Annual Return/Report of Employee Benefit Plan

2021 Form 5500 Instructions Clean

Annual Return/Report of Employee Benefit Plan

OMB: 1545-1610

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2024-04-15 - No material or nonsubstantive change to a currently approved collection
2023-08-31 - No material or nonsubstantive change to a currently approved collection

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Department of the Treasury Department of Labor Pension Benefit

Internal Revenue Service Employee Benefits Guaranty Corporation

Security Administration

2021

Instructions for Form 5500

Annual Return/Report of Employee Benefit Plan

Code section references are to the Internal Revenue Code unless otherwise noted. ERISA refers to the Employee Retirement Income Security Act of 1974.

EFAST2 Processing System

Under the computerized ERISA Filing Acceptance System (EFAST2), you must electronically file your 2021 Form 5500. Your Form 5500 entries will be initially screened electronically. For more information, see the instructions for Electronic Filing Requirement and the EFAST2 website at www.efast.dol.gov. You cannot file a paper Form 5500 by mail or other delivery service.

_{About
the Form 5500}

The Form 5500, Annual Return/Report of Employee Benefit Plan, including all required schedules and attachments (Form 5500 return/report), is used to report information concerning employee benefit plans and Direct Filing Entities (DFEs). Any administrator or sponsor of an employee benefit plan subject to ERISA must file information about each benefit plan every year (pursuant to Code section 6058 and ERISA sections 104 and 4065). Some plans participate in certain trusts, accounts, and other investment arrangements that file a Form 5500 Annual Return/Report as DFEs. See Who Must File and When To File.

The Internal Revenue Service (IRS), Department of Labor (DOL), and Pension Benefit Guaranty Corporation (PBGC) have consolidated certain returns and report forms to reduce the filing burden for plan administrators and employers. Employers and administrators who comply with the instructions for the Form 5500 generally will satisfy the annual reporting requirements for the IRS and DOL.

Defined contribution and defined benefit pension plans may have to file additional information with the IRS including Form 5330, Return of Excise Taxes Related to Employee Benefit Plans, Form 5310-A, Notice of Plan Merger or Consolidation, Spinoff, or Transfer of Plan Assets or Liabilities; Notice of Qualified Separate Lines of Business, and Form 8955-SSA, Annual Registration Statement Identifying Separated Participants with Deferred Vested Benefits. See www.irs.gov for more information.

Plans covered by the PBGC have special additional requirements, including premiums and reporting certain transactions directly with that agency. See PBGC’s website (www.pbgc.gov/practitioners/) for information on premium payments and reporting and disclosure.

Each Form 5500 must accurately reflect the characteristics and operations that applied during the reporting year of the plan or arrangement. The requirements for completing the Form 5500 will vary according to the type of plan or arrangement. The section What To File summarizes what information must be reported for different types of plans and arrangements. The Quick Reference Chart of Form 5500, Schedules and Attachments, gives a brief guide to the annual return/report requirements of the 2021 Form 5500. See also the “Troubleshooters Guide to Filing the ERISA Annual Reports” available on www.dol.gov/ebsa, which is intended to help filers comply with the Form 5500 and Form 5500-SF annual reporting requirements and avoid common reporting errors.

The Form 5500 must be filed electronically as noted above. See Section 3 – Electronic Filing Requirement and the EFAST2 website at www.efast.dol.gov. Your Form 5500 entries will be initially screened electronically. Your entries must satisfy this screening for your filing to be received. Once received, your form may be subject to further detailed review, and your filing may be rejected based upon this further review.

ERISA and the Code provide for the assessment or imposition of penalties for not submitting the required information when due. See Penalties.

Annual reports filed under Title I of ERISA must be made available by plan administrators to plan participants and beneficiaries and by the DOL to the public pursuant to ERISA sections 104 and 106. Pursuant to Section 504 of the Pension Protection Act of 2006 (PPA) Pub. L. 109-280, this availability for defined benefit pension plans must include the posting of identification and basic plan information and actuarial information (Form 5500, Schedule SB or MB, and all of the Schedule SB or MB attachments) on any plan sponsor intranet website (or website maintained by the plan administrator on behalf of the plan sponsor) that is used for the purpose of communicating with employees and not the public. Section 504 also requires DOL to display such information on DOL’s website within 90 days after the filing of the plan’s annual return/report. To see plan year 2009 and later Forms 5500, including actuarial information, see www.dol.gov/ebsa. See www.dol.gov/ebsa/actuarialsearch.html for 2008 and short plan year 2009 actuarial information filed under the previous paper-based system.

_{Changes
to Note}

Retroactively adopted plan permitted by SECURE Act section 201. New Checkbox E is added to Part I for a plan sponsor who adopted the plan in the 2021 plan year and treated the plan as being adopted and effective in the 2020 plan year pursuant to SECURE Act section 201. For defined benefit plans in this category, the 2021 instructions provide information about how to report data regarding 2020 funding requirements (i.e., Schedule SB data).

Administrative Penalties. The instructions have been updated to reflect an increase to $2,259 per day in the maximum civil penalty amount assessable under Employee Retirement Income Security Act section 502(c)(2), as required by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015. The increased penalty under section 502(c)(2) is applicable for civil penalties assessed after Jan. 15, 2021, whose associated violation(s) occurred after Nov. 2, 2015. (86 FR 2964 (January 14, 2021)).

Schedule MB. A new line 3(d) has been added to require a multiemployer defined benefit plan to report the amount of withdrawal liability payments that is included in line 3(b) employer contributions.

Schedule SB. Line 6 is broken down into new lines 6a, 6b, and 6c requiring that the target normal cost and expected plan-related expenses be reported separately. Line 6a reports the present value of current plan year accruals decreased by any mandatory employee contributions. Line 6b reports expected plan-related expenses, and line 6c reports the sum of lines 6a and 6b. Line 31a makes a conforming change to reflect that it is total target normal cost as reported on line 6c.

Table of Contents Page

Section 1: Who Must File 2

Pension Benefit Plan 2

Welfare Benefit Plan 3

Direct Filing Entity (DFE) 4

Section 2: When To File 4

Extension of Time To File 4

Section 3: Electronic Filing Requirement 5

Amended Return/Report 6

Final Return/Report 6

Signature and Date 6

Change in Plan Year 7

Penalties 7

Administrative Penalties 7

Other Penalties 7

Section 4: What To File 7

Form 5500 Schedules 8

Pension Schedules 8

General Schedules 8

Pension Benefit Plan Filing Requirements 8

Limited Pension Plan Reporting 9

Welfare Benefit Plan Filing Requirements 9

Direct Filing Entity (DFE) Filing Requirements 10

Master Trust Investment Account (MTIA) 10

Common/Collective Trust (CCT) and Pooled
Separate Account (PSA) 10

103-12 Investment Entity (103-12 IE) 11

Group Insurance Arrangement (GIA) 11

Quick Reference Chart of Form 5500, Schedules, and
Attachments 12

Section 5: Line-by-Line Instructions for the 2021
Form 5500 and Schedules 14

Part I (Form 5500) – Annual Return/Report Identification Information 14

Part II (Form 5500) – Basic Plan Information 15

M-1 Compliance Information 18

Schedule A – Insurance Information 21

Schedule C – Service Provider Information 24

Schedule D – DFE/Participating Plan Information 29

Schedule G – Financial Transaction Schedules 31

Schedule H – Financial Information 33

Schedule I – Financial Information – Small Plan 43

Schedule MB – Multiemployer Defined Benefit Plan and
Certain Money Purchase Plan Actuarial
Information 51

Schedule R – Retirement Plan Information 58

Schedule SB – Single-Employer Defined Benefit Plan
Actuarial Information 63

Paperwork Reduction Act Notice 77

Codes for Principal Business Activity 78

ERISA Compliance Quick Checklist 81

Index 82

How To Get Assistance

If you need help completing this form or have related questions, call the EFAST2 Help Desk at 1-866-GO-EFAST

(1-866-463-3278) (toll-free) or access the EFAST2 or IRS websites. The EFAST2 Help Desk is available Monday through Friday from 8:00 am to 8:00 pm, Eastern Time.

You can access the EFAST2 website 24 hours a day, 7 days a week at www.efast.dol.gov to:

 File the Form 5500-SF or 5500, and any needed schedules or attachments.

 Check on the status of a filing you submitted.

 View filings posted by EFAST2.

 Register for electronic credentials to sign or submit filings.

 View forms and related instructions.

 Get information regarding EFAST2, including approved software vendors.

 See answers to frequently asked questions about the Form 5500-SF, the Form 5500 and its schedules, and EFAST2.

 Access the main EBSA and DOL websites for news, regulations, and publications.

You can access the IRS website 24 hours a day, 7 days a week at www.irs.gov to:

 View forms, instructions, and publications.

 See answers to frequently asked tax questions.

 Search publications on-line by topic or keyword.

 Send comments or request help by e-mail.

 Sign up to receive local and national tax news by e-mail.

You can order other IRS forms and publications at http://www.irs.gov/orderforms. You can order EBSA publications by calling 1-866-444-EBSA (3272).

Section 1: Who Must File

A return/report must be filed every year for every pension benefit plan, welfare benefit plan, and for every entity that files as a DFE as specified below (pursuant to Code section 6058 and ERISA sections 104 and 4065).

If you are a small plan (generally under 100 participants at the beginning of the plan year), you may be eligible to file the Form 5500-SF instead of the Form 5500. For more information, see the instructions to the Form 5500-SF.

Pension Benefit Plan

All pension benefit plans covered by ERISA must file an annual return/report except as provided in this section. The return/ report must be filed whether or not the plan is “tax-qualified,” benefits no longer accrue, contributions were not made this plan year, or contributions are no longer made. Pension benefit plans required to file include both defined benefit plans and defined contribution plans.

The following are among the pension benefit plans for which a return/report must be filed.

1. Profit-sharing plans, stock bonus plans, money purchase plans, 401(k) plans, etc.

2. Annuity arrangements under Code section 403(b)(1) and custodial accounts established under Code section 403(b)(7) for regulated investment company stock. For more information regarding filing requirements for 403(b) plans subject to Title I of ERISA, see Field Assistance Bulletins 2009-02 and 2010-01.

3. Individual retirement accounts (IRAs) established by an employer under Code section 408(c).

4. Church pension plans electing coverage under Code section 410(d).

5. Pension benefit plans that cover residents of Puerto Rico, the U.S. Virgin Islands, Guam, Wake Island, or American Samoa. This includes a plan that elects to have the provisions of section 1022(i)(2) of ERISA apply.

6. Plans that satisfy the Actual Deferral Percentage requirements of Code section 401(k)(3)(A)(ii) by adopting the ‘‘SIMPLE’’ provisions of section 401(k)(11).

See What To File for more information about what must be completed for pension plans.

Do Not File a Form 5500 for a Pension Benefit Plan That Is Any of the Following:

1. An unfunded excess benefit plan. See ERISA section 4(b)(5).

2. An annuity or custodial account arrangement under Code sections 403(b)(1) or (7) not established or maintained by an employer as described in DOL Regulation 29 CFR 2510.3-2(f).

3. A Savings Incentive Match Plan for Employees of Small Employers (SIMPLE) that involves SIMPLE IRAs under Code section 408(p).

4. A simplified employee pension (SEP) or a salary reduction SEP described in Code section 408(k) that conforms to the alternative method of compliance in 29 CFR 2520.104-48 or 2520.104-49. A SEP is a pension plan that meets certain minimum qualifications regarding eligibility and employer contributions.

5. A church pension benefit plan not electing coverage under Code section 410(d).

6. A pension plan that is maintained outside the United States primarily for the benefit of persons substantially all of whom are nonresident aliens. However, certain foreign plans are required to file the Form 5500-EZ on paper with the IRS or electronically with EFAST2. A foreign plan must file the Form 5500-EZ electronically with EFAST2 instead of filing a paper Form 5500-EZ with the IRS, if the filer is required to file at least 250 returns of any type with the IRS during the calendar year, including information returns (for example, Forms W-2 and Forms 1099), income tax returns, employment tax returns, and excise tax returns. For more information on filing Form 5500-EZ, see the Instructions for Form 5500-EZ, or go to www.irs.gov.

7. An unfunded pension plan for a select group of management or highly compensated employees that meets the requirements of 29 CFR 2520.104-23, including timely filing of a registration statement with the DOL.

8. An unfunded dues financed pension benefit plan that meets the alternative method of compliance provided by 29 CFR 2520.104-27.

9. An individual retirement account or annuity not considered a pension plan under 29 CFR 2510.3-2(d).

10. A governmental plan.

11. A “one-participant plan,” as defined below. However, certain one-participant plans are required to file the Form 5500-EZ, Annual Return of A One-Participant (Owners/Partners and Their Spouses) Retirement Plan or A Foreign Plan, on paper with the IRS or electronically with EFAST2. A one-participant plan must file the Form 5500-EZ electronically with EFAST2 instead of filing a paper Form 5500-EZ with the IRS, if the filer is required to file at least 250 returns of any type with the IRS during the calendar year, including information returns (for example, Forms W-2 and Forms 1099), income tax returns, employment tax returns, and excise tax returns. For more information on filing Form 5500-EZ, see the Instructions for Form 5500-EZ, or go to www.irs.gov. For this purpose, a “one-participant plan” is:

a. a pension benefit plan that covers only an individual or an individual and his or her spouse who wholly own a trade or business, whether incorporated or unincorporated; or

b. a pension benefit plan for a partnership that covers only the partners or the partners and the partners’ spouses (treating 2% shareholder of an S corporation, as defined in IRC §1372(b), as a partner).

See the instructions to the Form 5500-EZ for eligibility conditions and filing requirements. For more information, go to www.irs.gov/ep.

Welfare Benefit Plan

All welfare benefit plans covered by ERISA are required to file a Form 5500 except as provided in this section. Welfare benefit plans provide benefits such as medical, dental, life insurance, apprenticeship and training, scholarship funds, severance pay, disability, etc. See What To File for more information.

Reminder: The administrator of an employee welfare benefit plan that provides benefits wholly or partially through a Multiple-Employer Welfare Arrangement (MEWA) as defined in ERISA section 3(40) must file a Form 5500, unless otherwise exempt. Plans required to file a Form M-1, Report for Multiple-Employer Welfare Arrangements (MEWAs) and Certain Entities Claiming Exception (ECEs), are not eligible for the filing exemption in 29 CFR 2520.104-20 described below. Such plans are required to file the Form 5500 regardless of the plan size or type of funding.

Do Not File a Form 5500 for a Welfare Benefit Plan That Is Any of the Following:

1. A welfare benefit plan that covered fewer than 100 participants as of the beginning of the plan year and is unfunded, fully insured, or a combination of insured and unfunded, and which is not subject to the Form M-1 requirements under § 2520.101-2, as specified in 29 CFR 2520.104-20.

Note. To determine whether the plan covers fewer than 100 participants for purposes of these filing exemptions for insured and unfunded welfare plans, see instructions for lines 5 and 6 on counting participants in a welfare plan. See also 29 CFR 2510.3-3(d).

a. An unfunded welfare benefit plan has its benefits paid as needed directly from the general assets of the employer or employee organization that sponsors the plan.

Note. Plans that are NOT unfunded include those plans that received employee (or former employee) contributions during the plan year and/or used a trust or separately maintained fund (including a Code section 501(c)(9) trust) to hold plan assets or act as a conduit for the transfer of plan assets during the year. A welfare benefit plan with employee contributions that is associated with a cafeteria plan under Code section 125 may be treated for annual reporting purposes as an unfunded welfare plan if it meets the requirements of DOL Technical Release 92-01, 57 Fed. Reg. 23272 (June 2, 1992) and 58 Fed. Reg. 45359 (Aug. 27, 1993). The mere receipt of COBRA contributions or other after-tax participant contributions (e.g., retiree contributions) by a cafeteria plan would not by itself affect the availability of the relief provided for cafeteria plans that otherwise meet the requirements of DOL Technical Release 92-01. See 61 Fed. Reg. 41220, 41222-23 (Aug. 7, 1996).

b. A fully insured welfare benefit plan has its benefits provided exclusively through insurance contracts or policies, the premiums of which must be paid directly to the insurance carrier by the employer or employee organization from its general assets or partly from its general assets and partly from contributions by its employees or members (which the employer or employee organization forwards within three (3) months of receipt). The insurance contracts or policies discussed above must be issued by an insurance company or similar organization (such as Blue Cross, Blue Shield or a health maintenance organization) that is qualified to do business in any state.

c. A combination unfunded/insured welfare benefit plan has its benefits provided partially as an unfunded plan and partially as a fully insured plan. An example of such a plan is a welfare benefit plan that provides medical benefits as in a above and life insurance benefits as in b above. See 29 CFR 2520.104-20.

2. A welfare benefit plan maintained outside the United States primarily for persons substantially all of whom are nonresident aliens.

3. A governmental plan.

4. An unfunded or insured welfare benefit plan maintained for a select group of management or highly compensated employees, which meets the requirements of 29 CFR 2520.104-24.

5. An employee benefit plan maintained only to comply with workers’ compensation, unemployment compensation, or disability insurance laws.

6. A welfare benefit plan that participates in a group insurance arrangement that files a Form 5500 on behalf of the welfare benefit plan as specified in 29 CFR 2520.103-2. See 29 CFR 2520.104-43.

7. An apprenticeship or training plan meeting all of the conditions specified in 29 CFR 2520.104-22.

8. An unfunded dues financed welfare benefit plan exempted by 29 CFR 2520.104-26.

9. A church plan under ERISA section 3(33).

10. A welfare benefit plan maintained solely for (1) an individual or an individual and his or her spouse, who wholly own a trade or business, whether incorporated or unincorporated, or (2) partners or the partners and the partners’ spouses in a partnership. See 29 CFR 2510.3-3(b).

Direct Filing Entity (DFE)

Some plans participate in certain trusts, accounts, and other investment arrangements that file the Form 5500 Annual Return/Report as a DFE in accordance with the Direct Filing Entity (DFE) Filing Requirements. A Form 5500 must be filed for a master trust investment account (MTIA). A Form 5500 is not required but may be filed for a common/collective trust (CCT), pooled separate account (PSA), 103-12 investment entity (103-12 IE), or group insurance arrangement (GIA). Plans that participate in CCTs, PSAs, 103-12 IEs, or GIAs that file as DFEs, however, generally are eligible for certain annual reporting relief. For reporting purposes, a CCT, PSA,

103-12 IE, or GIA is not considered a DFE unless a Form 5500 and all required attachments are filed for it in accordance with the Direct Filing Entity (DFE) Filing Requirements.

Note. Special requirements also apply to Schedules D and H attached to the Form 5500 filed by plans participating in MTIAs, CCTs, PSAs, and 103-12 IEs. See these schedules and their instructions.

Section 2: When To File

Plans and GIAs. File 2021 returns/reports for plan and GIA years that began in 2021. All required forms, schedules, statements, and attachments must be filed by the last day of the 7th calendar month after the end of the plan or GIA year (not to exceed 12 months in length) that began in 2021. If the plan or GIA year differs from the 2021 calendar year, fill in the fiscal year beginning and ending dates in the space provided.

DFEs other than GIAs. File 2021 returns/reports no later than 9½ months after the end of the DFE year that ended in 2021. A Form 5500 filed for a DFE must report information for the DFE year (not to exceed 12 months in length). If the DFE year differs from the 2021 calendar year, fill in the fiscal year beginning and ending dates in the space provided.

Short Years. For a plan year of less than 12 months (short plan year), file the form and applicable schedules by the last day of the 7th calendar month after the short plan year ends or by the extended due date, if filing under an authorized extension of time. Fill in the short plan year beginning and ending dates in the space provided and check the appropriate box in Part I, line B, of the Form 5500. For purposes of this return/report, the short plan year ends on the date of the change in accounting period or upon the complete distribution of assets of the plan. Also see the instructions for Final Return/ Report to determine if “the final return/report” box in line B should be checked.

Notes. (1) If the filing due date falls on a Saturday, Sunday, or Federal holiday, the return/report may be filed on the next daythat is not a Saturday, Sunday, or Federal holiday. (2) If the 2021 Form 5500 is not available before the plan or DFE filing is due, use the 2021 Form 5500 and enter the 2021 fiscal year beginning and ending dates on the line provided at the top of the form.

Extension of Time To File Using Form 5558

A plan or GIA may obtain a one-time extension of time to file a Form 5500 Annual Return/Report (up to 2½ months) by filing IRS Form 5558, Application for Extension of Time To File Certain Employee Plan Returns, on or before the normal due date (not including any extensions) of the return/report. You MUST file Form 5558 with the IRS. Approved copies of the Form 5558 will not be returned to the filer. A copy of the completed extension request must, however, be retained withe the filer’s records.

File Form 5558 with the Department of the Treasury, Internal Revenue Service Center, Ogden, UT 84201-0045.

Using Extension of Time To File Federal Income Tax Return

An automatic extension of time to file the Form 5500 Annual Return/Report until the due date of the federal income tax return of the employer will be granted if all of the following conditions are met: (1) the plan year and the employer’s tax year are the same; (2) the employer has been granted an extension of time to file its federal income tax return to a date later than the normal due date for filing the Form 5500; and (3) a copy of the application for extension of time to file the federal income tax return is maintained with the filer’s records. An extension granted by using this automatic extension procedure CANNOT be extended further by filing a Form 5558, nor can it be extended beyond a total of 9½ months beyond the close of the plan year.

Note. A tax-exempt organization is not required to file a federal income tax return. However, if the organization uses a Form 8868 to request an extension for its Form 990 series return, the filer is automatically granted an extension of time to file the Form 5500 until the extended due date of filing Form 990 series if all conditions listed above are met. An extension granted by using this automatic extension procedure cannot be extended beyond a total of 9½ months beyond the close of the plan year.

Note. An extension of time to file the Form 5500 does not operate as an extension of time to file a Form 5500 filed for a DFE (other than a GIA), to file PBGC premiums or annual financial and actuarial reports (if required by section 4010 of ERISA) or to file the Form 8955-SSA (Annual Registration Statement Identifying Separated Participants with Deferred Vested Benefits) (required to be filed with the IRS under Code section 6057(a)).

Other Extensions of Time

The IRS, DOL, and PBGC may announce special extensions of time under certain circumstances, such as extensions for Presidentially-declared disasters or for service in, or in support of, the Armed Forces of the United States in a combat zone. See www.irs.gov, www.efast.dol.gov, and www.pbgc.gov/practitioners for announcements regarding such special extensions. If you are relying on one of these announced special extensions, check the appropriate box on Form 5500, Part I, line D, and enter a description of the announced authority for the extension.

Delinquent Filer Voluntary Compliance (DFVC) Program

The DFVC Program facilitates voluntary compliance by plan administrators who are delinquent in filing annual reports under Title I of ERISA by permitting administrators to pay reduced civil penalties for voluntarily complying with their DOL annual reporting obligations. If the Form 5500 is being filed under the DFVC Program, check the appropriate box in Form 5500, Part I, line D, to indicate that the Form 5500 is being filed under the DFVC Program. See www.efast.dol.gov for additional information.

Plan administrators are reminded that they can use the online calculator available at www.dol.gov/ebsa/calculator/dfvcpmain.html to compute the penalties due under the program. Payments under the DFVC Program also may be submitted electronically. For information on how to pay DFVC Program payments online, go to www.dol.gov/ebsa.

F ilers who wish to participate in the DFVC Program for plan years prior to 2020 must use the 2021 version of Form 5500 or, if applicable, Form 5500-SF. Use the Form 5500 Version Selection Tool available at www.efast.dol.gov for further information.

Section 3: Electronic Filing Requirement

Under the computerized ERISA Filing Acceptance System (EFAST2), you must file your 2021 Form 5500 Annual Return/ Report electronically. You may file online using EFAST2’s web-based filing system or you may file through an EFAST2-approved vendor. Detailed information on electronic filing is available at www.efast.dol.gov. For telephone assistance, call the EFAST2 Help Desk at 1-866-GO-EFAST (1-866-463-3278). The EFAST2 Help Desk is available Monday through Friday from 8:00 am to 8:00 pm, Eastern Time.

A nnual returns/reports filed under Title I of ERISA must be made available by plan administrators to plan participants and beneficiaries and by the DOL to the public pursuant to ERISA sections 104 and 106. Even though the Form 5500 must be filed electronically, the administrator must keep a copy of the Form 5500, including schedules and attachments, with all required signatures on file as part of the plan’s records and must make a paper copy available upon request to participants, beneficiaries, and the DOL as required by section 104 of ERISA and 29 CFR 2520.103-1. Filers may use electronic media for record maintenance and retention, so long as they meet the applicable requirements. (See 29 CFR 2520.107-1).

Note. Effective for plan years beginning after 2019, a one-participant plan or a foreign plan can file Form 5500-EZ electronically using the EFAST2 filing system. Information filed on Form 5500-EZ using EFAST2 is required to be made available to the public. However, information filed with EFAST2 using Form 5500-EZ will not be published on the internet.

Generally, questions on the Form 5500 relate to the plan year entered at the top of the first page of the form. Therefore, answer all questions on the 2021 Form 5500 with respect to the 2021 plan year unless otherwise explicitly stated in the instructions or on the form itself.

Your entries must be in the proper format in order for the EFAST2 system to process your filing. For example, if a question requires you to enter a dollar amount, you cannot enter a word. Your software will not let you submit your return/ report unless all entries are in the proper format. To reduce the possibility of correspondence and penalties:

 Complete all lines on the Form 5500 unless otherwise specified. Also complete and electronically attach, as required, applicable schedules and attachments.

 Do not enter “N/A” or “Not Applicable” on the Form 5500 unless specifically permitted. “Yes” or “No” questions on the forms and schedules cannot be left blank, unless specifically permitted. Answer either “Yes” or “No,” but not both.

All schedules and attachments to the Form 5500 must be properly identified, and must include the name of the plan or DFE, EIN, and plan number (PN) as found on the Form 5500, lines, 1a, 2b, and 1b, respectively. At the top of each attachment, indicate the schedule and line, if any (e.g., Schedule H, line 4i) to which the attachment relates.

Check your return/report for errors before signing or submitting it to EFAST2. Your filing software or, if you are using it, the EFAST2 web-based filing system will allow you to check your return/report for errors. If, after reasonable attempts to correct your filing to eliminate any identified problem or problems, you are unable to address them, or you believe that you are receiving the message in error, call the EFAST2 Help Desk at 1-866-GO-EFAST (1-866-463-3278) or contact the service provider you used to help prepare and file your annual return/report.

Once you complete the return/report and finish the electronic signature process, you can electronically submit it to EFAST2. When you electronically submit your return/report, EFAST2 is designed to immediately notify you if your submission was received and whether the return/report is ready to be processed by EFAST2. If EFAST2 does not notify you that your submission was successfully received and is ready to be processed, you will need to take steps to correct the problem or you may be deemed a non-filer subject to penalties from DOL, IRS, and/or PBGC.

Once EFAST2 receives your return/report, the EFAST2 system should be able to provide a filing status within 20 minutes. The person submitting the filing should check back into the EFAST2 system to determine the filing status of your return/report. The filing status message will include a list of any filing errors or warnings that EFAST2 may have identified in your filing. If EFAST2 did not identify any filing errors or warnings, EFAST2 will show the filing status of your return/ report as “Filing_Received.” Persons other than the submitter can check whether the filing was received by the system by calling the EFAST2 Help Desk at 1-866-GO-EFAST (1-866-463-3278) and using the automated telephone system.

To reduce the possibility of correspondence and penalties from the DOL, IRS, and/or PBGC, you should do the following: (1) Before submitting your return/report to EFAST2, check it for errors, and (2) after you have submitted it to EFAST2, verify that you have received a filing status of “Filing Received” and attempt to correct and resolve any errors or warnings listed in the status report.

Note. Even after being received by the EFAST2 system, your return/report filing may be subject to further detailed review by DOL, IRS, and/or PBGC, and your filing may be deemed deficient based upon this further review. See Penalties on Page 7.

D o not enter social security numbers in response to questions asking for an employer identification number (EIN). Because of privacy concerns, the inclusion of a social security number or any portion thereof on the Form 5500 or on a schedule or attachment that is open to public inspection may result in the rejection of the filing. If you discover a filing disclosed on the EFAST2 website that contains a social security number, immediately call the EFAST2 Help Desk at 1-866-GO-EFAST (1-866-463-3278).

Employers without an EIN must apply for one as soon as possible. The EBSA does not issue EINs. To apply for an EIN from the IRS:

 Mail or fax Form SS-4, Application for Employer Identification Number, obtained at http://www.irs.gov/orderforms.

 See https://www.IRS.gov/Businesses and click on “Employer ID Numbers” for additional information. The EIN is issued immediately once the application information is validated. (The online application process is not yet available for corporations with addresses in foreign countries or Puerto Rico.)

Do not attach a copy of the annual registration statement (IRS Form 8955-SSA) identifying separated participants with deferred vested benefits, or a previous year’s Schedule SSA (Form 5500) to your 2021 Form 5500 Annual Return/Report. The annual registration statement must be filed directly with the IRS and cannot be attached to a Form 5500 submission with EFAST2.

Amended Return/Report

File an amended return/report to correct errors and/or omissions in a previously filed annual return/report for the 2021 plan year. The amended Form 5500 and any amended schedules and/or attachments must conform to the requirements in these instructions. See the DOL website at www.efast.dol.gov for information on filing amended returns/ reports for prior years.

C heck the line B box for “an amended return/report” if you filed a previous 2021 annual return/report that was given a “Filing_Received,” “Filing_Error,” or “Filing_Stopped” status by EFAST2. Do not check the line B box for “an amended return/report” if your previous submission attempts were not successfully received by EFAST2 because of problems with the transmission of your return/report. For more information, go to the EFAST2 website at www.efast.dol.gov or call the EFAST2 Help Desk at 1-866-GO-EFAST (1-866-463-3278).

Final Return/Report

If all assets under the plan (including insurance/annuity contracts) have been distributed to the participants and beneficiaries or legally transferred to the control of another plan, and when all liabilities for which benefits may be paid under a welfare benefit plan have been satisfied, check the final return/report box in Part I, line B at the top of the Form 5500. Do not mark the final return/report box if you are reporting participants and/or assets at the end of the plan year. If a trustee is appointed for a terminated defined benefit plan pursuant to ERISA section 4042, the last plan year for which a return/report must be filed is the year in which the trustee is appointed. If you are in this situation you may contact [email protected] for further information.

Examples:

Mergers/Consolidations

A final return/report should be filed for the plan year (12 months or less) that ends when all plan assets were legally transferred to the control of another plan.

Pension and Welfare Plans That Terminated Without

Distributing All Assets

If the plan was terminated, but all plan assets were not distributed, a return/report must be filed for each year the plan has assets. The return/report must be filed by the plan administrator, if designated, or by the person or persons who actually control the plan’s assets/property.

Welfare Plans Still Liable To Pay Benefits

A welfare plan cannot file a final return/report if the plan is still liable to pay benefits for claims that were incurred prior to the termination date, but not yet paid. See 29 CFR 2520.104b-2(g)(2)(ii).

Signature and Date

For purposes of Title I of ERISA, the plan administrator is required to file the Form 5500. If the plan administrator does not sign a filing, the filing status will indicate that there is an error with your filing, and your filing will be subject to further review, correspondence, rejection, and civil penalties.

The plan administrator must electronically sign the Form 5500 or 5500-SF submitted to EFAST2.

A fter submitting your filing, you must check the Filing Status. If the filing status is "Processing Stopped" or “Unprocessable”, it is possible your submission was not sent with a valid electronic signature as required, and depending on the error, may be considered not to have been filed. By looking closer at the Filing Status, you can see specific error messages applicable to the transmitted filing and determine whether it was sent with a valid electronic signature and what other errors may need to be corrected.

Note. If the plan administrator is an entity, the electronic signature must be in the name of a person authorized to sign on behalf of the plan administrator.

Authorized Service Provider Signatures. A statement for service providers that use this electronic signature option is in the IFILE application. The statement provides that, by signing the electronic filing, the service provider is attesting: (1) that the service provider has been authorized in writing by the plan administrator, plan sponsor/employer, or DFE, as applicable, to electronically submit the return/report; (2) that a copy of the specific written authorization will be kept in the service provider’s records; (3) that, in addition to any other required schedules or attachments, the electronic filing includes a true and correct PDF copy of the completed Form 5500 (without schedules or attachments) bearing the manual signature of the plan administrator, employer/plan sponsor, or DFE, as applicable, under penalty of perjury; (4) that the service provider advised the plan administrator, employer/plan sponsor, or DFE, as applicable, that by selecting this electronic signature option, the image of the plan administrator’s, employer/plan sponsor’s, or DFE’s manual signature will be included with the rest of the return/report posted by the Department of Labor on the Internet for public disclosure; and (5) that the service provider will communicate to the plan administrator, employer/plan sponsor, or DFE, as applicable, any inquiries and information received from EFAST2, DOL, IRS or PBGC regarding the return/report.

Note. The Code permits either the plan sponsor/employer or the administrator to sign the filing. However, any Form 5500 that is not electronically signed by the plan administrator will be subject to rejection and civil penalties under Title I of ERISA.

For DFE filings, a person authorized to sign on behalf of the DFE must sign for the DFE.

The Form 5500 Annual Return/Report must be filed electronically and signed. To obtain an electronic signature, go to www.efast.dol.gov and register in EFAST2 as a signer. You will be provided with a UserID and PIN. Both the UserID and PIN are needed to sign the Form 5500. The plan administrator must keep a copy of the Form 5500, including schedules and attachments with all required signatures on file as part of the plan’s records. See 29 CFR 2520.103-1.

Electronic signatures on annual returns/reports filed under EFAST2 are governed by the applicable statutory and regulatory requirements.

Change in Plan Year

Generally, only defined benefit pension plans need to get approval for a change in the plan year. See Code section 412(d)(1). However, under Revenue Procedure 87-27, 1987-1 C.B. 769, these pension plans may be eligible for automatic approval of a change in plan year.

If a change in plan year for a pension or welfare benefit plan creates a short plan year, file the form and applicable schedules by the last day of the 7th calendar month after the short plan year ends or by the extended due date, if filing under an authorized extension of time. Fill in the short plan year beginning and ending dates in the space provided in Part I and check the appropriate box in Part I, line B of the Form 5500. For purposes of this return/report, the short plan year ends on the date of the change in accounting period or upon the complete distribution of assets of the plan. Also, see the instructions for the Final Return/Report to determine if “final return/report” in line B should be checked.

Penalties

Plan administrators and plan sponsors must provide complete and accurate information and must otherwise comply fully with the filing requirements. ERISA and the Code provide for the DOL and the IRS, respectively, to assess or impose penalties for not giving complete and accurate information and for not filing complete and accurate statements and returns/reports. Certain penalties are administrative (i.e., they may be imposed or assessed by one of the governmental agencies delegated to administer the collection of the annual return/report data). Others require a legal conviction.

Administrative Penalties

Listed below are various penalties under ERISA and the Code that may be assessed or imposed for not meeting the annual return/report filing requirements. Generally, whether the penalty is under ERISA or the Code, or both, depends upon the agency for which the information is required to be filed. One or more of the following administrative penalties may be assessed or imposed in the event of incomplete filings or filings received after the due date unless it is determined that your failure to file properly is for reasonable cause:

1. A penalty of up to $2,259 a day for each day a plan administrator fails or refuses to file a complete and accurate report. See ERISA section 502(c)(2), 29 CFR 2560.502c-2, and the Federal Civil Penalties Inflation Adjustment Act of 1990, as amended by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015 (2015 Inflation Adjustment Act). Pub. L. No. 114-74; 129 Stat. 599 and the DOL’s implementing regulation at 86 FR 2964 (Jan. 14, 2021). The 2015 Inflation Adjustment Act requires agencies to adjust the levels of civil monetary penalties with an initial catch-up adjustment, followed by annual adjustments for inflation. Because the Federal Civil Penalties Inflation Adjustment Improvements Act of 2015 (Pub. L. No. 114-74; 129 Stat. 599), requires the penalty amount to be adjusted annually after the Form 5500 and its schedules, attachments, and instructions are published for filing, be sure to check DOL’s website for any possible required inflation adjustments of the maximum penalty amount that may have been published in the Federal Register after the instructions have been posted.

2. A penalty of $250 a day (up to $150,000) for not filing returns for certain plans of deferred compensation, trusts and annuities, and bond purchase plans by the due date(s). See Code section 6652(e).

3. A penalty of $1,000 for each failure to file an actuarial statement (Schedule MB (Form 5500) or Schedule SB (Form 5500)) required by the applicable instructions. See Code section 6692.

Other Penalties

1. Any individual who willfully violates any provision of Part 1 of Title I of ERISA shall on conviction be fined not more than $100,000 or imprisoned not more than 10 years, or both. See ERISA section 501.

2. A penalty up to $10,000, five (5) years imprisonment, or both, may be imposed for making any false statement or representation of fact, knowing it to be false, or for knowingly concealing or not disclosing any fact required by ERISA. See section 1027, Title 18, U.S. Code, as amended by section 111 of ERISA.

Section 4: What To File

The Form 5500 reporting requirements vary depending on whether the Form 5500 is being filed for a ‘‘large plan,’’ a ‘‘small plan,’’ and/or a DFE, and on the particular type of plan or DFE involved (e.g., welfare plan, pension plan, common/collective trust (CCT), pooled separate account (PSA), master trust investment account (MTIA), 103-12 IE, or group insurance arrangement (GIA)).

The instructions below provide detailed information about each of the Form 5500 schedules and which plans and DFEs are required to file them.

The schedules are grouped in the instructions by type: (1) Pension Benefit Schedules and (2) General Schedules. Each schedule is listed separately with a description of the subject matter covered by the schedule and the plans and DFEs that are required to file the schedule.

Filing requirements also are listed by type of filer: (1) Pension Benefit Plan Filing Requirements; (2) Welfare Benefit Plan Filing Requirements; and (3) DFE Filing Requirements. For each filer type there is a separate list of the schedules that must be filed with the Form 5500 (including where applicable, separate lists for large plan filers, small plan filers, and different types of DFEs).

The filing requirements also are summarized in a “Quick Reference Chart of Form 5500, Schedules, and Attachments.”

Generally, a return/report filed for a pension benefit plan or welfare benefit plan that covered fewer than 100 participants as of the beginning of the plan year should be completed following the requirements below for a “small plan,” and a return/report filed for a plan that covered 100 or more participants as of the beginning of the plan year should be completed following the requirements below for a “large plan.”

Use the number of participants required to be entered in line 5 of the Form 5500 to determine whether a plan is a “small plan” or “large plan.”

Exceptions:

(1) 80-120 Participant Rule: If the number of participants reported on line 5 is between 80 and 120, and a Form 5500 Annual Return/Report was filed for the prior plan year, you may elect to complete the return/report in the same category (‘‘large plan’’ or ‘‘small plan’’) as was filed for the prior return/report. Thus, if a Form 5500-SF or a Form 5500 Annual Return/Report was filed for the 2020 plan year as a small plan, including the Schedule I if applicable, and the number entered on line 5 of the 2021 Form 5500 is 120 or less, you may elect to complete the 2021 Form 5500 and schedules in accordance with the instructions for a small plan, including for eligible filers, filing the Form 5500-SF instead of the Form 5500.

(2) Short Plan Year Rule: If the plan had a short plan year of seven (7) months or less for either the prior plan year or the plan year being reported on the 2021 Form 5500, an election can be made to defer filing the accountant’s report in accordance with 29 CFR 2520.104-50. If such an election was made for the prior plan year, the 2021 Form 5500 must be completed following the requirements for a large plan, including the attachment of the Schedule H and the accountant’s reports, regardless of the number of participants entered in Part II, line 5.

Form 5500 Schedules

Pension Schedules

Schedule R (Retirement Plan Information) – is required for a pension benefit plan that is a defined benefit plan or is otherwise subject to Code section 412 or ERISA section 302. Schedule R may also be required for certain other pension benefit plans unless otherwise specified under limited Pension Plan Reporting. For additional information, see the Schedule R instructions.

Schedule MB (Multiemployer Defined Benefit Plan and Certain Money Purchase Plan Actuarial Information) – is required for most multiemployer defined benefit plans and for defined contribution pension plans that currently amortize a waiver of the minimum funding requirements specified in the instructions for the Schedule MB. For additional information, see the instructions for the Schedule MB and the Schedule R.

Schedule SB (Single-Employer Defined Benefit Plan Actuarial Information) – is required for most single-employer defined benefit plans, including multiple-employer defined benefit pension plans. For additional information, see the instructions for the Schedule SB.

General Schedules

Schedule H (Financial Information) – is required for pension benefit plans and welfare benefit plans filing as “large plans” and for all DFE filings. Employee benefit plans, 103-12 IEs, and GIAs filing the Schedule H are generally required to engage an independent qualified public accountant (IQPA) and attach a report of the IQPA pursuant to ERISA section 103(a)(3)(A). These plans and DFEs are also generally required to attach to the Form 5500 a “Schedule of Assets (Held At End of Year),” and, if applicable, a “Schedule of Assets (Acquired and Disposed of Within Year),” a “Schedule of Reportable Transactions,” and a “Schedule of Delinquent Participant Contributions.” For additional information, see the Schedule H instructions.

Exceptions: Insured, unfunded, or combination unfunded/insured welfare plans, as described in 29 CFR 2520.104-44(b)(1) and certain pension plans and arrangements, as described in 29 CFR 2520.104-44(b)(2) and in Limited Pension Plan Reporting, are exempt from completing the Schedule H.

Schedule I (Financial Information - Small Plan) – is required for all pension benefit plans and welfare benefit plans filing the Form 5500 Annual Return/Report, rather than the Form 5500-SF, as ‘‘small plans,’’ except for certain pension benefit plans and arrangements described in 29 CFR 2520.104-44(b)(2) and Limited Pension Plan Reporting. For additional information, see the Schedule I instructions.

Note. A welfare plan that would have been eligible for the filing exemption under 29 CFR 2520.104-20, but for the fact that it is required to file a Form M-1, is exempt from completing a Schedule I if it meets the requirements of 29 CFR 2520.104-44(b)(1).

Schedule A (Insurance Information) – is required if any benefits under an employee benefit plan are provided by an insurance company, insurance service or other similar organization (such as Blue Cross, Blue Shield, or a health maintenance organization). This includes investment contracts with insurance companies, such as guaranteed investment contracts and pooled separate accounts. For additional information, see the Schedule A instructions.

Note. Do not file Schedule A for Administrative Services Only (ASO) contracts. Do not file Schedule A if a Schedule A is filed for the contract as part of the Form 5500 filed directly by a master trust investment account (MTIA) or 103-12 IE.

Schedule C (Service Provider Information) – is required for a large plan, MTIA, 103-12 IE, or GIA if (1) any service provider who rendered services to the plan or DFE during the plan or DFE year received $5,000 or more in compensation, directly or indirectly from the plan or DFE, or (2) an accountant and/or enrolled actuary has been terminated. For additional information, see the Schedule C instructions.

Schedule D (DFE/Participating Plan Information) – Part I is required for a plan or DFE that invested or participated in any MTIAs, 103-12 IEs, CCTs, and/or PSAs. Part II is required when the Form 5500 is filed for a DFE. For additional information, see the Schedule D instructions.

Schedule G (Financial Transaction Schedules) – is required for a large plan, MTIA, 103-12 IE, or GIA when Schedule H (Financial Information) lines 4b, 4c, and/or 4d are checked ‘‘Yes.’’ Part I of the Schedule G reports loans or fixed income obligations in default or classified as uncollectible. Part II of the Schedule G reports leases in default or classified as uncollectible. Part III of the Schedule G reports nonexempt transactions. For additional information, see the Schedule G instructions.

A n unfunded, fully insured, or combination unfunded/ insured welfare plan with 100 or more participants exempt under 29 CFR 2520.104-44 from completing Schedule H must still complete Schedule G, Part III, to report nonexempt transactions.

Pension Benefit Plan Filing Requirements

Pension benefit plan filers must complete the Form 5500 Annual Return/Report, including the signature block and, unless otherwise specified, attach the following schedules and information:

Small Pension Plan

The following schedules (including any additional information required by the instructions to the schedules) must be attached to a Form 5500 filed for a small pension plan that is neither exempt from filing nor is filing the Form 5500-SF:

1. Schedule A (as many as needed), to report insurance, annuity, and investment contracts held by the plan.

2. Schedule D, Part I, to list any CCTs, PSAs, MTIAs, and 103-12 IEs in which the plan participated at any time during the plan year.

3. Schedule I, to report small plan financial information, unless exempt.

4. Schedule MB or SB, to report actuarial information, if applicable.

5. Schedule R, to report retirement plan information, if applicable.

I f Schedule I, line 4k, is checked “No,” you must attach the report of the independent qualified public accountant (IQPA) or a statement that the plan is eligible and elects to defer attaching the IQPA’s opinion pursuant to 29 CFR 2520.104-50 in connection with a short plan year of seven months or less.

Large Pension Plan

The following schedules (including any additional information required by the instructions to the schedules) must be attached to a Form 5500 filed for a large pension plan:

1. Schedule A (as many as needed), to report insurance, annuity, and investment contracts held by the plan.

2. Schedule C, if applicable, to report information on service providers and, if applicable, any terminated accountants or enrolled actuaries.

3. Schedule D, Part I, to list any CCTs, PSAs, MTIAs, and 103-12 IEs in which the plan invested at any time during the plan year.

4. Schedule G, to report loans or fixed income obligations in default or determined to be uncollectible as of the end of the plan year, leases in default or classified as uncollectible, and nonexempt transactions, i.e., file Schedule G if Schedule H (Form 5500) lines 4b, 4c, and/or 4d are checked ‘‘Yes.’’

5. Schedule H, to report large plan financial information, unless exempt.

6. Schedule MB or SB, to report actuarial information, if applicable.

7. Schedule R, to report retirement plan information, if applicable.

Eligible Combined Plans

Section 903 of PPA established rules for a new type of pension plan, an “eligible combined plan,” effective for plan years beginning after December 31, 2009. See Code section 414(x) and ERISA section 210(e). An eligible combined plan consists of a defined benefit plan and a defined contribution plan that includes a qualified cash or deferred arrangement under Code section 401(k), with the assets of the two plans held in a single trust, but clearly identified and allocated between the plans. The eligible combined plan design is available only to employers that employed an average of at least two, but not more than 500 employees, on business days during the calendar year preceding the plan year as of which the eligible combined plan is established and that employs at least two employees on the first day of the plan year that the plan is established. Because an eligible combined plan includes both a defined benefit plan and a defined contribution plan, the Form 5500 filed for the plan must include all the information, schedules, and attachments that would be required for either a defined benefit plan (such as a Schedule SB) or a defined contribution plan.

Limited Pension Plan Reporting

The pension benefit plans or arrangements described below are eligible for limited annual reporting:

1. IRA Plans: A pension plan using individual retirement accounts or annuities (as described in Code section 408) as the sole funding vehicle for providing pension benefits need complete only Form 5500, Part I and Part II, lines 1 through 4, and 8 (enter pension feature code 2N).

2. Fully Insured Pension Plan: A pension benefit plan providing benefits exclusively through an insurance contract or contracts that are fully guaranteed and that meet all of the conditions of 29 CFR 2520.104-44(b)(2) during the entire plan year must complete all the requirements listed under this Pension Benefit Plan Filing Requirements section, except that such a plan is exempt from attaching Schedule H, Schedule I, and an independent qualified public accountant’s opinion, and from the requirement to engage an IQPA.

A pension benefit plan that has insurance contracts of the type described in 29 CFR 2520.104-44 as well as other assets must complete all requirements for a pension benefit plan, except that the value of the plan’s allocated contracts (see below) should not be reported in Part I of Schedule H or I. All other assets should be reported on Schedule H or Schedule I, and any other required schedules. If Schedule H is filed, attach an accountant’s report in accordance with the Schedule H instructions.

Note. For purposes of the annual return/report and the alternative method of compliance set forth in 29 CFR 2520.104-44, a contract is considered to be ‘‘allocated’’ only if the insurance company or organization that issued the contract unconditionally guarantees, upon receipt of the required premium or consideration, to provide a retirement benefit of a specified amount. This amount must be provided to each participant without adjustment for fluctuations in the market value of the underlying assets of the company or organization, and each participant must have a legal right to such benefits, which is legally enforceable directly against the insurance company or organization. For example, deposit administration, immediate participation guarantee, and guaranteed investment contracts are NOT allocated contracts for Form 5500 Annual Return/Report purposes.

Welfare Benefit Plan Filing Requirements

Welfare benefit plan filers must complete the Form 5500 Annual Return/Report, including the signature block and, unless otherwise specified, attach the following schedules and information:

Small Welfare Plan

The following schedules (including any additional information required by the instructions to the schedules) must be attached to a Form 5500 filed for a small welfare plan that is neither exempt from filing nor filing the Form 5500-SF:

1. Schedule A (as many as needed), to report insurance contracts held by the plan.

2. Schedule D, Part I, to list any CCTs, PSAs, MTIAs, and 103-12 IEs in which the plan participated at any time during the plan year.

