Document
Form 5500
ICR 201610-1210-001 · OMB 1210-0110 · Object 68625401.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Form 5500 |
| Author | Bruce Silver |
| Last Modified By | Writer |
| File Modified | 2016-05-03 |
| File Created | 2026-09-01 |
| Conversion State | complete |
Extracted Text
SCHEDULE C (Form 5500) Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Service Provider Information This schedule is required to be filed under section 104 of the Employee Retirement Income Security Act of 1974 (ERISA). File as an attachment to Form 5500. OMB No. 1210-0110 2016 This Form is Open to Public Inspection. For calendar plan year 2016 or fiscal plan year beginning and ending A Name of plan ABCDEFGHI B Three-digit plan number (PN) 001 C Plan sponsor’s name as shown on line 2a of Form 5500 ABCDEFGHI D Employer Identification Number (EIN) 012345678 Part II Service Providers Who Fail or Refuse to Provide Information 4 Provide, to the extent possible, the following information for each service provider who failed or refused to provide the information necessary to complete this Schedule. (a) Enter name and EIN or address of service provider (see instructions) (b) Nature of Service Code(s) (c) Describe the information that the service provider failed or refused to provide ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 10 11 12 13 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 1234567890 (a) Enter name and EIN or address of service provider (see instructions) (b) Nature of Service Code(s) (c) Describe the information that the service provider failed or refused to provide ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 10 11 12 13 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI 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