
uses default investment account for participants who fail
to direct assets in their account.

Use this code if employer contributions in the return year
were based on one of the following allocation types:
Age/service weighted or new comparability or similar
plan – Age/service weighted plan: Allocations are based
on age, service, or age and service. New comparability
or similar plan: Allocations are based on participant
classifications and a classification(s) consists entirely or
predominantly of highly compensated employees; or the
plan provides an additional allocation rate on
compensation above a specified threshold, and the
threshold or additional rate exceeds the maximum
threshold or rate allowed under the permitted disparity
rules of Code section 401(l).

2B

Target benefit plan.

2C

Money purchase (other than target benefit).

2D

Offset plan – Plan benefits are subject to offset for
retirement benefits provided in another plan or
arrangement of the employer.

2E

Profit-sharing.

CODE

Other Pension Benefit Features

3B

Use this code if the plan covered self-employed
individuals in the return year.Plan covering self-employed
individuals. .

3C

Plan not intended to be qualified – A plan not intended to
be qualified under Code sections 401, 403, or 408.

3D

Pre-approved pension plan – A master, prototype, or
volume submitter plan that is the subject of a favorable
opinion or advisory letter from the IRS.

3F

Plan sponsor(s) received services of leased employees,
as defined in Code section 414(n), during the plan year.

LIST OF PLAN CHARACTERISTICS CODES FOR LINES 8a AND 8b (Continued)

-20-

Instructions for Part I and Part II of Form 5500

3H

Plan sponsor(s) is (are) a member(s) of a controlled
group (Code sections 414(b), (c), or (m)).

3I

Plan requiring that all or part of employer contributions
be invested and held, at least for a limited period, in
employer securities.

3J

CODE

U.S.-based plan that covers residents of Puerto Rico and
is qualified under both Code section 401 and section
1165 of Puerto Rico Code.

4K

Scholarship (funded).

4L

Death benefits (include travel accident but not life
insurance).

4P

Taft-Hartley Financial Assistance for Employee Housing
Expenses.

4Q

Other.

4R

Unfunded, fully insured, or combination unfunded/fully
insured welfare plan that will not file an annual report for
next plan year pursuant to 29 CFR 2520.104-20.

4S

Unfunded, fully insured, or combination unfunded/fully
insured welfare plan that stopped filing annual reports in
an earlier plan year pursuant to 29 CFR 2520.104-20.

4T

10 or more employer plan under Code section
419A(f)(6).

4U

Collectively-bargained welfare benefit arrangement
under Code section 419A(f)(5).

Welfare Benefit Features

4A

Health (other than vision or dental).

4B

Life insurance.

4C

Supplemental unemployment.

4D

Dental.

4E

Vision.

4F

Temporary disability (accident and sickness).

4G

Prepaid legal.

4H

Long-term disability.

4I

Severance pay.

4J

Apprenticeship and training.

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Instructions for Part I and Part II of Form 5500

this Schedule A or any of its attachments may result in the
rejection of the filing.
You can apply for an EIN from the IRS online, by
telephone, by fax, or by mail depending on how soon you need
to use the EIN. For more information, see Section 3: Electronic
Filing Requirement under General Instructions to Form 5500.
The EBSA does not issue EINs.

2014 2015 Instructions for Schedule A
(Form 5500)
Insurance Information
General Instructions

Part I – Information Concerning Insurance Contract
Coverage, Fees, and Commissions

Who Must File
Schedule A (Form 5500) must be attached to the Form 5500
filed for every defined benefit pension plan, defined
contribution pension plan, and welfare benefit plan required to
file a Form 5500 if any benefits under the plan are provided by
an insurance company, insurance service, or other similar
organization (such as Blue Cross, Blue Shield, or a health
maintenance organization). This includes investment contracts
with insurance companies such as guaranteed investment
contracts (GICs). In addition, Schedules A must be attached to
a Form 5500 filed for GIAs, MTIAs, and 103-12 IEs for each
insurance or annuity contract held in the MTIA, or 103-12 IE or
by the GIA.
If Form 5500 line 9a(1), 9a(2), 9b(1), or 9b(2) is
checked, indicating that either the plan funding
arrangement or plan benefit arrangement includes an
account, policy, or contract with an insurance company (or
similar organization), at least one Schedule A would be
required to be attached to the Form 5500 filed for a pension or
welfare plan to provide information concerning the contract
year ending with or within the plan year.

Line 1(c). Enter the code number assigned by the National
Association of Insurance Commissioners (NAIC) to the
insurance company. If none has been assigned, enter zeros
“0” in the spaces provided.
Line 1(d). If individual policies with the same carrier are
grouped as a unit for purposes of this report, and the group
does not have one identification number, you may use the
contract or identification number of one of the individual
contracts, provided this number is used consistently to report
these contracts as a group and the plan administrator
maintains the records necessary to disclose all the individual
contract numbers in the group upon request. Use separate
Schedules A to report individual contracts that cannot be
grouped as a unit.
Line 1(e). Since plan coverage may fluctuate during the year,
the administrator should estimate the number of persons that
were covered by the contract at the end of the policy or contract
year. Where contracts covering individual employees are
grouped, compute entries as of the end of the plan year.
Line 1(f) and (g). Enter the beginning and ending dates of the
policy year for the contract identified in 1(d). Leave 1(f) blank if
separate contracts covering individual employees are grouped.
Line 2. Report on line 2 the total of all insurance fees and
commissions directly or indirectly attributable to the contract or
policy placed with or retained by the plan.
Totals. Enter on line 2 the total of all such commissions and
fees paid to agents, brokers, and other persons listed on line 3.
Complete a separate line 3 item (elements (a) through (e)) for
each person listed.
For purposes of lines 2 and 3, commissions and fees
include sales and base commissions and all other monetary
and non-monetary forms of compensation where the broker’s
agent’s, or other person’s eligibility for the payment or the
amount of the payment is based, in whole or in part, on the
value (e.g., policy amounts, premiums) of contracts or policies
(or classes thereof) placed with or retained by an ERISA plan,
including, for example, persistency and profitability bonuses.
The amount (or pro rata share of the total) of such
commissions or fees attributable to the contract or policy
placed with or retained by the plan must be reported in line 2
and in line 3, element (b) and/or (c), as appropriate.
Insurers must provide plan administrators with a
proportionate allocation of commissions and fees attributable
to each contract. Any reasonable method of allocating
commissions and fees to policies or contracts is acceptable,
provided the method is disclosed to the plan administrator. A
reasonable allocation method could, in the Department of
Labor’s view, allocate fees and commissions to a Schedule A
based on a calendar year calculation even if the plan year or
policy year was not a calendar year. For additional information
on these Schedule A reporting requirements, see ERISA
Advisory Opinion 2005-02A, available on the Internet at
www.dol.gov/ebsa.
Where benefits under a plan are purchased from and
guaranteed by an insurance company, insurance service, or

Do not file Schedule A for a contract that is an Administrative
Services Only (ASO) contract, a fidelity bond or policy, or a
fiduciary liability insurance policy. Also, if a Schedule A for a
contract or policy is filed as part of a Form 5500 for an MTIA or
103-12 IE that holds the contract, do not include a Schedule A
for the contract or policy on the Form 5500s filed for the plans
participating in the MTIA or 103-12 IE.
Check the Schedule A box on the Form 5500 (Part II, line
10b(3)), and enter the number attached in the space provided
if one or more Schedules A are attached to the Form 5500.

Specific Instructions
Information entered on Schedule A should pertain to the
insurance contract or policy year ending with or within the plan
year (for reporting purposes, a year cannot exceed 12
months).
Example. If an insurance contract year begins on July 1 and
ends on June 30, and the plan year begins on January 1 and
ends on December 31, the information on the Schedule A
attached to the 2014 2015 Form 5500 should be for the
insurance contract year ending on June 30, 20142015.
Exception. If the insurance company maintains records on the
basis of a plan year rather than a policy or contract year, the
information entered on Schedule A may pertain to the plan
year instead of the policy or contract year.
Include only the contracts issued to or held by the plan,
GIA, MTIA, or 103-12 IE for which the Form 5500 is being filed.
Lines A, B, C, and D. This information must be the same as
reported in Part II of the Form 5500 to which this Schedule A is
attached.
Do not use a social security number in lieu of an EIN. The
Schedule A and its attachments are open to public inspection,
and the contents are public information and are subject to
publication on the Internet. Because of privacy concerns, the
inclusion of a social security number or any portion thereof on
Instructions for Schedule A (Form 5500)

-22-

other similar organization, and the contract or policy is reported
on a Schedule A, payments of reasonable monetary
compensation by the insurer out of its general assets to
affiliates or third parties for performing administrative activities
necessary for the insurer to fulfill its contractual obligation to
provide benefits, where there is no direct or indirect charge to
the plan for the administrative services other than the
insurance premium, then the payments for administrative
services by the insurer to the affiliates or third parties do not
need to be reported on lines 2 and 3 of Schedule A. This would
include compensation for services such as recordkeeping and
claims processing services provided by a third party pursuant
to a contract with the insurer to provide those services but
would not include compensation provided by the insurer
incidental to the sale or renewal of a policy, such as finder’s
fees, insurance brokerage commissions and fees, or similar
fees.
Schedule A reporting also is not required for compensation
paid by the insurer to a “general agent” or “manager” for that
general agent’s or manager’s management of an agency or
performance of administrative functions for the insurer. For this
purpose, (1) a “general agent” or “manager” does not include
brokers representing insureds, and (2) payments would not be
treated as paid for managing an agency or performance of
administrative functions where the recipient’s eligibility for the
payment or the amount of the payment is dependent or based
on the value (e.g., policy amounts, premiums) of contracts or
policies (or classes thereof) placed with or retained by ERISA
plan(s).
Schedule A reporting is not required for occasional nonmonetary gifts or meals of insubstantial value that are tax
deductible for federal income tax purposes by the person
providing the gift or meal and would not be taxable income to
the recipient. For this exemption to be available, the gift or
gratuity must be both occasional and insubstantial. For this
exemption to apply, the gift must be valued at less than $50,
the aggregate value of gifts from one source in a calendar year
must be less than $100, but gifts with a value of less than $10
do not need to be counted toward the $100 annual limit. If the
$100 aggregate value limit is exceeded, then the aggregate
value of all the gifts will be reportable. For this purpose, nonmonetary gifts of less than $10 also do not need to be included
in calculating the aggregate value of all gifts required to be
reported if the $100 limit is exceeded.
Gifts from multiple employees of one service provider
should be treated as originating from a single source when
calculating whether the $100 threshold applies. On the other
hand, in applying the threshold to an occasional gift received
from one source by multiple employees of a single service
provider, the amount received by each employee should be
separately determined in applying the $50 and $100
thresholds. For example, if six employees of a broker attend a
business conference put on by an insurer designed to educate
and explain the insurer’s products for employee benefit plans,
and the insurer provides, at no cost to the attendees,
refreshments valued at $20 per individual, the gratuities would
not be reportable on lines 2 and 3 of the Schedule A even
though the total cost of the refreshments for all the employees
would be $120.
These thresholds are for purposes of Schedule A reporting.
Filers are cautioned that the payment or receipt of gifts and
gratuities of any amount by plan fiduciaries may violate ERISA
and give rise to civil liabilities and criminal penalties.
Line 3. Identify agents, brokers, and other persons individually
in descending order of the amount paid. Complete as many
entries as necessary to report all required information.
Instructions for Schedule A (Form 5500)

-23-

Complete elements (a) through (e) for each person as
specified below.
Element (a). Enter the name and address of the agents,
brokers, or other persons to whom commissions or fees were
paid.
Element (b). Report all sales and base commissions here. For
purposes of this element, sales and/or base commissions are
monetary amounts paid by an insurer that are charged directly
to the contract or policy and that are paid to a licensed agent or
broker for the sale or placement of the contract or policy. All
other payments should be reported in element (c) as fees.
Element (c). Fees to be reported here represent payments by
an insurer attributable directly or indirectly to a contract or
policy to agents, brokers, and other persons for items other
than sales and/or base commissions (e.g., service fees,
consulting fees, finders fees, profitability and persistency
bonuses, awards, prizes, and non-monetary forms of
compensation). Fees paid to persons other than agents and
brokers should be reported here, not in Parts II and III on
Schedule A as acquisition costs, administrative charges, etc.
Element (d). Enter the purpose(s) for which fees were paid.
Element (e). Enter the most appropriate organization code for
the broker, agent, or other person entered in element (a).
Code Type of Organization
1
Banking, Savings & Loan Association, Credit Union,
or other similar financial institution
2
Trust Company
3
Insurance Agent or Broker
4
Agent or Broker other than insurance
5
Third party administrator
6
Investment Company/Mutual Fund
7
Investment Manager/Adviser
8
Labor Union
9
Foreign entity (e.g., an agent or broker, bank,
insurance company, etc., not operating within the
jurisdictional boundaries of the United States)
0
Other
For plans, GIAs, MTIAs, and 103-12 IEs required to file Part
I of Schedule C, commissions and fees listed on the Schedule
A are not required to be reported again on Schedule C. The
amount of the compensation that must be reported on
Schedule A must, however, be taken into account in
determining whether the agent’s, broker’s, or other person’s
direct or indirect compensation in relation to the plan or DFE is
$5,000 or more and, thus, requiring the compensation not
listed on the Schedule A to be reported on the Schedule C.
See FAQs about the Schedule C available on the EBSA
website at www.dol.gov/ebsa/faqs.

Part II – Investment and Annuity Contract
Information
Line 4. Enter the current value of the plan’s interest at year
end in the contract reported on line 7, e.g., deposit
administration (DA), immediate participation guarantee (IPG),
or guaranteed investment contracts (GIC).
Exception. Contracts reported on line 7 need not be included
on line 4 if (1) the Schedule A is filed for a defined benefit
pension plan and the contract was entered into before March
20, 1992, or (2) the Schedule A is filed for a defined
contribution pension plan and the contract is a fully benefitresponsive contract, i.e., it provides a liquidity guarantee by a
financially responsible third party of principal and previously
accrued interest for liquidations, transfers, loans, or hardship
withdrawals initiated by plan participants exercising their rights
to withdraw, borrow, or transfer funds under the terms of a

defined contribution plan that does not include substantial
restrictions to participants’ access to plan funds.
Important Reminder. Plans may treat multiple individual
annuity contracts, including Code section 403(b)(1) annuity
contracts, issued by the same insurance company as a single
group contract for reporting purposes on Schedule A.
Line 6a. The rate information called for here may be furnished
by attaching the appropriate schedules of current rates filed
with the appropriate state insurance department or by
providing a statement regarding the basis of the rates. Enter
“see attached” if appropriate.
Lines 7a through 7f. Report contracts with unallocated funds.
Do not include portions of these contracts maintained in
separate accounts. Show deposit fund amounts rather than
experience credit records when both are maintained.

Part III – Welfare Benefit Contract Information
Line 8i. Report a stop-loss insurance policy that is an asset of
the plan.
Note. Employers sponsoring welfare plans may purchase a
stop-loss insurance policy with the employer as the insured to
help the employer manage its risk associated with its liabilities
under the plan. These employer contracts with premiums paid
exclusively out of the employer’s general assets without any
employee contributions generally are not plan assets and are
not reportable on Schedule A.

Part IV – Provision of Information
The insurance company, insurance service, or other similar
organization is required under ERISA section 103(a)(2) to
provide the plan administrator with the information needed to
complete this return/report. If you do not receive this
information in a timely manner, contact the insurance
company, insurance service, or other similar organization.
Lines 11 and 12. If information is missing on Schedule A due
to a refusal by the insurance company, insurance service, or
other similar organization to provide information, check “Yes”
on line 11 and enter a description of the information not
provided on line 12. If you received all the information
necessary to receive the Schedule A, check “No” and leave
line 12 blank.
As noted above, the insurance company, insurance
service, or other similar organization is statutorily
required to provide you with all of the information
necessary to complete the Schedule A, but need not provide
the information on a Schedule A itself.

-24-

Instructions for Schedule A (Form 5500)

Lines A, B, C, and D. This information must be the same as
reported in Part II of the Form 5500 to which this Schedule C is
attached.
Do not use a social security number in line D in lieu of an
EIN. The Schedule C and its attachments are open to public
inspection, and the contents are public information subject to
publication on the Internet. Because of privacy concerns, the
inclusion of a social security number or any portion thereof on
this Schedule C or any of its attachments may result in the
rejection of the filing.
You can apply for an EIN from the IRS online, by
telephone, by fax, or by mail depending on how soon you need
to use the EIN. For more information, see Section 3: Electronic
Filing Requirement under General Instructions to Form 5500.
The EBSA does not issue EINs.
Do not list the PBGC or the IRS on Schedule C as service
providers.
Either the cash or accrual basis may be used for the
recognition of transactions reported on the Schedule C as long
as you use one method consistently.
If service provider compensation is reported on a Schedule
C filed as a part of a Form 5500 filed for a MTIA or a
103-12 IE, do not report the same compensation again on the
Schedule C filed for the plans that participate in the MTIA or
103-12 IE.

2014 2015 Instructions for Schedule C
(Form 5500)
Service Provider Information
General Instructions
Who Must File
Schedule C (Form 5500) must be attached to a Form 5500
filed for a large pension or welfare benefit plan, an MTIA, a
103-12 IE, or a GIA to report certain information concerning
service providers. Remember to check the Schedule C box on
the Form 5500 (Part II, line 10b(4)) if a Schedule C is attached
to the Form 5500.
Part I of the Schedule C must be completed to report
persons who rendered services to or who had transactions with
the plan (or with the DFE in the case of a Schedule C filed by a
DFE) during the reporting year if the person received, directly
or indirectly, $5,000 or more in reportable compensation in
connection with services rendered or their position with the
plan or DFE, except:
1. Employees of the plan whose only compensation in
relation to the plan was less than $25,000 for the plan year;
2. Employees of the plan sponsor or other business entity
where the plan sponsor or business entity is reported on the
Schedule C as a service provider, provided the employee did
not separately receive reportable direct or indirect
compensation in relation to the plan;
3. Persons whose only compensation in relation to the plan
consists of insurance fees and commissions listed in a
Schedule A filed for the plan; and
4. Payments made directly by the plan sponsor that are not
reimbursed by the plan. In the case of a multiemployer or
multiple-employer plan, where the “plan sponsor” would be the
joint board of trustees for the plan, payments by contributing
employers, directly or through an employer association, or by
participating employee organizations, should be treated the
same as payments by a plan sponsor.
Only line 1 of Part I of the Schedule C must be completed
for persons who received only “eligible indirect compensation”
as defined below.
Part II of the Schedule C must be completed to report
service providers who fail or refuse to provide information
necessary to complete Part I of this Schedule.
Part III of the Schedule C must be completed to report a
termination in the appointment of an accountant or enrolled
actuary during the 2014 2015 plan year.
For plans, GIAs, MTIAs, and 103-12 IEs required to file Part
I of Schedule C, commissions and fees listed on the Schedule
A are not required to be reported again on Schedule C. The
amount of the compensation that must be reported on
Schedule A must, however, be taken into account in
determining whether the service provider’s direct or indirect
compensation in relation to the plan or DFE is $5,000 or more
and, thus, requiring the compensation not listed on the
Schedule A to be reported on the Schedule C. See FAQs
about the Schedule C available on the EBSA website at
www.dol.gov/ebsa/faqs.
Health and welfare plans that meet the conditions of
the limited exemption at 29 CFR 2520.104-44 or
Technical Release 92-01 are not required to
complete and file a Schedule C.

Specific Instructions
Part I – Service Provider Information
You must enter the information required for each person who
rendered services to or had transactions with the plan and
who received $5,000 or more in total direct or indirect
compensation in connection with services rendered to the
plan or the person’s position with the plan during the plan
year.
Example. A plan had service providers, A, B, C, and D,
who received $12,000, $6,000, $4,500, and $430,
respectively, in direct and indirect compensation from the
plan. Service providers A and B must be identified
separately by name, EIN, etc. As service providers C and D
each received less than $5,000, they do not need to be
reported on the Schedule C.
For Schedule C purposes, reportable compensation
includes money and any other thing of value (for example,
gifts, awards, trips) received by a person, directly or indirectly,
from the plan (including fees charged as a percentage of
assets and deducted from investment returns) in connection
with services rendered to the plan, or the person’s position with
the plan. The term “person” for this purpose includes
individuals, trades and businesses (whether incorporated or
unincorporated). See ERISA section 3(9).
Direct Compensation: Payments made directly by the
plan for services rendered to the plan or because of a person’s
position with the plan are reportable as direct compensation.
Direct payments by the plan would include, for example, direct
payments by the plan out of a plan account, charges to plan
forfeiture accounts and fee recapture accounts, charges to a
plan’s trust account before allocations are made to individual
participant accounts, and direct charges to plan participant
individual accounts. Payments made by the plan sponsor,
which are not reimbursed by the plan, are not subject to
Schedule C reporting requirements even if the sponsor is
paying for services rendered to the plan.
Indirect Compensation: Compensation received from
sources other than directly from the plan or plan sponsor is
reportable on Schedule C as indirect compensation from the
-25-

Instructions for Schedule C (Form 5500)

plan if the compensation was received in connection with
services rendered to the plan during the plan year or the
person’s position with the plan. For this purpose,
compensation is considered to have been received in
connection with services rendered to the plan or the person’s
position with the plan if the person’s eligibility for a payment is
based, in whole or in part, on services that were rendered to
the plan or on a transaction or series of transactions with the
plan. Indirect compensation would not include compensation
that would have been received had the service not been
rendered or the transaction had not taken place and that
cannot be reasonably allocated to the services performed or
transaction(s) with the plan.
Persons that provide investment management,
recordkeeping, claims processing, participant communication,
brokerage, and other services to the plan as part of an
investment contract or transaction are considered to be
providing services to the plan for purposes of Schedule C
reporting and would be required to be identified in Part I if they
received $5,000 or more in reportable compensation for
providing those services.
Examples of reportable indirect compensation include fees
and expense reimbursement payments received by a person
from mutual funds, bank commingled trusts, insurance
company pooled separate accounts, and other separately
managed accounts and pooled investment funds in which the
plan invests that are charged against the fund or account and
reflected in the value of the plan’s investment (such as
management fees paid by a mutual fund to its investment
adviser, sub-transfer agency fees, shareholder servicing fees,
account maintenance fees, and 12b-1 distribution fees). The
investment of plan assets and payment of premiums for
insurance contracts, however, are not in and of themselves
payments for services rendered to the plan for purposes of
Schedule C reporting and the investment and payment of
premiums themselves are not reportable compensation for
purposes of Part I of the Schedule C.
In the case of charges against an investment fund,
reportable “indirect compensation” includes, for example, the
fund’s investment adviser asset-based investment
management fee from the fund, brokerage commissions and
fees charged in connection with purchases and sales of
interests in the fund, fees related to purchases and sales of
interests in the fund (including 12b-1 fees), fees for providing
services to plan investors or plan participants such as
communication and other shareholder services, and fees
relating to the administration of the employee benefit plan such
as recordkeeping services, Form 5500 return/report filing and
other compliance services. Amounts charged against the fund
for other ordinary operating expenses, such as attorneys’ fees,
accountants’ fees, printers fees, are not reportable indirect
compensation for Schedule C purposes. Also, brokerage costs
associated with a broker-dealer effecting securities
transactions within the portfolio of a mutual fund or for the
portfolio of an investment fund that holds “plan assets” for
ERISA purposes should be treated for Schedule C purposes
as an operating expense of the investment fund, not reportable
indirect compensation paid to a plan service provider or in
connection with a transaction with the plan.
Other examples of reportable indirect compensation are
finder’s fees, float revenue, brokerage commissions
(regardless of whether the broker is granted discretion),
research or other products or services, other than execution,
received from a broker-dealer or other third party in connection
with securities transactions (soft dollars), and other transaction
based fees received in connection with transactions or

services involving the plan whether or not they are capitalized
as investment costs.
For more information, see FAQs about the Schedule C,
available on the EBSA website at www.dol.gov/ebsa/faqs.
Special rules for non-monetary compensation of
insubstantial value, guaranteed benefit insurance policies,
bundled service arrangements, and allocating
compensation among multiple plans:
Excludable Non-Monetary Compensation: You may
exclude non-monetary compensation of insubstantial value
(such as gifts or meals of insubstantial value) that is tax
deductible for federal income tax purposes by the person
providing the gift or meal and would not be taxable income to
the recipient. The gift or gratuity must be valued at less than
$50, and the aggregate value of gifts from one source in a
calendar year must be less than $100, but gifts with a value of
less than $10 do not need to be counted toward the $100 limit.
If the $100 aggregate value limit is exceeded, then the value of
all the gifts over $10 will be reportable. Gifts received by one
person from multiple employees of one entity must be treated
as originating from a single source when calculating whether
the $100 threshold applies. On the other hand, gifts received
from one person by multiple employees of one entity can be
treated as separate compensation when calculating the $50
and $100 thresholds. For more information, see FAQs about
the Schedule C, available on the EBSA website at
www.dol.gov/ebsa/faqs.
These thresholds are for purposes of Schedule C
reporting only. Filers are strongly cautioned that gifts
and gratuities of any amount paid to or received by
plan fiduciaries may violate ERISA and give rise to civil
liabilities and criminal penalties.
Fully Insured Group Health and Similarly Fully Insured
Benefits: Where benefits under a plan are purchased from
and guaranteed by an insurance company, insurance service,
or other similar organization, and the contract or policy is
reported on a Schedule A, payments of reasonable monetary
compensation by the insurer out of its general assets to
persons for performing administrative activities necessary for
the insurer to fulfill its contractual obligation to provide benefits,
where there is no direct or indirect charge to the plan for the
administrative services other than the insurance premium,
would not be treated as indirect compensation for services
provided to the plan for Schedule C reporting purposes. This
would include compensation for services such as
recordkeeping and claims processing services provided by a
third party pursuant to a contract with the insurer to provide
those services, but would not include compensation provided
by the insurer incidental to the sale or renewal of a policy, such
as finder’s fees, insurance brokerage commissions and fees,
or similar fees. Insurance investment contracts are not eligible
for this exception.
Bundled Service Arrangements: For Schedule C
reporting purposes, a bundled service arrangement includes
any service arrangements where the plan hires one company
to provide a range of services either directly from the
company, through affiliates or subcontractors, or through a
combination, which are priced to the plan as a single package
rather than on a service-by-service basis. A bundled service
arrangement would also include an investment transaction in
which the plan receives a range of services either directly from
the investment provider, through affiliates or subcontractors, or
through a combination.
Direct payments by the plan to the bundled service provider
should be reported as direct compensation to the bundled
-26-

Instructions for Schedule C (Form 5500)

service provider. Such direct payments by the plan do not
need to be allocated among affiliates or subcontractors and do
not need to be reported as indirect compensation received by
the affiliates or subcontractors unless the amount paid to the
affiliate or subcontractor is set on a per transaction basis, e.g.,
brokerage fees and commissions.
Fees charged to the plan’s investment and reflected in the
net value of the investment, such as management fees paid by
mutual funds to their investment advisers, float revenue,
commissions (including “soft dollars”), finder’s fees, 12b-1
distribution fees, account maintenance fees, and shareholder
servicing fees, must, subject to the alternative reporting option
for “eligible indirect compensation,” described below, be
treated as separate reportable compensation by the person
receiving the fee for purposes of Schedule C reporting.
For each person who is a fiduciary to the plan or provides
one or more of the following services to the plan – contract
administrator, consulting, investment advisory (plan or
participants), investment management, securities brokerage,
or recordkeeping – commissions and other transaction based
fees, finder’s fees, float revenue, soft dollar and other nonmonetary compensation, would also be required to be treated
as separate compensation for Schedule C purposes even if
those fees were paid from mutual fund management fees or
other fees charged to the plan’s investment and reflected in the
net value of the investment.
Other revenue sharing payments among members of a
bundled service arrangement do not need to be allocated
among affiliates or subcontractors and treated as indirect
compensation received by the affiliates or subcontractors in
determining whether the affiliate or subcontractor must be
separately identified on line 2 of the Schedule C.
For more information about bundled arrangements for
reporting purposes, see FAQs about the Schedule C, available
on the EBSA website at www.dol.gov/ebsa/faqs.
Allocating Compensation Among Multiple Plans: Where
reportable compensation is received by a person in connection
with several plans or DFEs, any reasonable method of
allocating the compensation among the plans or DFEs may be
used provided that the allocation method is disclosed to the
plan administrator. In calculating the $5,000 threshold for
purposes of determining whether a person must be identified in
Part I, include the amount of compensation received by the
person that is attributable to the plan or DFE filing the Form
5500, not the aggregate amount received in connection with all
the plans or DFEs.
Affiliates: For purposes of Schedule C reporting, an
“affiliate” of a person includes any person, directly or indirectly,
through one or more intermediaries, controlling, controlled by,
or under common control with the person applying principles
consistent with the regulations prescribed under section 414(c)
of the Code.
Line 1. Check “Yes” or “No” on line 1a to indicate whether you
are relying on the alternative reporting option for a person or
persons who received only “eligible indirect compensation.” If
you check “Yes” on line 1a, provide as many entries in line 1b
as necessary to identify the person or persons who provided
you with the necessary disclosures regarding the eligible
indirect compensation. If any indirect compensation is either
not of the type described below or if the plan did not receive
the written disclosures described below, the indirect
compensation is not “eligible indirect compensation” for
purposes of Part 1.
(1) Eligible Indirect Compensation: The types of indirect
compensation that can be treated as eligible indirect
Instructions for Schedule C (Form 5500)

-27-

compensation are indirect compensation that is fees or
expense reimbursement payments charged to investment
funds and reflected in the value of the investment or return on
investment of the participating plan or its participants finder’s
fees “soft dollar” revenue, float revenue, and/or brokerage
commissions or other transaction-based fees for transactions
or services involving the plan that were not paid directly by the
plan or plan sponsor (whether or not they are capitalized as
investment costs).
Investment funds or accounts for this purpose would
include mutual funds, bank commingled trusts, including
common and collective trusts, insurance company pooled
separate accounts, and other separately managed accounts
and pooled investment vehicles in which the plan invests.
Investment funds or accounts would also include separately
managed investment accounts that contain assets of individual
plans.
(2) Required Written Disclosures: For the types of
indirect compensation described above to be treated as
eligible indirect compensation for purposes of completing line
1, you must have received written materials that disclosed and
described (a) the existence of the indirect compensation; (b)
the services provided for the indirect compensation or the
purpose for payment of the indirect compensation; (c) the
amount (or estimate) of the compensation or a description of
the formula used to calculate or determine the compensation;
and (d) the identity of the party or parties paying and receiving
the compensation. The written disclosures for a bundled
arrangement must separately disclose and describe each
element or indirect compensation that would be required to be
separately reported if you were not relying on this alternative
reporting option.
If any person received eligible indirect compensation
and either direct compensation and/or indirect
compensation that does not meet the requirements of
this line to be eligible indirect compensation, you cannot rely
on the alternative reporting option for that person and must
complete line 2 for each such person who received $5,000 or
more in direct and indirect compensation.
Line 2. Except for those persons and eligible indirect
compensation for which you answered “Yes” to line 1 above,
complete as many entries as needed to list each person
receiving, directly or indirectly, $5,000 or more in total direct
and indirect compensation. Start with the most highly
compensated and list in descending order of compensation.
Enter in element (a) the person’s name and complete elements
(a) through (h) as specified below. Use as many entries as
necessary to list all persons and information required to be
reported.
Element (a). Enter the EIN for the person identified in
element (a). If the name of an individual is entered in element
(a) and the individual does not have an EIN, enter the EIN of
the individual’s employer. If the person is self-employed and
does not have an EIN, you may enter the person’s address
and telephone number. Do not use a social security number in
lieu of an EIN. The Schedule C and its attachments are open
to public inspection and are subject to publication on the
Internet. Because of privacy concerns, the inclusion of a social
security number or any portion thereof on this Schedule C or
any of its attachments may result in the rejection of the filing.
Element (b). Select from the list below all codes that
describe both the kind of services provided and the type of
compensation received. Enter as many codes as apply:
Code Service/Compensation
10
11

Accounting (including auditing)
Actuarial

12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
40

49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
70
71
72
73
99

Claims processing
Contract Administrator
Plan Administrator
Recordkeeping and information management (computing,
tabulating, data processing, etc.)
Consulting (general)
Consulting (pension)
Custodial (other than securities)
Custodial (securities)
Trustee (individual)
Trustee (bank, trust company, or similar financial institution)
Insurance agents and brokers
Insurance services
Trustee (discretionary)
Trustee (directed)
Investment advisory (participants)
Investment advisory (plan)
Investment management
Legal
Employee (plan)

fee or commission, but agrees to offset the fee or commission
with any revenue received from a party other than the plan or
plan sponsor, for example, as part of a commission recapture
or other offset arrangement, only the amount paid directly by
the plan after any revenue sharing offset should be entered in
element (d). Enter in element (d), as direct payments by the
plan, amounts that a plan sponsor, or contributing employer or
participating employee organization in the case of a
multiemployer or multiple-employer plan, pays a plan thirdparty service provider that are reimbursed by the plan.
Note. Do not leave element (d) blank. If no direct
compensation was received, enter “0”.
Element (e). Check “Yes” if the person identified in
element (a), or any related person, received during the plan
year indirect compensation in connection with the person’s
position with the plan or services provided to the plan. (See
instructions above on definition of indirect compensation.) If
the answer is “No,” skip elements (f) through (h) for the person
identified in element (a).
Element (f). Check “Yes” if any of the indirect
compensation was eligible indirect compensation for which the
plan received the necessary disclosures. See instructions for
line 1 for definition of eligible indirect compensation. Check
“No” if none of the indirect compensation was eligible indirect
compensation.
Element (g). Enter the total of all indirect compensation
that is not eligible indirect compensation for which the plan
received the necessary disclosure. Do not leave blank. If none,
enter “0”.
Element (h). Check “Yes” if the service provider, instead of
an amount or an estimated amount, gave the plan a formula or
other description of the method used to determine some or all
of the indirect compensation received.
Line 3. For each person identified in line 2 who is a fiduciary to
the plan or provides one or more of the following services to
the plan – contract administrator, consulting custodial,
investment advisory (plan or participants), investment
management, broker, or recordkeeping – enter the requested
information for each source from whom the person received
indirect compensation if (1) the amount of the compensation
was $1,000 or more, or (2) the plan was given a formula or
other description of the method used to determine the indirect
compensation rather than an amount or estimated amount of
the indirect compensation.

Named fiduciary
Real estate brokerage
Securities brokerage
Valuation (appraisals, etc.)
Employee (plan sponsor)
Copying and duplicating
Participant loan processing
Participant communication
Foreign entity (e.g., an agent or broker, bank, insurance
company, etc. not operating within jurisdictional boundaries of
the United States)
Other services
Direct payment from the plan
Investment management fees paid directly by plan
Investment management fees paid indirectly by plan
Insurance brokerage commissions and fees
Sales loads (front end and deferred)
Other commissions
Non-monetary compensation
Redemption fees
Product termination fees (surrender charges, etc.)
Shareholder servicing fees
Sub-transfer agency fees
Finders’ fees/placement fees
Float revenue
Distribution (12b-1) fees
Recordkeeping fees
Account maintenance fees
Insurance mortality and expense charge
Other insurance wrap fees
“’Soft dollars’ commissions”
Consulting fees
Securities brokerage commissions and fees
Other investment fees and expenses
Other insurance fees and expenses
Other fees

Part II –Service Providers Who Fail or Refuse To
Provide Information
Line 4. Provide the requested information for each plan
fiduciary or service provider who you believe failed or refused
to provide any of the information necessary to complete Part I
of this schedule.
Important Reminder. Before identifying a fiduciary or service
provider as a person who failed or refused to provide
information, you should contact the fiduciary or service
provider to request the necessary information and tell them
that you will list them on the Schedule C as a fiduciary or
service provider who failed or refused to provide information if
they do not provide the necessary information.

Element (c). Enter any relationship of the person
identified in element (a) to the plan sponsor, to the participating
employer or employee organization, or to any person known to
be a party-in-interest, for example, employee of employer,
vice-president of employer, union officer, affiliate of plan
recordkeeper, etc.
Element (d). Enter the total amount of compensation
received directly from the plan for services rendered to the plan
during the plan year. If a service provider charges the plan a

Part III – Termination Information on Accountants
and Enrolled Actuaries
Complete Part III if there was a termination in the appointment
of an accountant or enrolled actuary during the 2014 2015 plan
year. This information must be provided on the Form 5500 for
the plan year during which the termination occurred. For
example, if an accountant was terminated in the 2014 2015
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Instructions for Schedule C (Form 5500)

plan year after completing work on an audit for the 2013 2014
plan year, the termination should be reported on the Schedule
C filed with the 2014 2015 plan year Form 5500. If the
accountant is a firm (such as a corporation, partnership, etc.),
report when the service provider (not an individual within the
firm) was terminated. An enrolled actuary is by definition an
individual and not a firm, and you must report when the
individual is terminated.
Provide an explanation of the reasons for the termination of
an accountant or enrolled actuary. Include a description of any
material disputes or matters of disagreement concerning the
termination, even if resolved prior to the termination. If an
individual is listed, and the individual does not have an EIN,
the EIN to be entered should be the EIN of the individual’s

employer.
Do not use a social security number in lieu of an EIN. The
Schedule C and its attachments are open to public inspection,
and the contents are public information and are subject to
publication on the Internet. Because of privacy concerns, the
inclusion of a social security number or any portion thereof on
this Schedule C or any of its attachments may result in the
rejection of the filing.
The plan administrator must also provide the terminated
accountant or enrolled actuary with a copy of the explanation
for the termination provided in Part III of the Schedule C, along
with a completed copy of the notice below.

Notice to Terminated Accountant
or Enrolled Actuary
I, as plan administrator, verify that the explanation that is reproduced below or attached to this notice is the explanation concerning
your termination reported on the Schedule C (Form 5500) attached to the 2014 2015 Form 5500, Annual Return/Report of Employee
Benefit Plan, for the __________________________________________________________(enter name of plan). This Form 5500
is identified in line 2b by the nine-digit EIN
(enter sponsor’s EIN), and in line 1b by the three-digit
PN________(enter plan number).
You have the opportunity to comment to the Department of Labor concerning any aspect of this explanation. Comments should
include the name, EIN, and PN of the plan and be submitted to: Office of Enforcement, Employee Benefits Security Administration,
U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, DC 20210.
Signed
Dated

Instructions for Schedule C (Form 5500)

-29-

2014 2015 Instructions for Schedule D
(Form 5500)
DFE / Participating Plan Information
General Instructions
Purpose of Schedule
When the Form 5500 is filed for a plan or Direct Filing Entity
(DFE) that invested or participated in any master trust
investment accounts (MTIAs), 103-12 Investment Entities
(103-12 IEs), common/collective trusts (CCTs), and/or pooled
separate accounts (PSAs), Part I provides information about
these entities. When the Form 5500 is filed for a DFE, Part II
provides information about plans participating in the DFE.

Who Must File
Employee Benefit Plans: Schedule D (Form 5500) must be
attached to a Form 5500 filed for an employee benefit plan that
participated or invested in one or more CCTs, PSAs, MTIAs, or
103-12 IEs at anytime during the plan year.
Direct Filing Entities: Schedule D (Form 5500) must be
attached to a Form 5500 filed for a CCT, PSA, MTIA,
103-12 IE, or Group Insurance Arrangement (GIA), as a Direct
Filing Entity (i.e., when a “DFE” is checked on Part I, line A, of
the Form 5500). For more information, see instructions for
Direct Filing Entity (DFE) Filing Requirements.
Check the Schedule D box on the Form 5500 (Part II, line
10b(5)) if a Schedule D is attached to the Form 5500.
Complete as many repeating entries as necessary to report the
required information.

Specific Instructions
Lines A, B, C, and D. The information must be the same as
reported in Part II of the Form 5500 to which this Schedule D is
attached.
Do not use a social security number in line D in lieu of an
EIN. The Schedule D and its attachments are open to public
inspection, and the contents are public information and are
subject to publication on the Internet. Because of privacy
concerns, the inclusion of a social security number or any
portion thereof on this Schedule D or any of its attachments
may result in the rejection of the filing.
You can apply for an EIN from the IRS online, by telephone,
by fax, or by mail depending on how soon you need to use the
EIN. For more information, see Section 3: Electronic Filing
Requirement under General Instructions to Form 5500. The
EBSA does not issue EINs.

Type of entity

Enter in (d)

MTIA

M

CCT

C

PSA

P

103-12 IE

E





Element (e). Enter the dollar value of the plan’s or DFE’s
interest as of the end of the year. If the plan or DFE for which
this Schedule D is filed had no interest in the MTIA, CCT, PSA,
or 103-12 IE listed at the end of the year, enter ‘‘0’’.
Example for Part I: If a plan participates in an MTIA, the
MTIA is named in element (a); the MTIA’s sponsor is named in
element (b); the MTIA’s EIN and PN are entered in element (c)
(such as: 12-3456789-001); an ‘‘M’’ is entered in element (d);
and the dollar value of the plan’s interest in the MTIA as of the
end of plan year is entered in element (e).
If the plan also participates in a CCT for which a Form 5500
was not filed, the CCT is named in another element (a); the
name of the CCT sponsor is entered in element (b); the EIN for
the CCT, followed by 000 is entered in element (c) (such as:
99-8765432-000); a “C” is entered in element (d); and the
dollar value of the plan’s interest in the CCT is entered in
element (e).
If the plan also participates in a PSA for which a Form 5500
was filed, the PSA is named in a third element (a); the name of
the PSA sponsor is entered in element (b); the PSA’s EIN and
PN is entered in element (c) (such as: 98-7655555-001); a “P”
is entered in element (d); and the dollar value of the plan’s
interest in the PSA is entered in element (e).