3. Schedule I, to report small plan financial information.

A welfare plan that covered fewer than 100 participants as of the beginning of the plan year and is required to file a Form M-1, Report for Multiple-Employer Welfare Arrangements (MEWAs) and Certain Entities Claiming Exception (ECEs), is exempt from attaching Schedule I if the plan meets the requirements of 29 CFR 2520.104-44. However, Schedule G, Part III, must be attached to the Form 5500 to report any nonexempt transactions.

Large Welfare Plan

The following schedules (including any additional information required by the instructions to the schedules) must be attached to a Form 5500 filed for a large welfare plan:

1. Schedule A (as many as needed), to report insurance and investment contracts held by the plan.

2. Schedule C, if applicable, to report information on service providers and any terminated accountants or actuaries.

3. Schedule D, Part I, to list any CCTs, PSAs, MTIAs, and 103-12 IEs in which the plan invested at any time during the plan year.

5. Schedule H, to report financial information, unless exempt.

A ttach the report of the independent qualified public accountant (IQPA) identified on Schedule H, line 3c, unless line 3d(2) is checked.

N either Schedule H nor an IQPA’s opinion should be attached to a Form 5500 filed for an unfunded, fully insured or combination unfunded/insured welfare plan that covered 100 or more participants as of the beginning of the plan year that meets the requirements of 29 CFR 2520.104-44. However, Schedule G, Part III, must be attached to the Form 5500 to report any nonexempt transactions. A welfare benefit plan that uses a ‘‘voluntary employees’ beneficiary association’’ (VEBA) under Code section 501(c)(9) is generally not exempt from the requirement of engaging an IQPA.

Direct Filing Entity (DFE) Filing Requirements

Some plans participate in certain trusts, accounts, and other investment arrangements that file the Form 5500 Annual Return/Report as a DFE. A Form 5500 must be filed for a master trust investment account (MTIA). A Form 5500 is not required but may be filed for a common/collective trust (CCT), pooled separate account (PSA), 103-12 investment entity (103-12 IE), or group insurance arrangement (GIA). However, plans that participate in CCTs, PSAs, 103-12 IEs, or GIAs that file as DFEs generally are eligible for certain annual reporting relief. For reporting purposes, a CCT, PSA, 103-12 IE, or GIA is considered a DFE only when a Form 5500 and all required schedules and attachments are filed for it in accordance with the following instructions.

Only one Form 5500 should be filed for each DFE for all plans participating in the DFE; however, the Form 5500 filed for the DFE, including all required schedules and attachments, must report information for the DFE year (not to exceed 12 months in length) that ends with or within the participating plan’s year.

Any Form 5500 filed for a DFE is an integral part of the annual report of each participating plan, and the plan administrator may be subject to penalties for failing to file a complete annual report unless both the DFE Form 5500 and the plan’s Form 5500 are properly filed. The information required for a Form 5500 filed for a DFE varies according to the type of DFE. The following paragraphs provide specific guidance for the reporting requirements for each type of DFE.

Master Trust Investment Account (MTIA)

The administrator filing a Form 5500 for an employee benefit plan is required to file or have a designee file a Form 5500 for each MTIA in which the plan participated at any time during the plan year. For reporting purposes, a ‘‘master trust’’ is a trust for which a regulated financial institution (as defined below) serves as trustee or custodian (regardless of whether such institution exercises discretionary authority or control with respect to the management of assets held in the trust), and in which assets of more than one plan sponsored by a single employer or by a group of employers under common control are held.

‘‘Common control’’ is determined on the basis of all relevant facts and circumstances (whether or not such employers are incorporated).

A ‘‘regulated financial institution’’ means a bank, trust company, or similar financial institution that is regulated, supervised, and subject to periodic examination by a state or federal agency. A securities brokerage firm is not a ‘‘similar financial institution’’ as used here. See DOL Advisory Opinion 93-21A (available at www.dol.gov/ebsa).

The assets of a master trust are considered for reporting purposes to be held in one or more ‘‘investment accounts.’’ A ‘‘master trust investment account’’ may consist of a pool of assets or a single asset. Each pool of assets held in a master trust must be treated as a separate MTIA if each plan that has an interest in the pool has the same fractional interest in each asset in the pool as its fractional interest in the pool, and if each such plan may not dispose of its interest in any asset in the pool without disposing of its interest in the pool. A master trust may also contain assets that are not held in such a pool. Each such asset must be treated as a separate MTIA.

Notes. (1) If an MTIA consists solely of one plan’s asset(s) during the reporting period, the plan may report the asset(s) either as an investment account on an MTIA Form 5500, or as a plan asset(s) that is not part of the master trust (and therefore subject to all instructions concerning assets not held in a master trust) on the plan’s Form 5500. (2) If a master trust holds assets attributable to participant or beneficiary directed transactions under an individual account plan and the assets are interests in registered investment companies, interests in contracts issued by an insurance company licensed to do business in any state, interests in common/collective trusts maintained by a bank, trust company or similar institution, or the assets have a current value that is readily determinable on an established market, those assets may be treated as a single MTIA.

The Form 5500 submitted for the MTIA must comply with the Form 5500 instructions for a Large Pension Plan, unless otherwise specified in the forms and instructions. The MTIA must file:

1. Form 5500, except lines C, D, 1c, 2d, and 5 through 9. Be certain to enter ‘‘M’’ in Part I, line A, as the DFE code.

2. Schedule A (as many as needed) to report insurance, annuity and investment contracts held by the MTIA.

3. Schedule C, if applicable, to report service provider information. Part III is not required for an MTIA.

4. Schedule D, to list CCTs, PSAs, and 103-12 IEs in which the MTIA invested at any time during the MTIA year and to list all plans that participated in the MTIA during its year.

5. Schedule G, to report loans or fixed income obligations in default or determined to be uncollectible as of the end of the MTIA year, all leases in default or classified as uncollectible, and nonexempt transactions.

6. Schedule H, except lines 1b(1), 1b(2), 1c(8), 1g, 1h, 1i, 2a, 2b(1)(E), 2e, 2f, 2g, 4a, 4e, 4f, 4g, 4h, 4k, 4l, 4m, 4n, and 5, to report financial information. An independent qualified public accountant’s (IQPA’s) opinion is not required for an MTIA.

7. Additional information required by the instructions to the above schedules, including, for example, the schedules of assets held for investment and the schedule of reportable transactions. For purposes of the schedule of reportable transactions, the 5% figure shall be determined by comparing the current value of the transaction at the transaction date with the current value of the investment account assets at the beginning of the applicable fiscal year of the MTIA. All attachments must be properly labeled.

Common/Collective Trust (CCT) and Pooled Separate Account (PSA)

A Form 5500 is not required to be filed for a CCT or PSA. However, the administrator of a large plan or DFE that participates in a CCT or PSA that files as specified below is entitled to reporting relief that is not available to plans or DFEs participating in a CCT or PSA for which a Form 5500 is not filed.

For reporting purposes, ‘‘common/collective trust’’ and ‘‘pooled separate account’’ are, respectively: (1) a trust maintained by a bank, trust company, or similar institution or (2) an account maintained by an insurance carrier, which is regulated, supervised, and subject to periodic examination by a state or federal agency in the case of a CCT, or by a state agency in the case of a PSA, for the collective investment and reinvestment of assets contributed thereto from employee benefit plans maintained by more than one employer or controlled group of corporations as that term is used in Code section 1563. See 29 CFR 2520.103-3, 103-4, 103-5, and

103-9.

Note. For reporting purposes, a separate account that is not considered to be holding plan assets pursuant to 29 CFR 2510.3-101(h)(1)(iii) does not constitute a pooled separate account.

The Form 5500 submitted for a CCT or PSA must comply with the Form 5500 instructions for a Large Pension Plan, unless otherwise specified in the forms and instructions.

The CCT or PSA must file:

1. Form 5500, except lines C, D, 1c, 2d, and 5 through 9. Enter ‘‘C’’ or ‘‘P,’’ as appropriate, in Part I, line A, as the DFE code.

2. Schedule D, to list all CCTs, PSAs, MTIAs, and

103-12 IEs in which the CCT or PSA invested at any time during the CCT or PSA year and to list in Part II all plans that participated in the CCT or PSA during its year.

3. Schedule H, except lines 1b(1), 1b(2), 1c(8), 1d, 1e, 1g, 1h, 1i, 2a, 2b(1)(E), 2e, 2f, and 2g, to report financial information. Part IV and an accountant’s (IQPA’s) opinion are not required for a CCT or PSA.

D ifferent requirements apply to the Schedules D and H attached to the Form 5500 filed by plans and DFEs participating in CCTs and PSAs, depending upon whether a DFE Form 5500 has been filed for the CCT or PSA. See the instructions for these schedules.

103-12 Investment Entity (103-12 IE)

DOL Regulation 2520.103-12 provides an alternative method of reporting for plans that invest in an entity (other than an MTIA, CCT, or PSA), whose underlying assets include ‘‘plan assets’’ within the meaning of 29 CFR 2510.3-101 of two or more plans that are not members of a ‘‘related group’’ of employee benefit plans. Such an entity for which a Form 5500 is filed constitutes a ‘‘103-12 IE.’’ A Form 5500 is not required to be filed for such entities; however, filing a Form 5500 as a 103-12 IE provides certain reporting relief, including the limitation of the examination and report of the independent qualified public accountant (IQPA) provided by 29 CFR 2520.103-12(d), to participating plans and DFEs. For this reporting purpose, a ‘‘related group’’ of employee benefit plans consists of each group of two or more employee benefit plans (1) each of which receives 10% or more of its aggregate contributions from the same employer or from a member of the same controlled group of corporations (as determined under Code section 1563(a), without regard to Code section 1563(a)(4) thereof); or (2) each of which is either maintained by, or maintained pursuant to a collective-bargaining agreement negotiated by, the same employee organization or affiliated employee organizations. For purposes of this paragraph, an ‘‘affiliate’’ of an employee organization means any person controlling, controlled by, or under common control with such organization. See 29 CFR 2520.103-12.

The Form 5500 submitted for a 103-12 IE must comply with the Form 5500 instructions for a Large Pension Plan, unless otherwise specified in the forms and instructions. The 103-12 IE must file:

1. Form 5500, except lines C, D, 1c, 2d, and 5 through 9. Enter ‘‘E’’ in part I, line A, as the DFE code.

2. Schedule A (as many as needed), to report insurance, annuity and investment contracts held by the 103-12 IE.

3. Schedule C, if applicable, to report service provider information and any terminated accountants.

4. Schedule D, to list all CCTs, PSAs, and 103-12 IEs in which the 103-12 IE invested at any time during the

103-12 IE’s year, and to list all plans that participated in the 103-12 IE during its year.

5. Schedule G, to report loans or fixed income obligations in default or determined to be uncollectible as of the end of the 103-12 IE year, leases in default or classified as uncollectible, and nonexempt transactions.

6. Schedule H, except lines 1b(1), 1b(2), 1c(8), 1d, 1e, 1g, 1h, 1i, 2a, 2b(1)(E), 2e, 2f, 2g, 4a, 4e, 4f, 4g, 4h, 4j, 4k, 4l, 4m, 4n, and 5, to report financial information.

7. Additional information required by the instructions to the above schedules, including, for example, the report of the independent qualified public accountant (IQPA) identified on Schedule H, line 3c, and the schedule(s) of assets held for investment. All attachments must be properly labeled.

Group Insurance Arrangement (GIA)

Each welfare benefit plan that is part of a group insurance arrangement is exempt from the requirement to file a Form 5500 if a consolidated Form 5500 report for all the plans in the arrangement was filed in accordance with 29 CFR 2520.104-43. For reporting purposes, a ‘‘group insurance arrangement’’ provides benefits to the employees of two or more unaffiliated employers (not in connection with a multiemployer plan or a collectively-bargained multiple-employer plan), fully insures one or more welfare plans of each participating employer, uses a trust or other entity as the holder of the insurance contracts, and uses a trust as the conduit for payment of premiums to the insurance company. The GIA must file:

1. Form 5500, except lines C and 2d. (Enter ‘‘G’’ in Part I, line A, as the DFE code).

2. Schedule A (as many as needed), to report insurance, annuity and investment contracts held by the GIA.

3. Schedule C, if applicable, to report service provider information and any terminated accountants.

4. Schedule D, to list all CCTs, PSAs, and 103-12 IEs in which the GIA invested at any time during the GIA year, and to list all plans that participated in the GIA during its year.

5. Schedule G, to report loans or fixed income obligations in default or determined to be uncollectible as of the end of the GIA year, leases in default or classified as uncollectible, and nonexempt transactions.

6. Schedule H, except lines 4a, 4e, 4f, 4g, 4h, 4k, 4m, 4n, and 5, to report financial information.

7. Additional information required by the instructions to the above schedules, including, for example, the report of the independent qualified public accountant (IQPA) identified on Schedule H, line 3c, the schedules of assets held for investment and the schedule of reportable transactions. (All attachments must be properly labeled.)

Quick Reference Chart of Form 5500, Schedules, and Attachments (Not Applicable for Form 5500-SF Filers)¹
	Large Pension Plan	Small Pension Plan²	Large Welfare Plan	Small Welfare Plan²	DFE
Form 5500	Must complete.	Must complete.	Must complete.³	Must complete.³	Must complete.
Schedule A (Insurance Information)	Must complete if plan has insurance contracts.	Must complete if plan has insurance contracts.⁴	Must complete if plan has insurance contracts.	Must complete if plan has insurance contracts.⁴	Must complete if MTIA, 103-12 IE, or GIA has insurance contracts.
Schedule C (Service Provider Information)	Must complete Part I if service provider was paid $5,000 or more, Part II if a service provider failed to provide information necessary for the completion of Part I, and Part III if an accountant or actuary was terminated.	Not required.	Must complete Part I if service provider was paid $5,000 or more, Part II if a service provider failed to provide information necessary for the completion of Part I, and Part III if an accountant or actuary was terminated.	Not required.	MTIAs, GIAs, and 103-12 IEs must complete Part I if service provider paid $5,000 or more, and Part II if a service provider failed to provide information necessary for the completion of Part I. GIAs and 103-12 IEs must complete Part III if accountant was terminated.
Schedule D (DFE/Participating Plan Information)	Must complete Part I if plan participated in a CCT, PSA, MTIA, or 103-12 IE.	Must complete Part I if plan participated in a CCT, PSA, MTIA, or 103-12 IE.⁴	Must complete Part I if plan participated in a CCT, PSA, MTIA, or 103-12 IE.	Must complete Part I if plan participated in a CCT, PSA, MTIA, or 103-12 IE.⁴	All DFEs must complete Part II, and DFEs that invest in a CCT, PSA, or 103-12 IE must also complete Part I.

Schedule G (Financial Schedules)	Must complete if Schedule H, lines 4b, 4c, or 4d are “Yes.”	Not required.	Must complete if Schedule H, lines 4b, 4c, or 4d are “Yes.”³	Not required ³.	Must complete if Schedule H, lines 4b, 4c, or 4d for a GIA, MTIA, or 103-12 IE are “Yes.”
Schedule H (Financial Information)	Must complete.⁵	Not required.	Must complete.^3, 5	Not required.	All DFEs must complete Parts I, II, and III. MTIAs, 103-12 IEs, and GIAs must also complete Part IV.⁵
Schedule I (Financial Information)	Not required.	Must complete.⁴	Not required.	Must complete.⁴	Not required.
Schedule MB (Actuarial Information)	Must complete if multiemployer defined benefit plan or money purchase plan subject to minimum funding standards.⁶	Must complete if multiemployer defined benefit plan or money purchase plan subject to minimum funding standards.⁶	Not required.	Not required.	Not required.
Schedule R (Pension Plan Information)	Must complete.⁷	Must complete.^4, 7	Not required.	Not required.	Not required.
Schedule SB (Actuarial Information)	Must complete if single-employer or multiple-employer defined benefit plan, including an eligible combined plan and subject to minimum funding standards.	Must complete if single-employer or multiple-employer defined benefit plan, including an eligible combined plan and subject to minimum funding standards.	Not required.	Not required.	Not required.
	Large Pension Plan	Small Pension Plan²	Large Welfare Plan	Small Welfare Plan²	DFE
Accountant’s Report	Must attach.	Not required unless Schedule I, line 4k, is checked “No.”	Must attach.³	Not required.	Must attach for a GIA or 103-12 IE.

¹ This chart provides only general guidance. Not all rules and requirements are reflected. Refer to specific Form 5500 instructions for complete information on filing requirements (e.g., Who Must File and What To File). For example, a pension plan is exempt from filing any schedules if the plan uses Code section 408 individual retirement accounts as the sole funding vehicle for providing benefits. See Limited Pension Plan Reporting.

² Pension plans and welfare plans with fewer than 100 participants at the beginning of the plan year that are not exempt from filing an annual return/report may be eligible to file the Form 5500-SF, a simplified report. In addition to the limitation on the number of participants, a Form 5500-SF may only be filed for a plan that is exempt from the requirement that the plan’s books and records be audited by an independent qualified public accountant (but not by reason of enhanced bonding), has 100 percent of its assets invested in certain secure investments with a readily determinable fair market value, holds no employer securities, and is not a multiemployer plan. See Who Must File.

³ Unfunded, fully insured, or combination unfunded/fully insured welfare plans covering fewer than 100 participants at the beginning of the plan year that meet the requirements of 29 CFR 2520.104-20 are exempt from filing an annual report. See Who Must File. Such a plan with 100 or more participants must file an annual report, but is exempt under 29 CFR 2520.104-44 from the accountant’s report requirement and completing Schedule H, but MUST complete Schedule G, Part III, to report any nonexempt transactions. See What To File. All Plans required to file Form M-1 (Report for Multiple-Employer Welfare Arrangements (MEWAs) and Certain Entities Claiming Exception (ECEs)) must file a Form 5500 regardless of plan size or type of funding.

⁴ Do not complete if filing the Form 5500-SF instead of the Form 5500.

⁵ Schedules of assets and reportable (5%) transactions also must be filed with the Form 5500 if Schedule H, line 4i or 4j is “Yes.”

⁶ Money purchase defined contribution plans that are amortizing a funding waiver are required to complete lines 3, 9, and 10 of the Schedule MB in accordance with the instructions. Also see instructions for line 5 of Schedule R and line 12a of Form 5500-SF.

⁷ Schedule R should not be completed when the Form 5500 Annual Return/Report is filed for a pension plan that uses, as the sole funding vehicle for providing benefits, individual retirement accounts or annuities (as described in Code section 408). See the Form 5500 instructions for Limited Pension Plan Reporting for more information.

Section 5: Line-by-Line

Instructions for the 2021

Form 5500 and Schedules

Part I – Annual Return/Report Identification Information

File the 2021 Form 5500 Annual Return/Report for a plan year that began in 2021 or a DFE year that ended in 2021. Enter the beginning and ending dates in Part I. The 2021 Form 5500 Annual Return/Report must be filed electronically.

One Form 5500 is generally filed for each plan or entity described in the instructions to the boxes in line A. Do not check more than one box.

A separate Form 5500, with line A (single-employer plan) checked, must be filed by each employer participating in a plan or program of benefits in which the funds attributable to each employer are available to pay benefits only for that employer’s employees, even if the plan is maintained by a controlled group.

A “controlled group” is generally considered one employer for Form 5500 reporting purposes. A “controlled group” is a controlled group of corporations under Code section 414(b), a group of trades or businesses under common control under Code section 414(c), or an affiliated service group under Code section 414(m).

Line A – Box for Multiemployer Plan. Check this box if the Form 5500 is filed for a multiemployer plan. A plan is a multiemployer plan if: (a) more than one employer is required to contribute, (b) the plan is maintained pursuant to one or more collective bargaining agreements between one or more employee organizations and more than one employer; (c) an election under Code section 414(f)(5) and ERISA section 3(37)(E) has not been made; and (d) the plan meets any other applicable conditions of 29 CFR 2510.3-37. A plan that has made a proper election under ERISA section 3(37)(G) and Code section 414(f)(6) on or before August 17, 2007, is also a multiemployer plan. Participating employers do not file individually for these plans.

Line A – Box for Single-Employer Plan. Check this box if the Form 5500 is filed for a single-employer plan. A single-employer plan for this Form 5500 reporting purpose is an employee benefit plan maintained by one employer or one employee organization.

Line A – Box for Multiple-Employer Plan. Check this box if the Form 5500 is being filed for a multiple-employer plan. A multiple-employer plan is a plan that is maintained by more than one employer and is not one of the plans already described. A multiple-employer plan can be collectively bargained and collectively funded, but if covered by PBGC termination insurance, must have properly elected before September 27, 1981, not to be treated as a multiemployer plan under Code section 414(f)(5) or ERISA sections 3(37)(E) and 4001(a)(3), and have not revoked that election or made an election to be treated as a multiemployer plan under Code section 414(f)(6) or ERISA section 3(37)(G). Participating employers do not file individually for this type of plan.

Note. Do not check this box if all of the employers maintaining the plan are members of the same controlled group or affiliated service group under Code sections 414(b), (c), or (m).

Except as provided below, multiple-employer pension plans and multiple-employer welfare plans required to file a Form 5500 must include an attachment using the format below that (1) lists each participating employer in the plan during the plan year, identified by name and employer identification number (EIN), and (2) includes a good faith estimate of each employer’s percentage of the total contributions (including employer and participant contributions) made by all participating employers during the year. Any employer who was obligated to make contributions to the plan for the plan year, made contributions to the plan for the plan year, or whose employees were covered under the plan is a “participating employer” for this purpose. If a participating employer made no contributions, enter “-0-” in element (c).

The attachment must be properly identified at the top with the label “Multiple-Employer Plan Participating Employer Information,” and the name of the plan, EIN, and plan number (PN) as found on the plan’s Form 5500.

Multiple-employer welfare plans that are exempt under 29 CFR 2520.104-44 from the obligation to file financial statements with their annual report are required to include only a list of participating employers with the corresponding EIN/PN numbers in elements (a) and (b) of the “Multiple-Employer Plan Participating Employer Information” attachment included with their Form 5500.

Complete as many entries as needed to report the required information for all participating employers.

Multiple-Employer Plan Participating Employer Information

(Insert Name of Plan and EIN/PN as shown on the Form 5500)

(a) Name of participating employer

(b) EIN

(a) Name of participating employer

(b) EIN

Line A –Box for Direct Filing Entity (DFE). Check this box and enter the correct letter from the following chart in the space provided to indicate the type of entity.

Type of entity	Enter the letter
Master Trust Investment Account	M
Common/Collective Trust	C
Pooled Separate Account	P
103-12 Investment Entity	E
Group Insurance Arrangement	G

Note. A separate annual report with “M” entered as the DFE code on Form 5500, line A, must be filed for each MTIA. See instructions on page 10.

Line B – Box for First Return/Report. Check this box if an annual return/report has not been previously filed for this plan or DFE. For the purpose of completing this box, the Form 5500-EZ is not considered an annual return/report.

Line B – Box for Amended Return/Report. Check this box if you have already filed for the 2021 plan year and are now filing an amended return/report to correct errors and/or omissions on the previously filed return/report. See instructions on page 6.

C heck the line B box for an “amended return/report” if you filed a previous 2021 annual return/report that was given a “Filing_Received,” “Filing_Error,” or “Filing_Stopped” status by EFAST2. Do not check the line B box for an “amended return/report” if your previous submission attempts were not successfully received by EFAST2 because of problems with the transmission of your return/report. For more information, go to the EFAST2 website at www.efast.dol.gov or call the EFAST2 Help Desk at 1-866-GO-EFAST (1-866-463-3278).

Line B – Box for Final Return/Report. Check this box if this Form 5500 is the last annual return/report required to be submitted for this plan. (See Final Return/Report.)

Note. Do not check box B (Final Return/Report) if “4R” is entered on line 8b for a welfare plan that is not required to file a Form 5500 for the next plan year because the welfare plan has become eligible for an annual reporting exemption. For example, certain unfunded and insured welfare plans may be required to file the 2021 Form 5500 and be exempt from filing a Form 5500 for the plan year 2021 if the number of participants covered as of the beginning of the 2021 plan year drops below 100. See Who Must File. Should the number of participants covered by such a plan increase to 100 or more in a future year, the plan must resume filing Form 5500 and enter ‘‘4S’’ on line 8b on that year’s Form 5500. See 29 CFR 2520.104-20.

Line B – Box for Short Plan Year Return/Report. Check this box if this Form 5500 is being filed for a plan year period of less than 12 months. Provide the dates in Part I, Plan Year Beginning and Ending.

Line C – Box for Collectively-Bargained Plan. Check this box when the contributions to the plan and/or the benefits paid by the plan are subject to the collective bargaining process (even if the plan is not established and administered by a joint board of trustees and even if only some of the employees covered by the plan are members of a collective bargaining unit that negotiates contributions and/or benefits). The contributions and/or benefits do not have to be identical for all employees under the plan.

Line D – Box for Extension and DFVC Program. Check the appropriate box here if:

You filed for an extension of time to file this form with the IRS using a completed Form 5558, Application for Extension of Time To File Certain Employee Plan Returns (maintain a copy of the Form 5558 with the filer’s records);
You are filing using the automatic extension of time to file Form 5500 until the due date of the federal income tax return of the employer (maintain a copy of the employer’s extension of time to file the income tax return with the filer’s records);
You are filing using a special extension of time to file the Form 5500 that has been announced by the IRS, DOL, and PBGC. If you checked that you are using a special extension of time, enter a description of the extension of time in the space provided.
You are filing under DOL’s Delinquent Filer Voluntary Compliance (DFVC) Program.

Line E – Box for a retroactively adopted plan as permitted by SECURE Act section 201. Check this box if the plan sponsor adopted the plan during the 2021 plan year (i.e., by the due date, including extension, for filing the plan sponsor’s tax return for the 2020 taxable year) and elected to treat the plan as having been adopted before the 2021 plan year began (i.e., at the close as of the last day of the sponsor’s taxable year) as permitted by section 201 of the Setting Every Community Up for Retirement Enhancement Act of 2019 (SECURE ACT). Plans in this situation are not required to file a 2020 Form 5500. However, if the plan is a defined benefit pension plan, the 2020 Schedule SB (Form 5500) must be included as an attachment to the 2021 Schedule SB (Form 5500) as part of the 2021 Form 5500. Please see Instructions for Schedule SB for more information.

Shape3 Shape4 Shape5 Shape6 Part II – Basic Plan Information

Line 1a. Enter the formal name of the plan or DFE or enough information to identify the plan or DFE. Abbreviate if necessary. If an annual return/report has previously been filed on behalf of the plan, regardless of the type of form that was filed (Form 5500, Form 5500-EZ, or Form 5500-SF), use the same name or abbreviation as was used on the prior filings. Once you use an abbreviation, continue to use it for that plan on all future annual return/report filings with the IRS, DOL, and PBGC. Do not use the same name or abbreviation for any other plan, even if the first plan is terminated. If the plan has changed its name from the prior year filing(s), complete line 4 to indicate that the plan was previously identified by a different name.

Line 1b. Enter the three-digit plan or entity number (PN) the employer or plan administrator assigned to the plan or DFE. This three-digit number, in conjunction with the employer identification number (EIN) entered on line 2b, is used by the IRS, DOL, and PBGC as a unique 12-digit number to identify the plan or DFE.

Start at 001 for plans providing pension benefits, plans providing pension and welfare benefits, or DFEs as illustrated in the table below. Start at 501 for plans providing only welfare benefits and GIAs. Do not use 888 or 999.

Once you use a plan or DFE number, continue to use it for that plan or DFE on all future filings with the IRS, DOL, and PBGC. Do not use it for any other plan or DFE, even if the first plan or DFE is terminated.

For each Form 5500 with the same EIN (line 2b), when

Assign PN

Shape8

Part II, line 8a is completed, or Part I, line A, for a DFE is checked and an M, C, P, or E is entered

001 to the first plan or DFE. Consecutively number others as 002, 003…

Part II, line 8b is completed and 8a is not checked, or Part I, line A, for a DFE is checked and a G is entered

501 to the first plan or GIA. Consecutively number others as 502, 503…

Exception. If Part II, line 8a is completed and 333 (or a higher number in a sequence beginning with 333) was previously assigned to the plan, that number may be entered on line 1b.

Line 1c. Enter the date the plan first became effective.

Line 2a. Limit your response to the information required in each row as specified below:

1. Enter the name of the plan sponsor or, in the case of a Form 5500 filed for a DFE, the name of the insurance company, financial institution, or other sponsor of the DFE (e.g., in the case of a GIA, the trust or other entity that holds the insurance contract, or in the case of an MTIA, one of the sponsoring employers). If the plan covers only the employees of one employer, enter the employer’s name.

The term ‘‘plan sponsor’’ means:

The employer, for an employee benefit plan that a single employer established or maintains;
The employee organization in the case of a plan of an employee organization; or
The association, committee, joint board of trustees, or other similar group of representatives of the parties who establish or maintain the plan, if the plan is established or maintained jointly by one or more employers and one or more employee organizations, or by two or more employers.

Note. In the case of a multiple-employer plan, file only one annual return/report for the plan. If an association or other entity is not the sponsor, enter the name of a participating employer as sponsor. A plan of a controlled group of corporations should enter the name of one of the sponsoring members. In either case, the same name must be used in all subsequent filings of the Form 5500 for the multiple-employer plan or controlled group (see instructions to line 4 concerning change in sponsorship).

2. Enter any ‘‘in care of’’ (C/O) name.

3. Enter the current street address. A post office box number may be entered if the Post Office does not deliver mail to the sponsor’s street address.

4. Enter the name of the city.

5. Enter the two-character abbreviation of the U.S. state or possession and zip code.

6. Enter the foreign routing code, if applicable. Leave U.S. state and zip code blank if entering a foreign routing code and country name.

7. Enter the foreign country, if applicable.

8. Enter the D/B/A (the doing business as) or trade name of the sponsor if different from the plan sponsor’s name.

9. Enter any second address. Use only a street address here, not a P.O. Box.

Note. Use the IRS Form 8822-B, Change of Address – Business, to notify the IRS if the address provided here is a change in your business mailing address or your business location.

Line 2b. Enter the nine-digit employer identification number (EIN) assigned to the plan sponsor/employer, for example, 00-1234567. In the case of a DFE, enter the employer identification number (EIN) assigned to the CCT, PSA, MTIA, 103-12 IE, or GIA.

Do not use a social security number in lieu of an EIN. The Form 5500 is open to public inspection, and the contents are public information and are subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on this line may result in the rejection of the filing.

Employers without an EIN must apply for one as soon as possible. The EBSA does not issue EINs. To apply for an EIN from the IRS:

Mail or fax Form SS-4, Application for Employer Identification Number, obtained at www.irs.gov/orderforms.
See https://www.IRS.gov/Businesses and click on “Employer ID Numbers” for additional information. The EIN is issued immediately once the application information is validated. (The online application process is not yet available for corporations with addresses in foreign countries or Puerto Rico.)

A multiple-employer plan or plan of a controlled group of corporations should use the EIN of the sponsor identified in line 2a. The EIN must be used in all subsequent filings of the Form 5500 for these plans (see instructions to line 4 concerning change in EIN).

If the plan sponsor is a group of individuals, get a single EIN for the group. When you apply for the EIN, provide the name of the group, such as ‘‘Joint Board of Trustees of the Local 187 Machinists’ Retirement Plan.’’ (If filing Form SS-4, enter the group name on line 1.)

Note. EINs for funds (trusts or custodial accounts) associated with plans (other than DFEs) are generally not required to be furnished on the Form 5500; the IRS will issue EINs for such funds for other reporting purposes. EINs may be obtained as explained above. Plan sponsors should use the trust EIN described above when opening a bank account or conducting other transactions for a trust that require an EIN.

Line 2d. Enter the six-digit business code from the list of business codes on pages 78, 79, and 80 that:

In the case of a single-employer plan, best describes the primary nature of the plan sponsor’s business, and
In the case of a multiemployer plan, best describes the predominant industry in which the active participants are employed (e.g., 484120 - General Freight Trucking, Long-distance, 236110 - Residential Building Construction).

Do not enter code 525100 (Insurance & Employee Benefit Funds) or 813930 (Labor Unions and Similar Labor Organizations) unless the predominant industry in which the active participants are employed is the industry of insurance and employee benefit funds, or labor unions and similar labor organizations.

Line 3a. Please limit your response to the information required:

1. Enter the name and address of the plan administrator unless the administrator is the sponsor identified in line 2. If both the plan administrator name and address are the same as the plan sponsor name and address, check the “Same as Plan Sponsor” box and disregard items 2 through 6 below. If the Form 5500 is submitted for a DFE, check the appropriate box in Part I, line A, and enter the appropriate DFE code.

The term “plan administrator” means:

The person or group of persons specified as the administrator by the instrument under which the plan is operated;
The plan sponsor/employer if an administrator is not so designated; or
Any other person prescribed by regulations if an administrator is not designated and a plan sponsor cannot be identified.

2. Enter any “in care of” (C/O) name.

3. Enter the current street address. A post office box number may be entered if the Post Office does not deliver mail to the administrator’s street address.

4. Enter the name of the city.

5. Enter the two-character abbreviation of the U.S. state or possession and zip code.

6. Enter the foreign routing code and foreign country, if applicable. Leave U.S. state and zip code blank if entering foreign routing code and country information.

Line 3b. Enter the plan administrator’s nine-digit EIN. A plan administrator must have an EIN for Form 5500 reporting purposes. If the plan administrator does not have an EIN, apply for one as explained in the instructions for line 2b. One EIN should be entered for a group of individuals who are, collectively, the plan administrator.

Note. Employees of the plan sponsor who perform administrative functions for the plan are generally not the plan administrator unless specifically designated in the plan document. If an employee of the plan sponsor is designated as the plan administrator, that employee must get an EIN.

Line 4. If the plan sponsor’s or DFE’s name and/or EIN have changed or the plan name has changed since the last return/report was filed for this plan or DFE, enter the plan sponsor’s or DFE’s name, EIN, the plan name, and the plan number as it appeared on the last return/report filed.

T he failure to indicate on line 4 that a plan sponsor was previously identified by a different name or a different employer identification number (EIN) or that the plan name has been changed could result in correspondence from the DOL and/or the IRS.

Lines 5 and 6. All filers must complete both lines 5 and 6 unless the Form 5500 is filed for an IRA Plan described in Limited Pension Plan Reporting or for a DFE. Note. Welfare plans complete only lines 5, 6a(1), 6a(2), 6b, 6c, and 6d.

The description of ‘‘participant’’ in the instructions below is only for purposes of these lines.

An individual becomes a participant covered under an employee welfare benefit plan on the earliest of:

the date designated by the plan as the date on which the individual begins participation in the plan;
the date on which the individual becomes eligible under the plan for a benefit subject only to occurrence of the contingency for which the benefit is provided; or
the date on which the individual makes a contribution to the plan, whether voluntary or mandatory.

See 29 CFR 2510.3-3(d)(1). This includes former employees who are receiving group health continuation coverage benefits pursuant to Part 6 of ERISA and who are covered by the employee welfare benefit plan. Covered dependents are not counted as participants. A child who is an “alternate recipient” entitled to health benefits under a qualified medical child support order (QMCSO) should not be counted as a participant for lines 5 and 6. An individual is not a participant covered under an employee welfare plan on the earliest date on which the individual (a) is ineligible to receive any benefit under the plan even if the contingency for which such benefit is provided should occur, and (b) is not designated by the plan as a participant. See 29 CFR 2510.3-3(d)(2).

B efore counting the number of participants, especially in a welfare benefit plan, it is important to determine whether the plan sponsor has established one or more plans for Form 5500/Form 5500-SF reporting purposes. As a matter of plan design, plan sponsors can offer benefits through various structures and combinations. For example, a plan sponsor could create (i) one plan providing major medical benefits, dental benefits, and vision benefits, (ii) two plans with one providing major medical benefits and the other providing self-insured dental and vision benefits; or (iii) three separate plans. You must review the governing documents and actual operations to determine whether welfare benefits are being provided under a single plan or separate plans.

The fact that you have separate insurance policies for each different welfare benefit does not necessarily mean that you have separate plans. Some plan sponsors use a “wrap” document to incorporate various benefits and insurance policies into one comprehensive plan. In addition, whether a benefit arrangement is deemed to be a single plan may be different for purposes other than Form 5500/Form 5500-SF reporting. For example, special rules may apply for purposes of HIPAA, COBRA, and Internal Revenue Code compliance. If you need help determining whether you have a single welfare benefit plan for Form 5500/Form 5500-SF reporting purposes, you should consult a qualified benefits consultant or legal counsel.

For pension benefit plans, “alternate payees” entitled to benefits under a qualified domestic relations order are not to be counted as participants for this line.

For pension benefit plans, “participant” for this line means any individual who is included in one of the categories below:

1. Active participants (i.e., any individuals who are currently in employment covered by the plan and who are earning or retaining credited service under the plan). This includes any individuals who are eligible to elect to have the employer make payments under a Code section 401(k) qualified cash or deferred arrangement. Active participants also include any nonvested individuals who are earning or retaining credited service under the plan. This does not include (a) nonvested former employees who have incurred the break in service period specified in the plan or (b) former employees who have received a “cash-out” distribution or deemed distribution of their entire nonforfeitable accrued benefit.

2. Retired or separated participants receiving benefits (i.e., individuals who are retired or separated from employment covered by the plan and who are receiving benefits under the plan). This does not include any individual to whom an insurance company has made an irrevocable commitment to pay all the benefits to which the individual is entitled under the plan.

3. Other retired or separated participants entitled to future benefits (i.e., any individuals who are retired or separated from employment covered by the plan and who are entitled to begin receiving benefits under the plan in the future). This does not include any individual to whom an insurance company has made an irrevocable commitment to pay all the benefits to which the individual is entitled under the plan.

4. Deceased individuals who had one or more beneficiaries who are receiving or are entitled to receive benefits under the plan. This does not include any individual to whom an insurance company has made an irrevocable commitment to pay all the benefits to which the beneficiaries of that individual are entitled under the plan.

Line 6g. Enter the number of participants included on line 6f (total participants at the end of the plan year) who have account balances. For example, for a Code section 401(k) plan the number entered on line 6g should be the number of participants counted on line 6f who have made a contribution, or for whom a contribution has been made, to the plan for this plan year or any prior plan year. Defined benefit plans should leave line 6g blank.

Line 6h. Include any individual who terminated employment during this plan year, whether or not he or she (a) incurred a break in service, (b) received an irrevocable commitment from an insurance company to pay all the benefits to which he or she is entitled under the plan, and/or (c) received a cash distribution or deemed cash distribution of his or her nonforfeitable accrued benefit. Multiemployer plans and multiple-employer plans that are collectively bargained do not have to complete line 6h.

Line 7. Only multiemployer plans should complete line 7. Multiemployer plans must enter the total number of employers obligated to contribute to the plan. For purposes of line 7 of the Form 5500, an employer obligated to contribute is defined as an employer who, during the 2021 plan year, is a party to the collective bargaining agreement(s) pursuant to which the plan is maintained or who may otherwise be subject to withdrawal liability pursuant to ERISA section 4203. Any two or more contributing entities (e.g., places of business with separate collective bargaining agreements) that have the same nine-digit employer identification number (EIN) must be aggregated and counted as one employer for this purpose.

Line 8 - Benefits Provided Under the Plan. In the boxes for line 8a and 8b, as appropriate, enter all applicable plan characteristics codes that applied during the reporting year from the List of Plan Characteristics Codes on pages 19 and 20 that describe the characteristics of the plan being reported.

Note. In the case of an eligible combined plan under Code section 414(x) and ERISA section 210(e), the codes entered in line 8a must include any codes applicable for either the defined benefit pension features or the defined contribution pension features of the plan.

F or plan sponsors of Puerto Rico plans, enter characteristic code 3C only if:

only Puerto Rico residents participate,
the trust is exempt from income tax under the laws of Puerto Rico, and
the plan administrator has not made the election under ERISA section 1022(i)(2), and, therefore, the plan is not intended to qualify under section 401(a) of the Internal Revenue Code (U.S).

Line 9 - Funding and Benefit Arrangements. Check all boxes that apply to indicate the funding and benefit arrangements used during the plan year. The ‘‘funding arrangement’’ is the method for the receipt, holding, investment, and transmittal of plan assets prior to the time the plan actually provides benefits. The ‘‘benefit arrangement’’ is the method by which the plan provides benefits to participants. For purposes of line 9:

‘‘Insurance’’ means the plan has an account, contract, or policy with an insurance company, insurance service, or other similar organization (such as Blue Cross, Blue Shield, or a health maintenance organization) during the plan or DFE year. (This includes investments with insurance companies such as guaranteed investment contracts (GICs).) An annuity account arrangement under Code section 403(b)(1) that is required to complete the Form 5500 should mark “insurance” for both the plan funding arrangement and plan benefit arrangement. Do not check ‘‘insurance’’ if the sole function of the insurance company was to provide administrative services.

‘‘Code section 412(e)(3) insurance contracts’’ are contracts that provide retirement benefits under a plan that are guaranteed by an insurance carrier. In general, such contracts must provide for level premium payments over the individual’s period of participation in the plan (to retirement age), premiums must be timely paid as currently required under the contract, no rights under the contract may be subject to a security interest, and no policy loans may be outstanding. If a plan is funded exclusively by the purchase of such contracts, the otherwise applicable minimum funding requirements of section 412 of the Code and section 302 of ERISA do not apply for the year and neither the Schedule MB nor the Schedule SB is required to be filed.

‘‘Trust’’ includes any fund or account that receives, holds, transmits, or invests plan assets other than an account or policy of an insurance company. A custodial account arrangement under Code section 403(b)(7) that is required to complete the Form 5500 should mark “trust” for both the plan funding arrangement and the plan benefit arrangement.

‘‘General assets of the sponsor’’ means either the plan had no assets or some assets were commingled with the general assets of the plan sponsor prior to the time the plan actually provided the benefits promised.

Example. If the plan holds all its assets invested in registered investment companies and other non-insurance company investments until it purchases annuities to pay out the benefits promised under the plan, box 9a(3) should be checked as the funding arrangement and box 9b(1) should be checked as the benefit arrangement.

Note. An employee benefit plan that checks boxes 9a(1), 9a(2), 9b(1), and/or 9b(2) must attach Schedule A (Form 5500), Insurance Information, to provide information concerning each contract year ending with or within the plan year. See the instructions to the Schedule A and enter the number of Schedules A on line 10b(3), if applicable.

Line 10. Check the boxes on line 10 to indicate the schedules being filed and, where applicable, count the schedules and enter the number of attached schedules in the space provided.

Form M-1 Compliance Information (to be provided by all welfare plans).

Line 11a. All plans providing welfare benefits must complete Part III, line 11a by answering either “Yes” or “No”. Do not leave the answer blank. If the plan is a multiple-employer welfare arrangement or an Entity Claiming Exception (ECE) subject to the Form M-1, Report for Multiple-Employer Welfare Arrangements (MEWAs) and Certain Entities Claiming Exception (ECEs) filing requirements, check “Yes” and complete line 11, elements 11b and 11c. If the answer is “No,” skip elements 11b and 11c of line 11.

Generally, a Form M-1 must be filed each year by March 1^st following the calendar year in which a plan operates subject to the Form M-1 filing requirement. (For example, a plan MEWA that was operating in 2021 must file the 2021 Form M-1 annual report by March 1, 2022.) In addition, Form M-1 filings are necessary in the case of certain registration, origination, or special events. See the instructions for Form M-1 at http://www.askebsa.dol.gov/mewa, and 29 CFR 2520.101-2 for more information regarding the Form M-1 filing requirements for plan MEWAs and ECEs.

Line 11b. All plans that answered ‘‘Yes’’ in line 11a must complete line 11b by answering either ‘‘Yes’’ or ‘‘No.’’ Do not leave the answer blank.

Line 11c. All plans that answered ‘‘Yes’’ in line 11a must enter a Receipt Confirmation Code for the 2021 Form M–1 annual report that was required to be filed with the Department of Labor under the Form M–1 filing requirements. The Receipt Confirmation Code is a unique code generated by the Form M–1 electronic filing system. You can find this code under the ‘‘completed filings’’ area when you log into your Form M–1 electronic filing system at http://www.askebsa.dol.gov/mewa.

If a plan that is subject to the Form M-1 filing requirements was not required to file a 2021 Form M–1 annual report, enter the Receipt Confirmation Code for the most recent Form M–1 that was required to be filed under the Form M–1 filing requirements on or before the date of filing the 2021 Form 5500. (For example, if a plan was not required to file a 2021 Form M–1 annual report by March 1, 2022 for the 2021 calendar year because it experienced a registration event between October 1 and December 31, 2021, and made a timely Form M–1 registration filing, the plan must enter on line 11c of the 2021 Form 5500 the Receipt Confirmation Code issued for the Form M–1 registration filing.)

A welfare benefit plan’s failure to answer line 11a, and if applicable, lines 11b and 11c, or enter a valid Receipt Confirmation Code in line 11c, will subject the Form 5500 filing to rejection as incomplete and civil penalties may be assessed pursuant to ERISA Section 502(c)(2) and 29 CFR 2560.502c-2.

LIST OF PLAN CHARACTERISTICS CODES FOR LINES 8a AND 8b

CODE	Defined Benefit Pension Features
1A	Benefits are primarily pay related.
1B	Benefits are primarily flat dollar (includes dollars per year of service).
1C	Cash balance or similar plan – Plan has a “cash balance” formula. For this purpose, a “cash balance” formula is a benefit formula in a defined benefit plan by whatever name (for example, personal account plan, pension equity plan, life cycle plan, cash account plan, etc.) that rather than, or in addition to, expressing the accrued benefit as a life annuity commencing at normal retirement age, defines benefits for each employee in terms more common to a defined contribution plan such as a single sum distribution amount (for example, 10% of final average pay times years of service, or the amount of the employee’s hypothetical account balance).
1D	Floor-offset plan – to offset for retirement benefits provided by an employer-sponsored defined contribution plan.
1E	Code section 401(h) arrangement – Plan contains separate accounts under Code section 401(h) to provide employee health benefits.
1F	Code section 414(k) arrangement – Benefits are based partly on the balance of the separate account of the participant (also include appropriate defined contribution pension feature codes).
1H	Plan covered by PBGC that was terminated and closed out for PBGC purposes – Before the end of the plan year (or a prior plan year), (1) the plan terminated in a standard (or distress) termination and completed the distribution of plan assets in satisfaction of all benefit liabilities (or all ERISA Title IV benefits for distress termination); or (2) a trustee was appointed for a terminated plan pursuant to ERISA section 4042.
1I	Frozen plan – As of the last day of the plan year, the plan provides that no participant will get any new benefit accrual (whether because of service or compensation).
CODE	Defined Contribution Pension Features
2A	Use this code if employer contributions in the return year were based on one of the following allocation types: Age/service weighted or new comparability or similar plan – Age/service weighted plan: Allocations are based on age, service, or age and service. New comparability or similar plan: Allocations are based on participant classifications and a classification(s) consists entirely or predominantly of highly compensated employees; or the plan provides an additional allocation rate on compensation above a specified threshold, and the threshold or additional rate exceeds the maximum threshold or rate allowed under the permitted disparity rules of Code section 401(l).
2B	Target benefit plan.
2C	Money purchase (other than target benefit) plan.
2D	Offset plan – Plan benefits are subject to offset for retirement benefits provided in another plan or arrangement of the employer.
2E	Profit-sharing plan.
2F	ERISA section 404(c) plan – This plan, or any part of it, is intended to meet the conditions of 29 CFR 2550.404c-1.
2G	Total participant-directed account plan – Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
2H	Partial participant-directed account plan – Participants have the opportunity to direct the investment of a portion of the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
2I	Stock bonus.
2J	Code section 401(k) feature – A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
2K	Code section 401(m) arrangement – Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contributions to the plan. Not applicable if plan is a Code section 401(k) plan with only QNECs and/or QMACs. Also not applicable if plan is a Code section 403(b)(1), 403(b)(7), or 408 arrangement/accounts annuities.
2L	An annuity contract purchased by Code section 501(c)(3) organization or public school as described in Code section 403(b)(1) arrangement.”
2M	Custodial accounts for regulated investment company stock as described in Code section 403(b)(7).
2N	Code section 408 accounts and annuities – See Limited Pension Plan Reporting instructions for pension plan utilizing Code section 408 individual retirement accounts or annuities as the funding vehicle for providing benefits.
2O	ESOP other than a leveraged ESOP.
2P	Leveraged ESOP – An ESOP that acquires employer securities with borrowed money or other debt-financing techniques.
2Q	The employer maintaining this ESOP is an S corporation.
2R	Participant-directed brokerage accounts provided as an investment option under the plan.
2S	401(k) plan or 403(b) plan that provides for automatic enrollment in plan that has elective contributions deducted from payroll
2T	Total or partial participant-directed account plan – plan uses default investment account for participants who fail to direct assets in their account.
CODE	Other Pension Benefit Features
3B	Use this code if the plan covered self-employed individuals in the return year.
3C	Plan not intended to be qualified - A plan not intended to be qualified under Code sections 401, 403, or 408.
3D	Pre-approved pension plan - A pre-approved plan under sections 401, 403(a), and 4975(e)(7) of the Code that is subject to a favorable opinion letter from the IRS.
3F	Plan sponsor(s) received services of leased employees, as defined in Code section 414(n), during the plan year.

