2016 Schedule SB ( 2016 Schedule SB (Form 5500) - Single-Employer Defined B

SCHEDULE SB

OMB No. 1210-0110

Single-Employer Defined Benefit Plan
Actuarial Information

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

2016

This schedule is required to be filed under section 104 of the Employee
Retirement Income Security Act of 1974 (ERISA) and section 6059 of the
Internal Revenue Code (the Code).

Pension Benefit Guaranty Corporation

This Form is Open to Public
Inspection

 File as an attachment to Form 5500 or 5500-SF.

For calendar plan year 2016 or fiscal plan year beginning

and ending

Round off amounts to nearest dollar.
Caution: A penalty of $1,000 will be assessed for late filing of this report unless reasonable cause is established.
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 or 5500-SF
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
E Type of plan: X Single

X Multiple-A X Multiple-B

B

Three-digit
plan number (PN)



001

D Employer Identification Number (EIN)
012345678

F Prior year plan size: X 100 or fewer X 101-500 X More than 500

Part I
Basic Information
1 Enter the valuation date:
Month _________ Day _________ Year _________
2 Assets:
-123456789012345
a Market value..............................................................................................................................................................
2a
2b
-123456789012345
b Actuarial value ..........................................................................................................................................................
(1) Number of
(2) Vested Funding
(3) Total Funding
3 Funding target/participant count breakdown
participants

Target

Target

a For retired participants and beneficiaries receiving payment .................................................................................... .
b For terminated vested participants ............................................................................................................................
c For active participants ...............................................................................................................................................
4

d Total .........................................................................................................................................................................
If the plan is in at-risk status, check the box and complete lines (a) and (b) ............................. X
a Funding target disregarding prescribed at-risk assumptions ....................................................................................4a
b Funding target reflecting at-risk assumptions, but disregarding transition rule for plans that have been in at-risk 4b
status for fewer than five consecutive years and disregarding loading factor ...........................................................

5
6

Effective interest rate ..................................................................................................................................................5
Target normal cost .....................................................................................................................................................6

-123456789012345
-123456789012345
123.12%
-123456789012345

Statement by Enrolled Actuary
To the best of my knowledge, the information supplied in this schedule and accompanying schedules, statements and attachments, if any, is complete and accurate. Each prescribed assumption was applied in
accordance with applicable law and regulations. In my opinion, each other assumption is reasonable (taking into account the experience of the plan and reasonable expectations) and such other assumptions, in
combination, offer my best estimate of anticipated experience under the plan.

SIGN
HERE
Signature of actuary

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
Type or print name of actuary

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
Firm name

123456789 ABCDEFGHI ABCDEFGHI ABCDE
123456789 ABCDEFGHI ABCDEFGHI ABCDE
UK

Date

YYYY-MM-DD
Most recent enrollment number

1234567
Telephone number (including area code)

1234567890

Address of the firm
If the actuary has not fully reflected any regulation or ruling promulgated under the statute in completing this schedule, check the box and see
X
instructions
For Paperwork Reduction Act Notice, see the Instructions for Form 5500 or 5500-SF.
Schedule SB (Form 5500) 2016
v. 160205

Page 2 - 1- x

Schedule SB (Form 5500) 2016

Part II

Beginning of Year Carryover and Prefunding Balances
(a) Carryover balance

7 Balance at beginning of prior year after applicable adjustments (line 13 from prior
year) ..............................................................................................................................

8 Portion elected for use to offset prior year’s funding requirement (line 35 from prior
year) ..........................................................................................................................

9 Amount remaining (line 7 minus line 8) ..........................................................................
10 Interest on line 9 using prior year’s actual return of
% ..................................
11 Prior year’s excess contributions to be added to prefunding balance:
a Present value of excess contributions (line 38a from prior year) .................................
b(1) Interest on the excess, if any, of line 38a over line 38b from prior year
Schedule SB, using prior year's effective interest rate of

(b) Prefunding balance

-123456789012345

-123456789012345

-123456789012345
-123456789012345
-123456789012345

-123456789012345
-123456789012345
-123456789012345
-123456789012345

% .................

-123456789012345

b(2) Interest on line 38b from prior year Schedule SB, using prior year's actual
return ...................................................................................................................

c Total available at beginning of current plan year to add to prefunding balance ..................
d Portion of (c) to be added to prefunding balance........................................................
12 Other reductions in balances due to elections or deemed elections ...............................
13 Balance at beginning of current year (line 9 + line 10 + line 11d – line 12) .....................

-123456789012345
-123456789012345

-123456789012345
-123456789012345
-123456789012345
-123456789012345

Part III
Funding Percentages
14 Funding target attainment percentage .........................................................................................................................................................................14
15 Adjusted funding target attainment percentage ..........................................................................................................................................15
16 Prior year’s funding percentage for purposes of determining whether carryover/prefunding balances may be used to reduce current 16
year’s funding requirement ........................................................................................................................................................................