Part II – Information on Participating Plans
(To Be Completed Only by DFEs)

Part I – Information on Interests in MTIAs, CCTs,
PSAs, and 103-12 IEs (To Be Completed by Plans
and DFEs)
Complete as many repeating entries as necessary to enter the
information specified below for all MTIAs, CCTs, PSAs, and
103-12 IEs in which the plan or DFE filing the Form 5500
participated at any time during the plan or DFE year.
Complete a separate item (elements (a) through (e)) for
each MTIA, CCT, PSA, or 103-12 IE.
Element (a). Enter the name of the MTIA, CCT, PSA, or
103-12 IE in which the plan or DFE filing the Form 5500
participated at any time during the plan or DFE year.
Element (b). Enter the name of the sponsor of the MTIA, CCT,
PSA, or 103-12 IE named in element (a).
Element (c). Enter the nine-digit employer identification
number (EIN) and three-digit plan/entity number (PN) for each
Instructions for Schedule D (Form 5500)

MTIA, CCT, PSA, or 103-12 IE named in element (a). This
must be the same DFE EIN/PN as reported on lines 2b and 1b
of the Form 5500 filed for the DFE. If a Form 5500 was not
filed for a CCT or PSA named in element (a), enter the EIN for
the CCT or PSA and enter 000 for the PN. Do not use a social
security number or any portion thereof in lieu of an EIN. The
Schedule D and its attachments are open to public inspection,
and the contents are public information and are subject to
publication on the Internet. Because of privacy concerns, the
inclusion of a social security number or any portion thereof on
this Schedule D or any of its attachments may result in the
rejection of the filing.
Element (d). Enter an M, C, P, or E, as appropriate, (see table
below) to identify the type of entity (MTIA, CCT, PSA, or
103-12 IE).

-30-

Complete as many repeating entries as necessary to enter the
information specified below for all plans invested or
participated in the DFE at any time during the DFE year.
Complete a separate item (elements (a) through (c)) for each
plan.
Element (a). Enter the name of each plan that invested or
participated in the DFE at any time during the DFE year. GIAs
need not complete element (a).
Element (b). Enter the name of the sponsor of each and every
plan investing or participating in the DFE.
Element (c). Enter the nine-digit EIN and three-digit PN for
each plan named in element (a). This is the EIN and PN
entered on lines 2b and 1b of the plan’s Form 5500 or Form
5500-SF. GIAs should enter the EIN of the sponsor listed in

element (b). Do not use a social security number in lieu of an
EIN. The Schedule D and its attachments are open to public
inspection, and the contents are public information and are
subject to publication on the Internet. Because of privacy
concerns, the inclusion of a social security number or any
portion thereof on this Schedule D or any of its attachments
may result in the rejection of the filing.

Instructions for Schedule D (Form 5500)

-31-

obligation upon maturity. Obligations that require periodic
repayment can default at any time. Generally loans and fixed
income obligations are considered uncollectible when payment
has not been made and there is little probability that payment
will be made. A fixed income obligation has a fixed maturity
date at a specified interest rate.
Do not report in Part I participant loans under an individual
account plan with investment experience segregated for each
account, that are made in accordance with 29 CFR 2550.408b1, and that are secured solely by a portion of the participant’s
vested accrued benefit. Report all other participant loans in
default or classified as uncollectible on Part I, and list each
such loan individually.

2014 2015 Instructions for Schedule G
(Form 5500)
Financial Transaction Schedules
General Instructions
Who Must File
Schedule G (Form 5500) must be attached to a Form 5500
filed for a large plan, MTIA, 103-12 IE, or GIA to report loans or
fixed income obligations in default or determined to be
uncollectible as of the end of the plan year, leases in default or
classified as uncollectible, and nonexempt transactions.
Check the Schedule G box on the Form 5500 (Part II, line
10b(6)) if a Schedule G is attached to the Form 5500.
Complete as many entries as necessary to report the required
information.
The Schedule G consists of three parts. Part I of the
Schedule G reports any loans or fixed income obligations in
default or determined to be uncollectible as of the end of the
plan year. Part II of the Schedule G reports any leases in
default or classified as uncollectible. Part III of the Schedule G
reports nonexempt transactions.

Part II – Leases in Default or Classified as
Uncollectible
List any leases in default or classified as uncollectible. A lease
is an agreement conveying the right to use property, plant, or
equipment for a stated period. A lease is in default when the
required payment(s) has not been made. An uncollectible
lease is one where the required payments have not been
made and for which there is little probability that payment will
be made. Provide, on a separate attachment, an explanation of
what steps have been taken or will be taken to collect overdue
amounts for each lease listed and label the attachment
“Schedule G, Part II – Overdue Lease Explanation.”

Specific Instructions

Part III – Nonexempt Transactions

Lines A, B, C, and D. This information must be the same as
reported in Part II of the Form 5500 to which this Schedule G is
attached.
Do not use a social security number in Line D in lieu of an
EIN. The Schedule G and its attachments are open to public
inspection, and the contents are public information and are
subject to publication on the internet. Because of privacy
concerns, the inclusion of a social security number or any
portion thereof on this Schedule G or any of its attachments
may result in the rejection of the filing.
You can apply for an EIN from the IRS online, by telephone,
by fax, or by mail depending on how soon you need to use the
EIN. For more information, see Section 3: Electronic Filing
Requirement under General Instructions to Form 5500. The
EBSA does not issue EINs.

All nonexempt party-in-interest transactions must be reported,
regardless of whether disclosed in the accountant’s report,
unless the nonexempt transaction is:
1. Statutorily exempt under Part 4 of Title I of ERISA;
2. Administratively exempt under ERISA section 408(a);
3. Exempt under Code sections 4975(c) or 4975(d);
4. The holding of participant contributions in the employer’s
general assets for a welfare plan that meets the conditions of
ERISA Technical Release 92-01;
5. A transaction of a 103-12 IE with parties other than
the plan; or
6. A delinquent participant contribution or a delinquent
participant loan repayment reported on Schedule H, line 4a.
Nonexempt transactions with a party-in-interest include
any direct or indirect:
A. Sale or exchange, or lease, of any property between the
plan and a party-in-interest.
B. Lending of money or other extension of credit between
the plan and a party-in-interest.
C. Furnishing of goods, services, or facilities between the
plan and a party-in-interest.
D. Transfer to, or use by or for the benefit of, a party-ininterest, of any income or assets of the plan.
E. Acquisition, on behalf of the plan, of any employer
security or employer real property in violation of ERISA
section 407(a).
F. Dealing with the assets of the plan for a fiduciary’s own
interest or own account
G. Acting in a fiduciary’s individual or any other capacity in
any transaction involving the plan on behalf of a party (or
represent a party) whose interests are adverse to the
interests of the plan or the interests of its participants or
beneficiaries.
H. A receipt of any consideration for his or her own personal
account by a party-in-interest who is a fiduciary from any
party dealing with the plan in connection with a transaction
involving the income or assets of the plan.

Part I – Loans or Fixed Income Obligations in Default
or Classified as Uncollectible
List all loans or fixed income obligations in default or
determined to be uncollectible as of the end of the plan year or
the fiscal year of the GIA, MTIA, or 103-12 IE. Include:
 Obligations where the required payments have not been
made by the due date;
 Fixed income obligations that have matured, but have not
been paid, for which it has been determined that payment will
not be made; and
 Loans that were in default even if renegotiated later during
the year.
Note. Identify in element (a) each obligor known to be a partyin-interest to the plan.
Provide, on a separate attachment, an explanation of what
steps have been taken or will be taken to collect overdue
amounts for each loan listed and label the attachment
“Schedule G, Part I – Overdue Loan Explanation.”
The due date, payment amount, and conditions for
determining default in the case of a note or loan are usually
contained in the documents establishing the note or loan. A
loan is in default when the borrower is unable to pay the
Instructions for Schedule G (Form 5500)

-32-

For purposes of this form, party-in-interest is deemed to
include a disqualified person. See Code section 4975(e)(2).
The term ‘‘party-in-interest’’ means, as to an employee
benefit plan:
A. Any fiduciary (including, but not limited to, any
administrator, officer, trustee or custodian), counsel, or
employee of the plan;
B. A person providing services to the plan;
C. An employer, any of whose employees are covered by
the plan;
D. An employee organization, any of whose members are
covered by the plan;
E. An owner, direct or indirect, of 50% or more of: (1) the
combined voting power of all classes of stock entitled to vote
or the total value of shares of all classes of stock of a
corporation, (2) the capital interest or the profits interest of a
partnership, or (3) the beneficial interest of a trust or
unincorporated enterprise that is an employer or an
employee organization described in C or D;
F. A relative of any individual described in A, B, C, or E;
G. A corporation, partnership, or trust or estate of which (or
in which) 50% or more of: (1) the combined voting power of
all classes of stock entitled to vote or the total value of
shares of all classes of stock of such corporation, (2) the
capital interest or profits interest of such partnership, or (3)
the beneficial interest of such trust or estate is owned
directly or indirectly, or held by, persons described in A, B,
C, D, or E;
H. An employee, officer, director (or individual having
powers or responsibilities similar to those of officers or
directors), or a 10% or more shareholder, directly or
indirectly, of a person described in B, C, D, E, or G, or of the
employee benefit plan; or
I. A 10% or more (directly or indirectly in capital or profits)
partner or joint venture of a person described in B, C, D, E,
or G.
An unfunded, fully insured, or combination
unfunded/insured welfare plan with 100 or more
participants exempt under 29 CFR 2520.104-44

Instructions for Schedule G (Form 5500)

-33-

from completing Schedule H must still complete Schedule G,
Part III, to report nonexempt transactions.
A plan that is required to file a Form M-1, Report for MultipleEmployer Welfare Arrangements (MEWAs) and Certain
Entities Claiming Exception (ECEs), but that is not required to
file the Schedule I because it has fewer than 100 participants
and meets the requirements of 29 CFR 2520.104-44, also
must complete Schedule G, Part III, to report nonexempt
transactions.
If you are unsure whether a transaction is exempt or not, you
should consult with either the plan’s independent qualified
public accountant or legal counsel or both.
You may indicate that an application for an administrative
exemption is pending.
If the plan is a qualified pension plan and a nonexempt
prohibited transaction occurred with respect to a disqualified
person, an IRS Form 5330, Return of Excise Taxes Related to
Employee Benefit Plans, is required to be filed with the IRS to
pay the excise tax on the transaction.
The DOL Voluntary Fiduciary Correction Program
(VFCP) describes how to apply, the specific
transactions covered (which transactions include
delinquent participation contributions to pension and welfare
plans), and acceptable methods for correcting violations. In
addition, applicants that satisfy both the VFCP requirements
and the conditions of Prohibited Transaction Exemption (PTE)
2002-51 are eligible for immediate relief from payment of
certain prohibited excise taxes for certain corrected
transactions, and are also relieved from the obligation to file
the Form 5330 with the IRS. For more information, see 71 Fed.
Reg. 20261 (Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19,
2006). If conditions of PTE 2002-51 are satisfied, corrected
transactions should be treated as exempt under Code section
4975(c) for the purposes of answering Schedule G, Part III.
Information about the VFCP is also available on the internet at
www.dol.gov/ebsa.

2014 2015 Instructions for Schedule H
(Form 5500)
Financial Information
General Instructions
Who Must File
Schedule H (Form 5500) must be attached to a Form 5500 filed
for a pension benefit plan or a welfare benefit plan that covered
100 or more participants as of the beginning of the plan year
and a Form 5500 filed for an MTIA, CCT, PSA, 103-12 IE, or
GIA. See the instructions to the Form 5500 in Section 4: Direct
Filing Entity (DFE) Filing Requirements.
Exceptions: (1) Fully insured, unfunded, or a combination of
unfunded/insured welfare plans and fully insured pension plans
that meet the requirements of 29 CFR 2520.104-44 are exempt
from completing the Schedule H. (2) If a Schedule I was filed for
the plan for the 2013 2014 plan year or a Form 5500-SF and the
plan covered fewer than 121 participants as of the beginning of
the 2014 2015 plan year, the Schedule I may be completed
instead of a Schedule H. See What To File. If eligible, such a
plan may file the Form 5500-SF instead of the Form 5500 and
its schedules, including the Schedule I. See Instructions for
Form 5500-SF. (3) Plans that file a Form 5500-SF for the 2014
2015 plan year are not required to file a Schedule H for that
year.
Check the Schedule H box on the Form 5500 (Part II, line
10b(1)) if a Schedule H is attached to the Form 5500. Do not
attach both a Schedule H and a Schedule I to the same Form
5500.

Specific Instructions
Lines A, B, C, and D. This information must be the same as
reported in Part II of the Form 5500 to which this Schedule H is
attached.
Do not use a social security number in line D in lieu of an
EIN. The Schedule H and its attachments are open to public
inspection, and the contents are public information and are
subject to publication on the Internet. Because of privacy
concerns, the inclusion of a social security number or any
portion thereof on this Schedule H or any of its attachments may
result in the rejection of the filing.
You can apply for an EIN from the IRS online, by telephone,
by fax, or by mail depending on how soon you need to use the
EIN. For more information, see Section 3: Electronic Filing
Requirement under General Instructions to Form 5500. The
EBSA does not issue EINs.

Part I – Asset and Liability Statement
Note. The cash, modified cash, or accrual basis may be used
for recognition of transactions in Parts I and II, as long as you
use one method consistently. Round off all amounts reported
on the Schedule H to the nearest dollar. Any other amounts are
subject to rejection. Check all subtotals and totals carefully.
If the assets of two or more plans are maintained in a fund or
account that is not a DFE, a registered investment company, or
the general account of an insurance company under an the
unallocated contract (see the instructions for lines 1c(9) through
1c(14)), complete Parts I and II of the Schedule H by entering
the plan’s allocable part of each line item.
Exception. When completing Part II of the Schedule H for a
plan or DFE that participates in a CCT or PSA for which a Form
5500 has not been filed, do not allocate the income of the CCT
or PSA and expenses that were subtracted from the gross
income of the CCT or PSA in determining their net investment
Instructions for Schedule H (Form 5500)

gain (loss). Instead, enter the CCT or PSA net gain (loss) on
line 2b(6) or (7) in accordance with the instructions for these
lines.
If assets of one plan are maintained in two or more trust
funds, report the combined financial information in Parts I and II.
Current value means fair market value where available.
Otherwise, it means the fair value as determined in good faith
under the terms of the plan by a trustee or a named fiduciary,
assuming an orderly liquidation at time of the determination.
See ERISA section 3(26).
Note. For the 2014 2015 plan year, plans that provide
participant-directed brokerage accounts as an investment
alternative (and have entered pension feature code ‘‘2R’’ on line
8a of the Form 5500) may report investments in assets made
through participant-directed brokerage accounts either:
1. As individual investments on the applicable asset and
liability categories in Part I and the income and expense
categories in Part II, or
2. By including on line 1c(15) the total aggregate value of the
assets and on line 2c the total aggregate investment income
(loss) before expenses, provided the assets are not loans,
partnership or joint-venture interests, real property, employer
securities, or investments that could result in a loss in excess of
the account balance of the participant or beneficiary who
directed the transaction. Expenses charged to the accounts
must be reported on the applicable expense line items.
Participant-directed brokerage account assets reported in the
aggregate on line 1c(15) should be treated as one asset held for
investment for purposes of the line 4i schedules, except that
investments in tangible personal property must continue to be
reported as separate assets on the line 4i schedules.
In the event that investments made through a
participant-directed brokerage account are loans, partnership or
joint venture interests, real property, employer securities, or
investments that could result in a loss in excess of the account
balance of the participant or beneficiary who directed the
transaction, such assets must be broken out and treated as
separate assets on the applicable asset and liability categories
in Part I, income and expense categories in Part II, and on the
line 4i schedules. The remaining assets in the participantdirected brokerage account may be reported in the aggregate
as set forth in paragraph 2 above.
Columns (a) and (b). Enter the current value on each line as of
the beginning and end of the plan year.
Note. Amounts reported in column (a) must be the same as
reported for the end of the plan year for corresponding line
items of the return/report for the preceding plan year. Do not
include contributions designated for the 2014 2015 plan year in
column (a).
Line 1a. Total noninterest bearing cash includes, among other
things, cash on hand or cash in a noninterest bearing checking
account.
Line 1b(1). Noncash basis filers must include contributions due
the plan by the employer but not yet paid. Do not include other
amounts due from the employer such as the reimbursement of
an expense or the repayment of a loan.
Line 1b(2). Noncash basis filers must include contributions
withheld by the employer from participants and amounts due
directly from participants that have not yet been received by the
plan. Do not include the repayment of participant loans.
Line 1b(3). Noncash basis filers must include amounts due to
the plan that are not includable in lines 1b(1) or 1b(2). These
amounts may include investment income earned but not yet
received by the plan and other amounts due to the plan such as
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amounts due from the employer or another plan for expense
reimbursement or from a participant for the repayment of an
overpayment of benefits.
Line 1c(1). Include all assets that earn interest in a financial
institution account such as interest bearing checking accounts,
passbook savings accounts, or in money market accounts.
Line 1c(2). Include securities issued or guaranteed by the U.S.
Government or its designated agencies such as U.S. Savings
Bonds, Treasury Bonds, Treasury Bills, FNMA, and GNMA.
Line 1c(3). Include investment securities (other than employer
securities defined below in line 1d(1)) issued by a corporate
entity at a stated interest rate repayable on a particular future
date such as most bonds, debentures, convertible debentures,
commercial paper and zero coupon bonds. Do not include debt
securities of governmental units that should be reported on line
1c(2) or 1c(15).
‘‘Preferred’’ means any of the above securities that are
publicly traded on a recognized securities exchange and the
securities have a rating of ‘‘A’’ or above. If the securities are not
‘‘Preferred,’’ they are listed as ‘‘Other.’’
Line 1c(4)(A). Include stock issued by corporations (other than
employer securities defined in line 1d(1) below) which is
accompanied by preferential rights such as the right to share in
distributions of earnings at a higher rate or which has general
priority over the common stock of the same entity. Include the
value of warrants convertible into preferred stock.
Line 1c(4)(B). Include any stock (other than employer securities
defined in line 1d(1)) that represents regular ownership of the
corporation and is not accompanied by preferential rights.
Include the value of warrants convertible into common stock.
Line 1c(5). Include the value of the plan’s participation in a
partnership or joint venture if the underlying assets of the
partnership or joint venture are not considered to be plan assets
under 29 CFR 2510.3-101. Do not include the value of a plan’s
interest in a partnership or joint venture that is a 103-12
Investment Entity (103-12 IE). Include the value of a 103-12 IE
in line 1c(12).
Line 1c(6). Include the current value of both income and nonincome producing real property owned by the plan. Do not
include the value of property that is employer real property or
property used in plan operations that must be reported on lines
1d and 1e, respectively.
Line 1c(7). Enter the current value of all loans made by the
plan, except participant loans reportable on line 1c(8). Include
the sum of the value of loans for construction, securities loans,
commercial and/or residential mortgage loans that are not
subject to Code section 72(p) (either by making or participating
in the loans directly or by purchasing loans originated by a third
party), and other miscellaneous loans.
Line 1c(8). Enter the current value of all loans to participants
including residential mortgage loans that are subject to Code
section 72(p). Include the sum of the value of the unpaid
principal balances, plus accrued but unpaid interest, if any, for
participant loans made under an individual account plan with
investment experience segregated for each account, that are
made in accordance with 29 CFR 2550.408b-1 and secured
solely by a portion of the participant’s vested accrued benefit.
When applicable, combine this amount with the current value of
any other participant loans. Do not include in column (b) a
participant loan that has been deemed distributed during the
plan year under the provisions of Code section 72(p) and
Treasury Regulations section 1.72(p)-1, if both of the following
circumstances apply:

Instructions for Schedule H (Form 5500)

1. Under the plan, the participant loan is treated as a
directed investment solely of the participant’s individual account;
and
2. As of the end of the plan year, the participant is not
continuing repayment under the loan.
If both of these circumstances apply, report the loan as a
deemed distribution on line 2g. However, if either of these
circumstances does not apply, the current value of the
participant loan (including interest accruing thereon after the
deemed distribution) must be included in column (b) without
regard to the occurrence of a deemed distribution.
Note. After a participant loan that has been deemed distributed
is reported on line 2g, it is no longer to be reported as an asset
on Schedule H or Schedule I unless, in a later year, the
participant resumes repayment under the loan. However, such a
loan (including interest accruing thereon after the deemed
distribution) that has not been repaid is still considered
outstanding for purposes of applying Code section 72(p)(2)(A)
to determine the maximum amount of subsequent loans. Also,
the deemed distribution is not treated as an actual distribution
for other purposes, such as the qualification requirements of
Code section 401, including, for example, the determination of
top-heavy status under Code section 416 and the vesting
requirements of Treasury Regulations section 1.411(a)-7(d)(5).
See Q&As 12 and 19 of Treasury Regulations section 1.72(p)-1.
The entry on line 1c(8), column (b), of Schedule H
(participant loans - end of year) or on line 1a, column (b), of
Schedule I (plan assets - end of year) must include the current
value of any participant loan that was reported as a deemed
distribution on line 2g for any earlier year if the participant
resumes repayment under the loan during the plan year. In
addition, the amount to be entered on line 2g must be reduced
by the amount of the participant loan that was reported as a
deemed distribution on line 2g for the earlier year.
Lines 1c(9), (10), (11), and (12). Enter the total current value of
the plan’s or DFE’s interest in DFEs on the appropriate lines as
of the beginning and end of the plan or DFE year. The value of
the plan’s or DFE’s interest in each DFE at the end of the plan
or DFE year must be reported on the Schedule D (Form 5500).
The plan’s or DFE’s interest in common/collective trusts (CCTs)
and pooled separate accounts (PSAs) for which a DFE
Form 5500 has not been filed may not be included on
lines 1c(9) or 1c(10). The plan’s or DFE’s interest in
the underlying assets of such CCTs and PSAs must be
allocated and reported in the appropriate categories on a lineby-line basis on Part I of the Schedule H.
Note. For reporting purposes, a separate account that is not
considered to be holding plan assets pursuant to 29 CFR
2510.3-101(h)(1)(iii) does not constitute a PSA.
Line 1c(13). A registered investment company is an investment
company registered under the Investment Company Act of
1940. These are mutual funds (legally known as open-end
companies), closed-end funds (legally known as closed-end
companies), and UITs (legally known as unit investment trusts).
Line 1c(14). Use the same method for determining the value of
the insurance contracts reported here as you used for line 4 of
Schedule A, or, if line 4 is not required, line 7 of Schedule A.
Line 1c(15). Include all other investments not includable in lines
1c(1) through (14), such as options, index futures, state and
municipal securities, collectibles, and other personal property.
Line 1d(1). An employer security is any security issued by an
employer (including affiliates) of employees covered by the plan.
These may include common stocks, preferred stocks, bonds,
zero coupon bonds, debentures, convertible debentures, notes
and commercial paper.
-35-

Line 1d(2). The term ‘‘employer real property’’ means real
property (and related personal property) that is leased to an
employer of employees covered by the plan, or to an affiliate of
such employer. For purposes of determining the time at which a
plan acquires employer real property for purposes of this line,
such property shall be deemed to be acquired by the plan on
the date on which the plan acquires the property or on the date
on which the lease to the employer (or affiliate) is entered into,
whichever is later.
Line 1e. Include the current (not book) value of the buildings
and other property used in the operation of the plan. Buildings
or other property held as plan investments should be reported in
1c(6) and 1d(2).
Do not include the value of future pension payments on lines
1g, h, i, j, or k.
Line 1g. Noncash basis plans must include the total amount of
benefit claims that have been processed and approved for
payment by the plan. Include welfare plan ‘‘incurred but not
reported’’ (IBNR) benefit claims on this line.
Line 1h. Noncash basis plans must include the total amount of
obligations owed by the plan which were incurred in the normal
operations of the plan and have been approved for payment by
the plan but have not been paid.
Line 1i. ‘‘Acquisition indebtedness,’’ for debt-financed property
other than real property, means the outstanding amount of the
principal debt incurred:
1. By the organization in acquiring or improving the
property;
2. Before the acquisition or improvement of the property if
the debt was incurred only to acquire or improve the property; or
3. After the acquisition or improvement of the property if the
debt was incurred only to acquire or improve the property and
was reasonably foreseeable at the time of such acquisition or
improvement. For further explanation, see Code section 514(c).
Line 1j. Noncash basis plans must include amounts owed for
any liabilities that would not be classified as benefit claims
payable, operating payables, or acquisition indebtedness.
Line 1l. Enter the net assets as of the beginning and end of the
plan year (Subtract line 1k from line 1f.) The entry in column (b)
must equal the sum of the entry in column (a) plus lines 2k and
2l(1), minus 2l(2).

Line 2b(1)(C). Generally, this is the interest earned on
securities that are reported on lines 1c(3)(A) and (B) and 1d(1).
Line 2b(2). Generally, the dividends are for investments
reported on lines 1c(4)(A) and (B), 1c(13), and 1d(1). For
accrual basis plans, include any dividends declared for stock
held on the date of record, but not yet received as of the end of
the plan year.
Line 2b(3). Generally, rents represent the income earned on the
real property that is reported in lines 1c(6) and 1d(2). Enter
rents as a ‘‘Net’’ figure. Net rents are determined by taking the
total rent received and subtracting all expenses directly
associated with the property. If the real property is jointly used
as income producing property and for the operation of the plan,
net that portion of the expenses attributable to the income
producing portion of the property against the total rents
received.
Line 2b(4). Enter in column (b), the total of net gain (loss) on
sale of assets. This equals the sum of the net realized gain (or
loss) on each asset held at the beginning of the plan year which
was sold or exchanged during the plan year, and on each asset
that was both acquired and disposed of within the plan year.
Note. As current value reporting is required for the Form 5500,
assets are revalued to current value at the end of the plan year.
For purposes of this form, the increase or decrease in the value
of assets since the beginning of the plan year (if held on the first
day of the plan year) or their acquisition date (if purchased
during the plan year) is reported in line 2b(5) below, with two
exceptions: (1) the realized gain (or loss) on each asset that
was disposed of during the plan year is reported in line 2b(4)
(NOT on line 2b(5)), and (2) the net investment gain (or loss)
from CCTs, PSAs, MTIAs, 103-12 IEs, and registered
investment companies is reported in lines 2b(6) through (10).
The sum of the realized gain (or loss) of assets sold or
exchanged during the plan year is to be calculated as follows:
1. Enter in line 2b(4)(A), column (a), the sum of the amount
received for these former assets;
2. Enter in line 2b(4)(B), column (a), the sum of the current
value of these former assets as of the beginning of the plan year
and the purchase price for assets both acquired and disposed of
during the plan year; and
3. Enter in 2b(4) (C), column (b), the result obtained when
2b(4)(B) is subtracted from 2b(4)(A). If entering a negative
number, enter a minus sign “–” to the left of the number.
Note. Bond write-offs should be reported as realized losses.
Line 2b(5). Subtract the current value of assets at the beginning
of the year plus the cost of any assets acquired during the plan
year from the current value of assets at the end of the year to
obtain this figure. If entering a negative number, enter a minus
sign “–” to the left of the number. Do not include the value of
assets reportable in lines 2b(4) and 2b(6) through 2b(10).
Lines 2b(6), (7), (8), and (9). Report all earnings, expenses,
gains or losses, and unrealized appreciation or depreciation
included in computing the net investment gain (or loss) from all
CCTs, PSAs, MTIAs, and 103-12 IEs here. If some plan funds
are held in any of these entities and other plan funds are held in
other funding media, complete all applicable subitems of line 2
to report plan earnings and expenses relating to the other
funding media. The net investment gain (or loss) allocated to the
plan for the plan year from the plan’s investment in these
entities is equal to:
1. The sum of the current value of the plan’s interest in each
entity at the end of the plan year,
2. Minus the current value of the plan’s interest in each entity
at the beginning of the plan year,

Part II – Income and Expense Statement
Line 2a. Include the total cash contributions received and/or (for
accrual basis plans) due to be received.
Note. Plans using the accrual basis of accounting should not
include contributions designated for years before the 2014 2015
plan year on line 2a.
Line 2a(1)(B). For welfare plans, report all employee
contributions, including all elective contributions under a
cafeteria plan (Code section 125). For pension benefit plans,
participant contributions, for purposes of this item, also include
elective contributions under a qualified cash or deferred entities
arrangement (Code section 401(k)).
Line 2a(2). Use the current value, at date contributed, of
securities or other noncash property.
Line 2b(1)(A). Enter interest earned on interest-bearing cash,
including earnings from sweep accounts, STIF accounts, money
market accounts, certificates of deposit, etc. This is the interest
earned on the investments reported on line 1c(1).
Line 2b(1)(B). Enter interest earned on U.S. Government
Securities. This is the interest earned on the investments
reported on line 1c(2).

-36-

Instructions for Schedule H (Form 5500)

3. Plus any amounts transferred out of each entity by the
plan during the plan year, and
4. Minus any amounts transferred into each entity by the
plan during the plan year.
Enter the net gain as a positive number or the net loss as a
negative number.
Note. Enter the combined net investment gain or loss from all
CCTs and PSAs, regardless of whether a DFE Form 5500 was
filed for the CCTs and PSAs.
Line 2b(10). Enter net investment gain (loss) from registered
investment companies here. Compute in the same manner as
discussed above for lines 2b(6) through (9), except do not
include dividends reported on line 2b(2)(C).
Line 2c. Include all other plan income earned that is not
included in line 2a or 2b. Do not include transfers from other
plans that should be reported in line 2l.
Line 2e(1). Include the current value of all cash, securities, or
other property at the date of distribution. Include all eligible
rollover distributions as defined in Code section 401(a)(31)(D)
paid at the participant’s election to an eligible retirement plan
(including an IRA within the meaning of section 401(a)(31)(E)).
Line 2e(2). Include payments to insurance companies and
similar organizations such as Blue Cross, Blue Shield, and
health maintenance organizations for the provision of plan
benefits (e.g., paid-up annuities, accident insurance, health
insurance, vision care, dental coverage, stop-loss insurance
whose claims are paid to the plan (or which is otherwise an
asset of the plan )), etc.
Line 2e(3). Include all payments made to other organizations
or individuals providing benefits. Generally, these are individual
providers of welfare benefits such as legal services, day care
services, training, and apprenticeship services.
Line 2f. Include on this line all distributions paid during the
plan year of excess deferrals under Code section
402(g)(2)(A)(ii), excess contributions under Code section
401(k)(8), and excess aggregate contributions under Code
section 401(m)(6). Include allocable income distributed. Also
include on this line any elective deferrals and employee
contributions distributed or returned to employees during the
plan year, as well as any attributable income that was also
distributed.
Line 2g. Report on line 2g a participant loan that has been
deemed distributed during the plan year under the provisions of
Code section 72(p) and Treasury Regulations section 1.72(p)-1
only if both of the following circumstances apply:
1. Under the plan, the participant loan is treated as a
directed investment solely of the participant’s individual account;
and
2. As of the end of the plan year, the participant is not
continuing repayment under the loan.
If either of these circumstances does not apply, a deemed
distribution of a participant loan should not be reported on line
2g. Instead, the current value of the participant loan (including
interest accruing thereon after the deemed distribution) must be
included on line 1c(8), column (b) (participant loans – end of
year), without regard to the occurrence of a deemed distribution.
Note. The amount to be reported on line 2g of Schedule H or
Schedule I must be reduced if, during the plan year, a
participant resumes repayment under a participant loan reported
as a deemed distribution on line 2g for any earlier year. The
amount of the required reduction is the amount of the participant
loan reported as a deemed distribution on line 2g for the earlier
year. If entering a negative number, enter a minus sign “ – ” to
the left of the number. The current value of the participant loan
Instructions for Schedule H (Form 5500)

must then be included in line 1c(8), column (b), of Schedule H
(participant loans - end of year) or in line 1a, column (b), of
Schedule I (plan assets - end of year).
Although certain participant loans deemed distributed are to
be reported on line 2g of the Schedule H or Schedule I, and are
not to be reported on the Schedule H or Schedule I as an asset
thereafter (unless the participant resumes repayment under the
loan in a later year), they are still considered outstanding loans
and are not treated as actual distributions for certain purposes.
See Q&As 12 and 19 of Treasury Regulations section 1.72(p)-1.
Line 2h. Interest expense is a monetary charge for the use of
money borrowed by the plan. This amount should include the
total of interest paid or to be paid (for accrual basis plans)
during the plan year.
Line 2i. Report all administrative expenses (by specified
category) paid by or charged to the plan, including those that
were not subtracted from the gross income of CCTs, PSAs,
MTIAs, and 103-12 IEs in determining their net investment
gain(s) or loss(es). Expenses incurred in the general operations
of the plan are classified as administrative expenses.
Line 2i(1). Include the total fees paid (or in the case of accrual
basis plans, costs incurred during the plan year but not paid as
of the end of the plan year) by the plan for outside accounting,
actuarial, legal, and valuation/appraisal services. Include fees
for the annual audit of the plan by an independent qualified
public accountant (IQPA); for payroll audits; for
accounting/bookkeeping services; for actuarial services
rendered to the plan; and to a lawyer for rendering legal
opinions, litigation, and advice (but not for providing legal
services as a benefit to plan participants). Report here fees and
expenses for corporate trustees and individual plan trustees,
including reimbursement of expenses associated with trustees,
such as lost time, seminars, travel, meetings, etc. Include the
fee(s) for valuations or appraisals to determine the cost, quality,
or value of an item such as real property, personal property
(gemstones, coins, etc.), and for valuations of closely held
securities for which there is no ready market. Do not include
amounts paid to plan employees to perform bookkeeping/
accounting functions that should be included in line 2i(4).
Line 2i(2). Enter the total fees paid (or in the case of accrual
basis plans, costs incurred during the plan year but not paid as
of the end of the plan year) to a contract administrator for
performing administrative services for the plan. For purposes of
the return/report, a contract administrator is any individual,
partnership, or corporation, responsible for managing the
clerical operations (e.g., handling membership rosters, claims
payments, maintaining books and records) of the plan on a
contractual basis. Do not include salaried staff or employees of
the plan or banks or insurance carriers.
Line 2i(3). Enter the total fees paid (or in the case of accrual
basis plans, costs incurred during the plan year but not paid as
of the end of the plan year) to an individual, partnership or
corporation (or other person) for advice to the plan relating to its
investment portfolio. These may include fees paid to manage
the plan’s investments, fees for specific advice on a particular
investment, and fees for the evaluation for the plan’s investment
performance.
Line 2i(4). Other expenses are those that cannot be included in
2i(1) through 2i(3). These may include plan expenditures such
as salaries and other compensation and allowances (e.g.,
payment of premiums to provide health insurance benefits to
plan employees), expenses for office supplies and equipment,
cars, telephone, postage, rent, expenses associated with the
ownership of a building used in the operation of the plan, and all

-37-

miscellaneous expenses. Include premium payments to the
PBGC when paid from plan assets.
Line 2l. Include in these reconciliation figures the value of all
transfers of assets or liabilities into or out of the plan resulting
from, among other things, mergers and consolidations. A
transfer of assets or liabilities occurs when there is a reduction
of assets or liabilities with respect to one plan and the receipt of
these assets or the assumption of these liabilities by another
plan. A transfer is not a shifting of one plan’s assets or liabilities
from one investment to another. A transfer is not a distribution of
all or part of an individual participant’s account balance that is
reportable on IRS Form 1099-R, Distributions From Pensions,
Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance
Contracts, etc., (see the instructions for line 2e). Transfers out
at the end of the year should be reported as occurring during
the plan year.
Note. If this Schedule H is filed for a CCT, PSA, MTIA, or
103-12 IE, report the value of all asset transfers to the CCT,
PSA, MTIA, or 103-12 IE, including those resulting from
contributions to participating plans on line 2l(1), and report the
total value of all assets transferred out of the CCT, PSA, MTIA,
or 103-12 IE, including assets withdrawn for disbursement as
benefit payments by participating plans, on line 2l(2).
Contributions and benefit payments are considered to be made
to/by the plan (not to/by a CCT, PSA, MTIA, or 103-12 IE).

transaction exemption (PTE) 2002-51 do not need to be treated
as part of the schedule of nonexempt party-in-interest
transactions.
If the required IQPA’s report is not attached to the Form
5500, the filing is subject to rejection as incomplete and
penalties may be assessed.
Lines 3a(1) through 3a(4). These boxes identify the type of
opinion offered by the IQPA.
Line 3a(1). Check if an unqualified opinion was issued.
Generally, an unqualified opinion is issued when the IQPA
concludes that the plan’s financial statements present fairly, in
all material respects, the financial status of the plan as of the
end of the period audited and the changes in its financial status
for the period under audit in conformity with generally accepted
accounting principles (GAAP) or another comprehensive basis
of accounting (OCBOA), e.g., cash basis.
Line 3a(2). Check if a qualified opinion was issued. Generally,
a qualified opinion is issued by an IQPA when the plan’s
financial statements present fairly, in all material respects, the
financial status of the plan as of the end of the audit period and
the changes in its financial status for the period under audit in
conformity with GAAP or OCBOA, except for the effects of one
or more matters described in the opinion.
Line 3a(3). Check if a disclaimer of opinion was issued. A
disclaimer of opinion is issued when the IQPA does not express
an opinion on the financial statements because he or she has
not performed an audit sufficient in scope to enable him or her
to form an opinion on the financial statements.
Line 3a(4). Check if the plan received an adverse accountant’s
opinion. Generally, an adverse opinion is issued by an IQPA
when the plan’s financial statements do not present fairly, in all
material respects, the financial status of the plan as of the end
of the audit period and the changes in its financial status for the
period under audit in conformity with GAAP or OCBOA.
Line 3b. Check “Yes” if a box is checked on line 3a and the
only limitation on the scope of the plan’s audit was pursuant to
DOL regulations 29 CFR 2520.103-8 and 2520.103-12(d)
because the examination and report of an IQPA did not extend
to: (a) statements or information regarding assets held by a
bank, similar institution, or insurance carrier that is regulated
and supervised and subject to periodic examination by a state
or federal agency provided that the statements or information
are prepared by and certified to by the bank or similar institution
or an insurance carrier, or (b) information included with the
Form 5500 filed for a 103-12 IE. The term ‘‘similar institution’’ as
used here does not extend to securities brokerage firms (see
DOL Advisory Opinion 93-21A). See 29 CFR 2520.103-8 and
2520.103-12(d).
Check “No” if the scope of the plan’s audit was limited
for any reason in addition to that pursuant to DOL
regulations 29 CFR 2520.103-8 and 2520.103-12.
Note. These regulations do not exempt the plan administrator
from engaging an IQPA or from attaching the IQPA’s report to
the Form 5500. If you check line 3b, you must also check the
appropriate box on line 3a to identify the type of opinion offered
by the IQPA.
Line 3c. Enter the name and EIN of the accountant (or
accounting firm) in the space provided on line 3c. Do not use a
social security number or any portion thereof in lieu of an EIN.
The Schedule H is open to public inspection, and the contents
are public information and are subject to publication on the
Internet. Because of privacy concerns, the inclusion of a social
security number or any portion thereof on this Schedule H may
result in the rejection of the filing.

Part III – Accountant’s Opinion
Line 3. The administrator of an employee benefit plan who files
a Schedule H generally must engage an Independent Qualified
Public Accountant (IQPA) pursuant to ERISA section
103(a)(3)(A) and 29 CFR 2520.103-1(b). This requirement also
applies to a Form 5500 filed for a 103-12 IE and for a GIA (see
29 CFR 2520.103-12 and 29 CFR 2520.103-2). The IQPA’s
report must be attached to the Form 5500 when a Schedule H is
attached unless line 3d(1) or 3d(2) on the Schedule H is
checked.
Note. An IQPA Report generally consists of an Accountant’s
Opinion, Financial Statements, Notes to the Financial
Statements, and Supplemental Schedules.
29 CFR 2520.103-1(b) requires that any separate financial
statements prepared in order for the IQPA to form the opinion
and notes to these financial statements must be attached to the
Form 5500. Any separate statements must include the
information required to be disclosed in Parts I and II of the
Schedule H; however, they may be aggregated into categories
in a manner other than that used on the Schedule H. The
separate statements must consist of reproductions of Parts I
and II or statements incorporating by reference Parts I and II.
See ERISA section 103(a)(3)(A), and the DOL regulations 29
CFR 2520.103-1(a)(2) and (b), 2520.103-2, and 2520.104-50.
Note. Delinquent participant contributions reported on line 4a
should be treated as part of the separate schedules referenced
in ERISA section 103(a)(3)(A) and 29 CFR 2520.103-1(b) and
2520.103-2(b) for purposes of preparing the IQPA’s opinion
described on line 3 even though they are no longer required to
be listed on Part III of the Schedule G. If the information
contained on line 4a is not presented in accordance with
regulatory requirements, i.e., when the IQPA concludes that the
scheduled information required by line 4a does not contain all
the required information or contains information that is
inaccurate or is inconsistent with the plan’s financial statements,
the IQPA report must make the appropriate disclosures in
accordance with generally accepted auditing standards.
Delinquent participant contributions that are exempt because
they satisfy the DOL Voluntary Fiduciary Correction Program
(VFCP) requirements and the conditions of prohibited
-38-

Instructions for Schedule H (Form 5500)

Line 3d(1). Check this box only if the Schedule H is being filed
for a CCT, PSA, or MTIA.
Line 3d(2). Check this box if the plan has elected to defer
attaching the IQPA’s opinion for the first of two (2) consecutive
plan years, one of which is a short plan year of seven (7)
months or fewer. The Form 5500 for the first of the two (2) years
must be complete and accurate, with all required attachments,
except for the IQPA’s report, including an attachment explaining
why one of the two (2) plan years is of seven (7) or fewer
months duration and stating that the annual report for the
immediately following plan year will include a report of an IQPA
with respect to the financial statements and accompanying
schedules for both of the two (2) plan years. The Form 5500 for
the second year must include: (a) financial schedules and
statements for both plan years; (b) a report of an IQPA with
respect to the financial schedules and statements for each of
the two (2) plan years (regardless of the number of participants
covered at the beginning of each plan year); and (c) a statement
identifying any material differences between the unaudited
financial information submitted with the first Form 5500 and the
audited financial information submitted with the second Form
5500. See 29 CFR 2520.104-50.
Note. Do not check the box on line 3d(2) if the Form 5500 is
filed for a 103-12 IE or a GIA. A deferral of the IQPA’s opinion is
not permitted for a 103-12 IE or a GIA. If an “E” or “G” is entered
on Form 5500, Part I, line A(4), an IQPA’s opinion must be
attached to the Form 5500 and the type of opinion must be
reported on Schedule H, line 3a.

employer for purposes of transmittal to the plan that were not
transmitted to the plan in a timely fashion must be reported
either on line 4a in accordance with the reporting requirements
that apply to delinquent participant contributions or on line 4d.
See Advisory Opinion 2002-02A, available at
www.dol.gov/ebsa.
Delinquent participant contributions reported on line 4a
should be treated as part of the separate schedules
referenced in ERISA section 103(a)(3)(A) and 29 CFR
2520.103-1(b) and 2520.103-2(b) for purposes of preparing the
IQPA’s opinion described on line 3 even though they are no
longer required to be listed on Part III of the Schedule G. If the
information contained on line 4a is not presented in accordance
with regulatory requirements, i.e., when the IQPA concludes
that the scheduled information required by line 4a does not
contain all the required information or contains information that
is inaccurate or is inconsistent with the plan’s financial
statements, the IQPA report must make the appropriate
disclosures in accordance with generally accepted auditing
standards. For more information, see EBSA’s Frequently Asked
Questions About Reporting Delinquent Contributions on the
Form 5500, available on the Internet at www.dol.gov/ebsa.
These Frequently Asked Questions clarify that plans have an
obligation to include delinquent participant contributions on their
financial statements and supplemental schedules and that the
IQPA’s report covers such delinquent contributions even though
they are not required to be included on Part III of the Schedule
G. Although all delinquent participant contributions must be
reported on line 4a, delinquent contributions for which the DOL
VFCP requirements and the conditions of PTE 2002-51 have
been satisfied do not need to be treated as nonexempt party-ininterest transactions.
The VFCP describes how to apply, the specific transactions
covered (which transactions include delinquent participant
contributions to pension and welfare plans), and acceptable
methods for correcting violations. In addition, applicants that
satisfy both the VFCP requirements and the conditions of PTE
2002-51 are eligible for immediate relief from payment of certain
prohibited transaction excise taxes for certain corrected
transactions, and are also relieved from the obligation to file the
IRS Form 5330 with the IRS. For more information, see 71 Fed.
Reg. 20261 (Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19,
2006). Information about the VFCP is also available on the
Internet at www.dol.gov/ebsa.