LIST OF PLAN CHARACTERISTICS CODES FOR LINES 8a AND 8b (Continued)

3H	Plan sponsor(s) is (are) a member(s) of a controlled group under Code section 414(b) or (c) or of an affiliated service group under section 414(m).
3I	Plan requiring that all or part of employer contributions be invested and held, at least for a limited period, in employer securities.
3J	U.S.-based plan that covers residents of Puerto Rico and is qualified under both Code section 401 and section 1165 of the Internal Revenue Code of Puerto Rico.
CODE	Welfare Benefit Features
4A	Health (other than vision or dental).
4B	Life insurance.
4C	Supplemental unemployment.
4D	Dental.
4E	Vision.
4F	Temporary disability (accident and sickness).
4G	Prepaid legal.
4H	Long-term disability.
4I	Severance pay.
4J	Apprenticeship and training.

4K	Scholarship (funded).
4L	Death benefits (include travel accident but not life insurance).
4P	Taft-Hartley Financial Assistance for Employee Housing Expenses.
4Q	Other.
4R	Unfunded, fully insured, or combination unfunded/fully insured welfare plan that will not file an annual report for next plan year pursuant to 29 CFR 2520.104-20.
4S	Unfunded, fully insured, or combination unfunded/fully insured welfare plan that stopped filing annual reports in an earlier plan year pursuant to 29 CFR 2520.104-20.
4T	10 or more employer plan under Code section 419A(f)(6).
4U	Collectively-bargained welfare benefit arrangement under Code section 419A(f)(5).

2021 Instructions for Schedule A

(Form 5500)

Insurance Information

General Instructions

Who Must File

Schedule A (Form 5500) must be attached to the Form 5500 filed for every defined benefit pension plan, defined contribution pension plan, and welfare benefit plan required to file a Form 5500 if any benefits under the plan are provided by an insurance company, insurance service, or other similar organization (such as Blue Cross, Blue Shield, or a health maintenance organization). This includes investment contracts with insurance companies such as guaranteed investment contracts (GICs). In addition, Schedules A must be attached to a Form 5500 filed for GIAs, MTIAs, and 103-12 IEs for each insurance or annuity contract held in the MTIA, or 103-12 IE or by the GIA.

I f Form 5500 line 9a(1), 9a(2), 9b(1), or 9b(2) is checked, indicating that either the plan funding arrangement or plan benefit arrangement includes an account, policy, or contract with an insurance company (or similar organization), at least one Schedule A would be required to be attached to the Form 5500 filed for a pension or welfare plan to provide information concerning the contract year ending with or within the plan year.

Do not file Schedule A for a contract that is an Administrative Services Only (ASO) contract, a fidelity bond or policy, or a fiduciary liability insurance policy. Also, if a Schedule A for a contract or policy is filed as part of a Form 5500 for an MTIA or 103-12 IE that holds the contract, do not include a Schedule A for the contract or policy on the Form 5500s filed for the plans participating in the MTIA or 103-12 IE.

Check the Schedule A box on the Form 5500 (Part II, line 10b(3)), and enter the number attached in the space provided if one or more Schedules A are attached to the Form 5500.

Specific Instructions

Information entered on Schedule A should pertain to the insurance contract or policy year ending with or within the plan year (for reporting purposes, a year cannot exceed 12 months).

Example. If an insurance contract year begins on July 1 and ends on June 30, and the plan year begins on January 1 and ends on December 31, the information on the Schedule A attached to the 2021 Form 5500 should be for the insurance contract year ending on June 30, 2021.

Exception. If the insurance company maintains records on the basis of a plan year rather than a policy or contract year, the information entered on Schedule A may pertain to the plan year instead of the policy or contract year.

Include only the contracts issued to or held by the plan, GIA, MTIA, or 103-12 IE for which the Form 5500 is being filed.

Lines A, B, C, and D. This information must be the same as reported in Part II of the Form 5500 to which this Schedule A is attached.

Do not use a social security number in lieu of an EIN. The Schedule A and its attachments are open to public inspection, and the contents are public information and are subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on this Schedule A or any of its attachments may result in the rejection of the filing.

You can apply for an EIN from the IRS online, by fax, or by mail depending on how soon you need to use the EIN. For more information, see Section 3: Electronic Filing Requirement under General Instructions to Form 5500. The EBSA does not issue EINs.

Part I – Information Concerning Insurance Contract Coverage, Fees, and Commissions

Line 1(c). Enter the code number assigned by the National Association of Insurance Commissioners (NAIC) to the insurance company. If none has been assigned, enter zeros “0” in the spaces provided.

Line 1(d). If individual policies with the same carrier are grouped as a unit for purposes of this report, and the group does not have one identification number, you may use the contract or identification number of one of the individual contracts, provided this number is used consistently to report these contracts as a group and the plan administrator maintains the records necessary to disclose all the individual contract numbers in the group upon request. Use separate Schedules A to report individual contracts that cannot be grouped as a unit.

Line 1(e). Since plan coverage may fluctuate during the year, the administrator should estimate the number of persons that were covered by the contract at the end of the policy or contract year. Where contracts covering individual employees are grouped, compute entries as of the end of the plan year.

Line 1(f) and (g). Enter the beginning and ending dates of the policy year for the contract identified in 1(d). Leave 1(f) blank if separate contracts covering individual employees are grouped.

Line 2. Report on line 2 the total of all insurance fees and commissions directly or indirectly attributable to the contract or policy placed with or retained by the plan.

Totals. Enter on line 2 the total of all such commissions and fees paid to agents, brokers, and other persons listed on line 3. Complete a separate line 3 item (elements (a) through (e)) for each person listed.

For purposes of lines 2 and 3, commissions and fees include sales and base commissions and all other monetary and non-monetary forms of compensation where the broker’s agent’s, or other person’s eligibility for the payment or the amount of the payment is based, in whole or in part, on the value (e.g., policy amounts, premiums) of contracts or policies (or classes thereof) placed with or retained by an ERISA plan, including, for example, persistency and profitability bonuses. The amount (or pro rata share of the total) of such commissions or fees attributable to the contract or policy placed with or retained by the plan must be reported in line 2 and in line 3, element (b) and/or (c), as appropriate.

Insurers must provide plan administrators with a proportionate allocation of commissions and fees attributable to each contract. Any reasonable method of allocating commissions and fees to policies or contracts is acceptable, provided the method is disclosed to the plan administrator. A reasonable allocation method could, in the Department of Labor’s view, allocate fees and commissions to a Schedule A based on a calendar year calculation even if the plan year or policy year was not a calendar year. For additional information on these Schedule A reporting requirements, see ERISA Advisory Opinion 2005-02A, available on the Internet at www.dol.gov/ebsa.

Where benefits under a plan are purchased from and guaranteed by an insurance company, insurance service, or other similar organization, and the contract or policy is reported on a Schedule A, payments of reasonable monetary compensation by the insurer out of its general assets to affiliates or third parties for performing administrative activities necessary for the insurer to fulfill its contractual obligation to provide benefits, where there is no direct or indirect charge to the plan for the administrative services other than the insurance premium, then the payments for administrative services by the insurer to the affiliates or third parties do not need to be reported on lines 2 and 3 of Schedule A. This would include compensation for services such as recordkeeping and claims processing services provided by a third party pursuant to a contract with the insurer to provide those services but would not include compensation provided by the insurer incidental to the sale or renewal of a policy, such as finder’s fees, insurance brokerage commissions and fees, or similar fees.

Schedule A reporting also is not required for compensation paid by the insurer to a “general agent” or “manager” for that general agent’s or manager’s management of an agency or performance of administrative functions for the insurer. For this purpose, (1) a “general agent” or “manager” does not include brokers representing insureds, and (2) payments would not be treated as paid for managing an agency or performance of administrative functions where the recipient’s eligibility for the payment or the amount of the payment is dependent or based on the value (e.g., policy amounts, premiums) of contracts or policies (or classes thereof) placed with or retained by ERISA plan(s).

Schedule A reporting is not required for occasional non-monetary gifts or meals of insubstantial value that are tax deductible for federal income tax purposes by the person providing the gift or meal and would not be taxable income to the recipient. For this exemption to be available, the gift or gratuity must be both occasional and insubstantial. For this exemption to apply, the gift must be valued at less than $50, the aggregate value of gifts from one source in a calendar year must be less than $100, but gifts with a value of less than $10 do not need to be counted toward the $100 annual limit. If the $100 aggregate value limit is exceeded, then the aggregate value of all the gifts will be reportable. For this purpose, non-monetary gifts of less than $10 also do not need to be included in calculating the aggregate value of all gifts required to be reported if the $100 limit is exceeded.

Gifts from multiple employees of one service provider should be treated as originating from a single source when calculating whether the $100 threshold applies. On the other hand, in applying the threshold to an occasional gift received from one source by multiple employees of a single service provider, the amount received by each employee should be separately determined in applying the $50 and $100 thresholds. For example, if six employees of a broker attend a business conference put on by an insurer designed to educate and explain the insurer’s products for employee benefit plans, and the insurer provides, at no cost to the attendees, refreshments valued at $20 per individual, the gratuities would not be reportable on lines 2 and 3 of the Schedule A even though the total cost of the refreshments for all the employees would be $120.

These thresholds are for purposes of Schedule A reporting. Filers are cautioned that the payment or receipt of gifts and gratuities of any amount by plan fiduciaries may violate ERISA and give rise to civil liabilities and criminal penalties.

Line 3. Identify agents, brokers, and other persons individually in descending order of the amount paid. Complete as many entries as necessary to report all required information. Complete elements (a) through (e) for each person as specified below.

Element (a). Enter the name and address of the agents,
brokers, or other persons to whom commissions or fees were paid.

Element (b). Report all sales and base commissions here. For purposes of this element, sales and/or base commissions are monetary amounts paid by an insurer that are charged directly to the contract or policy and that are paid to a licensed agent or broker for the sale or placement of the contract or policy. All other payments should be reported in element (c) as fees.

Element (c). Fees to be reported here represent payments by an insurer attributable directly or indirectly to a contract or policy to agents, brokers, and other persons for items other than sales and/or base commissions (e.g., service fees, consulting fees, finders fees, profitability and persistency bonuses, awards, prizes, and non-monetary forms of compensation). Fees paid to persons other than agents and brokers should be reported here, not in Parts II and III on Schedule A as acquisition costs, administrative charges, etc.

Element (d). Enter the purpose(s) for which fees were paid.

Element (e). Enter the most appropriate organization code for the broker, agent, or other person entered in element (a).

Code Type of Organization

1 Banking, Savings & Loan Association, Credit Union, or other similar financial institution

2 Trust Company

3 Insurance Agent or Broker

4 Agent or Broker other than insurance

5 Third party administrator

6 Investment Company/Mutual Fund

7 Investment Manager/Adviser

8 Labor Union

9 Foreign entity (e.g., an agent or broker, bank, insurance company, etc., not operating within the jurisdictional boundaries of the United States)

0 Other

For plans, GIAs, MTIAs, and 103-12 IEs required to file Part I of Schedule C, commissions and fees listed on the Schedule A are not required to be reported again on Schedule C. The amount of the compensation that must be reported on Schedule A must, however, be taken into account in determining whether the agent’s, broker’s, or other person’s direct or indirect compensation in relation to the plan or DFE is $5,000 or more and, thus, requiring the compensation not listed on the Schedule A to be reported on the Schedule C. See FAQs about the Schedule C available on the EBSA website at www.dol.gov/ebsa/faqs.

Part II – Investment and Annuity Contract Information

Line 4. Enter the current value of the plan’s interest at year end in the contract reported on line 7, e.g., deposit administration (DA), immediate participation guarantee (IPG), or guaranteed investment contracts (GIC).

Exception. Contracts reported on line 7 need not be included on line 4 if (1) the Schedule A is filed for a defined benefit pension plan and the contract was entered into before March 20, 1992, or (2) the Schedule A is filed for a defined contribution pension plan and the contract is a fully benefit-responsive contract, i.e., it provides a liquidity guarantee by a financially responsible third party of principal and previously accrued interest for liquidations, transfers, loans, or hardship withdrawals initiated by plan participants exercising their rights to withdraw, borrow, or transfer funds under the terms of a defined contribution plan that does not include substantial restrictions to participants’ access to plan funds.

Important Reminder. Plans may treat multiple individual annuity contracts, including Code section 403(b)(1) annuity contracts, issued by the same insurance company as a single group contract for reporting purposes on Schedule A.

Line 6a. The rate information called for here may be furnished by attaching the appropriate schedules of current rates filed with the appropriate state insurance department or by providing a statement regarding the basis of the rates. Enter “see attached” if appropriate.

Lines 7a through 7f. Report contracts with unallocated funds. Do not include portions of these contracts maintained in separate accounts. Show deposit fund amounts rather than experience credit records when both are maintained.

Part III – Welfare Benefit Contract Information

Line 8i. Report a stop-loss insurance policy that is an asset of the plan.

Note. Employers sponsoring welfare plans may purchase a stop-loss insurance policy with the employer as the insured to help the employer manage its risk associated with its liabilities under the plan. These employer contracts with premiums paid exclusively out of the employer’s general assets without any employee contributions generally are not plan assets and are not reportable on Schedule A.

Part IV – Provision of Information

The insurance company, insurance service, or other similar organization is required under ERISA section 103(a)(2) to provide the plan administrator with the information needed to complete this return/report. If you do not receive this information in a timely manner, contact the insurance company, insurance service, or other similar organization.

Lines 11 and 12. If information is missing on Schedule A due to a refusal by the insurance company, insurance service, or other similar organization to provide information, check “Yes” on line 11 and enter a description of the information not provided on line 12. If you received all the information necessary to receive the Schedule A, check “No” and leave line 12 blank.

As noted above, the insurance company, insurance service, or other similar organization is statutorily required to provide you with all of the information necessary to complete the Schedule A, but need not provide the information on a Schedule A itself.

2021 Instructions for Schedule C

(Form 5500)

Service Provider Information

General Instructions

Who Must File

Schedule C (Form 5500) must be attached to a Form 5500 filed for a large pension or welfare benefit plan, an MTIA, a 103-12 IE, or a GIA to report certain information concerning service providers. Remember to check the Schedule C box on the Form 5500 (Part II, line 10b(4)) if a Schedule C is attached to the Form 5500.

Part I of the Schedule C must be completed to report persons who rendered services to or who had transactions with the plan (or with the DFE in the case of a Schedule C filed by a DFE) during the reporting year if the person received, directly or indirectly, $5,000 or more in reportable compensation in connection with services rendered or their position with the plan or DFE, except:

1. Employees of the plan whose only compensation in relation to the plan was less than $25,000 for the plan year;

2. Employees of the plan sponsor or other business entity where the plan sponsor or business entity is reported on the Schedule C as a service provider, provided the employee did not separately receive reportable direct or indirect compensation in relation to the plan;

3. Persons whose only compensation in relation to the plan consists of insurance fees and commissions listed in a Schedule A filed for the plan; and

4. Payments made directly by the plan sponsor that are not reimbursed by the plan. In the case of a multiemployer or multiple-employer plan, where the “plan sponsor” would be the joint board of trustees for the plan, payments by contributing employers, directly or through an employer association, or by participating employee organizations, should be treated the same as payments by a plan sponsor.

Only line 1 of Part I of the Schedule C must be completed for persons who received only “eligible indirect compensation” as defined below.

Part II of the Schedule C must be completed to report service providers who fail or refuse to provide information necessary to complete Part I of this Schedule.

Part III of the Schedule C must be completed to report a termination in the appointment of an accountant or enrolled actuary during the 2021 plan year.

For plans, GIAs, MTIAs, and 103-12 IEs required to file Part I of Schedule C, commissions and fees listed on the Schedule A are not required to be reported again on Schedule C. The amount of the compensation that must be reported on Schedule A must, however, be taken into account in determining whether the service provider’s direct or indirect compensation in relation to the plan or DFE is $5,000 or more and, thus, requiring the compensation not listed on the Schedule A to be reported on the Schedule C. See FAQs about the Schedule C available on the EBSA website at www.dol.gov/ebsa/faqs.

H ealth and welfare plans that meet the conditions of the limited exemption at 29 CFR 2520.104-44 or Technical Release 92-01 are not required to complete and file a Schedule C.

Lines A, B, C, and D. This information must be the same as reported in Part II of the Form 5500 to which this Schedule C is attached.

Do not use a social security number in line D in lieu of an EIN. The Schedule C and its attachments are open to public inspection, and the contents are public information subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on this Schedule C or any of its attachments may result in the rejection of the filing.

You can apply for an EIN from the IRS online, by fax, or by mail depending on how soon you need to use the EIN. For more information, see Section 3: Electronic Filing Requirement under General Instructions to Form 5500. The EBSA does not issue EINs.

Do not list the PBGC or the IRS on Schedule C as service providers.

Either the cash or accrual basis may be used for the recognition of transactions reported on the Schedule C as long as you use one method consistently.

If service provider compensation is reported on a Schedule C filed as a part of a Form 5500 filed for a MTIA or a 103-12 IE, do not report the same compensation again on the Schedule C filed for the plans that participate in the MTIA or 103-12 IE.

Specific Instructions

Part I – Service Provider Information

You must enter the information required for each person who rendered services to or had transactions with the plan and who received $5,000 or more in total direct or indirect compensation in connection with services rendered to the plan or the person’s position with the plan during the plan year.

Example. A plan had service providers, A, B, C, and D, who received $12,000, $6,000, $4,500, and $430, respectively, in direct and indirect compensation from the plan. Service providers A and B must be identified separately by name, EIN, etc. As service providers C and D each received less than $5,000, they do not need to be reported on the Schedule C.

For Schedule C purposes, reportable compensation includes money and any other thing of value (for example, gifts, awards, trips) received by a person, directly or indirectly, from the plan (including fees charged as a percentage of assets and deducted from investment returns) in connection with services rendered to the plan, or the person’s position with the plan. The term “person” for this purpose includes individuals, trades and businesses (whether incorporated or unincorporated). See ERISA section 3(9).

Direct Compensation: Payments made directly by the plan for services rendered to the plan or because of a person’s position with the plan are reportable as direct compensation. Direct payments by the plan would include, for example, direct payments by the plan out of a plan account, charges to plan forfeiture accounts and fee recapture accounts, charges to a plan’s trust account before allocations are made to individual participant accounts, and direct charges to plan participant individual accounts. Payments made by the plan sponsor, which are not reimbursed by the plan, are not subject to Schedule C reporting requirements even if the sponsor is paying for services rendered to the plan.

Indirect Compensation: Compensation received from sources other than directly from the plan or plan sponsor is reportable on Schedule C as indirect compensation from the plan if the compensation was received in connection with services rendered to the plan during the plan year or the person’s position with the plan. For this purpose, compensation is considered to have been received in connection with services rendered to the plan or the person’s position with the plan if the person’s eligibility for a payment is based, in whole or in part, on services that were rendered to the plan or on a transaction or series of transactions with the plan. Indirect compensation would not include compensation that would have been received had the service not been rendered or the transaction had not taken place and that cannot be reasonably allocated to the services performed or transaction(s) with the plan.

Persons that provide investment management, recordkeeping, claims processing, participant communication, brokerage, and other services to the plan as part of an investment contract or transaction are considered to be providing services to the plan for purposes of Schedule C reporting and would be required to be identified in Part I if they received $5,000 or more in reportable compensation for providing those services.

Examples of reportable indirect compensation include fees and expense reimbursement payments received by a person from mutual funds, bank commingled trusts, insurance company pooled separate accounts, and other separately managed accounts and pooled investment funds in which the plan invests that are charged against the fund or account and reflected in the value of the plan’s investment (such as management fees paid by a mutual fund to its investment adviser, sub-transfer agency fees, shareholder servicing fees, account maintenance fees, and 12b-1 distribution fees). The investment of plan assets and payment of premiums for insurance contracts, however, are not in and of themselves payments for services rendered to the plan for purposes of Schedule C reporting and the investment and payment of premiums themselves are not reportable compensation for purposes of Part I of the Schedule C.

In the case of charges against an investment fund, reportable “indirect compensation” includes, for example, the fund’s investment adviser asset-based investment management fee from the fund, brokerage commissions and fees charged in connection with purchases and sales of interests in the fund, fees related to purchases and sales of interests in the fund (including 12b-1 fees), fees for providing services to plan investors or plan participants such as communication and other shareholder services, and fees relating to the administration of the employee benefit plan such as recordkeeping services, Form 5500 return/report filing and other compliance services. Amounts charged against the fund for other ordinary operating expenses, such as attorneys’ fees, accountants’ fees, printers fees, are not reportable indirect compensation for Schedule C purposes. Also, brokerage costs associated with a broker-dealer effecting securities transactions within the portfolio of a mutual fund or for the portfolio of an investment fund that holds “plan assets” for ERISA purposes should be treated for Schedule C purposes as an operating expense of the investment fund, not reportable indirect compensation paid to a plan service provider or in connection with a transaction with the plan.

Other examples of reportable indirect compensation are finder’s fees, float revenue, brokerage commissions (regardless of whether the broker is granted discretion), research or other products or services, other than execution, received from a broker-dealer or other third party in connection with securities transactions (soft dollars), and other transaction based fees received in connection with transactions or services involving the plan whether or not they are capitalized as investment costs.

For more information, see FAQs about the Schedule C, available on the EBSA website at www.dol.gov/ebsa/faqs.

Special rules for non-monetary compensation of insubstantial value, guaranteed benefit insurance policies, bundled service arrangements, and allocating compensation among multiple plans:

Excludable Non-Monetary Compensation: You may exclude non-monetary compensation of insubstantial value (such as gifts or meals of insubstantial value) that is tax deductible for federal income tax purposes by the person providing the gift or meal and would not be taxable income to the recipient. The gift or gratuity must be valued at less than $50, and the aggregate value of gifts from one source in a calendar year must be less than $100, but gifts with a value of less than $10 do not need to be counted toward the $100 limit. If the $100 aggregate value limit is exceeded, then the value of all the gifts over $10 will be reportable. Gifts received by one person from multiple employees of one entity must be treated as originating from a single source when calculating whether the $100 threshold applies. On the other hand, gifts received from one person by multiple employees of one entity can be treated as separate compensation when calculating the $50 and $100 thresholds. For more information, see FAQs about the Schedule C, available on the EBSA website at www.dol.gov/ebsa/faqs.

These thresholds are for purposes of Schedule C reporting only. Filers are strongly cautioned that gifts and gratuities of any amount paid to or received by plan fiduciaries may violate ERISA and give rise to civil liabilities and criminal penalties.

Fully Insured Group Health and Similarly Fully Insured Benefits: Where benefits under a plan are purchased from and guaranteed by an insurance company, insurance service, or other similar organization, and the contract or policy is reported on a Schedule A, payments of reasonable monetary compensation by the insurer out of its general assets to persons for performing administrative activities necessary for the insurer to fulfill its contractual obligation to provide benefits, where there is no direct or indirect charge to the plan for the administrative services other than the insurance premium, would not be treated as indirect compensation for services provided to the plan for Schedule C reporting purposes. This would include compensation for services such as recordkeeping and claims processing services provided by a third party pursuant to a contract with the insurer to provide those services, but would not include compensation provided by the insurer incidental to the sale or renewal of a policy, such as finder’s fees, insurance brokerage commissions and fees, or similar fees. Insurance investment contracts are not eligible for this exception.

Bundled Service Arrangements: For Schedule C

reporting purposes, a bundled service arrangement includes any service arrangements where the plan hires one company to provide a range of services either directly from the company, through affiliates or subcontractors, or through a combination, which are priced to the plan as a single package rather than on a service-by-service basis. A bundled service arrangement would also include an investment transaction in which the plan receives a range of services either directly from the investment provider, through affiliates or subcontractors, or through a combination.

Direct payments by the plan to the bundled service provider should be reported as direct compensation to the bundled service provider. Such direct payments by the plan do not need to be allocated among affiliates or subcontractors and do not need to be reported as indirect compensation received by the affiliates or subcontractors unless the amount paid to the affiliate or subcontractor is set on a per transaction basis, e.g., brokerage fees and commissions.

Fees charged to the plan’s investment and reflected in the net value of the investment, such as management fees paid by mutual funds to their investment advisers, float revenue, commissions (including “soft dollars”), finder’s fees, 12b-1 distribution fees, account maintenance fees, and shareholder servicing fees, must, subject to the alternative reporting option for “eligible indirect compensation,” described below, be treated as separate reportable compensation by the person receiving the fee for purposes of Schedule C reporting.

For each person who is a fiduciary to the plan or provides one or more of the following services to the plan – contract administrator, consulting, investment advisory (plan or participants), investment management, securities brokerage, or recordkeeping – commissions and other transaction based fees, finder’s fees, float revenue, soft dollar and other non-monetary compensation, would also be required to be treated as separate compensation for Schedule C purposes even if those fees were paid from mutual fund management fees or other fees charged to the plan’s investment and reflected in the net value of the investment.

Other revenue sharing payments among members of a bundled service arrangement do not need to be allocated among affiliates or subcontractors and treated as indirect compensation received by the affiliates or subcontractors in determining whether the affiliate or subcontractor must be separately identified on line 2 of the Schedule C.

Shape9 Shape10 For more information about bundled arrangements for reporting purposes, see FAQs about the Schedule C, available on the EBSA website at www.dol.gov/ebsa/faqs.

Allocating Compensation Among Multiple Plans: Where reportable compensation is received by a person in connection with several plans or DFEs, any reasonable method of allocating the compensation among the plans or DFEs may be used provided that the allocation method is disclosed to the plan administrator. In calculating the $5,000 threshold for purposes of determining whether a person must be identified in Part I, include the amount of compensation received by the person that is attributable to the plan or DFE filing the Form 5500, not the aggregate amount received in connection with all the plans or DFEs.

Affiliates: For purposes of Schedule C reporting, an “affiliate” of a person includes any person, directly or indirectly, through one or more intermediaries, controlling, controlled by, or under common control with the person applying principles consistent with the regulations prescribed under section 414(c) of the Code.

Line 1. Check “Yes” or “No” on line 1a to indicate whether you are relying on the alternative reporting option for a person or persons who received only “eligible indirect compensation.” If you check “Yes” on line 1a, provide as many entries in line 1b as necessary to identify the person or persons who provided you with the necessary disclosures regarding the eligible indirect compensation. If any indirect compensation is either not of the type described below or if the plan did not receive the written disclosures described below, the indirect compensation is not “eligible indirect compensation” for purposes of Part 1.

(1) Eligible Indirect Compensation: The types of indirect compensation that can be treated as eligible indirect compensation are indirect compensation that is fees or expense reimbursement payments charged to investment funds and reflected in the value of the investment or return on investment of the participating plan or its participants, finder’s fees, “soft dollar” revenue, float revenue, and/or brokerage commissions or other transaction-based fees for transactions or services involving the plan that were not paid directly by the plan or plan sponsor (whether or not they are capitalized as investment costs).

Investment funds or accounts for this purpose would include mutual funds, bank commingled trusts, including common and collective trusts, insurance company pooled separate accounts, and other separately managed accounts and pooled investment vehicles in which the plan invests. Investment funds or accounts would also include separately managed investment accounts that contain assets of individual plans.

(2) Required Written Disclosures: For the types of indirect compensation described above to be treated as eligible indirect compensation for purposes of completing line 1, you must have received written materials that disclosed and described (a) the existence of the indirect compensation; (b) the services provided for the indirect compensation or the purpose for payment of the indirect compensation; (c) the amount (or estimate) of the compensation or a description of the formula used to calculate or determine the compensation; and (d) the identity of the party or parties paying and receiving the compensation. The written disclosures for a bundled arrangement must separately disclose and describe each element or indirect compensation that would be required to be separately reported if you were not relying on this alternative reporting option.

I f any person received eligible indirect compensation and either direct compensation and/or indirect compensation that does not meet the requirements of this line to be eligible indirect compensation, you cannot rely on the alternative reporting option for that person and must complete line 2 for each such person who received $5,000 or more in direct and indirect compensation.

Line 2. Except for those persons and eligible indirect compensation for which you answered “Yes” to line 1 above, complete as many entries as needed to list each person receiving, directly or indirectly, $5,000 or more in total direct and indirect compensation. Start with the most highly compensated and list in descending order of compensation. Enter in element (a) the person’s name and complete elements (a) through (h) as specified below. Use as many entries as necessary to list all persons and information required to be reported.

Element (a). Enter the EIN for the person identified in element (a). If the name of an individual is entered in element (a) and the individual does not have an EIN, enter the EIN of the individual’s employer. If the person is self-employed and does not have an EIN, you may enter the person’s address and telephone number. Do not use a social security number in lieu of an EIN. The Schedule C and its attachments are open to public inspection and are subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on this Schedule C or any of its attachments may result in the rejection of the filing.

Element (b). Select from the list below all codes that describe both the kind of services provided and the type of compensation received. Enter as many codes as apply:

Code Service/Compensation

10 Accounting (including auditing)

11 Actuarial

12 Claims processing

13 Contract Administrator

14 Plan Administrator

15 Recordkeeping and information management (computing,

tabulating, data processing, etc.)

16 Consulting (general)

17 Consulting (pension)

18 Custodial (other than securities)

19 Custodial (securities)

20 Trustee (individual)

21 Trustee (bank, trust company, or similar financial institution)

22 Insurance agents and brokers

23 Insurance services

24 Trustee (discretionary)

25 Trustee (directed)

26 Investment advisory (participants)

27 Investment advisory (plan)

28 Investment management

29 Legal

30 Employee (plan)

31 Named fiduciary

32 Real estate brokerage

33 Securities brokerage

34 Valuation (appraisals, etc.)

35 Employee (plan sponsor)

36 Copying and duplicating

37 Participant loan processing

38 Participant communication

40 Foreign entity (e.g., an agent or broker, bank, insurance

company, etc. not operating within jurisdictional boundaries of the United States)

49 Other services

50 Direct payment from the plan

51 Investment management fees paid directly by plan

52 Investment management fees paid indirectly by plan

53 Insurance brokerage commissions and fees

54 Sales loads (front end and deferred)

55 Other commissions

56 Non-monetary compensation

57 Redemption fees

58 Product termination fees (surrender charges, etc.)

59 Shareholder servicing fees

60 Sub-transfer agency fees

61 Finders’ fees/placement fees

62 Float revenue

63 Distribution (12b-1) fees

64 Recordkeeping fees

65 Account maintenance fees

66 Insurance mortality and expense charge

67 Other insurance wrap fees

68 “’Soft dollars’ commissions”

70 Consulting fees

71 Securities brokerage commissions and fees

72 Other investment fees and expenses

73 Other insurance fees and expenses

99 Other fees

Shape11 Element (c). Enter any relationship of the person identified in element (a) to the plan sponsor, to the participating employer or employee organization, or to any person known to be a party-in-interest, for example, employee of employer, vice-president of employer, union officer, affiliate of plan recordkeeper, etc.

Element (d). Enter the total amount of compensation received directly from the plan for services rendered to the plan during the plan year. If a service provider charges the plan a fee or commission, but agrees to offset the fee or commission with any revenue received from a party other than the plan or plan sponsor, for example, as part of a commission recapture or other offset arrangement, only the amount paid directly by the plan after any revenue sharing offset should be entered in element (d). Enter in element (d), as direct payments by the plan, amounts that a plan sponsor, or contributing employer or participating employee organization in the case of a multiemployer or multiple-employer plan, pays a plan third-party service provider that are reimbursed by the plan.

Note. Do not leave element (d) blank. If no direct compensation was received, enter “0”.

Element (e). Check “Yes” if the person identified in element (a), or any related person, received during the plan year indirect compensation in connection with the person’s position with the plan or services provided to the plan. (See instructions above on definition of indirect compensation.) If the answer is “No,” skip elements (f) through (h) for the person identified in element (a).

Element (f). Check “Yes” if any of the indirect compensation was eligible indirect compensation for which the plan received the necessary disclosures. See instructions for line 1 for definition of eligible indirect compensation. Check “No” if none of the indirect compensation was eligible indirect compensation.

Element (g). Enter the total of all indirect compensation that is not eligible indirect compensation for which the plan received the necessary disclosure. Do not leave blank. If none, enter “0”.

Element (h). Check “Yes” if the service provider, instead of an amount or an estimated amount, gave the plan a formula or other description of the method used to determine some or all of the indirect compensation received.

Line 3. For each person identified in line 2 who is a fiduciary to the plan or provides one or more of the following services to the plan – contract administrator, consulting custodial, investment advisory (plan or participants), investment management, broker, or recordkeeping – enter the requested information for each source from whom the person received indirect compensation if (1) the amount of the compensation was $1,000 or more, or (2) the plan was given a formula or other description of the method used to determine the indirect compensation rather than an amount or estimated amount of the indirect compensation.

Part II –Service Providers Who Fail or Refuse To Provide Information

Line 4. Provide the requested information for each plan fiduciary or service provider who you believe failed or refused to provide any of the information necessary to complete Part I of this schedule.

Important Reminder. Before identifying a fiduciary or service provider as a person who failed or refused to provide information, you should contact the fiduciary or service provider to request the necessary information and tell them that you will list them on the Schedule C as a fiduciary or service provider who failed or refused to provide information if they do not provide the necessary information.

Part III – Termination Information on Accountants and Enrolled Actuaries

Complete Part III if there was a termination in the appointment of an accountant or enrolled actuary during the 2021 plan year. This information must be provided on the Form 5500 for the plan year during which the termination occurred. For example, if an accountant was terminated in the 2021 plan year after completing work on an audit for the 2020 plan year, the termination should be reported on the Schedule C filed with the 2021 plan year Form 5500. If the accountant is a firm (such as a corporation, partnership, etc.), report when the service provider (not an individual within the firm) was terminated. An enrolled actuary is by definition an individual and not a firm, and you must report when the individual is terminated.

Provide an explanation of the reasons for the termination of an accountant or enrolled actuary. Include a description of any material disputes or matters of disagreement concerning the termination, even if resolved prior to the termination. If an individual is listed, and the individual does not have an EIN, the EIN to be entered should be the EIN of the individual’s employer.

Do not use a social security number in lieu of an EIN. The Schedule C and its attachments are open to public inspection, and the contents are public information and are subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on this Schedule C or any of its attachments may result in the rejection of the filing.

The plan administrator must also provide the terminated accountant or enrolled actuary with a copy of the explanation for the termination provided in Part III of the Schedule C, along with a completed copy of the notice below.

Shape12 Notice to Terminated Accountant

or Enrolled Actuary

I, as plan administrator, verify that the explanation that is reproduced below or attached to this notice is the explanation concerning your termination reported on the Schedule C (Form 5500) attached to the 2021 Form 5500, Annual Return/Report of Employee Benefit Plan, for the __________________________________________________________(enter name of plan). This Form 5500 is identified in line 2b by the nine-digit EIN - (enter sponsor’s EIN), and in line 1b by the three-digit PN________(enter plan number).

You have the opportunity to comment to the Department of Labor concerning any aspect of this explanation. Comments should include the name, EIN, and PN of the plan and be submitted to: Office of Enforcement, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, DC 20210.

Signed

Dated

Instructions for Schedule C (Form 5500) -25-

2021 Instructions for Schedule D

(Form 5500)

DFE / Participating Plan Information

General Instructions

Purpose of Schedule

When the Form 5500 is filed for a plan or Direct Filing Entity (DFE) that invested or participated in any master trust investment accounts (MTIAs), 103-12 Investment Entities (103-12 IEs), common/collective trusts (CCTs), and/or pooled separate accounts (PSAs), Part I provides information about these entities. When the Form 5500 is filed for a DFE, Part II provides information about plans participating in the DFE.

Who Must File

Employee Benefit Plans: Schedule D (Form 5500) must be attached to a Form 5500 filed for an employee benefit plan that participated or invested in one or more CCTs, PSAs, MTIAs, or 103-12 IEs at anytime during the plan year.

Direct Filing Entities: Schedule D (Form 5500) must be attached to a Form 5500 filed for a CCT, PSA, MTIA, 103-12 IE, or Group Insurance Arrangement (GIA), as a Direct Filing Entity (i.e., when a “DFE” is checked on Part I, line A, of the Form 5500). For more information, see instructions for Direct Filing Entity (DFE) Filing Requirements.

Check the Schedule D box on the Form 5500 (Part II, line

10b(5)) if a Schedule D is attached to the Form 5500. Complete as many repeating entries as necessary to report the required information.

Specific Instructions

Lines A, B, C, and D. The information must be the same as reported in Part II of the Form 5500 to which this Schedule D is attached.

Do not use a social security number in line D in lieu of an EIN. The Schedule D and its attachments are open to public inspection, and the contents are public information and are subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on this Schedule D or any of its attachments may result in the rejection of the filing.

Part I – Information on Interests in MTIAs, CCTs, PSAs, and 103-12 IEs (To Be Completed by Plans and DFEs)

Complete as many repeating entries as necessary to enter the information specified below for all MTIAs, CCTs, PSAs, and 103-12 IEs in which the plan or DFE filing the Form 5500 participated at any time during the plan or DFE year.

Complete a separate item (elements (a) through (e)) for each MTIA, CCT, PSA, or 103-12 IE.

Element (a). Enter the name of the MTIA, CCT, PSA, or 103-12 IE in which the plan or DFE filing the Form 5500 participated at any time during the plan or DFE year.

Element (b). Enter the name of the sponsor of the MTIA, CCT, PSA, or 103-12 IE named in element (a).

Element (c). Enter the nine-digit employer identification number (EIN) and three-digit plan/entity number (PN) for each MTIA, CCT, PSA, or 103-12 IE named in element (a). This must be the same DFE EIN/PN as reported on lines 2b and 1b of the Form 5500 filed for the DFE. If a Form 5500 was not filed for a CCT or PSA named in element (a), enter the EIN for the CCT or PSA and enter 000 for the PN. Do not use a social security number or any portion thereof in lieu of an EIN. The Schedule D and its attachments are open to public inspection, and the contents are public information and are subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on this Schedule D or any of its attachments may result in the rejection of the filing.

Element (d). Enter an M, C, P, or E, as appropriate, (see table below) to identify the type of entity (MTIA, CCT, PSA, or

103-12 IE).

Type of entity 	Enter in (d) 
MTIA	M
CCT	C
PSA	P
103-12 IE	E

Element (e). Enter the dollar value of the plan’s or DFE’s interest as of the end of the year. If the plan or DFE for which this Schedule D is filed had no interest in the MTIA, CCT, PSA, or 103-12 IE listed at the end of the year, enter ‘‘0’’.

Example for Part I: If a plan participates in an MTIA, the MTIA is named in element (a); the MTIA’s sponsor is named in element (b); the MTIA’s EIN and PN are entered in element (c) (such as: 12-3456789-001); an ‘‘M’’ is entered in element (d); and the dollar value of the plan’s interest in the MTIA as of the end of plan year is entered in element (e).

If the plan also participates in a CCT for which a Form 5500 was not filed, the CCT is named in another element (a); the name of the CCT sponsor is entered in element (b); the EIN for the CCT, followed by 000 is entered in element (c) (such as: 99-8765432-000); a “C” is entered in element (d); and the dollar value of the plan’s interest in the CCT is entered in element (e).

If the plan also participates in a PSA for which a Form 5500 was filed, the PSA is named in a third element (a); the name of the PSA sponsor is entered in element (b); the PSA’s EIN and PN is entered in element (c) (such as: 98-7655555-001); a “P” is entered in element (d); and the dollar value of the plan’s interest in the PSA is entered in element (e).

Part II – Information on Participating Plans

(To Be Completed Only by DFEs)

Complete as many repeating entries as necessary to enter the information specified below for all plans invested or participated in the DFE at any time during the DFE year.

Complete a separate item (elements (a) through (c)) for each plan.

Element (a). Enter the name of each plan that invested or participated in the DFE at any time during the DFE year. GIAs need not complete element (a).

Element (b). Enter the name of the sponsor of each and every plan investing or participating in the DFE.

Element (c). Enter the nine-digit EIN and three-digit PN for each plan named in element (a). This is the EIN and PN entered on lines 2b and 1b of the plan’s Form 5500 or Form 5500-SF. GIAs should enter the EIN of the sponsor listed in element (b). Do not use a social security number in lieu of an EIN. The Schedule D and its attachments are open to public inspection, and the contents are public information and are subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on this Schedule D or any of its attachments may result in the rejection of the filing.

2021 Instructions for Schedule G

(Form 5500)

Financial Transaction Schedules

General Instructions

Who Must File

Schedule G (Form 5500) must be attached to a Form 5500 filed for a large plan, MTIA, 103-12 IE, or GIA to report loans or fixed income obligations in default or determined to be uncollectible as of the end of the plan year, leases in default or classified as uncollectible, and nonexempt transactions.

Check the Schedule G box on the Form 5500 (Part II, line 10b(6)) if a Schedule G is attached to the Form 5500. Complete as many entries as necessary to report the required information.

The Schedule G consists of three parts. Part I of the Schedule G reports any loans or fixed income obligations in default or determined to be uncollectible as of the end of the plan year. Part II of the Schedule G reports any leases in default or classified as uncollectible. Part III of the Schedule G reports nonexempt transactions.

Specific Instructions

Lines A, B, C, and D. This information must be the same as reported in Part II of the Form 5500 to which this Schedule G is attached.

Do not use a social security number in line D in lieu of an EIN. The Schedule G and its attachments are open to public inspection, and the contents are public information and are subject to publication on the internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on this Schedule G or any of its attachments may result in the rejection of the filing.

You can apply for an EIN from the IRS online, by fax, or by mail depending on how soon you need to use the EIN. For more information, see Section 3: Electronic Filing Requirement under General Instructions to Form 5500. The EBSA does not issue EINs.

Part I – Loans or Fixed Income Obligations in Default or Classified as Uncollectible

List all loans or fixed income obligations in default or determined to be uncollectible as of the end of the plan year or the fiscal year of the GIA, MTIA, or 103-12 IE. Include:

Obligations where the required payments have not been made by the due date;

Fixed income obligations that have matured, but have not been paid, for which it has been determined that payment will not be made; and
Loans that were in default even if renegotiated later during the year.

Note. Identify in element (a) each obligor known to be a party-in-interest to the plan.

Provide, on a separate attachment, an explanation of what steps have been taken or will be taken to collect overdue amounts for each loan listed and label the attachment “Schedule G, Part I – Overdue Loan Explanation.”

The due date, payment amount, and conditions for determining default in the case of a note or loan are usually contained in the documents establishing the note or loan. A loan is in default when the borrower is unable to pay the obligation upon maturity. Obligations that require periodic repayment can default at any time. Generally loans and fixed income obligations are considered uncollectible when payment has not been made and there is little probability that payment will be made. A fixed income obligation has a fixed maturity date at a specified interest rate.

Do not report in Part I participant loans under an individual account plan with investment experience segregated for each account, that are made in accordance with 29 CFR 2550.408b-1, and that are secured solely by a portion of the participant’s vested accrued benefit. Report all other participant loans in default or classified as uncollectible on Part I, and list each such loan individually.

Part II – Leases in Default or Classified as Uncollectible

List any leases in default or classified as uncollectible. A lease is an agreement conveying the right to use property, plant, or equipment for a stated period. A lease is in default when the required payment(s) has not been made. An uncollectible lease is one where the required payments have not been made and for which there is little probability that payment will be made. Provide, on a separate attachment, an explanation of what steps have been taken or will be taken to collect overdue amounts for each lease listed and label the attachment “Schedule G, Part II – Overdue Lease Explanation.”

Part III – Nonexempt Transactions

All nonexempt party-in-interest transactions must be reported, regardless of whether disclosed in the accountant’s report, unless the nonexempt transaction is:

1. Statutorily exempt under Part 4 of Title I of ERISA;

2. Administratively exempt under ERISA section 408(a);

3. Exempt under Code sections 4975(c) or 4975(d);

4. The holding of participant contributions in the employer’s general assets for a welfare plan that meets the conditions of ERISA Technical Release 92-01;

5. A transaction of a 103-12 IE with parties other than
the plan; or

6. A delinquent participant contribution or a delinquent participant loan repayment reported on Schedule H, line 4a.

Nonexempt transactions with a party-in-interest include any direct or indirect:

A. Sale or exchange, or lease, of any property between the plan and a party-in-interest.

B. Lending of money or other extension of credit between the plan and a party-in-interest.

C. Furnishing of goods, services, or facilities between the plan and a party-in-interest.

D. Transfer to, or use by or for the benefit of, a party-in-interest, of any income or assets of the plan.

E. Acquisition, on behalf of the plan, of any employer security or employer real property in violation of ERISA section 407(a).

F. Dealing with the assets of the plan for a fiduciary’s own interest or own account

G. Acting in a fiduciary’s individual or any other capacity in any transaction involving the plan on behalf of a party (or represent a party) whose interests are adverse to the interests of the plan or the interests of its participants or beneficiaries.

H. A receipt of any consideration for his or her own personal account by a party-in-interest who is a fiduciary from any party dealing with the plan in connection with a transaction involving the income or assets of the plan.

For purposes of this form, party-in-interest is deemed to include a disqualified person. See Code section 4975(e)(2). The term ‘‘party-in-interest’’ means, as to an employee benefit plan:

A. Any fiduciary (including, but not limited to, any administrator, officer, trustee or custodian), counsel, or employee of the plan;

B. A person providing services to the plan;

C. An employer, any of whose employees are covered by the plan;

D. An employee organization, any of whose members are covered by the plan;

E. An owner, direct or indirect, of 50% or more of: (1) the combined voting power of all classes of stock entitled to vote or the total value of shares of all classes of stock of a corporation, (2) the capital interest or the profits interest of a partnership, or (3) the beneficial interest of a trust or unincorporated enterprise that is an employer or an employee organization described in C or D;

F. A relative of any individual described in A, B, C, or E;

G . A corporation, partnership, or trust or estate of which (or in which) 50% or more of: (1) the combined voting power of all classes of stock entitled to vote or the total value of shares of all classes of stock of such corporation, (2) the capital interest or profits interest of such partnership, or (3) the beneficial interest of such trust or estate is owned directly or indirectly, or held by, persons described in A, B, C, D, or E;

H. An employee, officer, director (or individual having powers or responsibilities similar to those of officers or directors), or a 10% or more shareholder, directly or indirectly, of a person described in B, C, D, E, or G, or of the employee benefit plan; or

I. A 10% or more (directly or indirectly in capital or profits) partner or joint venture of a person described in B, C, D, E, or G.

An unfunded, fully insured, or combination unfunded/insured welfare plan with 100 or more participants exempt under 29 CFR 2520.104-44 from completing Schedule H must still complete Schedule G, Part III, to report nonexempt transactions.

A plan that is required to file a Form M-1, Report for Multiple-Employer Welfare Arrangements (MEWAs) and Certain Entities Claiming Exception (ECEs), but that is not required to file the Schedule I because it has fewer than 100 participants and meets the requirements of 29 CFR 2520.104-44, also must complete Schedule G, Part III, to report nonexempt transactions.

If you are unsure whether a transaction is exempt or not, you should consult with either the plan’s independent qualified public accountant or legal counsel or both.

You may indicate that an application for an administrative exemption is pending.

If the plan is a qualified pension plan and a nonexempt prohibited transaction occurred with respect to a disqualified person, an IRS Form 5330, Return of Excise Taxes Related to Employee Benefit Plans, is required to be filed with the IRS to pay the excise tax on the transaction.

The DOL Voluntary Fiduciary Correction Program (VFCP) describes how to apply, the specific transactions covered (which transactions include delinquent participation contributions to pension and welfare plans), and acceptable methods for correcting violations. In addition, applicants that satisfy both the VFCP requirements and the conditions of Prohibited Transaction Exemption (PTE) 2002-51 are eligible for immediate relief from payment of certain prohibited excise taxes for certain corrected transactions, and are also relieved from the obligation to file the Form 5330 with the IRS. For more information, see 71 Fed. Reg. 20261 (Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19, 2006). If conditions of PTE 2002-51 are satisfied, corrected transactions should be treated as exempt under Code section 4975(c) for the purposes of answering Schedule G, Part III. Information about the VFCP is also available on the internet at www.dol.gov/ebsa.

2021 Instructions for Schedule H

(Form 5500)

Financial Information

General Instructions

Who Must File

Schedule H (Form 5500) must be attached to a Form 5500 filed for a pension benefit plan or a welfare benefit plan that covered 100 or more participants as of the beginning of the plan year and a Form 5500 filed for an MTIA, CCT, PSA, 103-12 IE, or GIA. See the instructions to the Form 5500 in Section 4: Direct Filing Entity (DFE) Filing Requirements.

