SCHEDULE G(Form 5500)
Department
of Treasury
Department of Labor Employee Benefits Security Administration |
Financial Transaction Schedules
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). File as an attachment to Form 5500. |
OMB No. 1210-0110
This Form is Open to Public Inspection. |
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For calendar plan year 2016 or fiscal plan year beginning and ending |
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A Name of plan ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
B
Three-digit |
001 |
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C Plan sponsor’s name as shown on line 2a of Form 5500 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
D
Employer Identification Number (EIN) |
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Part I |
Schedule
of Loans or Fixed Income Obligations in Default or Classified as
Uncollectible |
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(a) |
(b) Identity and address of obligor |
(c) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan and the terms of the renegotiation, and other material items |
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X |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE |
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Amount received during reporting year |
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Amount overdue |
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(d) Original amount of loan |
(e) Principal |
(f) Interest |
(g) Unpaid balance at end of year |
(h) Principal |
(i) Interest |
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123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
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(a) |
(b) Identity and address of obligor |
(c) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan and the terms of the renegotiation, and other material items |
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X |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE |
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Amount received during reporting year |
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Amount overdue |
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(d) Original amount of loan |
(e) Principal |
(f) Interest |
(g) Unpaid balance at end of year |
(h) Principal |
(i) Interest |
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123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
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(a) |
(b) Identity and address of obligor |
(c) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan and the terms of the renegotiation, and other material items |
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X |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE |
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Amount received during reporting year |
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Amount overdue |
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(d) Original amount of loan |
(e) Principal |
(f) Interest |
(g) Unpaid balance at end of year |
(h) Principal |
(i) Interest |
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123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
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For Paperwork Reduction Act Notice, see the Instructions for Form 5500. |
Schedule G (Form 5500) 2016 v. 160205 |
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(a) |
(b) Identity and address of obligor |
(c) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan and the terms of the renegotiation, and other material items |
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X |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE |
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Amount received during reporting year |
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Amount overdue |
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(d) Original amount of loan |
(e) Principal |
(f) Interest |
(g) Unpaid balance at end of year |
(h) Principal |
(i) Interest |
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123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
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(a) |
(b) Identity and address of obligor |
(c) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan and the terms of the renegotiation, and other material items |
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X |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE |
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Amount received during reporting year |
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Amount overdue |
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(d) Original amount of loan |
(e) Principal |
(f) Interest |
(g) Unpaid balance at end of year |
(h) Principal |
(i) Interest |
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123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
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(a) |
(b) Identity and address of obligor |
(c) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan and the terms of the renegotiation, and other material items |
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X |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE |
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Amount received during reporting year |
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Amount overdue |
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(d) Original amount of loan |
(e) Principal |
(f) Interest |
(g) Unpaid balance at end of year |
(h) Principal |
(i) Interest |
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123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
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(a) |
(b) Identity and address of obligor |
(c) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan and the terms of the renegotiation, and other material items |
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X |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE |
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Amount received during reporting year |
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Amount overdue |
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(d) Original amount of loan |
(e) Principal |
(f) Interest |
(g) Unpaid balance at end of year |
(h) Principal |
(i) Interest |
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123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
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(a) |
(b) Identity and address of obligor |
(c) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan and the terms of the renegotiation, and other material items |
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X |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE |
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Amount received during reporting year |
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Amount overdue |
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(d) Original amount of loan |
(e) Principal |
(f) Interest |
(g) Unpaid balance at end of year |
(h) Principal |
(i) Interest |
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123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
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Part II |
Schedule of Leases in Default or Classified as Uncollectible Complete as many entries as needed to report all leases in default or classified as uncollectible. Check box (a) if lessor or lessee is known to be a party in interest. Attach Overdue Lease Explanation for each lease listed. (See instructions) |
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(a) |
(b) Identity of lessor/lessee |
(c) Relationship to plan, employer, employee organization, or other party-in-interest |
(d) Terms and description (type of property, location and date it was purchased, terms regarding rent, taxes, insurance, repairs, expenses, renewal options, date property was leased) |
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X |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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(e) Original cost |
(f) Current value at time of lease |
(g) Gross rental receipts during the plan year |
(h) Expenses paid during the plan year |
(i) Net receipts |
(j) Amount in arrears |
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123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
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(a) |
(b) Identity of lessor/lessee |
(c) Relationship to plan, employer, employee organization, or other party-in-interest |
(d) Terms and description (type of property, location and date it was purchased, terms regarding rent, taxes, insurance, repairs, expenses, renewal options, date property was leased) |
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X |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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(e) Original cost |
(f) Current value at time of lease |
(g) Gross rental receipts during the plan year |
(h) Expenses paid during the plan year |
(i) Net receipts |
(j) Amount in arrears |
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123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
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(a) |
(b) Identity of lessor/lessee |
(c) Relationship to plan, employer, employee organization, or other party-in-interest |
(d) Terms and description (type of property, location and date it was purchased, terms regarding rent, taxes, insurance, repairs, expenses, renewal options, date property was leased) |
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X |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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(e) Original cost |
(f) Current value at time of lease |
(g) Gross rental receipts during the plan year |
(h) Expenses paid during the plan year |
(i) Net receipts |
(j) Amount in arrears |
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123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
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(a) |
(b) Identity of lessor/lessee |
(c) Relationship to plan, employer, employee organization, or other party-in-interest |
(d) Terms and description (type of property, location and date it was purchased, terms regarding rent, taxes, insurance, repairs, expenses, renewal options, date property was leased) |
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X |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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(e) Original cost |
(f) Current value at time of lease |
(g) Gross rental receipts during the plan year |
(h) Expenses paid during the plan year |
(i) Net receipts |
(j) Amount in arrears |
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123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
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(a) |
(b) Identity of lessor/lessee |
(c) Relationship to plan, employer, employee organization, or other party-in-interest |
(d) Terms and description (type of property, location and date it was purchased, terms regarding rent, taxes, insurance, repairs, expenses, renewal options, date property was leased) |
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X |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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(e) Original cost |
(f) Current value at time of lease |
(g) Gross rental receipts during the plan year |
(h) Expenses paid during the plan year |
(i) Net receipts |
(j) Amount in arrears |
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123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
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(a) |
(b) Identity of lessor/lessee |
(c) Relationship to plan, employer, employee organization, or other party-in-interest |
(d) Terms and description (type of property, location and date it was purchased, terms regarding rent, taxes, insurance, repairs, expenses, renewal options, date property was leased) |
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X |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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(e) Original cost |
(f) Current value at time of lease |
(g) Gross rental receipts during the plan year |
(h) Expenses paid during the plan year |
(i) Net receipts |
(j) Amount in arrears |
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123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
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Part III |
Nonexempt Transactions Complete as many entries as needed to report all nonexempt transactions. Caution: If a nonexempt prohibited transaction occurred with respect to a disqualified person, file Form 5330 with the IRS to pay the excise tax on the transaction. |
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(a) Identity of party involved |
(b) Relationship to plan, employer, or other party-in-interest |
(c) Description of transaction including maturity date, rate of interest, collateral, par or maturity value |
(d) Purchase price |
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ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
123456789012345 |
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(e) Selling price |
(f) Lease rental |
(g) Transaction expenses |
(h) Cost of asset |
(i) Current value of asset |
(j)
Net
gain (or loss) on |
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123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
12345678901235 |
-1234567890123455 |
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(a) Identity of party involved |
(b) Relationship to plan, employer, or other party-in-interest |
(c) Description of transaction including maturity date, rate of interest, collateral, par or maturity value |
(d) Purchase price |
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ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
123456789012345 |
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(e) Selling price |
(f) Lease rental |
(g) Transaction expenses |
(h) Cost of asset |
(i) Current value of asset |
(j)
Net
gain (or loss) on |
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(a) Identity of party involved |
(b) Relationship to plan, employer, or other party-in-interest |
(c) Description of transaction including maturity date, rate of interest, collateral, par or maturity value |
(d) Purchase price |
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ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
123456789012345 |
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(e) Selling price |
(f) Lease rental |
(g) Transaction expenses |
(h) Cost of asset |
(i) Current value of asset |
(j)
Net
gain (or loss) on |
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123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
12345678901235 |
-1234567890123455 |
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(a) Identity of party involved |
(b) Relationship to plan, employer, or other party-in-interest |
(c) Description of transaction including maturity date, rate of interest, collateral, par or maturity value |
(d) Purchase price |
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ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
123456789012345 |
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(e) Selling price |
(f) Lease rental |
(g) Transaction expenses |
(h) Cost of asset |
(i) Current value of asset |
(j)
Net
gain (or loss) on |
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(a) Identity of party involved |
(b) Relationship to plan, employer, or other party-in-interest |
(c) Description of transaction including maturity date, rate of interest, collateral, par or maturity value |
(d) Purchase price |
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ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
123456789012345 |
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(e) Selling price |
(f) Lease rental |
(g) Transaction expenses |
(h) Cost of asset |
(i) Current value of asset |
(j)
Net
gain (or loss) on |
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123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
12345678901235 |
-1234567890123455 |
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(a) Identity of party involved |
(b) Relationship to plan, employer, or other party-in-interest |
(c) Description of transaction including maturity date, rate of interest, collateral, par or maturity value |
(d) Purchase price |
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ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
123456789012345 |
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(e) Selling price |
(f) Lease rental |
(g) Transaction expenses |
(h) Cost of asset |
(i) Current value of asset |
(j)
Net
gain (or loss) on |
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123456789012345 |
123456789012345 |
123456789012345 |
123456789012345 |
12345678901235 |
-1234567890123455 |
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Form 5500 |
| Author | Bruce Silver |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |