2016 Schedule I (F 2016 Schedule I (Form 5500) - Financial Information - Sm

SCHEDULE I

OMB No. 1210-0110

Financial Information—Small Plan

(Form 5500)
Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security Administration

20152016

This schedule is required to be filed under section 104 of the Employee
Retirement Income Security Act of 1974 (ERISA), and section 6058(a) of the
Internal Revenue Code (the Code).

This Form is Open to Public
Inspection

 File as an attachment to Form 5500.

Pension Benefit Guaranty Corporation

For calendar plan year 2015 2016 or fiscal plan year beginning

A Name of plan
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
C Plan sponsor’s name as shown on line 2a of Form 5500
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI

and ending

B

Three-digit
plan number (PN)



001

D Employer Identification Number (EIN)67

Complete Schedule I if the plan covered fewer than 100 participants as of the beginning of the plan year. You may also complete Schedule I if you are filing as a
small plan under the 80-120 participant rule (see instructions). Complete Schedule H if reporting as a large plan or DFE.

Part I

Small Plan Financial Information

Report below the current value of assets and liabilities, income, expenses, transfers and changes in net assets during the plan year. Combine the value of plan
assets held in more than one trust. Do not enter the value of the portion of an insurance contract that guarantees during this plan year to pay a specific dollar
benefit at a future date. Include all income and expenses of the plan including any trust(s) or separately maintained fund(s) and any payments/receipts to/from
insurance carriers. Round off amounts to the nearest dollar.

1
a
b
c
2
a

Plan Assets and Liabilities:
Total plan assets ..............................................................................................
1a
Total plan liabilities ..........................................................................................
1b
1c
Net plan assets (subtract line 1b from line 1a) ...............................................
Income, Expenses, and Transfers for this Plan Year:
(1) Employers ................................................................................................
2a(1)
(3) Others (including rollovers) .....................................................................
2a(3)
Noncash contributions .....................................................................................
2b
Other income ...................................................................................................
2c

(a) Amount

(b) End of Year

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(b) Total

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-123456789012345
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-123456789012345
-123456789012345

Total income (add lines 2a(1), 2a(2), 2a(3), 2b, and 2c) ................................
2d
Corrective distributions (see instructions) .......................................................
2f

-123456789012345
-123456789012345

Certain deemed distributions of participant loans
2g
(see instructions) .............................................................................................

-123456789012345

Benefits paid (including direct rollovers) .........................................................
2e

h Administrative service providers (salaries, fees, and
2h
commissions) ...................................................................................................

i
j
k
l
3

-123456789012345
-123456789012345
-123456789012345

Contributions received or receivable:
(2) Participants ..............................................................................................
2a(2)

b
c
d
e
f
g

(a) Beginning of Year

Other expenses................................................................................................
2i

-123456789012345
-123456789012345

Total expenses (add lines 2e, 2f, 2g, 2h, and 2i) ...........................................
2j
Net income (loss) (subtract line 2j from line 2d) .............................................
2k
Transfers to (from) the plan (see instructions) ................................................
2l

-123456789012345
-123456789012345
-123456789012345

Specific Assets: If the plan held assets at any time during the plan year in any of the following categories, check “Yes” and enter the current value of any assets
remaining in the plan as of the end of the plan year. 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 unless the trust meets one of the specific exceptions described in the instructions.
Yes
No
Amount

a Partnership/joint venture interests.........................................................................................................
3a

-123456789012345

b Employer real property ..........................................................................................................................
3b

-123456789012345

c Real estate (other than employer real property) ...................................................................................
3c

-123456789012345

d
e
f
g

-123456789012345

Employer securities ...............................................................................................................................
3d
Participant loans ....................................................................................................................................
3e
Loans (other than to participants) ........................................................................................................
3f
Tangible personal property ...................................................................................................................
3g

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

Schedule I (Form 5500) 20152016
v. 150123160205

Page 2-

Schedule I (Form 5500) 2016

1

x

Part II Compliance Questions
4 During the plan year:
a Was there a failure to transmit to the plan any participant contributions within the time period

