2017 Schedule G (F 2017 Schedule G (Form 5500) - Financial Transaction Sche

Annual Information Return/Report

170203 Clean Sch G

Annual Information Return/Report

OMB: 1212-0057

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1212-0057 can be found here:
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SCHEDULE G

OMB No. 1210-0110

Financial Transaction Schedules

(Form 5500)
Department of Treasury
Internal Revenue Service

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).

2017

 File as an attachment to Form 5500.

This Form is Open to Public
Inspection.

Department of Labor
Employee Benefits Security Administration

For calendar plan year 2017 or fiscal plan year beginning

and ending

A Name of plan
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
Part I

B Three-digit
plan number (PN)



001

D Employer Identification Number (EIN)
012345678

Schedule of Loans or Fixed Income Obligations in Default or Classified as Uncollectible
Complete as many entries as needed to report all loans or fixed income obligations in default or classified as uncollectible. Check box (a) if obligor
is known to be a party in interest. Attach Overdue Loan Explanation for each loan listed. See Instructions.

(a)

X

(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

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

Amount received during reporting year
(d) Original amount of
loan

(e) Principal

(f) Interest

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345 123456789012345
(a)

X

(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

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

Amount received during reporting year
(d) Original amount of
loan

(e) Principal

(f) Interest

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345
(a)

X

(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

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

Amount received during reporting year
(d) Original amount of
loan

(e) Principal

(f) Interest

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345 123456789012345
For Paperwork Reduction Act Notice, see the Instructions for Form 5500.

Schedule G (Form 5500) 2017
v. 170203

Page 2

Schedule G (Form 5500)2017
(a)

X

(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

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

- 1 x

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

Amount received during reporting year
(d) Original amount of
loan

(e) Principal

(f) Interest

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345 123456789012345
(a)

X

(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

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

Amount received during reporting year
(d) Original amount of
loan

(e) Principal

(f) Interest

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345 123456789012345
(a)

X

(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

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

Amount received during reporting year
(d) Original amount of
loan

(e) Principal

(f) Interest

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345 123456789012345
(a)

X

(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

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

Amount received during reporting year
(d) Original amount of
loan

(e) Principal

(f) Interest

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345 123456789012345
(a)

X

(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

(b) Identity and address of obligor

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCD
ABCD
ABCD
ABCD
ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDE

Amount received during reporting year
(d) Original amount of
loan

(e) Principal

(f) Interest

Amount overdue
(g) Unpaid balance at end
of year

(h) Principal

(i) Interest

123456789012345 123456789012345 123456789012345 123456789012345 123456789012345 123456789012345

Page 3

Schedule G (Form 5500) 2017

Part II

(a)

X

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)
(c) Relationship to plan, employer,
(d) Terms and description (type of property, location and date it was
(b) Identity of lessor/lessee
employee organization, or other
purchased, terms regarding rent, taxes, insurance, repairs,
party-in-interest
expenses, renewal options, date property was leased)

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

(e) Original cost

123456789012345
(a)

X

X

(a)

X

(a)

X

(a)

X

(h) Expenses paid during
the plan year

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD
(g) Gross rental receipts
during the plan year

(c) Relationship to plan, employer,
employee organization, or other
party-in-interest

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD
(g) Gross rental receipts
during the plan year

(c) Relationship to plan, employer,
employee organization, or other
party-in-interest

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

(f) Current value at time of
lease

(g) Gross rental receipts
during the plan year

123456789012345 123456789012345

(i) Net receipts

(j) Amount in arrears

123456789012345 123456789012345

(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)

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCD
(h) Expenses paid during
the plan year

(i) Net receipts

(j) Amount in arrears

123456789012345 123456789012345

(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)

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCD
(h) Expenses paid during
the plan year

(i) Net receipts

(j) Amount in arrears

123456789012345 123456789012345

(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)

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCD
(h) Expenses paid during
the plan year

123456789012345 123456789012345 123456789012345

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

123456789012345

(g) Gross rental receipts
during the plan year

(c) Relationship to plan, employer,
employee organization, or other
party-in-interest

