2017 Form 5500-SF 2017 Short Form Annual Return/Report of Small Employee B

Form 5500-SF
Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security Administration
Pension Benefit Guaranty Corporation

Part I

OMB Nos. 1210-0110
1210-0089

Short Form Annual Return/Report of Small Employee
Benefit Plan
This form is required to be filed under sections 104 and 4065 of the Employee Retirement
Income Security Act of 1974 (ERISA), and sections 6057(b) and 6058(a) of the Internal
Revenue Code (the Code).

2017
This Form is Open to
Public Inspection

 Complete all entries in accordance with the instructions to the Form 5500-SF.

Annual Report Identification Information

For calendar plan year 2017 or fiscal plan year beginning

A This return/report is for:
B This return/report is

and ending

X a single-employer plan

X a multiple-employer plan (not multiemployer) (Filers checking this box must attach a

X a one-participant plan

X a foreign plan

X the first return/report
X an amended return/report

X the final return/report
X a short plan year return/report (less than 12 months)

list of participating employer information in accordance with the form instructions.)

C Check box if filing under:

X Form 5558
X automatic extension
X special extension (enter description)
Part II
Basic Plan Information—enter all requested information
1a Name of plan ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI
2a Plan sponsor’s name (employer, if for a single-employer plan)
Mailing address (include room, apt., suite no. and street, or P.O. Box)
City or town, state or province, country, and ZIP or foreign postal code (if foreign, see instructions)

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGH ABCDEFGHI ABCDEFGHI ABCDEFGHI I
3a Plan administrator’s name and address X Same as Plan Sponsor.ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI
123456789 ABCDEFGHI ABCDEFGHI ABCDE
123456789 ABCDEFGHI ABCDEFGHI ABCDE
CITYEFGHI
ABCDEFGHI
AB, ST 012345678901I A
4 If the name and/or
EIN of the plan sponsor or the plan name has changed since the last return/report filed for
this plan, enter the plan sponsor’s name, EIN, the plan name and the plan number from the last return/report.
a Sponsor’s name
c Plan Name D
EFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI CDEFGHI

5a Total number of participants at the beginning of the plan year ................................................................................
b Total number of participants at the end of the plan year .........................................................................................
c Number of participants with account balances as of the end of the plan year (only defined contribution plans
complete this item) .................................................................................................................................................

X DFVC program

1b Three-digit
plan number
(PN) 

001

1c Effective date of plan
YYYY-MM-DD
2b Employer Identification Number
(EIN)
012345678
2c Sponsor’s telephone number
1234567890
2d Business code (see instructions)
123456

3b Administrator’s EIN
012345678
3c Administrator’s telephone number
1234567890

4b EIN012345678
012

4d PN

5a
5b

12345678
12345678

5c

d(1) Total number of active participants at the beginning of the plan year .................................................................. 5d(1)
d(2) Total number of active participants at the end of the plan year ........................................................................... 5d(2)
e Number of participants who terminated employment during the plan year with accrued benefits that were less
5e

than 100% vested .................................................................................................................................................
Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established.
Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return/report, including, if applicable, a Schedule
SB or Schedule MB completed and signed by an enrolled actuary, as well as the electronic version of this return/report, and to the best of my knowledge and
belief, it is true, correct, and complete.
SIGN
HERE
SIGN
HERE

Signature of plan administrator

Date

Enter name of individual signing as plan administrator

Signature of employer/plan sponsor

Date

Enter name of individual signing as employer or plan sponsor

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

Form 5500-SF (2017)
v.170203

Form 5500-SF 2017

Page 2

X Yes X No

6a Were all of the plan’s assets during the plan year invested in eligible assets? (See instructions.) .........................................................
b Are you claiming a waiver of the annual examination and report of an independent qualified public accountant (IQPA)

X Yes X No

under 29 CFR 2520.104-46? (See instructions on waiver eligibility and conditions.) ..............................................................................
If you answered “No” to either line 6a or line 6b, the plan cannot use Form 5500-SF and must instead use Form 5500.

c 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 III Financial Information
7 Plan Assets and Liabilities
a Total plan assets ....................................................................................7a
b Total plan liabilities .................................................................................7b
c Net plan assets (subtract line 7b from line 7a) ........................................7c
8 Income, Expenses, and Transfers for this Plan Year
a Contributions received or receivable from:
(1) Employers .......................................................................................
8a(1)
(2) Participants ......................................................................................
8a(2)
(3) Others (including rollovers)...............................................................
8a(3)

b Other income (loss) ................................................................................8b
c Total income (add lines 8a(1), 8a(2), 8a(3), and 8b) ...............................8c
d Benefits paid (including direct rollovers and insurance premiums
to provide benefits) .................................................................................8d

e
f
g
h
i
j

Certain deemed and/or corrective distributions (see instructions) ...........8e
Administrative service providers (salaries, fees, commissions) ...............8f
Other expenses ......................................................................................8g