Exceptions: (1) Fully insured, unfunded, or a combination of

unfunded/insured welfare plans and fully insured pension plans that meet the requirements of 29 CFR 2520.104-44 are exempt from completing the Schedule H. (2) If a Schedule I was filed for the plan for the 2020 plan year or a Form 5500-SF and the plan covered fewer than 121 participants as of the beginning of the 2021 plan year, the Schedule I may be completed instead of a Schedule H. See What To File. If eligible, such a plan may file the Form 5500-SF instead of the Form 5500 and its schedules, including the Schedule I. See Instructions for Form 5500-SF. (3) Plans that file a Form 5500-SF for the 2021 plan year are not required to file a Schedule H for that year.

Check the Schedule H box on the Form 5500 (Part II, line

10b(1)) if a Schedule H is attached to the Form 5500. Do not attach both a Schedule H and a Schedule I to the same Form

5500.

Specific Instructions

Lines A, B, C, and D. This information must be the same as

reported in Part II of the Form 5500 to which this Schedule H is attached.

Do not use a social security number in line D in lieu of an EIN. The Schedule H and its attachments are open to public inspection, and the contents are public information and are

subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on this Schedule H or any of its attachments may result in the rejection of the filing.

You can apply for an EIN from the IRS online, by fax, or by mail depending on how soon you need to use the

EIN. For more information, see Section 3: Electronic Filing Requirement under General Instructions to Form 5500. The EBSA does not issue EINs.

Part I – Asset and Liability Statement

Note. The cash, modified cash, or accrual basis may be used

for recognition of transactions in Parts I and II, as long as you use one method consistently. Round off all amounts reported

on the Schedule H to the nearest dollar. Any other amounts are subject to rejection. Check all subtotals and totals carefully.

If the assets of two or more plans are maintained in a fund or account that is not a DFE, a registered investment company, or the general account of an insurance company under an unallocated contract (see the instructions for lines 1c(9) through 1c(14)), complete Parts I and II of the Schedule H by entering the plan’s allocable part of each line item.

Exception. When completing Part II of the Schedule H for a plan or DFE that participates in a CCT or PSA for which a Form 5500 has not been filed, do not allocate the income of the CCT or PSA and expenses that were subtracted from the gross income of the CCT or PSA in determining their net investment gain (loss). Instead, enter the CCT or PSA net gain (loss) on line 2b(6) or (7) in accordance with the instructions for these lines.

If assets of one plan are maintained in two or more trust funds, report the combined financial information in Parts I and II.

Current value means fair market value where available. Otherwise, it means the fair value as determined in good faith under the terms of the plan by a trustee or a named fiduciary, assuming an orderly liquidation at time of the determination. See ERISA section 3(26).

Note. For the 2021 plan year, plans that provide participant-directed brokerage accounts as an investment alternative (and have entered pension feature code ‘‘2R’’ on line 8a of the Form 5500) may report investments in assets made through participant-directed brokerage accounts either:

1. As individual investments on the applicable asset and liability categories in Part I and the income and expense categories in Part II, or

2. By including on line 1c(15) the total aggregate value of the assets and on line 2c the total aggregate investment income (loss) before expenses, provided the assets are not loans, partnership or joint-venture interests, real property, employer securities, or investments that could result in a loss in excess of the account balance of the participant or beneficiary who directed the transaction. Expenses charged to the accounts must be reported on the applicable expense line items. Participant-directed brokerage account assets reported in the aggregate on line 1c(15) should be treated as one asset held for investment for purposes of the line 4i schedules, except that investments in tangible personal property must continue to be reported as separate assets on the line 4i schedules.

In the event that investments made through a

participant-directed brokerage account are loans, partnership or joint venture interests, real property, employer securities, or investments that could result in a loss in excess of the account balance of the participant or beneficiary who directed the transaction, such assets must be broken out and treated as separate assets on the applicable asset and liability categories in Part I, income and expense categories in Part II, and on the line 4i schedules. The remaining assets in the participant-directed brokerage account may be reported in the aggregate as set forth in paragraph 2 above.

Columns (a) and (b). Enter the current value on each line as of the beginning and end of the plan year.

Note. Amounts reported in column (a) must be the same as reported for the end of the plan year for corresponding line items of the return/report for the preceding plan year. Do not include contributions designated for the 2021 plan year in column (a).

Line 1a. Total noninterest bearing cash includes, among other things, cash on hand or cash in a noninterest bearing checking account.

Line 1b(1). Noncash basis filers must include contributions due the plan by the employer but not yet paid. Do not include other amounts due from the employer such as the reimbursement of an expense or the repayment of a loan.

Line 1b(2). Noncash basis filers must include contributions withheld by the employer from participants and amounts due directly from participants that have not yet been received by the plan. Do not include the repayment of participant loans.

Line 1b(3). Noncash basis filers must include amounts due to the plan that are not includable in lines 1b(1) or 1b(2). These amounts may include investment income earned but not yet received by the plan and other amounts due to the plan such as amounts due from the employer or another plan for expense reimbursement or from a participant for the repayment of an overpayment of benefits.

Line 1c(1). Include all assets that earn interest in a financial institution account such as interest bearing checking accounts, passbook savings accounts, or in money market accounts.

Line 1c(2). Include securities issued or guaranteed by the U.S. Government or its designated agencies such as U.S. Savings Bonds, Treasury Bonds, Treasury Bills, FNMA, and GNMA.

Line 1c(3). Include investment securities (other than employer securities defined below in line 1d(1)) issued by a corporate entity at a stated interest rate repayable on a particular future date such as most bonds, debentures, convertible debentures, commercial paper and zero coupon bonds. Do not include debt securities of governmental units that should be reported on line 1c(2) or 1c(15).

‘‘Preferred’’ means any of the above securities that are publicly traded on a recognized securities exchange and the securities have a rating of ‘‘A’’ or above. If the securities are not ‘‘Preferred,’’ they are listed as ‘‘Other.’’

Line 1c(4)(A). Include stock issued by corporations (other than employer securities defined in line 1d(1) below) which is accompanied by preferential rights such as the right to share in distributions of earnings at a higher rate or which has general priority over the common stock of the same entity. Include the value of warrants convertible into preferred stock.

Line 1c(4)(B). Include any stock (other than employer securities defined in line 1d(1)) that represents regular ownership of the corporation and is not accompanied by preferential rights. Include the value of warrants convertible into common stock.

Line 1c(5). Include the value of the plan’s participation in a partnership or joint venture if the underlying assets of the partnership or joint venture are not considered to be plan assets under 29 CFR 2510.3-101. Do not include the value of a plan’s interest in a partnership or joint venture that is a 103-12 Investment Entity (103-12 IE). Include the value of a 103-12 IE in line 1c(12).

L ine 1c(6). Include the current value of both income and non-income producing real property owned by the plan. Do not include the value of property that is employer real property or property used in plan operations that must be reported on lines 1d and 1e, respectively.

Line 1c(7). Enter the current value of all loans made by the plan, except participant loans reportable on line 1c(8). Include the sum of the value of loans for construction, securities loans, commercial and/or residential mortgage loans that are not subject to Code section 72(p) (either by making or participating in the loans directly or by purchasing loans originated by a third party), and other miscellaneous loans.

Line 1c(8). Enter the current value of all loans to participants including residential mortgage loans that are subject to Code section 72(p). Include the sum of the value of the unpaid principal balances, plus accrued but unpaid interest, if any, for participant loans made under an individual account plan with investment experience segregated for each account, that are made in accordance with 29 CFR 2550.408b-1 and secured solely by a portion of the participant’s vested accrued benefit. When applicable, combine this amount with the current value of any other participant loans. Do not include in column (b) a participant loan that has been deemed distributed during the plan year under the provisions of Code section 72(p) and Treasury Regulations section 1.72(p)-1, if both of the following circumstances apply:

1. Under the plan, the participant loan is treated as a directed investment solely of the participant’s individual account; and

2. As of the end of the plan year, the participant is not continuing repayment under the loan.

If both of these circumstances apply, report the loan as a deemed distribution on line 2g. However, if either of these circumstances does not apply, the current value of the participant loan (including interest accruing thereon after the deemed distribution) must be included in column (b) without regard to the occurrence of a deemed distribution.

Note. After a participant loan that has been deemed distributed is reported on line 2g, it is no longer to be reported as an asset on Schedule H or Schedule I unless, in a later year, the participant resumes repayment under the loan. However, such a loan (including interest accruing thereon after the deemed distribution) that has not been repaid is still considered outstanding for purposes of applying Code section 72(p)(2)(A) to determine the maximum amount of subsequent loans. Also, the deemed distribution is not treated as an actual distribution for other purposes, such as the qualification requirements of Code section 401, including, for example, the determination of top-heavy status under Code section 416 and the vesting requirements of Treasury Regulations section 1.411(a)-7(d)(5). See Q&As 12 and 19 of Treasury Regulations section 1.72(p)-1.

The entry on line 1c(8), column (b), of Schedule H (participant loans - end of year) or on line 1a, column (b), of Schedule I (plan assets - end of year) must include the current value of any participant loan that was reported as a deemed distribution on line 2g for any earlier year if the participant resumes repayment under the loan during the plan year. In addition, the amount to be entered on line 2g must be reduced by the amount of the participant loan that was reported as a deemed distribution on line 2g for the earlier year.

Lines 1c(9), (10), (11), and (12). Enter the total current value of the plan’s or DFE’s interest in DFEs on the appropriate lines as of the beginning and end of the plan or DFE year. The value of the plan’s or DFE’s interest in each DFE at the end of the plan or DFE year must be reported on the Schedule D (Form 5500).

The plan’s or DFE’s interest in common/collective trusts (CCTs) and pooled separate accounts (PSAs) for which a DFE Form 5500 has not been filed may not be included on lines 1c(9) or 1c(10). The plan’s or DFE’s interest in the underlying assets of such CCTs and PSAs must be allocated and reported in the appropriate categories on a line-by-line basis on Part I of the Schedule H.

Note. For reporting purposes, a separate account that is not considered to be holding plan assets pursuant to 29 CFR 2510.3-101(h)(1)(iii) does not constitute a PSA.

Line 1c(13). A registered investment company is an investment company registered under the Investment Company Act of 1940. These are mutual funds (legally known as open-end companies), closed-end funds (legally known as closed-end companies), and UITs (legally known as unit investment trusts).

Line 1c(14). Use the same method for determining the value of the insurance contracts reported here as you used for line 4 of Schedule A, or, if line 4 is not required, line 7 of Schedule A. Line 1c(15). Include all other investments not includable in lines 1c(1) through (14), such as options, index futures, state and municipal securities, collectibles, and other personal property.

Line 1d(1). An employer security is any security issued by an employer (including affiliates) of employees covered by the plan. These may include common stocks, preferred stocks, bonds, zero coupon bonds, debentures, convertible debentures, notes and commercial paper.

Line 1d(2). The term ‘‘employer real property’’ means real property (and related personal property) that is leased to an employer of employees covered by the plan, or to an affiliate of such employer. For purposes of determining the time at which a plan acquires employer real property for purposes of this line, such property shall be deemed to be acquired by the plan on the date on which the plan acquires the property or on the date on which the lease to the employer (or affiliate) is entered into, whichever is later.

Line 1e. Include the current (not book) value of the buildings and other property used in the operation of the plan. Buildings or other property held as plan investments should be reported in 1c(6) and 1d(2).

Do not include the value of future pension payments on lines 1g, h, i, j, or k.

Line 1g. Noncash basis plans must include the total amount of benefit claims that have been processed and approved for payment by the plan. Include welfare plan ‘‘incurred but not reported’’ (IBNR) benefit claims on this line.

Line 1h. Noncash basis plans must include the total amount of obligations owed by the plan which were incurred in the normal operations of the plan and have been approved for payment by the plan but have not been paid.

Line 1i. ‘‘Acquisition indebtedness,’’ for debt-financed property other than real property, means the outstanding amount of the principal debt incurred:

1. By the organization in acquiring or improving the

property;

2. Before the acquisition or improvement of the property if the debt was incurred only to acquire or improve the property; or

3. After the acquisition or improvement of the property if the debt was incurred only to acquire or improve the property and was reasonably foreseeable at the time of such acquisition or improvement. For further explanation, see Code section 514(c).

Line 1j. Noncash basis plans must include amounts owed for any liabilities that would not be classified as benefit claims payable, operating payables, or acquisition indebtedness.

Line 1l. Enter the net assets as of the beginning and end of the plan year (Subtract line 1k from line 1f.) The entry in column (b) must equal the sum of the entry in column (a) plus lines 2k and 2l(1), minus 2l(2).

Part II – Income and Expense Statement

Line 2a. Include the total cash contributions received and/or (for accrual basis plans) due to be received.

Note. Plans using the accrual basis of accounting should not include contributions designated for years before the 2021 plan year on line 2a.

Line 2a(1)(B). For welfare plans, report all employee contributions, including all elective contributions under a cafeteria plan (Code section 125). For pension benefit plans, participant contributions, for purposes of this item, also include elective contributions under a qualified cash or deferred arrangement (Code section 401(k)).

Line 2a(2). Use the current value, at date contributed, of securities or other noncash property.

Line 2b(1)(A). Enter interest earned on interest-bearing cash, including earnings from sweep accounts, STIF accounts, money market accounts, certificates of deposit, etc. This is the interest earned on the investments reported on line 1c(1).

Line 2b(1)(B). Enter interest earned on U.S. Government Securities. This is the interest earned on the investments reported on line 1c(2).

Line 2b(1)(C). Generally, this is the interest earned on securities that are reported on lines 1c(3)(A) and (B) and 1d(1).

Line 2b(2). Generally, the dividends are for investments reported on lines 1c(4)(A) and (B), 1c(13), and 1d(1). For accrual basis plans, include any dividends declared for stock held on the date of record, but not yet received as of the end of the plan year.

Line 2b(3). Generally, rents represent the income earned on the real property that is reported in lines 1c(6) and 1d(2). Enter rents as a ‘‘Net’’ figure. Net rents are determined by taking the total rent received and subtracting all expenses directly associated with the property. If the real property is jointly used as income producing property and for the operation of the plan, net that portion of the expenses attributable to the income producing portion of the property against the total rents received.

Line 2b(4). Enter in column (b), the total of net gain (loss) on sale of assets. This equals the sum of the net realized gain (or loss) on each asset held at the beginning of the plan year which was sold or exchanged during the plan year, and on each asset that was both acquired and disposed of within the plan year.

Note. As current value reporting is required for the Form 5500, assets are revalued to current value at the end of the plan year. For purposes of this form, the increase or decrease in the value of assets since the beginning of the plan year (if held on the first day of the plan year) or their acquisition date (if purchased during the plan year) is reported in line 2b(5) below, with two exceptions: (1) the realized gain (or loss) on each asset that was disposed of during the plan year is reported in line 2b(4) (NOT on line 2b(5)), and (2) the net investment gain (or loss) from CCTs, PSAs, MTIAs, 103-12 IEs, and registered investment companies is reported in lines 2b(6) through (10).

The sum of the realized gain (or loss) of assets sold or exchanged during the plan year is to be calculated as follows:

1. Enter in line 2b(4)(A), column (a), the sum of the amount received for these former assets;

2. Enter in line 2b(4)(B), column (a), the sum of the current value of these former assets as of the beginning of the plan year and the purchase price for assets both acquired and disposed of during the plan year; and

3. Enter in 2b(4) (C), column (b), the result obtained when 2b(4)(B) is subtracted from 2b(4)(A). If entering a negative number, enter a minus sign “–” to the left of the number.

Note. Bond write-offs should be reported as realized losses.

Line 2b(5). Subtract the current value of assets at the beginning of the year plus the cost of any assets acquired during the plan year from the current value of assets at the end of the year to obtain this figure. If entering a negative number, enter a minus sign “–” to the left of the number. Do not include the value of assets reportable in lines 2b(4) and 2b(6) through 2b(10).

Lines 2b(6), (7), (8), and (9). Report all earnings, expenses, gains or losses, and unrealized appreciation or depreciation included in computing the net investment gain (or loss) from all CCTs, PSAs, MTIAs, and 103-12 IEs here. If some plan funds are held in any of these entities and other plan funds are held in other funding media, complete all applicable subitems of line 2 to report plan earnings and expenses relating to the other funding media. The net investment gain (or loss) allocated to the plan for the plan year from the plan’s investment in these entities is equal to:

1. The sum of the current value of the plan’s interest in each entity at the end of the plan year,

2. Minus the current value of the plan’s interest in each entity at the beginning of the plan year,

3. Plus any amounts transferred out of each entity by the plan during the plan year, and

4. Minus any amounts transferred into each entity by the plan during the plan year.

Enter the net gain as a positive number or the net loss as a negative number.

Note. Enter the combined net investment gain or loss from all CCTs and PSAs, regardless of whether a DFE Form 5500 was filed for the CCTs and PSAs.

Line 2b(10). Enter net investment gain (loss) from registered investment companies here. Compute in the same manner as discussed above for lines 2b(6) through (9), except do not include dividends reported on line 2b(2)(C).

Line 2c. Include all other plan income earned that is not included in line 2a or 2b. Do not include transfers from other plans that should be reported in line 2l.

Line 2e(1). Include the current value of all cash, securities, or other property at the date of distribution. Include all eligible rollover distributions as defined in Code section 401(a)(31)(D) paid at the participant’s election to an eligible retirement plan (including an IRA within the meaning of section 401(a)(31)(E)).

Line 2e(2). Include payments to insurance companies and similar organizations such as Blue Cross, Blue Shield, and health maintenance organizations for the provision of plan benefits (e.g., paid-up annuities, accident insurance, health insurance, vision care, dental coverage, stop-loss insurance whose claims are paid to the plan (or which is otherwise an asset of the plan)), etc.

Line 2e(3). Include all payments made to other organizations or individuals providing benefits. Generally, these are individual providers of welfare benefits such as legal services, day care services, training, and apprenticeship services.

Line 2f. Include on this line all distributions paid during the plan year of excess deferrals under Code section 402(g)(2)(A)(ii), excess contributions under Code section 401(k)(8), and excess aggregate contributions under Code section 401(m)(6). Include allocable income distributed. Also include on this line any elective deferrals and employee contributions distributed or returned to employees during the plan year, as well as any attributable income that was also distributed.

Line 2g. Report on line 2g a participant loan that has been deemed distributed during the plan year under the provisions of Code section 72(p) and Treasury Regulations section 1.72(p)-1 only if both of the following circumstances apply:

1. Under the plan, the participant loan is treated as a directed investment solely of the participant’s individual account; and

2. As of the end of the plan year, the participant is not continuing repayment under the loan.

If either of these circumstances does not apply, a deemed distribution of a participant loan should not be reported on line 2g. Instead, the current value of the participant loan (including interest accruing thereon after the deemed distribution) must be included on line 1c(8), column (b) (participant loans – end of year), without regard to the occurrence of a deemed distribution.

Note. The amount to be reported on line 2g of Schedule H or Schedule I must be reduced if, during the plan year, a participant resumes repayment under a participant loan reported as a deemed distribution on line 2g for any earlier year. The amount of the required reduction is the amount of the participant loan reported as a deemed distribution on line 2g for the earlier year. If entering a negative number, enter a minus sign “ – ” to the left of the number. The current value of the participant loan must then be included in line 1c(8), column (b), of Schedule H (participant loans - end of year) or in line 1a, column (b), of Schedule I (plan assets - end of year).

Although certain participant loans deemed distributed are to be reported on line 2g of the Schedule H or Schedule I, and are not to be reported on the Schedule H or Schedule I as an asset thereafter (unless the participant resumes repayment under the loan in a later year), they are still considered outstanding loans and are not treated as actual distributions for certain purposes. See Q&As 12 and 19 of Treasury Regulations section 1.72(p)-1.

Line 2h. Interest expense is a monetary charge for the use of money borrowed by the plan. This amount should include the total of interest paid or to be paid (for accrual basis plans) during the plan year.

Line 2i. Report all administrative expenses (by specified category) paid by or charged to the plan, including those that were not subtracted from the gross income of CCTs, PSAs, MTIAs, and 103-12 IEs in determining their net investment gain(s) or loss(es). Expenses incurred in the general operations of the plan are classified as administrative expenses.

Line 2i(1). Include the total fees paid (or in the case of accrual basis plans, costs incurred during the plan year but not paid as of the end of the plan year) by the plan for outside accounting, actuarial, legal, and valuation/appraisal services. Include fees for the annual audit of the plan by an independent qualified public accountant (IQPA); for payroll audits; for accounting/bookkeeping services; for actuarial services rendered to the plan; and to a lawyer for rendering legal opinions, litigation, and advice (but not for providing legal services as a benefit to plan participants). Report here fees and expenses for corporate trustees and individual plan trustees, including reimbursement of expenses associated with trustees, such as lost time, seminars, travel, meetings, etc. Include the fee(s) for valuations or appraisals to determine the cost, quality, or value of an item such as real property, personal property (gemstones, coins, etc.), and for valuations of closely held securities for which there is no ready market. Do not include amounts paid to plan employees to perform bookkeeping/ accounting functions that should be included in line 2i(4).

Line 2i(2). Enter the total fees paid (or in the case of accrual basis plans, costs incurred during the plan year but not paid as of the end of the plan year) to a contract administrator for performing administrative services for the plan. For purposes of the return/report, a contract administrator is any individual, partnership, or corporation, responsible for managing the clerical operations (e.g., handling membership rosters, claims payments, maintaining books and records) of the plan on a contractual basis. Do not include salaried staff or employees of the plan or banks or insurance carriers.

Line 2i(3). Enter the total fees paid (or in the case of accrual basis plans, costs incurred during the plan year but not paid as of the end of the plan year) to an individual, partnership or corporation (or other person) for advice to the plan relating to its investment portfolio. These may include fees paid to manage the plan’s investments, fees for specific advice on a particular investment, and fees for the evaluation for the plan’s investment performance.

Line 2i(4). Other expenses are those that cannot be included in 2i(1) through 2i(3). These may include plan expenditures such as salaries and other compensation and allowances (e.g., payment of premiums to provide health insurance benefits to plan employees), expenses for office supplies and equipment, cars, telephone, postage, rent, expenses associated with the ownership of a building used in the operation of the plan, and all miscellaneous expenses. Include premium payments to the PBGC when paid from plan assets.

Line 2l. Include in these reconciliation figures the value of all transfers of assets or liabilities into or out of the plan resulting from, among other things, mergers and consolidations. A transfer of assets or liabilities occurs when there is a reduction of assets or liabilities with respect to one plan and the receipt of these assets or the assumption of these liabilities by another plan. A transfer is not a shifting of one plan’s assets or liabilities from one investment to another. A transfer is not a distribution of all or part of an individual participant’s account balance that is reportable on IRS Form 1099-R, Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc., (see the instructions for line 2e). Transfers out at the end of the year should be reported as occurring during the plan year.

Note. If this Schedule H is filed for a CCT, PSA, MTIA, or 103-12 IE, report the value of all asset transfers to the CCT, PSA, MTIA, or 103-12 IE, including those resulting from contributions to participating plans on line 2l(1), and report the total value of all assets transferred out of the CCT, PSA, MTIA, or 103-12 IE, including assets withdrawn for disbursement as benefit payments by participating plans, on line 2l(2). Contributions and benefit payments are considered to be made to/by the plan (not to/by a CCT, PSA, MTIA, or 103-12 IE).

Part III – Accountant’s Opinion

Line 3. The administrator of an employee benefit plan who files a Schedule H generally must engage an Independent Qualified Public Accountant (IQPA) pursuant to ERISA section 103(a)(3)(A) and 29 CFR 2520.103-1(b). This requirement also applies to a Form 5500 filed for a 103-12 IE and for a GIA (see 29 CFR 2520.103-12 and 29 CFR 2520.103-2). The IQPA’s report must be attached to the Form 5500 when a Schedule H is attached unless line 3d(1) or 3d(2) on the Schedule H is checked.

Notes. (1) The Auditing Standards Board’s Statement on Auditing Standards (SAS) 136, Forming an Opinion and Reporting on Financial Statements of Employee Benefit Plans Subject to ERISA, addresses the IQPA’s responsibility to form an opinion on the financial statements of employee benefit plans subject to ERISA. SAS 136 also addresses the form and content of the auditor’s report issued as a result of an audit of an ERISA plan’s financial statements. The SAS applies to audits of single employer, multiple employer, and multiemployer plans subject to ERISA. An IQPA Report generally consists of an Accountant’s Opinion, the plan or DFE Financial Statements, Notes to the Financial Statements, and Supplemental Schedules.

29 CFR 2520.103-1(b) requires that any separate financial statements prepared in order for the IQPA to form the opinion and notes to these financial statements must be attached to the Form 5500. Any separate statements must include the information required to be disclosed in Parts I and II of the Schedule H; however, they may be aggregated into categories in a manner other than that used on the Schedule H. The separate statements must consist of reproductions of Parts I and II or statements incorporating by reference Parts I and II. See ERISA section 103(a)(3)(A), and the DOL regulations 29 CFR 2520.103-1(a)(2) and (b), 2520.103-2, and 2520.104-50.

(2) Delinquent participant contributions reported on line 4a should be treated as part of the separate schedules referenced in ERISA section 103(a)(3)(A) and 29 CFR 2520.103-1(b) and 2520.103-2(b) for purposes of preparing the IQPA’s opinion described on line 3 even though they are no longer required to be listed on Part III of the Schedule G. If the information contained on line 4a is not presented in accordance with regulatory requirements, i.e., when the IQPA concludes that the scheduled information required by line 4a does not contain all the required information or contains information that is inaccurate or is inconsistent with the plan’s financial statements, the IQPA report must make the appropriate disclosures in accordance with generally accepted auditing standards. Delinquent participant contributions that are exempt because they satisfy the DOL’s Voluntary Fiduciary Correction Program (VFCP) requirements and the conditions of prohibited transaction exemption (PTE) 2002-51 do not need to be treated as part of the schedule of nonexempt party-in-interest transactions.

If the required IQPA’s report is not attached to the Form 5500, the filing is subject to rejection as incomplete and penalties may be assessed.

Lines 3a(1) through 3a(4). These boxes identify the type of opinion offered by the IQPA.

T he Plan Administrator should confirm with their IQPA whether the opinion was an unmodified, qualified, disclaimer of, or adverse opinion before answering Line 3a.

Line 3a(1). Check if an unmodified opinion was issued pursuant to SAS 136. Generally, an unmodified opinion is issued when the IQPA concludes that the plan’s financial statements are presented fairly, in all material respects, in accordance with the applicable financial reporting framework (generally accepted accounting principles (GAAP) or another basis such as modified cash or cash basis). This also includes the form of opinion that SAS 136 permits an IQPA to issue when the IQPA has performed an ERISA section 103(a)(3)(C) audit pursuant to 29 CFR 2520.103-8 or 29 CFR 2520.103-12, or both, and had no modifications.

Under 29 CFR 2520.103-8, the examination and report of an IQPA does not need to extend to statements or information regarding assets held by a bank, similar institution, or insurance carrier that is regulated and supervised and subject to periodic examination by a state or federal agency provided that the statements or information are prepared by and certified to by the bank or similar institution or the insurance carrier. The term ‘‘similar institution’’ as used here does not extend to securities brokerage firms (see DOL Advisory Opinion 93-21A). Under 29 CFR 2520.103-12, an audit of an employee benefit plan does not need extend to the investments in a pooled investment fund that files a separate audited Form 5500 as a 103-12 IE. For more information on filing requirements for 103-12 IEs, See Section 4: What to File. Neither of these regulations exempt the plan administrator from engaging an IQPA nor from attaching the IQPA’s report to the Form 5500.

Line 3a(2). Check if a qualified opinion was issued. Generally, a qualified opinion is issued by an IQPA when (a) the IQPA, having obtained sufficient appropriate audit evidence, concludes that misstatements, individually or in the aggregate, are material but not pervasive to the financial statements or (b) the IQPA is unable to obtain sufficient appropriate audit evidence on which to base the opinion, but the auditor concludes that the possible effects on the financial statements of undetected misstatements, if any, could be material but not pervasive.

Line 3a(3). Check if a disclaimer of opinion was issued. A disclaimer of opinion is issued when the IQPA is unable to obtain sufficient appropriate audit evidence on which to base the opinion, and the IQPA concludes that the possible effects on the financial statements of undetected misstatements, if any, could be both material and pervasive.

Line 3a(4). Check if the plan received an adverse accountant’s opinion. Generally, an adverse opinion is issued by an IQPA when the IQPA having obtained sufficient appropriate audit evidence, concludes that misstatements, individually or in the aggregate, are both material and pervasive to the financial statements.

Line 3b. Check “DOL Regulation 2520.103-8” or “DOL Regulation 2520.103-12(d)” (or both boxes, if applicable) if the IQPA performed an ERISA Section 103(a)(3)(C) audit of the plan’s financial statements pursuant to DOL regulations 29 CFR 2520.103-8, 29 CFR 2520.103-12(d), or under both. If it was not performed pursuant to 29 CFR 2520.103-8 or 29 CFR 2520 103-12(d), check box (3).

Note. These regulations do not exempt the plan administrator from engaging an IQPA or from attaching the IQPA’s report to the Form 5500. If you check box 103-8 or 103-12(d) or both, you must also check the appropriate box on line 3a to identify the type of opinion offered by the IQPA.

Line 3c. Enter the name and EIN of the accountant (or accounting firm) in the space provided on line 3c. Do not use a social security number or any portion thereof in lieu of an EIN. The Schedule H is open to public inspection, and the contents are public information and are subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on this Schedule H may result in the rejection of the filing.

Line 3d(1). Check this box only if the Schedule H is being filed for a CCT, PSA, or MTIA.

Line 3d(2). Check this box if the plan has elected to defer attaching the IQPA’s opinion for the first of two (2) consecutive plan years, one of which is a short plan year of seven (7) months or fewer. The Form 5500 for the first of the two (2) years must be complete and accurate, with all required attachments, except for the IQPA’s report, including an attachment explaining why one of the two (2) plan years is of seven (7) or fewer months duration and stating that the annual report for the immediately following plan year will include a report of an IQPA with respect to the financial statements and accompanying schedules for both of the two (2) plan years. The Form 5500 for the second year must include: (a) financial schedules and statements for both plan years; (b) a report of an IQPA with respect to the financial schedules and statements for each of the two (2) plan years (regardless of the number of participants covered at the beginning of each plan year); and (c) a statement identifying any material differences between the unaudited financial information submitted with the first Form 5500 and the audited financial information submitted with the second Form 5500. See 29 CFR 2520.104-50.

Note. Do not check the box on line 3d(2) if the Form 5500 is filed for a 103-12 IE or a GIA. A deferral of the IQPA’s opinion is not permitted for a 103-12 IE or a GIA. If an “E” or “G” is entered on Form 5500, Part I, line A(4), an IQPA’s opinion must be attached to the Form 5500 and the type of opinion must be reported on Schedule H, line 3a.

Part IV – Compliance Questions

Lines 4a through 4n. Plans completing Schedule H must answer all these lines with either ‘‘Yes’’ or ‘‘No.’’ Do not leave any answer blank, unless otherwise directed. For lines 4a through 4h and line 4l, if the answer is “Yes,” an amount must be entered.

Report investments in CCTs, PSAs, MTIAs, and 103-12 IEs, but not the investments made by these entities. Plans with all of their funds held in a master trust should check ‘‘No’’ on line 4b, 4c, 4i, and 4j. 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, or 4n. 103-12 IEs also do not complete line 4j and 4l. MTIAs also do not complete line 4l.

Line 4a. Amounts paid by a participant or beneficiary to an employer and/or withheld by an employer for contribution to the plan are participant contributions that become plan assets as of the earliest date on which such contributions can reasonably be segregated from the employer’s general assets (see 29 CFR 2510.3-102). Plans that check “Yes” must enter the aggregate amount of all late contributions for the year. The total amount of the delinquent contributions should be included on line 4a of the Schedule H or I, as applicable, for the year in which the contributions were delinquent and should be carried over and reported again on line 4a of the Schedule H or I, as applicable, for each subsequent year until the year after the violation has been fully corrected, which correction includes payment of the late contributions and reimbursement of the plan for lost earnings or profits. If no participant contributions were received or withheld by the employer during the plan year, answer “No.”

An employer holding these assets after that date commingled with its general assets will have engaged in a prohibited use of plan assets (see ERISA section 406). If such a nonexempt prohibited transaction occurred with respect to a disqualified person (see Code section 4975(e)(2)), file IRS Form 5330, Return of Excise Taxes Related to Employee Benefit Plans, with the IRS to pay any applicable excise tax on the transaction.

Participant loan repayments paid to and/or withheld by an employer for purposes of transmittal to the plan that were not transmitted to the plan in a timely fashion must be reported either on line 4a in accordance with the reporting requirements that apply to delinquent participant contributions or on line 4d. See Advisory Opinion 2002-02A, available at www.dol.gov/ebsa.

D elinquent participant contributions reported on line 4a should be treated as part of the separate schedules referenced in ERISA section 103(a)(3)(A) and 29 CFR 2520.103-1(b) and 2520.103-2(b) for purposes of preparing the IQPA’s opinion described on line 3 even though they are no longer required to be listed on Part III of the Schedule G. If the information contained on line 4a is not presented in accordance with regulatory requirements, i.e., when the IQPA concludes that the scheduled information required by line 4a does not contain all the required information or contains information that is inaccurate or is inconsistent with the plan’s financial statements, the IQPA report must make the appropriate disclosures in accordance with generally accepted auditing standards. For more information, see EBSA’s Frequently Asked Questions About Reporting Delinquent Contributions on the Form 5500, available on the Internet at www.dol.gov/ebsa. These Frequently Asked Questions clarify that plans have an obligation to include delinquent participant contributions on their financial statements and supplemental schedules and that the IQPA’s report covers such delinquent contributions even though they are not required to be included on Part III of the Schedule G. Although all delinquent participant contributions must be reported on line 4a, delinquent contributions for which the DOL VFCP requirements and the conditions of PTE 2002-51 have been satisfied do not need to be treated as nonexempt party-in-interest transactions.

The VFCP describes how to apply, the specific transactions covered (which transactions include delinquent participant contributions to pension and welfare plans), and acceptable methods for correcting violations. In addition, applicants that satisfy both the VFCP requirements and the conditions of PTE 2002-51 are eligible for immediate relief from payment of certain prohibited transaction excise taxes for certain corrected transactions, and are also relieved from the obligation to file the IRS Form 5330 with the IRS. For more information, see 71 Fed. Reg. 20261 (Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19, 2006). Information about the VFCP is also available on the Internet at www.dol.gov/ebsa.

All delinquent participant contributions must be reported on line 4a even if violations have been corrected.

Line 4a Schedule. Attach a Schedule of Delinquent Participant Contributions using the format below if you entered “Yes.” If you chose to include participant loan repayments on line 4a, you must apply the same supplemental schedule and IQPA disclosure requirements to the loan repayments as applied to delinquent transmittals of participant contributions.

Schedule H Line 4a –Schedule of Delinquent
Participant Contributions

Participant Contributions Transferred Late to Plan	Total that Constitute Nonexempt Prohibited Transactions			Total Fully Corrected Under VFCP and PTE 2002-51
Check here if Late Participant Loan Repayments are included:	Contributions Not Corrected	Contributions Corrected Outside VFCP	Contributions Pending Correction in VFCP	Total Fully Corrected Under VFCP and PTE 2002-51

Line 4b. Plans that check “Yes” must enter the amount and complete Part I of Schedule G. The due date, payment amount and conditions for determining default of a note or loan are usually contained in the documents establishing the note or loan. A loan by the plan is in default when the borrower is unable to pay the obligation upon maturity. Obligations that require periodic repayment can default at any time. Generally, loans and fixed income obligations are considered uncollectible when payment has not been made and there is little probability that payment will be made. A fixed income obligation has a fixed maturity date at a specified interest rate. Do not include participant loans made under an individual account plan with investment experience segregated for each account that were made in accordance with 29 CFR 2550.408b-1 and secured solely by a portion of the participant’s vested accrued benefit.

Line 4c. Plans that check “Yes” must enter the amount and complete Part II of Schedule G. A lease is an agreement conveying the right to use property, plant, or equipment for a stated period. A lease is in default when the required payment(s) has not been made. An uncollectible lease is one where the required payments have not been made and for which there is little probability that payment will be made.

Line 4d. Plans that check “Yes” must enter the amount and complete Part III of Schedule G. Check ‘‘Yes’’ if any nonexempt transaction with a party-in-interest occurred regardless of whether the transaction is disclosed in the IQPA’s report. Do not check “Yes” or complete Schedule G, Part III, with respect to transactions that are: (1) statutorily exempt under Part 4 of Title I of ERISA; (2) administratively exempt under ERISA section 408(a); (3) exempt under Code sections 4975(c) or 4975(d); (4) the holding of participant contributions in the employer’s general assets for a welfare plan that meets the conditions of ERISA Technical Release 92-01; (5) a transaction of a 103-12 IE with parties other than the plan; or (6) delinquent participant contributions or delinquent participant loan repayments reported on line 4a.

Note. See the instructions for Part III of the Schedule G (Form 5500) concerning nonexempt transactions and party-in-interest.

You may indicate that an application for an administrative exemption is pending. If you are unsure as to whether a transaction is exempt or not, you should consult with either the plan’s IQPA or legal counsel or both.

A pplicants that satisfy the VFCP requirements and the conditions of PTE 2002-51 (see the instructions for line 4a) are eligible for immediate relief from payment of certain prohibited transaction excise taxes for certain corrected transactions, and are also relieved from the obligation to file the IRS Form 5330 with the IRS. For more information, see 71 Fed. Reg. 20261 (Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19, 2006). When the conditions of PTE 2002-51 have been satisfied, the corrected transactions should be treated as exempt under Code section 4975(c) for the purposes of answering line 4d.

Line 4e. Plans that check “Yes” must enter the aggregate amount of fidelity bond coverage for all claims. Check ‘‘Yes’’ only if the plan itself (as opposed to the plan sponsor or administrator) is a named insured under a fidelity bond from an approved surety covering plan officials and that protects the plan from losses due to fraud or dishonesty as described in 29 CFR Part 2580. Generally, every plan official of an employee benefit plan who ‘‘handles’’ funds or other property of such plan must be bonded. Generally, a person shall be deemed to be ‘‘handling’’ funds or other property of a plan, so as to require bonding, whenever his or her duties or activities with respect to given funds are such that there is a risk that such funds could be lost in the event of fraud or dishonesty on the part of such person, acting either alone or in collusion with others. Section 412 of ERISA and 29 CFR Part 2580 describe the bonding requirements, including the definition of “handling” (29 CFR 2580.412-6), the permissible forms of bonds (29 CFR 2580.412-10), the amount of the bond (29 CFR Part 2580, subpart C), and certain exemptions such as the exemption for unfunded plans, certain banks and insurance companies (ERISA section 412), and the exemption allowing plan officials to purchase bonds from surety companies authorized by the Secretary of the Treasury as acceptable reinsurers on federal bonds (29 CFR 2580.412-23). Information concerning the list of approved sureties and reinsures is available on the Internet at www.fms.treas.gov/c570. For more information on the fidelity bonding requirements, see Field Assistance Bulletin 2008-04, available on the Internet at www.dol.gov/ebsa.

Note. Plans are permitted under certain conditions to purchase fiduciary liability insurance. These fiduciary liability insurance policies are not written specifically to protect the plan from losses due to dishonest acts and cannot be reported as fidelity bonds on line 4e.

Line 4f. Check ‘‘Yes,’’ if the plan suffered or discovered any loss as a result of any dishonest or fraudulent act(s) even if the loss was reimbursed by the plan’s fidelity bond or from any other source. If ‘‘Yes’’ is checked enter the full amount of the loss. If the full amount of the loss has not yet been determined, provide an estimate and disclose that the figure is an estimate as determined in good faith by a plan fiduciary. You must keep, in accordance with ERISA section 107, records showing how the estimate was determined.

W illful failure to report is a criminal offense. See ERISA section 501.

Lines 4g and 4h. Current value means fair market value where available. Otherwise, it means the fair value as determined in good faith under the terms of the plan by a trustee or a named fiduciary, assuming an orderly liquidation at the time of the determination. See ERISA section 3(26).

An accurate assessment of fair market value is essential to a pension plan’s ability to comply with the requirements set forth in the Code (e.g., the exclusive benefit rule of Code section 401(a)(2), the limitations on benefits and contributions under Code section 415, and the minimum funding requirements under Code section 412) and must be determined annually.

Examples of assets that may not have a readily determinable value on an established market (e.g., NYSE, AMEX, over the counter, etc.) include real estate, nonpublicly traded securities, shares in a limited partnership, and collectibles. Do not check “Yes” on line 4g for mutual fund shares or insurance company investment contracts for which the plan receives valuation information at least annually. Also, do not check ‘‘Yes’’ on line 4g if the plan is a defined contribution plan and the only assets the plan holds, that do not have a readily determinable value on an established market, are: (1) participant loans not in default, or (2) assets over which the participant exercises control within the meaning of section 404(c) of ERISA.

Although the current value of plan assets must be determined each year, there is no requirement that the assets (other than certain nonpublicly traded employer securities held in ESOPs) be valued every year by independent third-party appraisers.

Enter in the amount column the fair market value of the assets referred to on line 4g whose value was not readily determinable on an established market and which were not valued by an independent third-party appraiser in the plan year. Generally, as it relates to these questions, an appraisal by an independent third party is an evaluation of the value of an asset prepared by an individual or firm who knows how to judge the value of such assets and does not have an ongoing relationship with the plan or plan fiduciaries except for preparing the appraisals.

Line 4i. Check “Yes” if the plan had any assets held for investment purposes, and attach a schedule of assets held for investment purposes at end of year, a schedule of assets held for investment purposes that were both acquired and disposed of within the plan year, or both, as applicable. The schedules must use the format set forth below or a similar format. See 29 CFR 2520.103-11.

Assets held for investment purposes shall include:

 Any investment asset held by the plan on the last day of the plan year; and

 Any investment asset purchased during the plan year and sold before the end of the plan year except:

1. Debt obligations of the U.S. or any U.S. agency.

2. Interests issued by a company registered under the Investment Company Act of 1940 (e.g., a mutual fund).

3. Bank certificates of deposit with a maturity of one year or less.

4. Commercial paper with a maturity of 9 months or less if it is valued in the highest rating category by at least two nationally recognized statistical rating services and is issued by a company required to file reports with the Securities and Exchange Commission under section 13 of the Securities Exchange Act of 1934.

5. Participations in a bank common or collective trust.

6. Participations in an insurance company pooled separate account.

7. Securities purchased from a broker-dealer registered under the Securities Exchange Act of 1934 and either: (1) listed on a national securities exchange and registered under section 6 of the Securities Exchange Act of 1934 or (2) quoted on NASDAQ.

Assets held for investment purposes shall not include any investment that was not held by the plan on the last day of the plan year if that investment is reported in the annual report for that plan year in any of the following:

1. The schedule of loans or fixed income obligations in default required by Schedule G, Part I;

2. The schedule of leases in default or classified as uncollectible required by Schedule G, Part II;

3. The schedule of nonexempt transactions required by Schedule G, Part III; or

4. The schedule of reportable transactions required by Schedule H, line 4j.

Line 4i schedules. The first schedule required to be attached is a schedule of all assets held for investment purposes at the end of the plan year, aggregated and identified by issue, maturity date, rate of interest, collateral, par or maturity value, cost and current value, and, in the case of a loan, the payment schedule.

In column (a), place an asterisk (*) on the line of each identified person known to be a party-in-interest to the plan. In column (c), include any restriction on transferability of corporate securities. (Include lending of securities permitted under Prohibited Transactions Exemption 81-6.)

This schedule must be clearly labeled “Schedule H, line 4i –Schedule of Assets (Held At End of Year).”

(a)	(b) Identity of issue, borrower, lessor, or similar party	(c) Description of investment including maturity date, rate of interest, collateral, par, or maturity value	(d) Cost	(e) Current value

The second schedule required to be attached is a schedule of investment assets that were both acquired and disposed of within the plan year. This schedule must be clearly labeled “Schedule H, line 4i –Schedule of Assets (Acquired and Disposed of Within Year).”

(a) Identity of issue, borrower, lessor, or similar party	(b) Description of investment including maturity date, rate of interest, collateral, par, or maturity value	(c) Cost of acquisitions	(d) Proceeds of dispositions

Notes: (1) Participant loans under an individual account plan with investment experience segregated for each account, that are made in accordance with 29 CFR 2550.408b-1 and that are secured solely by a portion of the participant’s vested accrued benefit, may be aggregated for reporting purposes in line 4i. Under identity of borrower enter “Participant loans,” under rate of interest enter the lowest rate and the highest rate charged during the plan year (e.g., 8%–10%), under the cost and proceeds columns enter zero, and under current value enter the total amount of these loans. (2) Column (d) cost information for the Schedule of Assets (Held At End of Year) and the column (c) cost of acquisitions information for the Schedule of Assets (Acquired and Disposed of Within Year) may be omitted when reporting investments of an individual account plan that a participant or beneficiary directed with respect to assets allocated to his or her account (including a negative election authorized under the terms of the plan). Likewise, cost information for investments in Code sections 403(b)(1) annuity contracts and 403(b)(7) custodial accounts may also be omitted.

(3) Participant-directed brokerage account assets reported in the aggregate on line 1c(15) must be treated as one asset held for investment for purposes of the line 4i schedules, except investments in tangible personal property must continue to be reported as separate assets on the line 4i schedules. Investments in Code section 403(b)(1) annuity contracts and Code section 403(b)(7) custodial accounts should also be treated as one asset held for investment for purposes on the line 4i schedules.

Line 4j. Check “Yes” and attach to the Form 5500 the following schedule if the plan had any reportable transactions (see 29 CFR 2520.103-6 and the examples provided in the regulation). The schedule must use the format set forth below or a similar format. See 29 CFR 2520.103-11.

A reportable transaction includes:

1.A single transaction within the plan year in excess of 5% of the current value of the plan assets;

2.Any series of transactions with or in conjunction with the same person, involving property other than securities, which amount in the aggregate within the plan year (regardless of the category of asset and the gain or loss on any transaction) to more than 5% of the current value of plan assets;

3.Any transaction within the plan year involving securities of the same issue if within the plan year any series of transactions with respect to such securities amount in the aggregate to more than 5% of the current value of the plan assets; and

4.Any transaction within the plan year with respect to securities with, or in conjunction with, a person if any prior or subsequent single transaction within the plan year with such person, with respect to securities, exceeds 5% of the current value of plan assets.

The 5% figure is determined by comparing the current value of the transaction at the transaction date with the current value of the plan assets at the beginning of the plan year. If this is the initial plan year, you may use the current value of the plan assets at the end of the plan year to determine the 5% figure.

If the assets of two or more plans are maintained in one trust, except as provided below, the plan’s allocable portion of the transactions of the trust shall be combined with the other transactions of the plan, if any, to determine which transactions (or series of transactions) are reportable (5%) transactions.

For investments in common/collective trusts (CCTs), pooled separate accounts (PSAs), 103-12 IEs, and registered investment companies, determine the 5% figure by comparing the transaction date value of the acquisition and/or disposition of units of participation or shares in the entity with the current value of the plan assets at the beginning of the plan year. If the Schedule H is attached to a Form 5500 filed for a plan with all plan funds held in a master trust, check ‘‘No’’ on line 4j. Plans with assets in a master trust that have other transactions should determine the 5% figure by subtracting the current value of plan assets held in the master trust from the current value of all plan assets at the beginning of the plan year and check ‘‘Yes’’ or “No,” as appropriate. Do not include individual transactions of (CCTs), (PSAs), master trust investment accounts (MTIAs), 103-12 IEs, and registered investment companies in which this plan or DFE invests.

In the case of a purchase or sale of a security on the market, do not identify the person from whom purchased or to whom sold.

Special rule for certain participant-directed transactions. Transactions under an individual account plan that a participant or beneficiary directed with respect to assets allocated to his or her account (including a negative election authorized under the terms of the plan) should not be treated for purposes of line 4j as reportable transactions. The current value of all assets of the plan, including these participant-directed transactions, should be included in determining the 5% figure for all other transaction.

Line 4j schedule. The schedule required to be attached is a schedule of reportable transactions that must be clearly labeled “Schedule H, line 4j – Schedule of Reportable Transactions.”

(a) Identity of party involved	(b) Description of asset (include interest rate and maturity in case of a loan)	(c) Purchase price	(d) Selling price	(e) Lease rental	(f) Expense incurred with transaction	(g) Cost of asset	(h) Current value of asset on transaction date	(i) Net gain or (loss)

Line 4k. Check “Yes” if all the plan assets (including insurance/annuity contracts) were distributed to the participants and beneficiaries, legally transferred to the control of another plan, or brought under the control of the PBGC.

