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pdfSCHEDULE H
OMB No. 1210-0110
Financial Information
(Form 5500)
Department of the Treasury
Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security Administration
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).
20176
File as an attachment to Form 5500.
This Form is Open to Public
Inspection
Pension Benefit Guaranty Corporation
For calendar plan year 20176 or fiscal plan year beginning
A Name of plan
and ending
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
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
B
Three-digit
plan number (PN)
001
D Employer Identification Number (EIN)
012345678
Part I
Asset and Liability Statement
1 Current value of plan assets and liabilities at the beginning and end of the plan year. Combine the value of plan assets held in more than one trust. Report
the value of the plan’s interest in a commingled fund containing the assets of more than one plan on a line-by-line basis unless the value is reportable on
lines 1c(9) through 1c(14). Do not enter the value of that portion of an insurance contract which guarantees, during this plan year, to pay a specific dollar
benefit at a future date. Round off amounts to the nearest dollar. MTIAs, CCTs, PSAs, and 103-12 IEs do not complete lines 1b(1), 1b(2), 1c(8), 1g, 1h,
and 1i. CCTs, PSAs, and 103-12 IEs also do not complete lines 1d and 1e. See instructions.
Assets
(a) Beginning of Year
(b) End of Year
1a
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(1) Employer contributions .........................................................................
1b(1)
(2) Participant contributions ........................................................................
1b(2)
(3) Other ....................................................................................................
1b(3)
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a Total noninterest-bearing cash ......................................................................
b Receivables (less allowance for doubtful accounts):
c General investments:
(1) Interest-bearing cash (include money market accounts & certificates
of deposit) ...........................................................................................
1c(1)
(2) U.S. Government securities ..................................................................
1c(2)
(3) Corporate debt instruments (other than employer securities):
(A) Preferred ........................................................................................
1c(3)(A)
(B) All other ..........................................................................................
1c(3)(B)
(4) Corporate stocks (other than employer securities):
(5) Partnership/joint venture interests .........................................................
1c(5)
(6) Real estate (other than employer real property) ....................................
1c(6)
(7) Loans (other than to participants) ..........................................................
1c(7)
(8) Participant loans ...................................................................................
1c(8)
(9) Value of interest in common/collective trusts .........................................
1c(9)
(10) Value of interest in pooled separate accounts .......................................
1c(10)
(11) Value of interest in master trust investment accounts ............................
1c(11)
(12) Value of interest in 103-12 investment entities ......................................
(13) Value of interest in registered investment companies (e.g., mutual
funds) ...................................................................................
(14) Value of funds held in insurance company general account (unallocated
contracts)..............................................................................................
1c(12)
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1c(13)
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1c(14)
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(15) Other.....................................................................................................
1c(15)
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(A) Preferred ........................................................................................
1c(4)(A)
(B) Common ........................................................................................
1c(4)(B)
For Paperwork Reduction Act Notice, see the Instructions for Form 5500.
Schedule H (Form 5500) 20176
v.170203160205
Page 2
Schedule H (Form 5500) 20176
1d Employer-related investments:
(a) Beginning of Year
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1k
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1l
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(2) Employer real property ..........................................................................
1d(2)
1e Buildings and other property used in plan operation ....................................
1f Total assets (add all amounts in lines 1a through 1e) ..................................
Liabilities
1g Benefit claims payable ................................................................................
1h Operating payables .....................................................................................
1i Acquisition indebtedness .............................................................................
1j Other liabilities.............................................................................................
1k Total liabilities (add all amounts in lines 1g through1j) .................................
Net Assets
1l Net assets (subtract line 1k from line 1f) ......................................................
(b) End of Year
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(1) Employer securities ...............................................................................
1d(1)
1e
1f
1g
1h
1i
1j
Part II Income and Expense Statement
2 Plan income, expenses, and changes in net assets for the year. Include all income and expenses of the plan, including any trust(s) or separately maintained
fund(s) and any payments/receipts to/from insurance carriers. Round off amounts to the nearest dollar. MTIAs, CCTs, PSAs, and 103-12 IEs do not
complete lines 2a, 2b(1)(E), 2e, 2f, and 2g.
Income
(a) Amount
(b) Total
a Contributions:
(1) Received or receivable in cash from: (A) Employers .............................