(f) Current value at time of
lease

(b) Identity of lessor/lessee

(e) Original cost

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

(j) Amount in arrears

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCD

123456789012345 123456789012345 123456789012345

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

123456789012345

(c) Relationship to plan, employer,
employee organization, or other
party-in-interest

(f) Current value at time of
lease

(b) Identity of lessor/lessee

(e) Original cost

(g) Gross rental receipts
during the plan year

(i) Net receipts

(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)

123456789012345 123456789012345 123456789012345

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

123456789012345

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

(f) Current value at time of
lease

(b) Identity of lessor/lessee

(e) Original cost

(h) Expenses paid during
the plan year

123456789012345 123456789012345 123456789012345

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

123456789012345

(c) Relationship to plan, employer,
employee organization, or other
party-in-interest

(f) Current value at time of
lease

(b) Identity of lessor/lessee

(e) Original cost

(g) Gross rental receipts
during the plan year

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCD

123456789012345 123456789012345 123456789012345

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

123456789012345

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

(f) Current value at time of
lease

(b) Identity of lessor/lessee

(e) Original cost

(a)

- 1 x

(i) Net receipts

(j) Amount in arrears

123456789012345 123456789012345

(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)

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCD
(h) Expenses paid during
the plan year

123456789012345 123456789012345 123456789012345

(i) Net receipts

(j) Amount in arrears

123456789012345 123456789012345

Page 4

Schedule G (Form 5500) 2017

Part III

- 1 x

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.
(b) Relationship to plan, employer, (c) Description of transaction including maturity date,
(a) Identity of party involved
(d) Purchase price
or other party-in-interest
rate of interest, collateral, par or maturity value

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

(e) Selling price

123456789012345

(f) Lease rental

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(g) Transaction expenses

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCD

(h) Cost of asset

(i) Current value of
asset

123456789012345

(j) Net gain (or loss) on
each transaction

123456789012345 123456789012345 123456789012345 12345678901235 -1234567890123455

(a) Identity of party involved

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI ABCD
(e) Selling price

(a) Identity of party involved

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI ABCD
(e) Selling price

(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

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(f) Lease rental

(g) Transaction expenses

(b) Relationship to plan, employer,
or other party-in-interest

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

(f) Lease rental

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCD

(h) Cost of asset

(i) Current value of
asset

(c) Description of transaction including maturity date,
rate of interest, collateral, par or maturity value

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(g) Transaction expenses

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCD

(h) Cost of asset

(i) Current value of
asset

(d) Purchase price

123456789012345

(j) Net gain (or loss) on
each transaction

(d) Purchase price

123456789012345

(j) Net gain (or loss) on
each transaction

123456789012345 123456789012345 123456789012345 123456789012345 12345678901235 -1234567890123455
(a) Identity of party involved

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI ABCD
(e) Selling price

(a) Identity of party involved

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI ABCD
(e) Selling price

(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

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(f) Lease rental

(g) Transaction expenses

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCD

(h) Cost of asset

(i) Current value of
asset

(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

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(f) Lease rental

(g) Transaction expenses

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCD

(h) Cost of asset

(i) Current value of
asset

(d) Purchase price

123456789012345

(j) Net gain (or loss) on
each transaction

(d) Purchase price

123456789012345

(j) Net gain (or loss) on
each transaction

123456789012345 123456789012345 123456789012345 123456789012345 12345678901235 -1234567890123455
(a) Identity of party involved

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI ABCD
(e) Selling price

(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

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCD

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

(f) Lease rental

(g) Transaction expenses

ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
ABCD

(h) Cost of asset

(i) Current value of
asset

(d) Purchase price

123456789012345

(j) Net gain (or loss) on
each transaction

123456789012345 123456789012345 123456789012345 123456789012345 12345678901235 -1234567890123455
File Type	application/pdf
File Title	Form 5500
Author	Bruce Silver
File Modified	2017-03-27
File Created	2017-03-27