Sch H (Form 5500) Financial Information

Annual Return/Report of Employee Benefit Plan

201209 Sch H Clean

Annual Return/Report of Employee Benefit Plan

OMB: 1545-1610

Document [docx]
Download: docx | pdf
SCHEDULE H

(Form 5500)

Department of the Treasury

Department of the Treasury

Internal Revenue Service

Department of Labor
Employee Benefits Security Administration

Pension Benefit Guaranty Corporation

Financial Information


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).

File as an attachment to Form 5500.

OMB No. 1210-0110


2021


This Form is Open to Public Inspection

For calendar plan year 2021 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

B Three-digit
plan number (PN)

001


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

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

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

a Total noninterest-bearing cash

1a

-123456789012345

-123456789012345

b Receivables (less allowance for doubtful accounts):




(1) Employer contributions

1b(1)

-123456789012345

-123456789012345

(2) Participant contributions

1b(2)

-123456789012345

-123456789012345

(3) Other

1b(3)

-123456789012345

-123456789012345

c General investments:




(1) Interest-bearing cash (include money market accounts & certificates
of deposit)

1c(1)

-123456789012345

-123456789012345

(2) U.S. Government securities

1c(2)

-123456789012345

-123456789012345

(3) Corporate debt instruments (other than employer securities):




(A) Preferred

1c(3)(A)

-123456789012345

-123456789012345

(B) All other

1c(3)(B)

-123456789012345

-123456789012345

(4) Corporate stocks (other than employer securities):




(A) Preferred

1c(4)(A)

-123456789012345

-123456789012345

(B) Common

1c(4)(B)

-123456789012345

-123456789012345

(5) Partnership/joint venture interests

1c(5)

-123456789012345

-123456789012345

(6) Real estate (other than employer real property)

1c(6)

-123456789012345

-123456789012345

(7) Loans (other than to participants)

1c(7)

-123456789012345

-123456789012345

(8) Participant loans

1c(8)

-123456789012345

-123456789012345

(9) Value of interest in common/collective trusts

1c(9)

-123456789012345

-123456789012345

(10) Value of interest in pooled separate accounts

1c(10)

-123456789012345

-123456789012345

(11) Value of interest in master trust investment accounts

1c(11)

-123456789012345

-123456789012345

(12) Value of interest in 103-12 investment entities

1c(12)

-123456789012345

-123456789012345

(13) Value of interest in registered investment companies (e.g., mutual

funds)

1c(13)

-123456789012345

-123456789012345

(14) Value of funds held in insurance company general account (unallocated contracts)

1c(14)

-123456789012345

-123456789012345

(15) Other

1c(15)

-123456789012345

-123456789012345


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

Schedule H (Form 5500) 2021

v. 201209




1d Employer-related investments:


(a) Beginning of Year

(b) End of Year

(1) Employer securities

1d(1)

-123456789012345

-123456789012345

(2) Employer real property

1d(2)

-123456789012345

-123456789012345

1e Buildings and other property used in plan operation

1e

-123456789012345

-123456789012345

1f Total assets (add all amounts in lines 1a through 1e)

1f

-123456789012345

-123456789012345

Liabilities




1g Benefit claims payable

1g

-123456789012345

-123456789012345

1h Operating payables

1h

-123456789012345

-123456789012345

1i Acquisition indebtedness

1i

-123456789012345

-123456789012345

1j Other liabilities

1j

-123456789012345

-123456789012345

1k Total liabilities (add all amounts in lines 1g through1j)

1k

-123456789012345

-123456789012345

Net Assets




1l Net assets (subtract line 1k from line 1f)

1l

-123456789012345

-123456789012345


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)

-123456789012345


(B) Participants

2a(1)(B)

-123456789012345

(C) Others (including rollovers)

2a(1)(C)

-123456789012345

(2) Noncash contributions

2a(2)

-123456789012345

(3) Total contributions. Add lines 2a(1)(A), (B), (C), and line 2a(2)

2a(3)


-123456789012345

b Earnings on investments:




(1) Interest:


(A) Interest-bearing cash (including money market accounts and certificates of deposit)

2b(1)(A)

-123456789012345


(B) U.S. Government securities

2b(1)(B)

-123456789012345


(C) Corporate debt instruments

2b(1)(C)

-123456789012345

(D) Loans (other than to participants)

2b(1)(D)

-123456789012345

(E) Participant loans

2b(1)(E)