Check ‘‘No’’ for a welfare benefit plan that is still liable to pay benefits for claims incurred before the termination date, but not yet paid. See 29 CFR 2520.104b-2(g)(2)(ii).

Line 4l. You must check “Yes” if any benefits due under the plan were not timely paid or not paid in full. This would include minimum required distributions to 5% owners who have attained 72 whether or not retired and/or non-5% owners who have attained 72 and have retired or separated from service, see Code section 401(a)(9). Include in this amount the total of any outstanding amounts that were not paid when due in previous years that have continued to remain unpaid.

Note. In the absence of other guidance, filers do not need to report on this line unpaid required minimum distribution (RMD) amounts for participants who have retired or separated from service, or their beneficiaries, who cannot be located after reasonable efforts or where the plan is in the process of engaging in such reasonable efforts at the end of the plan year reporting period. Plan administrators and employers should review their plan documents for written procedures on locating missing participants. Although the Department of Labor’s Field Assistance Bulletin 2014-01 is specifically applicable to terminated defined contribution plans, employers and plan administrators of ongoing plans may want to consider periodically using one or more of the search methods described in the FAB in connection with making reasonable efforts to locate RMD-eligible missing participants.

Line 4m. Check “Yes” if there was a “blackout period.” A blackout period is a temporary suspension of more than three (3) consecutive business days during which participants or beneficiaries of a 401(k) or other individual account pension plan were unable to, or were limited or restricted in their ability to, direct or diversify assets credited to their accounts, obtain loans from the plan, or obtain distributions from the plan. A “blackout period” generally does not include a temporary suspension of the right of participants and beneficiaries to direct or diversity assets credited to their accounts, obtain loans from the plan, or obtain distributions from the plan if the temporary suspension is: (1) part of the regularly scheduled operations of the plan that has been disclosed to participants and beneficiaries; (2) due to a qualified domestic relations order (QDRO) or because of a pending determination as to whether a domestic relations order is a QDRO; (3) due to an action or a failure to take action by an individual participant or because of an action or claim by someone other than the plan regarding a participant’s individual account; or (4) by application of federal securities laws. For more information, see 29 CFR 2520.101-3 (available at www.dol.gov/ebsa).

Line 4n. If there was a blackout period, did you provide the required notice not less than 30 days nor more than 60 days in advance of restricting the rights of participants and beneficiaries to change their plan investments, obtain loans from the plan, or obtain distributions from the plan? If so, check “Yes.” See 29 CFR 2520.101-3 for specific notice requirements and for exceptions from the notice requirement. Also, answer “Yes” if one of the exceptions to the notice requirement under 29 CFR 2520.101-3 applies.

Line 5a. Check “Yes” if a resolution to terminate the plan was adopted during this or any prior plan year, unless the termination was revoked and no assets reverted to the employer. If ‘‘Yes’’ is checked, enter the amount of plan assets that reverted to the employer during the plan year in connection with the implementation of such termination. Enter “0” if no reversion occurred during the current plan year.

A Form 5500 must be filed for each year the plan has assets, and, for a welfare benefit plan, if the plan is still liable to pay benefits for claims incurred before the termination date, but not yet paid. See 29 CFR 2520.104b-2(g)(2)(ii).

Line 5b. Enter information concerning assets and/or liabilities transferred from this plan to another plan(s) (including spinoffs) during the plan year. A transfer of assets or liabilities occurs when there is a reduction of assets or liabilities with respect to one plan and the receipt of these assets or the assumption of these liabilities by another plan. Enter the name, plan sponsor EIN, and PN for the transferee plan(s) involved on lines 5b(1), (2), and (3).

Do not use a social security number in lieu of an EIN or include an attachment that contains visible social security numbers. The Schedule H is open to public inspection, and the contents are public information and are subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on this Schedule H or the inclusion of a visible social security number or any portion thereof on an attachment may result in the rejection of the filing.

Note. A distribution of all or part of an individual participant’s account balance that is reportable on Form 1099-R should not be included on line 5b. Do not submit Form 1099-R with the Form 5500.

IRS Form 5310-A, Notice of Plan Merger or Consolidation, Spinoff, or Transfer of Plan Assets or Liabilities; Notice of Qualified Separate Lines of Business, may be required to be filed at least 30 days before any plan merger or consolidation or any transfer of plan assets or liabilities to another plan. There is a penalty for not filing IRS Form 5310-A on time. In addition, a transfer of benefit liabilities involving a plan covered by PBGC insurance may be reportable to the PBGC. See PBGC Form 10, Post-Event Notice of Reportable Events, and PBGC Form 10-Advance, Advance Notice of Reportable Events.

Line 5c. Check “Yes” if the plan was covered by PBGC at any time during the plan year to which the Form 5500 relates and enter the My PAA generated confirmation number for the premium filing for that plan year reported (see filing receipt). “Yes” must be checked even if coverage has ceased and/or final premiums have been paid before the Form 5500 is due.

If you are uncertain whether the plan is covered under the PBGC termination insurance program, check the box “Not determined” and contact PBGC either by phone at 1-800-736-2444, by E-mail at [email protected], or in writing to Pension Benefit Guaranty Corporation, Standard Termination Compliance Division, Suite 930, Processing and Technical Assistance Branch, 1200 K Street, NW, Washington, DC 20005-4026. If you amended your premium filing for this plan year, enter the confirmation number for that filing and not for the previous filing(s). Defined contribution plans and welfare plans do not need to complete this item.

Note: A church defined benefit pension plan that has made an election under Code section 410(d) should see www.pbgc.gov for the procedures prescribed by PBGC on how to notify PBGC that it wishes to have title IV of ERISA apply to it.

2021 Instructions for Schedule I

(Form 5500)

Financial Information – Small Plan

General Instructions

Who Must File

Schedule I (Form 5500) must be attached to a Form 5500 filed for pension benefit plans and welfare benefit plans that covered fewer than 100 participants as of the beginning of the plan year and that are not eligible to file Form 5500-SF.

Note. If a Schedule I or a Form 5500-SF was filed for the plan for the 2020 plan year and the plan covered fewer than 121 participants as of the beginning of the 2021 plan year, the Schedule I may be completed instead of a Schedule H.

Exception. Certain insured, unfunded or combination unfunded/insured welfare plans are exempt from filing the Form 5500 and the Schedule I. In addition, certain fully insured pension benefit plans are exempt from completing the Schedule I. See the Form 5500 instructions for Who Must File and Limited Pension Plan Reporting for more information.

A plan that is required to file a Form M-1, Report for Multiple-Employer Welfare Arrangements (MEWAs) and Certain Entities Claiming Exception (ECEs) is not required to file the Schedule I if it has fewer than 100 participants at the beginning of the plan year and meets the requirements of 29 CFR 2520.104-44.

Check the Schedule I box on the Form 5500 (Part II, line 10b(2)) if a Schedule I is attached to the Form 5500. Do not attach both a Schedule I and a Schedule H to the same Form 5500.

Specific Instructions

Lines A, B, C, and D. This information must be the same as reported in Part II of the Form 5500 to which this Schedule I is attached.

Do not use a social security number in line D in lieu of an EIN. The Schedule I and its attachments are open to public inspection, and the contents are public information and are subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on this Schedule I or any of its attachments may result in the rejection of the filing.

Note. The cash, modified cash, or accrual basis may be used for recognition of transactions, as long as you use one method consistently. Round off all amounts reported on the Schedule I to the nearest dollar. Any other amounts are subject to rejection. Check all subtotals and totals carefully.

If the assets of two or more plans are maintained in one fund, such as when an employer has two plans funded through a single trust (except a DFE), complete Parts I and II by entering the plan’s allocable part of each line item.

If assets of one plan are maintained in two or more trust funds, report the combined financial information in Part I.

Part I – Small Plan Financial Information

Amounts reported on lines 1a, 1b, and 1c for the beginning of the plan year must be the same as reported for the end of the

plan year for corresponding lines on the return/report for the preceding plan year.

Do not include contributions designated for the 2021 plan year in column (a).

Line 1a. A plan with assets held in common/collective trusts (CCTs), pooled separate accounts (PSAs), master trust investment accounts (MTIAs), and/or 103-12 IEs must also attach Schedule D.

Use the same method for determining the value of the plan’s interest in an insurance company general account (unallocated contracts) that you used for line 4 of Schedule A, or, if line 4 is not required, line 7 of Schedule A.

Note. Do not include in column (b) a participant loan that has been deemed distributed during the plan year under the provisions of Code section 72(p) and Treasury Regulations section 1.72(p)-1, if both of the following circumstances apply:

1. Under the plan, the participant loan is treated as a directed investment solely of the participant’s individual account; and

2. As of the end of the plan year, the participant is not continuing repayment under the loan.

If the deemed distributed participant loan is included in column (a) and both of these circumstances apply, report the loan as a deemed distribution on line 2g. However, if either of these circumstances does not apply, the current value of the participant loan (including interest accruing thereon after the deemed distribution) should be included in column (b) without regard to the occurrence of a deemed distribution.

After a participant loan that has been deemed distributed is reported on line 2g, it is no longer to be reported as an asset on Schedule H or Schedule I unless, in a later year, the participant resumes repayment under the loan. However, such a loan (including interest accruing thereon after the deemed distribution) that has not been repaid is still considered outstanding for purposes of applying Code section 72(p)(2)(A) to determine the maximum amount of subsequent loans. Also, the deemed distribution is not treated as an actual distribution for other purposes, such as the qualification requirements of Code section 401, including, for example, the determination of top-heavy status under Code section 416 and the vesting requirements of Treasury Regulations section 1.411(a)-7(d)(5). See Q&As 12 and 19 of Treasury Regulations section 1.72(p)-1.

The entry on line 1a, column (b), of Schedule I (plan assets - end of year) or on line 1c(8), column (b), of Schedule H (participant loans - end of year) must include the current value of any participant loan reported as a deemed distribution on line 2g for any earlier year if, during the plan year, the participant resumes repayment under the loan. In addition, the amount to be entered on line 2g must be reduced by the amount of the participant loan reported as a deemed distribution on line 2g for the earlier year.

Line 1b. Enter the total liabilities at the beginning and end of the plan year. Liabilities to be entered here do not include the value of future pension payments to plan participants. However, the amount to be entered in line 1b for accrual basis filers includes, among other things:

1. Benefit claims that have been processed and approved for payment by the plan but have not been paid (including all incurred but not reported welfare benefit claims);

2. Accounts payable obligations owed by the plan that were incurred in the normal operations of the plan but have not been paid; and

3. Other liabilities such as acquisition indebtedness and any other amount owed by the plan.

Line 1c. Enter the net assets as of the beginning and end of the plan year. (Subtract line 1b from 1a.) Line 1c, column (b) must equal the sum of line 1c, column (a) plus lines 2k and 2l.

Line 2a. Include the total cash contributions received or (for accrual basis plans) due to be received.

Line 2a(1). Plans using the accrual basis of accounting must not include contributions designated for years before the 2021 plan year on line 2a(1).

Line 2a(2). For welfare plans, report all employee contributions, including all elective contributions under a cafeteria plan (Code section 125). For pension benefit plans, participant contributions, for purposes of this item, also include elective contributions under a qualified cash or deferred arrangement (Code section 401(k)).

Line 2b. Use the current value, at date contributed, of securities or other noncash property.

Line 2c. Enter all other plan income for the plan year. Do not include transfers from other plans that are reported on line 2l. Other income received and/or receivable would include:

1. Interest on investments (including money market accounts, sweep accounts, STIF accounts, etc.).

2. Dividends. (Accrual basis plans should include dividends declared for all stock held by the plan even if the dividends have not been received as of the end of the plan year.)

3. Rents from income-producing property owned by the plan.

4. Royalties.

5. Net gain or loss from the sale of assets.

6. Other income, such as unrealized appreciation (depreciation) in plan assets.

To compute this amount subtract the current value of all assets at the beginning of the year plus the cost of any assets acquired during the plan year from the current value of all assets at the end of the year minus assets disposed of during the plan year.

Line 2d. Enter the total of all cash contributions (lines 2a(1) through (3)), noncash contributions (line 2b), and other plan income (line 2c) during the plan year. If entering a negative number, enter a minus sign “-” to the left of the number.

Line 2e. Include: (1) payments made (and for accrual basis filers) payments due to or on behalf of participants or beneficiaries in cash, securities, or other property (including rollovers of an individual’s accrued benefit or account balance). Include all eligible rollover distributions as defined in Code section 401(a)(31)(D) paid at the participant’s election to an eligible retirement plan (including an IRA within the meaning of Code section 401(a)(31)(E)); (2) payments to insurance companies and similar organizations such as Blue Cross, Blue Shield, and health maintenance organizations for the provision of plan benefits (e.g., paid-up annuities, accident insurance, health insurance, vision care, dental coverage, etc.); and (3) payments made to other organizations or individuals providing benefits. Generally, these payments discussed in (3) are made to individual providers of welfare benefits such as legal services, day care services, and training and apprenticeship services. If securities or other property are distributed to plan participants or beneficiaries, include the current value on the date of distribution.

Line 2g. Report on line 2g a participant loan included in line 1a, column (a) (participant loans - beginning of year) and that has been deemed distributed during the plan year under the provisions of Code section 72(p) and Treasury Regulations section 1.72(p)-1 only if both of the following circumstances apply:

1. Under the plan, the participant loan is treated as a directed investment solely of the participant’s individual account; and

2. As of the end of the plan year, the participant is not continuing repayment under the loan.

If either of these circumstances does not apply, a deemed distribution of a participant loan should not be reported on line 2g. Instead, the current value of the participant loan (including interest accruing thereon after the deemed distribution) should be included on line 1a, column (b) (plan assets – end of year), without regard to the occurrence of a deemed distribution.

Note. The amount to be reported on line 2g of Schedule H or Schedule I must be reduced if, during the plan year, a participant resumes repayment under a participant loan reported as a deemed distribution on line 2g for any earlier year. The amount of the required reduction is the amount of the participant loan reported as a deemed distribution on line 2g for the earlier year. If entering a negative number, enter a minus sign “-” to the left of the number. The current value of the participant loan must then be included in line 1c(8), column (b), of Schedule H (participant loans – end of year) or in line 1a, column (b), of Schedule I (plan assets – end of year).

Line 2h. The amount to be reported for expenses involving administrative service providers (salaries, fees, and commissions) includes the total fees paid (or in the case of accrual basis plans, costs incurred during the plan year but not paid as of the end of the plan year) by the plan for, among others:

1. Salaries to employees of the plan;

2. Fees and expenses for accounting, actuarial, legal, investment management, investment advice, and securities brokerage services;

3. Contract administrator fees;

4. Fees and expenses for individual plan trustees, including reimbursement for travel, seminars, and meeting expenses; and

5. Fees and expenses paid for valuations and appraisals of real estate and closely held securities.

Line 2i. Other expenses (paid and/or payable) include other administrative and miscellaneous expenses paid by or charged to the plan, including among others, office supplies and equipment, telephone, postage, rent and expenses associated with the ownership of a building used in operation of the plan.

Line 2j. Enter the total of all benefits paid or due as reported on lines 2e, 2f, and 2g and all other plan expenses (lines 2h and 2i) during the year.

Line 2l. Enter the net value of all assets transferred to and from the plan during the plan year including those resulting from mergers and spinoffs. A transfer of assets or liabilities occurs when there is a reduction of assets or liabilities with respect to one plan and the receipt of these assets or the assumption of these liabilities by another plan. Transfers out at the end of the year should be reported as occurring during the plan year.

Note. A distribution of all or part of an individual participant’s account balance that is reportable on Form 1099-R, Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc., should not be included on line 2l but must be included in benefit payments reported on line 2e. Do not submit IRS Form 1099-R with Form 5500.

Lines 3a through 3g. You must check either “Yes” or “No” on each line to report whether the plan held any assets in the listed categories at any time during the plan year. If “Yes” is checked on any line, enter in the amount column for that line the current value of the assets held at the end of the plan year or “0” if no assets remain in the category at the end of the plan year. You should allocate the value of the plan’s interest in a commingled trust containing the assets of more than one plan on a line-by-line basis, except do not include on lines 3a through 3g the value of the plan’s interest in any CCT, PSA, MTIA, or 103-12 IE (see instructions definitions of CCT, PSA, MTIA, and 103-12 IE).

Line 3a. Enter the value of the plan’s participation in a partnership or joint venture, unless the partnership or joint venture is a 103-12 IE.

Line 3b. The term ‘‘employer real property’’ means real property (and related personal property) that is leased to an employer of employees covered by the plan, or to an affiliate of such employer. For purposes of determining the time at which a plan acquires employer real property for purposes of this line, such property shall be deemed to be acquired by the plan on the date on which the plan acquires the property or on the date on which the lease to the employer (or affiliate) is entered into, whichever is later.

Line 3d. An employer security is any security issued by an employer (including affiliates) of employees covered by the plan. These may include common stocks, preferred stocks, bonds, zero coupon bonds, debentures, convertible debentures, notes and commercial paper.

Line 3e. Enter the current value of all loans to participants including residential mortgage loans that are subject to Code section 72(p). Include the sum of the value of the unpaid principal balances, plus accrued but unpaid interest, if any, for participant loans made under an individual account plan with investment experience segregated for each account, that are made in accordance with 29 CFR 2550.408b-1 and secured solely by a portion of the participant’s vested accrued benefit. When applicable, combine this amount with the current value of any other participant loans. Do not include any amount of a participant loan deemed distributed during the plan year under the provisions of Code section 72(p) and Treasury Regulations section 1.72(p)-1, if both of the following circumstances apply:

1. Under the plan, the participant loan is treated as a directed investment solely of the participant’s individual account; and

2. As of the end of the plan year, the participant is not continuing repayment under the loan.

If both of these circumstances apply, report the loan as a deemed distribution on line 2g. However, if either of these circumstances does not apply, the current value of the participant loan (including interest accruing thereon after the deemed distribution) should be included on line 3e without regard to the occurrence of a deemed distribution.

Note. After participant loans have been deemed distributed and reported on line 2g of the Schedule I or H, they are no longer required to be reported as assets on the Schedule I or H. However, such loans (including interest accruing thereon after the deemed distribution) that have not been repaid are still considered outstanding for purposes of applying Code section 72(p)(2)(A) to determine the maximum amount of subsequent loans. Also, the deemed distribution is not treated as an actual distribution for other purposes, such as the qualification requirements of Code section 401, including, for example, the determination of top-heavy status under Code section 416 and the vesting requirements of Treasury Regulations section 1.411(a)-7(d)(5). See Q&As 12 and 19 of Treasury Regulations section 1.72(p)-1.

Line 3f. Enter the current value of all loans made by the plan, except participant loans reportable on line 3e. Include the sum of the value of loans for construction, securities loans, commercial and/or residential mortgage loans that are not subject to Code section 72(p) (either by making or participating in the loans directly or by purchasing loans originated by a third party), and other miscellaneous loans.

Line 3g. Include all property that has concrete existence and is capable of being processed, such as goods, wares, merchandise, furniture, machines, equipment, animals, automobiles, etc. This includes collectibles, such as works of art, rugs, antiques, metals, gems, stamps, coins, alcoholic beverages, musical instruments, and historical objects (documents, clothes, etc.). Do not include the value of a plan’s interest in property reported on lines 3a through 3f, or intangible property, such as patents, copyrights, goodwill, franchises, notes, mortgages, stocks, claims, interests, or other property that embodies intellectual or legal rights.

Part II – Compliance Questions

Answer all lines with either ‘‘Yes’’ or ‘‘No.’’ Do not leave any answer blank, unless otherwise directed. For lines 4a through 4i and line 4l, if the answer is “Yes,” an amount must be entered. If you check ‘‘No’’ on line 4k you must attach the report of an independent qualified public accountant (IQPA) or a statement that the plan is eligible and elects to defer attaching the IQPA’s opinion pursuant to 29 CFR 2520.104-50 in connection with a short plan year of seven months or less. Plans with all of their fund held in a master trust should check “No” on Schedule I, lines 4b, c, and i.

Line 4a. Amounts paid by a participant or beneficiary to an employer and/or withheld by an employer for contribution to the plan are participant contributions that become plan assets as of the earliest date on which such contributions can reasonably be segregated from the employer’s general assets. See 29 CFR 2510.3-102. In the case of a plan with fewer than 100 participants at the beginning of the plan year, any amount deposited with such plan not later than the 7^th business day following the day on which such amount is received by the employer (in the case of amounts that a participant or beneficiary pays to an employer), or the 7^th business day following the day on which such amount would otherwise have been payable to the participant in cash (in the case of amount withheld by an employer from a participant’s wages), shall be deemed to be contributed or repaid to such plan on the earliest date on which such contributions or participant loan repayments can reasonably be segregated from the employer’s general assets. See 29 CFR 2510.3102(a)(2).

Plans that check “Yes” must enter the aggregate amount of all late contributions for the year. The total amount of the delinquent contributions must be included on line 4a of the Schedule H or I, as applicable, for the year in which the contributions were delinquent and must be carried over and reported again on line 4a of the Schedule H or I, as applicable, for each subsequent year until the year after the violation has been fully corrected, which correction includes payment of the late contributions and reimbursement of the plan for lost earnings or profits. If no participant contributions were received or withheld by the employer during the plan year, answer ‘‘No.’’

An employer holding participant contributions commingled with its general assets after the earliest date on which such contributions can reasonably be segregated from the employer’s general assets will have engaged in prohibited use of plan assets (see ERISA section 406). If such a nonexempt prohibited transaction occurred with respect to a disqualified person (see Code section 4975(e)(2)), file IRS Form 5330, Return of Excise Taxes Related to Employee Benefit Plans, with the IRS to pay any applicable excise tax on the transaction.

F or those Schedule I filers required to submit an IQPA report, delinquent participant contributions reported on line 4a must be treated as part of the separate schedules referenced in ERISA section 103(a)(3)(A) and 29 CFR 2520.103-1(b) and 2520.103-2(b) for purposes of preparing the IQPA’s opinion even though they are not required to be listed on Part III of the Schedule G. If the information contained on line 4a is not presented in accordance with regulatory requirements, i.e., when the IQPA concludes that the scheduled information required by line 4a does not contain all the required information or contains information that is inaccurate or is inconsistent with the plan’s financial statements, the IQPA report must make the appropriate disclosures in accordance with generally accepted auditing standards. For more information, see EBSA’s Frequently Asked Questions about Reporting Delinquent Contributions on the Form 5500, available on the Internet at www.dol.gov/ebsa. These Frequently Asked Questions clarify that plans have an obligation to include delinquent participant contributions on their financial statements and supplemental schedules and that the IQPA’s report covers such delinquent contributions even though they are no longer required to be included on Part III of the Schedule G. Although all delinquent participant contributions must be reported on line 4a, delinquent contributions for which the DOL Voluntary Fiduciary Correction Program (VFCP) requirements and the conditions of the Prohibited Transaction Exemption (PTE) 2002-51 have been satisfied do not need to be treated as nonexempt party-in-interest transactions.

The VFCP describes how to apply, the specific transactions covered (which transactions include delinquent participant contributions to pension and welfare plans), and acceptable methods for correcting violations. In addition, applicants that satisfy both the VFCP requirements and the conditions of Prohibited Transaction Exemption (PTE) 2002-51 are eligible for immediate relief from payment of certain prohibited transaction excise taxes for certain corrected transactions, and are also relieved from the obligation to file the IRS Form 5330 with the IRS. For more information, see 71 Fed. Reg. 20261 (Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19, 2006). All delinquent participant contributions must be reported on line 4a even if violations have been corrected. Information about the VFCP is also available on the Internet at www.dol.gov/ebsa.

Line 4a Schedule. Attach a Schedule of Delinquent Participant Contributions using the format below if you entered “Yes” on line 4a and you are checking “No” on line 4k because you are not claiming the audit waiver for the plan. If you choose to include participant loan repayments on line 4a, you must apply the same supplemental schedule and IQPA disclosure requirements to the loan repayments as apply to delinquent transmittals of participant contributions.

Shape18 Schedule I Line 4a – Schedule of Delinquent Participant Contributions

Participant Contributions Transferred Late to Plan

Total that Constitute Nonexempt Prohibited Transactions

Total Fully Corrected Under VFCP and PTE

2002-51

Check here if Late Participant Loan Repayments are included:

Contributions Not Corrected

Contributions Corrected Outside VFCP

Contributions Pending Correction in VFCP

Line 4b. Plans that check “Yes” must enter the amount. The due date, payment amount and conditions for determining default of a note or loan are usually contained in the documents establishing the note or loan. A loan by the plan is in default when the borrower is unable to pay the obligation upon maturity. Obligations that require periodic repayment can default at any time. Generally, loans and fixed income obligations are considered uncollectible when payment has not been made and there is little probability that payment will be made. A fixed income obligation has a fixed maturity date at a specified interest rate. Do not include participant loans made under an individual account plan with investment experience segregated for each account that were made in accordance with 29 CFR 2550.408b-1 and secured solely by a portion of the participant’s vested accrued benefit.

Line 4c. Plans that check “Yes” must enter the amount. A lease is an agreement conveying the right to use property, plant or equipment for a stated period. A lease is in default when the required payment(s) has not been made. An uncollectible lease is one where the required payments have not been made and for which there is little probability that payment will be made.

Line 4d. Plans that check “Yes” must enter the amount. Check “Yes” if any nonexempt transaction with a party-in-interest occurred regardless of whether the transaction is disclosed in the IQPA’s report. Do not check “Yes” with respect to transactions that are: (1) statutorily exempt under Part 4 of Title I of ERISA; (2) administratively exempt under ERISA section 408(a); (3) exempt under Code sections 4975(c) or 4975(d); (4) the holding of participant contributions in the employer’s general assets for a welfare plan that meets the conditions of ERISA Technical Release 92-01; (5) a transaction of a 103-12 IE with parties other than the plan; or (6) delinquent participant contributions or delinquent participant loan repayments reported on line 4a. You may indicate that an application for an administrative exemption is pending. If you are unsure whether a transaction is exempt or not, you should consult with either a qualified public accountant, legal counsel or both. If the plan is a qualified pension plan and a nonexempt prohibited transaction occurred with respect to a disqualified person, an IRS Form 5330 should be filed with the IRS to pay the excise tax on the transaction.

A pplicants that satisfy the VFCP requirements and the conditions of PTE 2002-51 (see the instructions for line 4a) are eligible for immediate relief from payment of certain prohibited transaction excise taxes for certain corrected transactions, and are also relieved from the obligation to file the Form 5330 with the IRS. For more information, see 71 Fed. Reg. 20261 (Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19, 2006). When the conditions of PTE 2002-51 have been satisfied, the corrected transactions should be treated as exempt under Code section 4975(c) for the purposes of answering line 4d.

Party-in-Interest. For purposes of this form, party-in-interest is deemed to include a disqualified person. See Code section 4975(e)(2). The term ‘‘party-in-interest’’ means, as to an employee benefit plan:

A. Any fiduciary (including, but not limited to, any administrator, officer, trustee, or custodian), counsel, or employee of the plan;

B. A person providing services to the plan;

C. An employer, any of whose employees are covered by the plan;

D. An employee organization, any of whose members are covered by the plan;

F. A relative of any individual described in A, B, C, or E;

G. A corporation, partnership, or trust or estate of which (or in which) 50% or more of: (1) the combined voting power of all classes of stock entitled to vote or the total value of shares of all classes of stock of such corporation, (2) the capital interest or profits interest of such partnership, or (3) the beneficial interest of such trust or estate is owned directly or indirectly, or held by, persons described in A, B, C, D, or E;

H. An employee, officer, director (or an individual having powers or responsibilities similar to those of officers or directors), or a 10% or more shareholder, directly or indirectly, of a person described in B, C, D, E, or G, or of the employee benefit plan;

I . A 10% or more (directly or indirectly in capital or profits) partner or joint venturer of a person described in B, C, D, E, or G.

Nonexempt transactions with a party-in-interest include any direct or indirect:

A. Sale or exchange, or lease, of any property between the plan and a party-in-interest.

B. Lending of money or other extension of credit between the plan and a party-in-interest.

C. Furnishing of goods, services, or facilities between the plan and a party-in-interest.

D. Transfer to, or use by or for the benefit of, a party-in-interest, of any income or assets of the plan.

E. Acquisition, on behalf of the plan, of any employer security or employer real property in violation of ERISA section 407(a).

F. Dealing with the assets of the plan for a fiduciary’s own interest or own account.

H. Receipt of any consideration for his or her own personal account by a party-in-interest who is a fiduciary from any party dealing with the plan in connection with a transaction involving the income or assets of the plan.

Line 4e. Plans that check “Yes” must enter the aggregate amount of fidelity bond coverage for all claims. Check ‘‘Yes’’ only if the plan itself (as opposed to the plan sponsor or administrator) is a named insured under a fidelity bond from an approved surety covering plan officials and that protects the plan from losses due to fraud or dishonesty as described in 29 CFR Part 2580. Generally, every plan official of an employee benefit plan who ‘‘handles’’ funds or other property of such plan must be bonded. Generally, a person shall be deemed to be ‘‘handling’’ funds or other property of a plan, so as to require bonding, whenever his or her duties or activities with respect to given funds are such that there is a risk that such funds could be lost in the event of fraud or dishonesty on the part of such person, acting either alone or in collusion with others. Section 412 of ERISA and 29 CFR Part 2580 describe the bonding requirements, including the definition of ‘‘handling’’ (29 CFR 2580.412-6), the permissible forms of bonds (29 CFR 2580.412-10), the amount of the bond (29 CFR Part 2580, subpart C), and certain exemptions such as the exemption for unfunded plans, certain banks and insurance companies (ERISA section 412), and the exemption allowing plan officials to purchase bonds from surety companies authorized by the Secretary of the Treasury as acceptable reinsurers on federal bonds (29 CFR 2580.412-23). Information concerning the list of approved sureties and reinsurers is available on the Internet at www.fms.treas.gov/c570. For more information on the fidelity bonding requirements, see Field Assistance Bulletin 2008-04, available on the Internet at www.dol.gov/ebsa.

Line 4f. Check ‘‘Yes,’’ if the plan had suffered or discovered any loss as a result of any dishonest or fraudulent act(s) even if the loss was reimbursed by the plan’s fidelity bond or from any other source. If ‘‘Yes’’ is checked enter the full amount of the loss. If the full amount of the loss has not yet been determined, provide an estimate as determined in good faith by a plan fiduciary. You must keep, in accordance with ERISA section 107, records showing how the estimate was determined.

Willful failure to report is a criminal offense. See ERISA section 501.

Examples of assets that may not have a readily determinable value on an established market (e.g., NYSE, AMEX, over the counter, etc.) include real estate, nonpublicly traded securities, shares in a limited partnership, and collectibles. Do not check “Yes” on line 4g for mutual fund shares or insurance company investment contracts for which the plan receives valuation information at least annually. Also do not check ‘‘Yes’’ on line 4g if the plan is a defined contribution plan and the only assets the plan holds, that do not have a readily determinable value on an established market, are: (1) participant loans not in default, or (2) assets over which the participant exercises control within the meaning of section 404(c) of ERISA.

Line 4i. Include as a single security all securities of the same issue. An example of a single issue is a certificate of deposit issued by the XYZ Bank on July 1, 2019, which matures on June 30, 2021, and yields x%. For the purposes of line 4i, do not check ‘‘Yes’’ for securities issued by the U.S. Government or its agencies. Also, do not check “Yes” for securities held as a result of participant-directed transactions.

Line 4j. Check “Yes” if all the plan assets (including insurance/annuity contracts) were distributed to the participants and beneficiaries, legally transferred to the control of another plan, or brought under the control of the PBGC.

Check ‘‘No’’ for a welfare benefit plan that is still liable to pay benefits for claims that were incurred before the termination date, but not yet paid. See 29 CFR 2520.104b-2(g)(2)(ii).

Line 4k. Check ‘‘Yes’’ if you are claiming a waiver of the annual examination and report of an independent qualified public accountant (IQPA) under 29 CFR 2520.104-46. You are eligible to claim the waiver if the Schedule I is being filed for:

1. A small welfare plan, or

2. A small pension plan for a plan year that began on or after April 18, 2001, that complies with the conditions of 29 CFR 2520.104-46 summarized below.

Check ‘‘No’’ and attach the report of the IQPA meeting the requirements of 29 CFR 2520.103-1(b) if you are not claiming the waiver. Also check ‘‘No,’’ and attach the required IQPA reports or the required explanatory statement if you are relying on 29 CFR 2520.104-50 in connection with a short plan year of seven months or less. At the top of any attached 2520.104-50 statement, enter “2520.104-50 Statement, Schedule I, Line 4k.”

For more information on the requirements for deferring an IQPA report pursuant to 29 CFR 2520.104-50 in connection with a short plan year of seven months or less and the contents of the required explanatory statement, see the instructions for Schedule H, line 3d(2) or call the EFAST2 Help Desk at 1-866-GO-EFAST (1-866-463-3278) (toll-free).

Note. For plans that check “No,” the IQPA report must make the appropriate disclosures in accordance with generally accepted auditing standards if the information reported on line 4a is not presented in accordance with regulatory requirements.

The following summarizes the conditions of 29 CFR 2520.104-46 that must be met for a small pension plan with a plan year beginning on or after April 18, 2001, to be eligible for the waiver. For more information regarding these requirements, see the EBSA’s Frequently Asked Questions on the Small Pension Plan Audit Waiver Regulation and 29 CFR 2520.104-46, which are available at www.dol.gov/ebsa, or call the EFAST2 Help Desk at 1-866-GO-EFAST (1-866-463-3278) (toll-free)

Condition 1: At least 95 percent of plan assets are “qualifying plan assets” as of the end of the preceding plan year, or any person who handles assets of the plan that do not constitute qualifying plan assets is bonded in accordance with the requirements of ERISA section 412 (see the instructions for line 4e), except that the amount of the bond shall not be less than the value of such non-qualifying assets.

The determination of the “percent of plan assets” as of the end of the preceding plan year and the amount of any required bond must be made at the beginning of the plan’s reporting year for which the waiver is being claimed. For purposes of this line, you will have satisfied the requirement to make these determinations at the beginning of the plan reporting year for which the waiver is being claimed if they are made as soon after the date when such year begins as the necessary information from the preceding reporting year can practically be ascertained. See 29 CFR 2580.412-11, 14 and 19 for additional guidance on these determinations, and 29 CFR 2580.412-15 for procedures to be used for estimating these amounts if there is no preceding plan year.

The term ‘‘qualifying plan assets,’’ for purposes of this line, means:

1. Any assets held by any of the following regulated financial institutions:

a. A bank or similar financial institution as defined in 29 CFR 2550.408b-4(c);

b. An insurance company qualified to do business under the laws of a state;

c. An organization registered as a broker-dealer under the Securities Exchange Act of 1934; or

d. Any other organization authorized to act as a trustee for individual retirement accounts under Code section 408.

2. Shares issued by an investment company registered under the Investment Company Act of 1940 (e.g., mutual funds);

3. Investment and annuity contracts issued by any insurance company qualified to do business under the laws of a state;

4. In the case of an individual account plan, any assets in the individual account of a participant or beneficiary over which the participant or beneficiary has the opportunity to exercise control and with respect to which the participant or beneficiary is furnished, at least annually, a statement from a regulated financial institution referred to above describing the assets held or issued by the institution and the amount of such assets;

5. Qualifying employer securities, as defined in ERISA section 407(d)(5); and

6. Participant loans meeting the requirements of ERISA section 408(b)(1).

Condition 2: The administrator must disclose the following information in the summary annual report (SAR) furnished to participants and beneficiaries, in accordance with 29 CFR 2520.104b-10. For defined benefit pension plans that are required pursuant to section 101(f) of ERISA to furnish an Annual Funding Notice (AFN), the administrator must instead either provide the information to participants and beneficiaries with the AFN or as a stand-alone notification at the time a SAR would have been due and in accordance with the rules for furnishing an SAR, although such plans do not have to furnish a SAR.

1. The name of each regulated financial institution holding or issuing qualifying plan assets and the amount of such assets reported by the institution as of the end of the plan year (this SAR disclosure requirement does not apply to qualifying employer securities, participant loans and individual account assets described in paragraphs 4,5 and 6 above);

2. The name of the surety company issuing the fidelity bond, if the plan has more than 5% of its assets in non-qualifying plan assets;

3. A notice that participants and beneficiaries may, upon request and without charge, examine or receive from the plan evidence of the required bond and copies of statements from the regulated financial institutions describing the qualifying plan assets; and

4. A notice that participants and beneficiaries should contact the EBSA Regional Office if they are unable to examine or obtain copies of the regulated financial institution statements or evidence of the required bond, if applicable.

A Model Notice that plans can use to satisfy the enhanced SAR (or Annual Funding Notice) disclosure requirements to be eligible for the audit waiver is available as an Appendix to 29 CFR 2520.104-46.

Condition 3: In addition, in response to a request from any participant or beneficiary, the administrator, without charge to the participant or beneficiary, must make available for examination, or upon request furnish copies of, each regulated financial institution statement and evidence of any required bond.

Examples. Plan A, which has a plan year that began on or after April 18, 2001, had total assets of $600,000 as of the end of the 2000 plan year that included: investments in various bank, insurance company and mutual fund products of $520,000; investments in qualifying employer securities of $40,000; participant loans (meeting the requirements of ERISA section 408(b)(1)), totaling $20,000; and a $20,000 investment in a real estate limited partnership. Because the only asset of the plan that did not constitute a ‘‘qualifying plan asset’’ is the $20,000 real estate limited partnership investment and that investment represents less than 5% of the plan’s total assets, no fidelity bond is required as a condition for the plan to be eligible for the waiver for the 2001 plan year.

Plan B is identical to Plan A except that of Plan B’s total assets of $600,000 as of the end of the 2000 plan year, $558,000 constitutes ‘‘qualifying plan assets’’ and $42,000 constitutes non-qualifying plan assets. Because 7% – more than 5% – of Plan B’s assets do not constitute ‘‘qualifying plan assets,’’ Plan B, as a condition to be eligible for the waiver for the 2001 plan year, must ensure that it has a fidelity bond in an amount equal to at least $42,000 covering persons handling its non-qualifying plan assets. Inasmuch as compliance with ERISA section 412 generally requires the amount of the bond be not less than 10% of the amount of all the plan’s funds or other property handled, the bond acquired for ERISA section 412 purposes may be adequate to cover the non-qualifying plan assets without an increase (i.e., if the amount of the bond determined to be needed for the relevant persons for ERISA section 412 purposes is at least $42,000). As demonstrated by the foregoing example, where a plan has more than 5% of its assets in non-qualifying plan assets, the required bond is for the total amount of the non-qualifying plan assets, not just the amount in excess of 5%.

If you need further information regarding these requirements, see 29 CFR 2520.104-46 which is available at www.dol.gov/ebsa or call the EFAST2 Help Desk at 1-866-GO-EFAST (1-866-463-3278) (toll-free)

Line 4l. You must check “Yes” if any benefits due under the plan were not timely paid or not paid in full. This would include required minimum distributions to 5% owners who have attained 72 whether or not retired and/or non-5% owners who have attained 72 and have retired or separated from service, see Code section 401(a)(9). Include in this amount the total of any outstanding amounts that were not paid when due in previous years that have continued to remain unpaid.

Line 4m. Check “Yes” if there was a “blackout period.” A blackout period is a temporary suspension of more than three (3) consecutive business days during which participants or beneficiaries of a 401(k) or other individual account pension plan were unable to, or were limited or restricted in their ability to, direct or diversify assets credited to their accounts, obtain loans from the plan, or obtain distributions from the plan. A “blackout period” generally does not include a temporary suspension of the right of participants and beneficiaries to direct or diversify assets credited to their accounts, obtain loans from the plan, or obtain distributions from the plan if the temporary suspension is: (1) part of the regularly scheduled operations of the plan that has been disclosed to participants and beneficiaries; (2) due to a qualified domestic relations order (QDRO) or because of a pending determination as to whether a domestic relations order is a QDRO; (3) due to an action or a failure to take action by an individual participant or because of an action or claim by someone other than the plan regarding a participant’s individual account; (4) by application of federal securities laws. For more information, see 29 CFR 2520.101-3 (available at www.dol.gov/ebsa).

Line 5a. Check “Yes” if a resolution to terminate the plan was adopted during this or any prior plan year, unless the termination was revoked and no assets reverted to the employer. If ‘‘Yes’’ is checked, enter the amount of plan assets that reverted to the employer during the plan year in connection with the implementation of such termination. Enter ‘‘0’’ if no reversion occurred during the current plan year.

A Form 5500 must be filed for each year the plan has assets, and, for a welfare benefit plan, if the plan is still liable to pay benefits for claims that were incurred before the termination date, but not yet paid. See 29 CFR 2520.104b-2(g)(2)(ii).

Do not use a social security number in lieu of an EIN or include an attachment that contains visible social security numbers. The Schedule I and its attachments are open to public inspection, and the contents are public information and are subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on this Schedule I or the inclusion of a visible social security number or any portion thereof on an attachment may result in the rejection of the filing.

Note. A distribution of all or part of an individual participant’s account balance that is reportable on IRS Form 1099-R should not be included on line 5b. Do not submit IRS Form 1099-R with the Form 5500.

IRS Form 5310-A, Notice of Plan Merger or Consolidation, Spinoff, or Transfer of Plan Assets or Liabilities; Notice of Qualified Separate Lines of Business, may be required to be filed at least 30 days before any plan merger or consolidation or any transfer of plan assets or liabilities to another plan. There is a penalty of $25 a day (up to a maximum of $15,000) for not filing IRS Form 5310-A on time.” In addition, a transfer of benefit liabilities involving a plan covered by PBGC insurance may be reportable to the PBGC. See PBGC Form 10, Post-Event Notice of Reportable Events, and PBGC Form 10-Advance, Advance Notice of Reportable Events.

If you are uncertain whether the plan is covered under the PBGC termination insurance program, check the box “Not determined” and contact PBGC either by phone at 1-800-736-2444, by E-mail at [email protected], or in writing to Pension Benefit Guaranty Corporation, Standard Termination Compliance Division, Suite 930, Processing and Technical Assistance Branch, 1200 K Street, NW, Washington, DC 20005-4026. If you checked the box “Yes,” enter the My PAA generated confirmation number for the premium filing for this plan year (see filing receipt). If you amended your premium filing for this plan year, enter the confirmation number for that filing and not for the previous filing(s). Defined contribution plans and welfare plans do not need to complete this item.

Note: A church defined benefit pension plan that has made an election under Code section 410(d) should see www.pbgc.gov for the procedures prescribed by PBGC on how to notify PBGC that it wishes to have title IV of ERISA apply to it.

2021 Instructions for Schedule MB

(Form 5500)

Multiemployer Defined Benefit Plan and

Certain Money Purchase Plan Actuarial

Information

General Instructions

Who Must File

As the first step, the plan administrator of any multiemployer defined benefit plan that is subject to the minimum funding standards (see Code sections 412 and 431 and Part 3 of Title I of ERISA) must obtain a completed Schedule MB (Form 5500) that is prepared and signed by the plan’s enrolled actuary as discussed below in the Statement by Enrolled Actuary section. The plan administrator must retain with the plan records the Schedule MB that is prepared and signed by the plan’s actuary.

Next, the plan administrator of a multiemployer defined benefit plan must ensure that the information from the actuary’s Schedule MB is entered electronically into the annual return/report being submitted. When entering the information, whether using EFAST2-approved software or EFAST2’s web-based filing system, all the fields required for the type of plan must be completed (see instructions for fields that need to be completed).

Further, the plan administrator of a multiemployer defined benefit plan must attach to the Form 5500 an electronic reproduction of the Schedule MB prepared and signed by the plan’s enrolled actuary. This electronic reproduction must be labeled “MB Actuary Signature” and must be included as a Portable Document Format (PDF) attachment or any alternative electronic attachment allowable under EFAST2.

If a money purchase defined contribution plan (including a target benefit plan) has received a waiver of the minimum funding standard, and the waiver is currently being amortized, lines 3, 9, and 10 of Schedule MB must be completed but it need not be signed by an enrolled actuary. In such a case, the Form 5500 or the Form 5500-SF that is submitted under EFAST2 must include the Schedule MB with lines 3, 9, and 10 completed, but is not required to include a PDF attachment of a signed Schedule MB.

Note. Schedule MB does not have to be filed with the Form 5500-EZ regardless of whether it is filed on paper with the IRS or electronically with EFAST2, but, if required, it must be retained (in accordance with the instructions for the Form 5500-EZ under the What to File section). Also, the funding standard account for the plan must continue to be maintained, even if the Schedule MB is not filed.

Check the Schedule MB box on the Form 5500 (Part II, line 10a(2)) if a Schedule MB is attached to the Form 5500.

Lines A through E must be completed for ALL plans. If the Schedule MB is attached to a Form 5500 or Form 5500-SF, lines A, B, C, and D should include the same information as reported in Part II of the Form 5500 or Form 5500-SF. You may abbreviate the plan name.

Do not use a social security number in line D in lieu of an EIN. The Schedule MB and its attachments are open to public inspection if filed with a Form 5500 or Form 5500-SF, and the contents are public information and are subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on this Schedule MB or any of its attachments may result in the rejection of the filing.

You can apply for an EIN from the IRS online, by fax, or by mail depending on how soon you need to use the EIN. For more information, see Section 3: Electronic Filing Requirement under the General Instructions to Form 5500 and How to File – Electronic Filing Requirement under the General Instructions to Form 5500-SF. The EBSA does not issue EINs.

Note. (1) For split-funded plans, the costs and contributions

reported on Schedule MB must include those relating to both trust funds and insurance carriers. (2) For plans with funding standard account amortization charges and credits, see the instructions for lines 9c and 9h. (3) For terminating multiemployer plans, Code section 412(e)(4) and ERISA section 301(c) provide that minimum funding standards apply until the last day of the plan year in which the plan terminates within the meaning of section 4041A(a)(2) of ERISA. Accordingly, the Schedule MB is not required to be filed for any later plan year.

Statement by Enrolled Actuary

An enrolled actuary must sign Schedule MB unless, as described above, the plan is a money purchase defined contribution plan that has received a waiver of the minimum funding standard. The signature of the enrolled actuary may be qualified to state that it is subject to attached qualifications. See Treasury Regulations section 301.6059-1(d) for permitted qualifications. Except as otherwise provided in these instructions, a stamped or machine produced signature is not acceptable. If the actuary has not fully reflected any final or temporary regulation, revenue ruling, or notice promulgated under the statute in completing the Schedule MB, check the box on the last line of page 1. If this box is checked, indicate on an attachment whether an accumulated funding deficiency or a contribution that is not wholly deductible would result if the actuary had fully reflected such regulation, revenue ruling, or notice, and label this attachment “Schedule MB – Statement by Enrolled Actuary.” In addition, the actuary may offer any other comments related to the information contained in Schedule MB.

The actuary must provide the completed and signed Schedule MB to the plan administrator to be retained with the plan records and included (in accordance with these instructions) with the Form 5500 that is submitted under EFAST2. The plan’s actuary is permitted to sign the Schedule MB on page one using the actuary’s signature or by inserting the actuary’s typed name in the signature line followed by the actuary’s handwritten initials. The actuary’s most recent enrollment number must be entered on the Schedule MB that is prepared and signed by the plan’s actuary.

Attachments

All attachments to the Schedule MB must be properly identified, and must include the name of the plan, the plan sponsor’s EIN, and the plan number. Put “Schedule MB” and the line number to which the attachment relates at the top of each attachment. Do not include attachments that contain a visible social security number. The Schedule MB and its attachments are open to public inspection, and the contents are public information and are subject to publication on the Internet. Because of privacy concerns, the inclusion of a visible social security number or any portion thereof on an attachment may result in the rejection of the filing.

Specific Instructions

Line 1. All entries must be reported as of the valuation date.

Line 1a. Actuarial Valuation Date. The valuation for a plan year may be as of any date in the plan year, including the first or last day of the plan year. Valuations must be performed within the period specified by Code section 431(c)(7) and ERISA section 304(c)(7).

Line 1b(1). Current Value of Assets. Enter the current value of assets as of the valuation date. The current value is the same as the fair market value. Do not adjust for items such as the existing credit balance or the outstanding balances of certain amortization bases. Contributions designated for 2021 should not be included in this amount. Note that this entry may be different from the entry in line 2a. Such a difference may result, for example, if the valuation date is not the first day of the plan year, or if insurance contracts are excluded from assets reported on line 1b(1) but not on line 2a.

Rollover amounts or other assets held in individual accounts that are not available to provide defined benefits under the plan should not be included on line 1b(1), regardless of whether they are reported on the 2021 Schedule H (Form 5500) (line 1I, column (a)) or Schedule I (Form 5500) (line 1c, column (a)). Additionally, asset and liability amounts must be determined in a consistent manner. Therefore, if the value of any insurance contracts have been excluded from the amount reported on line 1b(1), liabilities satisfied by such contracts should also be excluded from the liability values reported on lines 1c(1), 1c(2), and 1d(2) of the Schedule MB.