2a(1)(A)
(B) Participants ...................................................................................
2a(1)(B)
(C) Others (including rollovers) ............................................................
2a(1)(C)
(2) Noncash contributions ...........................................................................
2a(2)
(3) Total contributions. Add lines 2a(1)(A), (B), (C), and line 2a(2) .............
2a(3)
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b Earnings on investments:
(1) Interest:
(A) Interest-bearing cash (including money market accounts and
certificates of deposit)....................................................................
2b(1)(A)
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(B) U.S. Government securities ...........................................................
2b(1)(B)
(C) Corporate debt instruments ...........................................................
2b(1)(C)
(D) Loans (other than to participants) ..................................................
2b(1)(D)
(E) Participant loans ............................................................................
2b(1)(E)
(F) Other .............................................................................................
2b(1)(F)
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(G) Total interest. Add lines 2b(1)(A) through (F).................................
2b(1)(G)
(2) Dividends: (A) Preferred stock...............................................................
2b(2)(A)
(B) Common stock ..............................................................................
2b(2)(B)
(C) Registered investment company shares (e.g. mutual funds) ..........
2b(2)(C)
(D) Total dividends. Add lines 2b(2)(A), (B), and (C)
2b(2)(D)
(3) Rents ....................................................................................................
2b(3)
(4) Net gain (loss) on sale of assets: (A) Aggregate proceeds ...................
2b(4)(A)
(B) Aggregate carrying amount (see instructions) ................................
2b(4)(B)
(C) Subtract line 2b(4)(B) from line 2b(4)(A) and enter result ..............
2b(4)(C)
(5) Unrealized appreciation (depreciation) of assets: (A) Real estate ....................
2b(5)(A)
(B) Other .............................................................................................
(C) Total unrealized appreciation of assets.
Add lines 2b(5)(A) and (B) ............................................................
2b(5)(B)
2b(5)(C)
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Page 3
Schedule H (Form 5500) 20176
(a) Amount
2b(6)
(7) Net investment gain (loss) from pooled separate accounts ......................
2b(7)
(8) Net investment gain (loss) from master trust investment accounts ..........
2b(8)
(9) Net investment gain (loss) from 103-12 investment entities .....................
(10) Net investment gain (loss) from registered investment
companies (e.g., mutual funds) ...............................................................
2b(9)
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2b(10)
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2c
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c Other income ................................................................................................
d Total income. Add all income amounts in column (b) and enter total....................
Expenses
e Benefit payment and payments to provide benefits:
f
g
h
i
(b) Total
(6) Net investment gain (loss) from common/collective trusts ........................
2d
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(1) Directly to participants or beneficiaries, including direct rollovers .............
2e(1)
(2) To insurance carriers for the provision of benefits ...................................
2e(2)
(3) Other .......................................................................................................
2e(3)
(4) Total benefit payments. Add lines 2e(1) through (3) ................................
2e(4)
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Corrective distributions (see instructions) ......................................................
2f
Certain deemed distributions of participant loans (see instructions) ...............
2g
Interest expense............................................................................................
2h
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Administrative expenses: (1) Professional fees ............................................
2i(1)
(2) Contract administrator fees .....................................................................
2i(2)
(3) Investment advisory and management fees ............................................
2i(3)
(4) Other .......................................................................................................
2i(4)
(5) Total administrative expenses. Add lines 2i(1) through (4) ......................
2i(5)
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2j
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2k
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(1) To this plan..............................................................................................
2l(1)
(2) From this plan .........................................................................................
2l(2)
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j Total expenses. Add all expense amounts in column (b) and enter total .......
Net Income and Reconciliation
k Net income (loss). Subtract line 2j from line 2d .........................................................
l Transfers of assets:
Part III Accountant’s Opinion
3 Complete lines 3a through 3c if the opinion of an independent qualified public accountant is attached to this Form 5500. Complete line 3d if an opinion is not
attached.
a The attached opinion of an independent qualified public accountant for this plan is (see instructions):
(1) X Unqualified
(2) X Qualified
(3) X Disclaimer
(4) X Adverse
X Yes
X No
b Did the accountant perform a limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)?
c Enter the name and EIN of the accountant (or accounting firm) below:
(1) Name: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
(2) EIN: 123456789
d The opinion of an independent qualified public accountant is not attached because:
(1) X This form is filed for a CCT, PSA, or MTIA.