Part IV – Compliance Questions
Lines 4a through 4n4p. Plans completing Schedule H must
answer all these lines with either ‘‘Yes’’ or ‘‘No.’’ Do not leave
any answer blank, unless otherwise directed. For lines 4a
through 4h and line 4l, and lines 4o-4p, if the answer is “Yes,”
an amount must be entered.
Report investments in CCTs, PSAs, MTIAs, and 103-12 IEs,
but not the investments made by these entities. Plans with all of
their funds held in a master trust should check ‘‘No’’ on line 4b,
4c, 4i, and 4j. CCTs and PSAs do not complete Part IV. MTIAs,
103-12 IEs, and GIAs do not complete lines 4a, 4e, 4f, 4g, 4h,
4k, 4m, or 4n. 103-12 IEs also do not complete line 4j and 4l.
MTIAs also do not complete line 4l.
Line 4a. Amounts paid by a participant or beneficiary to an
employer and/or withheld by an employer for contribution to the
plan are participant contributions that become plan assets as of
the earliest date on which such contributions can reasonably be
segregated from the employer’s general assets (see 29 CFR
2510.3-102). Plans that check “Yes” must enter the aggregate
amount of all late contributions for the year. The total amount of
the delinquent contributions should be included on line 4a of the
Schedule H or I, as applicable, for the year in which the
contributions were delinquent and should be carried over and
reported again on line 4a of the Schedule H or I, as applicable,
for each subsequent year until the year after the violation has
been fully corrected, which correction includes payment of the
late contributions and reimbursement of the plan for lost
earnings or profits. If no participant contributions were received
or withheld by the employer during the plan year, answer “No.”
An employer holding these assets after that date commingled
with its general assets will have engaged in a prohibited use of
plan assets (see ERISA section 406). If such a nonexempt
prohibited transaction occurred with respect to a disqualified
person (see Code section 4975(e)(2)), file IRS Form 5330,
Return of Excise Taxes Related to Employee Benefit Plans, with
the IRS to pay any applicable excise tax on the transaction.
Participant loan repayments paid to and/or withheld by an
Instructions for Schedule H (Form 5500)

All delinquent participant contributions must be reported on
line 4a even if violations have been corrected.
Line 4a Schedule. Attach a Schedule of Delinquent
Participant Contributions using the format below if you entered
“Yes.” If you chose to include participant loan repayments on
line 4a, you must apply the same supplemental schedule and
IQPA disclosure requirements to the loan repayments as
applied to delinquent transmittals of participant contributions.
Schedule H Line 4a –Schedule of Delinquent
Participant Contributions
Participant
Contributions
Transferred
Late to Plan

Total Fully
Corrected
Under
VFCP and
Check here if Contributions Contributions Contributions PTE 200251
Late
Not
Corrected
Pending
Participant
Corrected
Outside
Correction in
Loan
VFCP
VFCP
Repayments
are included:

-39-

Total that Constitute Nonexempt
Prohibited Transactions

Line 4b. Plans that check “Yes” must enter the amount and
complete Part I of Schedule G. The due date, payment amount
and conditions for determining default of a note or loan are
usually contained in the documents establishing the note or
loan. A loan by the plan is in default when the borrower is
unable to pay the obligation upon maturity. Obligations that
require periodic repayment can default at any time. Generally,
loans and fixed income obligations are considered uncollectible
when payment has not been made and there is little probability
that payment will be made. A fixed income obligation has a fixed
maturity date at a specified interest rate. Do not include
participant loans made under an individual account plan with
investment experience segregated for each account that were
made in accordance with 29 CFR 2550.408b-1 and secured
solely by a portion of the participant’s vested accrued benefit.
Line 4c. Plans that check “Yes” must enter the amount and
complete Part II of Schedule G. A lease is an agreement
conveying the right to use property, plant, or equipment for a
stated period. A lease is in default when the required
payment(s) has not been made. An uncollectible lease is one
where the required payments have not been made and for
which there is little probability that payment will be made.
Line 4d. Plans that check “Yes” must enter the amount and
complete Part III of Schedule G. Check ‘‘Yes’’ if any nonexempt
transaction with a party-in-interest occurred regardless of
whether the transaction is disclosed in the IQPA’s report. Do not
check “Yes” or complete Schedule G, Part III, with respect to
transactions that are: (1) statutorily exempt under Part 4 of Title
I of ERISA; (2) administratively exempt under ERISA section
408(a); (3) exempt under Code sections 4975(c) or 4975(d); (4)
the holding of participant contributions in the employer’s general
assets for a welfare plan that meets the conditions of ERISA
Technical Release 92-01; (5) a transaction of a 103-12 IE with
parties other than the plan; or (6) delinquent participant
contributions or delinquent participant loan repayments reported
on line 4a.
Note. See the instructions for Part III of the Schedule G (Form
5500) concerning nonexempt transactions and party-in-interest.
You may indicate that an application for an administrative
exemption is pending. If you are unsure as to whether a
transaction is exempt or not, you should consult with either the
plan’s IQPA or legal counsel or both.
Applicants that satisfy the VFCP requirements and the
conditions of PTE 2002-51 (see the instructions for line
4a) are eligible for immediate relief from payment of
certain prohibited transaction excise taxes for certain corrected
transactions, and are also relieved from the obligation to file the
IRS Form 5330 with the IRS. For more information, see 71 Fed.
Reg. 20261 (Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19,
2006). When the conditions of PTE 2002-51 have been
satisfied, the corrected transactions should be treated as
exempt under Code section 4975(c) for the purposes of
answering line 4d.
Line 4e. Plans that check “Yes” must enter the aggregate
amount of fidelity bond coverage for all claims. Check ‘‘Yes’’
only if the plan itself (as opposed to the plan sponsor or
administrator) is a named insured under a fidelity bond from an
approved surety covering plan officials and that protects the
plan from losses due to fraud or dishonesty as described in 29
CFR Part 2580. Generally, every plan official of an employee
benefit plan who ‘‘handles’’ funds or other property of such plan
must be bonded. Generally, a person shall be deemed to be
‘‘handling’’ funds or other property of a plan, so as to require
bonding, whenever his or her duties or activities with respect to
given funds are such that there is a risk that such funds could
be lost in the event of fraud or dishonesty on the part of such

person, acting either alone or in collusion with others. Section
412 of ERISA and 29 CFR Part 2580 describe the bonding
requirements, including the definition of “handling” (29 CFR
2580.412-6), the permissible forms of bonds (29 CFR 2580.41210), the amount of the bond (29 CFR Part 2580, subpart C), and
certain exemptions such as the exemption for unfunded plans,
certain banks and insurance companies (ERISA section 412),
and the exemption allowing plan officials to purchase bonds
from surety companies authorized by the Secretary of the
Treasury as acceptable reinsurers on federal bonds (29 CFR
2580.412-23). Information concerning the list of approved
sureties and reinsures is available on the Internet at
www.fms.treas.gov/c570. For more information on the fidelity
bonding requirements, see Field Assistance Bulletin 2008-04,
available on the Internet at www.dol.gov/ebsa.
Note. Plans are permitted under certain conditions to purchase
fiduciary liability insurance. These fiduciary liability insurance
policies are not written specifically to protect the plan from
losses due to dishonest acts and cannot be reported as fidelity
bonds on line 4e.
Line 4f. Check ‘‘Yes,’’ if the plan suffered or discovered any
loss as a result of any dishonest or fraudulent act(s) even if the
loss was reimbursed by the plan’s fidelity bond or from any
other source. If ‘‘Yes’’ is checked enter the full amount of the
loss. If the full amount of the loss has not yet been determined,
provide an estimate and disclose that the figure is an estimate
as determined in good faith by a plan fiduciary. You must keep,
in accordance with ERISA section 107, records showing how
the estimate was determined.
Willful failure to report is a criminal offense. See ERISA
section 501.
Lines 4g and 4h. Current value means fair market value
where available. Otherwise, it means the fair value as
determined in good faith under the terms of the plan by a trustee
or a named fiduciary, assuming an orderly liquidation at the time
of the determination. See ERISA section 3(26).
An accurate assessment of fair market value is essential to a
pension plan’s ability to comply with the requirements set forth
in the Code (e.g., the exclusive benefit rule of Code section
401(a)(2), the limitations on benefits and contributions under
Code section 415, and the minimum funding requirements
under Code section 412) and must be determined annually.
Examples of assets that may not have a readily determinable
value on an established market (e.g., NYSE, AMEX, over the
counter, etc.) include real estate, nonpublicly traded securities,
shares in a limited partnership, and collectibles. Do not check
“Yes” on line 4g for mutual fund shares or insurance company
investment contracts for which the plan receives valuation
information at least annually. Also, do not check ‘‘Yes’’ on line
4g if the plan is a defined contribution plan and the only assets
the plan holds, that do not have a readily determinable value on
an established market, are: (1) participant loans not in default,
or (2) assets over which the participant exercises control within
the meaning of section 404(c) of ERISA.
Although the current value of plan assets must be determined
each year, there is no requirement that the assets (other than
certain nonpublicly traded employer securities held in ESOPs)
be valued every year by independent third-party appraisers.
Enter in the amount column the fair market value of the
assets referred to on line 4g whose value was not readily
determinable on an established market and which were not
valued by an independent third-party appraiser in the plan year.
Generally, as it relates to these questions, an appraisal by an
independent third party is an evaluation of the value of an asset
prepared by an individual or firm who knows how to judge the
-40-

Instructions for Schedule H (Form 5500)

value of such assets and does not have an ongoing relationship
with the plan or plan fiduciaries except for preparing the
appraisals.
Line 4i. Check “Yes” if the plan had any assets held for
investment purposes, and attach a schedule of assets held for
investment purposes at end of year, a schedule of assets held
for investment purposes that were both acquired and disposed
of within the plan year, or both, as applicable. The schedules
must use the format set forth below or a similar format. See 29
CFR 2520.103-11.
Assets held for investment purposes shall include:

issued by a company required to file reports with the
Securities and Exchange Commission under section 13 of
the Securities Exchange Act of 1934.
5. Participations in a bank common or collective trust.
6. Participations in an insurance company pooled
separate account.
7. Securities purchased from a broker-dealer
registered under the Securities Exchange Act of 1934 and
either: (1) listed on a national securities exchange and
registered under section 6 of the Securities Exchange Act
of 1934 or (2) quoted on NASDAQ.

 Any investment asset held by the plan on the last day of the
plan year; and
 Any investment asset purchased during the plan year and sold
before the end of the plan year except:
1. Debt obligations of the U.S. or any U.S. agency.
2. Interests issued by a company registered under the
Investment Company Act of 1940 (e.g., a mutual fund).
3. Bank certificates of deposit with a maturity of one
year or less.
4. Commercial paper with a maturity of 9 months or
less if it is valued in the highest rating category by at least
two nationally recognized statistical rating services and is

Assets held for investment purposes shall not include any
investment that was not held by the plan on the last day of the
plan year if that investment is reported in the annual report for
that plan year in any of the following:
1. The schedule of loans or fixed income obligations in
default required by Schedule G, Part I;
2. The schedule of leases in default or classified as
uncollectible required by Schedule G, Part II;
3. The schedule of nonexempt transactions required by
Schedule G, Part III; or
4. The schedule of reportable transactions required by
Schedule H, line 4j.

Line 4i schedules. The first schedule required to be attached is a schedule of all assets held for investment purposes at the end
of the plan year, aggregated and identified by issue, maturity date, rate of interest, collateral, par or maturity value, cost and current
value, and, in the case of a loan, the payment schedule.
In column (a), place an asterisk (*) on the line of each identified person known to be a party-in-interest to the plan. In column
(c), include any restriction on transferability of corporate securities. (Include lending of securities permitted under Prohibited
Transactions Exemption 81-6.)
This schedule must be clearly labeled “Schedule H, line 4i –Schedule of Assets (Held At End of Year).”
(a)

(b) Identity of issue, borrower, lessor, or similar party

(c) Description of investment including maturity date, rate of
interest, collateral, par, or maturity value

(d) Cost

(e) Current
value

The second schedule required to be attached is a schedule of investment assets that were both acquired and disposed of
within the plan year. This schedule must be clearly labeled “Schedule H, line 4i –Schedule of Assets (Acquired and Disposed of
Within Year).”
(a) Identity of issue, borrower, lessor, or similar party

(b) Description of investment including maturity date, rate of
interest, collateral, par, or maturity value

(c) Cost of acquisitions

(d) Proceeds
of
dispositions

Notes: (1) Participant loans under an individual account plan with investment experience segregated for each account, that are
made in accordance with 29 CFR 2550.408b-1 and that are secured solely by a portion of the participant’s vested accrued benefit,
may be aggregated for reporting purposes in line 4i. Under identity of borrower enter “Participant loans,” under rate of interest
enter the lowest rate and the highest rate charged during the plan year (e.g., 8%–10%), under the cost and proceeds columns enter
zero, and under current value enter the total amount of these loans. (2) Column (d) cost information for the Schedule of Assets
(Held At End of Year) and the column (c) cost of acquisitions information for the Schedule of Assets (Acquired and Disposed
of Within Year) may be omitted when reporting investments of an individual account plan that a participant or beneficiary directed
with respect to assets allocated to his or her account (including a negative election authorized under the terms of the plan). Likewise,
cost information for investments in Code sections 403(b)(1) annuity contracts and 403(b)(7) custodial accounts may also be omitted.
(3) Participant-directed brokerage account assets reported in the aggregate on line 1c(15) must be treated as one asset held for
investment for purposes of the line 4i schedules, except investments in tangible personal property must continue to be reported
as separate assets on the line 4i schedules. Investments in Code section 403(b)(1) annuity contracts and Code section 403(b)(7)
custodial accounts should also be treated as one asset held for investment for purposes on the line 4i schedules.

Instructions for Schedule H (Form 5500)

-41-

Line 4j. Check “Yes” and attach to the Form 5500 the following
schedule if the plan had any reportable transactions (see 29
CFR 2520.103-6 and the examples provided in the regulation).
The schedule must use the format set forth below or a similar
format. See 29 CFR 2520.103-11.
A reportable transaction includes:
1. A single transaction within the plan year in excess of 5%
of the current value of the plan assets;
2. Any series of transactions with or in conjunction with the
same person, involving property other than securities, which
amount in the aggregate within the plan year (regardless of the
category of asset and the gain or loss on any transaction) to
more than 5% of the current value of plan assets;
3. Any transaction within the plan year involving securities of
the same issue if within the plan year any series of transactions
with respect to such securities amount in the aggregate to more
than 5% of the current value of the plan assets; and
4. Any transaction within the plan year with respect to
securities with, or in conjunction with, a person if any prior or
subsequent single transaction within the plan year with such
person, with respect to securities, exceeds 5% of the current
value of plan assets.
The 5% figure is determined by comparing the current value
of the transaction at the transaction date with the current value
of the plan assets at the beginning of the plan year. If this is the
initial plan year, you may use the current value of the plan
assets at the end of the plan year to determine the 5% figure.
If the assets of two or more plans are maintained in one trust,
except as provided below, the plan’s allocable portion of the
transactions of the trust shall be combined with the other
transactions of the plan, if any, to determine which transactions
(or series of transactions) are reportable (5%) transactions.
For investments in common/collective trusts (CCTs), pooled
separate accounts (PSAs), 103-12 IEs, and registered
investment companies, determine the 5% figure by comparing
the transaction date value of the acquisition and/or disposition of
units of participation or shares in the entity with the current
value of the plan assets at the beginning of the plan year. If the
Schedule H is attached to a Form 5500 filed for a plan with all
plan funds held in a master trust, check ‘‘No’’ on line 4j. Plans
with assets in a master trust that have other transactions should
determine the 5% figure by subtracting the current value of plan
assets held in the master trust from the current value of all plan
assets at the beginning of the plan year and check ‘‘Yes’’ or
“No,” as appropriate. Do not include individual transactions of
(CCTs), (PSAs), master trust investment accounts (MTIAs),
103-12 IEs, and registered investment companies in which this
plan or DFE invests.
In the case of a purchase or sale of a security on the market,
do not identify the person from whom purchased or to whom
sold.
Special rule for certain participant-directed transactions.
Transactions under an individual account plan that a participant
or beneficiary directed with respect to assets allocated to his or
her account (including a negative election authorized under the
terms of the plan) should not be treated for purposes of line 4j
as reportable transactions. The current value of all assets of the
plan, including these participant-directed transactions, should be
included in determining the 5% figure for all other transactions.
Line 4k. Check “Yes” if all the plan assets (including
insurance/annuity contracts) were distributed to the participants
and beneficiaries, legally transferred to the control of another
plan, or brought under the control of the PBGC.
Check ‘‘No’’ for a welfare benefit plan that is still liable to pay
benefits for claims incurred before the termination date, but not
Instructions for Schedule H (Form 5500)

yet paid. See 29 CFR 2520.104b-2(g)(2)(ii).
Line 4l. You must check “Yes” if any benefits due under the
plan were not timely paid or not paid in full. This would include
minimum required distributions to 5% owners who have attained
70½ whether or not retired and/or non-5% owners who have
attained 70½ and have retired or separated from service, see
section 401(a)(9) of the Code. Include in this amount the total
of any outstanding amounts that were not paid when due in
previous years that have continued to remain unpaid.
Line 4m. Check “Yes” if there was a “blackout period.” A
blackout period is a temporary suspension of more than three
(3) consecutive business days during which participants or
beneficiaries of a 401(k) or other individual account pension
plan were unable to, or were limited or restricted in their ability
to, direct or diversify assets credited to their accounts, obtain
loans from the plan, or obtain distributions from the plan. A
“blackout period” generally does not include a temporary
suspension of the right of participants and beneficiaries to direct
or diversity assets credited to their accounts, obtain loans from
the plan, or obtain distributions from the plan if the temporary
suspension is: (1) part of the regularly scheduled operations of
the plan that has been disclosed to participants and
beneficiaries; (2) due to a qualified domestic relations order
(QDRO) or because of a pending determination as to whether a
domestic relations order is a QDRO; (3) due to an action or a
failure to take action by an individual participant or because of
an action or claim by someone other than the plan regarding a
participant’s individual account; or (4) by application of federal
securities laws. For more information, see 29 CFR 2520.101-3
(available at www.dol.gov/ebsa).
Line 4n. If there was a blackout period, did you provide the
required notice not less than 30 days nor more than 60 days in
advance of restricting the rights of participants and beneficiaries
to change their plan investments, obtain loans from the plan, or
obtain distributions from the plan? If so, check “Yes.” See 29
CFR 2520.101-3 for specific notice requirements and for
exceptions from the notice requirement. Also, answer “Yes” if
one of the exceptions to the notice requirement under 29 CFR
2520.101-3 applies.
Line 4o. Plans that check “Yes” must enter any amount of
unrelated business taxable income as a result of gross income
derived from any trade or business regularly carried on and not
substantially related to the plan’s exempt purpose under Code
section 512. Form 990-T, Exempt Organization Business
Income Tax Return, is required for any gross income of $1000
or more generated by an employer’s trust by the 15th day of the
4th month following the end of the trust’s tax year. See
Instructions to Form 990-T for more details.
Note. You are required to complete Line 4o if you are required
to file at least 250 returns of any type with the IRS during the
calendar year. However, if you are a small filer (file fewer than
250 returns of any type with the IRS during the calendar year)
and you do not voluntarily complete this Line 4o, then you must
file the Form 5500-SUP with the IRS on paper.
Line 4p. Plans that check “Yes” must enter the amounts of any
distributions made prior to attainment of retirement, death,
disability, and severance of employment or termination of the
plan. These amounts would include any distribution allowed
under a profit-sharing plan after a fixed number of years. See
Treasury Regulations 1.401-1(b)(1)(ii). This includes any
hardship distributions under Code section 401(k)(2)(B)(i)(IV) or
any distribution allowed under terms of the plan upon attainment
of age 62 under a money purchase plan or defined benefit plan
for plan years beginning after December 31, 2006.
Note. You are required to complete Line 4p if you are required
-42-

to file at least 250 returns of any type with the IRS during the
calendar year. However, if you are a small filer (file fewer than
250 returns of any type with the IRS during the calendar year)
and you do not voluntarily complete this Line 4p question, then
you must file the Form 5500-SUP with IRS on paper.
Line 5a. Check “Yes” if a resolution to terminate the plan was
adopted during this or any prior plan year, unless the
termination was revoked and no assets reverted to the
employer. If ‘‘Yes’’ is checked, enter the amount of plan assets
that reverted to the employer during the plan year in connection
with the implementation of such termination. Enter “0” if no
reversion occurred during the current plan year.

Line 4j schedule. The schedule required to be attached is a schedule of reportable transactions that must be clearly labeled
“Schedule H, line 4j – Schedule of Reportable Transactions.”
(a) Identity of
party
involved

(b) Description of
asset (include
interest rate and
maturity in case of
a loan)

(c)
Purchase
price

(d) Selling
price

(e) Lease
rental

(g) Cost
of asset

(h) Current value
of asset on
transaction date

(i) Net
gain or
(loss)

Termination Compliance Division, Suite 930, Processing and
Technical Assistance Branch, 1200 K Street, NW, Washington,
DC 20005-4026. Defined contribution plans and welfare plans
do not need to complete this item.

A Form 5500 must be filed for each year the plan has assets,
and, for a welfare benefit plan, if the plan is still liable to
pay benefits for claims incurred before the termination
date, but not yet paid. See 29 CFR 2520.104b2(g)(2)(ii).
Line 5b. Enter information concerning assets and/or liabilities
transferred from this plan to another plan(s) (including spinoffs)
during the plan year. A transfer of assets or liabilities occurs
when there is a reduction of assets or liabilities with respect to
one plan and the receipt of these assets or the assumption of
these liabilities by another plan. Enter the name, EIN, and PN
for the transferee plan(s) involved on lines 5b(1), (2), and (3).
Do not use a social security number in lieu of an EIN or
include an attachment that contains visible social security
numbers. The Schedule H is open to public inspection, and the
contents are public information and are subject to publication on
the Internet. Because of privacy concerns, the inclusion of a
social security number or any portion thereof on this Schedule H
or the inclusion of a visible social security number or any portion
thereof on an attachment may result in the rejection of the filing.
Note. A distribution of all or part of an individual participant’s
account balance that is reportable on Form 1099-R should not
be included on line 5b. Do not submit Form 1099-R with the
Form 5500.
IRS Form 5310-A, Notice of Plan Merger or
Consolidation, Spinoff, or Transfer of Plan Assets or
Liabilities; Notice of Qualified Separate Lines of
Business, may be required to be filed at least 30 days before
any plan merger or consolidation or any transfer of plan assets
or liabilities to another plan. There is a penalty for not filing IRS
Form 5310-A on time. In addition, a transfer of benefit liabilities
involving a plan covered by PBGC insurance may be reportable
to the PBGC. See PBGC Form 10, Post-Event Notice of
Reportable Events, and PBGC Form 10-Advance, Advance
Notice of Reportable Events.
Line 5c. If you are uncertain whether the plan is covered under
the PBGC termination insurance program, check the box “Not
determined” and contact the PBGC either by phone at
1-800-736-2444, by E-mail at [email protected], or in
writing to Pension Benefit Guaranty Corporation, Standard
Instructions for Schedule H (Form 5500)

(f) Expense
incurred with
transaction

Part V – Trust Information (Optional)
Line 6a. (Optional) You may use this line to enter the “Name of
trust.” If a plan uses more than one trust or custodial account
for its fund, you should enter the primary trust or custodial
account in which the greatest dollar amount or largest
percentage of the plan assets as of the end of the plan year is
held on this Line. For example, if a plan uses three different
trusts, X, Y, Z, with the percentages of plan assets, 35%, 45%,
and 20%, respectively, trust Y that held the 45% of plan assets
would be entered in Line 6a.
Line 6b. (Optional) You may use this line to enter the “Trust’s
Employer Identification Number (EIN)” assigned to the
employee benefit trust or custodial account, if one has been
issued to you. The trust EIN should be used for transactions
conducted for the trust. If you do not have a trust EIN, enter the
EIN you would use on Form 1099-R, Distributions From
Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs,
Insurance Contracts, etc., to report distributions from employee
benefit plans and on Form 945, Annual Return of Withheld
Federal Income Tax, to report withheld amounts of income tax
from those payments.
Do not use a social security number in lieu of an EIN. Form
5500 and its attachments are open to public inspection, and the
contents are public information and are subject to publication on
the Internet. Because of privacy concerns, the inclusion of a
social security number or any portion thereof may result in the
rejection of the filing.
Trust EIN can be obtained from the IRS by applying for one on
Form SS-4, Application for Employer Identification Number. See
Instructions to Line 2b (Form 5500) for applying for an EIN. Also
see IRS EIN application link page for further information.
Note. Although Lines 6a and 6b are optional, the IRS
encourages filers to provide trust information on these lines.
Line 6c. Enter the name of the plan trustee or custodian.
Line 6d. Enter the telephone number for the plan trustee or
-43-

custodian.
Current value means fair market value where available.
Otherwise, it means the fair value as determined in good faith
under the terms of the plan by a trustee or a named fiduciary,
assuming an orderly liquidation at time of the determination.
See ERISA section 3(26).

2014 2015 Instructions for Schedule I
(Form 5500)
Financial Information – Small Plan

Part I – Small Plan Financial Information

General Instructions

Amounts reported on lines 1a, 1b, and 1c for the beginning of
the plan year must be the same as reported for the end of the
plan year for corresponding lines on the return/report for the
preceding plan year.
Do not include contributions designated for the 2014 2015
plan year in column (a).
Line 1a. A plan with assets held in common/collective trusts
(CCTs), pooled separate accounts (PSAs), master trust
investment accounts (MTIAs), and/or 103-12 IEs must also
attach Schedule D.
Use the same method for determining the value of the plan’s
interest in an insurance company general account (unallocated
contracts) that you used for line 4 of Schedule A, or, if line 4 is
not required, line 7 of Schedule A.
Note. Do not include in column (b) a participant loan that has
been deemed distributed during the plan year under the
provisions of Code section 72(p) and Treasury Regulations
section 1.72(p)-1, if both of the following circumstances apply:
1. Under the plan, the participant loan is treated as a
directed investment solely of the participant’s individual
account; and
2. As of the end of the plan year, the participant is not
continuing repayment under the loan.
If the deemed distributed participant loan is included in
column (a) and both of these circumstances apply, report the
loan as a deemed distribution on line 2g. However, if either of
these circumstances does not apply, the current value of the
participant loan (including interest accruing thereon after the
deemed distribution) should be included in column (b) without
regard to the occurrence of a deemed distribution.
After a participant loan that has been deemed distributed is
reported on line 2g, it is no longer to be reported as an asset
on Schedule H or Schedule I unless, in a later year, the
participant resumes repayment under the loan. However, such
a loan (including interest accruing thereon after the deemed
distribution) that has not been repaid is still considered
outstanding for purposes of applying Code section 72(p)(2)(A)
to determine the maximum amount of subsequent loans. Also,
the deemed distribution is not treated as an actual distribution
for other purposes, such as the qualification requirements of
Code section 401, including, for example, the determination of
top-heavy status under Code section 416 and the vesting
requirements of Treasury Regulations section 1.411(a)-7(d)(5).
See Q&As 12 and 19 of Treasury Regulations section 1.72(p)1.
The entry on line 1a, column (b), of Schedule I (plan assets
- end of year) or on line 1c(8), column (b), of Schedule H
(participant loans - end of year) must include the current value
of any participant loan reported as a deemed distribution on
line 2g for any earlier year if, during the plan year, the
participant resumes repayment under the loan. In addition, the
amount to be entered on line 2g must be reduced by the
amount of the participant loan reported as a deemed
distribution on line 2g for the earlier year.

Who Must File
Schedule I (Form 5500) must be attached to a Form 5500 filed
for pension benefit plans and welfare benefit plans that
covered fewer than 100 participants as of the beginning of the
plan year and that are not eligible to file Form 5500-SF.
Note. If a Schedule I or a Form 5500-SF was filed for the plan
for the 2013 2014 plan year and the plan covered fewer than
121 participants as of the beginning of the 2014 2015 plan
year, the Schedule I may be completed instead of a Schedule
H.
Exception. Certain insured, unfunded or combination
unfunded/insured welfare plans are exempt from filing the
Form 5500 and the Schedule I. In addition, certain fully insured
pension benefit plans are exempt from completing the
Schedule I. See the Form 5500 instructions for Who Must File
and Limited Pension Plan Reporting for more information.
A plan that is required to file a Form M-1, Report for
Multiple-Employer Welfare Arrangements (MEWAs) and
Certain Entities Claiming Exception (ECEs) is not required to
file the Schedule I if it has fewer than 100 participants at the
beginning of the plan year and meets the requirements of 29
CFR 2520.104-44.
Check the Schedule I box on the Form 5500 (Part II, line
10b(2)) if a Schedule I is attached to the Form 5500. Do not
attach both a Schedule I and a Schedule H to the same Form
5500.

Specific Instructions
Lines A, B, C, and D. This information must be the same as
reported in Part II of the Form 5500 to which this Schedule I is
attached.
Do not use a social security number in Line D in lieu of an
EIN. The Schedule I and its attachments are open to public
inspection, and the contents are public information and are
subject to publication on the Internet. Because of privacy
concerns, the inclusion of a social security number or any
portion thereof on this Schedule I or any of its attachments
may result in the rejection of the filing.
You can apply for an EIN from the IRS online, by telephone,
by fax, or by mail depending on how soon you need to use the
EIN. For more information, see Section 3: Electronic Filing
Requirement under General Instructions to Form 5500. The
EBSA does not issue EINs.
Note. The cash, modified cash, or accrual basis may be used
for recognition of transactions, as long as you use one method
consistently. Round off all amounts reported on the Schedule I
to the nearest dollar. Any other amounts are subject to
rejection. Check all subtotals and totals carefully.
If the assets of two or more plans are maintained in one
fund, such as when an employer has two plans funded through
a single trust (except a DFE), complete Parts I and II by
entering the plan’s allocable part of each line item.
If assets of one plan are maintained in two or more trust
funds, report the combined financial information in Part I.
-44-

Instructions for Schedule H (Form 5500)

Line 1b. Enter the total liabilities at the beginning and end of
the plan year. Liabilities to be entered here do not include the
value of future pension payments to plan participants.
However, the amount to be entered in line 1b for accrual basis
filers includes, among other things:
1. Benefit claims that have been processed and approved
for payment by the plan but have not been paid (including all
incurred but not reported welfare benefit claims);
2. Accounts payable obligations owed by the plan that were
incurred in the normal operations of the plan but have not been
paid; and
3. Other liabilities such as acquisition indebtedness and
any other amount owed by the plan.
Line 1c. Enter the net assets as of the beginning and end of
the plan year. (Subtract line 1b from 1a.) Line 1c, column (b)
must equal the sum of line 1c, column (a) plus lines 2k and 2l.
Line 2a. Include the total cash contributions received or (for
accrual basis plans) due to be received.
Line 2a(1). Plans using the accrual basis of accounting must
not include contributions designated for years before the 2014
2015 plan year on line 2a(1).
Line 2a(2). For welfare plans, report all employee
contributions, including all elective contributions under a
cafeteria plan (Code section 125). For pension benefit plans,
participant contributions, for purposes of this item, also include
elective contributions under a qualified cash or deferred
arrangement (Code section 401(k)).
Line 2b. Use the current value, at date contributed, of
securities or other noncash property.
Line 2c. Enter all other plan income for the plan year. Do not
include transfers from other plans that are reported on line 2l.
Other income received and/or receivable would include:
1. Interest on investments (including money market
accounts, sweep accounts, STIF accounts, etc.).
2. Dividends. (Accrual basis plans should include dividends
declared for all stock held by the plan even if the dividends
have not been received as of the end of the plan year.)
3. Rents from income-producing property owned by the
plan.
4. Royalties.
5. Net gain or loss from the sale of assets.
6. Other income, such as unrealized appreciation
(depreciation) in plan assets.
To compute this amount subtract the current value of all
assets at the beginning of the year plus the cost of any assets
acquired during the plan year from the current value of all
assets at the end of the year minus assets disposed of during
the plan year.
Line 2d. Enter the total of all cash contributions (lines 2a(1)
through (3)), noncash contributions (line 2b), and other plan
income (line 2c) during the plan year. If entering a negative
number, enter a minus sign “-” to the left of the number.
Line 2e. Include: (1) payments made (and for accrual basis
filers) payments due to or on behalf of participants or
beneficiaries in cash, securities, or other property (including
rollovers of an individual’s accrued benefit or account balance).
Include all eligible rollover distributions as defined in Code
section 401(a)(31)(D) paid at the participant’s election to an
eligible retirement plan (including an IRA within the meaning of
Code section 401(a)(31)(E)); (2) payments to insurance
companies and similar organizations such as Blue Cross, Blue
Shield, and health maintenance organizations for the provision
of plan benefits (e.g., paid-up annuities, accident insurance,
health insurance, vision care, dental coverage, etc.); and (3)

payments made to other organizations or individuals providing
benefits. Generally, these payments discussed in (3) are made
to individual providers of welfare benefits such as legal
services, day care services, and training and apprenticeship
services. If securities or other property are distributed to plan
participants or beneficiaries, include the current value on the
date of distribution.
Line 2f. Include on this line all distributions paid during the
plan year of excess deferrals under Code section
402(g)(2)(A)(ii), excess contributions under Code section
401(k)(8), and excess aggregate contributions under Code
section 401(m)(6). Include allocable income distributed. Also
include on this line any elective deferrals and employee
contributions distributed or returned to employees during the
plan year, as well as any attributable income that was also
distributed.
Line 2g. Report on line 2g a participant loan included in line
1a, column (a) (participant loans - beginning of year) and that
has been deemed distributed during the plan year under the
provisions of Code section 72(p) and Treasury Regulations
section 1.72(p)-1 only if both of the following circumstances
apply:
1. Under the plan, the participant loan is treated as a
directed investment solely of the participant’s individual
account; and
2. As of the end of the plan year, the participant is not
continuing repayment under the loan.
If either of these circumstances does not apply, a deemed
distribution of a participant loan should not be reported on line
2g. Instead, the current value of the participant loan (including
interest accruing thereon after the deemed distribution) should
be included on line 1a, column (b) (plan assets – end of year),
without regard to the occurrence of a deemed distribution.
Note. The amount to be reported on line 2g of Schedule H or
Schedule I must be reduced if, during the plan year, a
participant resumes repayment under a participant loan
reported as a deemed distribution on line 2g for any earlier
year. The amount of the required reduction is the amount of
the participant loan reported as a deemed distribution on line
2g for the earlier year. If entering a negative number, enter a
minus sign “-” to the left of the number. The current value of
the participant loan must then be included in line 1c(8), column
(b), of Schedule H (participant loans – end of year) or in line
1a, column (b), of Schedule I (plan assets – end of year).
Although certain participant loans deemed distributed are to
be reported on line 2g of the Schedule H or Schedule I, and
are not to be reported on the Schedule H or Schedule I as an
asset thereafter (unless the participant resumes repayment
under the loan in a later year), they are still considered
outstanding loans and are not treated as actual distributions for
certain purposes. See Q&As 12 and 19 of Treasury
Regulations section 1.72(p)-1.
Line 2h. The amount to be reported for expenses involving
administrative service providers (salaries, fees, and
commissions) includes the total fees paid (or in the case of
accrual basis plans, costs incurred during the plan year but not
paid as of the end of the plan year) by the plan for, among
others:
1. Salaries to employees of the plan;
2. Fees and expenses for accounting, actuarial, legal,
investment management, investment advice, and securities
brokerage services;
3. Contract administrator fees;

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Instructions for Schedule I (Form 5500)

4. Fees and expenses for individual plan trustees, including
reimbursement for travel, seminars, and meeting expenses;
and
5. Fees and expenses paid for valuations and appraisals of
real estate and closely held securities.
Line 2i. Other expenses (paid and/or payable) include other
administrative and miscellaneous expenses paid by or charged
to the plan, including among others, office supplies and
equipment, telephone, postage, rent and expenses associated
with the ownership of a building used in operation of the plan.
Line 2j. Enter the total of all benefits paid or due as reported
on lines 2e, 2f, and 2g and all other plan expenses (lines 2h
and 2i) during the year.
Line 2l. Enter the net value of all assets transferred to and
from the plan during the plan year including those resulting
from mergers and spinoffs. A transfer of assets or liabilities
occurs when there is a reduction of assets or liabilities with
respect to one plan and the receipt of these assets or the
assumption of these liabilities by another plan. Transfers out at
the end of the year should be reported as occurring during the
plan year.
Note. A distribution of all or part of an individual participant’s
account balance that is reportable on Form 1099-R,
Distributions From Pensions, Annuities, Retirement or ProfitSharing Plans, IRAs, Insurance Contracts, etc., should not be
included on line 2l but must be included in benefit payments
reported on line 2e. Do not submit IRS Form 1099-R with Form
5500.
Lines 3a through 3g. You must check either “Yes” or “No” on
each line to report whether the plan held any assets in the
listed categories at any time during the plan year. If “Yes” is
checked on any line, enter in the amount column for that line
the current value of the assets held at the end of the plan year
or “0” if no assets remain in the category at the end of the plan
year. You should allocate the value of the plan’s interest in a
commingled trust containing the assets of more than one plan
on a line-by-line basis, except do not include on lines 3a
through 3g the value of the plan’s interest in any CCT, PSA,
MTIA, or 103-12 IE (see instructions definitions of CCT, PSA,
MTIA, and 103-12 IE).
Line 3a. Enter the value of the plan’s participation in a
partnership or joint venture, unless the partnership or joint
venture is a 103-12 IE.
Line 3b. The term ‘‘employer real property’’ means real
property (and related personal property) that is leased to an
employer of employees covered by the plan, or to an affiliate of
such employer. For purposes of determining the time at which
a plan acquires employer real property for purposes of this
line, such property shall be deemed to be acquired by the plan
on the date on which the plan acquires the property or on the
date on which the lease to the employer (or affiliate) is entered
into, whichever is later.
Line 3d. An employer security is any security issued by an
employer (including affiliates) of employees covered by the
plan. These may include common stocks, preferred stocks,
bonds, zero coupon bonds, debentures, convertible
debentures, notes and commercial paper.
Line 3e. Enter the current value of all loans to participants
including residential mortgage loans that are subject to Code
section 72(p). Include the sum of the value of the unpaid
principal balances, plus accrued but unpaid interest, if any, for
participant loans made under an individual account plan with
investment experience segregated for each account, that are
made in accordance with 29 CFR 2550.408b-1 and secured
solely by a portion of the participant’s vested accrued benefit.
Instructions for Schedule I (Form 5500)

When applicable, combine this amount with the current value
of any other participant loans. Do not include any amount of a
participant loan deemed distributed during the plan year under
the provisions of Code section 72(p) and Treasury Regulations
section 1.72(p)-1, if both of the following circumstances apply:
1. Under the plan, the participant loan is treated as a
directed investment solely of the participant’s individual
account; and
2. As of the end of the plan year, the participant is not
continuing repayment under the loan.
If both of these circumstances apply, report the loan as a
deemed distribution on line 2g. However, if either of these
circumstances does not apply, the current value of the
participant loan (including interest accruing thereon after the
deemed distribution) should be included on line 3e without
regard to the occurrence of a deemed distribution.
Note. After participant loans have been deemed distributed
and reported on line 2g of the Schedule I or H, they are no
longer required to be reported as assets on the Schedule I or
H. However, such loans (including interest accruing thereon
after the deemed distribution) that have not been repaid are
still considered outstanding for purposes of applying Code
section 72(p)(2)(A) to determine the maximum amount of
subsequent loans. Also, the deemed distribution is not treated
as an actual distribution for other purposes, such as the
qualification requirements of Code section 401, including, for
example, the determination of top-heavy status under Code
section 416 and the vesting requirements of Treasury
Regulations section 1.411(a)-7(d)(5). See Q&As 12 and 19 of
Treasury Regulations section 1.72(p)-1.
Line 3f. Enter the current value of all loans made by the plan,
except participant loans reportable on line 3e. Include the sum
of the value of loans for construction, securities loans,
commercial and/or residential mortgage loans that are not
subject to Code section 72(p) (either by making or participating
in the loans directly or by purchasing loans originated by a
third party), and other miscellaneous loans.
Line 3g. Include all property that has concrete existence and is
capable of being processed, such as goods, wares,
merchandise, furniture, machines, equipment, animals,
automobiles, etc. This includes collectibles, such as works of
art, rugs, antiques, metals, gems, stamps, coins, alcoholic
beverages, musical instruments, and historical objects
(documents, clothes, etc.). Do not include the value of a plan’s
interest in property reported on lines 3a through 3f, or
intangible property, such as patents, copyrights, goodwill,
franchises, notes, mortgages, stocks, claims, interests, or other
property that embodies intellectual or legal rights.

