Form 5500 Schedule Single-Employer Defined Benefit Plan Actuarial Informati

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