-123456789012345

(F) Other

2b(1)(F)

-123456789012345

(G) Total interest. Add lines 2b(1)(A) through (F)

2b(1)(G)


-123456789012345

(2) Dividends: (A) Preferred stock

2b(2)(A)

-123456789012345


(B) Common stock

2b(2)(B)

-123456789012345

(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)


-123456789012345

(3) Rents

2b(3)

-123456789012345

(4) Net gain (loss) on sale of assets: (A) Aggregate proceeds

2b(4)(A)

-123456789012345


(B) Aggregate carrying amount (see instructions)

2b(4)(B)

-123456789012345


(C) Subtract line 2b(4)(B) from line 2b(4)(A) and enter result

2b(4)(C)


-123456789012345

(5) Unrealized appreciation (depreciation) of assets: (A) Real estate

2b(5)(A)



(B) Other

2b(5)(B)



(C) Total unrealized appreciation of assets.
Add lines
2b(5)(A) and (B)

2b(5)(C)










(a) Amount

(b) Total

(6) Net investment gain (loss) from common/collective trusts

2b(6)


123456789012345

(7) Net investment gain (loss) from pooled separate accounts

2b(7)


-123456789012345-123456789012345

(8) Net investment gain (loss) from master trust investment accounts

2b(8)


-123456789012345-123456789012345

(9) Net investment gain (loss) from 103-12 investment entities

2b(9)


-123456789012345-123456789012345

(10) Net investment gain (loss) from registered investment
companies (e.g., mutual funds)

2b(10)


-123456789012345-123456789012345

c Other income

2c


-123456789012345

d Total income. Add all income amounts in column (b) and enter total

2d



Expenses




e Benefit payment and payments to provide benefits:




(1) Directly to participants or beneficiaries, including direct rollovers

2e(1)

-123456789012345



(2) To insurance carriers for the provision of benefits

2e(2)

-123456789012345

(3) Other

2e(3)

-123456789012345

(4) Total benefit payments. Add lines 2e(1) through (3)

2e(4)



f Corrective distributions (see instructions)

2f


g Certain deemed distributions of participant loans (see instructions)

2g


h Interest expense

2h


i Administrative expenses: (1) Professional fees

2i(1)

-123456789012345


(2) Contract administrator fees

2i(2)

-123456789012345

(3) Investment advisory and management fees

2i(3)

-123456789012345

(4) Other

2i(4)

-123456789012345

(5) Total administrative expenses. Add lines 2i(1) through (4)

2i(5)


-123456789012345

j Total expenses. Add all expense amounts in column (b) and enter total

2j


-123456789012345

Net Income and Reconciliation




k Net income (loss). Subtract line 2j from line 2d

2k



l Transfers of assets:




(1) To this plan

2l(1)

-123456789012345

(2) From this plan

2l(2)

-123456789012345


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 Unmodified (2) X Qualified (3) X Disclaimer (4) X Adverse

b Check the appropriate box(es) to indicate whether the IQPA performed an ERISA section 103(a)(3)(C) audit. Check both boxes (1) and (2) if the audit was performed pursuant to both 29 CFR 2520.103-8 and 29 CFR 2520.103-12(d). Check box (3) if pursuant to neither.

(1) X DOL Regulation 2520.103-8 (2) X DOL Regulation 2520.103-12(d) (3) X neither DOL Regulation 2520.103-8 nor DOL Regulation 2520.103-12(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.

During the plan year:


Yes

No

Amount

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












Yes

No

Amount

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




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



-123456789012345

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



-123456789012345

e Was this plan covered by a fidelity bond?

4e



-123456789012345

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





4f



-123456789012345

g 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



-123456789012345

h 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



-123456789012345

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




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





4k




l Has the plan failed to provide any benefit when due under the plan?

4l



-123456789012345

m If this is an individual account plan, was there a blackout period? (See instructions and 29 CFR 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)

5b(2) EIN(s)

5b(3) PN(s)


123456789

123

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

123456789

123

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

123456789

123

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFHI

123456789

123

5c Was the plan a defined benefit plan covered under the PBGC insurance program at any time during this plan year? (See ERISA section 4021 and instructions.) ………………………………………………………………………………………………………….. 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 ____________________.



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title2020 Sch H
AuthorBruce Silver
File Modified0000-00-00
File Created2021-03-31

© 2024 OMB.report | Privacy Policy