17 If the current value of the assets of the plan is less than 70 percent of the funding target, enter such percentage. ....................................17

123.12%
123.12%
123.12%
123.12%

Part IV
Contributions and Liquidity Shortfalls
18 Contributions made to the plan for the plan year by employer(s) and employees:
(a) Date
(MM-DD-YYYY)

(b) Amount paid by
employer(s)

(c) Amount paid by
employees

(a) Date
(MM-DD-YYYY)

12345678901234
5
12345678901234
5
12345678901234
5
12345678901234
5
12345678901234
5

12345678901234
5
12345678901234
5
12345678901234
5
12345678901234
5
12345678901234
5

YYYY-MM-DD
YYYY-MM-DD
YYYY-MM-DD
YYYY-MM-DD

(b) Amount paid by
employer(s)

(c) Amount paid by
employees

12345678901234
1234567890123455123456789012345
12345678901234
12345678901234512345678901234
-123456789012345
5123456789012345
12345678901234
1234567890123455
-123456789012345
12345678901234
-123456789012345
5123456789012345
12345678901234
123456789012345-123456789012345
5
-123456789012345
12345678901234
-123456789012345
5123456789012345
12345678901234
-123456789012345
-123456789012345
5
-123456789012345
12345678901234
-123456789012345
5
12345678901234
-123456789012345
Totals ►
18(b)
18(c)
-123456789012345
5
-123456789012345
5
12345678901234
-123456789012345
19 Discounted employer contributions – see instructions for small plan with a valuation date after the beginning
of
the
year:
-123456789012345
12345678901234
5
12345678901234
-123456789012345
a Contributions allocated toward unpaid minimum required contributions from prior years...............................................
19a 5
-123456789012345
12345678901234
5
-123456789012345
5
b Contributions made to avoid restrictions adjusted to valuation date ..............................................................................
19b
12345678901234
12345678901234
-123456789012345
c Contributions allocated toward minimum required contribution for current year adjusted to valuation date12345678901234
.................................
19c 5
5
12345678901234
5
20 Quarterly contributions and liquidity shortfalls:
5
12345678901234
12345678901234
a Did the plan have a “funding shortfall” for the prior year? ..........................................................................................................................
X Yes X No
5
12345678901234
5
12345678901234
b If line 20a is “Yes,” were required quarterly installments for the current year made in a timely manner?
...................................................
X Yes X No
5
5
12345678901234
c If line 20a is “Yes,” see instructions and complete the following table as applicable:
12345678901234
5
12345678901234
Liquidity shortfall as of end of quarter of this plan year
5
12345678901234
5
(1) 1st
(2) 2nd
(3) 3rd
(4) 4th
5
12345678901234
-123456789012345
-123456789012345
-123456789012345
5
12345678901234
5
-123456789012345
YYYY-MM-DD
YYYY-MM-DD
YYYY-MM-DD
YYYY-MM-DD
YYYY-MM-DD

Page 3

Schedule SB (Form 5500) 2016

Part V
Assumptions Used to Determine Funding Target and Target Normal Cost
21 Discount rate:
1st segment:
2nd segment:
3rd segment:
a Segment rates:
123.12_%
123.12_%
123.12 %

X N/A, full yield curve used
1
12

b Applicable month (enter code) ....................................................................................................................................
21b
22 Weighted average retirement age ..................................................................................................................................
22
23 Mortality table(s) (see instructions)
Part VI

X Prescribed - combined

X Prescribed - separate

X Substitute

Miscellaneous Items

24 Has a change been made in the non-prescribed actuarial assumptions for the current plan year? If “Yes,” see instructions regarding required
attachment. .................................................................................................................................................................................................. X Yes X No
25 Has a method change been made for the current plan year? If “Yes,” see instructions regarding required attachment. ............................... X Yes X No
26 Is the plan required to provide a Schedule of Active Participants? If “Yes,” see instructions regarding required attachment. ....................... X Yes X No
27 If the plan is subject to alternative funding rules, enter applicable code and see instructions regarding

27

attachment .....................................................................................................................................................................

Part VII Reconciliation of Unpaid Minimum Required Contributions For Prior Years
28 Unpaid minimum required contributions for all prior years ..............................................................................................
28
29 Discounted employer contributions allocated toward unpaid minimum required contributions from prior years
29

(line 19a) ........................................................................................................................................................................

30 Remaining amount of unpaid minimum required contributions (line 28 minus line 29) ....................................................
30

-123456789012345
-123456789012345
-123456789012345

Part VIII Minimum Required Contribution For Current Year
31 Target normal cost and excess assets (see instructions):
-123456789012345
a Target normal cost (line 6) ...........................................................................................................................................
31a
b Excess assets, if applicable, but not greater than line 31a ..........................................................................................................
31b
Outstanding Balance
Installment
32 Amortization installments:
-123456789012345
a Net shortfall amortization installment ............................................................................. -123456789012345
-123456789012345
b Waiver amortization installment .................................................................................... -123456789012345
33 If a waiver has been approved for this plan year, enter the date of the ruling letter granting the approval
33
(Month _________ Day _________ Year _________ )_and the waived amount .....................................................

-123456789012345

34 Total funding requirement before reflecting carryover/prefunding balances (lines 31a - 31b + 32a + 32b - 33).....

-123456789012345

Carryover balance

34

Prefunding balance

Total balance

35 Balances elected for use to offset funding
requirement ..........................................................

-123456789012345

-123456789012345

36
36 Additional cash requirement (line 34 minus line 35) ........................................................................................................
37 Contributions allocated toward minimum required contribution for current year adjusted to valuation date (line
37

19c)................................................................................................................................................................................

38 Present value of excess contributions for current year (see instructions)
38a
a Total (excess, if any, of line 37 over line 36) ...............................................................................................................
38b
b Portion included in line 38a attributable to use of prefunding and funding standard carryover balances .....................
39
39 Unpaid minimum required contribution for current year (excess, if any, of line 36 over line 37).......................................
40
40 Unpaid minimum required contributions for all years ......................................................................................................
Part IX

-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345

Pension Funding Relief Under Pension Relief Act of 2010 (See Instructions)

41 If an election was made to use PRA 2010 funding relief for this plan:
a Schedule elected .........................................................................................................................................................

2 plus 7 years

X 15 years

b Eligible plan year(s) for which the election in line 41a was made .......................................................................... X 2008 X 2009 X 2010 X 2011
42 Amount of acceleration adjustment ...................................................................................................................................................................................
42
43 Excess installment acceleration amount to be carried over to future plan years .................................................................................................................
43