Part II – Compliance Questions
Answer all lines with either ‘‘Yes’’ or ‘‘No.’’ Do not leave any
answer blank, unless otherwise directed. For lines 4a through
4i and line 4l, if the answer is “Yes,” an amount must be
entered. If you check ‘‘No’’ on line 4k you must attach the
report of an independent qualified public accountant (IQPA) or
a statement that the plan is eligible and elects to defer
attaching the IQPA’s opinion pursuant to 29 CFR 2520.104-50
in connection with a short plan year of seven months or less.
Plans with all of their fund held in a master trust should check
“No” on Schedule I, lines 4b, c, and i.
Line 4a. Amounts paid by a participant or beneficiary to an
employer and/or withheld by an employer for contribution to
the plan are participant contributions that become plan assets
as of the earliest date on which such contributions can
reasonably be segregated from the employer’s general assets.
See 29 CFR 2510.3-102. In the case of a plan with fewer than
-46-

of the Prohibited Transaction Exemption (PTE) 2002-51 have
been satisfied do not need to be treated as nonexempt partyin-interest transactions.
The VFCP describes how to apply, the specific transactions
covered (which transactions include delinquent participant
contributions to pension and welfare plans), and acceptable
methods for correcting violations. In addition, applicants that
satisfy both the VFCP requirements and the conditions of
Prohibited Transaction Exemption (PTE) 2002-51 are eligible
for immediate relief from payment of certain prohibited
transaction excise taxes for certain corrected transactions, and
are also relieved from the obligation to file the IRS Form 5330
with the IRS. For more information, see 71 Fed. Reg. 20261
(Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19, 2006). All
delinquent participant contributions must be reported on line 4a
even if violations have been corrected. Information about the
VFCP is also available on the Internet at www.dol.gov/ebsa.
Line 4a Schedule. Attach a Schedule of Delinquent
Participant Contributions using the format below if you entered
“Yes” on line 4a and you are checking “No” on line 4k because
you are not claiming the audit waiver for the plan. If you
choose to include participant loan repayments on line 4a, you
must apply the same supplemental schedule and IQPA
disclosure requirements to the loan repayments as apply to
delinquent transmittals of participant contributions.

100 participants at the beginning of the plan year, any amount
th
deposited with such plan not later than the 7 business day
following the day on which such amount is received by the
employer (in the case of amounts that a participant or
th
beneficiary pays to an employer), or the 7 business day
following the day on which such amount would otherwise have
been payable to the participant in cash (in the case of amount
withheld by an employer from a participant’s wages), shall be
deemed to be contributed or repaid to such plan on the earliest
date on which such contributions or participant loan
repayments can reasonably be segregated from the
employer’s general assets. See 29 CFR 2510.3102(a)(2).
Plans that check “Yes” must enter the aggregate amount of all
late contributions for the year. The total amount of the
delinquent contributions must be included on line 4a of the
Schedule H or I, as applicable, for the year in which the
contributions were delinquent and must be carried over and
reported again on line 4a of the Schedule H or I, as applicable,
for each subsequent year until the year after the violation has
been fully corrected, which correction includes payment of the
late contributions and reimbursement of the plan for lost
earnings or profits. If no participant contributions were received
or withheld by the employer during the plan year, answer ‘‘No.’’
An employer holding participant contributions commingled
with its general assets after the earliest date on which such
contributions can reasonably be segregated from the
employer’s general assets will have engaged in prohibited use
of plan assets (see ERISA section 406). If such a nonexempt
prohibited transaction occurred with respect to a disqualified
person (see Code section 4975(e)(2)), file IRS Form 5330,
Return of Excise Taxes Related to Employee Benefit Plans,
with the IRS to pay any applicable excise tax on the
transaction.
Participant loan repayments paid to and/or withheld by an
employer for purposes of transmittal to the plan that were not
transmitted to the plan in a timely fashion must be reported
either on line 4a in accordance with the reporting requirements
that apply to delinquent participant contributions or on line 4d.
See Advisory Opinion 2002-02A, available at
www.dol.gov/ebsa.
For those Schedule I filers required to submit an IQPA
report, delinquent participant contributions reported on
line 4a must be treated as part of the separate
schedules referenced in ERISA section 103(a)(3)(A) and 29
CFR 2520.103-1(b) and 2520.103-2(b) for purposes of
preparing the IQPA’s opinion even though they are not
required to be listed on Part III of the Schedule G. If the
information contained on line 4a is not presented in
accordance with regulatory requirements, i.e., when the IQPA
concludes that the scheduled information required by line 4a
does not contain all the required information or contains
information that is inaccurate or is inconsistent with the plan’s
financial statements, the IQPA report must make the
appropriate disclosures in accordance with generally accepted
auditing standards. For more information, see EBSA’s
Frequently Asked Questions about Reporting Delinquent
Contributions on the Form 5500, available on the Internet at
www.dol.gov/ebsa. These Frequently Asked Questions clarify
that plans have an obligation to include delinquent participant
contributions on their financial statements and supplemental
schedules and that the IQPA’s report covers such delinquent
contributions even though they are no longer required to be
included on Part III of the Schedule G. Although all delinquent
participant contributions must be reported on line 4a,
delinquent contributions for which the DOL Voluntary Fiduciary
Correction Program (VFCP) requirements and the conditions

Schedule I Line 4a – Schedule of Delinquent
Participant Contributions
Participant
Total that Constitute Nonexempt Prohibited
Contributions
Transactions
Transferred
Late to Plan

Total
Fully
Corrected
Under
Check here if Contributions Contributions Contributions VFCP
and PTE
Late
Not
Corrected
Pending
Participant
Corrected
Outside
Correction in 2002-51
Loan
VFCP
VFCP
Repayments
are included:

Line 4b. Plans that check “Yes” must enter the amount. The
due date, payment amount and conditions for determining
default of a note or loan are usually contained in the
documents establishing the note or loan. A loan by the plan is
in default when the borrower is unable to pay the obligation
upon maturity. Obligations that require periodic repayment can
default at any time. Generally, loans and fixed income
obligations are considered uncollectible when payment has not
been made and there is little probability that payment will be
made. A fixed income obligation has a fixed maturity date at a
specified interest rate. Do not include participant loans made
under an individual account plan with investment experience
segregated for each account that were made in accordance
with 29 CFR 2550.408b-1 and secured solely by a portion of
the participant’s vested accrued benefit.
Line 4c. Plans that check “Yes” must enter the amount. A
lease is an agreement conveying the right to use property,
plant or equipment for a stated period. A lease is in default
when the required payment(s) has not been made. An
uncollectible lease is one where the required payments have
not been made and for which there is little probability that
payment will be made.
Line 4d. Plans that check “Yes” must enter the amount. Check
“Yes” if any nonexempt transaction with a party-in-interest
occurred regardless of whether the transaction is disclosed in
the IQPA’s report. Do not check “Yes” with respect to
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Instructions for Schedule I (Form 5500)

transactions that are: (1) statutorily exempt under Part 4 of
Title I of ERISA; (2) administratively exempt under ERISA
section 408(a); (3) exempt under Code sections 4975(c) or
4975(d); (4) the holding of participant contributions in the
employer’s general assets for a welfare plan that meets the
conditions of ERISA Technical Release 92-01; (5) a
transaction of a 103-12 IE with parties other than the plan; or
(6) delinquent participant contributions or delinquent participant
loan repayments reported on line 4a. You may indicate that an
application for an administrative exemption is pending. If you
are unsure whether a transaction is exempt or not, you should
consult with either a qualified public accountant, legal counsel
or both. If the plan is a qualified pension plan and a nonexempt
prohibited transaction occurred with respect to a disqualified
person, an IRS Form 5330 should be filed with the IRS to pay
the excise tax on the transaction.

plan and a party-in-interest.
B. Lending of money or other extension of credit between
the plan and a party-in-interest.
C. Furnishing of goods, services, or facilities between the
plan and a party-in-interest.
D. Transfer to, or use by or for the benefit of, a party-ininterest, of any income or assets of the plan.
E. Acquisition, on behalf of the plan, of any employer
security or employer real property in violation of ERISA
section 407(a).
F. Dealing with the assets of the plan for a fiduciary’s own
interest or own account.
G. Acting in a fiduciary’s individual or any other capacity in
any transaction involving the plan on behalf of a party (or
represent a party) whose interests are adverse to the
interests of the plan or the interests of its participants or
beneficiaries.
H. Receipt of any consideration for his or her own personal
account by a party-in-interest who is a fiduciary from any
party dealing with the plan in connection with a transaction
involving the income or assets of the plan.
Line 4e. Plans that check “Yes” must enter the aggregate
amount of fidelity bond coverage for all claims. Check ‘‘Yes’’
only if the plan itself (as opposed to the plan sponsor or
administrator) is a named insured under a fidelity bond from an
approved surety covering plan officials and that protects the
plan from losses due to fraud or dishonesty as described in 29
CFR Part 2580. Generally, every plan official of an employee
benefit plan who ‘‘handles’’ funds or other property of such
plan must be bonded. Generally, a person shall be deemed to
be ‘‘handling’’ funds or other property of a plan, so as to
require bonding, whenever his or her duties or activities with
respect to given funds are such that there is a risk that such
funds could be lost in the event of fraud or dishonesty on the
part of such person, acting either alone or in collusion with
others. Section 412 of ERISA and 29 CFR Part 2580 describe
the bonding requirements, including the definition of ‘‘handling’’
(29 CFR 2580.412-6), the permissible forms of bonds (29 CFR
2580.412-10), the amount of the bond (29 CFR Part 2580,
subpart C), and certain exemptions such as the exemption for
unfunded plans, certain banks and insurance companies
(ERISA section 412), and the exemption allowing plan officials
to purchase bonds from surety companies authorized by the
Secretary of the Treasury as acceptable reinsurers on federal
bonds (29 CFR 2580.412-23). Information concerning the list
of approved sureties and reinsurers is available on the Internet
at www.fms.treas.gov/c570. For more information on the
fidelity bonding requirements, see Field Assistance Bulletin
2008-04, available on the Internet at www.dol.gov/ebsa.
Note. Plans are permitted under certain conditions to purchase
fiduciary liability insurance. These fiduciary liability insurance
policies are not written specifically to protect the plan from
losses due to dishonest acts and cannot be reported as fidelity
bonds on line 4e.
Line 4f. Check ‘‘Yes,’’ if the plan had suffered or discovered
any loss as a result of any dishonest or fraudulent act(s) even
if the loss was reimbursed by the plan’s fidelity bond or from
any other source. If ‘‘Yes’’ is checked enter the full amount of
the loss. If the full amount of the loss has not yet been
determined, provide an estimate as determined in good faith
by a plan fiduciary. You must keep, in accordance with ERISA
section 107, records showing how the estimate was
determined.
Willful failure to report is a criminal offense. See
ERISA section 501.

Applicants that satisfy the VFCP requirements and the
conditions of PTE 2002-51 (see the instructions for
line 4a) are eligible for immediate relief from payment
of certain prohibited transaction excise taxes for certain
corrected transactions, and are also relieved from the
obligation to file the Form 5330 with the IRS. For more
information, see 71 Fed. Reg. 20261 (Apr. 19, 2006) and 71
Fed. Reg. 20135 (Apr. 19, 2006). When the conditions of PTE
2002-51 have been satisfied, the corrected transactions should
be treated as exempt under Code section 4975(c) for the
purposes of answering line 4d.
Party-in-Interest. For purposes of this form, party-ininterest is deemed to include a disqualified person. See Code
section 4975(e)(2). The term ‘‘party-in-interest’’ means, as to
an employee benefit plan:
A. Any fiduciary (including, but not limited to, any
administrator, officer, trustee, or custodian), counsel, or
employee of the plan;
B. A person providing services to the plan;
C. An employer, any of whose employees are covered by
the plan;
D. An employee organization, any of whose members are
covered by the plan;
E. An owner, direct or indirect, of 50% or more of: (1) the
combined voting power of all classes of stock entitled to vote
or the total value of shares of all classes of stock of a
corporation, (2) the capital interest or the profits interest of a
partnership, or (3) the beneficial interest of a trust or
unincorporated enterprise that is an employer or an
employee organization described in C or D;
F. A relative of any individual described in A, B, C, or E;
G. A corporation, partnership, or trust or estate of which (or
in which) 50% or more of: (1) the combined voting power of
all classes of stock entitled to vote or the total value of
shares of all classes of stock of such corporation, (2) the
capital interest or profits interest of such partnership, or (3)
the beneficial interest of such trust or estate is owned
directly or indirectly, or held by, persons described in A, B,
C, D, or E;
H. An employee, officer, director (or an individual having
powers or responsibilities similar to those of officers or
directors), or a 10% or more shareholder, directly or
indirectly, of a person described in B, C, D, E, or G, or of the
employee benefit plan;
I. A 10% or more (directly or indirectly in capital or profits)
partner or joint venturer of a person described in B, C, D, E,
or G.
Nonexempt transactions with a party-in-interest include
any direct or indirect:
A. Sale or exchange, or lease, of any property between the
Instructions for Schedule I (Form 5500)

-48-

Check ‘‘No’’ and attach the report of the IQPA meeting the
requirements of 29 CFR 2520.103-1(b) if you are not claiming
the waiver. Also check ‘‘No,’’ and attach the required IQPA
reports or the required explanatory statement if you are relying
on 29 CFR 2520.104-50 in connection with a short plan year of
seven months or less. At the top of any attached 2520.104-50
statement, enter “2520.104-50 Statement, Schedule I, Line
4k.”

Lines 4g and 4h. Current value means fair market value
where available. Otherwise, it means the fair value as
determined in good faith under the terms of the plan by a
trustee or a named fiduciary, assuming an orderly liquidation at
time of the determination. See ERISA section 3(26).
An accurate assessment of fair market value is essential to
a pension plan’s ability to comply with the requirements set
forth in the Code (e.g., the exclusive benefit rule of Code
section 401(a)(2), the limitations on benefits and contributions
under Code section 415, and the minimum funding
requirements under Code section 412) and must be
determined annually.
Examples of assets that may not have a readily
determinable value on an established market (e.g., NYSE,
AMEX, over the counter, etc.) include real estate, nonpublicly
traded securities, shares in a limited partnership, and
collectibles. Do not check “Yes” on line 4g for mutual fund
shares or insurance company investment contracts for which
the plan receives valuation information at least annually. Also
do not check ‘‘Yes’’ on line 4g if the plan is a defined
contribution plan and the only assets the plan holds, that do
not have a readily determinable value on an established
market, are: (1) participant loans not in default, or (2) assets
over which the participant exercises control within the meaning
of section 404(c) of ERISA.
Although the current value of plan assets must be
determined each year, there is no requirement that the assets
(other than certain nonpublicly traded employer securities held
in ESOPs) be valued every year by independent third-party
appraisers.
Enter in the amount column the fair market value of the
assets referred to on line 4g whose value was not readily
determinable on an established market and which were not
valued by an independent third-party appraiser in the plan
year. Generally, as it relates to these questions, an appraisal
by an independent third party is an evaluation of the value of
an asset prepared by an individual or firm who knows how to
judge the value of such assets and does not have an ongoing
relationship with the plan or plan fiduciaries except for
preparing the appraisals.
Line 4i. Include as a single security all securities of the same
issue. An example of a single issue is a certificate of deposit
issued by the XYZ Bank on July 1, 2014, which matures on
June 30, 2015, and yields x%.An example of a single issue is a
certificate of deposit issued by the XYZ Bank on July 1, 2010,
which matures on June 30, 2013, and yields 5.5%. For the
purposes of line 4i, do not check ‘‘Yes’’ for securities issued by
the U.S. Government or its agencies. Also, do not check “Yes”
for securities held as a result of participant-directed
transactions.
Line 4j. Check “Yes” if all the plan assets (including
insurance/annuity contracts) were distributed to the
participants and beneficiaries, legally transferred to the control
of another plan, or brought under the control of the PBGC.
Check ‘‘No’’ for a welfare benefit plan that is still liable to pay
benefits for claims that were incurred before the termination
date, but not yet paid. See 29 CFR 2520.104b-2(g)(2)(ii).
Line 4k. Check ‘‘Yes’’ if you are claiming a waiver of the
annual examination and report of an independent qualified
public accountant (IQPA) under 29 CFR 2520.104-46. You are
eligible to claim the waiver if the Schedule I is being filed for:
1. A small welfare plan, or
2. A small pension plan for a plan year that began on or
after April 18, 2001, that complies with the conditions of 29
CFR 2520.104-46 summarized below.

For more information on the requirements for deferring an
IQPA report pursuant to 29 CFR 2520.104-50 in connection
with a short plan year of seven months or less and the
contents of the required explanatory statement, see the
instructions for Schedule H, line 3d(2) or call the EFAST2 Help
Line at 1-866-GO-EFAST (1-866-463-3278) (toll-free).
Note. For plans that check “No,” the IQPA report must make
the appropriate disclosures in accordance with generally
accepted auditing standards if the information reported on line
4a is not presented in accordance with regulatory
requirements.
The following summarizes the conditions of 29 CFR
2520.104-46 that must be met for a small pension plan with a
plan year beginning on or after April 18, 2001, to be eligible for
the waiver. For more information regarding these
requirements, see the EBSA’s Frequently Asked Questions on
the Small Pension Plan Audit Waiver Regulation and 29 CFR
2520.104-46, which are available at www.dol.gov/ebsa, or call
the EFAST2 Help Line at 1-866-GO-EFAST (1-866-463-3278)
(toll-free)
Condition 1: At least 95 percent of plan assets are
“qualifying plan assets” as of the end of the preceding plan
year, or any person who handles assets of the plan that do not
constitute qualifying plan assets is bonded in accordance with
the requirements of ERISA section 412 (see the instructions
for line 4e), except that the amount of the bond shall not be
less than the value of such non-qualifying assets.
The determination of the “percent of plan assets” as of the
end of the preceding plan year and the amount of any required
bond must be made at the beginning of the plan’s reporting
year for which the waiver is being claimed. For purposes of this
line, you will have satisfied the requirement to make these
determinations at the beginning of the plan reporting year for
which the waiver is being claimed if they are made as soon
after the date when such year begins as the necessary
information from the preceding reporting year can practically
be ascertained. See 29 CFR 2580.412-11, 14 and 19 for
additional guidance on these determinations, and 29 CFR
2580.412-15 for procedures to be used for estimating these
amounts if there is no preceding plan year.
The term ‘‘qualifying plan assets,’’ for purposes of this line,
means:
1. Any assets held by any of the following regulated financial
institutions:
a. A bank or similar financial institution as defined in 29
CFR 2550.408b-4(c);
b. An insurance company qualified to do business under the
laws of a state;
c. An organization registered as a broker-dealer under the
Securities Exchange Act of 1934; or
d. Any other organization authorized to act as a trustee for
individual retirement accounts under Code section 408.
2. Shares issued by an investment company registered
under the Investment Company Act of 1940 (e.g., mutual
funds);

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Instructions for Schedule I (Form 5500)

Plan B is identical to Plan A except that of Plan B’s total
assets of $600,000 as of the end of the 2000 plan year,
$558,000 constitutes ‘‘qualifying plan assets’’ and $42,000
constitutes non-qualifying plan assets. Because 7% – more
than 5% – of Plan B’s assets do not constitute ‘‘qualifying plan
assets,’’ Plan B, as a condition to be eligible for the waiver for
the 2001 plan year, must ensure that it has a fidelity bond in an
amount equal to at least $42,000 covering persons handling its
non-qualifying plan assets. Inasmuch as compliance with
ERISA section 412 generally requires the amount of the bond
be not less than 10% of the amount of all the plan’s funds or
other property handled, the bond acquired for ERISA section
412 purposes may be adequate to cover the non-qualifying
plan assets without an increase (i.e., if the amount of the bond
determined to be needed for the relevant persons for ERISA
section 412 purposes is at least $42,000). As demonstrated by
the foregoing example, where a plan has more than 5% of its
assets in non-qualifying plan assets, the required bond is for
the total amount of the non-qualifying plan assets, not just the
amount in excess of 5%.
If you need further information regarding these
requirements, see 29 CFR 2520.104-46 which is available at
www.dol.gov/ebsa or call the EFAST2 Help Line at 1-866-GOEFAST (1-866-463-3278) (toll-free)
Line 4l. You must check “Yes” if any benefits due under the
plan were not timely paid or not paid in full. This would include
required minimum distributions to 5% owners who have
attained 70½ whether or not retired and/or non-5% owners
who have attained 70½ and have retired or separated from
service, see section 401(a)(9) of the Code. Include in this
amount the total of any outstanding amounts that were not
paid when due in previous years that have continued to remain
unpaid.
Line 4m. Check “Yes” if there was a “blackout period.” A
blackout period is a temporary suspension of more than three
(3) consecutive business days during which participants or
beneficiaries of a 401(k) or other individual account pension
plan were unable to, or were limited or restricted in their ability
to, direct or diversify assets credited to their accounts, obtain
loans from the plan, or obtain distributions from the plan. A
“blackout period” generally does not include a temporary
suspension of the right of participants and beneficiaries to
direct or diversify assets credited to their accounts, obtain
loans from the plan, or obtain distributions from the plan if the
temporary suspension is: (1) part of the regularly scheduled
operations of the plan that has been disclosed to participants
and beneficiaries; (2) due to a qualified domestic relations
order (QDRO) or because of a pending determination as to
whether a domestic relations order is a QDRO; (3) due to an
action or a failure to take action by an individual participant or
because of an action or claim by someone other than the plan
regarding a participant’s individual account; (4) by application
of federal securities laws. For more information, see 29 CFR
2520.101-3 (available at www.dol.gov/ebsa).
Line 4n. If there was a blackout period, did you provide the
required notice not less than 30 days nor more than 60 days in
advance of restricting the rights of participants and
beneficiaries to change their plan investments, obtain loans
from the plan, or obtain distributions from the plan? If so, check
“Yes.” See 29 CFR 2520.101-3 for specific notice requirements
and for exceptions from the notice requirement. Also, answer
“Yes” if one of the exceptions to the notice requirement under
29 CFR 2520.101-3 applies.
Line 4o. Plans that check “Yes” must enter any amount of
unrelated business taxable income as a result of gross income
derived from any trade or business regularly carried on and not

3. Investment and annuity contracts issued by any
insurance company qualified to do business under the laws of
a state;
4. In the case of an individual account plan, any assets in
the individual account of a participant or beneficiary over which
the participant or beneficiary has the opportunity to exercise
control and with respect to which the participant or beneficiary
is furnished, at least annually, a statement from a regulated
financial institution referred to above describing the assets held
or issued by the institution and the amount of such assets;
5. Qualifying employer securities, as defined in ERISA
section 407(d)(5); and
6. Participant loans meeting the requirements of ERISA
section 408(b)(1).
Condition 2: The administrator must disclose the following
information in the summary annual report (SAR) furnished to
participants and beneficiaries, in accordance with 29 CFR
2520.104b-10. For defined benefit pension plans that are
required pursuant to section 101(f) of ERISA to furnish an
Annual Funding Notice (AFN), the administrator must instead
either provide the information to participants and beneficiaries
with the AFN or as a stand-alone notification at the time a SAR
would have been due and in accordance with the rules for
furnishing an SAR, although such plans do not have to furnish
a SAR.
1. The name of each regulated financial institution holding
or issuing qualifying plan assets and the amount of such
assets reported by the institution as of the end of the plan year
(this SAR disclosure requirement does not apply to qualifying
employer securities, participant loans and individual account
assets described in paragraphs 4,5 and 6 above);
2. The name of the surety company issuing the fidelity bond,
if the plan has more than 5% of its assets in non-qualifying
plan assets;
3. A notice that participants and beneficiaries may, upon
request and without charge, examine or receive from the plan
evidence of the required bond and copies of statements from
the regulated financial institutions describing the qualifying
plan assets; and
4. A notice that participants and beneficiaries should contact
the EBSA Regional Office if they are unable to examine or
obtain copies of the regulated financial institution statements or
evidence of the required bond, if applicable.
A Model Notice that plans can use to satisfy the enhanced
SAR (or Annual Funding Notice) disclosure requirements to be
eligible for the audit waiver is available as an Appendix to 29
CFR 2520.104-46.
Condition 3: In addition, in response to a request from any
participant or beneficiary, the administrator, without charge to
the participant or beneficiary, must make available for
examination, or upon request furnish copies of, each regulated
financial institution statement and evidence of any required
bond.
Examples. Plan A, which has a plan year that began on or
after April 18, 2001, had total assets of $600,000 as of the end
of the 2000 plan year that included: investments in various
bank, insurance company and mutual fund products of
$520,000; investments in qualifying employer securities of
$40,000; participant loans (meeting the requirements of ERISA
section 408(b)(1)), totaling $20,000; and a $20,000 investment
in a real estate limited partnership. Because the only asset of
the plan that did not constitute a ‘‘qualifying plan asset’’ is the
$20,000 real estate limited partnership investment and that
investment represents less than 5% of the plan’s total assets,
no fidelity bond is required as a condition for the plan to be
eligible for the waiver for the 2001 plan year.
Instructions for Schedule I (Form 5500)

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substantially related to the plan’s exempt purpose under Code
section 512. Form 990-T, Exempt Organization Business
Income Tax Return, is required for any gross income of $1000
or more generated by an employer’s trust by the 15th day of
the 4th month following the end of the trust’s tax year. See
Instructions to Form 990-T for more details.
Note. You are required to complete Line 4o if you are required
to file at least 250 returns of any type with the IRS during the
calendar year. However, if you are a small filer (file fewer than
250 returns of any type with the IRS during the calendar year)
and you do not voluntarily complete this Line 4o, then you
must file the Form 5500-SUP with the IRS on paper.
Line 4p. Plans that check “Yes” must enter the amounts of any
distributions made prior to attainment of retirement, death,
disability, and severance of employment or termination of the
plan. These amounts would include any distribution allowed
under a profit-sharing plan after a fixed number of years. See
Treasury Regulations 1.401-1(b)(1)(ii). This includes any
hardship distributions under Code section 401(k)(2)(B)(i)(IV) or
any distribution allowed under terms of the plan upon
attainment of age 62 under a money purchase plan or defined
benefit plan for plan years beginning after December 31,
2006.
Note. You are required to complete Line 4p if you are required
to file at least 250 returns of any type with the IRS during the
calendar year. However, if you are a small filer (file fewer than
250 returns of any type with the IRS during the calendar year)
and you do not voluntarily complete this Line 4p question, then
you must file the Form 5500-SUP with IRS on paper.
Line 5a. Check “Yes” if a resolution to terminate the plan was
adopted during this or any prior plan year, unless the
termination was revoked and no assets reverted to the
employer. If ‘‘Yes’’ is checked, enter the amount of plan assets
that reverted to the employer during the plan year in
connection with the implementation of such termination. Enter
‘‘0’’ if no reversion occurred during the current plan year.
A Form 5500 must be filed for each year the plan has
assets, and, for a welfare benefit plan, if the plan is
still liable to pay benefits for claims that were incurred
before the termination date, but not yet paid. See 29
CFR 2520.104b-2(g)(2)(ii).
Line 5b. Enter information concerning assets and/or liabilities
transferred from this plan to another plan(s) (including spinoffs)
during the plan year. A transfer of assets or liabilities occurs
when there is a reduction of assets or liabilities with respect to
one plan and the receipt of these assets or the assumption of
these liabilities by another plan. Enter the name, EIN, and PN
for the transferee plan(s).
Do not use a social security number in lieu of an EIN or
include an attachment that contains visible social security
numbers. The Schedule I and its attachments are open to
public inspection, and the contents are public information and
are subject to publication on the Internet. Because of privacy
concerns, the inclusion of a social security number or any
portion thereof on this Schedule I or the inclusion of a visible
social security number or any portion thereof on an attachment
may result in the rejection of the filing.
Note. A distribution of all or part of an individual participant’s
account balance that is reportable on IRS Form 1099-R should
not be included on line 5b. Do not submit IRS Form 1099-R

with the Form 5500.
IRS Form 5310-A, Notice of Plan Merger or Consolidation,
Spinoff, or Transfer of Plan Assets or Liabilities; Notice of
Qualified Separate Lines of Business, may be required to be
filed at least 30 days before any plan merger or consolidation
or any transfer of plan assets or liabilities to another plan.
There is a penalty of $25 a day (up to a maximum of $15,000)
for not filing IRS Form 5310-A on time.” In addition, a transfer
of benefit liabilities involving a plan covered by PBGC
insurance may be reportable to the PBGC. See PBGC Form
10, Post-Event Notice of Reportable Events, and PBGC Form
10-Advance, Advance Notice of Reportable Events.
Line 5c. If you are uncertain whether the plan is covered under
the PBGC termination insurance program, check the box “Not
determined” and contact the PBGC either by phone at
1-800-736-2444, by E-mail at [email protected], or in
writing to Pension Benefit Guaranty Corporation, Standard
Termination Compliance Division, Suite 930, Processing and
Technical Assistance Branch, 1200 K Street, NW, Washington,
DC 20005-4026. Defined contribution plans and welfare plans
do not need to complete this item.

Part III – Trust Information (Optional)
Line 6a. (Optional) You may use this line to enter the “Name of
trust.” If a plan uses more than one trust or custodial account
for its fund, you should enter the primary trust or custodial
account in which the greatest dollar amount or largest
percentage of the plan assets as of the end of the plan year is
held on this Line. For example, if a plan uses three different
trusts, X, Y, Z, with the percentages of plan assets, 35%, 45%,
and 20%, respectively, trust Y that held the 45% of plan assets
would be entered in Line 6a.
Line 6b. (Optional) You may use this line to enter the “Trust’s
Employer Identification Number (EIN)” assigned to the
employee benefit trust or custodial account, if one has been
issued to you. The trust EIN should be used for transactions
conducted for the trust. If you do not have a trust EIN, enter
the EIN you would use on Form 1099-R, Distributions From
Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs,
Insurance Contracts, etc., to report distributions from employee
benefit plans and on Form 945, Annual Return of Withheld
Federal Income Tax, to report withheld amounts of income tax
from those payments.
Do not use a social security number in lieu of an EIN. Form
5500 and its attachments are open to public inspection, and
the contents are public information and are subject to
publication on the Internet. Because of privacy concerns, the
inclusion of a social security number or any portion thereof
may result in the rejection of the filing.
Trust EINs can be obtained from the IRS by applying for one
on Form SS-4, Application for Employer Identification Number.
See Instructions to Line 2b (Form 5500) for applying for an
EIN. Also see IRS EIN application link page for further
information.
Note. Although Lines 6a and 6b are optional, the IRS
encourages filers to provide trust information on these lines.
Line 6c. Enter the name of the plan trustee or custodian.
Line 6d. Enter the telephone number for the plan trustee or
custodian

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Instructions for Schedule I (Form 5500)

Lines A through E must be completed for ALL plans. If the
Schedule MB is attached to a Form 5500 or Form 5500-SF,
lines A, B, C, and D should include the same information as
reported in Part II of the Form 5500 or Form 5500-SF. You
may abbreviate the plan name.
Do not use a social security number in line D in lieu of an
EIN. The Schedule MB and its attachments are open to public
inspection if filed with a Form 5500 or Form 5500-SF, and the
contents are public information and are subject to publication
on the Internet. Because of privacy concerns, the inclusion of a
social security number or any portion thereof on this Schedule
MB or any of its attachments may result in the rejection of the
filing.
You can apply for an EIN from the IRS online, by telephone,
by fax, or by mail depending on how soon you need to use the
EIN. For more information, see Section 3: Electronic Filing
Requirement under the General Instructions to Form 5500 and
How to File – Electronic Filing Requirement under the General
Instructions to Form 5500-SF. The EBSA does not issue EINs.
Note. (1) For split-funded plans, the costs and contributions
reported on Schedule MB must include those relating to both
trust funds and insurance carriers. (2) For plans with funding
standard account amortization charges and credits, see the
instructions for lines 9c and 9h. (3) For terminating
multiemployer plans, Code section 412(e)(4) and ERISA
section 301(c) provide that minimum funding standards apply
until the last day of the plan year in which the plan terminates
within the meaning of section 4041A(a)(2) of ERISA.
Accordingly, the Schedule MB is not required to be filed for any
later plan year.

2014 2015 Instructions for Schedule
MB
(Form 5500)
Multiemployer Defined Benefit Plan and
Certain Money Purchase Plan Actuarial
Information
General Instructions
Who Must File
As the first step, the plan administrator of any multiemployer
defined benefit plan that is subject to the minimum funding
standards (see Code sections 412 and 431 and Part 3 of Title I
of ERISA) must obtain a completed Schedule MB (Form 5500)
that is prepared and signed by the plan’s enrolled actuary as
discussed below in the Statement by Enrolled Actuary section.
The plan administrator must retain with the plan records the
Schedule MB that is prepared and signed by the plan’s actuary.
Next, the plan administrator of a multiemployer defined
benefit plan must ensure that the information from the
actuary’s Schedule MB is entered electronically into the annual
return/report being submitted. When entering the information,
whether using EFAST2-approved software or EFAST2’s webbased filing system, all the fields required for the type of plan
must be completed (see instructions for fields that need to be
completed).
Further, the plan administrator of a multiemployer defined
benefit plan must attach to the Form 5500 an electronic
reproduction of the Schedule MB prepared and signed by the
plan’s enrolled actuary. This electronic reproduction must be
labeled “MB Actuary Signature” and must be included as a
Portable Document Format (PDF) attachment or any
alternative electronic attachment allowable under EFAST2.
If a money purchase defined contribution plan (including a
target benefit plan) has received a waiver of the minimum
funding standard, and the waiver is currently being amortized,
lines 3, 9, and 10 of Schedule MB must be completed but it
need not be signed by an enrolled actuary. In such a case, the
Form 5500 or the Form 5500-SF that is submitted under
EFAST2 must include the Schedule MB with lines 3, 9, and 10
completed, but is not required to include a PDF attachment of a
signed Schedule MB.
Note. Schedule MB does not have to be filed with the Form
5500-EZ, but, if required, it must be retained (in accordance
with the instructions for Form 5500-EZ under the What to File
section). Similarly, if a plan is a one-participant plan that meets
the requirements for filing a Form 5500-EZ, but a Form 5500SF is instead filed for the plan, the Schedule MB, if required,
does not have to be filed with the Form 5500-SF, but it must be
retained (in accordance with the instructions for the Form
5500-SF under Schedule MB in the Specific Instructions Only
for “One-Participant Plans” section). Also, the funding standard
account for the plan must continue to be maintained, even if
the Schedule MB is not filed.
Check the Schedule MB box on the Form 5500 (Part II, line
10a(2)) if a Schedule MB is attached to the Form 5500.
Instructions for Schedule I (Form 5500)

Statement by Enrolled Actuary
An enrolled actuary must sign Schedule MB unless, as
described above, the plan is a money purchase defined
contribution plan that has received a waiver of the minimum
funding standard. The signature of the enrolled actuary may be
qualified to state that it is subject to attached qualifications.
See Treasury Regulations section 301.6059-1(d) for permitted
qualifications. Except as otherwise provided in these
instructions, a stamped or machine produced signature is not
acceptable. If the actuary has not fully reflected any final or
temporary regulation, revenue ruling, or notice promulgated
under the statute in completing the Schedule MB, check the
box on the last line of page 1. If this box is checked, indicate
on an attachment whether an accumulated funding deficiency
or a contribution that is not wholly deductible would result if the
actuary had fully reflected such regulation, revenue ruling, or
notice, and label this attachment “Schedule MB – Statement
by Enrolled Actuary.” In addition, the actuary may offer any
other comments related to the information contained in
Schedule MB.
The actuary must provide the completed and signed
Schedule MB to the plan administrator to be retained with the
plan records and included (in accordance with these
instructions) with the Form 5500 that is submitted under
EFAST2. The plan’s actuary is permitted to sign the Schedule
MB on page one using the actuary’s signature or by inserting
the actuary’s typed name in the signature line followed by the
actuary’s handwritten initials. The actuary’s most recent
-52-

enrollment number must be entered on the Schedule MB that
is prepared and signed by the plan’s actuary.

calculations are used for purposes of the full funding limitation
(see Rev. Rul. 81-13, 1981-1 C.B. 229).
Line 1d(1). Amount Excluded from Current Liability.
Leave line 1(d)(1) blank.
Line 1d(2)(a). Current Liability. All multiemployer plans,
regardless of the number of participants, must provide the
information indicated in accordance with these instructions.
The interest rate used to compute the current liability must be
in accordance with guidelines issued by the IRS and, pursuant
to the Pension Protection Act of 2006 (PPA), must not be more
than 5 percent above and must not be more than 10 percent
below the weighted average of the rates of interest, as set forth
by the Treasury Department, on 30-year Treasury securities
during the 4-year period ending on the last day before the
beginning of the 2014 2015 plan year.
The current liability must be computed using the mortality
tables referenced in section 1.431(c)(6)-1 of the Treasury
Regulations.
Each other actuarial assumption used in calculating the
current liability must be the same assumption used for
calculating other costs for the funding standard account. See
Notice 90-11, 1990-1 C.B. 319. The actuary must take into
account rates of early retirement and the plan’s early
retirement and turnover provisions as they relate to benefits,
where these would significantly affect the results.
Regardless of the valuation date, current liability is computed
taking into account only credited service through the end of
the prior plan year. No salary scale projections should be
used in these computations. Do not include the expected
increase in current liability due to benefits accruing during
the plan year reported on line 1d(2)(b) in these
computations.
Line 1d(2)(b). Expected Increase in Current Liability.
Enter the amount by which the current liability is expected to
increase due to benefits accruing during the plan year on
account of credited service and/or salary changes for the
current year. One year’s salary scale may be reflected.
Line 1d(2)(c). Expected Release From Current Liability
for the Plan Year. Enter the expected release from current
liability on account of disbursements (including single-sum
distributions) from the plan expected to be paid after the
valuation date but prior to the end of the plan year (see also
Q&A-7 of Rev. Rul. 96-21, 1996-1 C.B. 64).
Line 1d(3). Expected Plan Disbursements. Enter the
amount of plan disbursements expected to be paid for the
plan year.
Line 2. All entries must be reported as of the beginning of
the 2014 2015 plan year. Lines 2a and 2b should include all
assets and liabilities under the plan except for assets and
liabilities attributable to: (1) rollover amounts or other
amounts in individual accounts that are not available to
provide defined benefits, or (2) benefits for which an insurer
has made an irrevocable commitment as defined in 29 CFR
4001.2.
Line 2a. Current Value of Assets. Enter the current value
of net assets as of the first day of the plan year. Except for
plans with excluded assets as described above, this entry
should be the same as reported on the 2014 2015 Schedule
H (Form 5500) (line 1l, column (a)) or Schedule I (Form
5500) (line 1c, column (a)). Note that contributions
designated for the 2014 2015 plan year are not included on
those lines.
Line 2b. Current Liability (beginning of plan year). Enter
the current liability as of the first day of the plan year. Do not
include the expected increase in current liability due to

Attachments
All attachments to the Schedule MB must be properly
identified, and must include the name of the plan, the plan
sponsor’s EIN, and the plan number. Put “Schedule MB” and
the line number to which the attachment relates at the top of
each attachment. Do not include attachments that contain a
visible social security number. The Schedule MB and its
attachments are open to public inspection, and the contents
are public information and are subject to publication on the
Internet. Because of privacy concerns, the inclusion of a visible
social security number or any portion thereof on an attachment
may result in the rejection of the filing.

Specific Instructions
Line 1. All entries must be reported as of the valuation date.
Line 1a. Actuarial Valuation Date. The valuation for a plan
year may be as of any date in the plan year, including the first
or last day of the plan year. Valuations must be performed
within the period specified by Code section 431(c)(7) and
ERISA section 304(c)(7).
Line 1b(1). Current Value of Assets. Enter the current value
of assets as of the valuation date. The current value is the
same as the fair market value. Do not adjust for items such as
the existing credit balance or the outstanding balances of
certain amortization bases. Contributions designated for 2014
2015 should not be included in this amount. Note that this
entry may be different from the entry in line 2a. Such a
difference may result, for example, if the valuation date is not
the first day of the plan year, or if insurance contracts are
excluded from assets reported on line 1b(1) but not on line 2a.
Rollover amounts or other assets held in individual
accounts that are not available to provide defined benefits
under the plan should not be included on line 1b(1), regardless
of whether they are reported on the 2014 2015 Schedule H
(Form 5500) (line 1I, column (a)) or Schedule I (Form 5500)
(line 1c, column (a)). Additionally, asset and liability amounts
must be determined in a consistent manner. Therefore, if the
value of any insurance contracts have been excluded from the
amount reported on line 1b(1), liabilities satisfied by such
contracts should also be excluded from the liability values
reported on lines 1c(1), 1c(2), and 1d(2) of the Schedule MB.
Line 1b(2). Actuarial Value of Assets. Enter the value of
assets determined in accordance with Code section 431(c)(2)
and ERISA section 304(c)(2). Do not adjust for items such as
the existing credit balance or the outstanding balances of
certain amortization bases, and do not include contributions
designated for 2014 2015 in this amount.
Line 1c(1). Accrued Liability for Immediate Gain Methods.
Complete this line only if you use an immediate gain method
(see Rev. Rul. 81-213, 1981-2 C.B. 101, for a definition of
immediate gain method).
Lines 1c(2)(a), (b), and (c). Information for Plans Using
Spread Gain Methods. Complete these lines only if you use a
spread gain method (see Rev. Rul. 81-213 for a definition of
spread gain method).
Line 1c(2)(a). Unfunded Liability for Methods with Bases.
Complete this line only if you use the frozen initial liability or
attained age normal cost method.
Lines 1c(2)(b) and (c). Entry Age Normal Accrued Liability
and Normal Cost. For spread gain methods, these

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Instructions for Schedule MB (Form 5500)

benefits accruing during the plan year. See the instructions
for line 1d(2)(a) for actuarial assumptions used in
determining current liability.
Column (1) – Enter the number of participants and
beneficiaries as of the beginning of the plan year. If the
current liability figures are derived from a valuation that
follows the first day of the plan year, the participant and
beneficiary count entries should be derived from the counts
used in that valuation in a manner consistent with the
derivation of the current liability reported in column (2).
Column (2) – Include the current liability attributable to
all benefits, with subtotals for vested and nonvested benefits
in the case of active participants.
Line 2c. This calculation is required under ERISA section
103(d)(11). Do not complete if line 2a divided by line 2b(4),
column (2), is 70% or greater.
Line 3. Contributions Made to Plan. Show all employer
and employee contributions for the plan year. Include
employer contributions made not later than 2½ months (or
the later date allowed under Code section 431(c)(8) and
ERISA section 304(c)(8)) after the end of the plan year.
Show only contributions actually made to the plan by the
date this Schedule MB is signed.
Add the amounts in both columns (b) and (c) and enter
both results on the total line. All contributions must be
credited toward a particular plan year.
Line 4. Information on Plan Status. All multiemployer plans
regardless of the number of participants must provide the
information indicated in accordance with these instructions.
Line 4a. All plans enter the funded percentage for monitoring
the plan’s status. This is line 1b(2) divided by line 1c(3).
Line 4a4b. Enter the code for the status of the
multiemployer plan for the plan year, as certified by the plan
actuary, (or as elected by the plan sponsor in accordance
with Code section 432(b)(4)(A) and ERISA section
305(b)(4)(A)) using one of the following codes:
Code
E
S
C
D
N

certification. Attach documentation comparing the current
status of the plan to the scheduled progress under the
applicable funding improvement or rehabilitation plan to this
Schedule MB. Label the documentation “Schedule MB, line
4c – Documentation Regarding Progress Under Funding
Improvement or Rehabilitation Plan.”
Lines 4d and 4e. If Code C (Critical Status) or Code D (Critical
and Declining Status) was entered on line 4a4b, an entry on
line 4d is required. For purposes of lines 4d and 4e, in
determining whether adjustable benefits have been reduced,
only adjustable benefits that would otherwise be protected
under Code section 411(d)(6) and ERISA section 204(g) are
taken into account if the plan is certified as being in critical
status. Plans that are certified as being in critical and declining
status should determine whether benefits have been reduced,
including all benefits that were adjusted (only adjustable
benefits that would otherwise be protected under Code section
411(d)(6) and ERISA section 204(g) are taken into account),
any benefits that have been suspended under Code section
432(e)(9), and any benefit reductions due to a partition under
ERISA section 4233. For a plan that has benefits suspended
under Code section 432(e)(9) and/or partitioned under ERISA
section 4233, attach a full description of the transaction and
label the attachment “Schedule MB, Lines 4d and 4e –
Description of Benefit Reductions Due to Suspension or
Partition”. In addition, only adjustable benefit reductions that
are first reflected in line 1c(3) for the current year's Schedule
MB should be reported, and this amount should not include
any amounts previously reported on any prior year's Schedule
MB.
Line 4f. If Code C (Critical Status) or Code D (Critical and
Declining Status) was entered on line 4a 4b you must complete
line 4f. If the rehabilitation plan projects emergence from
critical status or critical and declining status, enter the plan
year in which the plan is projected to emerge. If the
rehabilitation plan is based on forestalling possible insolvency,
check the box provided and enter the plan year in which the
insolvency is expected.
Line 5. Actuarial Cost Method. Enter the primary method
used. If the plan uses one actuarial cost method in one year as
the basis of establishing an accrued liability for use under the
frozen initial liability method in subsequent years, answer as if
the frozen initial liability method was used in all years. The
projected unit credit method is included in the “Accrued benefit
(unit credit)” category of line 5c. If a method other than a
method listed on lines 5a through 5g is used, check the box for
line 5j and specify the method. For example, if a modified
individual level premium method for which actuarial gains and
losses are spread as a part of future normal cost is used,
check the box for 5j and describe the cost method.
Check the appropriate box for the underlying actuarial
cost method used as the basis for this plan year’s funding
standard account computation. If box 5h is checked, enter
the period of use of the shortfall method in line 5k. For this
purpose, enter the calendar year (YY) which includes the
first day of the plan year in which the shortfall method was
first used. For plans in reorganization status, check the
appropriate box for the underlying actuarial cost method
used to determine charges and credits to the funding
standard account and check the box for 5i.
Changes in funding methods include changes in actuarial
cost method, changes in asset valuation method, and changes
in the valuation date of plan costs and liabilities or of plan
assets. Changes in the funding method of a plan include not
only changes to the overall funding method used by the plan,
but also changes to each specific method of computation used

Plan Status
Endangered Status
Seriously Endangered Status
Critical Status
Critical and Declining Status
Not in Endangered or Critical Status

If the plan is certified to be in endangered status, seriously
endangered status, or critical status, or critical and declining
status, attach a copy of the actuarial certification of such status
to this Schedule MB. Also attach an illustration showing the
details (including year-by-year cash flow projections
demonstrating the solvency of the plan over the relevant period
if the plan is certified as being in critical and declining status)
providing support for the actuarial certification of status and
label the illustration “Schedule MB, line 4a 4b – Illustration
Supporting Actuarial Certification of Status.” For example,
if a plan is certified to beas being in critical status based on
Code section 432(b)(2)(B), show the funded percentage (if
applicable) and the projection of the funding standard account
to for the year where in which the accumulated funding
deficiency occurs. All supporting documentation should include
descriptions of the assumptions used.
Line 4c. If, in the plan year in which the Schedule MB is filed, a
certification was required to be made under Code section
432(b)(3)(A)(ii) and ERISA section 305(b)(3)(A)(ii) with respect
to scheduled progress during the plan year for which the
Schedule MB is filed, check “Yes” or “No” to reflect the
Instructions for Schedule MB (Form 5500)

-54-

in applying the overall method. Generally, these changes
require IRS approval. If the change was made pursuant to
Rev. Proc. 2000-40, 2000-2 C.B. 357, or pursuant to other
automatic approval (such as the Preservation of Access to
Care for Medicare Beneficiaries and Pension Relief Act of
2010 (PRA 2010), Pub. L. No. 111-192), check “Yes” for line
5m. If approval was granted for this plan by either an individual
ruling letter or a class ruling letter, enter the date of the
applicable ruling letter in line 5n. Note that the plan sponsor's
agreement to certain changes in funding methods should be
reported on line 8 of Schedule R (Form 5500).
Shortfall Method: Only certain plans may elect the shortfall
funding method (see Treasury Regulations section
1.412(c)(1)-2). Advance approval from the IRS for the
election of the shortfall method of funding is NOT required if
it is first adopted for the first plan year to which Code section
412 applies. In addition, pursuant to PPA section 201(b), a
plan does NOT need advance approval from the IRS to
adopt or cease using the shortfall method if the plan (1) has
not adopted or ceased using the shortfall method during the
5-year period ending on the day before the date the plan is
to use the method, and (2) is not operating under an
amortization period extension and did not operate under
such an extension during such 5-year period. In such a case,
check “Yes” for line 5m. If a plan utilizes this automatic
approval to apply the shortfall method, the benefit increase
limitations of Code section 412(c)(7) apply.
If a plan is not eligible for automatic approval as set forth
in the preceding paragraph, advance approval from the IRS
is required if the shortfall funding method is adopted at a
later time, if a specific computation method is changed, or if
the shortfall method is discontinued. In such a case there is
no automatic limitation on benefit increases.
Reorganization Status: Attach an explanation of the basis
for the determination that the plan is in reorganization for this
plan year and label the explanation “Schedule MB, line 5 –
Reorganization Status Explanation.” Also, attach a
worksheet showing for this plan year:
1. The amounts considered contributed by employers,
2. Any amount waived by the IRS,
3. The development of the minimum contribution
requirement (taking into account the applicable overburden
credit, cash-flow amount, contribution bases and limitation
on required increases on the rate of employer contributions,
and any adjustments in accrued benefits), and
4. The resulting accumulated funding deficiency, if any,
which is to be reported on line 9n. (See Code sections 418B,
418C, and 418D.)
Label the worksheet “Schedule MB, line 5 – Reorganization
Status Worksheet.”
Line 6. Actuarial Assumptions. If gender-based
assumptions are used in developing plan costs, enter those
rates where appropriate in line 6. Note that requests for
gender-based cost information do not suggest that genderbased benefits are legal. If unisex tables are used, enter the
values in both “Male” and “Female” lines. Check “N/A” for
line 6b if the question is not applicable.
Attach a statement of actuarial assumptions (if not fully
described by line 6) and actuarial methods used to calculate
the figures shown in lines 1 and 9 (if not fully described by
line 5), and label the statement “Schedule MB, line 6 –
Statement of Actuarial Assumptions/Methods.” The
statement must describe all actuarial assumptions used to
determine the liabilities. For example, the statement for non-

traditional plans (e.g., cash balance plans) must include the
assumptions used to convert balances to annuities.
Also attach a summary of the principal eligibility and
benefit provisions on which the valuation was based,
including the status of the plan (e.g., eligibility frozen,
service/pay frozen, benefits frozen), optional forms of
benefits, special plan provisions, including those that apply
only to a subgroup of employees (e.g., those with imputed
service), supplemental benefits, an identification of benefits
not included in the valuation (e.g., shutdown benefits), a
description of any significant events that occurred during the
year, a summary of any changes in principal eligibility or
benefit provisions since the last valuation, a description (or
reasonably representative sample) of plan early retirement
factors, and any change in actuarial assumptions or cost
methods and justifications for any such change (see section
103(d) of ERISA). Label the summary “Schedule MB, line 6
– Summary of Plan Provisions.”
Also, include any other information needed to disclose the
actuarial position of the plan fully and fairly, including the
weighted average retirement age.
Line 6a. Current Liability Interest Rate. Enter the interest
rate used to determine current liability. The interest rate used
must be in accordance with the guidelines issued by the IRS
and, pursuant to PPA, must not be more than 5 percent
above and must not be more than 10 percent below the
weighted average of the rates of interest, as set forth by the
Treasury Department, on 30-year Treasury securities during
the 4-year period ending on the last day before the
beginning of the 2014 2015 plan year. Enter the rate to the
nearest .01 percent.
Line 6b. Check “Yes,” if the rates in the contract were used
(e.g., purchase rates at retirement).
Line 6c. Mortality Table. The mortality table published in
section 1.431(c)(6)-1 of the Treasury Regulations must be used
in the calculation of current liability for non-disabled lives. Enter
the mortality table code for non-disabled lives used for valuation
purposes as follows:
Mortality Table

Code

1951 Group Annuity ............................................................. 1
1971 Group Annuity Mortality (G.A.M.) ............................... 2
1971 Individual Annuity Mortality (I.A.M.) ............................ 3
UP-1984 .............................................................................. 4
1983 I.A.M. .......................................................................... 5
1983 G.A.M. ........................................................................ 6
1983 G.A.M. (solely per Rev. Rul. 95-28) ............................ 7
UP-1994 .............................................................................. 8
Mortality table applicable to current plan year under
section 1.431(c)(6)-1 of the Income Tax Regulations .......... 9
RP-2000............................................................................. 10
RP-2000 (with Blue Collar Adjustment) .............................. 11
Other ................................................................................... A
None ................................................................................... 0

Code 6 includes all sex-distinct versions of the 1983
G.A.M. table other than the table published in Rev. Rul. 9528, 1995-1 C.B. 74. Thus, for example, Code 6 also would
include the 1983 G.A.M. male-only table used for males,
where the 1983 G.A.M. male-only table with a 6-year
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Instructions for Schedule MB (Form 5500)

may attach a statement showing both the actuary’s estimate of
the rate of return and the actuary’s calculations of that rate,
and label the statement “Schedule MB, line 6g – Estimated
Rate of Investment Return (Actuarial Value).”
Line 6h. Estimated Investment Return – Current (Market)
Value. Enter the estimated rate of return on the current value
of plan assets for the 1-year period ending on the valuation
date. (The current value is the same as the fair market value —
see line 1b(1) instructions.) For this purpose, the rate of return
is determined by using the formula 2I/(A + B – I), where I is
the dollar amount of the investment return, A is the current
value of the assets one year ago, and B is the current value of
the assets on the current valuation date. Enter rates to the
nearest .1 percent. If entering a negative number, enter a
minus sign (“ – ”) to the left of the number.
Note. Use the above formula even if the actuary feels that the
result of using the formula does not represent the true
estimated rate of return on the current value of plan assets for
the 1-year period ending on the valuation date. The actuary
may attach a statement showing both the actuary’s estimate of
the rate of return and the actuary’s calculations of that rate,
and label the statement “Schedule MB, line 6h – Estimated
Rate of Investment Return (Current Value).”
Line 7. New Amortization Bases Established. List all new
amortization bases established in the current plan year (before
the combining of bases, if bases were combined). Use the
following table to indicate the type of base established, and
enter the appropriate code under “Type of base.” List
amortization bases and charges and/or credits as of the
valuation date. Bases that are considered fully amortized
because there is a credit for the plan year on line 9j(3) should
be listed. If entering a negative number, enter a minus sign (“–
”) to the left of the number.

setback is used for females. Code A includes mortality tables
other than those listed in Codes 1 through 9, including any
unisex version of the 1983 G.A.M. table.
Where an indicated table consists of separate tables for
males and females, add F to the female table (e.g., 1F).
When a projection is used with a table, follow the code with
“P” and the year of projection (omit the year if the projection
is unrelated to a single calendar year); the identity of the
projection scale should be omitted. When an age setback or
set forward is used, indicate with “ – ” or “+” and the number
of years. For example, if for females the 1951 Group Annuity
Table with Projection C to 1971 is used with a 5-year
setback, enter “1P71-5.” If the table is not one of those
listed, enter “A” with no further notation. If the valuation
assumes a maturity value to provide the post-retirement
income without separately identifying the mortality, interest
and expense elements, enter on line 6c, under “Postretirement,” the value of $1.00 of monthly pension beginning
at the plan’s weighted average retirement age, assuming the
normal form of annuity for an unmarried person. In such a
case, leave lines 6d and 6e blank.
Line 6d. Valuation Liability Interest Rate. Enter the
assumption as to the expected interest rate (investment
return) used to determine all the calculated values except for
current liability. If the assumed rate varies with the year,
enter the weighted average of the assumed rate for 20 years
following the valuation date. Enter rates to the nearest .01
percent.
Line 6e. Expense Loading. If there is no expense loading,
check the "N/A" boxes under "Pre-retirement" and "Postretirement”. For instance, there would be no expense loading
attributable to investments if the rate of investment return on
assets is adjusted to take investment expenses into account.
If there is a single expense loading not separately identified
as pre-retirement or post-retirement, enter it under “Preretirement” and check the “N/A“ box under “PostRetirement.” Where expenses are assumed other than as a
percentage of plan costs or liabilities, enter the assumed
pre-retirement expense as a percentage of the plan’s normal
cost, and enter the post-retirement expense as a percentage
of plan liabilities. If the normal cost of the plan is zero, enter
the assumed pre-retirement expense as a percentage of the
sum of lines 9c(1), 9c(2), and 9c(3), minus line 9h. Enter
rates to the nearest .1 percent.
Line 6f. Salary Scale. If a uniform level annual rate of salary
increase is used, enter that annual rate. Otherwise, enter the
level annual rate of salary increase that is equivalent to the
rate(s) of salary increase used. Enter the annual rate as a
percentage to the nearest .01 percent, used for a participant
from age 25 to assumed retirement age. If the plan’s benefit
formula is not related to compensation, check the “N/A” box.
Line 6g. Estimated Investment Return – Actuarial Value.
Enter the estimated rate of return on the actuarial value of
plan assets for the 1-year period ending on the valuation
date. For this purpose, the rate of return is determined by
using the formula 2I/(A + B – I), where I is the dollar amount
of the investment return under the asset valuation method
used for the plan, A is the actuarial value of the assets one
year ago, and B is the actuarial value of the assets on the
current valuation date. Enter rates to the nearest .1 percent.
If entering a negative number, enter a minus sign (“ – ”) to
the left of the number.
Note. Use the above formula even if the actuary feels that the
result of using the formula does not represent the true
estimated rate of return on the actuarial value of plan assets for
the 1-year period ending on the valuation date. The actuary
Instructions for Schedule MB (Form 5500)

Code
1
2
3
4
5
6
7

Type of Amortization Base
Experience gain or loss
Shortfall gain or loss
Change in unfunded liability due to plan amendment
Change in unfunded liability due to change in
actuarial assumptions
Change in unfunded liability due to change in
actuarial cost method
Waiver of the minimum funding standard
Initial unfunded liability (for new plan)

Line 8a and 8d. Funding Waivers or Extensions. If a
funding waiver or extension request is approved after the
Schedule MB is filed, an amended Schedule MB must be
filed with Form 5500 to report the waiver or extension
approval (also see instructions for line 9k(1)).
Line 8b(1). Schedule of Projection of Expected Benefit
Payments. Check “Yes” only if this is a multiemployer plan
covered by Title IV of ERISA that has 500 or more total
participants as of the valuation date.
If line 8b(1) is “Yes,” in an attachment, provide a
projection of benefits expected to be paid for the entire plan
(not to include expected expenses) in each of the next ten
years starting with the current plan year of this filing
assuming (1) no additional accruals, (2) experience (e.g.,
termination, mortality, and retirement) are in line with
valuation assumptions, and (3) no new entrants are covered
by the plan. Use the format shown below and label the
schedule “Schedule MB, line 8b(1) – Schedule of
Projection of Expected Benefit Payments”.
-56-

age/service bin, enter the average cash balance account of
the active participants in that bin. Do not enter the average
cash balance account in any age/service bin that contains
fewer than 20 active participants.
General Rule. In general, data to be shown in each
age/service bin includes:
1. the number of active participants in the age/service
bin,
2. the average compensation of the active participants in
the age/service bin, and
3. the average cash balance account of the active
participants in the age/service bin, using $0 for anyone who
has no cash balance account-based benefit.
If the accrued benefit is the greater of a cash balance benefit
or some other benefit, average in only the cash balance
account. If the accrued benefit is the sum of a cash balance

Schedule MB, line 8b(1) – Schedule of Projection of
Expected Benefit Payments
Expected Annual Benefit
Payments

Plan Year
Current Plan Year
Current Plan Year +1
Current Plan Year +2
Current Plan Year +3
Etc.
Current Plan Year +9

Line 8b(2). Schedule of Active Participant Data. Check
“Yes” only if this is a multiemployer plan covered by Title IV
of ERISA that has active participants.
Schedule MB, Line 8b(2) – Schedule of Active Participant Data

YEARS OF CREDITED SERVICE
1 to 4

Under 1
Attained
Age

Average
No.

Comp.

Cash Bal.

5 to 9

Average
No.

Comp.

40 & up

Average
No.

Cash Bal.

Comp.

Cash Bal.

Average
.
No.

Comp.

Cash Bal.

Under 25
25 to 29
30 to 34
35 to 39
40 to 44
45 to 49
50 to 54
55 to 59
60 to 64
65 to 69
70 & up

account benefit and some other benefit, average in only the
cash balance account. For both the average compensation
and the average cash balance account, do not enter an
amount for age/service bins with fewer than 20 active
participants.
In lieu of the above, two alternatives are provided for
showing compensation and cash balance accounts. Each
alternative provides for two age/service scatters (one
showing compensation and one showing cash balance
accounts) as follows:
Alternative A:
 Scatter 1 - Provide participant count and average
compensation for all active participants, whether or not
participants have account-based benefits.
 Scatter 2 - Provide participant count and average cash
balance account for all active participants, whether or not
participants have account-based benefits.
Alternative B:
 Scatter 1 - Provide participant count and average
compensation for all active participants, whether or not
participants have account-based benefits (i.e., identical to
Scatter 1 in Alternative A).
 Scatter 2 - Provide participant count and average cash
balance account for only those active participants with
account based benefits. If the number of participants with
account-based benefits in a bin is fewer than 20, the average
account should not be shown even if there are more than 20
active participants in this bin on Scatter 1.
In general, information should be determined as of the
valuation date. Average cash balance accounts may be
determined as of either:

If line 8b(2) is “Yes,” attach a schedule of the active plan
participant data used in the valuation for this plan year. Use
the format shown below above and label the schedule
“Schedule MB, line 8b(2) – Schedule of Active
Participant Data.”
Expand this schedule by adding columns after the “5 to
9” column and before the “40 & up” column for active
participants with total years of credited service in the
following ranges: 10 to14; 15 to 19; 20 to 24; 25 to 29; 30 to
34; and 35 to 39. For each column, enter the number of
active participants with the specified number of years of
credited service divided according to age group. For
participants with partial years of credited service, round the
total number of years of credited service to the next lower
whole number. Years of credited service are the years
credited under the plan’s benefit formula.
Plans reporting 1,000 or more active participants on line
2b(3)(c), column (1), and using compensation to determine
benefits must also provide average compensation data. For
each grouping, enter the average compensation of the active
participants in that group. For this purpose, compensation is
the compensation taken into account for each participant
under the plan’s benefit formula, limited to the amount
defined under section 401(a)(17) of the Code. Do not enter
the average compensation in any grouping that contains
fewer than 20 participants.
Cash balance plans (or any plans using characteristic code
1C on line 8a of Form 5500) reporting 1,000 or more active
participants on line 2b(3)(c), column (1), must also provide
average cash balance account data, regardless of whether
all active participants have cash balance accounts. For each
-57-

Instructions for Schedule MB (Form 5500)

Line 9k(1). Waived Funding Deficiency Credit. Enter a
credit for a waived funding deficiency for the current plan
year (Code section 431(b)(3)(C)). If a waiver of a funding
deficiency is pending, report a funding deficiency. If the
waiver is granted after Form 5500 or Form 5500-SF is filed,
file an amended Form 5500 or Form 5500-SF, as applicable,
with an amended Schedule MB to report the funding waiver
(see Amended Return/Report in the instructions for Form
5500 or Line B – Box for Amended Return/Report in the
instructions for Form 5500-SF, as applicable).
Line 9k(2). Other Credits. Enter a credit in the case of a
plan for which the accumulated funding deficiency is
determined under the funding standard account if such plan
year follows a plan year for which such deficiency was
determined under the alternative minimum funding standard.
Line 9o. Reconciliation Account. The reconciliation
account is made up of those components that upset the
balance equation of Treasury Regulations section
1.412(c)(3)-1(b). Valuation assets must not be adjusted by
the reconciliation account balance when computing the
required minimum funding.
Line 9o(1). This amount is equal to the prior year’s
accumulated reconciliation amount due to prior waived
funding deficiencies, increased with interest at the valuation
rate to the current valuation date.
Line 9o(2)(a). If an amortization extension is being
amortized at an interest rate that differs from the valuation
rate, enter the prior year’s “reconciliation amortization
extension outstanding balance,” increased with interest at
the valuation interest rate to the current valuation date, and
decreased by the year end amortization amount based on
the amortization interest rate from the prior plan year.
Line 9o(3). Enter the sum of lines 9o(1) and 9o(2)(b) (each
adjusted with interest at the valuation rate to the current
valuation date, if necessary).
Note. The net outstanding balance of amortization charges
and credits minus the prior year’s credit balance minus the
amount on line 9o(3) (each adjusted with interest at the
valuation rate, if necessary) must equal the unfunded
liability.
Line 10. Contribution Necessary to Avoid Deficiency.
Enter the amount from line 9n. For plans in reorganization,
see the instructions for line 5. If applicable, file IRS Form
5330, Return of Excise Taxes Related to Employee Benefit
Plans, with the IRS to pay the excise tax on the funding
deficiency. There is a penalty for not filing the Form 5330 on
time.
Line 11. In accordance with ERISA section 103(d)(3), attach
a justification for any change in actuarial assumptions for the
current plan year and label the attachment “Schedule MB,
line 11 – Justification for Change in Actuarial
Assumptions.”

1. the valuation date or
2. the day immediately preceding the valuation date.
Average cash balance accounts that are offset by
amounts from another plan may be reported either as
amounts prior to taking into account the offset or as amounts
after taking into account the offset. Do not report the offset
amount. For this or any other unusual or unique situation,
the attachment should include an explanation of what is
being provided.
Line 9. Shortfall Method. Under the shortfall method of
funding, the normal cost in the funding standard account is
the charge per unit of production (or per unit of service)
multiplied by the actual number of units of production (or
units of service) that occurred during the plan year. Each
amortization installment in the funding standard account is
similarly calculated.
Lines 9c and 9h. Amortization Charges and Credits. If
there are any amortization charges or credits, attach a
maintenance schedule of funding standard account bases
and label the schedule “Schedule MB, lines 9c and 9h –
Schedule of Funding Standard Account Bases.” The
attachment should clearly indicate the type of base (i.e.,
original unfunded liability, amendments, actuarial losses,
etc.), the outstanding balance of each base, the number of
years remaining in the amortization period, and the
amortization amount. If bases were combined in the current
year, the attachment should show information on bases both
prior to and after the combining of bases.
The outstanding balance and amortization charges and
credits must be calculated as of the valuation date for the
plan year.
Line 9c(3) should only include information related to the
amortization bases extended and amortized using the
interest rate under section 6621(b) of the Code.
Line 9d. Interest as Applicable. Interest as applicable
should be charged to the last day of the plan year.
Line 9f. Note that the credit balance or funding deficiency at
the end of “Year X” should be equal to the credit balance or
funding deficiency at the beginning of “Year X+1.” If such
credit balances or funding deficiencies are not equal, attach
an explanation and label the attachment “Schedule MB, line
9f – Explanation of Prior Year Credit Balance/Funding
Deficiency Discrepancy.” For example, if the difference is
because contributions for a prior year that were not
previously reported are received this plan year, attach a
listing of the amounts and dates of such contributions. As
another example, if the difference is due to the application of
funding relief under the Preservation of Access to Care for
Medicare Beneficiaries and Pension Relief Act of 2010 (PRA
2010), Pub. L. No. 111-192, the attachment should show
how the information on the Schedule MB filed for any
previous plan year would have differed if it had reflected
application of the special funding relief in accordance with
published guidance (to the extent that the plan sponsor has
applied the special funding relief).
Line 9j(1). ERISA Full Funding Limitation. Instructions for
this line are reserved pending published guidance.
Line 9j(2). “RPA ’94” Override. Instructions for this line are
reserved pending published guidance.
Line 9j(3). Full Funding Credit. Enter the excess of (1) the
accumulated funding deficiency, disregarding the credit
balance and contributions for the current year, if any, over
(2) the greater of lines 9j(1) or 9j(2).

Instructions for Schedule MB (Form 5500)

-58-

General Instructions

participants were distributed during the plan year in the
form of a single-sum distribution. See the instructions for
Part I, line 3, below.

The plan is not an ESOP.

The plan is not a multiemployer defined benefit plan.
Check the Schedule R box on the Form 5500 (Part II, line
10a(1)) if a Schedule R is attached to the Form 5500.

Purpose of Schedule

Specific Instructions

Schedule R (Form 5500) reports certain information on
retirement plan distributions, funding, nondiscrimination,
coverage, and the adoption of amendments, as well as certain
information on single employer and multiemployer defined
benefit plans. Schedule R (Form 5500) reports certain
information on plan distributions, funding, and the adoption of
amendments increasing or decreasing the value of benefits in
a defined benefit pension plan, as well as certain information
on employee stock ownership plans (ESOPs), and
multiemployer defined benefit plans.
Electronic Attachments. All attachments to Schedule R must
be properly identified, must include the name of the plan, plan
sponsor’s EIN, and plan number. Place “Schedule R” and the
Schedule R line number at the top of each attachment to
identify the information to which the attachment relates. Do not
include attachments that contain a visible social security
number. The Schedule R and its attachments are open to
public inspection, and the contents are subject to publication
on the Internet. Because of privacy concerns, the inclusion of a
visible social security number or any portion thereof on an
attachment may result in the rejection of the filing.

Lines A, B, C, and D. This information must be the same as
reported in Part II of the Form 5500 to which this Schedule R is
attached.
Do not use a social security number in line D instead of an
EIN. Schedule R and its attachments are open to public
inspection, and the contents are public information and are
subject to publication on the Internet. Because of privacy
concerns, the inclusion of a social security number or any portion
thereof on Schedule R or any of its attachments may result in the
rejection of the filing.
You can apply for an EIN from the IRS online, by
telephone, by fax, or by mail depending on how soon you
need to use the EIN. For more information, see Section 3:
Electronic Filing Requirement. The EBSA does not issue
EINs.
“Participant” for purposes of Schedule R, means any
present or former employee who at any time during the
plan year had an accrued benefit in the plan (account
balance in a defined contribution plan).

Who Must File

“Distribution” includes only payments of benefits during the
plan year, in cash, in kind, by purchase for the distributee of an
annuity contract from an insurance company, or by distribution
of life insurance contracts. It does not include:
1. Corrective distributions of excess deferrals, excess
contributions, or excess aggregate contributions, or the income
allocable to any of these amounts;
2. Distributions of automatic contributions pursuant to
Code section 414(w);
3. The distribution of elective deferrals or the return of
employee contributions to correct excess annual additions
under Code section 415, or the gains attributable to these
amounts; and
4. A loan deemed as a distribution under Code section
72(p).
Note. It does, however, include a distribution of a plan loan
offset amount as defined in Treasury Regulations section
1.402(c)-2, Q&A 9(b).
Line 1. Enter the total value of all distributions made during
the year (regardless of when the distribution began) in any
form other than cash, annuity contracts issued by an insurance
company, distribution of life insurance contracts, marketable
securities within the meaning of Code section 731(c)(2), or
plan loan offset amounts. Do not include eligible rollover
distributions paid directly to eligible retirement plans in a direct
rollover under Code section 401(a)(31) unless such direct
rollovers include property other than that enumerated in the
preceding sentence.
Line 2. Enter the EIN(s) of any payor(s) (other than the plan
sponsor or plan administrator on line 2b or 3b of the Form
5500) who paid benefits reportable on IRS Form 1099-R on
behalf of the plan to participants or beneficiaries during the
plan year. This is the EIN that appears on the IRS Forms
1099-R that are issued to report the payments. Include the EIN

2014 2015 Instructions for Schedule R
(Form 5500)
Retirement Plan Information

Part I – Distributions

Schedule R must be attached to a Form 5500 filed for both taxqualified and nonqualified pension benefit plans. The parts of
Schedule R that must be completed depend on whether the
plan is subject to the minimum funding standards of Code
section 412 or ERISA section 302 and the type of plan. See
line item requirements under Specific Instructions for more
details.
Exceptions: (1) Schedule R should not be completed when
the Form 5500 annual return/report is filed for a pension plan
that uses, as the sole funding vehicle for providing benefits,
individual retirement accounts or annuities (as described in
Code section 408). See the Form 5500 instructions for Limited
Pension Plan Reporting for more information.
(2) Schedule R also should not be completed if all of the
following conditions are met:

The plan is not a defined benefit plan or otherwise
subject to the minimum funding standards of Code section
412 or ERISA section 302.

No plan benefits that would be reportable on line 1 of
Part I of this Schedule R were distributed during the plan
year. See the instructions for Part I, line 1, below.

No benefits, as described in the instructions for Part I,
line 2, below, were paid during the plan year other than by
the plan sponsor or plan administrator. (This condition is
not met if benefits were paid by the trust or any other
payor(s) which are reportable on IRS Form 1099-R,
Distributions From Pensions, Annuities, Retirement or
Profit-Sharing Plans, IRAs, Insurance Contracts, etc.,
using an EIN other than that of the plan sponsor or plan
administrator reported on line 2b or 3b of Form 5500.)

Unless the plan is a profit-sharing, ESOP, or stock
bonus plan, no plan benefits of living or deceased
-59-

Instructions for Schedule MB (Form 5500)

of the trust if different than that of the sponsor or plan
administrator. If more than two payors made such payments
during the year, enter the EINs of the two payors who paid the
greatest dollar amounts during the year. For purposes of this
line 2, take into account all payments made during the plan
year, in cash or in kind, that are reportable on IRS Form 1099R, regardless of when the payments began, but take into
account payments from an insurance company under an
annuity only in the year the contract was purchased.
Line 3. Enter the number of living or deceased participants
whose benefits under the plan were distributed during the plan
year in the form of a single-sum distribution. For this purpose,
a distribution of a participant’s benefits will not fail to be a
single-sum distribution merely because, after the date of the
distribution, the plan makes a supplemental distribution as a
result of earnings or other adjustments made after the date of
the single-sum distribution. Also include any participants
whose benefits were distributed in the form of a direct rollover
to the trustee or custodian of a qualified plan or individual
retirement account.

either approved the amendment or failed to disapprove the
amendment within 90 days after the date the notice was filed.
See Treasury Temporary Regulations section 11.412(c)7(b) for details on when and how to make the election and
what information to include on the statement of election, which
must be filed with the Form 5500 annual return/report.
Line 5. If a money purchase defined contribution plan
(including a target benefit plan) has received a waiver of the
minimum funding standard, and the waiver is currently being
amortized, complete lines 3, 9, and 10 of Schedule MB. See
instructions for Schedule MB. Attach Schedule MB to Form
5500. The Schedule MB for a money purchase defined
contribution plan does not need to be signed by an enrolled
actuary.
Line 6a. The minimum required contribution for a money
purchase defined contribution plan (including a target benefit
plan) for a plan year is the amount required to be contributed
for the year under the formula set forth in the plan document. If
there is an accumulated funding deficiency for a prior year that
has not been waived, that amount should also be included as
part of the contribution required for the current year.
Line 6b. Include all contributions for the plan year made not
later than 8 ½ months after the end of the plan year. Show only
contributions actually made to the plan by the date the form is
filed. For example, do not include receivable contributions for
this purpose.
Line 6c. If the minimum required contribution exceeds the
contributions for the plan year made not later than 81/2 months
after the end of the plan year, the excess is an accumulated
funding deficiency for the plan year. File IRS Form 5330,
Return of Excise Taxes Related to Employee Benefit Plans,
with the IRS to pay the excise tax on the deficiency. There is a
penalty for not filing IRS Form 5330 on time.
Line 7. Check “Yes” if the minimum required contribution
remaining in line 6c will be made not later than 8 ½ months
after the end of the plan year. If “Yes,” and contributions are
actually made by this date, then there will be no reportable
deficiency and IRS Form 5330 will not need to be filed.
Line 8. Revenue Procedure 2000-40, 2000-2 C.B. 357,
providing for automatic approval for a change in funding
method for a plan year, generally does not apply unless the
plan administrator or an authorized representative of the plan
sponsor explicitly agrees to the change. If a change in funding
method made pursuant to such a revenue procedure (or a
class ruling letter) is to be applicable for the current plan year,
this line generally must be checked ‘‘Yes.” In certain situations,
however, the requirement that the plan administrator or an
authorized representative of the plan sponsor agree to the
change in funding method will be satisfied if the plan
administrator or an authorized representative of the plan
sponsor is made aware of the change. In these situations, this
line must be checked “N/A.” See section 6.01(2) of Rev. Proc.
2000-40. If the plan’s change in funding method is not made
pursuant to a revenue procedure or other authority providing
automatic approval which requires plan sponsor agreement, or
to a class ruling letter (e.g., it is pursuant to a regulation or the
Preservation of Access to Care for Medicare Beneficiaries and
Pension Relief Act of 2010 (PRA 2010), Pub. L. No. 111-192),
then this line should be checked “N/A.”

Part II – Funding Information
Complete Part II only if the plan is subject to the minimum
funding requirements of Code section 412 or ERISA section
302.
All qualified defined benefit and defined contribution plans
are subject to the minimum funding requirements of Code
section 412 unless they are described in the exceptions listed
under Code section 412(e)(2). These exceptions include profitsharing or stock bonus plans, insurance contract plans
described in Code section 412(e)(3), and certain plans to
which no employer contributions are made.
Nonqualified employee pension benefit plans are subject to
the minimum funding requirements of ERISA section 302
unless specifically exempted under ERISA sections 4(a) or
301(a).
The employer or plan administrator of a single-employer or
multiple-employer defined benefit plan that is subject to the
minimum funding requirements must file Schedule SB as an
attachment to Form 5500. Schedule MB is filed for
multiemployer defined benefit plans and certain money
purchase defined contribution plans (whether they are singleemployer or multiemployer plans). However, Schedule MB is
not required to be filed for a money purchase defined
contribution plan that is subject to the minimum funding
requirements unless the plan is currently amortizing a waiver of
the minimum funding requirements.
Line 4. Check ‘‘Yes’’ if, for purposes of computing the
minimum funding requirements for the plan year, the plan
administrator is making an election intended to satisfy the
requirements of Code section 412(d)(2) or ERISA section
302(d)(2). Under Code section 412(d)(2) and ERISA section
302(d)(2), a plan administrator may elect to have any
amendment, adopted after the close of the plan year for which
it applies, treated as having been made on the first day of the
plan year if all of the following requirements are met:
1. The amendment is adopted no later than two and onehalf months (two years for a multiemployer plan) after the close
of such plan year;
2. The amendment does not reduce the accrued benefit of
any participant determined as of the beginning of such plan
year; and
3. The amendment does not reduce the accrued benefit of
any participant determined as of the adoption of the
amendment unless the plan administrator notified the
Secretary of the Treasury of the amendment and the Secretary
Instructions for Schedule R (Form 5500)

Part III – Amendments
Line 9.
 Check “No” if no amendments were adopted during this
plan year that increased or decreased the value of
benefits.
-60-

 Check “Increase” if an amendment was adopted during
the plan year that increased the value of benefits in any
way. This includes an amendment providing for an
increase in the amount of benefits or rate of accrual, more
generous lump sum factors, COLAs, more rapid vesting,
additional payment forms, or earlier eligibility for some
benefits.
 Check “Decrease” if an amendment was adopted during
the plan year that decreased the value of benefits in any
way. This includes a decrease in future accruals, closure
of the plan to new employees, or accruals being frozen for
some or all participants.
 If the amendments that were adopted increased the
value of some benefits but decreased the value of others,
check “Both.”

The plan sponsor is required to annually update a Funding
Improvement Plan or Rehabilitation Plan that was adopted in a
prior year. The update must be filed as an attachment to the
Schedule R. The update attachment must identify the
modifications made to the Funding Improvement Plan or
Rehabilitation Plan during the plan year, including contribution
increases, benefit reductions, or other actions.
The attachment described above must be labeled
“Schedule R, Summary of Funding Improvement Plan,” or
“Schedule R, Summary of Rehabilitation Plan” as
appropriate, and if applicable, “Schedule R, Update of
Funding Improvement Plan or Rehabilitation Plan.” Each
attachment must also include the plan name, the plan
sponsor’s name and EIN, and the plan number.
Line 13. This line should be completed only by multiemployer
defined benefit pension plans that are subject to the minimum
funding standards (see Code section 412 and Part 3 of Title I
of ERISA). Enter the information on lines 13a through 13e for
any employer that contributed more than five (5) percent of the
plan’s total contributions for the 2014 2015 plan year. List
employers in descending order according to the dollar amount
of their contributions to the plan. Complete as many entries as
are necessary to list all employers that contributed more than
five (5) percent of the plan’s contributions.
Line 13a. Enter the name of the employer contributing to the
plan.
Line 13b. Enter the EIN of the employer contributing to the
plan. Do not enter a social security number in lieu of an EIN;
therefore, ensure that you have the employer’s EIN and not a
social security number. The Form 5500 is open to public
inspection, and the contents are public information and are
subject to publication on the Internet. Because of privacy
concerns, the inclusion of a social security number or any
portion thereof on this line may result in the rejection of the
filing.
EINs can be obtained from the IRS online, by telephone, by
fax, or by mail depending on when you need to use the EIN.
For more information, see Section 3: Electronic Filing
Requirement. The EBSA does not issue EINs.
Line 13c. Dollar Amount Contributed. Enter the total dollar
amount contributed to the plan by the employer for all covered
workers in all locations for the plan year. Do not include the
portion of an aggregated contribution that is for another plan,
such as a welfare benefit plan, a defined contribution pension
plan or another defined benefit pension plan.
Line 13d. Collective Bargaining Agreement Expiration
Date. Enter the date on which the employer’s collective
bargaining agreement expires. If the employer has more than
one collective bargaining agreement requiring contributions to
the plan, check the box and include, as an attachment, the
expiration date of each collective bargaining agreement
(regardless of the amount of contributions arising from such
agreement). Label the attachment: “Schedule R, line 13d –
Collective Bargaining Agreement Expiration Date.” Include
the plan name and the sponsor’s name and EIN.
Line 13e. Contribution Rate Information. Enter the
contribution rate (in dollars and cents) per contribution base
unit in line 13e(1) and the base unit measure in line 13e(2).
Indicate whether the base unit is measured on an hourly,
weekly, unit-of-production, or other basis. If “other,” specify the
base unit measure used. If the contribution rate changed
during the plan year, enter the last contribution rate in effect for
the plan year.
If the employer has different contribution rates for different
classifications of employees or different places of business,

Part IV – ESOP Information
Line 11b. A loan is a “back-to-back loan” if the following
requirements are satisfied:
1. The loan from the employer corporation to the ESOP
qualifies as an exempt loan under DOL regulations at 29 CFR
2550.408b-3 and under Treasury Regulations sections
54.4975-7 and 54.4975-11; and
2. The repayment terms of the loan from the sponsoring
corporation to the ESOP are substantially similar to the
repayment terms of the loan from the commercial lender to the
sponsoring employer.

Part V – Additional Employer Information for
Multiemployer Defined Benefit Pension Plans
If this is not a multiemployer plan, skip this Part.
Required attachments. Multiemployer defined benefit plans
that are in Endangered Status or Critical Status must attach a
summary of their Funding Improvement Plan or Rehabilitation
Plan (as updated, if applicable) and also any update to a
Funding Improvement Plan or Rehabilitation Plan.
The summary of any Funding Improvement Plan or
Rehabilitation Plan must reflect such plan in effect at the end of
the plan year (whether the original Funding Improvement Plan
or Rehabilitation Plan or as updated) and must include a
description of the various contribution and benefit schedules
that are being provided to the bargaining parties and any other
actions taken in connection with the Funding Improvement
Plan or Rehabilitation Plan, such as use of the shortfall funding
method or extension of an amortization period. The summary
must also identify the first year and the last year of the Funding
Improvement Period or the Rehabilitation Period. If an
extended Funding Improvement Period (of 13 or 18 years) or
Rehabilitation Period (of 13 years) applies because of an
election under section 205 of the Worker, Retiree, and
Employer Recovery Act of 2008 (“WRERA”), the summary
must include a statement to that effect and the date that the
election was filed with the IRS.
The summary must also include a schedule of the expected
annual progress for the funded percentage or other relevant
factors under the Funding Improvement Plan or Rehabilitation
Plan. If the sponsor of a multiemployer plan in Critical Status
has determined that, based on reasonable actuarial
assumptions and upon exhaustion of all reasonable measures,
the plan cannot emerge from Critical Status by the end of the
Rehabilitation Period as described in Code section
432(e)(3)(A)(ii), the summary must include an explanation of
the alternatives considered, why the plan is not reasonably
expected to emerge from Critical Status by the end of the
Rehabilitation Period, and when, if ever, it is expected to
emerge from Critical Status under the Rehabilitation Plan.
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Instructions for Schedule R (Form 5500)

check the box in the first line of line 13e and list in an
attachment each contribution rate and corresponding base unit
measure under which the employer made contributions
(regardless of the amount of contributions resulting from each
rate). Label the attachment: “Schedule R, line 13e –
Information on Contribution Rates and Base Units.” Include
the plan name and the sponsor’s name and EIN.
Line 14. Enter the number of participants on whose behalf no
contributions were made by an employer as an employer of the
participant. For purposes of line 14, count only those
participants whose last contributing employer had withdrawn
from the plan by the beginning of the relevant plan year.
Disregard any participants whose employers had not
withdrawn from the plan, even if, in the relevant year, no
contributions were made by the employer on behalf of those
participants. Thus, for the limited purposes of line 14 and
notwithstanding any contrary definition of such participants
applicable elsewhere, the deferred vested and retired
participants of employers who have not withdrawn from the
plan should not be included in these numbers.
Note. Withdrawal liability payments are not to be treated as
contributions for the purpose of determining the number of
participants for line 14.
Line 14a. Enter the number of participants for the 2014 2015
plan year described in the line 14 instructions.
Line 14b. Enter the number of participants for the 2013 2014
plan year described in the line 14 instructions.
Line 14c. Enter the number of participants for the 2012 2013
plan year described in the line 14 instructions.
Line 15. Enter the ratio of number of participants on whose
behalf no employer had an obligation to make a contribution for
the 2014 2015 plan year to the corresponding number for each
of the two preceding plan years. For the purpose of these
ratios, count all participants whose employers have withdrawn
from the plan as well as all deferred vested and retired
participants of employers still active in the plan (unless the
collective bargaining agreement specifically requires the
employer to make contributions for such participants).
Line 15a. Enter the ratio of the number of participants as
described in the line 15 instructions for the 2014 2015 plan
year to the number for the 2013 2014 plan year.
Line 15b. Enter the ratio of the number of participants as
described on the line 15 instructions for the 2014 2015 plan
year to the number for the 2012 2013 plan year.
Note. Withdrawal liability payments are not to be treated as
contributions for determining the number of participants on line
15.
Line 16a. Enter the number of employers that withdrew from
the plan during the 2013 2014 plan year.
Line 16b. If line 16a is greater than zero, enter the aggregate
amount of withdrawal liability assessed against these
employers. If the withdrawal liability for one or more
withdrawing employers has not yet been determined, include
the amounts estimated to be assessed against them in the
aggregate amount.
The definitions of withdrawal are those contained in Section
4203 of ERISA. If the plan is in the building and construction,
entertainment, or another industry that has special withdrawal
rules, withdrawing employers should only be counted if the
withdrawal adheres to the special rules applying to its specific
industry.
Line 17. If assets and liabilities from another plan were
transferred to or merged with the assets and liabilities of this
plan during the 2014 2015 plan year, check the box and
Instructions for Schedule R (Form 5500)

provide the following information as an attachment. The
attachment should include the names and employer
identification numbers of all plans that transferred assets and
liabilities to, or merged with, this plan. For each plan, including
this plan, the attachment should also include the actuarial
valuation of the total assets and total liabilities for the year
preceding the transfer or merger, based on the most recent
data available as of the day before the first day of the 2014
2015 plan year. Label the attachment “Schedule R, line 17 –
Information on Assets and Liabilities Transferred to or
Merged with This Plan” and include the plan name and the
plan sponsor’s name and EIN.

Part VI – Additional Information for Single-Employer
and Multiemployer Defined Benefit Pension Plans
Line 18. If any liabilities to participants or their beneficiaries
under the plan at the end of the plan year consist of liabilities
under two (2) or more plans as of the last day of the plan year
immediately before the 2014 2015 plan year, check the box
and provide the following information as an attachment. The
attachment should include the names, employer identification
numbers, and plan numbers of all plans, including the current
plan, that provided a portion of liabilities of the participants and
beneficiaries in question. The attachment should also include
the funding percentage of each plan as of the last day of the
2013 2014 plan year. For single-employer plans, the funding
percentage is the funding target attainment percentage, where
the numerator is the value of plan assets reduced by the sum
of the amount of the prefunding balance and the funding
standard carryover balance, and the denominator is the
funding target for the plan (for this purpose, if the plan is in at
risk status, then the funding target is determined as if the plan
were not in at risk status). For multiemployer plans, the funding
percentage is the ratio where the numerator is the actuarial
value of the plan’s assets and the denominator is the accrued
liability of the plan. For a terminated plan for which the funding
percentage is required to be reported, write “Terminated” in the
space where the plan’s funding percentage would otherwise
have been reported. Label the attachment “Schedule R, line
18 –Funded Percentage of Plans Contributing to the
Liabilities of Plan Participants” and include the plan name
and the plan sponsor’s name and EIN.
Line 19. This line must be completed for all defined benefit
pension plans (except DFEs) with 1,000 or more participants at
the beginning of the plan year. To determine if the plan has
1,000 or more participants, use the participant count shown on
line 3d(1) of the Schedule SB for single-employer plans or on
line 2b(4)(1) of the Schedule MB for multiemployer plans.
Line 19a. Show the beginning-of-year distribution of assets
for the categories shown. Use the market value of assets and
do not include the value of any receivables. These
percentages, expressed to the nearest whole percent, should
reflect the total assets held in stocks, investment-grade debt
instruments, high-yield debt instruments, real estate, or other
asset classes, regardless of how they are listed on the
Schedule H. The percentages in the five categories should
sum to 100 percent. Assets held in trusts, accounts, mutual
funds, and other investment arrangements should be
disaggregated and properly distributed among the five asset
components. The assets in these trusts, accounts, mutual
funds, and investment arrangements should not be included in
the “Other” component unless these investments contain no
stocks, bonds, or real estate holdings. The same methodology
should be used in disaggregating trust assets as is used when
disclosing the allocation of plan assets on the sponsor’s 10-K
filings to the Securities and Exchange Commission. Real
estate investment trusts (REITs) should be listed with stocks,
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while real estate limited partnerships should be included in the
Real Estate category.
Investment-grade debt-instruments are those with an S&P
rating of BBB – or higher, a Moody’s rating of Baa3 or higher, or
an equivalent rating from another rating agency. High-yield
debt instruments are those that have ratings below these rating
levels. If the debt does not have a rating, it should be included
in the “high-yield” category if it does not have the backing of a
government entity. Unrated debt with the backing of a
government entity would generally be included in the
“investment-grade” category unless it is generally accepted
that the debt should be considered as “high-yield.” Use the
ratings in effect as of the beginning of the plan year.
Line 19b. Check the box that shows the average duration of
the plan’s combined investment-grade and high-yield debt
portfolio. If the average duration falls exactly on the boundary
of two boxes, check the box with the lower duration. To
determine the average duration, use the “effective duration” or
any other generally accepted measure of duration. Report the
duration measure used in line 19c. If debt instruments are held
in multiple debt portfolios, report the weighted average of the
average durations of the various portfolios where the weights
are the dollar values of the individual portfolios.

401(m)(12). If the plan, by its terms, does not satisfy the safe
harbor method, it must satisfy the regular nondiscrimination
test, actual deferral percentage (ADP)/actual contribution
percentage (ACP) test.
Line 20c. If the ADP/ACP test was used to satisfy
nondiscrimination requirements under Code section 401(k)(3),
check “Yes” if an election was made to use the current year
testing method under which the ADP test is performed by
comparing the current plan year’s ADP for highly-compensated
employees (HCEs) with the current plan year’s (rather than the
prior plan year’s) ADP for nonhighly-compensated employees
(NHCEs).
Line 21a. Check the applicable testing method below used to
satisfy the minimum coverage requirements under Code
section 410(b). A plan satisfies the “ratio percentage test” of
Code section 410(b)(1)(B) with respect to employees if the
percentage of the employer’s nonhighly-compensated
employees (NHCEs) who benefit under the plan divided by the
percentage of highly-compensated active employees (HCEs)
who benefit under the plan is at least 70 percent (percentages
are calculated to the nearest hundredth). For example, if
Employer Y has 100 employees, of which 30 are HCEs and 70
are NHCEs, and Employer Y maintains a pension Plan A that
benefits 15 of the 30 HCEs (that is, 50 percent of the HCEs)
and 25 of the 70 NHCEs (that is, 35.71 percent of all NHCEs),
then the ratio percentage of 71.42 percent (35.71% / 50%) is
greater than 70 percent. Thus, Plan A satisfies the minimum
coverage requirement as required under Code section
410(b)(1). The average benefit test is a two-part test. First, the
plan must satisfy the nondiscriminatory classification test.
Second, the plan must satisfy the average benefit percentage
test. See Treasury Regulations sections 1.410(b)-4 and
1.410(b)-5 for more information.
Line 21b. Check “Yes” if this plan was permissively
aggregated with another plan to satisfy requirements under
Code sections 410(b) and 401(a)(4). Generally, each single
plan must separately satisfy the coverage and
nondiscrimination requirements. However, an employer may
designate two or more separate plans as a single plan for
purposes of applying the ratio percentage test of Treasury
Regulations section 1.410(b)-2(b)(2) or the nondiscretionary
classification test of Treasury Regulations section 1.401(b)-4.
Two or more plans that are permissively aggregated and
treated as a single plan for purposes of the minimum coverage
test of Code section 410(b) must also be treated as a single
plan for purpose of the nondiscrimination test under Code
section 401(a)(4). See Treasury Regulations sections 1.410(b)7 and 1.401(a)(4)-(9) for more information.
Line 22a. Check box “Yes” if a plan has timely adopted the
amendments for all required tax law changes. Check “N/A” if it
is a newly established plan. In order to be a qualified plan and
to retain these tax advantages, a pension plan must be timely
amended for all required tax law change and operate in
accordance with the plan document. The IRS generally
establishes a deadline by which plan amendments that reflect
tax law changes must be adopted. See Rev. Proc. 2007-44,
2007-28 I.R.B. 54, for more information.
Line 22b. Enter the date of the last plan amendment or
restatement for the required tax law changes, and enter the
applicable code indicating the tax law changes below:

Part VII – IRS Compliance Questions
Note. Plan administrators who are required to file an annual
return of employee benefit plans, as required under Code
section 6058, must complete Lines 20 through 23 unless you
are required to file fewer than 250 returns of any type with the
IRS, including information returns (for example, Forms W-2
and Forms 1099), income tax returns, employment tax returns,
and excise tax returns during the calendar year, then you can
alternatively file Form 5500-SUP with the IRS on paper. See
the Treasury Regulations on “Employee Retirement Benefit
Plan Returns Required on Magnetic Media” and Instructions for
Form 5500-SUP for more information [T.D. 9695, 79 FR 58256
at http://federalregister.gov/a/2014-23161].
Line 20a. Check “Yes” if the plan includes a cash or deferred
arrangement (CODA) under which a covered employee may
elect to have the employer either contribute an amount to the
plan’s trust on behalf of the employee or to pay the employee
directly in cash or some other taxable benefit. A 401(k) is a
feature of a qualified profit-sharing plan that allows employees
to contribute a portion of their wages to individual accounts.
The contributions go into a 401(k) account, with the employee
often choosing the investments based on options provided
under the plan. In some plans, the employer also makes
contributions, such as matching the employee’s contributions
up to a certain percentage. SIMPLE and safe harbor 401(k)
plans have mandatory employer contribution requirements.
Line 20b. If Line 20a is “Yes,” check the applicable testing
method being used to satisfy the nondiscrimination
requirements of Code sections 401(k) and (m). A safe harbor
401(k) plan is similar to a traditional 401(k) plan but, among
other things, it must provide for employer contributions that are
fully vested when made. These contributions may be employer
matching contributions, limited to employees who defer, or
employer contributions made on behalf of all eligible
employees, regardless of whether they make elective
deferrals. The safe harbor 401(k) plan is not subject to the
complex annual nondiscrimination tests that apply to traditional
401(k) plans. Check “Design-based safe harbor method” if this
is a safe harbor 401(k) plan that includes a SIMPLE 401(k)
plan under Code sections 401(k)(11) and 401(m)(10), a safe
harbor 401(k) plan under Code sections 401(k)(12) and
401(m)(11), and a safe harbor plan using automatic
contribution arrangements under Code sections 401(k)(13) and

Tax Law

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Code

Pension Protection Act of 2006 (PPA 06)

J

Economic Growth and Tax Relief Reconciliation
Act of 2001 (EGTRRA)

M

Instructions for Schedule R (Form 5500)

GATT, USERRA, SBJPA, and TRA (GUST)

individually-designed plan never received a favorable
determination letter.
Line 23. Check “Yes” if a plan is in a U.S territory, including
Puerto Rico (if no election under ERISA section 1022(i)(2) has
been made), American Samoa, Guam, the Commonwealth of
the Northern Mariana Islands or the U.S. Virgin Islands.

K

Line 22c. If a plan sponsor or an employer adopted a preapproved plan that includes a master & prototype plan (a
standardized or nonstandardized M&P) or a volume submitter
plan, enter the date of the most recent favorable opinion or
advisory letter issued by the IRS and the serial number listed
on that favorable letter.
Line 22d. If it is an individually-designed plan and received a
favorable determination letter from the IRS, enter the date of
the most recent determination letter. Leave it blank if this

2014 2015 Instructions for Schedule
SB
(Form 5500)
Single-Employer Defined Benefit Plan
Actuarial Information
Instructions for Schedule R (Form 5500)

-64-

section headed Specific Instructions Only for “One-Participant
Plans.” The enrolled actuary must complete and sign the
Schedule SB and forward it to the person responsible for filing
the Form 5500-EZ or Form 5500-SF, even if the Schedule SB
is not filed.
Check the Schedule SB box on the Form 5500 (Part II, line
10a(3)) if a Schedule SB is attached to Form 5500. Check
“Yes” on line 11 in Part VI of the Form 5500-SF if a Schedule
SB is required to be prepared for the plan, even if Schedule SB
is not required to be attached to Form 5500-SF (see
instructions in the Note above, pertaining to “one-participant
plans”).
Note. This schedule is not filed for a multiemployer plan nor for
a money purchase defined contribution plan (including a target
benefit plan) for which a waiver of the minimum funding
requirements is currently being amortized. Information for
these plans must be filed using Schedule MB (Form 5500).

General Instructions
Note. Final regulations under certain portions of Code section
430 (sections 430(d), 430(f), 430(g), 430(h), and 430(i)) and
Code section 436 (and the corresponding provisions of ERISA
(sections 206(g) and 303)) were published in the Federal
Register July 31, 2008, and October 15, 2009, and apply for
plan years beginning on or after January 1, 2010. Proposed
regulations providing additional rules under Code sections
430(a), 430(j) and 4971 (and the corresponding provisions of
ERISA (section 303)) were published in the Federal Register
on April 15, 2008. The final regulations that relate to those
proposed regulations have a later effective date than the final
regulations published October 15, 2009. With respect to
provisions for which the final regulations do not apply to a plan
for the plan year, plan sponsors must follow a reasonable
interpretation of the statute, taking into account the provisions
of the Worker, Retiree, and Employer Recovery Act of 2008
(“WRERA”), Pub. L. No. 110-458, the Preservation of Access
to Care for Medicare Beneficiaries and Pension Relief Act of
2010 (“PRA 2010”), Pub. L. No. 111-192, Moving Ahead for
st
Progress in the 21 Century Act (“MAP-21”), Pub. L. No. 112141, the Cooperative and Small Employer Charity Pension
Flexibility Act of 2014 (“CSEC Act”), Pub. L. No. 113-97 and
any other amendments to the funding rules that are enacted.
For this purpose, plan sponsors may rely on the provisions of
the proposed regulations or the final regulations, as applicable,
but must take into account the provisions of WRERA, PRA
2010, MAP-21, CSEC Act, any other amendments to the
funding rules that are enacted, and any applicable published
guidance.

Specific Instructions
Lines A through F. Identifying Information. Lines A – F
must be completed for all plans. Lines A through D should
include the same information as reported in corresponding
lines in Part II of the Form 5500, Form 5500-SF, or Form 5500EZ filed for the plan. You may abbreviate the plan name (if
necessary) to fit in the space provided.
Do not use a social security number in line D instead of an
EIN. The Schedule SB and its attachments are open to public
inspection if filed with a Form 5500 or Form 5500-SF, and the
contents are public information and are generally subject to
publication on the Internet. Because of privacy concerns, the
inclusion of a social security number or any portion thereof on
the Schedule SB or any of its attachments may result in the
rejection of the filing.
You can apply for an EIN from the IRS online, by
telephone, by fax, or by mail depending on how soon you need
to use the EIN. For more information, see Section 3: Electronic
Filing Requirement under General Instructions to Form 5500.
The EBSA does not issue EINs.
Line E. Type of Plan. Check the applicable box to indicate the
type of plan. A single-employer plan for this reporting purpose
is an employee benefit plan maintained by one employer or
one employee organization. A multiple-employer plan is a plan
that is maintained by more than one employer, but is not a
multiemployer plan. (See the Instructions for Form 5500, box A
for additional information on the definition of a multiemployer
plan.)
● Check “Single” if the Form 5500, Form 5500-SF, or Form
5500-EZ is filed for a single-employer plan (including a plan
maintained by more than one member of the same controlled
group).
● Check “Multiple-A” if the Form 5500 or Form 5500-SF is
being filed for a multiple-employer plan and the plan is subject
to the rules of Code section 413(c)(4)(A) (i.e., it is funded as if
each employer were maintaining a separate plan). This
includes plans established before January 1, 1989, for which
an election was made to fund in accordance with Code section
413(c)(4)(A).
● Check “Multiple-B” if the Form 5500 or Form 5500-SF is
being filed for a multiple-employer plan and the plan is subject
to the rules of Code section 413(c)(4)(B) (i.e., it is funded as if
all participants were employed by a single employer).
If “Multiple-A” is checked, with the exception of Part III, the
data entered on Schedule SB should be the sum of the
individual amounts computed for each employer. The
percentages reported in Part III should be calculated based on
the reported aggregate numbers rather than by summing up

Who Must File
As the first step, the plan administrator of any single-employer
defined benefit plan (including a multiple-employer defined
benefit plan) that is subject to the minimum funding standards
(see Code section 412 and Part 3 of Title I of ERISA) must
obtain a completed Schedule SB (including attachments) that
is prepared and signed by the plan’s enrolled actuary as
discussed below in the Statement by Enrolled Actuary section.
The plan administrator must retain with the plan records the
Schedule SB that is prepared and signed by the plan’s actuary.
Next, the plan administrator must ensure that the
information from the actuary’s Schedule SB is entered
electronically into the annual return/report being submitted.
When entering the information, whether using EFAST2approved software or EFAST2’s web-based filing system, all
the fields required for the type of plan must be completed (see
instructions for fields that need to be completed).
Further, the plan administrator of a single-employer defined
benefit plan must attach to the Form 5500 or Form 5500-SF an
electronic reproduction of the Schedule SB (including
attachments) prepared and signed by the plan’s enrolled
actuary. This electronic reproduction must be labeled “SB
Actuary Signature” and must be included as a Portable
Document Format (PDF) attachment or any alternative
electronic attachment allowable under EFAST2.
Note. The Schedule SB (Form 5500) does not have to be filed
with the Form 5500-EZ, but it must be retained (in accordance
with the Instructions for Form 5500-EZ under the What To File
section). Similarly, the Schedule SB does not have to be filed
with the Form 5500-SF for a one-participant plan (as defined in
the Form 5500-EZ instructions) that is eligible for the Form
5500-SF and elects to file such form instead of the Form 5500EZ. However, the Schedule SB must be retained in
accordance with the Instructions for Form 5500-SF under the
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Instructions for Schedule SB (Form 5500)

the individual percentages. The Schedule SB data for each
employer’s portion of the plan must be submitted as an
attachment. This is accomplished by completing and attaching
a Schedule SB for each employer or by attaching a document
containing that information (e.g., a table showing a row for
each Schedule SB data item and a column for each
employer). Label the attachment “Schedule SB – Information
for Each Individual Employer.”
Line F. Prior Year Plan Size. Check the applicable box based
on the highest number of participants (both active and inactive)
on any day of the preceding plan year, taking into account
participants in all defined benefit plans maintained by the same
employer (or any member of such employer’s controlled group)
who are or were also employees of that employer or member.
For this purpose, participants whose only defined benefit plan
is a multiemployer plan (as defined in Code section 414(f)) are
not counted, and participants who are covered in more than
one of the defined benefit plans described above are counted
only once. Inactive participants include vested terminated and
retired employees as well as beneficiaries of deceased
participants. If this is the first plan year that a plan described in
this paragraph exists, complete this line based on the highest
number of participants that the plan was reasonably expected
to have on any day during the first plan year.

standard 7-year period and use a special interest rate to
determine the funding target. Plans using this 10-year funding
option must complete the entire Schedule SB and provide
additional information. See the instructions for line 27 for more
information about which lines of Schedule SB need to be
completed and what additional attachments are required.
MAP-21 amended Code section 430(h)(2)(C) and ERISA
section 302(h)(2)(C) to provide that, for certain purposes, each
of the three segment rates described in those sections is
adjusted as necessary to fall within a specified range that is
determined based on an average of the corresponding
segment rates for the 25-year period ending on September 30
of the calendar year preceding the first day of the plan year.
Accordingly, if the funding target and target normal cost for a
plan are determined using these segment rates, the segment
rates used to determine the minimum required contribution and
the adjusted funding target attainment percentage (“AFTAP”)
used to apply funding-based benefit restrictions under Code
section 436 and ERISA section 206(g) may be different from
those used for other purposes (such as the segment rates
used to determine the deductible limit under Code section
404(o)). In such cases, report all information on Schedule SB
reflecting the assumptions used to determine the minimum
required contribution and the AFTAP used to apply fundingbased benefit restrictions.
Note. (1) For a plan funded with insurance (other than a plan
described in Code section 412(e)(3) or ERISA section 301(b)),
refer to section 1.430(d)-1(c)(2) of the Income Tax Regulations
regarding whether to include the liabilities for benefits covered
under insurance contracts held by the plan and whether to
include the value of the insurance contracts in plan assets.
(2) For terminating plans, Rev. Rul. 79-237, 1979-2 C.B. 190,
provides that minimum funding standards apply until the end of
the plan year that includes the termination date. Accordingly,
the Schedule SB is not required to be filed for any later plan
year. However, if a termination fails to occur — whether
because assets remain in the plan’s related trust (see Rev.
Rul. 89-87, 1989-2 C.B. 81) or for any other reason (e.g., the
PBGC issues a notice of noncompliance pursuant to 29 CFR
section 4041.31 for a standard termination) — there is no
termination date, and therefore, minimum funding standards
continue to apply and a Schedule SB continues to be required.

General Instructions, Parts I through IX, Statement
by Enrolled Actuary, and Attachments
The Pension Protection Act of 2006, as amended (PPA),
provides delayed effective dates for the funding rules under
Code section 430 for plans meeting certain criteria (certain
multiple-employer plans maintained by specified types of
cooperative organizations (eligible cooperative plans), and
maintained by section 501(c)(3) organizations (eligible charity
plans), as described in PPA section 104 as amended). Except
as noted below, Parts I through VIII must be completed for all
single and multiple-employer defined benefit plans, regardless
of size or type. See instructions for line 27 for additional
information to be provided for certain plans with special
circumstances. Part IX is completed only for those plans for
which an alternative amortization schedule was elected under
section 430(c)(2)(D) of the Code or section 303(c)(2)(D) of
ERISA, as amended by PRA 2010, and for those plans for
which funding relief was elected under section 107 of Pension
Protection Act of 2006, as added by PRA 2010.
The Pension Protection Act of 2006, as amended (PPA),
provides delayed effective dates for the funding rules under
Code section 430 for plans meeting certain criteria (certain
multiple-employer plans maintained by eligible cooperative
plans, and eligible charity plans, as described in PPA section
104). Eligible plans to which these delayed effective dates
apply do not need to complete the entire Schedule SB, but will
have to file information relating to pre-PPA calculations in an
attachment using the 2007 Schedule B form. See the
instructions for line 27 for more information about which lines
of Schedule SB need to be completed and what additional
attachments are required.
PPA provides funding relief for certain defined benefit plans
(other than multiemployer plans) maintained by a commercial
passenger airline or by an employer whose principal business
is providing catering services to a commercial passenger
airline, based on an alternative 17-year funding schedule.
Plans using this funding relief do not need to complete the
entire Schedule SB, but are required to provide supplemental
information as an attachment to Schedule SB. Alternatively,
these plans can elect to apply the funding rules generally
applicable to single-employer defined benefit plans, but
amortize the funding shortfall over 10 years instead of the
Instructions for Schedule SB (Form 5500)

Statement by Enrolled Actuary
An enrolled actuary must sign Schedule SB. The signature of
the enrolled actuary may be qualified to state that it is subject
to attached qualifications. See Treasury Regulations section
301.6059-1(d) for permitted qualifications. If the actuary has
not fully reflected any final or temporary regulation, revenue
ruling, or notice promulgated under the statute in completing
the Schedule SB, check the box on the last line of page 1. If
this box is checked, indicate on an attachment whether any
unpaid required contribution or a contribution that is not wholly
deductible would result if the actuary had fully reflected such
regulation, revenue ruling, or notice, and label this attachment
“Schedule SB – Statement by Enrolled Actuary.” In
addition, the actuary may offer any other comments related to
the information contained in Schedule SB. Except as otherwise
provided in these instructions, a stamped or machine produced
signature is not acceptable.
The actuary must provide the completed and signed
Schedule SB to the plan administrator to be retained with the
plan records and included (in accordance with these
instructions) with the Form 5500 or Form 5500-SF that is
submitted under EFAST2. The plan’s actuary is permitted to
sign the Schedule SB on page one using the actuary’s
signature or by inserting the actuary’s typed name in the
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signature line followed by the actuary’s handwritten initials. The
actuary’s most recent enrollment number must be entered on
the Schedule SB that is prepared and signed by the plan’s
actuary.

Line 2b. Actuarial Value of Assets. Do not adjust the
actuarial value of assets for items such as the funding standard
carryover balance, the prefunding balance, any unpaid
minimum required contributions, or the present value of any
remaining shortfall or waiver amortization installments. Treat
contributions designated for a current or prior plan year,
rollover amounts, insurance contracts, and other items in the
same manner as for line 2a.
If an averaging method is used to value plan assets (as
permitted under Code section 430(g)(3)(B) and ERISA section
303(g)(3)(B), as amended by WRERA), enter the value as of
the valuation date taking into account the requirement that
such value must be within 90% to 110% of the fair market
value of assets.
Note. Under Code section 430(g)(3)(B), the use of averaging
methods in determining the value of plan assets is permitted
only in accordance with methods prescribed in Treasury
regulations. Accordingly, taxpayers cannot use asset valuation
methods other than fair market value (as described in Code
section 430(g)(3)(A)), except as provided under Notice 200922, 2009-14 I.R.B. 741, or Treasury regulations.
Line 3. Funding Target/Participant Count Breakdown. All
amounts should be reported as of the valuation date.

Attachments
All attachments to the Schedule SB must be properly identified
as attachments to the Schedule SB, and must include the
name of the plan, plan sponsor’s EIN, plan number, and line
number to which the schedule relates.
Do not include attachments that contain a visible social
security number. Except for certain one-participant plans, the
Schedule SB and its attachments are open to public
inspection, and the contents are public information and are
subject to publication on the Internet. Because of privacy
concerns, the inclusion of a visible social security number or
any portion thereof on an attachment may result in the
rejection of the filing.

Part I – Basic Information
Note. All entries in Part I must be reported as of the valuation
date, reflecting the assumptions and amounts generally used
to determine the minimum required contribution. In the case of
a plan described in section 104 of PPA, the information should
be reported as if PPA provisions were effective for all plan
years beginning after December 31, 2007.
Line 1. Valuation Date. The valuation date for a plan year
must be the first day of the plan year unless the plan meets the
small-plan exception of Code section 430(g)(2)(B) and ERISA
section 303(g)(2)(B). For plans that qualify for the exception,
the valuation date may be any date in the plan year, including
the first or last day of the plan year.
A plan qualifies for this small-plan exception if there were
100 or fewer participants on each day of the prior plan year.
For the definition of participant as it applies in this case, see
the instructions for line F.
Line 2a. Market Value of Assets. Enter the fair market value
of assets as of the valuation date. Include contributions
designated for any previous plan year that are made after the
valuation date (but within the 8½-month period after the end of
the immediately preceding plan year), adjusted for interest for
the period between the date of payment and the valuation date
as provided in the applicable regulations.
Contributions made for the current plan year must be
excluded from the amount reported in line 2a. If these
contributions were made prior to the valuation date (which can
only occur for small plans with a valuation date other than the
first day of the plan year), the asset value must be adjusted to
exclude not only the contribution amounts, but interest on the
contributions from the date of payment to the valuation date,
using the current-year effective interest rate.
Do not adjust for items such as the funding standard
carryover balance, prefunding balance, any unpaid minimum
required contributions, or the present value of remaining
shortfall or waiver amortization installments. Rollover amounts
or other assets held in individual accounts that are not
available to provide defined benefits under the plan should not
be included on line 2a regardless of whether they are reported
on the Schedule H (Form 5500) (line 1l, column (a)) or
Schedule I (Form 5500) (line 1c, column (a)), or Form 5500-SF
(line 7c, column (a)). Additionally, asset and liability amounts
must be determined in a consistent manner. Therefore, if the
value of any insurance contracts has been excluded from the
amount reported in line 2a, liabilities satisfied by such contracts
should also be excluded from the funding target values
reported in lines 3 and 4.

 Column (1)—Enter the number of participants, including
beneficiaries of deceased participants, who are or who will be
entitled to benefits under the plan.
 Column (2)—Enter the portion of the funding target
attributable to vested benefits. For this purpose benefits
considered to be vested for PBGC premium purposes must be
included.
 Column (3)—Enter the funding target attributable to all
benefits, both vested and nonvested.
For columns (2) and (3), the funding target must be calculated
using the methods and assumptions provided in Code sections
430(h) and (i), ERISA sections 303(h) and (i), and other related
guidance.
Unless the plan sponsor has received approval to use
substitute mortality tables in accordance with Code section
430(h)(3)(C) and ERISA section 303(h)(3)(C), the funding
target must be computed using the mortality tables for nondisabled lives, as described in section 1.430(h)(3)-1 of the
regulations. If substitute mortality tables have been approved
(or deemed to have been approved) by the IRS, such tables
must be used instead of the mortality tables described in the
previous sentence, subject to the rules of Code section
430(h)(3) and ERISA section 303(h)(3). The funding target
may be computed taking into account the mortality tables for
disabled lives published in Rev. Rul. 96-7, 1996-1 C.B. 59, and
as provided in Notice 2008-29, 2008-12 I.R.B. 637.
Special rules for plans that are in at-risk status. If a plan
is in at-risk status, report the amount reflecting the additional
assumptions required in Code section 430(i)(1)(B) and ERISA
section 303(i)(1)(B).
If the plan has been in at-risk status for any two or more of
the preceding four plan years, also include the loading factor
required in Code section 430(i)(1)(C) and ERISA section
303(i)(1)(C). If the plan is in at-risk status and has been in atrisk status for fewer than five consecutive years, report the
funding target amounts after reflecting the transition rule
provided in Code section 430(i)(5) and ERISA section
303(i)(5). For example, the funding target for a plan that is in
at-risk status for 2014 2015 and was in at-risk status for the
20112012, 2012 2013 and 2013 2014 plan years (but not the
2010 2011 plan year) will reflect 80% of the funding target
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Instructions for Schedule SB (Form 5500)

using the special at-risk assumptions and 20% of the funding
target determined without regard to the at-risk assumptions.
Determining whether a plan is in at-risk status. Refer to
Code section 430(i)(4) and ERISA section 303(i)(4) to
determine whether the plan is in at-risk status. Generally, a
plan is in at-risk status for a plan year if it had more than 500
participants on any day during the preceding plan year (see
instructions for line F for the definition of participants) and the
plan’s funding target attainment percentage (“FTAP”) for the
preceding plan year fell below specified thresholds.
A plan with over 500 participants is in at-risk status for 2014
2015 if both:

section 303(h)(2)(A), and the applicable regulations. Enter rate
to the nearest .01% (e.g., 5.26%).
Line 6. Target Normal Cost. Report the present value of all
benefits which have been accrued or have been earned (or
that are expected to accrue or to be earned) under the plan
during the plan year, increased by any plan-related expenses
expected to be paid from plan assets during the plan year, and
decreased (but not below zero) by any mandatory employee
contributions expected to be made during the plan year.
Include any increase in benefits during the plan year that is a
result of any actual or projected increase in compensation
during the current plan year, even if that increase in benefits is
with respect to benefits attributable to services performed in a
preceding plan year.
This amount must be calculated as of the valuation date
and must generally be based on the same assumptions used
to determine the funding target reported in line 3c, column (3),
reflecting the special assumptions and the loading factor for atrisk plans, if applicable. If the plan is in at-risk status for the
current plan year and has been in at-risk status for fewer than
five consecutive years, report the target normal cost after
reflecting the transition rule provided in Code section 430(i)(5)
and ERISA section 303(i)(5).
Special rule for airlines using 10-year amortization
period under section 402(a)(2) of PPA. Section 402(a)(2) of
PPA (as amended by section 6615 of the U.S. Troop
Readiness, Veterans’ Care, Katrina Recovery, and Iraq
Accountability Appropriations Act, 2007, Public Law 110-28
(121 Stat.112)) states that for plans electing the 10-year
amortization period, the funding target during that period is
determined using an interest rate of 8.25% rather than the
interest rates or segment rates calculated on the basis of the
corporate bond yield curve. However, this special 8.25%
interest rate does not apply for other purposes, including the
calculation of target normal cost or the amortization of the
funding shortfall. Report the target normal cost using the
interest rates or segment rates otherwise applicable under
430(h)(2) and ERISA section 303(h)(2).

 the FTAP for 2013 2014 (line 14 of the 2013 2014 Schedule
SB) is less than 80%, and
 the at-risk funding target attainment percentage for 2013
2014 is less than 70%.
In general, the at-risk funding target attainment percentage is
determined in the same manner as the FTAP (as described in
the instructions for line 14), except that the funding target is
determined using the additional assumptions for plans in at-risk
status. For this purpose, the at-risk funding target is
determined by disregarding the transition rule of Code section
430(i)(5) and ERISA section 303(i)(5) for plans that have been
in at-risk status for fewer than five consecutive years, and
disregarding the loading factor in Code section 430(i)(1)(C)
and ERISA section 303(i)(1)(C). For plans that were in at-risk
status for the 2013 2014 plan year, the at-risk funding target
used to determine whether the plan is in at-risk status for the
2014 2015 plan year is the amount reported in line 4b of the
2013 2014Schedule SB.
Refer to the regulations under section 430(i) of the Code for
rules pertaining to new plans and other special situations.
Line 4. Additional Information for Plans in At-Risk Status.
If the plan is in at-risk status as provided under Code section
430(i)(4) and ERISA section 303(i)(4), check the box, complete
lines 4a and 4b, and include as an attachment the information
described below. Do not complete line 4 if the plan is not in atrisk status for the current plan year for purposes of determining
the minimum required contribution.
● Line 4a – Enter the amount of the funding target determined
as if the plan were not in at-risk status.
● Line 4b – Report the funding target disregarding the
transition rule of Code section 430(i)(5) and ERISA section
303(i)(5), and disregarding the loading factor in Code section
430(i)(1)(C) and ERISA section 303(i)(1)(C).
If the plan is in at-risk status for the current plan year,
attach a description of the at-risk assumptions for the assumed
form of payment (e.g., the optional form resulting in the highest
present value). Label the attachment “Schedule SB, line 4 –
Additional Information for Plans in At-Risk Status.”
Line 5. Effective Interest Rate. Enter the single rate of
interest which, if used instead of the interest rate(s) reported in
line 21 to determine the present value of the benefits that are
taken into account in determining the plan’s funding target for a
plan year, would result in an amount equal to the plan’s
funding target determined for the plan year, without regard to
calculations for plans in at-risk status. (This is the funding
target reported in line 3d, column (3) for plans not in at-risk
status, or in line 4a for plans in at-risk status.) However, if the
funding target for the plan year is zero, the effective interest
rate is determined as the single rate that would result in an
amount equal to the plan’s target normal cost determined for
the plan year, without regard to calculations for plans in at-risk
status. See the provisions of Code section 430(h)(2)(A), ERISA
Instructions for Schedule SB (Form 5500)

Part II – Beginning of Year Carryover Prefunding
Balances
Line 7. Balance at Beginning of Prior Plan Year After
Applicable Adjustments. In general, report the amount in the
corresponding columns of line 13 of the prior-year Schedule
SB. However, if the balance from the prior year has been
adjusted so that it does not match the corresponding amount in
line 13 of the prior-year Schedule SB, attach an explanation
and label the attachment “Schedule SB, Line 7 –
Explanation of Discrepancy in Prior Year Funding
Standard Carryover Balance or Prefunding Balance.” Note
that elections to add excess contributions or reduce balances
have specific deadlines, and generally cannot be changed
once they have been made.
If this is the first year for which the plan is subject to the
minimum funding rules of Code section 430 or ERISA section
303, leave both columns blank.
Line 8. Portion Elected for Use To Offset Prior Year’s
Funding Requirement. Report the amount for each column
from the corresponding column of line 35 of the prior-year
Schedule SB. If the valuation date is not the first day of the
plan year, report the amounts from line 35 of the prior-year
Schedule SB, discounted to the beginning of the prior plan
year using the effective interest rate for the prior plan year.
Reflect the full amount reported in line 35 of the prior-year
Schedule SB even if the amount is larger than the minimum
required contribution reported for that year on line 34 of the
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Step 3: Multiply the result in Step 2 by the prior year’s effective
interest rate in line 11(b)(1), and
Step 4: Reduce the result in Step 3 by interest on the result in
Step 2 of this paragraph for the period between the first day of
the prior plan year and the prior-year valuation date using the
effective interest rate for the prior year.
The amount reported in line 11(b)(1) is zero if the prior year’s
valuation date was the last day of the prior plan year.
Line 11(b)(2). In column (b), enter the product of the prior
year’s actual rate of return (from line 10) and the present value
of excess contributions reported on line 38b for the prior year.
However, if the valuation date for the prior plan year was not
the first day of the plan year (permitted for small plans only),
enter the result of the following calculation:
Step 1: Adjust the prior-year amount reported in line 38b to the
first day of the prior year, using the effective interest rate for
the prior year,
Step 2: Multiply the result in Step 1 by the prior year’s actual
rate of return (from line 10), and
Step 3: Reduce the result in Step 2 by interest on the result in
Step 1 for the period between the first day of the prior plan
year and the prior-year valuation date using the effective
interest rate for the prior year.
Line 11c. Enter the sum of lines 11a, 11b(1) and 11(b)(2).
Line 11d. Enter the amount of the excess contributions for the
prior year (with interest) that the plan sponsor elected to use to
increase the prefunding balance. This amount cannot be
greater than the amount reported on line 11c.
If this is the first year for which the plan is subject to the
minimum funding rules of Code section 430 or ERISA section
303, leave lines 11a–d blank.
Line 12. Other Reductions in Balances Due to Elections or
Deemed Elections. In each column, enter the amount by
which the employer elects to reduce (or is deemed to elect to
reduce, per Code section 436(f)(3) and ERISA section
206(g)(5)(C)) the funding standard carryover balance or
prefunding balance, as applicable, under Code section 430(f)
and ERISA section 303(f), other than any amount reported in
line 8 that is treated as a reduction in these balances under the
special rule in section 1.430(f)-1(f)(3)(ii) (relating to amounts
elected for use to offset the minimum required contribution that
exceed the minimum required contribution for the plan for the
plan year, and which are not revoked by the plan sponsor).
This amount cannot be greater than the sum of the amounts
reported in the corresponding column of lines 9, 10 and, if
applicable, 11d. Note that an election (or deemed election)
cannot be made to reduce the prefunding balance in column
(b) until the funding standard carryover balance in column (a)
has been reduced to zero.
If the valuation date is not the first day of the plan year,
adjust the amounts reported in line 12 to the first day of the
plan year, using the effective interest rate for the current plan
year. If the plan did not exist in the prior year and is not a
successor plan, leave both columns blank.
If this is the first year for which the plan is subject to the
minimum funding rules of Code section 430 or ERISA section
303, leave column (b) blank.
Line 13. Balance at Beginning of Current Year.

prior-year Schedule SB. This can occur under the special rule
for elections to use balances in excess of the minimum
required contribution under section 1.430(f)-1(f)(1)(ii) of the
regulations, if no timely election is made to revoke the excess
amount.
If this is the first year for which the plan is subject to the
minimum funding rules of Code section 430 or ERISA section
303, leave both columns blank.
Special rule for late election to apply balances to
quarterly installments. If an election was made to use the
funding standard carryover balance or the prefunding balance
to offset the amount of a required quarterly installment, but the
election was made after the due date of the installment, the
amount reported on line 8 may not be the same as the amount
reported on line 35 for the prior year. Refer to the regulations
under section 430 of the Code for additional information. An
attachment to Schedule SB should explain why the amount is
different. Label the attachment “Schedule SB, line 8 – Late
Election to Apply Balances to Quarterly Installments.”
Line 9. Amount Remaining. Enter the amount equal to line 7
minus line 8 in each column.
If this is the first year that the plan is subject to the
minimum funding requirements of Code section 430 or ERISA
section 303, enter the amount of any credit balance at the end
of the prior year (the “pre-effective plan year”) on line 9,
column (a) and leave line 9, column (b) blank. The amount
entered on line 9, column (a) is generally the amount reported
for the pre-effective plan year on line 9o of the 2007 version of
the Schedule B form that was submitted as an attachment to
the Schedule SB for that pre-effective plan year. If there has
been any adjustment to this amount so that it does not match
the amount so reported for the pre-effective plan year, attach
an explanation and label the attachment “Schedule SB, Line
9 – Explanation of Credit Balance Discrepancy.”
Line 10. Interest on Line 9. Enter the actual rate of return on
plan assets during the preceding plan year in the space
provided. Enter the rate to the nearest .01% (e.g., 6.53%). If
entering a negative number, enter a minus sign (“–”) to the left
of the number. In each column, enter the product of this
interest rate and the amount reported in the corresponding
column of line 9.
If this is the first year for which the plan is subject to the
minimum funding rules of Code section 430 or ERISA section
303, leave both columns blank.
Line 11. Prior Year’s Excess Contributions to be Added to
Prefunding Balance.
Line 11a. Enter the amount reported in line 38a on the
Schedule SB for the prior plan year.
Line 11b(1). Enter the effective interest rate for the prior plan
year, as reported on line 5 of the Schedule SB for the prior
plan year, in the space provided. Enter the rate to the nearest
.01% (e.g., 6.35%).
In column (b), enter the product of the prior year’s effective
interest rate in line 11b(1) and the excess (if any) of the
amount reported on line 38a for the prior year over the amount
reported on line 38b for the prior year.
However, if the valuation date for the prior plan year was not
the first day of the plan year (permitted for small plans only),
enter the result of the following calculation:
Step 1: Determine the excess (if any) of the amount reported
on line 38a for the prior year over the amount reported on line
38b for the prior year,
Step 2: Adjust the result in Step 1 to the first day of the prior
year using the effective interest rate for the prior year,

● Column (a) - Enter the sum of the amounts reported on lines
9 and 10 of column (a), minus the amount reported on line 12
of column (a).

