2015 Schedule D (F 2015 Schedule D (Form 5500) - DFE/Participating Provider

Annual Information Return/Report

150123 RLSO SchD

Annual Information Return/Report

OMB: 1212-0057

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1212-0057 can be found here:
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SCHEDULE D

DFE/Participating Plan Information

(Form 5500)
This schedule is required to be filed under section 104 of the Employee
Retirement Income Security Act of 1974 (ERISA).

Department of the Treasury
Internal Revenue Service

OMB No. 1210-0110

20152014

 File as an attachment to Form 5500.

Department of Labor
Employee Benefits Security Administration

This Form is Open to Public
Inspection.
For calendar plan year 20152014 or fiscal plan year beginning

and ending

A Name of plan
B Three-digit
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
001
plan number (PN)

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
C Plan or DFE sponsor’s name as shown on line 2a of Form 5500
D Employer Identification Number (EIN)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
012345678
ABCDEFGHI
Part I Information on interests in MTIAs, CCTs, PSAs, and 103-12 IEs (to be completed by plans and DFEs)
(Complete as many entries as needed to report all interests in DFEs)
a Name of MTIA, CCT, PSA, or 103-12 IE:
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
b Name of sponsor of entity listed in (a):
ABCDEFGHI
d
Entity
e Dollar value of interest in MTIA, CCT, PSA, or
c EIN-PN 123456789-123
1
-123456789012345
code
103-12 IE at end of year (see instructions)
a Name of MTIA, CCT, PSA, or 103-12 IE:
b Name of sponsor of entity listed in (a):
c EIN-PN 123456789-123

d Entity
code

a Name of MTIA, CCT, PSA, or 103-12 IE:
b Name of sponsor of entity listed in (a):
c EIN-PN 123456789-123

d Entity
code

a Name of MTIA, CCT, PSA, or 103-12 IE:
b Name of sponsor of entity listed in (a):
c EIN-PN 123456789-123

d Entity
code

a Name of MTIA, CCT, PSA, or 103-12 IE:
b Name of sponsor of entity listed in (a):
c EIN-PN 123456789-123

d Entity
code

a Name of MTIA, CCT, PSA, or 103-12 IE:
b Name of sponsor of entity listed in (a):
c EIN-PN 123456789-123

d Entity
code

a Name of MTIA, CCT, PSA, or 103-12 IE:
b Name of sponsor of entity listed in (a):
c EIN-PN 123456789-123

d Entity
code

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)

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

Schedule D (Form 5500) 20152014
v. 150123

Schedule D (Form 5500) 20152014

a Name of MTIA, CCT, PSA, or 103-12 IE:
b Name of sponsor of entity listed in (a):
c EIN-PN 123456789-123

d Entity
code

a Name of MTIA, CCT, PSA, or 103-12 IE:
b Name of sponsor of entity listed in (a):
c EIN-PN 123456789-123

d Entity
code

a Name of MTIA, CCT, PSA, or 103-12 IE:
b Name of sponsor of entity listed in (a):
c EIN-PN 123456789-123

d Entity
code

a Name of MTIA, CCT, PSA, or 103-12 IE:
b Name of sponsor of entity listed in (a):
c EIN-PN 123456789-123

d Entity
code

a Name of MTIA, CCT, PSA, or 103-12 IE:
b Name of sponsor of entity listed in (a):
c EIN-PN 123456789-123

d Entity
code

a Name of MTIA, CCT, PSA, or 103-12 IE:
b Name of sponsor of entity listed in (a):
c EIN-PN 123456789-123

d Entity
code

a Name of MTIA, CCT, PSA, or 103-12 IE:
b Name of sponsor of entity listed in (a):
c EIN-PN 123456789-123

d Entity
code

a Name of MTIA, CCT, PSA, or 103-12 IE:
b Name of sponsor of entity listed in (a):
c EIN-PN 123456789-123

d Entity
code

a Name of MTIA, CCT, PSA, or 103-12 IE:
b Name of sponsor of entity listed in (a):
c EIN-PN 123456789-123

d Entity
code

a Name of MTIA, CCT, PSA, or 103-12 IE:
b Name of sponsor of entity listed in (a):
c EIN-PN 123456789-123

d Entity
code

Page 2

- 1 x

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
e Dollar value of interest in MTIA, CCT, PSA, or
1
-123456789012345
103-12 IE at end of year (see instructions)

Schedule D (Form 5500) 20152014

Page 3

- 1 x

6

Part II

Information on Participating Plans (to be completed by DFEs)
(Complete as many entries as needed to report all participating plans)

a Plan name
b Name of
plan sponsor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
b Name of
plan sponsor
ABCDEFGHI ABCDEFGHI
123456789-123
a Plan name

a Plan name
b Name of
plan sponsor

a Plan name
b Name of
plan sponsor

a Plan name
b Name of
plan sponsor

a Plan name
b Name of
plan sponsor

a Plan name
b Name of
plan sponsor

a Plan name
b Name of
plan sponsor

a Plan name
b Name of
plan sponsor

a Plan name
b Name of
plan sponsor

a Plan name
b Name of
plan sponsor

a Plan name
b Name of
plan sponsor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c EIN-PN
ABCDEFGHI
123456789-123
File Type	application/pdf
File Title	Form 5500
Author	Bruce Silver
File Modified	2015-03-27
File Created	2015-03-27