Yes

No

Amount

described in 29 CFR 2510.3-102? Continue to answer “Yes” for any prior year failures until
fully corrected. (See instructions and DOL’s Voluntary Fiduciary Correction Program.) .......................
4a

-123456789012345

b Were any loans by the plan or fixed income obligations due the plan in default as of the
close of plan year or classified during the year as uncollectible? Disregard participant loans
secured by the participant’s account balance...........................................................................................
4b

-123456789012345

c Were any leases to which the plan was a party in default or classified during the year as

-123456789012345

uncollectible? ............................................................................................................................................
4c

d Were there any nonexempt transactions with any party-in-interest? (Do not include
transactions reported on line 4a.) .............................................................................................................
4d

-123456789012345

e Was the plan covered by a fidelity bond? .................................................................................................
4e

-123456789012345

Did the plan have a loss, whether or not reimbursed by the plan’s fidelity bond, that was
caused by fraud or dishonesty? ...............................................................................................................
4f

-123456789012345

f

g Did the plan hold any assets whose current value was neither readily determinable on an

-123456789012345

established market nor set by an independent third party appraiser? .....................................................
4g

h Did the plan receive any noncash contributions whose value was neither readily
determinable on an established market nor set by an independent third party appraiser? ..................
4h

-123456789012345

i

Did the plan at any time hold 20% or more of its assets in any single security, debt,
mortgage, parcel of real estate, or partnership/joint venture interest? ..................................................
4i

-123456789012345

j

Were all the plan assets either distributed to participants or beneficiaries, transferred to
another plan, or brought under the control of the PBGC? .....................................................................
4j

k Are you claiming a waiver of the annual examination and report of an independent qualified
public accountant (IQPA) under 29 CFR 2520.104-46? If “No,” attach an IQPA’s report or
4k
2520.104-50 statement. (See instructions on waiver eligibility and conditions.) ...........................................

l

-123456789012345

Has the plan failed to provide any benefit when due under the plan? ...................................................
4l

m If this is an individual account plan, was there a blackout period? (See instructions and 29
CFR 2520.101-3.) ....................................................................................................................................
4m

n If 4m was answered “Yes,” check the “Yes” box if you either provided the required notice or
4n
one of the exceptions to providing the notice applied under 29 CFR 2520.101-3 ................................

o Defined Benefit Plan or Money Purchase Pension Plan Only:
Were any distributions made during the plan year to an employee who attained age 62 and
4o
had not separated from service?..............................................................................................................................................................

ooDid the plan trust incur unrelated business taxable income? ………………………………………
p p

4o

4P1p(
1
(1) If this is a section 401(k) plan, were hardship distributions made during the plan year?
)
Were in-service distributions made during the plan year?

(2) If this is a defined benefit plan or a money purchase pension plan, did the plan make any
distributions during the plan year to employees who have attained age 62 and who were not
separated from service when the distributions were made?....................................

Formatted: Indent: Left: 0.03", First line: 0", Position:
Horizontal: Center, Relative to: Column

4p(2)

Formatted: Position: Horizontal: Center, Relative to:
Column

5a Has a resolution to terminate the plan been adopted during the plan year or any prior plan year?
If “Yes,” enter the amount of any plan assets that reverted to the employer this year........................... X Yes X No
Amount: 5b If, during this plan year, any assets or liabilities were transferred from this plan to another plan(s), identify the plan(s) to which assets or liabilities were
transferred. (See instructions.)
5b(1) Name of plan(s)

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

5b(2) EIN(s)

5b(3) PN(s)

123456789

123

123456789

123

123456789

123

5c If the plan is a defined benefit plan, is it covered under the PBGC insurance program (See ERISA section 4021.)? ..... … X Yes X No X Not determined.
If “Yes” is checked, enter the My PAA confirmation number from the PBGC premium filing for this plan year__________________________. (See instructions.)

Part III Trust Information
6a Name of trust

6b Trust’s EIN

Page 3- 1 x
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
6d Trustee’s or custodian telephone number
ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI

Schedule I (Form 5500) 2016

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
6c Name of trustee or custodian
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI