Form 5500 Schedule Single-Employer Defined Benefit Plan Actuarial Informati

Annual Information Return/Report of Employee Benefit Plan

160205 Clean Sch SB

Annual Information Return/Report of Employee Benefit Plan

OMB: 1210-0110

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SCHEDULE SB
(Form 5500)

Department of the Treasury

Internal Revenue Service

Department of Labor
Employee Benefits Security Administration

Pension Benefit Guaranty Corporation

Single-Employer Defined Benefit Plan Actuarial Information


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).

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

OMB No. 1210-0110


2016


This Form is Open to Public Inspection

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

B Three-digit
plan number (PN)

001


C Plan sponsor’s name as shown on line 2a of Form 5500 or 5500-SF

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

D Employer Identification Number (EIN)
012345678

E Type of plan: X Single X Multiple-A X Multiple-B


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:


a Market value

2a

-123456789012345

b Actuarial value

2b

-123456789012345


3 Funding target/participant count breakdown


(1) Number of participants

(2) Vested Funding Target

(3) Total Funding Target

a For retired participants and beneficiaries receiving payment .




b For terminated vested participants




c For active participants




d Total




4 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

-123456789012345

b Funding target reflecting at-risk assumptions, but disregarding transition rule for plans that have been in at-risk status for fewer than five consecutive years and disregarding loading factor

4b

-123456789012345

5 Effective interest rate

5

123.12%

6 Target normal cost

6

-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


Date

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE


YYYY-MM-DD

Type or print name of actuary


Most recent enrollment number

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE


1234567

Firm name


Telephone number (including area code)

123456789 ABCDEFGHI ABCDEFGHI ABCDE

123456789 ABCDEFGHI ABCDEFGHI ABCDE
UK


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 instructions

X

For Paperwork Reduction Act Notice, see the Instructions for Form 5500 or 5500-SF.



Schedule SB (Form 5500) 2016

v. 160205





Part II

Beginning of Year Carryover and Prefunding Balances


(a) Carryover balance

(b) Prefunding balance

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

-123456789012345

-123456789012345

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

-123456789012345

-123456789012345

9 Amount remaining (line 7 minus line 8)

-123456789012345

-123456789012345

10 Interest on line 9 using prior year’s actual return of %

-123456789012345

-123456789012345

11 Prior year’s excess contributions to be added to prefunding balance:



a Present value of excess contributions (line 38a from prior year)


-123456789012345

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(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


-123456789012345





d Portion of (c) to be added to prefunding balance


-123456789012345


-123456789012345

12 Other reductions in balances due to elections or deemed elections

-123456789012345

-123456789012345

13 Balance at beginning of current year (line 9 + line 10 + line 11d – line 12)

-123456789012345

-123456789012345

Part III

Funding Percentages

14 Funding target attainment percentage

14

123.12%

15 Adjusted funding target attainment percentage

15

123.12%

16 Prior year’s funding percentage for purposes of determining whether carryover/prefunding balances may be used to reduce current year’s funding requirement

16

123.12%

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%

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)

(b) Amount paid by employer(s)

(c) Amount paid by employees







YYYY-MM-DD

123456789012345


123456789012345


YYYY-MM-DD


123456789012345-123456789012345

-123456789012345

-123456789012345

-123456789012345

-123456789012345

-123456789012345

123456789012345-123456789012345

-123456789012345

-123456789012345

-123456789012345

-123456789012345

-123456789012345

YYYY-MM-DD

123456789012345


123456789012345


YYYY-MM-DD


123456789012345-123456789012345

-123456789012345

-123456789012345

-123456789012345

-123456789012345

-123456789012345

123456789012345-123456789012345

-123456789012345

-123456789012345

-123456789012345

-123456789012345

-123456789012345

YYYY-MM-DD

123456789012345


123456789012345


YYYY-MM-DD


123456789012345-123456789012345

-123456789012345

-123456789012345

-123456789012345

-123456789012345

-123456789012345

123456789012345-123456789012345

-123456789012345

-123456789012345

-123456789012345

-123456789012345

-123456789012345

YYYY-MM-DD

123456789012345


123456789012345


YYYY-MM-DD


123456789012345-123456789012345

-123456789012345

-123456789012345

-123456789012345

-123456789012345

-123456789012345

123456789012345-123456789012345

-123456789012345

-123456789012345

-123456789012345

-123456789012345

-123456789012345

YYYY-MM-DD

123456789012345


123456789012345






Totals ►

18(b)


18(c)



19 Discounted employer contributions – see instructions for small plan with a valuation date after the beginning of the year:


a Contributions allocated toward unpaid minimum required contributions from prior years.

19a

-123456789012345

b Contributions made to avoid restrictions adjusted to valuation date

19b

-123456789012345

c Contributions allocated toward minimum required contribution for current year adjusted to valuation date

19c

-123456789012345

20 Quarterly contributions and liquidity shortfalls:


a Did the plan have a “funding shortfall” for the prior year? X Yes X No

b If line 20a is “Yes,” were required quarterly installments for the current year made in a timely manner? X Yes X No

c If line 20a is “Yes,” see instructions and complete the following table as applicable:



Liquidity shortfall as of end of quarter of this plan year

(1) 1st

(2) 2nd

(3) 3rd

(4) 4th



-123456789012345

-123456789012345

-123456789012345

-123456789012345




Part V

Assumptions Used to Determine Funding Target and Target Normal Cost

21 Discount rate:

a Segment rates:

1st segment:

123.12_%

2nd segment:

123.12_%

3rd segment:
123.12 %

X N/A, full yield curve used

b Applicable month (enter code)

21b

1

22 Weighted average retirement age

22

12

23 Mortality table(s) (see instructions) X Prescribed - combined X Prescribed - separate X Substitute

Part VI

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 attachment

27


Part VII

Reconciliation of Unpaid Minimum Required Contributions For Prior Years

28 Unpaid minimum required contributions for all prior years

28

-123456789012345

29 Discounted employer contributions allocated toward unpaid minimum required contributions from prior years (line 19a)

29

-123456789012345

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

30

-123456789012345

Part VIII

Minimum Required Contribution For Current Year

31 Target normal cost and excess assets (see instructions):

a Target normal cost (line 6)

31a

-123456789012345

b Excess assets, if applicable, but not greater than line 31a

31b


32 Amortization installments:

Outstanding Balance

Installment

a Net shortfall amortization installment

-123456789012345

-123456789012345

b Waiver amortization installment

-123456789012345

-123456789012345

33 If a waiver has been approved for this plan year, enter the date of the ruling letter granting the approval (Month _________ Day _________ Year _________ )_and the waived amount

33

-123456789012345

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

34

-123456789012345

Carryover balance

Prefunding balance

Total balance

35 Balances elected for use to offset funding requirement

-123456789012345

-123456789012345

-123456789012345

36 Additional cash requirement (line 34 minus line 35)

36

-123456789012345

37 Contributions allocated toward minimum required contribution for current year adjusted to valuation date (line 19c)

37

-123456789012345

38 Present value of excess contributions for current year (see instructions)

-123456789012345

a Total (excess, if any, of line 37 over line 36)

38a


b Portion included in line 38a attributable to use of prefunding and funding standard carryover balances

38b


39 Unpaid minimum required contribution for current year (excess, if any, of line 36 over line 37)

39

-123456789012345

40 Unpaid minimum required contributions for all years

40

-123456789012345

Part IX

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



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleForm 5500
AuthorBruce Silver
File Modified0000-00-00
File Created2021-01-23

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