(2) X It will be attached to the next Form 5500 pursuant to 29 CFR 2520.104-50.
Part IV Compliance Questions
4
CCTs and PSAs do not complete Part IV. MTIAs, 103-12 IEs, and GIAs do not complete lines 4a, 4e, 4f, 4g, 4h, 4k, 4m, 4n, or 5.
103-12 IEs also do not complete lines 4j and 4l. MTIAs also do not complete line 4l.
Yes
During the plan year:
a
Was there a failure to transmit to the plan any participant contributions within the time
period described in 29 CFR 2510.3-102? Continue to answer “Yes” for any prior year failures until
fully corrected. (See instructions and DOL’s Voluntary Fiduciary Correction Program.) ....................
4a
b
Were any loans by the plan or fixed income obligations due the plan in default as of the
close of the plan year or classified during the year as uncollectible? Disregard participant loans
secured by participant’s account balance. (Attach Schedule G (Form 5500) Part I if “Yes” is
checked.) ........................................................................................................................................
4b
No
Amount
Page 4-
Schedule H (Form 5500) 20176
1
x
Yes
No
Amount
c
Were any leases to which the plan was a party in default or classified during the year as
uncollectible? (Attach Schedule G (Form 5500) Part II if “Yes” is checked.) .......................................
4c
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d
Were there any nonexempt transactions with any party-in-interest? (Do not include transactions
reported on line 4a. Attach Schedule G (Form 5500) Part III if “Yes” is
checked.) ...........................................................................................................................................
4d
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Was this plan covered by a fidelity bond? ...........................................................................................
4e
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Did the plan have a loss, whether or not reimbursed by the plan’s fidelity bond, that was caused by
fraud or dishonesty? ..........................................................................................................................
4f
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Did the plan hold any assets whose current value was neither readily determinable on an
established market nor set by an independent third party appraiser? .................................................
4g
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Did the plan receive any noncash contributions whose value was neither readily
determinable on an established market nor set by an independent third party appraiser? ..................
4h
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i
Did the plan have assets held for investment? (Attach schedule(s) of assets if “Yes” is checked, and
see instructions for format requirements.)...........................................................................................
4i
j
Were any plan transactions or series of transactions in excess of 5% of the current
value of plan assets? (Attach schedule of transactions if “Yes” is checked, and
see instructions for format requirements.)...........................................................................................
4j
Were all the plan assets either distributed to participants or beneficiaries, transferred to another
plan, or brought under the control of the PBGC? ................................................................................
4k
e
f
g
h
k
l
Has the plan failed to provide any benefit when due under the plan? ................................................. 4l
m If this is an individual account plan, was there a blackout period? (See instructions and 29 CFR
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2520.101-3.) ....................................................................................................................................... 4m
n
If 4m was answered “Yes,” check the “Yes” box if you either provided the required notice or one of
the exceptions to providing the notice applied under 29 CFR 2520.101-3...........................................
4n
5a
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year?........
X Yes X No
If “Yes,” enter the amount of any plan assets that reverted to the employer this year ____________________________________.
5b
If, during this plan year, any assets or liabilities were transferred from this plan to another plan(s), identify the plan(s) to which assets or liabilities were
transferred. (See instructions.)
5b(1) Name of plan(s)
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
5b(2) EIN(s)
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
5b(3) PN(s)
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
123456789
123
ABCDEFGHI
ABCDEFGHI
123456789
123
ABCDEFGHI
ABCDEFGHI
123456789
123
ABCDEFGHI
ABCDEFGHI
123456789
123
ABCDEFGHI
5c If the plan is a defined benefit plan, is it covered under the PBGC insurance program (See ERISA section 4021.)? ...... X Yes X No
X Not determined
If “Yes” is checked, enter the My PAA confirmation number from the PBGC premium filing for this plan year________________________. (See instructions.)
Part V Trust Information
6a Name of trust
6b Trust’s EIN
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
6c Name of trustee or custodian
6d Trustee’s or custodian’s telephone number
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
+12345678901234567890123456
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
| File Type | application/pdf |
| File Title | Form 5500 |
| Author | Bruce Silver |
| File Modified | 2017-03-27 |
| File Created | 2017-03-27 |