(a) Beginning of Year

(b) End of Year

-123456789012345
-123456789012345
-123456789012345

-123456789012345
123456789012345
-123456789012345

(a) Amount

(b) Total

-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345

Total expenses (add lines 8d, 8e, 8f, and 8g) .........................................8h
Net income (loss) (subtract line 8h from line 8c) .....................................8i
Transfers to (from) the plan (see instructions).........................................8j

-123456789012345

Part IV Plan Characteristics
9a If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristic Codes in the instructions:
b If the plan provides welfare benefits, enter the applicable welfare feature codes from the List of Plan Characteristic Codes in the instructions:
Part V
Compliance Questions
10 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? (See instructions and DOL’s Voluntary Fiduciary Correction
Program) ............................................................................................................................................
10a

b Were there any nonexempt transactions with any party-in-interest? (Do not include transactions

Yes

No

Amount

-123456789012345

10b
reported on line 10a.) ...........................................................................................................................

-123456789012345

c Was the plan covered by a fidelity bond? ............................................................................................
10c

-123456789012345

d Did the plan have a loss, whether or not reimbursed by the plan’s fidelity bond, that was caused
10d
by fraud or dishonesty? ........................................................................................................................

-123456789012345

e Were any fees or commissions paid to any brokers, agents, or other persons by an insurance
carrier, insurance service, or other organization that provides some or all of the benefits under
10e
the plan? (See instructions.) .................................................................................................................

-123456789012345

f Has the plan failed to provide any benefit when due under the plan? ..................................................10f

-123456789012345

g Did the plan have any participant loans? (If “Yes,” enter amount as of year-end.) ................................
10g
h If this is an individual account plan, was there a blackout period? (See instructions and 29 CFR
2520.101-3.) ........................................................................................................................................
10h

i

If 10h was answered “Yes,” check the box if you either provided the required notice or one of the
10i
exceptions to providing the notice applied under 29 CFR 2520.101-3 ..................................................

-123456789012345

Form 5500-SF 2017

Page 3-

1

x

Part VI Pension Funding Compliance
11 Is this a defined benefit plan subject to minimum funding requirements? (If "Yes," see instructions and complete Schedule SB
(Form 5500) and line 11a below) .............................................................................................................................................................

X Yes X No

11a Enter the unpaid minimum required contributions for all years from Schedule SB (Form 5500) line 40 ..........................................
11a
12 Is this a defined contribution plan subject to the minimum funding requirements of section 412 of the Code or section 302 of
a

X Yes X No
ERISA? ...................................................................................................................................................................................................
(If "Yes," complete line 12a or lines 12b, 12c, 12d, and 12e below, as applicable.)
If a waiver of the minimum funding standard for a prior year is being amortized in this plan year, see instructions, and enter the date of the letter ruling
granting the waiver. ............................................................................................................................. Month _______ Day _______ Year ________

If you completed line 12a, complete lines 3, 9, and 10 of Schedule MB (Form 5500), and skip to line 13.

b Enter the minimum required contribution for this plan year ............................................................................................. 12b

123456789012345

c Enter the amount contributed by the employer to the plan for this plan year ................................................................... 12c
d Subtract the amount in line 12c from the amount in line 12b. Enter the result (enter a minus sign to the left of a
12d

-123456789012345

negative amount) ..........................................................................................................................................................

e Will the minimum funding amount reported on line 12d be met by the funding deadline? ......................................................X Yes

YYYY-MM-DD
X No

X N/A

Part VII Plan Terminations and Transfers of Assets
X Yes
X No
13a Has a resolution to terminate the plan been adopted in any plan year? ......................................................................................................................................
13a
If “Yes,” enter the amount of any plan assets that reverted to the employer this year ..........................................................................................................

b Were all the plan assets distributed to participants or beneficiaries, transferred to another plan, or brought under the
control of the PBGC? .................................................................................................................................................................

X Yes X No

c 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.)
13c(1) Name of plan(s):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

13c(2) EIN(s)

123456789

13c(3) PN(s)

012