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Instructions for Schedule SB (Form 5500)

● Column (b) - Enter the sum of the amounts reported on lines
9, 10 and 11d of column (b), minus the amount reported on line
12 of column (b).
If this is the first year for which the plan is subject to the
minimum funding rules of Code section 430 or ERISA section
303, leave column (b) blank.

If the AFTAP reported on line 15 does not correspond to
the valuation results reported on this Schedule SB (for
instance, if any adjustments pertaining to the plan year were
made subsequent to the valuation), attach a schedule showing
each AFTAP that was certified or recertified for the plan year,
the date of the certification (or recertification), and a description
and the amount of each adjustment to the funding target,
actuarial value of assets, funding standard carryover balance
and prefunding balance used to determine the corresponding
AFTAP. Label the attachment, “Line 15, Reconciliation of
differences between valuation results and amounts used
to calculate AFTAP.” It is not necessary to include any
information pertaining to a range certification in this
attachment.
Special rules for airlines using 10-year amortization
period under section 402(a)(2) of PPA. Section 402(a)(2) of
PPA (as amended) states that for plans electing the 10-year
funding amortization period, the funding target during that
period is determined using an interest rate of 8.25% rather
than the interest rates or segment rates calculated on the basis
of the corporate bond yield curve. Report the AFTAP for these
plans based on the funding target determined using the special
8.25% interest rate.
Line 16. Prior Year’s Funding Percentage for Purposes of
Determining Whether Carryover/Prefunding Balances May
Be Used To Offset Current Year’s Funding Requirement.
Under Code section 430(f)(3) and ERISA section 303(f)(3), the
funding standard carryover balance and prefunding balance
may not be applied toward minimum contribution requirements
unless the ratio of plan assets for the preceding plan year to
the funding target for the preceding plan year (as described in
Code section 430(f)(3)(C) and ERISA section 303(f)(3)(C)) is
80% or more.
Enter the applicable percentage as described below,
truncated at .01% (e.g., report 81.239% as 81.23%). In
general, the percentage is the ratio that the prior-year actuarial
value of plan assets (reduced by the amount of any prefunding
balance, but not the funding standard carryover balance) bears
to the prior-year funding target determined without regard to
the additional rules for plans in at-risk status. This percentage
is determined as follows, with all amounts taken from the prior
year’s Schedule SB:
● For plans that are not in at-risk status, subtract the amount
reported on line 13, column (b) (adjusted for interest as
described below, if the valuation date is not the first day of the
plan year) from the amount reported on line 2b, and divide the
result by the funding target reported on line 3d, column (3).
● For plans that are in at-risk status, subtract the amount
reported on line 13, column (b) (adjusted for interest as
described below, if the valuation date is not the first day of the
plan year) from the amount reported on line 2b, and divide the
result by the funding target reported on line 4a.
If the valuation date for the prior plan year was not the first day
of that plan year, the amount subtracted from the assets for the
purpose of the above calculations is the amount reported on
line 13, column(b), adjusted for interest between the beginning
of the prior plan year and the prior year’s valuation date, using
the effective interest rate for the prior plan year.
Line 17. Ratio of Current Value of Assets to Funding
Target if Below 70%. This calculation is required under ERISA
section 103(d)(11). If line 2a divided by the funding target
reported in line 3d, column (3), is less than 70%, enter such
percentage. Otherwise, leave this line blank.

Part III – Funding Percentages
Enter all percentages in this section by truncating at .01%
(e.g., report 82.649% as 82.64%).
Line 14. Funding Target Attainment Percentage. Enter the
funding target attainment percentage (FTAP) determined in
accordance with Code section 430(d)(2) and ERISA section
303(d)(2). The FTAP is the ratio (expressed as a percentage)
which the actuarial value of plan assets (reduced by the
funding standard carryover balance and prefunding balance)
bears to the funding target determined without regard to the
additional rules for plans in at-risk status.
This percentage is determined by subtracting the sum of
the amounts reported in line 13 from line 2b and dividing the
result by the funding target. The funding target used for this
purpose is the number reported in line 3d, column (3) for plans
that are not in at-risk status and line 4a for plans that are in atrisk status. If the plan’s valuation date is not the first day of the
plan year, subtract the sum of the amounts reported in line 13,
adjusted for interest between the beginning of the plan year
and the valuation date using the effective interest rate for the
current plan year, from the amount reported in line 2b; and
divide by the funding target.
Line 15. Adjusted Funding Target Attainment Percentage.
Enter the adjusted funding target attainment percentage
(AFTAP) determined in accordance with Code section 436(j)(2)
and ERISA section 206(g)(9)(B). The AFTAP is calculated in
the same manner as the FTAP reported in line 14, except that
both the assets and the funding target used to calculate the
AFTAP are increased by the aggregate amount of purchases
of annuities for employees other than highly compensated
employees (as defined in Code section 414(q)) which were
made by the plan during the preceding two plan years.
See Code section 436(j)(3) and ERISA section 206(g)(9)(C)
for rules regarding circumstances in which the actuarial value
of plan assets is not reduced by the funding standard carryover
balance and prefunding balance for certain fully-funded plans
when determining the AFTAP. Note that this special rule
applies only to the calculation of the AFTAP and not to the
FTAP reported in line 14.
Report the final certified AFTAP for the plan year, even if it
does not correspond to the valuation results reported on this
Schedule SB (for instance, if any adjustments pertaining to the
plan year were made subsequent to the valuation or the
AFTAP). If no AFTAP was certified for the plan year, attach an
explanation and (1) report 100%, if the plan's adjusted funding
target for the plan year is zero, as described in section 1.4361(j)(1)(iv) of the Treasury regulations, or (2) leave line 15 blank
if the plan's adjusted funding target for the plan year is not
equal to zero. Label the attachment, "Line 15, Reconciliation
of differences between valuation results and amounts
used to calculate AFTAP.” For plans with valuation dates
other than the first day of the plan year, report the AFTAP that
is the final certified AFTAP based on the valuation results for
the current plan year at the time that the Schedule SB is filed
(reflecting contributions for the current plan year and reflecting
other adjustments as described in applicable guidance), even if
that AFTAP is not used to apply the restrictions under Code
section 436 and ERISA section 206(g) until the following plan
year.
Instructions for Schedule SB (Form 5500)

Part IV – Contributions and Liquidity Shortfalls

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Line 18. Contributions Made to the Plan. Show all employer
and employee contributions either designated for this plan year
or those allocated to unpaid minimum required contributions for
a prior plan year. Do not adjust contributions to reflect interest.
Show only employer contributions actually made to the plan
within 8½ months after the end of the plan year for which this
Schedule SB is filed (or actually made before the Schedule SB
is signed, if earlier).
Certain employer contributions must be made in quarterly
installments. See Code section 430(j) and ERISA section
303(j). Contributions made to meet the liquidity requirement of
Code section 430(j)(4) and ERISA section 303(j)(4) should be
reported. Include contributions made to avoid benefit
restrictions under Code section 436 and ERISA section 206(g).
Add the amounts in both columns 18(b) and 18(c)
separately and enter each result in the corresponding column
on the total line. All contributions except those made to avoid
benefit restrictions under Code section 436 and ERISA section
206(g) must be credited toward minimum funding requirements
for a particular plan year.
Line 19. Discounted Employer Contributions. Employer
contributions reported in line 18 that were made on a date
other than the valuation date must be adjusted to reflect
interest for the time period between the valuation date for the
plan year to which the contribution is allocated and the date the
contribution was made. In general, adjust each contribution
using the effective interest rate for the plan year to which the
contribution is allocated, as reported on line 5.
Allocate the interest-adjusted employer contributions to
lines 19a, 19b, and 19c to report the purpose for which they
were made (as described below).
Attach a schedule showing the dates and amounts of
individual contributions, the year to which the contributions (or
the portion of individual contributions) are applied, the interest
rate(s) used to adjust the contributions (i.e., the effective
interest rate for timely contributions and the applicable effective
interest rate plus 5% for late quarterly installments) and the
periods during which each rate applies, and the interestadjusted contribution. It is not necessary to include information
regarding interest-adjusted contributions allocated toward the
minimum required contribution for the current year (reported in
line 19c) in this schedule, unless any of those contributions
represent late quarterly installments. However, if any of the
contributions reported in line 19c represent late quarterly
installments, include all contributions reported in line 19c on
this schedule. Label the attachment “Schedule SB, line 19 –
Discounted Employer Contributions.”
Special note for small plans with valuation dates after
the beginning of the plan year. If the valuation date is after
the beginning of the plan year and contributions for the current
year were made during the plan year but before the valuation
date, such contributions are increased with interest to the
valuation date using the effective interest rate for the current
plan year. These contributions and the interest calculated as
described in the preceding sentence are excluded from the
value of assets reported in lines 2a and 2b.
Interest adjustment for contributions representing late
required quarterly installments — installments due after
the valuation date. If the full amount of a required installment
due after the valuation date for the current plan year is not paid
by the due date for that installment, increase the effective
interest rate used to discount the contribution by 5 percentage
points for the period between the due date for the required
installment and the date on which the payment is made. If all or
a portion of the late required quarterly installment is due to a

liquidity shortfall, the increased interest rate is used for a
period of time corresponding to the period between the due
date for the installment and the end of that quarter, regardless
of when the contribution is actually paid.
Interest adjustment for contributions representing late
required quarterly installments — small plans with
valuation dates after the beginning of the plan year installments due prior to the valuation date. See the
regulations under section 430 for rules regarding interest
adjustments for late quarterly contributions for quarterly
contributions due before the valuation date.
Line 19a. Contributions Allocated Toward Unpaid
Minimum Required Contributions from Prior Plan Years.
Code section 4971(c)(4)(B) provides that any payment to or
under a plan for any plan year shall be allocated first to unpaid
minimum required contributions for all preceding plan years on
a first-in, first-out basis and then to the minimum required
contribution for the current plan year. Report any contributions
from line 18 that are allocated toward unpaid minimum
required contributions from prior plan years, discounted for
interest from the date the contribution was made to the
valuation date for the plan year for which the contribution was
originally required as described above. Increase the effective
interest rate for the applicable plan year by 5 percentage points
for any portion of the unpaid minimum required contribution
that represents a late quarterly installment, for the period
between the due date for the installment and the date of
payment. Reflect the increased interest rate for any portion of
the unpaid minimum required contribution that represents a
late liquidity shortfall installment, for the period corresponding
to the time between the date the installment was due and the
end of the quarter during which it was due. The amount
reported in line 19a cannot be larger than the amount reported
in line 28.
For the purpose of allocating contribution amounts to
unpaid minimum required contributions, any unpaid minimum
required contribution attributable to an accumulated funding
deficiency at the end of the last plan year before Code section
430 or ERISA section 303 applied to the plan (the “preeffective plan year”) is treated as a single contribution due on
the last day of the pre-effective plan year (without separately
identifying any portion of the accumulated funding deficiency
attributable to late quarterly installments or late liquidity
shortfall installments), and the associated effective interest rate
is deemed to be the valuation interest rate for the pre-effective
plan year.
Line 19b. Contributions Made To Avoid Benefit
Restrictions. Include in this category current year
contributions made to avoid or terminate benefit restrictions
under Code section 436 and ERISA section 206(g). Adjust
each contribution for interest from the date the contribution was
made to the valuation date as described above.
Line 19c. Contributions Allocated Toward Minimum
Required Contribution for Current Year. Include in this
category contributions (including any contributions made in
excess of the minimum required contribution) that are not
included in line 19a or 19b. Adjust each contribution for interest
from the date the contribution was made to the valuation date
as described above.
Line 20. Quarterly Contributions and Liquidity Shortfalls.
Line 20a. Did the Plan Have a Funding Shortfall for the
Prior Plan Year? In accordance with Code section 430(j)(3)
and ERISA section 303(j)(3), only plans that have a funding
shortfall for the preceding plan year are subject to an
accelerated quarterly contribution schedule. For this purpose, a
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Instructions for Schedule SB (Form 5500)

plan is considered to have a funding shortfall for the prior year
if the funding target reported on line 3d, column (3) is greater
than the actuarial value of assets reported on line 2b, reduced
by the sum of the funding standard carryover balance and
prefunding balance reported on line 13, columns (a) and (b),
with all figures taken from the prior year’s Schedule SB.
If the valuation date for the prior plan year was not the first
day of that plan year, the amount subtracted from the actuarial
value of assets for the above calculation is the sum of the
amounts reported on line 13, columns (a) and (b) of the prioryear Schedule SB, but adjusted for interest between the
beginning of the prior plan year and the prior year’s valuation
date using the effective interest rate for the plan for the prior
plan year.
However, see Code section 430(f)(4)(B)(ii) and ERISA
section 303(f)(4)(B)(ii) for special rules in the case of a binding
agreement with the PBGC providing that all or a portion of the
funding standard carryover balance and/or prefunding balance
is not available to offset the minimum required contribution for
the prior plan year.
Please note that a plan may be considered to have a
funding shortfall for this purpose even if it is exempt from
establishing a shortfall amortization base under the provisions
of Code section 430(c)(5) and ERISA section 303(c)(5).
Line 20b. If line 20a is “No” (i.e., if the plan did not have a
funding shortfall in the prior plan year), the plan is not subject
to the quarterly contribution rules, and this line should not be
completed. If line 20a is “Yes,” check the “Yes” box on line 20b
if required installments for the current plan year were made in
a timely manner; otherwise, check “No.”
Line 20c. If line 20a is “No,” or the plan had 100 or fewer
participants on every day of the preceding plan year (as
defined for line F), the plan is not subject to the liquidity
requirement of Code section 430(j)(4) and ERISA section
303(j)(4) and this line should not be completed. Attach a
certification by the enrolled actuary if the special rule for
nonrecurring circumstances is used, and label the certification
“Schedule SB, line 20c –Liquidity Requirement
Certification.” See Code section 430(j)(4)(E)(ii)(II) and ERISA
section 303(j)(4)(E)(ii)(II).
If the plan is subject to the liquidity requirement and has a
liquidity shortfall for any quarter of the plan year (see Code
section 430(j)(4)(E) and ERISA section 303(j)(4)(E)), enter the
amount of the liquidity shortfall for each such quarter. If the
plan was subject to the liquidity requirement but did not have a
liquidity shortfall, enter zero. File IRS Form 5330, Return of
Excise Taxes Related to Employee Benefit Plans, with the IRS
to pay the 10% excise tax(es) if there is a failure to pay any
liquidity shortfall by the required due date, unless a waiver of
the 10% tax has been granted under Code section 4971(f)(4).

used to determine the target normal cost in accordance with
Code section 430(h)(2) and ERISA section 303(h)(2). Do not
enter the special 8.25% interest rate used to determine the
funding target under section 402(a)(2) of PPA.
Line 21b. Code section 430(h)(2)(E) and ERISA section
303(h)(2)(E) provide that the segment rate(s) used to measure
the funding target and target normal cost are those published
by Treasury for the month that includes the valuation date
(based on the average of the monthly corporate bond yield
curves for the 24-month period ending with the month
preceding that month). Alternatively, at the election of the plan
sponsor, the segment rate(s) used to measure the funding
target and target normal cost may be those published by
Treasury for any of the four months that precede the month
that includes the valuation date.
Enter the applicable month to indicate which segment rates
were used to determine the funding target and target normal
cost. Enter “0” if the rates used to determine the funding target
and target normal cost were published for the month that
includes the valuation date. Enter “1” if the rates were
published for the month immediately preceding the month that
includes the valuation date, “2” for the second preceding
month, and “3” or “4,” respectively, for the third or fourth
preceding months. For example, if the valuation date is
January 1 and the funding target and target normal cost were
determined based on rates published for November, enter “2.”
Note. The plan sponsor’s interest rate election under Code
section 430(h)(2) or ERISA section 303(h)(2) (an election to use
the yield curve or an election to use an applicable month other
than the default month) generally may not be changed unless
the plan sponsor obtains approval from the IRS. However, see
the regulations under section 430(h)(2) for circumstances in
which a change in interest rate may be made without obtaining
approval from the IRS.
Line 22. Weighted Average Retirement Age. Enter the
weighted average retirement age for active participants. If the
plan is in at-risk status, enter the weighted average retirement
age as if the plan were not in at-risk status. If each participant
is assumed to retire at his/her normal retirement age, enter the
age specified in the plan as normal retirement age. If the
normal retirement age differs for individual participants, enter
the age that is the weighted average normal retirement age; do
not enter “NRA.” Otherwise, enter the assumed retirement age.
If the valuation uses rates of retirement at various ages, enter
the nearest whole age that is the weighted average retirement
age.
On an attachment to Schedule SB, list the rate of
retirement at each age and describe the methodology used to
compute the weighted average retirement age, including a
description of the weight applied at each potential retirement
age, and label the attachment “Schedule SB, line 22 –
Description of Weighted Average Retirement Age.”
Line 23. Mortality Tables. Mortality tables described in Code
section 430(h)(3), ERISA section 303(h)(3), and section
1.430(h)(3)-1 of the regulations as published by the IRS must
be used to determine the funding target and target normal cost
for non-disabled participants and may be used to determine
the funding target and target normal cost for disabled
participants, unless the IRS has approved (or was deemed to
have approved) the use of a substitute mortality table for the
plan. Standard mortality tables must be either applied on a
generational basis, or the tables must be updated to reflect the
static tables published for the year in which the valuation date
occurs. Substitute mortality tables must be applied in
accordance with the terms of the IRS ruling letter.

Part V – Assumptions Used To Determine Funding
Target and Target Normal Cost
Line 21. Discount Rate. All discount rates are to be reported
and used as published by the IRS, and are to be applied as
annual rates without adjustment.
Line 21a. Enter the three segment rates used to calculate the
funding target and target normal cost as provided under Code
section 430(h)(2)(C) and ERISA section 303(h)(2)(C) and as
published by the IRS, unless the plan sponsor has elected to
use the full yield curve. If the sponsor has elected to use the
full yield curve, check the “N/A, full yield curve used” box.
Special rules for airlines using 10-year amortization
period under section 402(a)(2) of PPA (as amended). Enter
the information described above to reflect the discount rates
Instructions for Schedule SB (Form 5500)

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Separate standard mortality tables were published by the
IRS for annuitants (rates applying for periods when a
participant is assumed to receive a benefit under the plan) and
nonannuitants (rates applying to periods before a participant is
assumed to receive a benefit under the plan). If a plan has 500
or fewer participants as of the valuation date for the current
plan year as reported in line 3d, column (1), the plan sponsor
can elect to use the combined mortality tables published by the
IRS, which reflect combined rates for both annuitants and
nonannuitants.
Check the applicable box to indicate which mortality table
was used to determine the funding target and target normal
cost. If one mortality table was used for certain populations
within the plan and a different mortality table was used for
other populations, check the box for the table that applied to
the largest population. If more than one mortality table was
used, attach a statement describing the mortality table used for
each population and the size of that population. Label the
attachment “Schedule SB, line 23 – Information on Use of
Multiple Mortality Tables.”
● Check “Prescribed–combined” if the funding target and target
normal cost are based on the prescribed tables with combined
annuitant/nonannuitant mortality rates.
● Check “Prescribed–separate” if the funding target and target
normal cost are based on the prescribed tables with separate
mortality rates for nonannuitants and annuitants.
● Check “Substitute” if the funding target and target normal
cost are based on substitute mortality tables. If substitute
mortality tables are used, attach a statement including a
summary of plan populations for which substitute mortality
tables are used, plan populations for which the prescribed
tables are used, and the last plan year for which the IRS
approval of the substitute mortality tables applies. Label the
attachment “Schedule SB, line 23 – Information on Use of
Substitute Mortality Tables.”
Attach a statement of actuarial assumptions and funding
methods used to calculate the Schedule SB entries and label
the statement “Schedule SB, Part V – Statement of Actuarial
Assumptions/Methods.” The statement must describe all nonprescribed actuarial assumptions (e.g., retirement, withdrawal
rates) used to determine the funding target and target normal
cost, including the assumption as to the frequency with which
participants are assumed to elect each optional form of benefit
(including lump sum distributions), whether mortality tables are
applied on a static or generational basis, whether combined
mortality tables are used instead of separate annuitant and
nonannuitant mortality tables (for plans with 500 or fewer
participants as of the valuation date), and (for target normal
cost) expected plan-related expenses and increases in
compensation. For applicable defined benefit plans under Code
section 411(a)(13)(C) and ERISA section 203(f)(3) (e.g., cash
balance plans) the statement must include the assumptions
used to convert balances to annuities. In addition, the statement
must describe the method for determining the actuarial value of
assets and any other aspects of the funding method for
determining the Schedule SB entries that are not prescribed by
law.
Also attach a summary of the principal eligibility and benefit
provisions on which the valuation was based, including the
status of the plan (e.g., frozen eligibility, service/pay, or
benefits), optional forms of benefits, special plan provisions,
including those that apply only to a subgroup of employees
(e.g., those with imputed service), supplemental benefits, and
identification of benefits not included in the valuation, a
description of any significant events that occurred during the
year, a summary of any changes in principal eligibility or benefit

provisions since the last valuation, and a description (or
reasonably representative sample) of plan early retirement
reduction factors and optional form conversion factors. Label the
summary “Schedule SB, Part V – Summary of Plan
Provisions.”
Also, include any other information needed to disclose the
actuarial position of the plan fully and fairly.

Part VI – Miscellaneous Items
Line 24. Change in Non-Prescribed Actuarial Assumptions.
If a change has been made in the non-prescribed actuarial
assumptions for the current plan year, check “Yes.” If the only
assumption changes are statutorily required changes in the
discount or mortality rates, or changes required for plans in atrisk status, check “No.” Include as an attachment a description
of any change in non-prescribed actuarial assumptions and
justifications for any such change. (See section 103(d) of
ERISA.) Label the attachment “Schedule SB, line 24 –
Change in Actuarial Assumptions.”
If the “Yes” box is checked and the non-prescribed
assumptions have been changed in a way that decreases the
funding shortfall for the current plan year, approval for such a
change may be required.
Line 25. Change in Method. If a change in the method has
been made for the current plan year, check “Yes.” For this
purpose, a change in funding method refers to not only a
change in the overall method used by the plan, but also each
specific method of computation used in applying the overall
method. Accordingly, funding method changes include
modifications such as a change in the method for calculating the
actuarial value of assets or a change in the valuation date (not
an exclusive list). Also check "Yes" if there has been a change
in the method for determining the discount rates reported in line
21. In general, any changes in a plan’s method must be
approved by the IRS. However, see the regulations under Code
section 430 and Announcement 2010-3, 2010-4 I.R.B. 333, for
circumstances in which a change in method may be made
without obtaining approval from the IRS.
Include, as an attachment, a description of the change.
Label the attachment “Schedule SB, line 25 – Change in
Method.”
Note. The plan sponsor’s agreement to certain changes in
funding method should be reported on line 8 of Schedule R
(Form 5500).
Line 26. Schedule of Active Participant Data. Check “Yes”
only if (a) the plan is covered by Title IV of ERISA and (b) the
plan has active participants.
If line 26 is “Yes,” attach a schedule of the active plan
participant data used in the valuation for this plan year. Use the
format shown on the following page and label the schedule
“Schedule SB, line 26 – Schedule of Active Participant
Data.”
Expand this schedule by adding columns after the “5 to 9”
column and before the “40 & up” column for active participants
with total years of credited service in the following ranges: 10 to
14; 15 to 19; 20 to 24; 25 to 29; 30 to 34; and 35 to 39. For each
column, enter the number of active participants with the
specified number of years of credited service divided according
to age group. For participants with partial years of credited
service, round the total number of years of credited service to
the next lower whole number. Years of credited service are the
years credited under the plan’s benefit formula.
Plans reporting 1,000 or more active participants on line 3d,
column (1), must also provide average compensation data. For
each grouping, enter the average compensation of the active
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Instructions for Schedule SB (Form 5500)

participants in that group. For this purpose, compensation is the
compensation taken into account for each participant under the
plan’s benefit formula, limited to the amount defined under
section 401(a)(17) of the Code. Do not enter the average
compensation in any grouping that contains fewer than 20
participants.
In the case of a plan under which benefits are primarily payrelated and under which no future accruals are granted (i.e., a
“hard-frozen” plan as defined in the instructions for plan
characteristic “1I” applicable to line 8a of the Form 5500), report
the average annual accrued benefit in lieu of average
compensation. Include a note on the scatter indicating that the
plan is “hard frozen” and the average accrued benefits are in
lieu of compensation.
Cash balance plans (or any plans using characteristic code
1C on line 8a of Form 5500) reporting 1,000 or more active
participants on line 3d, column (1), must also provide average
cash balance account data, regardless of whether all active
participants have cash balance accounts. For each age/service
bin, enter the average cash balance account of the active
participants in that bin. Do not enter the average cash balance
account in any age/service bin that contains fewer than 20
active participants.
General Rule. When all active participants in the plan have
a cash balance account, data to be shown in each bin
includes:In general, data to be shown in each age/service bin
includes:
1. The number of active participants in the age/service bin,
2. The average compensation of the active participants in
the age/service bin, and
3. The average cash balance account of the active
participants in the age/service bin, using $0 for anyone who
has no cash balance account-based benefit.
If the accrued benefit is the greater of a cash balance benefit or
some other benefit, average in only the cash balance account. If
the accrued benefit is the sum of a cash balance account benefit
and some other benefit, average in only the cash balance
account. For both the average compensation and the average
cash balance account, do not enter an amount for age/service
bins with fewer than 20 active participants.
When some active participants do not have cash balance
accountsIn lieu of the above, two an alternatives are is provided

for showing compensation and cash balance accounts,
requiring. Each alternative provides for two age/service scatters
(one showing compensation and one showing cash balance
accounts) as follows:
Alternative A:
● Scatter 1 – Provide participant count and average
compensation for all active participants, . whether or not
participants have account-based benefits.
● Scatter 2 – Provide participant count and average cash
balance account for all active participants, whether or not
participants have account-based benefits.
Alternative B:
● Scatter 1 – Provide participant count and average
compensation for all active participants, whether or not
participants have account-based benefits (i.e., identical to
Scatter 1 in Alternative A).
● Scatter 2 – Provide participant count and average cash
balance account for only those active participants with
account-based benefits. If the number of participants with
account-based benefits in a bin is fewer than 20, the average
account should not be shown even if there are 20 or more
active participants in this bin on Scatter 1.
In general, information should be determined as of the
valuation date. Average cash balance accounts may be
determined as of either:
1. The valuation date or
2. The day immediately preceding the valuation date.
Average cash balance accounts that are offset by amounts
from another plan may be reported either as amounts prior to
taking into account the offset or as amounts after taking into
account the offset. Do not report the offset amount. For this or
any other unusual or unique situation, the attachment should
include an explanation of what is being provided.
If the plan is a multiple-employer plan, complete one or more
schedules of active-participant data in a manner consistent with
the computations for the funding requirements reported in Part
VIII. For example, if the funding requirements are computed as if
each participating employer maintained a separate plan, attach
a separate “Schedule SB, line 26 – Schedule of Active
Participant Data” for each participating employer in the
multiple-employer plan.

Schedule SB, Line 26 –Schedule of Active Participant Data
YEARS OF CREDITED SERVICE
1 to 4

Under 1
Attained
Age

Average
No.

Comp.

Cash Bal.

5 to 9

Average
No.

Comp.

40 & up

Average

Cash Bal.

No.

Comp.

Cash Bal.

Average
.
No.

Comp.

Cash Bal.

Under 25
25 to 29
30 to 34
35 to 39
40 to 44
45 to 49
50 to 54
55 to 59
60 to 64
65 to 69
70 & up

Line 27. Alternative Funding Rules. If one of the alternative
funding rules was used for this plan year, enter the appropriate
code from the table below and follow the special instructions
applicable to that code, including completion of any required
attachments.
Instructions for Schedule SB (Form 5500)

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Code
1

2

3
4

5

6

7
8

instructions. Under section 402(a)(2) of PPA (as amended), the
funding target for plans funded using this alternative is
determined using an interest rate of 8.25% for each of the 10
years during the amortization period instead of the interest rates
otherwise required under Code section 430(h)(2) and ERISA
section 303(h)(2). However, this special 8.25% interest rate
does not apply for other purposes, including the calculation of
target normal cost or the amortization of the funding shortfall.
Airlines with frozen plans using alternative 17-year
funding schedule (code 6). Complete the following lines on
Schedule SB and provide associated attachments:
● Lines A through F.
● Part I (including signature of enrolled actuary) – complete all
lines.
● Parts III through VII – complete all lines.
For this purpose, disregard the special funding rules under
section 402(e) of PPA except for the information reported on the
following lines:
● Line 19 – Discount contributions to the applicable valuation
date using the 8.85% discount rate provided under section
402(e)(4)(B) of PPA.
● Line 20 – Reflect required quarterly installments based on
the minimum required contribution determined under section
402(e) of PPA to the extent applicable (i.e., for purposes of
calculating the required annual payment under Code section
430(j)(3)(D)(ii)(l) and ERISA section 303(j)(3)(D)(ii)(l)).
● Line 29 – Reflect the minimum required contribution
determined under section 402(e) of PPA when determining the
unpaid minimum required contribution.
Also, attach a worksheet showing the information below,
determined in accordance with section 402(e) of PPA. Label this
worksheet “Schedule SB, line 27 – Alternative 17-Year
Funding Schedule for Airlines.”
● Date as of which plan benefits were frozen as required under
section 402(b)(2) of PPA.
● Date on which the first applicable plan year began.
● Accrued liability under the unit credit method calculated as of
the first day of the plan year, using an interest rate of 8.85%.
● A summary of all other assumptions used to calculate the
unit credit accrued liability.
● Fair market value of assets as of the first day of the plan
year.
● Unfunded liability under section 402(e)(3)(A) of PPA.
● Alternative funding schedule:
1. Contribution necessary to amortize the unfunded liability
over the remaining number of years, assuming payments at
the valuation date for each plan year and using an interest rate
of 8.85%;
2. Employer contributions for the plan year, discounted for
interest to the valuation date for the plan year, and using a rate
of 8.85%; and
3. Contribution shortfall, if any ((1)-(2) but not less than
zero).
Interstate transit company (code 7). Complete the entire
Schedule SB, reflecting the modifications to the otherwiserequired funding rules under section 115(b) of PPA, and
disregarding the attachment required for plans reporting the use
of the substitute mortality table in line 23.
Plans entitled to delayed effective dates for PPA funding
rules (code 8).

Alternative Funding Rule
A CSEC plan that is described in Code section
414(y). This includes certain multiple-employer
plans maintained by rural cooperatives and
other specified cooperative organizations and
certain plans maintained by more than 1
employer (determined after application of Code
section 414(b) and (c)), all of which are
described in Code section 501(c)(3). Do not use
Code 1 for a plan that satisfies the definition of a
CSEC plan that has made the election to not be
treated as a CSEC planIf a plan that satisfies
the definition of a CSEC plan has made the
election to not be treated as a CSEC plan, it
should not use Code 1.
This code, formerly used by certain plans
maintained by PBGC settlements as described
in section 105 of PPA, is no longer applicable
and should not be used
Reserved
Plans with binding agreements with PBGC to
maintain prefunding and/or funding standard
carryover balances described in Code section
430(f)(4)(B)(ii) and ERISA section
303(f)(4)(B)(ii)
Airlines using 10-year amortization period for
initial post-PPA shortfall amortization base
under section 402(a)(2) of PPA (as amended)
Airlines with frozen plans using alternative 17year funding schedule under section 402(a)(1)
of PPA
Interstate transit company described in section
115 of PPA
A plan subject to section 104 of PPA as
amended that is not a CSEC plan. This includes
plans that fit within the definition of a CSEC plan
that elect out of CSEC plan status and become
subject to section 104 of PPA as amended, and
certain plans maintained by more than 1
employer (determined without regard to section
414(c)) where all of the employers are described
in section 501(c)(3). Do not use Code 8 for a
PPA section 104 plan that has made the
election to not be treated as an eligible charity
planIf a PPA section 104 plan has made the
election to not be treated as an eligible charity
plan, it should not use Code 8.

Special Instructions for codes 1 through 8
Plans entitled to delayed effective dates for PPA funding
rules (codes 1 and 8). CSEC Plans, as described in Code
section 414(y) and subject to Code section 433 (code 1).
Reserved
Plans with binding agreements with the PBGC to
maintain prefunding and/or carryover balances (code 4).
Complete entire Schedule SB and attachments as outlined in
these instructions. In addition, report on an attachment the
amount subject to the binding agreement with the PBGC,
reported separately for the funding standard carryover balance
and prefunding balance. Label the attachment “Schedule SB,
line 27 – Balances Subject to Binding Agreement with
PBGC.”
Airlines using 10-year amortization period for initial
post-PPA shortfall amortization base (code 5). Complete the
entire Schedule SB and attachments as outlined in these

For plan years before Code section 430 and ERISA section
303 apply to the plan, complete only the following lines on
Schedule SB:
● Lines A through F.
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Instructions for Schedule SB (Form 5500)

● Part I (including signature of enrolled actuary), determined
as if PPA provisions were effective for all plan years beginning
after December 31, 2007.
● Part III, line 14, determined as if PPA provisions were
effective for all plan years beginning after December 31, 2007.

the period between the beginning of the plan year and the
valuation date, minus the funding target reported on line 3d,
column (3) (but not less than zero). Limit the amount reported
in line 31b so that it is not greater than the target normal cost
reported in line 31a.
Line 32. Amortization Installments.
Line 32a. Shortfall Amortization Bases and Amortization
Installments. Outstanding balance — If the plan’s funding
shortfall (determined under Code section 430(c)(4) and ERISA
section 303(c)(4)) is zero, all amortization bases and related
installments are considered fully amortized. In this case, enter
zero. Otherwise, enter the sum (but not less than zero) of the
outstanding balances of all shortfall amortization bases
(including any new shortfall amortization base established for
the current plan year). The outstanding balance for each
amortization base established in past years is equal to the
present value as of the valuation date of any remaining
amortization installments for each base (including the
amortization installment for the current plan year), using the
interest rates reported on line 21.
A plan is generally exempt from the requirement to establish
a new shortfall amortization base for the current plan year if the
funding target reported on line 3d, column (3), is less than or
equal to the reduced value of assets as described below.
For the purpose of determining whether a plan is exempt
from the requirement to establish a new shortfall amortization
base for the current plan year, the reduced value of assets is the
amount reported on line 2b, reduced by the full value of the
prefunding balance reported on line 13, column (b), adjusted for
interest for the period between the beginning of the plan year
and the valuation date using the effective interest rate for the
current plan year, if the valuation date is not the first day of the
plan year. However, the assets are reduced by the prefunding
balance if and only if the plan sponsor has elected to use any
portion of the prefunding balance to offset the minimum required
contribution for the current plan year, as reported on line 35.
The assets are not reduced by the amount of any funding
standard carryover balance for this calculation regardless of
whether any portion of the funding standard carryover balance is
used to offset the minimum required contribution for the plan
year.
If the plan is not exempt from the requirement to establish a
new shortfall amortization base for the current plan year, the
amount of that base is generally equal to the difference between
the funding shortfall as of the valuation date (determined under
Code section 430(c)(4) and ERISA section 303(c)(4)) and the
sum of any outstanding balances of any previously established
shortfall and waiver amortization bases. The new shortfall
amortization base may be either greater than or less than zero.
For the purpose of determining the amount of any new
shortfall amortization base, the funding shortfall is equal to the
amount of the funding target reported on line 3d, column (3),
minus the reduced value of assets, but not less than zero.
If the plan’s valuation date is the first day of the plan year,
then the reduced value of assets for the purpose of determining
the amount of any new shortfall amortization base is the amount
reported on line 2b, reduced by the sum of the funding standard
carryover balance and the prefunding balance reported on line
13, columns (a) and (b). However, if the plan’s valuation date is
not the first day of the plan year, then the reduced value of
assets for the purpose of determining the amount of any new
shortfall amortization base is the amount reported on line 2b,
reduced by the sum of the funding standard carryover balance
and the prefunding balance reported on line 13, columns (a) and
(b), adjusted for interest for the period between the beginning of

 Part IV, Line 18
● Part V, determined as if PPA provisions were effective for
all plan years beginning after December 31, 2007.
● If the minimum required contribution for any year was
determined using pension funding relief under section 107 of
PPA ’06, as added by PRA 2010, complete Part IX, lines 41a
and 41b. Refer to guidance issued by Treasury and the IRS
regarding additional information to be reported for plans for
which 15-year amortization was elected under section 107(c) of
PPA ’06, as added by PRA 2010.
Also, report other information for the current plan year using
a 2007 Schedule B (Form 5500). Label this attachment “2014
2015 Schedule SB, line 27 – Actuarial Information Based on
Pre-PPA Funding Rules.” Complete all items, and attach the
form and all applicable attachments to the Schedule SB. Note
that under PPA, the third segment rate determined under Code
section 430(h)(2)(C)(iii) and ERISA section 303(h)(2)(C)(iii) is
substituted for the current liability interest rate under Code
section 412(b)(5)(B) and ERISA section 302(b)(5)(B) (as in
effect before PPA).
For eligible charity plans that are covered under section 104
of PPA as amended, refer to guidance issued by Treasury and
the IRS regarding additional information to be reported.

Part VII – Reconciliation of Unpaid Minimum
Required Contributions for Prior Years
Line 28. Unpaid Minimum Required Contributions for Prior
Years. Enter the total amount of any unpaid minimum required
contributions for all years from line 40 of the Schedule SB for
the prior plan year.
If this is the first year that the plan is subject to the minimum
funding requirements of Code section 430 or ERISA section
303, enter the amount of any accumulated funding deficiency at
the end of the prior year (the pre-effective plan year). This is the
amount reported on line 9p of the 2007 Schedule B form that
was submitted as an attachment to the Schedule SB for the preeffective plan year.
Line 29. Employer Contributions Allocated Toward Unpaid
Minimum Required Contributions from Prior Years. Enter
the total amount of discounted contributions made for the
current plan year allocated toward unpaid minimum required
contributions from prior years as reported in line 19a.
Line 30. Remaining Unpaid Minimum Required
Contributions. Enter the amount in line 28 minus the amount
in line 29.

Part VIII – Minimum
Required Contribution for Current Year
Line 31. Target Normal Cost and Excess Assets.
Line 31a. Target Normal Cost (line 6). Enter the target
normal cost as reported in line 6.
Line 31b. Excess Assets. Enter the excess, if any, of the
value of assets reported on line 2b reduced by any funding
standard carryover balance and prefunding balance on line 13,
columns (a) and (b), over the funding target reported on line
3d, column (3). If the valuation date is not the first day of the
plan year, excess assets are determined as the value of assets
reported on line 2b reduced by any funding standard carryover
balance and prefunding balance reported on line 13, columns
(a) and (b), adjusted for interest at the effective interest rate for
Instructions for Schedule SB (Form 5500)

-76-

the plan year and the valuation date (using the effective interest
rate for the current plan year). See Code section 430(f)(4)(B)(ii)
and ERISA section 303(f)(4)(B)(ii) for special rules in the case of
a binding agreement with the PBGC providing that all or a
portion of the funding standard carryover balance and/or
prefunding balance is not available to offset the minimum
required contribution for the plan year.
Shortfall amortization installment — Enter the sum (but not
less than zero) of:
1. Any shortfall amortization installments that were
established to amortize shortfall amortization bases
established in prior years, excluding amortization installments
for bases that have been or are deemed to be fully amortized,
and
2. The shortfall amortization installment that corresponds to
any new shortfall amortization base established for the current
plan year. This amount is the level amortization payment that
will amortize the new shortfall amortization base over 7 annual
payments, using the interest rates reported in line 21 for the
current plan year.
Note. Shortfall amortization installments for a given shortfall
amortization base are not re-determined from year to year
regardless of any changes in interest rates or valuation dates.
Note. If an election was made to use an alternative shortfall
amortization schedule under Code section 430(c)(2)(D) and
ERISA section 303(c)(2)(D) added by PRA 2010, the shortfall
amortization installment is the amount determined in
accordance with the shortfall amortization schedule chosen
and guidance issued by Treasury and the IRS. Include any
increase to the shortfall amortization installment for this year
due to the installment acceleration amount, as provided in
Code section 430(c)(7) and ERISA section 303(c)(7).
Line 32b. Waiver Amortization Bases and Amortization
Installments. Outstanding balance — If the plan’s funding
shortfall (determined under Code section 430(c)(4) and ERISA
section 303(c)(4)) is zero, all waiver amortization bases and
related installments are considered fully amortized. In this
case, enter zero. Otherwise, enter the present value as of the
valuation date of all remaining waiver amortization installments
(including any installment for the current plan year), using the
interest rates reported on line 21. Do not include any new
waiver amortization base established for a waiver of minimum
funding requirements for the current plan year.
Waiver amortization installments — Enter the sum of any
remaining waiver amortization installments that were
established to amortize any waiver amortization bases for prior
plan years, unless such bases have been or are deemed to be
fully amortized. Do not include an amortization installment for
any new waiver amortization base established for a waiver of
minimum funding requirements for the current plan year.
Note. If a waiver of minimum funding requirements has been
granted for the current plan year, a waiver amortization base is
established as of the valuation date for the current plan year
equal to the amount of the funding waiver reported in line 33.
The waiver amortization installment that corresponds to any
waiver amortization base established for the current year is the
level amortization payment that will amortize the new waiver
amortization base over 5 annual payments, using the same
segment interest rates or rates from the full yield curve
reported on line 21 for the current plan year, but with the first
payment due on the valuation date for the following plan year.
The amount of the waiver amortization base and the waiver
amortization installments for this base are not reported in line
32b for the year in which they are established. Rather, these

are included in the entries for line 32b on the Schedule SB for
the following plan year.
Note. Waiver amortization installments (including the waiver
amortization installments of any waiver amortization base
established for the prior plan year) are not re-determined from
year to year regardless of any changes in interest rates or
valuation dates.
Required attachment. If there are any shortfall or waiver
amortization bases, include as an attachment a listing of all
bases (other than a base established for a funding waiver for the
current plan year) showing for each base:
1. The type of base (shortfall or waiver),
2. The present value of any remaining installments
(including the installment for the current plan year),
3. The valuation date as of which the base was established,
4. The number of years remaining in the amortization
period, and
5. The amortization installment.
If a base is negative (i.e., a “gain base”), show amounts in
parentheses or with a negative sign in front of them. All
amounts must be calculated as of the valuation date for the
plan year.
If any of the shortfall amortization bases shown on this
attachment are being amortized using an alternative
amortization schedule in accordance with Code section
430(c)(2)(D) or ERISA section 303(c)(2)(D), identify the
amortization schedule being used and show separately the
amount of any installment acceleration amount added to the
shortfall amortization installment for the current plan year
under Code section 430(c)(7) or ERISA section 303(c)(7).
Label the schedule “Schedule SB, line 32 – Schedule of
Amortization Bases.”
Line 33. Funding Waiver. If a waiver of minimum funding
requirements has been approved for the current plan year,
enter the date of the ruling letter granting the approval and the
waived amount (reported as of the valuation date) in the
spaces provided. If a waiver is pending, do not complete this
line. If a pending waiver is granted after Form 5500 is filed, file
an amended Form 5500 with an amended Schedule SB.
Line 34. Total Funding Requirement Before Reflecting
Carryover/Prefunding Balances. Enter the target normal cost
in line 31a, minus the excess assets in line 31b, plus the
amortization installments reported in lines 32a and 32b,
reduced by any waived amounts reported in line 33.
Line 35. Balances Elected for Use to Offset Funding
Requirement. If the percentage reported on line 16 is at least
80%, and the plan has a funding standard carryover balance
and/or prefunding balance (as reported on line 13, columns (a)
and (b)), the plan sponsor may elect to credit all or a portion of
such balances against the minimum required contribution.
Enter the amount of any balance elected for use for this
purpose in the applicable column of line 35, and enter the total
in the column headed “Total Balance.” No portion of the
prefunding balance can be used for this purpose unless the full
amount of any remaining funding standard carryover balance
(line 13, column (a)) is used. The amounts entered on line 35
cannot be larger than the corresponding amounts on line 13
(unless the plan’s valuation date is not the first day of the plan
year, as discussed below).
If the plan’s valuation date is not the first day of the plan
year, adjust the portion of the funding standard carryover
balance and prefunding balance used to offset the minimum
required contribution for interest between the beginning of the
plan year and the valuation date using the effective interest rate
for the current plan year.
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Instructions for Schedule SB (Form 5500)

Special rule for late election to apply balances to
quarterly installments. If an election was made to use the
funding standard carryover balance or the prefunding balance to
offset the amount of a required quarterly installment, but the
election was made after the due date of the installment, the
amount reported on line 35 may not be the same amount that is
subtracted from the plan’s balances in the following plan year (to
be reported in line 8 of Schedule SB for the following plan year).
Refer to the regulations under Section 430 of the Code for
additional information.
Special rule for elections to use balances in excess of
the minimum required contribution. Section 1.430(f)-1(f)(3)(ii)
of the regulations provides an exception to the general rule
requiring that any elections to use the funding standard
carryover balance and/or prefunding balance to offset the
minimum required contribution are irrevocable. Under this
exception, such an election may be revoked to the extent that
the amount of the election exceeds the minimum required
contribution for the plan year as reported in line 34. If a timely
election is made to revoke the excess amount, report only the
amount of the election used to offset the minimum required
contribution on line 35. If the excess amount is not revoked by
means of a timely election, report the full amount of the election
on line 35 even if it exceeds the minimum required contribution
reported on line 34.
Line 36. Additional Cash Requirement. Enter the amount in
line 34 minus the amount in the “Total Balance” column in line
35. (The result cannot be less than zero.) This represents the
contribution needed to satisfy the minimum funding
requirement for the current year, adjusted for interest to the
valuation date.
Line 37. Contributions Allocated Toward Minimum
Required Contribution for Current Year, Adjusted to
Valuation Date. Enter the amount reported in line 19c.
Line 38. Present Value of Excess Contributions for Current
Year.
Line 38a. If line 37 is greater than line 36, enter the amount by
which line 37 exceeds line 36. Otherwise, enter “0.” This
amount (plus interest, if applicable) is the maximum amount by
which the plan sponsor may elect to increase the prefunding
balance.
Line 38b. Enter the amount of any portion of the amount
shown on line 38a that results solely from the use of the
funding standard carryover balance and/or prefunding balance
to offset the minimum required contribution.
Line 39. Unpaid Minimum Required Contribution for
Current Year. If line 37 is less than line 36, enter the amount
by which line 36 exceeds line 37. Otherwise, enter “0”.
Line 40. Unpaid Minimum Required Contributions for All
Years. Enter the sum of the remaining unpaid minimum
required contributions from line 30 and the unpaid minimum
required contribution for the current year from line 39. If this
amount is greater than zero, file Form 5330, Return of Excise
Taxes Related to Employee Benefit Plans and pay the 10%
excise tax on the unpaid minimum required contributions.

election year using the extended amortization periods under
section 107 of PPA ’06, as added by PRA 2010 (complete lines
41a and 41b only).
Line 41a. Schedule elected. Check the applicable box to
indicate which alternative shortfall amortization schedule is
being used, the 2 plus 7-year schedule or the 15-year
schedule.
Line 41b. Eligible plan year(s) for which the election in line
41a was made. Check the box(es) to indicate the eligible plan
years for which the election was made to use an alternative
amortization schedule under Code section 430(c)(2)(D) or
ERISA section 303(c)(2)(D) or the relief under section 107 of
PPA ’06 as added by PRA 2010. Note that an election to use
an alternative amortization schedule may only be made with
respect to one or two eligible plan years. Refer to Code section
430(c)(2)(D)(v) or ERISA section 303(c)(2)(D)(v) for the
definition of eligible plan years.
Line 42. Amount of acceleration adjustment. Enter the total
amount included in the shortfall amortization installments
reported for the current year on line 32a as a result of
increases due to any installment acceleration amount under
Code section 430(c)(7) or ERISA section 303(c)(7), taking into
account any amounts carried over from previous years and the
annual limitation in Code section 430(c)(7)(C)(ii) or ERISA
section 303(c)(7)(C)(ii).
Line 43. Excess installment acceleration amount to be
carried over to future plan years. Enter the amount of any
excess installment acceleration amount for the current year
(including any amounts carried to the current year from prior
years) that will be carried over to future plan years in
accordance with Code section 430(c)(7)(C)(iii) or ERISA
section 303(c)(7)(C)(iii).

Part IX – Election to Use Pension Funding Relief
under PRA 2010
Note. This section is completed only if:
(1) an election was made to use an alternative shortfall
amortization schedule for any election year under Code section
430(c)(2)(D) or ERISA section 303(c)(2)(D), or
(2) in the case of a plan subject to a delayed effective date for
PPA funding rules under section 104 of PPA, an election was
made to determine the minimum required contribution for any
Instructions for Schedule SB (Form 5500)

-78-

OMB Control Numbers
Agency

OMB Number

Employee Benefits Security Administration...............................................1210 - 0110 and 1210 - 0089
Pension Benefit Guaranty Corporation .....................................................1212 - 0057
Internal Revenue Service ..........................................................................1545 - 1610
Paperwork Reduction Act Notice
We ask for the information on this form to carry out the law as specified in ERISA and in Code sections 6047(e), 6058(a), and
6059(a). You are required to give us the information. We need it to determine whether the plan is operating according to the law.
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form
displays a valid OMB control number. Books and records relating to a form or its instructions must be retained as long as their
contents may become material in the administration of the Internal Revenue Code or are required to be maintained pursuant to Title I
or IV of ERISA. Generally, the Form 5500 return/reports are open to public inspection and are subject to publication on the Internet.
The time needed to complete and file the forms listed below reflects the combined requirements of the Internal Revenue Service,
Department of Labor, and Pension Benefit Guaranty Corporation. These times will vary depending on individual circumstances. The
estimated average times are:
Pension Plans
Large
Form 5500
Schedule A
Schedule C
Schedule D
Schedule G
Schedule H
Schedule I
Schedule MB
Schedule R
Schedule SB

1 hr., 54 min.
2 hr., 52 min.
3 hr., 4 min
1 hr., 39 min.
11 hr., 29 min.
7 hr., 42 min.
N/A
7 hr., 52 min.
1 hr., 43 min.
6 hr., 38 min.

Welfare Plans
Small

1 hr., 19 min.
2 hr., 51 min.
N/A
20 min.
N/A
N/A
2 hr., 5 min.
4 hr., 14 min.
1 hr., 5 min.
6 hr., 49 min.

Large
1 hr., 45 min.
3 hr., 39 min.
3 hr., 38 min.
1 hr., 52 min.
11 hr.
8 hr., 35 min.
N/A
N/A
N/A
N/A

Small
1 hr., 14 min.
2 hr., 43 min.
N/A
20 min.
N/A
N/A
1 hr., 55 min.
N/A
N/A
N/A

If you have comments concerning the accuracy of these time estimates or suggestions for making these forms simpler, we would
be happy to hear from you. You can write to the Internal Revenue Service, Tax Products Coordinating Committee,
SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave NW, IR-6526, Washington, DC 20224. Do not send any of these forms or schedules to
this address. The forms and schedules must be filed electronically. See How To File – Electronic Filing Requirement.

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Forms 5500, 5500-SF, and
5500-EZ Codes for Principal
Business Activity
Code

Agriculture, Forestry, Fishing
and Hunting
Crop Production
111100 Oilseed & Grain Farming
111210 Vegetable & Melon Farming
(including potatoes & yams)
111300 Fruit & Tree Nut Farming
111400 Greenhouse, Nursery, &
Floriculture Production
111900 Other Crop Farming
(including tobacco, cotton,
sugarcane, hay, peanut,
sugar beet, & all other crop
farming)
Animal Production
112111 Beef Cattle Ranching &
Farming
112112 Cattle Feedlots
112120 Dairy Cattle & Milk
Production
112210 Hog & Pig Farming
112300 Poultry & Egg Production
112400 Sheep & Goat Farming
112510 Aquaculture (including
shellfish & finfish farms &
hatcheries)
112900 Other Animal Production
Forestry and Logging
113110 Timber Tract Operations
113210 Forest Nurseries & Gathering
of Forest Products
113310 Logging
Fishing, Hunting and Trapping
114110 Fishing
114210 Hunting & Trapping
Support Activities for Agriculture
and Forestry
115110 Support Activities for Crop
Production (including cotton
ginning, soil preparation,
planting, & cultivating)
115210 Support Activities for Animal
Production
115310 Support Activities for
Forestry

Mining
211110
212110
212200
212310
212320

212390
213110

Oil & Gas Extraction
Coal Mining
Metal Ore Mining
Stone Mining & Quarrying
Sand, Gravel, Clay, &
Ceramic & Refractory
Minerals Mining, & Quarrying
Other Nonmetallic Mineral
Mining & Quarrying
Support Activities for Mining

Utilities
221100
221210
221300
221500

Electric Power Generation,
Transmission & Distribution
Natural Gas Distribution
Water, Sewage & Other
Systems
Combination Gas & Electric

Construction
Construction of Buildings
236110 Residential Building
Construction
236200 Nonresidential Building
Construction
Heavy and Civil Engineering
Construction
237100 Utility System Construction
237210 Land Subdivision
237310 Highway, Street, & Bridge
Construction
237990 Other Heavy & Civil
Engineering Construction

This list of principal business activities and their associated
codes is designed to classify an enterprise by the type of
activity in which it is engaged.
Code
Specialty Trade Contractors
238100 Foundation, Structure, &
Building Exterior Contractors
(including framing carpentry,
masonry, glass, roofing, &
siding)
238210 Electrical Contractors
238220 Plumbing, Heating, &
Air-Conditioning Contractors
238290 Other Building Equipment
Contractors
238300 Building Finishing
Contractors (including
drywall, insulation, painting,
wallcovering, flooring, tile, &
finish carpentry)
238900 Other Specialty Trade
Contractors (including site
preparation)

Manufacturing
Food Manufacturing
311110 Animal Food Mfg
311200 Grain & Oilseed Milling
311300 Sugar & Confectionary
Product Mfg
311400 Fruit & Vegetable Preserving
& Specialty Food Mfg
311500 Dairy Product Mfg
311610 Animal Slaughtering and
Processing
311710 Seafood Product Preparation
& Packaging
311800 Bakeries, Tortilla & Dry Pasta
Mfg
311900 Other Food Mfg (including
coffee, tea, flavorings &
seasonings)
Beverage and Tobacco Product
Manufacturing
312110 Soft Drink & Ice Mfg
312120 Breweries
312130 Wineries
312140 Distilleries
312200 Tobacco Manufacturing
Textile Mills and Textile Product
Mills
313000 Textile Mills
314000 Textile Product Mills
Apparel Manufacturing
315100 Apparel Knitting Mills
315210 Cut & Sew Apparel
Contractors
315220 Men’s & Boys’ Cut & Sew
Apparel Mfg.
315240 Women’s, Girls’ and Infants’
Cut & Sew Apparel Mfg.
315280 Other Cut & Sew Apparel Mfg
315990 Apparel Accessories & Other
Apparel Mfg
Leather and Allied Product
Manufacturing
316110 Leather & Hide Tanning, &
Finishing
316210 Footwear Mfg (including
rubber & plastics)
316990 Other Leather & Allied
Product Mfg
Wood Product Manufacturing
321110 Sawmills & Wood
Preservation
321210 Veneer, Plywood, &
Engineered Wood Product
Mfg
321900 Other Wood Product Mfg
Paper Manufacturing
322100 Pulp, Paper, & Paperboard
Mills
322200 Converted Paper Product Mfg

These principal activity codes are based on the North American
Industry Classification System.

Code
Printing and Related Support
Activities
323100 Printing & Related Support
Activities
Petroleum and Coal Products
Manufacturing
324110 Petroleum Refineries
(including integrated)
324120 Asphalt Paving, Roofing, &
Saturated Materials Mfg
324190 Other Petroleum & Coal
Products Mfg
Chemical Manufacturing
325100 Basic Chemical Mfg
325200 Resin, Synthetic Rubber, &
Artificial & Synthetic Fibers &
Filaments Mfg
325300 Pesticide, Fertilizer, & Other
Agricultural Chemical Mfg
325410 Pharmaceutical & Medicine Mfg
325500 Paint, Coating, & Adhesive Mfg
325600 Soap, Cleaning Compound, &
Toilet Preparation Mfg
325900 Other Chemical Product &
Preparation Mfg
Plastics and Rubber Products
Manufacturing
326100 Plastics Product Mfg
326200 Rubber Product Mfg
Nonmetallic Mineral Product
Manufacturing
327100 Clay Product & Refractory Mfg
327210 Glass & Glass Product Mfg
327300 Cement & Concrete Product Mfg
327400 Lime & Gypsum Product Mfg
327900 Other Nonmetallic Mineral
Product Mfg
Primary Metal Manufacturing
331110 Iron & Steel Mills & Ferroalloy
Mfg
331200 Steel Product Mfg from
Purchased Steel
331310 Alumina & Aluminum
Production & Processing
331400 Nonferrous Metal (except
Aluminum) Production &
Processing
331500 Foundries
Fabricated Metal Product
Manufacturing
332110 Forging & Stamping
332210 Cutlery & Handtool Mfg
332300 Architectural & Structural
Metals Mfg
332400 Boiler, Tank, & Shipping
Container Mfg
332510 Hardware Mfg
332610 Spring & Wire Product Mfg
332700 Machine Shops; Turned
Product; & Screw, Nut, & Bolt
Mfg
332810 Coating, Engraving, Heat
Treating, & Allied Activities
332900 Other Fabricated Metal
Product Mfg
Machinery Manufacturing
333100 Agriculture, Construction, &
Mining Machinery Mfg
333200 Industrial Machinery Mfg
333310 Commercial & Service
Industry Machinery Mfg
333410 Ventilation, Heating,
Air-Conditioning, &
Commercial Refrigeration
Equipment Mfg
333510 Metalworking Machinery Mfg
333610 Engine, Turbine & Power
Transmission Equipment Mfg
333900 Other General Purpose
Machinery Mfg

-78-

Code
Computer and Electronic Product
Manufacturing
334110 Computer & Peripheral
Equipment Mfg
334200 Communications Equipment
Mfg
334310 Audio & Video Equipment Mfg
334410 Semiconductor & Other
Electronic Component Mfg
334500 Navigational, Measuring,
Electromedical, & Control
Instruments Mfg
334610 Manufacturing & Reproducing
Magnetic & Optical Media
Electrical Equipment, Appliance, and
Component Manufacturing
335100 Electric Lighting Equipment
Mfg
335200 Household Appliance Mfg
335310 Electrical Equipment Mfg
335900 Other Electrical Equipment &
Component Mfg
Transportation Equipment
Manufacturing
336100 Motor Vehicle Mfg
336210 Motor Vehicle Body & Trailer
Mfg
336300 Motor Vehicle Parts Mfg
336410 Aerospace Product & Parts
Mfg
336510 Railroad Rolling Stock Mfg
336610 Ship & Boat Building
336990 Other Transportation
Equipment Mfg
Furniture and Related Product
Manufacturing
337000 Furniture & Related Product
Manufacturing
Miscellaneous Manufacturing
339110 Medical Equipment &
Supplies Mfg
339900 Other Miscellaneous Mfg

Wholesale Trade
Merchant Wholesalers, Durable
Goods
423100 Motor Vehicle, & Motor
Vehicle Parts & Supplies
423200 Furniture & Home Furnishings
423300 Lumber & Other Construction
Materials
423400 Professional & Commercial
Equipment & Supplies
423500 Metal & Mineral (except
petroleum)
423600 Household Appliances and
Electrical & Electronic Goods
423700 Hardware, Plumbing, &
Heating Equipment &
Supplies
423800 Machinery, Equipment, &
Supplies
423910 Sporting & Recreational
Goods & Supplies
423920 Toy, & Hobby Goods, &
Supplies
423930 Recyclable Materials
423940 Jewelry, Watch, Precious
Stone, & Precious Metals
423990 Other Miscellaneous Durable
Goods
Merchant Wholesalers, Nondurable
Goods
424100 Paper & Paper Products
424210 Drugs & Druggists’ Sundries
424300 Apparel, Piece Goods, &
Notions
424400 Grocery & Related Products
424500 Farm Product Raw Materials
424600 Chemical & Allied Products

Forms 5500, 5500-SF, and 5500-EZ Codes for Principal Business Activity (continued)
Code
424700

Petroleum & Petroleum
Products
424800 Beer, Wine, & Distilled
Alcoholic Beverages
424910 Farm Supplies
424920 Book, Periodical, &
Newspapers
424930 Flower, Nursery Stock, &
Florists’ Supplies
424940 Tobacco & Tobacco Products
424950 Paint, Varnish, & Supplies
424990 Other Miscellaneous
Nondurable Goods
Wholesale Electronic Markets and
Agents and Brokers
425110 Business to Business
Electronic Markets
425120 Wholesale Trade Agents &
Brokers

Retail Trade
Motor Vehicle and Parts Dealers
441110
441120
441210
441222
441228

New Car Dealers
Used Car Dealers
Recreational Vehicle Dealers
Boat Dealers
Motorcycle, ATV, and All
Other Motor Vehicle Dealers
441300 Automotive Parts,
Accessories, & Tire Stores
Furniture and Home Furnishings
Stores
442110 Furniture Stores
442210 Floor Covering Stores
442291 Window Treatment Stores
442299 All Other Home Furnishings
Stores
Electronics and Appliance Stores
443141 Household Appliance Stores
443142 Electronics Stores (including
Audio, Video, Computer, and
Camera Stores)
Building Material and Garden
Equipment and Supplies Dealers
444110 Home Centers
444120 Paint & Wallpaper Stores
444130
444190

Hardware Stores
Other Building Material
Dealers
444200 Lawn & Garden Equipment &
Supplies Stores
Food and Beverage Stores
445110 Supermarkets and Other
Grocery (except
Convenience) Stores
445120 Convenience Stores
445210 Meat Markets
445220 Fish & Seafood Markets
445230 Fruit & Vegetable Markets
445291 Baked Goods Stores
445292 Confectionery & Nut Stores
445299 All Other Specialty Food
Stores
445310 Beer, Wine, & Liquor Stores
Health and Personal Care Stores
446110 Pharmacies & Drug Stores
446120 Cosmetics, Beauty Supplies,
& Perfume Stores
446130 Optical Goods Stores
446190 Other Health & Personal
Care Stores
Gasoline Stations
447100 Gasoline Stations (including
convenience stores with gas)
Clothing and Clothing Accessories
Stores
448110 Men’s Clothing Stores
448120 Women’s Clothing Stores
448130 Children’s & Infants’ Clothing
Stores

Code
448140
448150
448190
448210
448310
448320

Family Clothing Stores
Clothing Accessories Stores
Other Clothing Stores
Shoe Stores
Jewelry Stores
Luggage & Leather Goods
Stores
Sporting Goods, Hobby, Book, and
Music Stores
451110 Sporting Goods Stores
451120 Hobby, Toy, & Game Stores
451130 Sewing, Needlework, & Piece
Goods Stores
451140 Musical Instrument &
Supplies Stores
451211 Book Stores
451212 News Dealers & Newsstands
General Merchandise Stores
452110 Department Stores
452900 Other General Merchandise
Stores
Miscellaneous Store Retailers
453110 Florists
453210 Office Supplies & Stationery
Stores
453220 Gift, Novelty, & Souvenir
Stores
453310 Used Merchandise Stores
453910 Pet & Pet Supplies Stores
453920 Art Dealers
453930 Manufactured (Mobile) Home
Dealers
453990 All Other Miscellaneous Store
Retailers (including tobacco,
candle, & trophy shops)
Nonstore Retailers
454110 Electronic Shopping &
Mail-Order Houses
454210 Vending Machine Operators
454310 Fuel Dealers (including Heating
Oil and Liquefied Petroleum)
454390 Other Direct Selling
Establishments (including
door-to-door retailing, frozen
food plan providers, party
plan merchandisers, &
coffee-break service providers)

Transportation and
Warehousing
Air, Rail, and Water Transportation
481000 Air Transportation
482110 Rail Transportation
483000 Water Transportation
Truck Transportation
484110 General Freight Trucking,
Local
484120 General Freight Trucking,
Long-distance
484200 Specialized Freight Trucking
Transit and Ground Passenger
Transportation
485110 Urban Transit Systems
485210 Interurban & Rural Bus
Transportation
485310 Taxi Service
485320 Limousine Service
485410 School & Employee Bus
Transportation
485510 Charter Bus Industry
485990 Other Transit & Ground
Passenger Transportation
Pipeline Transportation
486000 Pipeline Transportation
Scenic & Sightseeing Transportation
487000 Scenic & Sightseeing
Transportation

Code
Support Activities for Transportation
488100 Support Activities for Air
Transportation
488210 Support Activities for Rail
Transportation
488300 Support Activities for Water
Transportation
488410 Motor Vehicle Towing
488490 Other Support Activities for
Road Transportation
488510 Freight Transportation
Arrangement
488990 Other Support Activities for
Transportation
Couriers and Messengers
492110 Couriers
492210 Local Messengers & Local
Delivery
Warehousing and Storage
493100 Warehousing & Storage
(except lessors of
miniwarehouses & self-storage
units)

Information
Publishing Industries (except Internet)
511110 Newspaper Publishers
511120 Periodical Publishers
511130 Book Publishers
511140 Directory & Mailing List
Publishers
511190 Other Publishers
511210 Software Publishers
Motion Picture and Sound Recording
Industries
512100 Motion Picture & Video
Industries (except video rental)
512200 Sound Recording Industries
Broadcasting (except Internet)
515100 Radio & Television
Broadcasting
515210 Cable & Other Subscription
Programming
Telecommunications
517000 Telecommunications
(including paging, cellular,
satellite, cable & other program
distribution, resellers, other
telecommunications, &
internet service providers)
Data Processing Services
518210 Data Processing, Hosting, &
Related Services
Other Information Services
519100 Other Information Services
(including news syndicates,
libraries, internet publishing &
broadcasting)

Finance and Insurance
Depository Credit Intermediation
522110 Commercial Banking
522120 Savings Institutions
522130 Credit Unions
522190 Other Depository Credit
Intermediation
Nondepository Credit Intermediation
522210 Credit Card Issuing
522220 Sales Financing
522291 Consumer Lending
522292 Real Estate Credit
(including mortgage bankers &
originators)
522293 International Trade Financing
522294 Secondary Market Financing
522298 All Other Nondepository
Credit Intermediation
Activities Related to Credit
Intermediation
522300 Activities Related to Credit
Intermediation (including loan
brokers, check clearing, &
money transmitting)

-79-

Code
Securities, Commodity Contracts,
and Other Financial Investments and
Related Activities
523110 Investment Banking &
Securities Dealing
523120 Securities Brokerage
523130 Commodity Contracts Dealing
523140 Commodity Contracts
Brokerage
523210 Securities & Commodity
Exchanges
523900 Other Financial Investment
Activities (including portfolio
management & investment
advice)
Insurance Carriers and Related
Activities
524130 Reinsurance Carriers
524140 Direct Life, Health, & Medical
Insurance Carriers
524150 Direct Insurance (except Life,
Health & Medical) Carriers
524210 Insurance Agencies &
Brokerages
524290 Other Insurance Related
Activities (including thirdparty administration of
Insurance and pension funds)
Funds, Trusts, and Other Financial
Vehicles
525100 Insurance & Employee
Benefit Funds
525910 Open-End Investment Funds
(Form 1120-RIC)
525920 Trusts, Estates, & Agency
Accounts
525990 Other Financial Vehicles
(including mortgage REITs &
closed-end investment funds)
“Offices of Bank Holding Companies”
and “Offices of Other Holding Companies”
are located under Management
of Companies (Holding Companies).

Real Estate and Rental and
Leasing
Real Estate
531110 Lessors of Residential
Buildings & Dwellings
(including equity REITs)
531120 Lessors of Nonresidential
Buildings (except
Miniwarehouses) (including
equity REITs)
531130 Lessors of Miniwarehouses &
Self-Storage Units (including
equity REITs)
531190 Lessors of Other Real Estate
Property (including equity
REITs)
531210 Offices of Real Estate Agents
& Brokers
531310 Real Estate Property
Managers
531320 Offices of Real Estate
Appraisers
531390 Other Activities Related to
Real Estate
Rental and Leasing Services
532100 Automotive Equipment Rental &
Leasing
532210 Consumer Electronics &
Appliances Rental
532220 Formal Wear & Costume Rental
532230 Video Tape & Disc Rental

Forms 5500, 5500-SF, and 5500-EZ Codes for Principal Business Activity (continued)
Code
532290

Code

Other Consumer Goods
Rental
532310 General Rental Centers
532400 Commercial & Industrial
Machinery & Equipment
Rental & Leasing
Lessors of Nonfinancial Intangible
Assets (except copyrighted works)
533110 Lessors of Nonfinancial
Intangible Assets (except
copyrighted works)

Professional, Scientific, and
Technical Services
Legal Services
541110 Offices of Lawyers
541190 Other Legal Services
Accounting, Tax Preparation,
Bookkeeping, and Payroll Services
541211 Offices of Certified Public
Accountants
541213 Tax Preparation Services
541214 Payroll Services
541219 Other Accounting Services
Architectural, Engineering, and
Related Services
541310 Architectural Services
541320 Landscape Architecture
Services
541330 Engineering Services
541340 Drafting Services
541350 Building Inspection Services
541360 Geophysical Surveying &
Mapping Services
541370 Surveying & Mapping (except
Geophysical) Services
541380 Testing Laboratories
Specialized Design Services
541400 Specialized Design Services
(including interior, industrial,
graphic, & fashion design)
Computer Systems Design and
Related Services
541511 Custom Computer
Programming Services
541512 Computer Systems Design
Services
541513 Computer Facilities
Management Services
541519 Other Computer Related
Services
Other Professional, Scientific, and
Technical Services
541600 Management, Scientific, &
Technical Consulting Services
541700 Scientific Research &
Development Services
541800 Advertising & Related
Services
541910 Marketing Research & Public
Opinion Polling
541920 Photographic Services
541930 Translation & Interpretation
Services
541940 Veterinary Services
541990 All Other Professional,
Scientific, & Technical
Services

Management of Companies
(Holding Companies)
551111
551112

Offices of Bank Holding
Companies
Offices of Other Holding
Companies

Administrative and Support and
Waste Management and
Remediation Services
Administration and Support Services
561110 Office Administrative Services
561210 Facilities Support Services
561300 Employment Services
561410 Document Preparation Services
561420 Telephone Call Centers
561430 Business Service Centers
(including private mail centers
& copy shops)
561440 Collection Agencies
561450 Credit Bureaus
561490 Other Business Support
Services (including
repossession services, court
reporting, & stenotype
services)
561500 Travel Arrangement &
Reservation Services
561600 Investigation & Security
Services
561710 Exterminating & Pest Control
Services
561720 Janitorial Services
561730 Landscaping Services
561740 Carpet & Upholstery Cleaning
Services
561790 Other Services to Buildings &
Dwellings
561900 Other Support Services
(including packaging &
labeling services, & convention
& trade show organizers)
Waste Management and
Remediation Services
562000 Waste Management and
Remediation Services

Educational Services
611000

Educational Services
(including schools, colleges,
& universities)

Health Care and Social Assistance
Offices of Physicians and Dentists
621111 Offices of Physicians (except
mental health specialists)
621112 Offices of Physicians, Mental
Health Specialists
621210 Offices of Dentists
Offices of Other Health Practitioners
621310 Offices of Chiropractors
621320 Offices of Optometrists
621330 Offices of Mental Health
Practitioners (except
Physicians)
621340 Offices of Physical,
Occupational & Speech
Therapists, & Audiologists
621391 Offices of Podiatrists
621399 Offices of all Other
Miscellaneous Health
Practitioners
Outpatient Care Centers
621410 Family Planning Centers
621420 Outpatient Mental Health &
Substance Abuse Centers
621491 HMO Medical Centers
621492 Kidney Dialysis Centers
621493 Freestanding Ambulatory
Surgical & Emergency Centers
621498 All Other Outpatient Care
Centers

Code
Medical and Diagnostic Laboratories
621510 Medical & Diagnostic
Laboratories
Home Health Care Services
621610 Home Health Care Services
Other Ambulatory Health Care Services
621900 Other Ambulatory Health Care
Services (including ambulance
services & blood & organ banks)
Hospitals
622000 Hospitals
Nursing and Residential Care
Facilities
623000 Nursing & Residential Care
Facilities
Social Assistance
624100 Individual & Family Services
624200 Community Food & Housing, &
Emergency & Other Relief
Services
624310 Vocational Rehabilitation
Services
624410 Child Day Care Services

Arts, Entertainment, and
Recreation
Performing Arts, Spectator Sports,
and Related Industries
711100 Performing Arts Companies
711210 Spectator Sports (including
sports clubs & racetracks)
711300 Promoters of Performing Arts,
Sports, & Similar Events
711410 Agents & Managers for
Artists, Athletes, Entertainers, &
Other Public Figures
711510 Independent Artists, Writers, &
Performers
Museums, Historical Sites, and Similar
Institutions
712100 Museums, Historical Sites, &
Similar Institutions
Amusements, Gambling, and
Recreation Industries
713100 Amusement Parks & Arcades
713200 Gambling Industries
713900 Other Amusement &
Recreation Industries
(including golf courses, skiing
facilities, marinas, fitness
centers, & bowling centers)

Accommodation and Food Services
Accommodation
721110 Hotels (except Casino Hotels) &
Motels
721120 Casino Hotels
721191 Bed & Breakfast Inns
721199 All other Traveler
Accommodation
721210 RV (Recreational Vehicle)
Parks & Recreational Camps
721310 Rooming & Boarding Houses
Food Services and Drinking Places
722300 Special Food Services
(including food service
contractors & caterers)
722410 Drinking Places (Alcoholic
Beverages)
722511 Full-Service Restaurants
722513 Limited-Service Restaurants
722514 Cafeterias and Buffets
722515 Snack and Non-alcoholic
Beverage Bars

-80-

Code

Other Services
Repair and Maintenance
811110 Automotive Mechanical, &
Electrical Repair &
Maintenance
811120 Automotive Body, Paint,
Interior, & Glass Repair
811190 Other Automotive Repair &
Maintenance (including oil
change & lubrication shops &
car washes)
811210 Electronic & Precision
Equipment Repair &
Maintenance
811310 Commercial & Industrial
Machinery & Equipment
(except Automotive &
Electronic) Repair &
Maintenance
811410 Home & Garden Equipment &
Appliance Repair &
Maintenance
811420 Reupholstery & Furniture
Repair
811430 Footwear & Leather Goods
Repair
811490 Other Personal & Household
Goods Repair & Maintenance
Personal and Laundry Services
812111 Barber Shops
812112 Beauty Salons
812113 Nail Salons
812190 Other Personal Care
Services (including diet &
weight reducing centers)
812210 Funeral Homes & Funeral
Services
812220 Cemeteries & Crematories
812310 Coin-Operated Laundries &
Drycleaners
812320 Drycleaning & Laundry
Services (except
Coin-Operated)
812330 Linen & Uniform Supply
812910 Pet Care (except Veterinary)
Services
812920 Photofinishing
812930 Parking Lots & Garages
812990 All Other Personal Services
Religious, Grantmaking, Civic,
Professional, and Similar
Organizations
813000 Religious, Grantmaking,
Civic, Professional, & Similar
Organizations (including
condominium and
homeowners associations)
813930 Labor Unions and Similar
Labor Organizations
921000 Governmental Instrumentality
or Agency

ERISA COMPLIANCE QUICK CHECKLIST
Compliance with the Employee Retirement Income Security Act (ERISA) begins with knowing the rules. Plan administrators and
other plan officials can use this checklist as a quick diagnostic tool for assessing a plan’s compliance with certain important
ERISA rules; it is not a complete description of all ERISA’s rules and it is not a substitute for a comprehensive compliance
review. Use of this checklist is voluntary, and it is not be filed with your Form 5500.
If you answer “No” to any of the questions below, you should review your plan’s operations because you may not be in
full compliance with ERISA’s requirements.
1.

Have you provided plan participants with a summary plan description, summaries of any material modifications of the
plan, and annual summary financial reports or annual pension funding reports?

2.

Do you maintain copies of plan documents at the principal office of the plan administrator for examination by
participants and beneficiaries?

3.

Do you respond to written participant inquires for copies of plan documents and information within 30 days?

4.

Does your plan include written procedures for making benefit claims and appealing denied claims, and are you
complying with those procedures?

5.

Is your plan covered by fidelity bonds protecting the plan against losses due to fraud or dishonesty by persons who
handle plan funds or other property?

6.

Are the plan’s investments diversified so as to minimize the risk of large losses?

7.

If the plan permits participants to select the investments in their plan accounts, has the plan provided them with
enough information to make informed decisions?

8.

Has a plan official determined that the investments are prudent and solely in the interest of the plan’s participants and
beneficiaries, and evaluated the risks associated with plan investments before making the investments?

9.

Did the employer or other plan sponsor send participant contributions to the plan on a timely basis?

10. Did the plan pay participant benefits on time and in the correct amounts?
11. Did the plan give participants and beneficiaries 30 days advance notice before imposing a “blackout period” of at least
three consecutive business days during which participants or beneficiaries of a 401(k) or other individual account
pension plan were unable to change their plan investments, obtain loans from the plan, or obtain distributions from
the plan?
If you answer “Yes” to any of the questions below, you should review your plan’s operations because you may not be
in full compliance with ERISA’s requirements.
1.

Has the plan engaged in any financial transactions with persons related to the plan or any plan official? (For example,
has the plan made a loan to or participated in an investment with the employer?)

2.

Has a plan official used the assets of the plan for his/her own interest?

3.

Have plan assets been used to pay expenses that were not authorized in the plan document, were not necessary for
the proper administration of the plan, or were more than reasonable in amount?

If you need help answering these questions or want additional guidance about ERISA requirements, a plan official
should contact the U.S. Department of Labor Employee Benefits Security Administration office in your region or consult
with the plan’s legal counsel or professional employee benefit advisor.

-81-

Index

80-120 Participant Rule ………. ...... 7
103-12 Investment Entity
(103-12 IE) ............................... 11
A
About the Form 5500 .................... 1
Additional Employer Information
for Multiemployer Defined
Benefit Pension Plans ...... 6059
Additional Information for
Single-Employer and
Multiemployer Defined
Benefit Pension Plans ......... 61
Amended Return/Report ............... 6
Amendments .............................. 59
C
Change in Plan Year ..................... 7
Changes to Note ........................... 1
Combination Unfunded/Insured
Welfare Plan ............................ 34
Common/Collective Trust ............ 10
D
Delinquent Filer Voluntary
Compliance (DFVC) Program ...... 5
Direct Filing Entity (DFE) – Who
Must File .................................... 4
Direct Filing Entity (DFE) – Filing
Requirements .......................... 10
Distributions ................................ 58
E
EFAST2 Processing System ......... 1
Electronic Filing Requirement ....... 5
ESOP Information ................... 6059
Extension of Time to File............... 4
F
Final Return/Report:
Mergers/Consolidations ............. 6
Pension and Welfare Plans
Terminated Without Distributing
All Assets ............................... 6
Welfare Plans Still Liable to Pay
Benefits .................................. 6
Form 5500 Schedules ................... 8
Fully Insured Welfare Benefit
Plan ......................................... 34
Funding Information ................ 5958
G
General Schedules ....................... 8
Group Insurance Arrangement
(GIA) ........................................ 11

I
Information Concerning Insurance
Contract Coverage, Fees, and
Commissions............................ 21
Instructions to Form 5500 ……….14
Instructions for Schedule A:
Who Must File .......................... 21
Instructions for Schedule C:
Who Must File .......................... 24
Instructions for Schedule D:
Who Must File .......................... 29
Instructions for Schedule G:
Who Must File .......................... 31
Instructions for Schedule H:
Who Must File .......................... 33
Instructions for Schedule I:
Who Must File .......................... 43
Instructions for Schedule MB:
Statement by Enrolled
Actuary ................................. 51
Who Must File .......................... 51
Instructions for Schedule R:
Who Must File .......................... 58
Instructions for Schedule SB:
Statement by Enrolled
Actuary ................................. 64
Who Must File .......................... 63
Investment and Annuity
Contract Information................. 22
L
Leases in Default or Classified
As Uncollectible …………………..31
Limited Pension Plan Reporting .... 9
List of Plan Characteristic Codes . 19
Loans or Fixed Income
Obligations in Default or Classified
As Uncollectible........................ 31
M
Master Trust Investment
Account (MTIA) ............................ 10
N
Nonexempt Transactions ....... 31, 47
Notice to Terminated Accountant
or Enrolled Actuary................... 28

O
On-Line Assistance………………..2
P
Party-In-Interest .................... 31, 47
Penalties:
Administrative ........................... 7
Other.......................................... 7
Pension Benefit Plan - Who
Must File ................................. 23
Pension Benefit Plan Filing
Requirements ............................ 8

H
How to get assistance ................... 2

-82-

Pension Schedules ........................ 8
Plan Administrator ………………..16
Plan Sponsor ............................... 15
Pooled Separate Account (PSA) . 10
Provision of Information ............... 23
Q
Quick Reference Chart of Form
5500, Schedules, and
Attachments……………………12
R
Reportable Transaction ............... 41
S
Schedule of Reportable
Transactions ....................... 4142
Service Provider Information ....... 24
Service Providers Who Fail or
Refuse To Provide
Information ............................... 27
Short Plan Year Rule .................. 78
Signature and Date ....................... 6
Small Plan Financial
Information ............................... 43
Special rule for certain
participant-directed
transactions ............................. 41
Statement by Enrolled
Actuary................................ 51,64
T
Telephone Assistance ................... 2
Termination Information on
Accountants and Enrolled
Actuaries .................................. 27
U
Unfunded Welfare Benefit Plan ..... 3
W
Welfare Benefit Contract
Information ............................... 23
Welfare Benefit Plan – Who
Must File .................................... 3
Welfare Benefit Plan Filing
Requirements ........................... 9
What To File .................................. 7
When To File:
DFEs other than GIAs ................ 4
Extensions ................................ 4
Plans and GIAs .......................... 4
Short Years ................................ 4
Who Must File ............................. 23