Line 1b(2). Actuarial Value of Assets. Enter the value of assets determined in accordance with Code section 431(c)(2) and ERISA section 304(c)(2). Do not adjust for items such as the existing credit balance or the outstanding balances of certain amortization bases, and do not include contributions designated for 2021 in this amount.

Line 1c(1). Accrued Liability for Immediate Gain Methods.

Complete this line only if you use an immediate gain method (see Revenue Ruling 81-213, 1981-2 C.B. 101, for a definition of immediate gain method).

Lines 1c(2)(a), (b), and (c). Information for Plans Using Spread Gain Methods. Complete these lines only if you use a spread gain method (see Revenue Ruling 81-213 for a definition of spread gain method).

Line 1c(2)(a). Unfunded Liability for Methods with Bases. Complete this line only if you use the frozen initial liability or attained age normal cost method.

Lines 1c(2)(b) and (c). Entry Age Normal Accrued Liability and Normal Cost. For spread gain methods, these calculations are used for purposes of the full funding limitation (see Revenue Ruling 81-13, 1981-1 C.B. 229).

Line 1d(1). Amount Excluded from Current Liability. Leave line 1(d)(1) blank.

Line 1d(2)(a). Current Liability. All multiemployer plans, regardless of the number of participants, must provide the information indicated in accordance with these instructions. The interest rate used to compute the current liability must be in accordance with guidelines issued by the IRS and, pursuant to the Pension Protection Act of 2006 (PPA), must not be more than 5 percent above and must not be more than 10 percent below the weighted average of the rates of interest, as set forth by the Treasury Department, on 30-year Treasury securities during the 4-year period ending on the last day before the beginning of the 2021 plan year.

The current liability must be computed using the mortality tables referenced in section 1.431(c)(6)-1 of the Treasury Regulations.

Each other actuarial assumption used in calculating the current liability must be the same assumption used for calculating other costs for the funding standard account. See Notice 90-11, 1990-1 C.B. 319. The actuary must take into account rates of early retirement and the plan’s early retirement and turnover provisions as they relate to benefits, where these would significantly affect the results. Regardless of the valuation date, current liability is computed taking into account only credited service through the end of the prior plan year. No salary scale projections should be used in these computations. Do not include the expected increase in current liability due to benefits accruing during the plan year reported on line 1d(2)(b) in these computations.

Line 1d(2)(b). Expected Increase in Current Liability. Enter the amount by which the current liability is expected to increase due to benefits accruing during the plan year on account of credited service and/or salary changes for the current year. One year’s salary scale may be reflected.

Line 1d(2)(c). Expected Release From Current Liability for the Plan Year. Enter the expected release from current liability on account of disbursements (including single-sum distributions) from the plan expected to be paid after the valuation date but prior to the end of the plan year (see also Q&A-7 of Revenue Ruling 96-21, 1996-1 C.B. 64).

Line 1d(3). Expected Plan Disbursements. Enter the amount of plan disbursements expected to be paid for the plan year.

Line 2. All entries must be reported as of the beginning of the 2021 plan year. Lines 2a and 2b should include all assets and liabilities under the plan except for assets and liabilities attributable to: (1) rollover amounts or other amounts in individual accounts that are not available to provide defined benefits, or (2) benefits for which an insurer has made an irrevocable commitment as defined in 29 CFR 4001.2.

Line 2a. Current Value of Assets. Enter the current value of net assets as of the first day of the plan year. Except for plans with excluded assets as described above, this entry should be the same as reported on the 2021 Schedule H (Form 5500) (line 1l, column (a)) or Schedule I (Form 5500) (line 1c, column (a)). Note that contributions designated for the 2021 plan year are not included on those lines.

Line 2b. Current Liability (beginning of plan year). Enter the current liability as of the first day of the plan year. Do not include the expected increase in current liability due to benefits accruing during the plan year. See the instructions for line 1d(2)(a) for actuarial assumptions used in determining current liability.

Column (1) – Enter the number of participants and beneficiaries as of the beginning of the plan year in each category (e.g., terminated vested participants). Enter “0” if no participants fall into the category. If the current liability figures are derived from a valuation that follows the first day of the plan year, the participant and beneficiary count entries should be derived from the counts used in that valuation in a manner consistent with the derivation of the current liability reported in column (2).

Column (2) – Enter the current liability attributable to all benefits, with subtotals for vested and nonvested benefits in the case of active participants. Enter “0” if there is no current liability attributable to a particular category of participants.

Line 2c. This calculation is required under ERISA section 103(d)(11). Do not complete if line 2a divided by line 2b(4), column (2), is 70% or greater.

Line 3. Contributions Made to Plan. Show all employer and employee contributions for the plan year. Include employer contributions made not later than 2½ months (or the later date allowed under Code section 431(c)(8) and ERISA section 304(c)(8)) after the end of the plan year. Show only contributions actually made to the plan by the date this Schedule MB is signed.

Add the amounts in both columns (b) and (c) and enter both results on the total line. All contributions must be credited toward a particular plan year.

If any of the contributions reported in line 3 include amounts owed for withdrawal liability, report in line 3(d) the total withdrawal liability amounts included in line 3(b). If a non-zero number is reported on line 3(d), attach a list of withdrawal liability payments and the dates such amounts were contributed. Label this attachment “Schedule MB, Line 3 – Withdrawal Liability Amounts.”

Line 4. Information on Plan Status. All multiemployer plans regardless of the number of participants must provide the information indicated in accordance with these instructions.

Line 4a. All plans enter the funded percentage for monitoring the plan’s status. This is line 1b(2) divided by line 1c(3).

Line 4b. Enter the code for the status of the multiemployer plan for the plan year, as certified by the plan actuary, (or as elected by the plan sponsor in accordance with Code section 432(b)(4)(A) and ERISA section 305(b)(4)(A)) using one of the following codes:

Code Plan Status

E Endangered Status

S Seriously Endangered Status

C Critical Status

D Critical and Declining Status

N Not in Endangered or Critical Status

If the plan is certified to be in endangered status, seriously endangered status, critical status, or critical and declining status, attach a copy of the actuarial certification of such status to this Schedule MB. Also attach an illustration showing the details (including year-by-year cash flow projections demonstrating the solvency of the plan over the relevant period if the plan is certified as being in critical and declining status) providing support for the actuarial certification of status and label the illustration “Schedule MB, line 4b – Illustration Supporting Actuarial Certification of Status.” For example, if a plan is certified as being in critical status based on Code section 432(b)(2)(B), show the funded percentage (if applicable) and the projection of the funding standard account for the year in which the accumulated funding deficiency occurs. All supporting documentation should include descriptions of the assumptions used.

Line 4c. If, in the plan year in which the Schedule MB is filed, a certification was required to be made under Code section 432(b)(3)(A)(ii) and ERISA section 305(b)(3)(A)(ii) with respect to scheduled progress during the plan year for which the Schedule MB is filed, check “Yes” or “No” to reflect the certification. Attach documentation comparing the current status of the plan to the scheduled progress under the applicable funding improvement or rehabilitation plan to this Schedule MB. Label the documentation “Schedule MB, line 4c – Documentation Regarding Progress Under Funding Improvement or Rehabilitation Plan.”

Lines 4d and 4e. If Code C (Critical Status) or Code D (Critical and Declining Status) was entered on line 4b, an entry on line 4d is required. For purposes of lines 4d and 4e, in determining whether benefits have been reduced, only adjustable benefits that would otherwise be protected under Code section 411(d)(6) and ERISA section 204(g) are taken into account if the plan is certified as being in critical status. Plans that are certified as being in critical and declining status should determine whether benefits have been reduced, including all benefits that were adjusted (only adjustable benefits that would otherwise be protected under Code section 411(d)(6) and ERISA section 204(g) are taken into account), any benefits that have been suspended under Code section 432(e)(9), and any benefit reductions due to a partition under ERISA section 4233. For a plan that has benefits suspended under Code section 432(e)(9) and/or partitioned under ERISA section 4233, attach a full description of the transaction and label the attachment “Schedule MB, Lines 4d and 4e – Description of Benefit Reductions Due to Suspension or Partition”. In addition, only benefit reductions that are first reflected in line 1c(3) for the current year's Schedule MB should be reported, and this amount should not include any amounts previously reported on any prior year's Schedule MB.

Line 4f. If Code C (Critical Status) or Code D (Critical and Declining Status) was entered on line 4b you must complete line 4f as follows:

If, under the terms of the most recently adopted rehabilitation plan, the plan is projected to emerge from critical status within 30 years, enter the plan year in which the plan is projected to emerge from critical status.
If, under the terms of the most recently adopted rehabilitation plan, the plan is projected to become insolvent within 30 years, check the box provided, enter the plan year in which the insolvency is expected. In addition, attach an illustration showing year-by-year cash flow projections for the period ending with the year the plan is projected to become insolvent (or the 20th year after the valuation year if earlier) and a summary of the assumptions underlying the projections. Label this attachment “Schedule MB, line 4f – Cash Flow Projections”.
If, under the terms of the most recently adopted rehabilitation plan, the plan is neither projected to emerge from critical status nor become insolvent within 30 years, check the box provided, enter the year of projected emergence or insolvency in the space for plan year (or “9999” if such year has not been determined). In addition, attach an illustration showing year-by-year cash flow projections ending with the 20th year after the valuation year and a summary of the assumptions underlying the projections. Label this attachment “Schedule MB, line 4f – Cash Flow Projections”.

Line 5. Actuarial Cost Method. Enter the primary method used. If the plan uses one actuarial cost method in one year as the basis of establishing an accrued liability for use under the frozen initial liability method in subsequent years, answer as if the frozen initial liability method was used in all years. The projected unit credit method is included in the “Accrued benefit (unit credit)” category of line 5c. If a method other than a method listed on lines 5a through 5g is used, check the box for line 5i and specify the method. For example, if a modified individual level premium method for which actuarial gains and losses are spread as a part of future normal cost is used, check the box for 5i and describe the cost method.

Check the appropriate box for the underlying actuarial cost method used as the basis for this plan year’s funding standard account computation. If box 5h is checked, enter the period of use of the shortfall method in line 5j. For this purpose, enter the calendar year (YY) which includes the first day of the plan year in which the shortfall method was first used.

Changes in funding methods include changes in actuarial cost method, changes in asset valuation method, and changes in the valuation date of plan costs and liabilities or of plan assets. Changes in the funding method of a plan include not only changes to the overall funding method used by the plan, but also changes to each specific method of computation used in applying the overall method. Generally, these changes require IRS approval. If the change was made pursuant to Revenue Procedure 2000-40, 2000-2 C.B. 357, or pursuant to other automatic approval, check “Yes” for line 5l. If approval was granted for this plan by either an individual ruling letter or a class ruling letter, enter the date of the applicable ruling letter in line 5m. Note that the plan sponsor's agreement to certain changes in funding methods should be reported on line 8 of Schedule R (Form 5500).

Shortfall Method: Only certain plans may elect the shortfall funding method (see Treasury Regulations section 1.412(c)(1)-2). Advance approval from the IRS for the election of the shortfall method of funding is NOT required if it is first adopted for the first plan year to which Code section 412 applies. In addition, pursuant to PPA section 201(b), a plan does NOT need advance approval from the IRS to adopt or cease using the shortfall method if the plan (1) has not adopted or ceased using the shortfall method during the 5-year period ending on the day before the date the plan is to use the method, and (2) is not operating under an amortization period extension and did not operate under such an extension during such 5-year period. In such a case, check “Yes” for line 5l. If a plan utilizes this automatic approval to apply the shortfall method, the benefit increase limitations of Code section 412(c)(7) apply.

If a plan is not eligible for automatic approval as set forth in the preceding paragraph, advance approval from the IRS is required if the shortfall funding method is adopted at a later time, if a specific computation method is changed, or if the shortfall method is discontinued. In such a case there is no automatic limitation on benefit increases.

Line 6. Actuarial Assumptions. If gender-based assumptions are used in developing plan costs, enter those rates where appropriate in line 6. Note that requests for gender-based cost information do not suggest that gender-based benefits are legal. If unisex tables are used, enter the values in both “Male” and “Female” lines. Check “N/A” for line 6b if the question is not applicable.

Attach a statement of actuarial assumptions (if not fully described by line 6) and actuarial methods used to calculate the figures shown in lines 1 and 9 (if not fully described by line 5), and label the statement “Schedule MB, line 6 – Statement of Actuarial Assumptions/Methods.” The statement must describe all actuarial assumptions used to determine the liabilities. For example, the statement for non-traditional plans (e.g., cash balance plans) must include the assumptions used to convert balances to annuities.

Also attach a summary of the principal eligibility and benefit provisions on which the valuation was based, including the status of the plan (e.g., eligibility frozen, service/pay frozen, benefits frozen), optional forms of benefits, special plan provisions, including those that apply only to a subgroup of employees (e.g., those with imputed service), supplemental benefits, an identification of benefits not included in the valuation (e.g., shutdown benefits), a description of any significant events that occurred during the year, a summary of any changes in principal eligibility or benefit provisions since the last valuation, a description (or reasonably representative sample) of plan early retirement factors, and any change in actuarial assumptions or cost methods and justifications for any such change (see section 103(d) of ERISA). Label the summary “Schedule MB, line 6 – Summary of Plan Provisions.”

Also, include any other information needed to disclose the actuarial position of the plan fully and fairly, including the weighted average retirement age.

Line 6a. Current Liability Interest Rate. Enter the interest rate used to determine current liability. The interest rate used must be in accordance with the guidelines issued by the IRS and, pursuant to PPA, must not be more than 5 percent above and must not be more than 10 percent below the weighted average of the rates of interest, as set forth by the Treasury Department, on 30-year Treasury securities during the 4-year period ending on the last day before the beginning of the 2021 plan year. Enter the rate to the nearest .01 percent.

Line 6b. Check “Yes,” if the rates in the contract were used (e.g., purchase rates at retirement).

Line 6c. Mortality Table. The mortality table published in section 1.431(c)(6)-1 of the Treasury Regulations must be used in the calculation of current liability for non-disabled lives. Enter the mortality table code for non-disabled lives used for valuation purposes as follows:

Mortality Table Code

1951 Group Annuity 1

1971 Group Annuity Mortality (G.A.M.) 2

1971 Individual Annuity Mortality (I.A.M.) 3

UP-1984 4

1983 I.A.M. 5

1983 G.A.M. 6

1983 G.A.M. (solely per Revenue Ruling 95-28) 7

UP-1994 8

Mortality table applicable to current plan year under
section 1.431(c)(6)-1 of the Income Tax Regulations 9

RP-2000 10

RP-2000 (with Blue Collar Adjustment) 11

RP-2014………………...………………….….…………....12

RP-2014 (Blue Collar)……………………………….........13

RP-2014 (adjusted to 2006 Base Year)…………….…...14

Other A

None 0

Code 6 includes all sex-distinct versions of the 1983 G.A.M. table other than the table published in Revenue Ruling 95-28, 1995-1 C.B. 74. Thus, for example, Code 6 also would include the 1983 G.A.M. male-only table used for males, where the 1983 G.A.M. male-only table with a 6-year setback is used for females. Code A includes mortality tables other than those listed in Codes 1 through 9, including any unisex version of the 1983 G.A.M. table.

Where an indicated table consists of separate tables for males and females, add F to the female table (e.g., 1F). When a projection is used with a table, follow the code with “P” and the year of projection (omit the year if the projection is unrelated to a single calendar year). The identity of the projection scale should be omitted from line 6c, but a description of projection techniques, including the projection scales used, should be included in the Schedule MB, line 6 – Statement of Actuarial Assumptions/Methods. When an age setback or set forward is used, indicate with “ – ” or “+” and the number of years. For example, if for females the 1951 Group Annuity Table with Projection C to 1971 is used with a 5-year setback, enter “1P71-5.” If the table is not one of those listed, enter “A” with no further notation. If the valuation assumes a maturity value to provide the post-retirement income without separately identifying the mortality, interest and expense elements, enter on line 6c, under “Post-retirement,” the value of $1.00 of monthly pension beginning at the plan’s weighted average retirement age, assuming the normal form of annuity for an unmarried person. In such a case, leave lines 6d and 6e blank.

Line 6d. Valuation Liability Interest Rate. Enter the assumption as to the interest rate used to determine all the calculated values except for current liability. If the assumed rate varies with the year, enter the weighted average of the assumed rate for 20 years following the valuation date. Enter rates to the nearest .01 percent.

Line 6e. Expense Loading. If there is no expense loading, check the "N/A" boxes under "Pre-retirement" and "Post-retirement”. For instance, there would be no expense loading attributable to investments if the rate of investment return on assets is adjusted to take investment expenses into account. If there is a single expense loading not separately identified as pre-retirement or post-retirement, enter it under “Pre-retirement” and check the “N/A“ box under “Post-Retirement.” Where expenses are assumed other than as a percentage of plan costs or liabilities, enter the assumed pre-retirement expense as a percentage of the plan’s normal cost, and enter the post-retirement expense as a percentage of plan liabilities. If the normal cost of the plan is zero, enter the assumed pre-retirement expense as a percentage of the sum of lines 9c(1), 9c(2), and 9c(3), minus line 9h. Enter rates to the nearest .1 percent.

Line 6f. Salary Scale. If a uniform level annual rate of salary increase is used, enter that annual rate. Otherwise, enter the level annual rate of salary increase that is equivalent to the rate(s) of salary increase used. Enter the annual rate as a percentage to the nearest .01 percent, used for a participant from age 25 to assumed retirement age. If the plan’s benefit formula is not related to compensation, check the “N/A” box.

Line 6g. Estimated Investment Return – Actuarial Value. Enter the estimated rate of return on the actuarial value of plan assets for the 1-year period ending on the valuation date. For this purpose, the rate of return is determined by using the formula 2I/(A + B – I), where I is the dollar amount of the investment return under the asset valuation method used for the plan, A is the actuarial value of the assets one year ago, and B is the actuarial value of the assets on the current valuation date. Enter rates to the nearest .1 percent. If entering a negative number, enter a minus sign (“ – ”) to the left of the number.

Note. Use the above formula even if the actuary feels that the result of using the formula does not represent the true estimated rate of return on the actuarial value of plan assets for the 1-year period ending on the valuation date. The actuary may attach a statement showing both the actuary’s estimate of the rate of return and the actuary’s calculations of that rate, and label the statement “Schedule MB, line 6g – Estimated Rate of Investment Return (Actuarial Value).”

Line 6h. Estimated Investment Return – Current (Market) Value. Enter the estimated rate of return on the current value of plan assets for the 1-year period ending on the valuation date. (The current value is the same as the fair market value — see line 1b(1) instructions.) For this purpose, the rate of return is determined by using the formula 2I/(A + B – I), where I is the dollar amount of the investment return, A is the current value of the assets one year ago, and B is the current value of the assets on the current valuation date. Enter rates to the nearest .1 percent. If entering a negative number, enter a minus sign (“ – ”) to the left of the number.

Note. Use the above formula even if the actuary feels that the result of using the formula does not represent the true estimated rate of return on the current value of plan assets for the 1-year period ending on the valuation date. The actuary may attach a statement showing both the actuary’s estimate of the rate of return and the actuary’s calculations of that rate, and label the statement “Schedule MB, line 6h – Estimated Rate of Investment Return (Current Value).”

Line 7. New Amortization Bases Established. List all new amortization bases established in the current plan year (before the combining of bases, if bases were combined). Use the following table to indicate the type of base established, and enter the appropriate code under “Type of base.” List amortization bases and charges and/or credits as of the valuation date. Bases that are considered fully amortized because there is a credit for the plan year on line 9j(3) should be listed. If entering a negative number, enter a minus sign (“–”) to the left of the number.

Code Type of Amortization Base

1 Experience gain or loss

2 Shortfall gain or loss

3 Change in unfunded liability due to plan amendment

4 Change in unfunded liability due to change in actuarial assumptions

5 Change in unfunded liability due to change in actuarial cost method

6 Waiver of the minimum funding standard

7 Initial unfunded liability (for new plan)

8 Net investment loss incurred in either of the first two plan years ending after August 31, 2008

Line 8a and 8d. Funding Waivers or Extensions. If a funding waiver or extension request is approved after the Schedule MB is filed, an amended Schedule MB must be filed with Form 5500 to report the waiver or extension approval (also see instructions for line 9k(1)).

Line 8b(1). Schedule of Projection of Expected Benefit Payments. Check “Yes” only if this is a multiemployer plan covered by Title IV of ERISA that has 500 or more total participants as of the valuation date.

If line 8b(1) is “Yes,” in an attachment, provide a projection of benefits expected to be paid for the entire plan (not to include expected expenses) in each of the next ten years starting with the current plan year of this filing assuming (1) no additional accruals, (2) experience (e.g., termination, mortality, and retirement) are in line with valuation assumptions, and (3) no new entrants are covered by the plan. Use the format shown below and label the schedule “Schedule MB, line 8b(1) – Schedule of Projection of Expected Benefit Payments”.

Schedule MB, line 8b(1) – Schedule of Projection of Expected Benefit Payments
Plan Year	Expected Annual Benefit Payments
Current Plan Year
Current Plan Year +1
Current Plan Year +2
Current Plan Year +3
Etc.
Current Plan Year +9

Line 8b(2). Schedule of Active Participant Data. Check “Yes” only if this is a multiemployer plan covered by Title IV of ERISA that has active participants.

Schedule MB, line 8b(2) – Schedule of Active Participant Data

YEARS OF CREDITED SERVICE

Under 1

1 to 4

5 to 9

40 & up

Attained

Age

No.

Average

No.

Average

Comp.

Cash Bal.

Comp.

Cash Bal.

No.

Comp.

Cash Bal.

No.

Comp.

Cash Bal.

Under 25

25 to 29

30 to 34

35 to 39

40 to 44

45 to 49

50 to 54

55 to 59

60 to 64

65 to 69

70 & up

If line 8b(2) is “Yes,” attach a schedule of the active plan

participant data used in the valuation for this plan year. Use the format shown above and label the schedule “Schedule MB, line 8b(2) – Schedule of Active Participant Data.”

Expand this schedule by adding columns after the “5 to 9” column and before the “40 & up” column for active participants with total years of credited service in the following ranges: 10 to 14; 15 to 19; 20 to 24; 25 to 29; 30 to 34; and 35 to 39. For each column, enter the number of active participants with the specified number of years of credited service divided according to age group. For participants with partial years of credited service, truncate the total number of years of credited service. Years of credited service are the years credited under the plan’s benefit formula.

Plans reporting 1,000 or more active participants on line 2b(3)(c), column (1), and using compensation to determine benefits must also provide average compensation data. For each grouping, enter the average compensation of the active participants in that group. For this purpose, compensation is the compensation taken into account for each participant under the plan’s benefit formula, limited to the amount defined under section 401(a)(17) of the Code. Do not enter the average compensation in any grouping that contains fewer than 20 participants.

Cash balance plans (or any plans using characteristic code 1C on line 8a of Form 5500) reporting 1,000 or more active participants on line 2b(3)(c), column (1), must also provide average cash balance account data, regardless of whether all active participants have cash balance accounts. For each age/service bin, enter the average cash balance account of the active participants in that bin. Do not enter the average cash balance account in any age/service bin that contains fewer than 20 active participants.

General Rule. In general, data to be shown in each age/service bin includes:

1. the number of active participants in the age/service bin,

2. the average compensation of the active participants in the age/service bin, and

3. the average cash balance account of the active participants in the age/service bin, using $0 for anyone who has no cash balance account-based benefit.

If the accrued benefit is the greater of a cash balance benefit or some other benefit, average in only the cash balance account. If the accrued benefit is the sum of a cash balance account benefit and some other benefit, average in only the cash balance account. For both the average compensation and the average cash balance account, do not enter an amount for age/service bins with fewer than 20 active participants.

In lieu of the above, two alternatives are provided for showing compensation and cash balance accounts. Each alternative provides for two age/service scatters (one showing compensation and one showing cash balance accounts) as follows:

Alternative A:

 Scatter 1 - Provide participant count and average compensation for all active participants, whether or not participants have account-based benefits.

 Scatter 2 - Provide participant count and average cash balance account for all active participants, whether or not participants have account-based benefits.

Alternative B:

 Scatter 1 - Provide participant count and average compensation for all active participants, whether or not participants have account-based benefits (i.e., identical to Scatter 1 in Alternative A).

 Scatter 2 - Provide participant count and average cash balance account for only those active participants with account based benefits. If the number of participants with account-based benefits in a bin is fewer than 20, the average account should not be shown even if there are more than 20 active participants in this bin on Scatter 1.

In general, information should be determined as of the valuation date. Average cash balance accounts may be determined as of either:

1. the valuation date or

2. the day immediately preceding the valuation date.

Average cash balance accounts that are offset by amounts from another plan may be reported either as amounts prior to taking into account the offset or as amounts after taking into account the offset. Do not report the offset amount. For this or any other unusual or unique situation, the attachment should include an explanation of what is being provided.

Line 9. Shortfall Method. Under the shortfall method of funding, the normal cost in the funding standard account is the charge per unit of production (or per unit of service) multiplied by the actual number of units of production (or units of service) that occurred during the plan year. Each amortization installment in the funding standard account is similarly calculated.

Lines 9c and 9h. Amortization Charges and Credits. If there are any amortization charges or credits, attach a maintenance schedule of funding standard account bases and label the schedule “Schedule MB, lines 9c and 9h –Schedule of Funding Standard Account Bases.” The attachment should clearly indicate the type of base (i.e., original unfunded liability, amendments, actuarial losses, etc.), the outstanding balance of each base, the number of years remaining in the amortization period, and the amortization amount. If bases were combined in the current year, the attachment should show information on bases both prior to and after the combining of bases.

The outstanding balance and amortization charges and credits must be calculated as of the valuation date for the plan year.

Line 9c(3) should only include information related to the amortization bases extended and amortized using the interest rate under section 6621(b) of the Code.

Line 9d. Interest as Applicable. Interest as applicable should be charged to the last day of the plan year.

Line 9f. Note that the credit balance or funding deficiency at the end of “Year X” should be equal to the credit balance or funding deficiency at the beginning of “Year X+1.” If such credit balances or funding deficiencies are not equal, attach an explanation and label the attachment “Schedule MB, line 9f – Explanation of Prior Year Credit Balance/Funding Deficiency Discrepancy.” For example, if the difference is because contributions for a prior year that were not previously reported are received this plan year, attach a listing of the amounts and dates of such contributions. As another example, if the difference is due to the application of funding relief under the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 (PRA 2010), Pub. L. No. 111-192, the attachment should show how the information on the Schedule MB filed for any previous plan year would have differed if it had reflected application of the special funding relief in accordance with published guidance (to the extent that the plan sponsor has applied the special funding relief).

Line 9j(1). ERISA Full Funding Limitation. Instructions for this line are reserved pending published guidance.

Line 9j(2). “RPA ’94” Override. Instructions for this line are reserved pending published guidance.

Line 9j(3). Full Funding Credit. Enter the excess of (1) the accumulated funding deficiency, disregarding the credit balance and contributions for the current year, if any, over (2) the greater of lines 9j(1) or 9j(2).

Line 9k(1). Waived Funding Deficiency Credit. Enter a credit for a waived funding deficiency for the current plan year (Code section 431(b)(3)(C)). If a waiver of a funding deficiency is pending, report a funding deficiency. If the waiver is granted after Form 5500 or Form 5500-SF is filed, file an amended Form 5500 or Form 5500-SF, as applicable, with an amended Schedule MB to report the funding waiver

(see Amended Return/Report in the instructions for Form 5500 or line B – Box for Amended Return/Report in the instructions for Form 5500-SF, as applicable).

Line 9k(2). Other Credits. Enter a credit in the case of a plan for which the accumulated funding deficiency is determined under the funding standard account if such plan year follows a plan year for which such deficiency was determined under the alternative minimum funding standard.

Line 9o. Reconciliation Account. The reconciliation account is made up of those components that upset the balance equation of Treasury Regulations section 1.412(c)(3)-1(b). Valuation assets must not be adjusted by the reconciliation account balance when computing the required minimum funding.

Line 9o(1). This amount is equal to the prior year’s accumulated reconciliation amount due to prior waived funding deficiencies, increased with interest at the valuation rate to the current valuation date.

Line 9o(2)(a). If an amortization extension is being amortized at an interest rate that differs from the valuation rate, enter the prior year’s “reconciliation amortization extension outstanding balance,” increased with interest at the valuation interest rate to the current valuation date, and decreased by the year end amortization amount based on the amortization interest rate from the prior plan year.

Line 9o(3). Enter the sum of lines 9o(1) and 9o(2)(b) (each adjusted with interest at the valuation rate to the current valuation date, if necessary).

Note. The net outstanding balance of amortization charges and credits minus the prior year’s credit balance minus the amount on line 9o(3) (each adjusted with interest at the valuation rate, if necessary) must equal the unfunded liability.

Line 10. Contribution Necessary to Avoid Deficiency. Enter the amount from line 9n. If applicable, file IRS Form 5330, Return of Excise Taxes Related to Employee Benefit Plans, with the IRS to pay the excise tax on the funding deficiency. There is a penalty for not filing the Form 5330 on time.

Line 11. In accordance with ERISA section 103(d)(3), attach a justification for any change in actuarial assumptions for the current plan year and label the attachment “Schedule MB, line 11 – Justification for Change in Actuarial Assumptions.”

2021 Instructions for Schedule R

(Form 5500)

Retirement Plan Information

General Instructions

Purpose of Schedule

Schedule R (Form 5500) reports certain information on retirement plan distributions, funding, nondiscrimination, coverage, and the adoption of amendments, as well as certain information on single employer and multiemployer defined benefit plans.

Electronic Attachments. All attachments to Schedule R must

be properly identified, must include the name of the plan, plan sponsor’s EIN, and plan number. Place “Schedule R” and the Schedule R line number at the top of each attachment to identify the information to which the attachment relates. Do not include attachments that contain a visible social security number. The Schedule R and its attachments are open to public inspection, and the contents are subject to publication on the Internet. Because of privacy concerns, the inclusion of a visible social security number or any portion thereof on an attachment may result in the rejection of the filing.

Who Must File

Schedule R must be attached to a Form 5500 filed for both tax-qualified and nonqualified pension benefit plans. The parts of Schedule R that must be completed depend on whether the plan is subject to the minimum funding standards of Code section 412 or ERISA section 302 and the type of plan. See line item requirements under Specific Instructions for more details.

Exceptions: (1) Schedule R should not be completed when the Form 5500 Annual Return/Report is filed for a pension plan that uses, as the sole funding vehicle for providing benefits, individual retirement accounts or annuities (as described in Code section 408). See the Form 5500 instructions for Limited Pension Plan Reporting for more information.

(2) Schedule R also should not be completed if all of the following conditions are met:

 The plan is not a defined benefit plan or otherwise subject to the minimum funding standards of Code Section 412 or ERISA section 302.

 No plan benefits that would be reportable on Line 1 of Part I of this schedule R were distributed during the plan year. See instructions for Part I, Line 1 below.

 No benefits, as described in the instructions Part I, line 2, below, were paid during the plan year other than by the plan sponsor or plan administrator. (This condition is not met if benefits were paid by the trust or any other payor(s) which are reportable on IRS Form 1099-R, Distributions from Pensions, Annuities, Retirement, or Profit-Sharing Plans, IRAs, Insurance contracts, etc, using an EIN other than that of the plan sponsor or plan administrator reported on line 2b or 3b of form 5500.)

 Unless the plan is a profit-sharing, ESOP, or stock bonus plan, no plan benefits of living or deceased participants were distributed during the plan year in the form of a single-sum distribution. See the instructions for Part I, line 3, below.

 The plan is not an ESOP.

 The plan is not a multiemployer defined benefit plan.

Check the Schedule R box on the Form 5500 (Part II, line 10a(1)) if a Schedule R is attached to the Form 5500.

Specific Instructions

Lines A, B, C, and D. This information must be the same as reported in Part II of the Form 5500 to which this Schedule R is attached.

Do not use a social security number in line D instead of an EIN. Schedule R and its attachments are open to public inspection, and the contents are public information and are subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on Schedule R or any of its attachments may result in the rejection of the filing.

You can apply for an EIN from the IRS online, by fax, or by mail depending on how soon you need to use the EIN. For more information, see Section 3: Electronic Filing Requirement. The EBSA does not issue EINs.

“Participant” for purposes of Schedule R, means any present or former employee who at any time during the plan year had an accrued benefit in the plan (account balance in a defined contribution plan).

Part I – Distributions

“Distribution” includes only payments of benefits during the plan year, in cash, in kind, by purchase for the distributee of an annuity contract from an insurance company, or by distribution of life insurance contracts. It does not include:

1. Corrective distributions of excess deferrals, excess contributions, or excess aggregate contributions, or the income allocable to any of these amounts;

2. Distributions of automatic contributions pursuant to Code section 414(w);

3. The distribution of elective deferrals or the return of employee contributions to correct excess annual additions under Code section 415, or the gains attributable to these amounts; and

4. A loan deemed as a distribution under Code section 72(p).

Note. It does, however, include a distribution of a plan loan offset amount as defined in Treasury Regulations section 1.402(c)-2, Q&A 9(b).

Line 1. Enter the total value of all distributions made during the year (regardless of when the distribution began) in any form other than cash, annuity contracts issued by an insurance company, distribution of life insurance contracts, marketable securities within the meaning of Code section 731(c)(2), or plan loan offset amounts. Do not include eligible rollover distributions paid directly to eligible retirement plans in a direct rollover under Code section 401(a)(31) unless such direct rollovers include property other than that enumerated in the preceding sentence.

Line 2. Enter the EIN(s) of any payor(s) (other than the plan sponsor or plan administrator on line 2b or 3b of the Form 5500) who paid benefits reportable on IRS Form 1099-R on behalf of the plan to participants or beneficiaries during the plan year. This is the EIN that appears on the IRS Forms 1099-R that are issued to report the payments. Include the EIN of the trust if different than that of the sponsor or plan administrator. If more than two payors made such payments during the year, enter the EINs of the two payors who paid the greatest dollar amounts during the year. For purposes of this line 2, take into account all payments made during the plan year, in cash or in kind, that are reportable on IRS Form 1099-R, regardless of when the payments began, but take into account payments from an insurance company under an annuity only in the year the contract was purchased.

Line 3. Enter the number of living or deceased participants whose benefits under the plan were distributed during the plan year in the form of a single-sum distribution. For this purpose, a distribution of a participant’s benefits will not fail to be a single-sum distribution merely because, after the date of the distribution, the plan makes a supplemental distribution as a result of earnings or other adjustments made after the date of the single-sum distribution. Also include any participants whose benefits were distributed in the form of a direct rollover to the trustee or custodian of a qualified plan or individual retirement account.

Part II – Funding Information

Complete Part II only if the plan is subject to the minimum funding requirements of Code section 412 or ERISA section 302.

All qualified defined benefit and defined contribution plans are subject to the minimum funding requirements of Code section 412 unless they are described in the exceptions listed under Code section 412(e)(2). These exceptions include profit- sharing or stock bonus plans, insurance contract plans described in Code section 412(e)(3), and certain plans to which no employer contributions are made.

Nonqualified employee pension benefit plans are subject to the minimum funding requirements of ERISA section 302 unless specifically exempted under ERISA sections 4(a) or 301(a).

The employer or plan administrator of a single-employer or multiple-employer defined benefit plan that is subject to the minimum funding requirements must file Schedule SB as an attachment to Form 5500. Schedule MB is filed for multiemployer defined benefit plans and certain money purchase defined contribution plans (whether they are single-employer or multiemployer plans). However, Schedule MB is not required to be filed for a money purchase defined contribution plan that is subject to the minimum funding requirements unless the plan is currently amortizing a waiver of the minimum funding requirements.

Line 4. Check ‘‘Yes’’ if, for purposes of computing the minimum funding requirements for the plan year, the plan administrator is making an election intended to satisfy the requirements of Code section 412(d)(2) or ERISA section 302(d)(2). Under Code section 412(d)(2) and ERISA section 302(d)(2), a plan administrator may elect to have any amendment, adopted after the close of the plan year for which it applies, treated as having been made on the first day of the plan year if all of the following requirements are met:

1. The amendment is adopted no later than two and one-half months (two years for a multiemployer plan) after the close of such plan year;

2. The amendment does not reduce the accrued benefit of any participant determined as of the beginning of such plan year; and

3. The amendment does not reduce the accrued benefit of any participant determined as of the adoption of the amendment unless the plan administrator notified the Secretary of the Treasury of the amendment and the Secretary either approved the amendment or failed to disapprove the amendment within 90 days after the date the notice was filed.

See Treasury Temporary Regulations section 11.412(c)-7(b) for details on when and how to make the election and what information to include on the statement of election, which must be filed with the Form 5500 Annual Return/Report.

Line 5. If a money purchase defined contribution plan (including a target benefit plan) has received a waiver of the minimum funding standard, and the waiver is currently being amortized, complete lines 3, 9, and 10 of Schedule MB. See instructions for Schedule MB. Attach Schedule MB to Form 5500. The Schedule MB for a money purchase defined contribution plan does not need to be signed by an enrolled actuary.

Line 6a. The minimum required contribution for a money purchase defined contribution plan (including a target benefit plan) for a plan year is the amount required to be contributed for the year under the formula set forth in the plan document. If there is an accumulated funding deficiency for a prior year that has not been waived, that amount should also be included as part of the contribution required for the current year.

Line 6b. Include all contributions for the plan year made not later than 8 ½ months after the end of the plan year. Show only contributions actually made to the plan by the date the form is filed. For example, do not include receivable contributions for this purpose.

Line 6c. If the minimum required contribution exceeds the contributions for the plan year made not later than 8¹/² months after the end of the plan year, the excess is an accumulated funding deficiency for the plan year. File IRS Form 5330, Return of Excise Taxes Related to Employee Benefit Plans, with the IRS to pay the excise tax on the deficiency. There is a penalty for not filing IRS Form 5330 on time.

Line 7. Check “Yes” if the minimum required contribution remaining in line 6c will be made not later than 8 ½ months after the end of the plan year. If “Yes,” and contributions are actually made by this date, then there will be no reportable deficiency and IRS Form 5330 will not need to be filed.

Line 8. Revenue Procedure 2017-56, 2017-44 IRB 465 and Revenue Procedure 2000-40, 2000-2 C.B. 357, providing for automatic approval for a change in funding method for a plan year, generally do not apply unless the plan administrator or an authorized representative of the plan sponsor explicitly agrees to the change. If a change in funding method made pursuant to such a revenue procedure (or a class ruling letter) is to be applicable for the current plan year, this line generally must be checked ‘‘Yes.” In certain situations, however, the requirement that the plan administrator or an authorized representative of the plan sponsor agree to the change in funding method will be satisfied if the plan administrator or an authorized representative of the plan sponsor is made aware of the change. In these situations, this line must be checked “N/A.” See section 6.01 of Revenue Procedure 2017-56 and section 6.01(2) of Revenue Procedure 2000-40. If the plan’s change in funding method is not made pursuant to a revenue procedure or other authority providing automatic approval which requires plan sponsor agreement, or to a class ruling letter (e.g., it is pursuant to a regulation, then this line should be checked “N/A.”

Part III – Amendments

Line 9.

Check “No” if no amendments were adopted during this plan year that increased or decreased the value of benefits.
Check “Increase” if an amendment was adopted during the plan year that increased the value of benefits in any way. This includes an amendment providing for an increase in the amount of benefits or rate of accrual, more generous lump sum factors, COLAs, more rapid vesting, additional payment forms, or earlier eligibility for some benefits.
Check “Decrease” if an amendment was adopted during the plan year that decreased the value of benefits in any way. This includes a decrease in future accruals, closure of the plan to new employees, or accruals being frozen for some or all participants.
If the amendments that were adopted increased the value of some benefits but decreased the value of others, check “Both.”

Part IV – ESOP Information

Line 11b. A loan is a “back-to-back loan” if the following requirements are satisfied:

1. The loan from the employer corporation to the ESOP qualifies as an exempt loan under DOL regulations at 29 CFR 2550.408b-3 and under Treasury Regulations sections 54.4975-7 and 54.4975-11; and

2. The repayment terms of the loan from the sponsoring corporation to the ESOP are substantially similar to the repayment terms of the loan from the commercial lender to the sponsoring employer.

Part V – Additional Employer Information for Multiemployer Defined Benefit Pension Plans

If this is not a multiemployer plan, skip this Part.

Required attachments. Multiemployer defined benefit plans that are in Endangered Status, Critical Status, or Critical and Declining Status must attach a summary of their Funding Improvement Plan or Rehabilitation Plan (as updated, if applicable) and also any update to a Funding Improvement Plan or Rehabilitation Plan.

The summary of any Funding Improvement Plan or Rehabilitation Plan must reflect such plan in effect at the end of the plan year (whether the original Funding Improvement Plan or Rehabilitation Plan or as updated) and must include a description of the various contribution and benefit schedules that are being provided to the bargaining parties and any other actions taken in connection with the Funding Improvement Plan or Rehabilitation Plan, such as use of the shortfall funding method or extension of an amortization period. The summary must also identify the first year and the last year of the Funding Improvement Period or the Rehabilitation Period. If an extended Funding Improvement Period (of 13 or 18 years) or Rehabilitation Period (of 13 years) applies because of an election under section 205 of the Worker, Retiree, and Employer Recovery Act of 2008 (“WRERA”), the summary must include a statement to that effect and the date that the election was filed with the IRS.

The summary must also include a schedule of the expected annual progress for the funded percentage or other relevant factors under the Funding Improvement Plan or Rehabilitation Plan. If the sponsor of a multiemployer plan in Critical Status has determined that, based on reasonable actuarial assumptions and upon exhaustion of all reasonable measures, the plan cannot emerge from Critical Status by the end of the Rehabilitation Period as described in Code section 432(e)(3)(A)(ii), the summary must include an explanation of the alternatives considered, why the plan is not reasonably expected to emerge from Critical Status by the end of the Rehabilitation Period, and when, if ever, it is expected to emerge from Critical Status under the Rehabilitation Plan.

The plan sponsor is required to annually update a Funding Improvement Plan or Rehabilitation Plan that was adopted in a prior year. The update must be filed as an attachment to the Schedule R. The update attachment must identify the modifications made to the Funding Improvement Plan or Rehabilitation Plan during the plan year, including contribution increases, benefit reductions, or other actions.

The attachment described above must be labeled “Schedule R, Summary of Funding Improvement Plan,” or “Schedule R, Summary of Rehabilitation Plan” as appropriate, and if applicable, “Schedule R, Update of Funding Improvement Plan or Rehabilitation Plan.” Each attachment must also include the plan name, the plan sponsor’s name and EIN, and the plan number.

Line 13. This line should be completed only by multiemployer defined benefit pension plans that are subject to the minimum funding standards (see Code section 412 and Part 3 of Title I of ERISA). Enter the information on lines 13a through 13e for any employer that contributed more than five (5) percent of the plan’s total contributions for the 2021 plan year. List employers in descending order according to the dollar amount of their contributions to the plan. Complete as many entries as are necessary to list all employers that contributed more than five (5) percent of the plan’s contributions.

Line 13a. Enter the name of the employer contributing to the plan.

Line 13b. Enter the EIN of the employer contributing to the plan. Do not enter a social security number in lieu of an EIN; therefore, ensure that you have the employer’s EIN and not a social security number. The Form 5500 is open to public inspection, and the contents are public information and are subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on this line may result in the rejection of the filing.

EINs can be obtained from the IRS online, by fax, or by mail depending on when you need to use the EIN. For more information, see Section 3: Electronic Filing Requirement. The EBSA does not issue EINs.

Line 13c. Dollar Amount Contributed. Enter the total dollar amount contributed to the plan by the employer for all covered workers in all locations for the plan year. Do not include the portion of an aggregated contribution that is for another plan, such as a welfare benefit plan, a defined contribution pension plan or another defined benefit pension plan.

Line 13d. Collective Bargaining Agreement Expiration Date. Enter the date on which the employer’s collective bargaining agreement expires. If the employer has more than one collective bargaining agreement requiring contributions to the plan, check the box and include, as an attachment, the expiration date of each collective bargaining agreement (regardless of the amount of contributions arising from such agreement). Label the attachment: “Schedule R, line 13d –Collective Bargaining Agreement Expiration Date.” Include the plan name and the sponsor’s name and EIN.

Line 13e. Contribution Rate Information. Enter the contribution rate (in dollars and cents) per contribution base unit in line 13e(1) and the base unit measure in line 13e(2). Indicate whether the base unit is measured on an hourly, weekly, unit-of-production, or other basis. If “other,” specify the base unit measure used. If the contribution rate changed during the plan year, enter the last contribution rate in effect for the plan year.

If the employer has different contribution rates for different classifications of employees or different places of business, check the box in the first line of line 13e and list in an attachment each contribution rate and corresponding base unit measure under which the employer made contributions (regardless of the amount of contributions resulting from each rate). Label the attachment: “Schedule R, line 13e – Information on Contribution Rates and Base Units.” Include the plan name and the sponsor’s name and EIN.

Line 14. Enter the number of deferred vested and retired participants (inactive participants), as of the beginning of the plan year, whose contributing employer is no longer making contributions to the plan. Generally, if there has been a prior withdrawal, unless all former vested participants of the withdrawn employer have been reemployed with a currently contributing employer, this line should not be zero. Plans must use one of the following counting methods to count these inactive participants.

1. Under the last contributing employer method, count only those inactive participants whose last contributing employer had withdrawn from the plan by the beginning of the relevant plan year. Disregard any inactive participants whose most recent employers had not withdrawn from the plan. Thus, for the limited purposes of line 14 and notwithstanding any contrary definition of such inactive participants applicable elsewhere, inactive participants of employers who have not withdrawn from the plan should not be included in these numbers;

2. Under the alternative method count only those inactive participants whose last contributing employer and all prior contributing employers had withdrawn from the plan by the beginning of the relevant plan year. Under this method, the plan would review the list of all contributing employers (employers that had not withdrawn from the plan by the beginning of the relevant plan year), and include on Line 14 only those inactive participants who had no covered service with any of these employers;

3. Under the reasonable approximation method, a plan that is unable to use the last contributing employer method or the alternative method, must make a reasonable, good faith effort to count inactive participants to satisfy the requirements of section 103(f)(2)(C) of ERISA and provide an attachment that explains the plan’s approximation method. The explanation must include a description of the data and a breakdown describing the number of clearly identified inactive participants and the number of estimated inactive participants.

Note. Withdrawal liability payments are not to be treated as contributions for the purpose of determining the number of inactive participants for line 14.

Line 14a. Enter the number of inactive participants described in the line 14 instructions for the current plan year. The current plan year is the plan year to which the Form 5500 relates.

Line 14b. Enter the number of inactive participants described in the line 14 instructions for the plan year immediately preceding the current plan year. Check the box if the number reported on line 14b differs from the number reported on line 14a for the plan year immediately preceding the current plan year. If the box is checked, provide an attachment with an explanation of the reason for the change.

Line 14c. Enter the number of inactive participants described in the line 14 instructions for the second preceding plan year. Check the box if the number reported on line 14c differs from the number reported on line 14b for the plan year immediately preceding the current plan year. If the box is checked, provide an attachment with an explanation of the reason for the change.

For any required attachment for line 14, label the attachment “Schedule R, Line 14 – Information on Inactive Participants Whose Contributing Employer is No Longer Making Contributions to the Plan”.

Line 15. Enter the ratio of number of participants on whose behalf no employer had an obligation to make a contribution for the 2021 plan year to the corresponding number for each of the two preceding plan years. For the purpose of these ratios, count all participants whose employers have withdrawn from the plan as well as all deferred vested and retired participants of employers still active in the plan (unless the collective bargaining agreement specifically requires the employer to make contributions for such participants).

Line 15a. Enter the ratio of the number of participants as described in the line 15 instructions for the 2021 plan year to the number for the 2020 plan year.

Line 15b. Enter the ratio of the number of participants as described on the line 15 instructions for the 2021 plan year to the number for the 2019 plan year.

Note. Withdrawal liability payments are not to be treated as contributions for determining the number of participants on line 15.

Line 16a. Enter the number of employers that withdrew from the plan during the 2020 plan year.

Line 16b. If line 16a is greater than zero, enter the aggregate amount of withdrawal liability assessed against these employers. If the withdrawal liability for one or more withdrawing employers has not yet been determined, include the amounts estimated to be assessed against them in the aggregate amount.

The definitions of withdrawal are those contained in Section 4203 of ERISA. If the plan is in the building and construction, entertainment, or another industry that has special withdrawal rules, withdrawing employers should only be counted if the withdrawal adheres to the special rules applying to its specific industry.

Line 17. If assets and liabilities from another plan were transferred to or merged with the assets and liabilities of this plan during the 2021 plan year, check the box and provide the following information as an attachment. The attachment should include the names and employer identification numbers of all plans that transferred assets and liabilities to, or merged with, this plan. For each plan, including this plan, the attachment should also include the actuarial valuation of the total assets and total liabilities for the year preceding the transfer or merger, based on the most recent data available as of the day before the first day of the 2021 plan year. Label the attachment “Schedule R, line 17 – Information on Assets and Liabilities Transferred to or Merged with This Plan” and include the plan name and the plan sponsor’s name and EIN.

Part VI – Additional Information for Single-Employer and Multiemployer Defined Benefit Pension Plans

Line 18. If any liabilities to participants or their beneficiaries under the plan at the end of the plan year consist of liabilities under two (2) or more plans as of the last day of the plan year immediately before the 2021 plan year, check the box and provide the following information as an attachment. The attachment should include the names, employer identification numbers, and plan numbers of all plans, including the current plan, that provided a portion of liabilities of the participants and beneficiaries in question. The attachment should also include the funded percentage of each plan as of the last day of the 2020 plan year. For single-employer plans, the funded percentage is the funding target attainment percentage, where the numerator is the value of plan assets reduced by the sum of the amount of the prefunding balance and the funding standard carryover balance, and the denominator is the funding target for the plan (for this purpose, if the plan is in at risk status, then the funding target is determined as if the plan were not in at risk status). For multiemployer plans, the funded percentage is the ratio where the numerator is the actuarial value of the plan’s assets and the denominator is the accrued liability of the plan. For a terminated plan for which the funded percentage is required to be reported, write “Terminated” in the space where the plan’s funded percentage would otherwise have been reported. Label the attachment “Schedule R, line 18 –Funded Percentage of Plans Contributing to the Liabilities of Plan Participants” and include the plan name and the plan sponsor’s name and EIN.

Line 19. This line must be completed for all defined benefit pension plans (except DFEs) with 1,000 or more participants at the beginning of the plan year. To determine if the plan has 1,000 or more participants, use the participant count shown on line 3d(1) of the Schedule SB for single-employer plans or on line 2b(4)(1) of the Schedule MB for multiemployer plans.

Line 19a. Show the beginning-of-year distribution of assets for the categories shown. Use the market value of assets and do not include the value of any receivables. These percentages, expressed to the nearest whole percent, should reflect the total assets held in stocks, investment-grade debt instruments, high-yield debt instruments, real estate, or other asset classes, regardless of how they are listed on the Schedule H. The percentages in the five categories should sum to 100 percent. Assets held in trusts, accounts, mutual funds, and other investment arrangements should be disaggregated and properly distributed among the five asset components. The assets in these trusts, accounts, mutual funds, and investment arrangements should not be included in the “Other” component unless these investments contain no stocks, bonds, or real estate holdings. The same methodology should be used in disaggregating trust assets as is used when disclosing the allocation of plan assets on the sponsor’s 10-K filings to the Securities and Exchange Commission. Real estate investment trusts (REITs) should be listed with stocks, while real estate limited partnerships should be included in the Real Estate category.

Investment-grade debt-instruments are those with an S&P rating of BBB – or higher, a Moody’s rating of Baa3 or higher, or an equivalent rating from another rating agency. High-yield debt instruments are those that have ratings below these rating levels. If the debt does not have a rating, it should be included in the “high-yield” category if it does not have the backing of a government entity. Unrated debt with the backing of a government entity would generally be included in the “investment-grade” category unless it is generally accepted that the debt should be considered as “high-yield.” Use the ratings in effect as of the beginning of the plan year.

Line 19b. Check the box that shows the average duration of the plan’s combined investment-grade and high-yield debt portfolio. If the average duration falls exactly on the boundary of two boxes, check the box with the lower duration. To determine the average duration, use the “effective duration” or any other generally accepted measure of duration. Report the duration measure used in line 19c. If debt instruments are held in multiple debt portfolios, report the weighted average of the average durations of the various portfolios where the weights are the dollar values of the individual portfolios.

Line 20. This line must be completed for all single-employer defined benefit plans that are covered by PBGC.

Line 20a. If the amount reported on Schedule SB (Form 5500) line 40 is greater than $0, check the “Yes” box and complete line 20b. Otherwise, check “No” and skip line 20b.

Line 20b. In general, a PBGC-insured single-employer plan must notify PBGC if a required contribution is not made by its due date. With the exception of situations where the accumulated value of missed contributions exceeds $1 million, PBGC waives reporting if contributions equal to or exceeding the missed amount are made by the 30^th day after the due date. For more information, see 29 CFR 4043.25 and 4043.81 and the filing instructions for PBGC Forms 10 and 200.

If PBGC has been notified of the missed contribution, check the “Yes” box. Otherwise, check the box that best explains why PBGC wasn’t notified. If the “No. Other. Provide explanation” box is checked, provide an explanation as to why PBGC wasn’t notified (e.g., “The due date for filing Form 10 has not yet passed; the plan administrator intends to file Form 10 with PBGC shortly” or “Reporting was waived under 29 CFR 4043.25(c)(3) because the unpaid contribution resulted solely from an administrative error related to an election to use a pre-funding balance”).

2021 Instructions for Schedule SB

(Form 5500)

Single-Employer Defined Benefit Plan

Actuarial Information

General Instructions

Note.To the extent that regulations and other items of published guidance under Code sections 430 and 436 do not take into account statutory changes since those regulations were issued, plan sponsors must take into account the provisions of the Worker, Retiree, and Employer Recovery Act of 2008 (“WRERA”), Pub. L. No. 110-458, the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 (“PRA 2010”), Pub. L. No. 111-192, Moving Ahead for Progress in the 21^st Century Act (“MAP‑21”), Pub. L. No. 112-141, the Cooperative and Small Employer Charity Pension Flexibility Act of 2014 (“CSEC Act”), Pub. L. No. 113-97, the Highway and Transportation Funding Act of 2014 (HATFA), Pub. L. No. 113-159, and the Bipartisan Budget Act of 2015 (BBA’15), Pub. L. No. 114-74, and any other amendments to the funding rules that are enacted.

Who Must File

As the first step, the plan administrator of any single-employer defined benefit plan (including a multiple-employer defined benefit plan) that is subject to the minimum funding standards (see Code section 412 and Part 3 of Title I of ERISA) must obtain a completed Schedule SB (including attachments) that is prepared and signed by the plan’s enrolled actuary as discussed below in the Statement by Enrolled Actuary section. The plan administrator must retain with the plan records the Schedule SB that is prepared and signed by the plan’s actuary.

Next, the plan administrator must ensure that the information from the actuary’s Schedule SB is entered electronically into the annual return/report being submitted. When entering the information, whether using EFAST2-approved software or EFAST2’s web-based filing system, all the fields required for the type of plan must be completed (see instructions for fields that need to be completed).

Further, the plan administrator of a single-employer defined benefit plan must attach to the Form 5500 or Form 5500-SF an electronic reproduction of the Schedule SB (including attachments) prepared and signed by the plan’s enrolled actuary. This electronic reproduction must be labeled “SB Actuary Signature” and must be included as a Portable Document Format (PDF) attachment or any alternative electronic attachment allowable under EFAST2.

Note. The Schedule SB (Form 5500) does not have to be filed with the Form 5500-EZ regardless of whether it is filed on paper with the IRS or electronically with EFAST2, but it must be retained in accordance with the Instructions for Form 5500-EZ under the What to File section. The enrolled actuary must complete and sign the Schedule SB and forward it to the person responsible for filing the Form 5500-EZ, even if the Schedule SB is not filed.

Check the Schedule SB box on the Form 5500 (Part II, line 10a(3)) if a Schedule SB is attached to Form 5500. Check “Yes” on line 11 in Part VI of the Form 5500-SF if a Schedule SB is required to be prepared for the plan, even if Schedule SB is not required to be attached to Form 5500-SF (see instructions in the Note above, pertaining to “one-participant plans”).

Note. This schedule is not filed for a multiemployer plan nor for a money purchase defined contribution plan (including a target benefit plan) for which a waiver of the minimum funding requirements is currently being amortized. Information for these plans must be filed using Schedule MB (Form 5500).

Specific Instructions

Lines A through F. Identifying Information. Lines A – F must be completed for all plans. Lines A through D should include the same information as reported in corresponding lines in Part II of the Form 5500, Form 5500-SF, or Form 5500-EZ filed for the plan. You may abbreviate the plan name (if necessary) to fit in the space provided.

Do not use a social security number in line D instead of an EIN. The Schedule SB and its attachments are open to public inspection if filed with a Form 5500 or Form 5500-SF, and the contents are public information and are generally subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on the Schedule SB or any of its attachments may result in the rejection of the filing.

Line E. Type of Plan. Check the applicable box to indicate the type of plan. A single-employer plan for this reporting purpose is an employee benefit plan maintained by one employer or one employee organization. A multiple-employer plan is a plan that is maintained by more than one employer, but is not a multiemployer plan. (See the Instructions for Form 5500, box A for additional information on the definition of a multiemployer plan.)

● Check “Single” if the Form 5500, Form 5500-SF, or Form 5500-EZ is filed for a single-employer plan (including a plan maintained by more than one member of the same controlled group).

● Check “Multiple-A” if the Form 5500 or Form 5500-SF is being filed for a multiple-employer plan and the plan is subject to the rules of Code section 413(c)(4)(A) (i.e., it is funded as if each employer were maintaining a separate plan). This includes plans established before January 1, 1989, for which an election was made to fund in accordance with Code section 413(c)(4)(A).

● Check “Multiple-B” if the Form 5500 or Form 5500-SF is being filed for a multiple-employer plan and the plan is subject to the rules of Code section 413(c)(4)(B) (i.e., it is funded as if all participants were employed by a single employer).

If “Multiple-A” is checked, with the exception of Part III, the data entered on Schedule SB should be the sum of the individual amounts computed for each employer. The percentages reported in Part III should be calculated based on the reported aggregate numbers rather than by summing up the individual percentages. The Schedule SB data for each employer’s portion of the plan must be submitted as an attachment. This is accomplished by completing and attaching a Schedule SB for each employer or by attaching a document containing that information (e.g., a table showing a row for each Schedule SB data item and a column for each employer). Label the attachment “Schedule SB – Information for Each Individual Employer.”

Line F. Prior Year Plan Size. Check the applicable box based on the highest number of participants (both active and inactive) on any day of the preceding plan year, taking into account participants in all defined benefit plans maintained by the same employer (or any member of such employer’s controlled group) who are or were also employees of that employer or member. For this purpose, participants whose only defined benefit plan is a multiemployer plan (as defined in Code section 414(f)) are not counted, and participants who are covered in more than one of the defined benefit plans described above are counted only once. Inactive participants include vested terminated and retired employees as well as beneficiaries of deceased participants. If this is the first plan year that a plan described in this paragraph exists, complete this line based on the highest number of participants that the plan was reasonably expected to have on any day during the first plan year.

General Instructions, Parts I through IX, Statement by Enrolled Actuary, and Attachments

Except as noted below, Parts I through VIII must be completed for all single and multiple-employer defined benefit plans, regardless of size or type. See instructions for line 27 for additional information to be provided for certain plans with special circumstances. Part IX is completed only for those plans for which an alternative amortization schedule was elected under section 430(c)(2)(D) of the Code or section 303(c)(2)(D) of ERISA, as amended by PRA 2010.

PPA provides funding relief for certain defined benefit plans (other than multiemployer plans) maintained by a commercial passenger airline or by an employer whose principal business is providing catering services to a commercial passenger airline, based on an alternative 17-year funding schedule. Plans using this funding relief do not need to complete the entire Schedule SB, but are required to provide supplemental information as an attachment to Schedule SB. See the instructions for line 27 for more information about which lines of Schedule SB need to be completed and what additional attachments are required.

Code section 430(h)(2)(C)(iv) and ERISA section 302(h)(2)(C)(iv) provide that, for certain purposes, each of the three segment rates described in those sections is adjusted as necessary to fall within a specified range that is determined based on an average of the corresponding segment rates for the 25-year period ending on September 30 of the calendar year preceding the first day of the plan year. Accordingly, if the funding target and target normal cost for a plan are determined using the segment rates, the segment rates used to determine the minimum required contribution and the adjusted funding target attainment percentage (“AFTAP”) used to apply funding-based benefit restrictions under Code section 436 and ERISA section 206(g) may be different from those used for other purposes (such as the segment rates used to determine the deductible limit under Code section 404(o)). In such cases, report all information on Schedule SB reflecting the assumptions used to determine the minimum required contribution and the AFTAP used to apply funding-based benefit restrictions.

Note. (1) For a plan funded with insurance (other than a plan described in Code section 412(e)(3) or ERISA section 301(b)), refer to section 1.430(d)‑1(c)(2) of the Income Tax Regulations regarding whether to include the liabilities for benefits covered under insurance contracts held by the plan and whether to include the value of the insurance contracts in plan assets.

(2) For terminating plans, Revenue Ruling 79-237, 1979-2 C.B. 190, provides that minimum funding standards apply until the end of the plan year that includes the termination date. Accordingly, the Schedule SB is not required to be filed for any later plan year. However, if a termination fails to occur — whether because assets remain in the plan’s related trust (see Revenue Ruling 89-87, 1989-2 C.B. 81) or for any other reason (e.g., the PBGC issues a notice of noncompliance pursuant to 29 CFR section 4041.31 for a standard termination) — there is no termination date, and therefore, minimum funding standards continue to apply and a Schedule SB continues to be required.

Statement by Enrolled Actuary

An enrolled actuary must sign Schedule SB. The signature of the enrolled actuary may be qualified to state that it is subject to attached qualifications. See Treasury Regulations section 301.6059-1(d) for permitted qualifications. If the actuary has not fully reflected any final or temporary regulation, revenue ruling, or notice promulgated under the statute in completing the Schedule SB, check the box on the last line of page 1. If this box is checked, indicate on an attachment whether any unpaid required contribution or a contribution that is not wholly deductible would result if the actuary had fully reflected such regulation, revenue ruling, or notice, and label this attachment “Schedule SB – Statement by Enrolled Actuary.” In addition, the actuary may offer any other comments related to the information contained in Schedule SB. Except as otherwise provided in these instructions, a stamped or machine produced signature is not acceptable.

The actuary must provide the completed and signed Schedule SB to the plan administrator to be retained with the plan records and included (in accordance with these instructions) with the Form 5500 or Form 5500-SF that is submitted under EFAST2. The plan’s actuary is permitted to sign the Schedule SB on page one using the actuary’s signature or by inserting the actuary’s typed name in the signature line followed by the actuary’s handwritten initials. The actuary’s most recent enrollment number must be entered on the Schedule SB that is prepared and signed by the plan’s actuary.

Attachments

All attachments to the Schedule SB must be properly identified as attachments to the Schedule SB, and must include the name of the plan, plan sponsor’s EIN, plan number, and line number to which the schedule relates.

Do not include attachments that contain a visible social security number. Except for certain one-participant plans, the Schedule SB and its attachments are open to public inspection, and the contents are public information and are subject to publication on the Internet. Because of privacy concerns, the inclusion of a visible social security number or any portion thereof on an attachment may result in the rejection of the filing.

The first year Schedule SB attachment for a plan retroactively adopted pursuant to SECURE Act section 201. If a plan sponsor adopted a defined benefit pension plan in 2021 (i.e., by the due date, including extension, for filing the plan sponsor’s tax return for the 2020 taxable year) and elected to treat the plan as having been adopted before the 2021 plan year began as permitted under SECURE Act section 201, then the enrolled actuary must complete and sign the 2020 Schedule SB (Form 5500). If the plan sponsor is required to file Schedule SB (see instructions for Schedule SB under “Who Must File”), attach the 2020 Schedule SB (Form 5500) as a Portable Document Format (PDF) attachment to the 2021 Schedule SB when filing the 2021 Form 5500. Label the attachment “The first year Schedule SB attachment for a plan retroactively adopted pursuant to SECURE Act 201”.

Part I – Basic Information

Note. All entries in Part I must be reported as of the valuation date, reflecting the assumptions and amounts generally used to determine the minimum required contribution. In the case of a plan described in section 104 of PPA, the information should be reported as if PPA provisions were effective for all plan years beginning after December 31, 2007.

Line 1. Valuation Date. The valuation date for a plan year must be the first day of the plan year unless the plan meets the small-plan exception of Code section 430(g)(2)(B) and ERISA section 303(g)(2)(B). For plans that qualify for the exception, the valuation date may be any date in the plan year, including the first or last day of the plan year.

A plan qualifies for this small-plan exception if there were 100 or fewer participants on each day of the prior plan year. For the definition of participant as it applies in this case, see the instructions for line F.

Line 2a. Market Value of Assets. Enter the fair market value of assets as of the valuation date. Include contributions designated for any previous plan year that are made after the valuation date (but within the 8½-month period after the end of the immediately preceding plan year), adjusted for interest for the period between the date of payment and the valuation date as provided in the applicable regulations.

Contributions made for the current plan year must be excluded from the amount reported in line 2a. If these contributions were made prior to the valuation date (which can only occur for small plans with a valuation date other than the first day of the plan year), the asset value must be adjusted to exclude not only the contribution amounts, but interest on the contributions from the date of payment to the valuation date, using the current-year effective interest rate.

Do not adjust for items such as the funding standard carryover balance, prefunding balance, any unpaid minimum required contributions, or the present value of remaining shortfall or waiver amortization installments. Rollover amounts or other assets held in individual accounts that are not available to provide defined benefits under the plan should not be included on line 2a regardless of whether they are reported on the Schedule H (Form 5500) (line 1l, column (a)) or Schedule I (Form 5500) (line 1c, column (a)), or Form 5500-SF (line 7c, column (a)). Additionally, asset and liability amounts must be determined in a consistent manner. Therefore, if the value of any insurance contracts has been excluded from the amount reported in line 2a, liabilities satisfied by such contracts should also be excluded from the funding target values reported in lines 3 and 4.

Line 2b. Actuarial Value of Assets. Do not adjust the actuarial value of assets for items such as the funding standard carryover balance, the prefunding balance, any unpaid minimum required contributions, or the present value of any remaining shortfall or waiver amortization installments. Treat contributions designated for a current or prior plan year, rollover amounts, insurance contracts, and other items in the same manner as for line 2a.

If an averaging method is used to value plan assets (as permitted under Code section 430(g)(3)(B) and ERISA section 303(g)(3)(B), as amended by WRERA), enter the value as of the valuation date taking into account the requirement that such value must be within 90% to 110% of the fair market value of assets.

Note. Under Code section 430(g)(3)(B), the use of averaging methods in determining the value of plan assets is permitted only in accordance with methods prescribed in Treasury regulations. Accordingly, taxpayers cannot use asset valuation methods other than fair market value (as described in Code section 430(g)(3)(A)), except as provided under Notice 2009-22, 2009-14 IRB 741, or Treasury regulations.

Line 3. Funding Target/Participant Count Breakdown. All amounts should be reported as of the valuation date.

Column (1)—Enter the number of participants in each category (e.g., terminated vested participants). Enter “0” if no participants fall into the category. Include beneficiaries of deceased participants who are or who will be entitled to benefits under the plan.
Column (2)—Enter the portion of the funding target attributable to vested benefits. If no portion of the funding target for a particular category is attributable to vested benefits, enter “0.” For this purpose, benefits considered to be vested for PBGC premium purposes must be included.
Column (3)—Enter the funding target attributable to all benefits, both vested and nonvested. Enter “0” if no portion of the funding target is for participants in a particular category.

For columns (2) and (3), the funding target must be calculated using the methods and assumptions provided in Code sections 430(h) and (i), ERISA sections 303(h) and (i), and other related guidance.

Unless the plan sponsor has received approval to use substitute mortality tables in accordance with Code section 430(h)(3)(C) and ERISA section 303(h)(3)(C), the funding target must be computed using the mortality tables for non-disabled lives, as described in section 1.430(h)(3)-1 of the regulations. If substitute mortality tables have been approved (or deemed to have been approved) by the IRS, such tables must be used instead of the mortality tables described in the previous sentence, subject to the rules of Code section 430(h)(3) and ERISA section 303(h)(3). The funding target may be computed taking into account the mortality tables for disabled lives published in Revenue Ruling 96-7, 1996-1 C.B. 59, and as provided in Notice 2008-29, 2008-12 IRB 637.

Special rules for plans that are in at-risk status. If a plan is in at-risk status, report the amount reflecting the additional assumptions required in Code section 430(i)(1)(B) and ERISA section 303(i)(1)(B).

If the plan has been in at-risk status for any two or more of the preceding four plan years, also include the loading factor required in Code section 430(i)(1)(C) and ERISA section 303(i)(1)(C). If the plan is in at-risk status and has been in at-risk status for fewer than five consecutive years, report the funding target amounts after reflecting the transition rule provided in Code section 430(i)(5) and ERISA section 303(i)(5). For example, the funding target for a plan that is in at-risk status for 2021 and was in at-risk status for the 2018, 2019 and 2020 plan years (but not the 2017 plan year) will reflect 80% of the funding target using the special at-risk assumptions and 20% of the funding target determined without regard to the at-risk assumptions.

Determining whether a plan is in at-risk status. Refer to Code section 430(i)(4) and ERISA section 303(i)(4) to determine whether the plan is in at-risk status. Generally, a plan is in at-risk status for a plan year if it had more than 500 participants on any day during the preceding plan year (see instructions for line F for the definition of participants) and the plan’s funding target attainment percentage (“FTAP”) for the preceding plan year fell below specified thresholds.

A plan with over 500 participants is in at-risk status for 2021 if both:

the FTAP for 2020 (line 14 of the 2020 Schedule SB) is less than 80%, and
the at-risk funding target attainment percentage for 2020 is less than 70%.

In general, the at-risk funding target attainment percentage is determined in the same manner as the FTAP (as described in the instructions for line 14), except that the funding target is determined using the additional assumptions for plans in at-risk status. For this purpose, the at-risk funding target is determined by disregarding the transition rule of Code section 430(i)(5) and ERISA section 303(i)(5) for plans that have been in at-risk status for fewer than five consecutive years, and disregarding the loading factor in Code section 430(i)(1)(C) and ERISA section 303(i)(1)(C). For plans that were in at-risk status for the 2020 plan year, the at-risk funding target used to determine whether the plan is in at-risk status for the 2021 plan year is the amount reported in line 4b of the 2020 Schedule SB.

Refer to the regulations under section 430(i) of the Code for rules pertaining to new plans and other special situations.

Line 4. Additional Information for Plans in At-Risk Status. If the plan is in at-risk status as provided under Code section 430(i)(4) and ERISA section 303(i)(4), check the box, complete lines 4a and 4b, and include as an attachment the information described below. Do not complete line 4 if the plan is not in at-risk status for the current plan year for purposes of determining the minimum required contribution.

● Line 4a – Enter the amount of the funding target determined as if the plan were not in at-risk status.

● Line 4b – Report the funding target disregarding the transition rule of Code section 430(i)(5) and ERISA section 303(i)(5), and disregarding the loading factor in Code section 430(i)(1)(C) and ERISA section 303(i)(1)(C).

If the plan is in at-risk status for the current plan year, attach a description of the at-risk assumptions for the assumed form of payment (e.g., the optional form resulting in the highest present value). Label the attachment “Schedule SB, line 4 – Additional Information for Plans in At-Risk Status.”

Line 5. Effective Interest Rate. Enter the single rate of interest which, if used instead of the interest rate(s) reported in line 21 to determine the present value of the benefits that are taken into account in determining the plan’s funding target for a plan year, would result in an amount equal to the plan’s funding target determined for the plan year, without regard to calculations for plans in at-risk status. (This is the funding target reported in line 3d, column (3) for plans not in at-risk status, or in line 4a for plans in at-risk status.) However, if the funding target for the plan year is zero, the effective interest rate is determined as the single rate that would result in an amount equal to the plan’s target normal cost determined for the plan year, without regard to calculations for plans in at-risk status. See the provisions of Code section 430(h)(2)(A), ERISA section 303(h)(2)(A), and the applicable regulations. Enter rate to the nearest .01% (e.g., 5.26%).

If the funding target calculation includes some benefits for which the present value is calculated using the 8.00% segment interest rates and other benefits for which present value is calculated using the applicable United States Treasury obligation yield curve, the effective interest rate must reflect both sets of rates.

Line 6. Target Normal Cost.

Line 6a. Present Value of Current Year Accruals. Enter the present value of all benefits which have been accrued or have been earned (or that are expected to accrue or to be earned) under the plan during the plan year, decreased (but not below zero) by any mandatory employee contributions expected to be made during the plan year. Include any increase in benefits during the plan year that is a result of any actual or projected increase in compensation during the current plan year, even if that increase in benefits is with respect to benefits attributable to services performed in a preceding plan year. This amount must be calculated as of the valuation date and must generally be based on the same assumptions used to determine the funding target reported in line 3c, column (3), reflecting the special assumptions and the loading factor for at-risk plans, if applicable. If the plan is in at-risk status for the current plan year and has been in at-risk status for fewer than five consecutive years, report the target normal cost after reflecting the transition rule provided in Code section 430(i)(5) and ERISA section 303(i)(5).

Line 6b. Expected Plan-related Expenses. Enter the aggregate amount of any plan-related expenses expected to be paid from plan assets during the plan year.

Line 6c. Total. Enter the sum of lines 6a and 6b.

Part II – Beginning of Year Carryover Prefunding Balances

Line 7. Balance at Beginning of Prior Plan Year After Applicable Adjustments. In general, report the amount in the corresponding columns of line 13 of the prior-year Schedule SB. However, if the balance from the prior year has been adjusted so that it does not match the corresponding amount in line 13 of the prior-year Schedule SB, attach an explanation and label the attachment “Schedule SB, line 7 – Explanation of Discrepancy in Prior Year Funding Standard Carryover Balance or Prefunding Balance.” Note that elections to add excess contributions or reduce balances have specific deadlines, and generally cannot be changed once they have been made.

If this is the first year for which the plan is subject to the minimum funding rules of Code section 430 or ERISA section 303, leave both columns blank.

Line 8. Portion Elected for Use To Offset Prior Year’s Funding Requirement. Report the amount for each column from the corresponding column of line 35 of the prior-year Schedule SB. If the valuation date is not the first day of the plan year, report the amounts from line 35 of the prior-year Schedule SB, discounted to the beginning of the prior plan year using the effective interest rate for the prior plan year.

Reflect the full amount reported in line 35 of the prior-year Schedule SB even if the amount is larger than the minimum required contribution reported for that year on line 34 of the prior-year Schedule SB. This can occur under the special rule for elections to use balances in excess of the minimum required contribution under section 1.430(f)-1(f)(1)(ii) of the regulations, if no timely election is made to revoke the excess amount.

If this is the first year for which the plan is subject to the minimum funding rules of Code section 430 or ERISA section 303, leave both columns blank.

Special rule for late election to apply balances to quarterly installments. If an election was made to use the funding standard carryover balance or the prefunding balance to offset the amount of a required quarterly installment, but the election was made after the due date of the installment, the amount reported on line 8 may not be the same as the amount reported on line 35 for the prior year. Refer to the regulations under section 430 of the Code for additional information. An attachment to Schedule SB should explain why the amount is different. Label the attachment “Schedule SB, line 8 – Late Election to Apply Balances to Quarterly Installments.”

Line 9. Amount Remaining. Enter the amount equal to line 7 minus line 8 in each column.

If this is the first year that the plan is subject to the minimum funding requirements of Code section 430 or ERISA section 303, enter the amount of any credit balance at the end of the prior year (the “pre-effective plan year”) on line 9, column (a) and leave line 9, column (b) blank. The amount entered on line 9, column (a) is generally the amount reported for the pre-effective plan year on line 9o of the 2007 version of the Schedule B form that was submitted as an attachment to the Schedule SB for that pre-effective plan year. If there has been any adjustment to this amount so that it does not match the amount so reported for the pre-effective plan year, attach an explanation and label the attachment “Schedule SB, line 9 – Explanation of Credit Balance Discrepancy.”

Line 10. Interest on Line 9. Enter the actual rate of return on plan assets during the preceding plan year in the space provided. Enter the rate to the nearest .01% (e.g., 6.53%). If entering a negative number, enter a minus sign (“–”) to the left of the number. In each column, enter the product of this interest rate and the amount reported in the corresponding column of line 9.

If this is the first year for which the plan is subject to the minimum funding rules of Code section 430 or ERISA section 303, leave both columns blank.

Line 11. Prior Year’s Excess Contributions to be Added to Prefunding Balance.

Line 11a. Enter the amount reported in line 38a on the Schedule SB for the prior plan year.

Line 11b(1). Enter the effective interest rate for the prior plan year, as reported on line 5 of the Schedule SB for the prior plan year, in the space provided. Enter the rate to the nearest .01% (e.g., 6.35%).

In column (b), enter the product of the prior year’s effective interest rate in line 11b(1) and the excess (if any) of the amount reported on line 38a for the prior year over the amount reported on line 38b for the prior year.

However, if the valuation date for the prior plan year was not the first day of the plan year (permitted for small plans only), enter the result of the following calculation:

Step 1: Determine the excess (if any) of the amount reported on line 38a for the prior year over the amount reported on line 38b for the prior year,

Step 2: Adjust the result in Step 1 to the first day of the prior year using the effective interest rate for the prior year,

Step 3: Multiply the result in Step 2 by the prior year’s effective interest rate in line 11(b)(1), and

Step 4: Reduce the result in Step 3 by interest on the result in Step 2 of this paragraph for the period between the first day of the prior plan year and the prior-year valuation date using the effective interest rate for the prior year.

The amount reported in line 11(b)(1) is zero if the prior year’s valuation date was the last day of the prior plan year.

Line 11(b)(2). In column (b), enter the product of the prior year’s actual rate of return (from line 10) and the present value of excess contributions reported on line 38b for the prior year.

However, if the valuation date for the prior plan year was not the first day of the plan year (permitted for small plans only), enter the result of the following calculation:

Step 1: Adjust the prior-year amount reported in line 38b to the first day of the prior year, using the effective interest rate for the prior year,

Step 2: Multiply the result in Step 1 by the prior year’s actual rate of return (from line 10), and

Step 3: Reduce the result in Step 2 by interest on the result in Step 1 for the period between the first day of the prior plan year and the prior-year valuation date using the effective interest rate for the prior year.

Line 11c. Enter the sum of lines 11a, 11b(1) and 11(b)(2).

Line 11d. Enter the amount of the excess contributions for the prior year (with interest) that the plan sponsor elected to use to increase the prefunding balance. This amount cannot be greater than the amount reported on line 11c.

If this is the first year for which the plan is subject to the minimum funding rules of Code section 430 or ERISA section 303, leave lines 11a–d blank.

Line 12. Other Reductions in Balances Due to Elections or Deemed Elections. In each column, enter the amount by which the employer elects to reduce (or is deemed to elect to reduce, per Code section 436(f)(3) and ERISA section 206(g)(5)(C)) the funding standard carryover balance or prefunding balance, as applicable, under Code section 430(f) and ERISA section 303(f), other than any amount reported in line 8 that is treated as a reduction in these balances under the special rule in section 1.430(f)-1(f)(3)(ii) (relating to amounts elected for use to offset the minimum required contribution that exceed the minimum required contribution for the plan for the plan year, and which are not revoked by the plan sponsor). This amount cannot be greater than the sum of the amounts reported in the corresponding column of lines 9, 10 and, if applicable, 11d. Note that an election (or deemed election) cannot be made to reduce the prefunding balance in column (b) until the funding standard carryover balance in column (a) has been reduced to zero.

If the valuation date is not the first day of the plan year, adjust the amounts reported in line 12 to the first day of the plan year, using the effective interest rate for the current plan year. If the plan did not exist in the prior year and is not a successor plan, leave both columns blank.

If this is the first year for which the plan is subject to the minimum funding rules of Code section 430 or ERISA section 303, leave column (b) blank.

Line 13. Balance at Beginning of Current Year.

● Column (a) - Enter the sum of the amounts reported on lines 9 and 10 of column (a), minus the amount reported on line 12 of column (a).

● Column (b) - Enter the sum of the amounts reported on lines 9, 10 and 11d of column (b), minus the amount reported on line 12 of column (b).

If this is the first year for which the plan is subject to the minimum funding rules of Code section 430 or ERISA section 303, leave column (b) blank.

Part III – Funding Percentages

Enter all percentages in this section by truncating at .01% (e.g., report 82.649% as 82.64%).

Line 14. Funding Target Attainment Percentage. Enter the funding target attainment percentage (FTAP) determined in accordance with Code section 430(d)(2) and ERISA section 303(d)(2). The FTAP is the ratio (expressed as a percentage) which the actuarial value of plan assets (reduced by the funding standard carryover balance and prefunding balance) bears to the funding target determined without regard to the additional rules for plans in at-risk status.

This percentage is determined by subtracting the sum of the amounts reported in line 13 from line 2b and dividing the result by the funding target. The funding target used for this purpose is the number reported in line 3d, column (3) for plans that are not in at-risk status and line 4a for plans that are in at-risk status. If the plan’s valuation date is not the first day of the plan year, subtract the sum of the amounts reported in line 13, adjusted for interest between the beginning of the plan year and the valuation date using the effective interest rate for the current plan year, from the amount reported in line 2b; and divide by the funding target.

Line 15. Adjusted Funding Target Attainment Percentage.

Enter the adjusted funding target attainment percentage (AFTAP) determined in accordance with Code section 436(j)(2) and ERISA section 206(g)(9)(B). The AFTAP is calculated in the same manner as the FTAP reported in line 14, except that both the assets and the funding target used to calculate the AFTAP are increased by the aggregate amount of purchases of annuities for employees other than highly compensated employees (as defined in Code section 414(q)) which were made by the plan during the preceding two plan years.

See Code section 436(j)(3) and ERISA section 206(g)(9)(C) for rules regarding circumstances in which the actuarial value of plan assets is not reduced by the funding standard carryover balance and prefunding balance for certain fully-funded plans when determining the AFTAP. Note that this special rule applies only to the calculation of the AFTAP and not to the FTAP reported in line 14.

Report the final certified AFTAP for the plan year, even if it does not correspond to the valuation results reported on this Schedule SB (for instance, if any adjustments pertaining to the plan year were made subsequent to the valuation or the AFTAP). If no AFTAP was certified for the plan year, attach an explanation and (1) report 100%, if the plan's adjusted funding target for the plan year is zero, as described in section 1.436-1(j)(1)(iv) of the Treasury regulations, or (2) leave line 15 blank if the plan's adjusted funding target for the plan year is not equal to zero. Label the attachment, "Line 15, Reconciliation of differences between valuation results and amounts used to calculate AFTAP.” For plans with valuation dates other than the first day of the plan year, report the AFTAP that is the final certified AFTAP based on the valuation results for the current plan year at the time that the Schedule SB is filed (reflecting contributions for the current plan year and reflecting other adjustments as described in applicable guidance), even if that AFTAP is not used to apply the restrictions under Code section 436 and ERISA section 206(g) until the following plan year.

If the AFTAP reported on line 15 does not correspond to the valuation results reported on this Schedule SB (for instance, if any adjustments pertaining to the plan year were made subsequent to the valuation), attach a schedule showing each AFTAP that was certified or recertified for the plan year, the date of the certification (or recertification), and a description and the amount of each adjustment to the funding target, actuarial value of assets, funding standard carryover balance and prefunding balance used to determine the corresponding AFTAP. Label the attachment, “Line 15, Reconciliation of differences between valuation results and amounts used to calculate AFTAP.” It is not necessary to include any information pertaining to a range certification in this attachment.

Line 16. Prior Year’s Funding Percentage for Purposes of Determining Whether Carryover/Prefunding Balances May Be Used to Offset Current Year’s Funding Requirement.

Under Code section 430(f)(3) and ERISA section 303(f)(3), the funding standard carryover balance and prefunding balance may not be applied toward minimum contribution requirements unless the ratio of plan assets for the preceding plan year to the funding target for the preceding plan year (as described in Code section 430(f)(3)(C) and ERISA section 303(f)(3)(C)) is 80% or more.

Enter the applicable percentage as described below, truncated at .01% (e.g., report 81.239% as 81.23%). In general, the percentage is the ratio that the prior-year actuarial value of plan assets (reduced by the amount of any prefunding balance, but not the funding standard carryover balance) bears to the prior-year funding target determined without regard to the additional rules for plans in at-risk status. This percentage is determined as follows, with all amounts taken from the prior year’s Schedule SB:

● For plans that are not in at-risk status, subtract the amount reported on line 13, column (b) (adjusted for interest as described below, if the valuation date is not the first day of the plan year) from the amount reported on line 2b, and divide the result by the funding target reported on line 3d, column (3).

● For plans that are in at-risk status, subtract the amount reported on line 13, column (b) (adjusted for interest as described below, if the valuation date is not the first day of the plan year) from the amount reported on line 2b, and divide the result by the funding target reported on line 4a.

If the valuation date for the prior plan year was not the first day of that plan year, the amount subtracted from the assets for the purpose of the above calculations is the amount reported on line 13, column(b), adjusted for interest between the beginning of the prior plan year and the prior year’s valuation date, using the effective interest rate for the prior plan year.

Line 17. Ratio of Current Value of Assets to Funding Target if Below 70%. This calculation is required under ERISA section 103(d)(11). If line 2a divided by the funding target reported in line 3d, column (3), is less than 70%, enter such percentage. Otherwise, leave this line blank.

Part IV – Contributions and Liquidity Shortfalls

Line 18. Contributions Made to the Plan. Show all employer and employee contributions either designated for this plan year or those allocated to unpaid minimum required contributions for a prior plan year. Do not adjust contributions to reflect interest. Show only employer contributions actually made to the plan within 8½ months after the end of the plan year for which this Schedule SB is filed (or actually made before the Schedule SB is signed, if earlier).

Certain employer contributions must be made in quarterly installments. See Code section 430(j) and ERISA section 303(j). Contributions made to meet the liquidity requirement of Code section 430(j)(4) and ERISA section 303(j)(4) should be reported. Include contributions made to avoid benefit restrictions under Code section 436 and ERISA section 206(g).

Add the amounts in both columns 18(b) and 18(c) separately and enter each result in the corresponding column on the total line. All contributions except those made to avoid benefit restrictions under Code section 436 and ERISA section 206(g) must be credited toward minimum funding requirements for a particular plan year.

Line 19. Discounted Employer Contributions. Employer contributions reported in line 18 that were made on a date other than the valuation date must be adjusted to reflect interest for the time period between the valuation date for the plan year to which the contribution is allocated and the date the contribution was made. In general, adjust each contribution using the effective interest rate for the plan year to which the contribution is allocated, as reported on line 5.

Allocate the interest-adjusted employer contributions to lines 19a, 19b, and 19c to report the purpose for which they were made (as described below).

Attach a schedule showing the dates and amounts of individual contributions, the year to which the contributions (or the portion of individual contributions) are applied, the interest rate(s) used to adjust the contributions (i.e., the effective interest rate for timely contributions and the applicable effective interest rate plus 5% for late quarterly installments) and the periods during which each rate applies, and the interest-adjusted contribution. It is not necessary to include information regarding interest-adjusted contributions allocated toward the minimum required contribution for the current year (reported in line 19c) in this schedule, unless any of those contributions represent late quarterly installments. However, if any of the contributions reported in line 19c represent late quarterly installments, include all contributions reported in line 19c on this schedule. Label the attachment “Schedule SB, line 19 –Discounted Employer Contributions.”

Special note for small plans with valuation dates after the beginning of the plan year. If the valuation date is after the beginning of the plan year and contributions for the current year were made during the plan year but before the valuation date, such contributions are increased with interest to the valuation date using the effective interest rate for the current plan year. These contributions and the interest calculated as described in the preceding sentence are excluded from the value of assets reported in lines 2a and 2b.

Interest adjustment for contributions representing late required quarterly installments — installments due after the valuation date. If the full amount of a required installment due after the valuation date for the current plan year is not paid by the due date for that installment, increase the effective interest rate used to discount the contribution by 5 percentage points for the period between the due date for the required installment and the date on which the payment is made. If all or a portion of the late required quarterly installment is due to a liquidity shortfall, the increased interest rate is used for a period of time corresponding to the period between the due date for the installment and the end of that quarter, regardless of when the contribution is actually paid.

Interest adjustment for contributions representing late required quarterly installments — small plans with valuation dates after the beginning of the plan year - installments due prior to the valuation date. See the regulations under section 430 for rules regarding interest adjustments for late quarterly contributions for quarterly contributions due before the valuation date.

Line 19a. Contributions Allocated Toward Unpaid Minimum Required Contributions from Prior Plan Years. Under code section 4971(c)(4)(B), if a plan has an unpaid minimum required contribution that has not been corrected at the time a payment is made (i.e., the deadline for making the minimum required contribution for a prior plan year had passed and the minimum required contribution for that year was not yet paid) that payment is allocated first to plan years with unpaid minimum required contributions, beginning with the earliest such plan year, and then to the minimum required contribution for the current plan year. Within a given plan year, payments are credited first to the earliest unpaid installment until the minimum required contribution for that plan year is satisfied. Report any contributions from line 18 that are allocated toward unpaid minimum required contributions from prior plan years, discounted for interest from the date the contribution was made to the valuation date for the plan year for which the contribution was originally required as described above. Increase the effective interest rate for the applicable plan year by 5 percentage points for any portion of the unpaid minimum required contribution that represents a late quarterly installment, for the period between the due date for the installment and the date of payment. Reflect the increased interest rate for any portion of the unpaid minimum required contribution that represents a late liquidity shortfall installment, for the period corresponding to the time between the date the installment was due and the end of the quarter during which it was due. The amount reported in line 19a cannot be larger than the amount reported in line 28.

For the purpose of allocating contribution amounts to unpaid minimum required contributions, any unpaid minimum required contribution attributable to an accumulated funding deficiency at the end of the last plan year before Code section 430 or ERISA section 303 applied to the plan (the “pre-effective plan year”) is treated as a single contribution due on the last day of the pre-effective plan year (without separately identifying any portion of the accumulated funding deficiency attributable to late quarterly installments or late liquidity shortfall installments), and the associated effective interest rate is deemed to be the valuation interest rate for the pre-effective plan year.

Line 19b. Contributions Made To Avoid Benefit Restrictions. Include in this category current year contributions made to avoid or terminate benefit restrictions under Code section 436 and ERISA section 206(g). Adjust each contribution for interest from the date the contribution was made to the valuation date as described above.

Line 19c. Contributions Allocated Toward Minimum Required Contribution for Current Year. Include in this category contributions (including any contributions made in excess of the minimum required contribution) that are not included in line 19a or 19b. Adjust each contribution for interest from the date the contribution was made to the valuation date as described above.

Line 20. Quarterly Contributions and Liquidity Shortfalls.

Line 20a. Did the Plan Have a Funding Shortfall for the Prior Plan Year? In accordance with Code section 430(j)(3) and ERISA section 303(j)(3), only plans that have a funding shortfall for the preceding plan year are subject to an accelerated quarterly contribution schedule. For this purpose, a plan is considered to have a funding shortfall for the prior year if the funding target reported on line 3d, column (3) is greater than the actuarial value of assets reported on line 2b, reduced by the sum of the funding standard carryover balance and prefunding balance reported on line 13, columns (a) and (b), with all figures taken from the prior year’s Schedule SB.

If the valuation date for the prior plan year was not the first day of that plan year, the amount subtracted from the actuarial value of assets for the above calculation is the sum of the amounts reported on line 13, columns (a) and (b) of the prior-year Schedule SB, but adjusted for interest between the beginning of the prior plan year and the prior year’s valuation date using the effective interest rate for the plan for the prior plan year.

However, see Code section 430(f)(4)(B)(ii) and ERISA section 303(f)(4)(B)(ii) for special rules in the case of a binding agreement with the PBGC providing that all or a portion of the funding standard carryover balance and/or prefunding balance is not available to offset the minimum required contribution for the prior plan year.

Please note that a plan may be considered to have a funding shortfall for this purpose even if it is exempt from establishing a shortfall amortization base under the provisions of Code section 430(c)(5) and ERISA section 303(c)(5).

Line 20b. If line 20a is “No” (i.e., if the plan did not have a funding shortfall in the prior plan year), the plan is not subject to the quarterly contribution rules, and this line should not be completed. If line 20a is “Yes,” check the “Yes” box on line 20b if required installments for the current plan year were made in a timely manner; otherwise, check “No.”

Line 20c. If line 20a is “No,” or the plan had 100 or fewer participants on every day of the preceding plan year (as defined for line F), the plan is not subject to the liquidity requirement of Code section 430(j)(4) and ERISA section 303(j)(4) and this line should not be completed. Attach a certification by the enrolled actuary if the special rule for nonrecurring circumstances is used, and label the certification “Schedule SB, line 20c –Liquidity Requirement Certification.” See Code section 430(j)(4)(E)(ii)(II) and ERISA section 303(j)(4)(E)(ii)(II).

If the plan is subject to the liquidity requirement and has a liquidity shortfall for any quarter of the plan year (see Code section 430(j)(4)(E) and ERISA section 303(j)(4)(E)), enter the amount of the liquidity shortfall for each such quarter. If the plan was subject to the liquidity requirement but did not have a liquidity shortfall, enter zero. File IRS Form 5330, Return of Excise Taxes Related to Employee Benefit Plans, with the IRS to pay the 10% excise tax(es) if there is a failure to pay any liquidity shortfall by the required due date, unless a waiver of the 10% tax has been granted under Code section 4971(f)(4)

Part V – Assumptions Used To Determine Funding Target and Target Normal Cost

Line 21. Discount Rate. All discount rates are to be reported and used as published by the IRS, and are to be applied as annual rates without adjustment.

Line 21a. Enter the three segment rates used to calculate the funding target and target normal cost as provided under Code section 430(h)(2)(C) and ERISA section 303(h)(2)(C) and as published by the IRS, unless the plan sponsor has elected to use the full yield curve. If the sponsor has elected to use the full yield curve, check the “N/A, full yield curve used” box.

If an election under Code section 430(m)(2) applies to the plan for a plan year, enter 8.00% in each of the three segment rates. Do not check the full yield curve box, even if some or all of the funding target or the target normal cost is calculated using the applicable United States Treasury obligation yield curve.

Line 21b. Code section 430(h)(2)(E) and ERISA section 303(h)(2)(E) provide that the segment rate(s) used to measure the funding target and target normal cost are those published by Treasury for the month that includes the valuation date (based on the average of the monthly corporate bond yield curves for the 24-month period ending with the month preceding that month). Alternatively, at the election of the plan sponsor, the segment rate(s) used to measure the funding target and target normal cost may be those published by Treasury for any of the four months that precede the month that includes the valuation date.

Enter the applicable month to indicate which segment rates were used to determine the funding target and target normal cost. Enter “0” if the rates used to determine the funding target and target normal cost were published for the month that includes the valuation date. Enter “1” if the rates were published for the month immediately preceding the month that includes the valuation date, “2” for the second preceding month, and “3” or “4,” respectively, for the third or fourth preceding months. For example, if the valuation date is January 1 and the funding target and target normal cost were determined based on rates published for November, enter “2.”

If an election under Code section 430(m)(2) applies to the plan for a plan year, enter “0”.

Note. The plan sponsor’s interest rate election under Code section 430(h)(2) or ERISA section 303(h)(2) (an election to use the yield curve or an election to use an applicable month other than the default month) generally may not be changed unless the plan sponsor obtains approval from the IRS. However, see the regulations under section 430(h)(2) for circumstances in which a change in interest rate may be made without obtaining approval from the IRS.

Line 22. Weighted Average Retirement Age. Enter the weighted average retirement age for active participants. If the plan is in at-risk status, enter the weighted average retirement age as if the plan were not in at-risk status. If each participant is assumed to retire at his/her normal retirement age, enter the age specified in the plan as normal retirement age. If the normal retirement age differs for individual participants, enter the age that is the weighted average normal retirement age; do not enter “NRA.” Otherwise, enter the assumed retirement age. If the valuation uses rates of retirement at various ages, enter the nearest whole age that is the weighted average retirement age.

On an attachment to Schedule SB, list the rate of retirement at each age and describe the methodology used to compute the weighted average retirement age, including a description of the weight applied at each potential retirement age, and label the attachment “Schedule SB, line 22 – Description of Weighted Average Retirement Age.”

Line 23. Mortality Tables. Mortality tables described in Code section 430(h)(3), ERISA section 303(h)(3), and section 1.430(h)(3)-1 of the regulations as published by the IRS must be used to determine the funding target and target normal cost for non-disabled participants and may be used to determine the funding target and target normal cost for disabled participants, unless the IRS has approved (or was deemed to have approved) the use of a substitute mortality table for the plan. Standard mortality tables must be either applied on a generational basis, or the tables must be updated to reflect the static tables published for the year in which the valuation date occurs. Substitute mortality tables must be applied in accordance with the terms of the IRS ruling letter.

Separate standard mortality tables were published by the IRS for annuitants (rates applying for periods when a participant is assumed to receive a benefit under the plan) and nonannuitants (rates applying to periods before a participant is assumed to receive a benefit under the plan). If a plan has 500 or fewer participants as of the valuation date for the current plan year as reported in line 3d, column (1), the plan sponsor can elect to use the combined mortality tables published by the IRS, which reflect combined rates for both annuitants and nonannuitants.

Check the applicable box to indicate which set of mortality tables was used to determine the funding target and target normal cost. If one set of mortality tables was used for certain populations within the plan and a different set of mortality tables was used for other populations, check the box for the set of mortality tables that applied to the largest population. If more than one set of mortality tables were used (other than for disabled lives pursuant to section 430(h)(3)(D)), attach a statement describing the mortality tables used for each population and the size of that population. Label the attachment “Schedule SB, line 23 – Information on Use of Multiple Sets of Mortality Tables.”

● Check “Prescribed–combined” if the funding target and target normal cost are based on the prescribed tables with combined annuitant/nonannuitant mortality rates.

● Check “Prescribed–separate” if the funding target and target normal cost are based on the prescribed tables with separate mortality rates for nonannuitants and annuitants.

● Check “Substitute” if the funding target and target normal cost are based on substitute mortality tables. If substitute mortality tables are used, attach a statement including a summary of plan populations for which substitute mortality tables are used, plan populations for which the prescribed tables are used, the mortality ratio used to develop the table for any population, whether the table is constructed based on full or partial credibility, the partial credibility weighting factor if applicable, plan populations for which the prescribed tables are used, and the last plan year for which the IRS approval of the substitute mortality tables applies. Label the attachment “Schedule SB, line 23 – Information on Use of Substitute Mortality Tables.”

Attach a statement of actuarial assumptions and funding methods used to calculate the Schedule SB entries and label the statement “Schedule SB, Part V – Statement of Actuarial Assumptions/Methods.” The statement must describe all non-prescribed actuarial assumptions (e.g., retirement, withdrawal rates) used to determine the funding target and target normal cost, including the assumption as to the frequency with which participants are assumed to elect each optional form of benefit (including lump sum distributions), whether mortality tables are

applied on a static or generational basis, whether combined mortality tables are used instead of separate annuitant and nonannuitant mortality tables (for plans with 500 or fewer participants as of the valuation date), and (for target normal cost) expected plan-related expenses and increases in compensation. For applicable defined benefit plans under Code section 411(a)(13)(C) and ERISA section 203(f)(3) (e.g., cash balance plans) the statement must include the assumptions used to convert balances to annuities. In addition, the statement must describe the method for determining the actuarial value of assets and any other aspects of the funding method for determining the Schedule SB entries that are not prescribed by law.

Also attach a summary of the principal eligibility and benefit provisions on which the valuation was based, including the status of the plan (e.g., frozen eligibility, service/pay, or benefits), optional forms of benefits, special plan provisions, including those that apply only to a subgroup of employees (e.g., those with imputed service), supplemental benefits, and identification of benefits not included in the valuation, a description of any significant events that occurred during the year, a summary of any changes in principal eligibility or benefit provisions since the last valuation, and a description (or reasonably representative sample) of plan early retirement reduction factors and optional form conversion factors. Label the summary “Schedule SB, Part V – Summary of Plan Provisions.”

Also, include any other information needed to disclose the actuarial position of the plan fully and fairly.

Part VI – Miscellaneous Items

Line 24. Change in Non-Prescribed Actuarial Assumptions. If a change has been made in the non-prescribed actuarial assumptions for the current plan year, check “Yes.” If the only assumption changes are statutorily required changes in the discount or mortality rates, or changes required for plans in at-risk status, check “No.” Include as an attachment a description of any change in non-prescribed actuarial assumptions and justifications for any such change. (See section 103(d) of ERISA.) Label the attachment “Schedule SB, line 24 – Change in Actuarial Assumptions.”

If the “Yes” box is checked and the non-prescribed assumptions have been changed in a way that decreases the funding shortfall for the current plan year, approval for such a change may be required.

Line 25. Change in Method. If a change in the method has been made for the current plan year, check “Yes.” For this purpose, a change in funding method refers to not only a change in the overall method used by the plan, but also each specific method of computation used in applying the overall method. Accordingly, funding method changes include modifications such as a change in the method for calculating the actuarial value of assets or a change in the valuation date (not an exclusive list). Also check "Yes" if there has been a change in the method for determining the discount rates reported in line 21. In general, any changes in a plan’s method must be approved by the IRS. However, see the regulations under Code section 430 and Revenue Procedure 2017-56, 2017-44 IRB 465, for circumstances in which a change in method may be made without obtaining approval from the IRS.

Include, as an attachment, a description of the change. Label the attachment “Schedule SB, line 25 – Change in Method.”

Note. The plan sponsor’s agreement to certain changes in funding method should be reported on line 8 of Schedule R (Form 5500).

Schedule SB, line 26 –Schedule of Active Participant Data

YEARS OF CREDITED SERVICE

Under 1

1 to 4

5 to 9

40 & up

Attained

Age

No.

Average

No.

Average

No.

Average

Comp.

Cash Bal.

Comp.

Cash Bal.

Comp.

Cash Bal.

No.

Comp.

Cash Bal.

Under 25

25 to 29

30 to 34

35 to 39

40 to 44

45 to 49

50 to 54

55 to 59

60 to 64

65 to 69

70 & up

Line 26. Schedule of Active Participant Data. Check “Yes” only if (a) the plan is covered by Title IV of ERISA and (b) the plan has active participants.

If line 26 is “Yes,” attach a schedule of the active plan participant data used in the valuation for this plan year. Use the format shown on the following page and label the schedule “Schedule SB, line 26 – Schedule of Active Participant Data.”

Expand this schedule by adding columns after the “5 to 9” column and before the “40 & up” column for active participants with total years of credited service in the following ranges: 10 to 14; 15 to 19; 20 to 24; 25 to 29; 30 to 34; and 35 to 39. For each column, enter the number of active participants with the specified number of years of credited service divided according to age group. For participants with partial years of credited service, truncate the total number of years of credited. Years of credited service are the years credited under the plan’s benefit formula.

Plans reporting 1,000 or more active participants on line 3d, column (1), must also provide average compensation data. For each grouping, enter the average compensation of the active participants in that group. For this purpose, compensation is the compensation taken into account for each participant under the plan’s benefit formula, limited to the amount defined under section 401(a)(17) of the Code. Do not enter the average compensation in any grouping that contains fewer than 20 participants.

In the case of a plan under which benefits are primarily pay-related and under which no future accruals are granted (i.e., a “hard-frozen” plan as defined in the instructions for plan characteristic “1I” applicable to line 8a of the Form 5500), report the average annual accrued benefit in lieu of average compensation. Include a note on the scatter indicating that the plan is “hard frozen” and the average accrued benefits are in lieu of compensation.

Cash balance plans (or any plans using characteristic code 1C on line 8a of Form 5500) reporting 1,000 or more active participants on line 3d, column (1), must also provide average cash balance account data, regardless of whether all active participants have cash balance accounts. For each age/service bin, enter the average cash balance account of the active participants in that bin. Do not enter the average cash balance account in any age/service bin that contains fewer than 20 active participants.

General Rule. When all active participants in the plan have a cash balance account, data to be shown in each bin includes:

1. The number of active participants in the age/service bin,

2. The average compensation of the active participants in the age/service bin, and

3. The average cash balance account of the active participants in the age/service bin.

When some active participants do not have cash balance accounts, an alternative is provided for showing compensation and cash balance accounts, requiring two age/service scatters as follows:

● Scatter 1 – Provide participant count and average compensation for all active participants.

● Scatter 2 – Provide participant count and average cash balance account for only those active participants with account-based benefits. If the number of participants with account-based benefits in a bin is fewer than 20, the average account should not be shown even if there are 20 or more active participants in this bin on Scatter 1.

In general, information should be determined as of the valuation date. Average cash balance accounts may be determined as of either:

1. The valuation date or

2. The day immediately preceding the valuation date.

If the plan is a multiple-employer plan, complete one or more schedules of active-participant data in a manner consistent with the computations for the funding requirements reported in Part VIII. For example, if the funding requirements are computed as if each participating employer maintained a separate plan, attach a separate “Schedule SB, line 26 – Schedule of Active Participant Data” for each participating employer in the multiple-employer plan.

Line 27. Alternative Funding Rules. If one of the alternative funding rules was used for this plan year, enter the appropriate code from the table below and follow the special instructions

applicable to that code, including completion of any required attachments.

Code Alternative Funding Rule

1 A CSEC plan that is described in Code section 414(y). This includes certain multiple-employer plans maintained by rural cooperatives and other specified cooperative organizations and certain plans maintained by more than 1 employer (determined after application of Code section 414(b) and (c)), all of which are described in Code section 501(c)(3). Do not use Code 1 for a plan that satisfies the definition of a CSEC plan that has made the election to not be treated as a CSEC plan.

2 This code, formerly used by certain plans maintained by PBGC settlements as described in section 105 of PPA, is no longer applicable and should not be used

3 Reserved

4 Plans with binding agreements with PBGC to maintain prefunding and/or funding standard carryover balances described in Code section 430(f)(4)(B)(ii) and ERISA section 303(f)(4)(B)(ii)

5 This code, formerly used by airlines using 10-year amortization period for initial post-PPA shortfall amortization base under section 402(a)(2) of PPA (as amended), is no longer applicable and should not be used.

6 Airlines with frozen plans using alternative 17-year funding schedule under section 402(a)(1) of PPA

7 Interstate transit company described in section 115 of PPA

8 This code, formerly used by a plan subject to section 104 of PPA (as amended) that is not a CSEC plan, is no longer applicable and should not be used.

9 Community Newspaper plans and plans within the controlled group, as described in SECURE Act section 115.

Special Instructions for codes 1 through 9

CSEC Plans, as described in Code section 414(y) and subject to Code section 433 (code 1).

Complete only the following on Schedule SB:

Lines A through F

Part I (including signature of enrolled actuary), determined as if PPA ’06 provisions were effective for all plan years beginning after December 31, 2007.
Part III, line 14, determined as if PPA ‘06 provisions were effective for all plan years beginning after December 31, 2007.
Part IV, line 18.
Part V, determined as if PPA ‘06 provisions were effective for all plan years beginning after December 31, 2007.

Also, report other information for the current plan year using a 2007 Schedule B (Form 5500). Label this attachment “2021 Schedule SB, line 27 – Actuarial Information for CSEC Plans.” Each attachment must include the plan name, the plan sponsor’s name and EIN, and the plan number. Complete all items from the 2007 Schedule B, excluding line 9f and Part II, and attach the 2007 Schedule B and all applicable attachments to the Schedule SB. Note that under PPA ‘06, the third segment rate determined under § 430(h)(2)(C)(iii) and ERISA section 303(h)(2)(C)(iii) is substituted for the current liability interest rate under § 412(b)(5)(B) and ERISA section 302(b)(5)(B) (as in effect before PPA ‘06).

If the plan’s funded percentage (as defined in § 433(j)(5)(B)) as of the beginning of the plan year is less than 80%, then the plan is in funding restoration status. If the plan’s enrolled actuary certifies that the plan is in funding restoration status for a plan year, include the following additional information in the attachment “2021 Schedule SB, line 27 – Actuarial Information for CSEC Plans:” (a) the annual certification by the enrolled actuary for the plan; and (b) the value of plan assets and the funding liability, including any adjustments to these amounts as specified in § 433(j)(4) and ERISA section 306(j)(4).

If a plan in funding restoration status has an accumulated funding deficiency based on the excess of the employer’s normal cost determined under line 9b, over the amount actually contributed to the plan for the plan year, as determined under § 433(j)(1) and ERISA section 306(j)(1), then the details of this calculation must be included in the attachment “2021 Schedule SB, line 27 – Actuarial Information for CSEC Plans.” In the case of a plan for which a spread gain funding method is used, the normal cost that is used to apply this rule is the normal cost determined under the entry age normal cost funding method.

Plans with binding agreements with the PBGC to maintain prefunding and/or carryover balances (code 4). Complete the entire Schedule SB and attachments as outlined in these instructions. In addition, report on an attachment the amount subject to the binding agreement with the PBGC, reported separately for the funding standard carryover balance and prefunding balance. Label the attachment “Schedule SB, line 27 – Balances Subject to Binding Agreement with PBGC.”

Airlines with frozen plans using alternative 17-year funding schedule (code 6). Complete the following lines on Schedule SB and provide associated attachments:

● Lines A through F.

● Part I (including signature of enrolled actuary) – complete all lines.

● Parts III through VII – complete all lines.

For this purpose, disregard the special funding rules under section 402(e) of PPA except for the information reported on the following lines:

● Line 19 – Discount contributions to the applicable valuation date using the 8.85% discount rate provided under section 402(e)(4)(B) of PPA.

● Line 20 – Reflect required quarterly installments based on the minimum required contribution determined under section 402(e) of PPA to the extent applicable (i.e., for purposes of calculating the required annual payment under Code section 430(j)(3)(D)(ii)(l) and ERISA section 303(j)(3)(D)(ii)(l)).

● Line 29 – Reflect the minimum required contribution determined under section 402(e) of PPA when determining the unpaid minimum required contribution.

Also, attach a worksheet showing the information below, determined in accordance with section 402(e) of PPA. Label this worksheet “Schedule SB, line 27 – Alternative 17-Year Funding Schedule for Airlines.”

● Date as of which plan benefits were frozen as required under section 402(b)(2) of PPA.

● Date on which the first applicable plan year began.

● Accrued liability under the unit credit method calculated as of the first day of the plan year, using an interest rate of 8.85%.

● A summary of all other assumptions used to calculate the unit credit accrued liability.

● Fair market value of assets as of the first day of the plan year.

● Unfunded liability under section 402(e)(3)(A) of PPA.

● Alternative funding schedule:

1. Contribution necessary to amortize the unfunded liability over the remaining number of years, assuming payments at the valuation date for each plan year and using an interest rate of 8.85%;

2. Employer contributions for the plan year, discounted for interest to the valuation date for the plan year, and using a rate of 8.85%; and

3. Contribution shortfall, if any ((1)-(2) but not less than zero).

Interstate transit company (code 7). Complete the entire Schedule SB, reflecting the modifications to the otherwise-required funding rules under section 115(b) of PPA, and disregarding the attachment required for plans reporting the use of the substitute mortality table in line 23.

Part VII – Reconciliation of Unpaid Minimum Required Contributions for Prior Years

Line 28. Unpaid Minimum Required Contributions for Prior Years. Enter the total amount of any unpaid minimum required contributions for all years from line 40 of the Schedule SB for the prior plan year.

If this is the first year that the plan is subject to the minimum funding requirements of Code section 430 or ERISA section 303, enter the amount of any accumulated funding deficiency at the end of the prior year (the pre-effective plan year). This is the amount reported on line 9p of the 2007 Schedule B form that was submitted as an attachment to the Schedule SB for the pre-effective plan year.

Line 29. Employer Contributions Allocated Toward Unpaid Minimum Required Contributions from Prior Years. Enter the total amount of discounted contributions made for the current plan year allocated toward unpaid minimum required contributions from prior years as reported in line 19a.

Line 30. Remaining Unpaid Minimum Required Contributions. Enter the amount in line 28 minus the amount in line 29.

Part VIII – Minimum

Required Contribution for Current Year

Line 31. Target Normal Cost and Excess Assets.

Line 31a. Target Normal Cost (line 6c). Enter the target normal cost as reported in line 6c.

Line 31b. Excess Assets. Enter the excess, if any, of the value of assets reported on line 2b reduced by any funding standard carryover balance and prefunding balance on line 13, columns (a) and (b), over the funding target reported on line 3d, column (3). If the valuation date is not the first day of the plan year, excess assets are determined as the value of assets reported on line 2b reduced by any funding standard carryover balance and prefunding balance reported on line 13, columns (a) and (b), adjusted for interest at the effective interest rate for the period between the beginning of the plan year and the valuation date, minus the funding target reported on line 3d, column (3) (but not less than zero). Limit the amount reported in line 31b so that it is not greater than the target normal cost reported in line 31a.

Line 32. Amortization Installments.

Line 32a. Shortfall Amortization Bases and Amortization Installments. Outstanding balance — If the plan’s funding shortfall (determined under Code section 430(c)(4) and ERISA section 303(c)(4)) is zero, all amortization bases and related installments are considered fully amortized. In this case, enter zero. Otherwise, enter the sum (but not less than zero) of the outstanding balances of all shortfall amortization bases (including any new shortfall amortization base established for the current plan year). The outstanding balance for each amortization base established in past years is equal to the present value as of the valuation date of any remaining amortization installments for each base (including the amortization installment for the current plan year), using the interest rates reported on line 21.

A plan is generally exempt from the requirement to establish a new shortfall amortization base for the current plan year if the funding target reported on line 3d, column (3), is less than or equal to the reduced value of assets as described below.

For the purpose of determining whether a plan is exempt from the requirement to establish a new shortfall amortization base for the current plan year, the reduced value of assets is the amount reported on line 2b, reduced by the full value of the prefunding balance reported on line 13, column (b), adjusted for interest for the period between the beginning of the plan year and the valuation date using the effective interest rate for the current plan year, if the valuation date is not the first day of the plan year. However, the assets are reduced by the prefunding balance if and only if the plan sponsor has elected to use any portion of the prefunding balance to offset the minimum required contribution for the current plan year, as reported on line 35. The assets are not reduced by the amount of any funding standard carryover balance for this calculation regardless of whether any portion of the funding standard carryover balance is used to offset the minimum required contribution for the plan year.

If the plan is not exempt from the requirement to establish a new shortfall amortization base for the current plan year, the amount of that base is generally equal to the difference between the funding shortfall as of the valuation date (determined under Code section 430(c)(4) and ERISA section 303(c)(4)) and the sum of any outstanding balances of any previously established shortfall and waiver amortization bases. The new shortfall amortization base may be either greater than or less than zero.

For the purpose of determining the amount of any new shortfall amortization base, the funding shortfall is equal to the amount of the funding target reported on line 3d, column (3), minus the reduced value of assets, but not less than zero.

If the plan’s valuation date is the first day of the plan year, then the reduced value of assets for the purpose of determining the amount of any new shortfall amortization base is the amount reported on line 2b, reduced by the sum of the funding standard carryover balance and the prefunding balance reported on line 13, columns (a) and (b). However, if the plan’s valuation date is not the first day of the plan year, then the reduced value of assets for the purpose of determining the amount of any new shortfall amortization base is the amount reported on line 2b, reduced by the sum of the funding standard carryover balance and the prefunding balance reported on line 13, columns (a) and (b), adjusted for interest for the period between the beginning of the plan year and the valuation date (using the effective interest rate for the current plan year). See Code section 430(f)(4)(B)(ii) and ERISA section 303(f)(4)(B)(ii) for special rules in the case of a binding agreement with the PBGC providing that all or a portion of the funding standard carryover balance and/or prefunding balance is not available to offset the minimum required contribution for the plan year.

Shortfall amortization installment — Enter the sum (but not less than zero) of:

1. Any shortfall amortization installments that were established to amortize shortfall amortization bases established in prior years, excluding amortization installments for bases that have been or are deemed to be fully amortized, and

2. The shortfall amortization installment that corresponds to any new shortfall amortization base established for the current plan year. This amount is the level amortization payment that will amortize the new shortfall amortization base over 7 annual payments, using the interest rates reported in line 21 for the current plan year.

Note. Shortfall amortization installments for a given shortfall amortization base are not re-determined from year to year regardless of any changes in interest rates or valuation dates.

Note. If an election was made to use an alternative shortfall amortization schedule under Code section 430(c)(2)(D) and ERISA section 303(c)(2)(D) added by PRA 2010, the shortfall amortization installment is the amount determined in accordance with the shortfall amortization schedule chosen and guidance issued by Treasury and the IRS. Include any increase to the shortfall amortization installment for this year due to the installment acceleration amount, as provided in Code section 430(c)(7) and ERISA section 303(c)(7).

Line 32b. Waiver Amortization Bases and Amortization Installments. Outstanding balance — If the plan’s funding shortfall (determined under Code section 430(c)(4) and ERISA section 303(c)(4)) is zero, all waiver amortization bases and related installments are considered fully amortized. In this case, enter zero. Otherwise, enter the present value as of the valuation date of all remaining waiver amortization installments (including any installment for the current plan year), using the interest rates reported on line 21. Do not include any new waiver amortization base established for a waiver of minimum funding requirements for the current plan year.

Waiver amortization installments — Enter the sum of any remaining waiver amortization installments that were established to amortize any waiver amortization bases for prior plan years, unless such bases have been or are deemed to be fully amortized. Do not include an amortization installment for any new waiver amortization base established for a waiver of minimum funding requirements for the current plan year.

Note. If a waiver of minimum funding requirements has been granted for the current plan year, a waiver amortization base is established as of the valuation date for the current plan year equal to the amount of the funding waiver reported in line 33. The waiver amortization installment that corresponds to any waiver amortization base established for the current year is the level amortization payment that will amortize the new waiver amortization base over 5 annual payments, using the same segment interest rates or rates from the full yield curve reported on line 21 for the current plan year, but with the first payment due on the valuation date for the following plan year. The amount of the waiver amortization base and the waiver amortization installments for this base are not reported in line 32b for the year in which they are established. Rather, these are included in the entries for line 32b on the Schedule SB for the following plan year.

Note. Waiver amortization installments (including the waiver amortization installments of any waiver amortization base established for the prior plan year) are not re-determined from year to year regardless of any changes in interest rates or valuation dates.

Required attachment. If there are any shortfall or waiver amortization bases, include as an attachment a listing of all bases (other than a base established for a funding waiver for the current plan year) showing for each base:

1. The type of base (shortfall or waiver),

2. The present value of any remaining installments (including the installment for the current plan year),

3. The valuation date as of which the base was established,

4. The number of years remaining in the amortization period, and

5. The amortization installment.

If a base is negative (i.e., a “gain base”), show amounts in parentheses or with a negative sign in front of them. All amounts must be calculated as of the valuation date for the plan year.

If any of the shortfall amortization bases shown on this attachment are being amortized using an alternative amortization schedule in accordance with Code section 430(c)(2)(D) or ERISA section 303(c)(2)(D), identify the amortization schedule being used and show separately the amount of any installment acceleration amount added to the shortfall amortization installment for the current plan year under Code section 430(c)(7) or ERISA section 303(c)(7). Label the schedule “Schedule SB, line 32 – Schedule of Amortization Bases.”

Line 33. Funding Waiver. If a waiver of minimum funding requirements has been approved for the current plan year, enter the date of the ruling letter granting the approval and the waived amount (reported as of the valuation date) in the spaces provided. If a waiver is pending, do not complete this line. If a pending waiver is granted after Form 5500 is filed, file an amended Form 5500 with an amended Schedule SB.

Line 34. Total Funding Requirement Before Reflecting Carryover/Prefunding Balances. Enter the target normal cost in line 31a, minus the excess assets in line 31b, plus the amortization installments reported in lines 32a and 32b, reduced by any waived amounts reported in line 33.

Line 35. Balances Elected for Use to Offset Funding Requirement. If the percentage reported on line 16 is at least 80%, and the plan has a funding standard carryover balance and/or prefunding balance (as reported on line 13, columns (a) and (b)), the plan sponsor may elect to credit all or a portion of such balances against the minimum required contribution. Enter the amount of any balance elected for use for this purpose in the applicable column of line 35, and enter the total in the column headed “Total Balance.” No portion of the prefunding balance can be used for this purpose unless the full amount of any remaining funding standard carryover balance (line 13, column (a)) is used. The amounts entered on line 35 cannot be larger than the corresponding amounts on line 13 (unless the plan’s valuation date is not the first day of the plan year, as discussed below).

If the plan’s valuation date is not the first day of the plan year, adjust the portion of the funding standard carryover balance and prefunding balance used to offset the minimum required contribution for interest between the beginning of the plan year and the valuation date using the effective interest rate for the current plan year.

Special rule for late election to apply balances to quarterly installments. If an election was made to use the funding standard carryover balance or the prefunding balance to offset the amount of a required quarterly installment, but the election was made after the due date of the installment, the amount reported on line 35 may not be the same amount that is subtracted from the plan’s balances in the following plan year (to be reported in line 8 of Schedule SB for the following plan year). Refer to the regulations under Section 430 of the Code for additional information.

Special rule for elections to use balances in excess of the minimum required contribution. Section 1.430(f)-1(f)(3)(ii) of the regulations provides an exception to the general rule requiring that any elections to use the funding standard carryover balance and/or prefunding balance to offset the minimum required contribution are irrevocable. Under this exception, such an election may be revoked to the extent that the amount of the election exceeds the minimum required contribution for the plan year as reported in line 34. If a timely election is made to revoke the excess amount, report only the amount of the election used to offset the minimum required contribution on line 35. If the excess amount is not revoked by means of a timely election, report the full amount of the election on line 35 even if it exceeds the minimum required contribution reported on line 34.

Line 36. Additional Cash Requirement. Enter the amount in line 34 minus the amount in the “Total Balance” column in line 35. (The result cannot be less than zero.) This represents the contribution needed to satisfy the minimum funding requirement for the current year, adjusted for interest to the valuation date.

Line 37. Contributions Allocated Toward Minimum Required Contribution for Current Year, Adjusted to Valuation Date. Enter the amount reported in line 19c.

Line 38. Present Value of Excess Contributions for Current Year.

Line 38a. If line 37 is greater than line 36, enter the amount by which line 37 exceeds line 36. Otherwise, enter “0.” This amount (plus interest, if applicable) is the maximum amount by which the plan sponsor may elect to increase the prefunding balance.

Line 38b. Enter the amount of any portion of the amount shown on line 38a that results solely from the use of the funding standard carryover balance and/or prefunding balance to offset the minimum required contribution.

Line 39. Unpaid Minimum Required Contribution for Current Year. If line 37 is less than line 36, enter the amount by which line 36 exceeds line 37. Otherwise, enter “0”.

Line 40. Unpaid Minimum Required Contributions for All Years. Enter the sum of the remaining unpaid minimum required contributions from line 30 and the unpaid minimum required contribution for the current year from line 39. If this amount is greater than zero, file IRS Form 5330, Return of Excise Taxes Related to Employee Benefit Plans and pay the 10% excise tax on the unpaid minimum required contributions. In addition, if this is a PBGC-covered plan and reporting to PBGC is not waived under 29 CFR 4043.25(c), file PBGC Form 10 or PBGC Form 200, whichever is applicable.

Part IX – Election to Use Pension Funding Relief under PRA 2010

Note. This section is completed only if:

(1) an election was made to use an alternative shortfall amortization schedule for any election year under Code section 430(c)(2)(D) or ERISA section 303(c)(2)(D), or

(2) in the case of a plan subject to a delayed effective date for PPA funding rules under section 104 of PPA, an election was made to determine the minimum required contribution for any election year using the extended amortization periods under section 107 of PPA ’06, as added by PRA 2010 (complete lines 41a and 41b only).

Line 41a. Schedule elected. Check the applicable box to indicate which alternative shortfall amortization schedule is being used, the 2 plus 7-year schedule or the 15-year schedule.

Line 41b. Eligible plan year(s) for which the election in line 41a was made. Check the box(es) to indicate the eligible plan years for which the election was made to use an alternative amortization schedule under Code section 430(c)(2)(D) or ERISA section 303(c)(2)(D) or the relief under section 107 of PPA ’06 as added by PRA 2010. Note that an election to use an alternative amortization schedule may only be made with respect to one or two eligible plan years. Refer to Code section 430(c)(2)(D)(v) or ERISA section 303(c)(2)(D)(v) for the definition of eligible plan years.

OMB Control Numbers

Agency OMB Number

Employee Benefits Security Administration 1210 - 0110 and 1210 - 0089

Pension Benefit Guaranty Corporation 1212 - 0057

Internal Revenue Service 1545 - 1610

Paperwork Reduction Act Notice

We ask for the information on this form to carry out the law as specified in ERISA and in Code sections 6047(e), 6058(a), and 6059(a). You are required to give us the information. We need it to determine whether the plan is operating according to the law.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books and records relating to a form or its instructions must be retained as long as their contents may become material in the administration of the Internal Revenue Code or are required to be maintained pursuant to Title I or IV of ERISA. Generally, the Form 5500 return/reports are open to public inspection and are subject to publication on the Internet.

The time needed to complete and file the forms listed below reflects the combined requirements of the Internal Revenue Service, Department of Labor, and Pension Benefit Guaranty Corporation. These times will vary depending on individual circumstances. The estimated average times are:

	Pension Plans		Welfare Plans
	Large	Small	Large	Small
Form 5500	1 hr., 54 min.	1 hr., 19 min.	1 hr., 45 min.	1 hr., 14 min.
Schedule A	2 hr., 52 min.	2 hr., 51 min.	3 hr., 39 min.	2 hr., 43 min.
Schedule C	3 hr., 4 min	N/A	3 hr., 38 min.	N/A
Schedule D	1 hr., 39 min.	20 min.	1 hr., 52 min.	20 min.
Schedule G	11 hr., 29 min.	N/A	11 hr.	N/A
Schedule H	7 hr., 42 min.	N/A	8 hr., 35 min.	N/A
Schedule I	N/A	2 hr., 5 min.	N/A	1 hr., 55 min.
Schedule MB	7 hr., 52 min.	4 hr., 14 min.	N/A	N/A
Schedule R	1 hr., 43 min.	1 hr., 5 min.	N/A	N/A
Schedule SB	6 hr., 38 min.	6 hr., 49 min.	N/A	N/A

If you have comments concerning the accuracy of these time estimates or suggestions for making these forms simpler, we would be happy to hear from you. You can write to the Internal Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave NW, IR-6526, Washington, DC 20224. Do not send any of these forms or schedules to this address. The forms and schedules must be filed electronically. See How To File – Electronic Filing Requirement.

Forms 5500, 5500-SF, and
5500-EZ Codes for Principal
Business Activity

This list of principal business activities and their associated codes is designed to classify an enterprise by the type of activity in which it is engaged.

These principal activity codes are based on the North American Industry Classification System.

Code	Code	Code	Code
Agriculture, Forestry, Fishing	Specialty Trade Contractors	Printing and Related Support	Computer and Electronic Product
and Hunting	238100 Foundation, Structure, &	Activities	Manufacturing
Crop Production	Building Exterior Contractors	323100 Printing & Related Support	334110 Computer & Peripheral
111100 Oilseed & Grain Farming	(including framing carpentry,	Activities	Equipment Mfg
111210 Vegetable & Melon Farming	masonry, glass, roofing, &	Petroleum and Coal Products	334200 Communications Equipment
(including potatoes & yams)	siding)	Manufacturing	Mfg
111300 Fruit & Tree Nut Farming	238210 Electrical Contractors	324110 Petroleum Refineries	334310 Audio & Video Equipment Mfg
111400 Greenhouse, Nursery, &	238220 Plumbing, Heating, &	(including integrated)	334410 Semiconductor & Other
Floriculture Production	Air-Conditioning Contractors	324120 Asphalt Paving, Roofing, &	Electronic Component Mfg
111900 Other Crop Farming	238290 Other Building Equipment	Saturated Materials Mfg	334500 Navigational, Measuring,
(including tobacco, cotton,	Contractors	324190 Other Petroleum & Coal	Electromedical, & Control
sugarcane, hay, peanut,	238300 Building Finishing	Products Mfg	Instruments Mfg
sugar beet, & all other crop	Contractors (including	Chemical Manufacturing	334610 Manufacturing & Reproducing
farming)	drywall, insulation, painting,	325100 Basic Chemical Mfg	Magnetic & Optical Media
Animal Production	wallcovering, flooring, tile, &	325200 Resin, Synthetic Rubber, &	Electrical Equipment, Appliance, and
112111 Beef Cattle Ranching &	finish carpentry)	Artificial & Synthetic Fibers &	Component Manufacturing
Farming	238900 Other Specialty Trade	Filaments Mfg	335100 Electric Lighting Equipment
112112 Cattle Feedlots	Contractors (including site	325300 Pesticide, Fertilizer, & Other	Mfg
112120 Dairy Cattle & Milk	preparation)	Agricultural Chemical Mfg	335200 Major Household Appliance Mfg
Production	Manufacturing	325410 Pharmaceutical & Medicine Mfg	335310 Electrical Equipment Mfg
112210 Hog & Pig Farming	Food Manufacturing	325500 Paint, Coating, & Adhesive Mfg	335900 Other Electrical Equipment &
112300 Poultry & Egg Production	311110 Animal Food Mfg	325600 Soap, Cleaning Compound, &	Component Mfg
112400 Sheep & Goat Farming	311200 Grain & Oilseed Milling	Toilet Preparation Mfg	Transportation Equipment
112510 Aquaculture (including	311300 Sugar & Confectionary	325900 Other Chemical Product &	Manufacturing
shellfish & finfish farms &	Product Mfg	Preparation Mfg	336100 Motor Vehicle Mfg
hatcheries)	311400 Fruit & Vegetable Preserving	Plastics and Rubber Products	336210 Motor Vehicle Body & Trailer
112900 Other Animal Production	& Specialty Food Mfg	Manufacturing	Mfg
Forestry and Logging	311500 Dairy Product Mfg	326100 Plastics Product Mfg	336300 Motor Vehicle Parts Mfg
113110 Timber Tract Operations	311610 Animal Slaughtering and	326200 Rubber Product Mfg	336410 Aerospace Product & Parts
113210 Forest Nurseries & Gathering	Processing	Nonmetallic Mineral Product	Mfg
of Forest Products	311710 Seafood Product Preparation	Manufacturing	336510 Railroad Rolling Stock Mfg
113310 Logging	& Packaging	327100 Clay Product & Refractory Mfg	336610 Ship & Boat Building
Fishing, Hunting and Trapping	311800 Bakeries, Tortilla & Dry Pasta	327210 Glass & Glass Product Mfg	336990 Other Transportation
114110 Fishing	Mfg	327300 Cement & Concrete Product Mfg	Equipment Mfg
114210 Hunting & Trapping	311900 Other Food Mfg (including	327400 Lime & Gypsum Product Mfg	Furniture and Related Product
Support Activities for Agriculture	coffee, tea, flavorings &	327900 Other Nonmetallic Mineral	Manufacturing
and Forestry	seasonings)	Product Mfg	337000 Furniture & Related Product
115110 Support Activities for Crop	Beverage and Tobacco Product	Primary Metal Manufacturing	Manufacturing
Production (including cotton	Manufacturing	331110 Iron & Steel Mills & Ferroalloy	Miscellaneous Manufacturing
ginning, soil preparation,	312110 Soft Drink & Ice Mfg	Mfg	339110 Medical Equipment &
planting, & cultivating)	312120 Breweries	331200 Steel Product Mfg from	Supplies Mfg
115210 Support Activities for Animal	312130 Wineries	Purchased Steel	339900 Other Miscellaneous Mfg
Production	312140 Distilleries	331310 Alumina & Aluminum	Wholesale Trade
115310 Support Activities for	312200 Tobacco Manufacturing	Production & Processing	Merchant Wholesalers, Durable
Forestry	Textile Mills and Textile Product	331400 Nonferrous Metal (except	Goods
Mining	Mills	Aluminum) Production &	423100 Motor Vehicle, & Motor
211120 Crude Petroleum Extraction	313000 Textile Mills	Processing	Vehicle Parts & Supplies
211130 Natural Gas Extraction	314000 Textile Product Mills	331500 Foundries	423200 Furniture & Home Furnishings
212110 Coal Mining	Apparel Manufacturing	Fabricated Metal Product	423300 Lumber & Other Construction
212200 Metal Ore Mining	315100 Apparel Knitting Mills	Manufacturing	Materials
212310 Stone Mining & Quarrying	315210 Cut & Sew Apparel	332110 Forging & Stamping	423400 Professional & Commercial
212320 Sand, Gravel, Clay, &	Contractors	332210 Cutlery & Handtool Mfg	Equipment & Supplies
Ceramic & Refractory	315220 Men’s & Boys’ Cut & Sew	332300 Architectural & Structural	423500 Metal & Mineral (except
Minerals Mining, & Quarrying	Apparel Mfg.	Metals Mfg	petroleum)
212390 Other Nonmetallic Mineral	315240 Women’s, Girls’ and Infants’	332400 Boiler, Tank, & Shipping	423600 Household Appliances and
Mining & Quarrying	Cut & Sew Apparel Mfg.	Container Mfg	Electrical & Electronic Goods
213110 Support Activities for Mining	315280 Other Cut & Sew Apparel Mfg	332510 Hardware Mfg	423700 Hardware, Plumbing, &
Utilities	315990 Apparel Accessories & Other	332610 Spring & Wire Product Mfg	Heating Equipment &
221100 Electric Power Generation,	Apparel Mfg	332700 Machine Shops; Turned	Supplies
Transmission & Distribution	Leather and Allied Product	Product; & Screw, Nut, & Bolt	423800 Machinery, Equipment, &
221210 Natural Gas Distribution	Manufacturing	Mfg	Supplies
221300 Water, Sewage & Other	316110 Leather & Hide Tanning, &	332810 Coating, Engraving, Heat	423910 Sporting & Recreational
Systems	Finishing	Treating, & Allied Activities	Goods & Supplies
221500 Combination Gas & Electric	316210 Footwear Mfg (including	332900 Other Fabricated Metal	423920 Toy, & Hobby Goods, &
Construction	rubber & plastics)	Product Mfg	Supplies
Construction of Buildings	316990 Other Leather & Allied	Machinery Manufacturing	423930 Recyclable Materials
236110 Residential Building	Product Mfg	333100 Agriculture, Construction, &	423940 Jewelry, Watch, Precious
Construction	Wood Product Manufacturing	Mining Machinery Mfg	Stone, & Precious Metals
236200 Nonresidential Building	321110 Sawmills & Wood	333200 Industrial Machinery Mfg	423990 Other Miscellaneous Durable
Construction	Preservation	333310 Commercial & Service	Goods
Heavy and Civil Engineering	321210 Veneer, Plywood, &	Industry Machinery Mfg	Merchant Wholesalers, Nondurable
Construction	Engineered Wood Product	333410 Ventilation, Heating,	Goods
237100 Utility System Construction	Mfg	Air-Conditioning, &	424100 Paper & Paper Products
237210 Land Subdivision	321900 Other Wood Product Mfg	Commercial Refrigeration	424210 Drugs & Druggists’ Sundries
237310 Highway, Street, & Bridge	Paper Manufacturing	Equipment Mfg	424300 Apparel, Piece Goods, &
	322100 Pulp, Paper, & Paperboard	333510 Metalworking Machinery Mfg	Notions
237990 Other Heavy & Civil	Mills	333610 Engine, Turbine & Power	424400 Grocery & Related Products
Engineering Construction	322200 Converted Paper Product Mfg	Transmission Equipment Mfg	424500 Farm Product Raw Materials
		333900 Other General Purpose	424600 Chemical & Allied Products
		Machinery Mfg



Forms 5500, 5500-SF, and 5500-EZ Codes for Principal Business Activity (continued)
Code	Code	Code	Code
424700 Petroleum & Petroleum	448140 Family Clothing Stores	Support Activities for Transportation	Securities, Commodity Contracts,
Products	448150 Clothing Accessories Stores	488100 Support Activities for Air	and Other Financial Investments and
424800 Beer, Wine, & Distilled	448190 Other Clothing Stores	Transportation	Related Activities
Alcoholic Beverages	448210 Shoe Stores	488210 Support Activities for Rail	523110 Investment Banking &
424910 Farm Supplies	448310 Jewelry Stores	Transportation	Securities Dealing
424920 Book, Periodical, &	448320 Luggage & Leather Goods	488300 Support Activities for Water	523120 Securities Brokerage
Newspapers	Stores	Transportation	523130 Commodity Contracts Dealing
424930 Flower, Nursery Stock, &	Sporting Goods, Hobby, Book, and	488410 Motor Vehicle Towing	523140 Commodity Contracts
Florists’ Supplies	Music Stores	488490 Other Support Activities for	Brokerage
424940 Tobacco & Tobacco Products	451110 Sporting Goods Stores	Road Transportation	523210 Securities & Commodity
424950 Paint, Varnish, & Supplies	451120 Hobby, Toy, & Game Stores	488510 Freight Transportation	Exchanges
424990 Other Miscellaneous	451130 Sewing, Needlework, & Piece	Arrangement	523900 Other Financial Investment
Nondurable Goods	Goods Stores	488990 Other Support Activities for	Activities (including portfolio
Wholesale Electronic Markets and	451140 Musical Instrument &	Transportation	management & investment
Agents and Brokers	Supplies Stores	Couriers and Messengers	advice)
425110 Business to Business	451211 Book Stores	492110 Couriers	Insurance Carriers and Related
Electronic Markets	451212 News Dealers & Newsstands	492210 Local Messengers & Local	Activities
425120 Wholesale Trade Agents &	General Merchandise Stores	Delivery	524130 Reinsurance Carriers
Brokers	452200 Department Stores	Warehousing and Storage	524140 Direct Life, Health, & Medical
Retail Trade	452300 General Merchandise Stores,	493100 Warehousing & Storage	Insurance Carriers
Motor Vehicle and Parts Dealers	incl. Warehouse Clubs &	(except lessors of	524150 Direct Insurance (except Life,
	Supercenters	miniwarehouses & self-storage	Health & Medical) Carriers
441110 New Car Dealers		units)	524210 Insurance Agencies &
441120 Used Car Dealers	Miscellaneous Store Retailers		Brokerages
441210 Recreational Vehicle Dealers	453110 Florists	Information	524290 Other Insurance Related
441222 Boat Dealers	453210 Office Supplies & Stationery	Publishing Industries (except Internet)	Activities (including third-
441228 Motorcycle, ATV, and All	Stores	511110 Newspaper Publishers	party administration of
Other Motor Vehicle Dealers	453220 Gift, Novelty, & Souvenir	511120 Periodical Publishers	Insurance and pension funds)
441300 Automotive Parts,	Stores	511130 Book Publishers	Funds, Trusts, and Other Financial
Accessories, & Tire Stores	453310 Used Merchandise Stores	511140 Directory & Mailing List	Vehicles
Furniture and Home Furnishings	453910 Pet & Pet Supplies Stores	Publishers	525100 Insurance & Employee
Stores	453920 Art Dealers	511190 Other Publishers	Benefit Funds
442110 Furniture Stores	453930 Manufactured (Mobile) Home	511210 Software Publishers	525910 Open-End Investment Funds
442210 Floor Covering Stores	Dealers	Motion Picture and Sound Recording	(Form 1120-RIC)
442291 Window Treatment Stores	453990 All Other Miscellaneous Store	Industries	525920 Trusts, Estates, & Agency
442299 All Other Home Furnishings	Retailers (including tobacco,	512100 Motion Picture & Video	Accounts
Stores	candle, & trophy shops)	Industries (except video rental)	525990 Other Financial Vehicles
Electronics and Appliance Stores	Nonstore Retailers	512200 Sound Recording Industries	(including mortgage REITs &
443141 Household Appliance Stores	454110 Electronic Shopping &	Broadcasting (except Internet)	closed-end investment funds)
443142 Electronics Stores (including	Mail-Order Houses	515100 Radio & Television	“Offices of Bank Holding Companies”
Audio, Video, Computer, and	454210 Vending Machine Operators	Broadcasting	and “Offices of Other Holding Companies”
Camera Stores)	454310 Fuel Dealers (including Heating	515210 Cable & Other Subscription	are located under Management
Building Material and Garden	Oil and Liquefied Petroleum)	Programming	of Companies (Holding Companies).
Equipment and Supplies Dealers	454390 Other Direct Selling	Telecommunications	Real Estate and Rental and
444110 Home Centers	Establishments (including	517000 Telecommunications	Leasing
444120 Paint & Wallpaper Stores	door-to-door retailing, frozen	(including paging, cellular,	Real Estate
	food plan providers, party	satellite, cable & other program	531110 Lessors of Residential
444130 Hardware Stores	plan merchandisers, &	distribution, resellers, other	Buildings & Dwellings
444190 Other Building Material	coffee-break service providers)	telecommunications, &	(including equity REITs)
Dealers	Transportation and	internet service providers)	531120 Lessors of Nonresidential
444200 Lawn & Garden Equipment &	Warehousing	Data Processing Services	Buildings (except
Supplies Stores	Air, Rail, and Water Transportation	518210 Data Processing, Hosting, &	Miniwarehouses) (including
Food and Beverage Stores	481000 Air Transportation	Related Services	equity REITs)
445110 Supermarkets and Other	482110 Rail Transportation	Other Information Services	531130 Lessors of Miniwarehouses &
Grocery (except	483000 Water Transportation	519100 Other Information Services	Self-Storage Units (including
Convenience) Stores	Truck Transportation	(including news syndicates,	equity REITs)
445120 Convenience Stores	484110 General Freight Trucking,	libraries, internet publishing &	531190 Lessors of Other Real Estate
445210 Meat Markets	Local	broadcasting)	Property (including equity
445220 Fish & Seafood Markets	484120 General Freight Trucking,	Finance and Insurance	REITs)
445230 Fruit & Vegetable Markets	Long-distance	Depository Credit Intermediation	531210 Offices of Real Estate Agents
445291 Baked Goods Stores	484200 Specialized Freight Trucking	522110 Commercial Banking	& Brokers
445292 Confectionery & Nut Stores	Transit and Ground Passenger	522120 Savings Institutions	531310 Real Estate Property
445299 All Other Specialty Food	Transportation	522130 Credit Unions	Managers
Stores	485110 Urban Transit Systems	522190 Other Depository Credit	531320 Offices of Real Estate
445310 Beer, Wine, & Liquor Stores	485210 Interurban & Rural Bus	Intermediation	Appraisers
Health and Personal Care Stores	Transportation	Nondepository Credit Intermediation	531390 Other Activities Related to
446110 Pharmacies & Drug Stores	485310 Taxi Service	522210 Credit Card Issuing	Real Estate
446120 Cosmetics, Beauty Supplies,	485320 Limousine Service	522220 Sales Financing	Rental and Leasing Services
& Perfume Stores	485410 School & Employee Bus	522291 Consumer Lending	532100 Automotive Equipment Rental &
446130 Optical Goods Stores	Transportation	522292 Real Estate Credit	Leasing
446190 Other Health & Personal	485510 Charter Bus Industry	(including mortgage bankers &	532210 Consumer Electronics &
Care Stores	485990 Other Transit & Ground	originators)	Appliances Rental
Gasoline Stations	Passenger Transportation	522293 International Trade Financing	532281 Formal Wear & Costume Rental
447100 Gasoline Stations (including	Pipeline Transportation	522294 Secondary Market Financing	532282 Video Tape & Disc Rental
convenience stores with gas)	486000 Pipeline Transportation	522298 All Other Nondepository
Clothing and Clothing Accessories	Scenic & Sightseeing Transportation	Credit Intermediation
Stores	487000 Scenic & Sightseeing	Activities Related to Credit
448110 Men’s Clothing Stores	Transportation	Intermediation
448120 Women’s Clothing Stores		522300 Activities Related to Credit
448130 Children’s & Infants’ Clothing		Intermediation (including loan
Stores		brokers, check clearing, &
		money transmitting)




Forms 5500, 5500-SF, and 5500-EZ Codes for Principal Business Activity (continued)
Code	Code	Code	Code
532283 Home Health Equipment	Administrative and Support and	Medical and Diagnostic Laboratories	Other Services
Rental	Waste Management and	621510 Medical & Diagnostic	Repair and Maintenance
532284 Recreational Goods Rental	Remediation Services	Laboratories	811110 Automotive Mechanical, &
532289 All Other Consumer Goods	Administration and Support Services	Home Health Care Services	Electrical Repair &
Rental	561110 Office Administrative Services	621610 Home Health Care Services	Maintenance
532310 General Rental Centers	561210 Facilities Support Services	Other Ambulatory Health Care Services	811120 Automotive Body, Paint,
532400 Commercial & Industrial	561300 Employment Services	621900 Other Ambulatory Health Care	Interior, & Glass Repair
Machinery & Equipment	561410 Document Preparation Services	Services (including ambulance	811190 Other Automotive Repair &
Rental & Leasing	561420 Telephone Call Centers	services & blood & organ banks)	Maintenance (including oil
Lessors of Nonfinancial Intangible	561430 Business Service Centers	Hospitals	change & lubrication shops &
Assets (except copyrighted works)	(including private mail centers	622000 Hospitals	car washes)
533110 Lessors of Nonfinancial	& copy shops)	Nursing and Residential Care	811210 Electronic & Precision
Intangible Assets (except	561440 Collection Agencies	Facilities	Equipment Repair &
copyrighted works)	561450 Credit Bureaus	623000 Nursing & Residential Care	Maintenance
Professional, Scientific, and	561490 Other Business Support	Facilities	811310 Commercial & Industrial
Technical Services	Services (including	Social Assistance	Machinery & Equipment
Legal Services	repossession services, court	624100 Individual & Family Services	(except Automotive &
541110 Offices of Lawyers	reporting, & stenotype	624200 Community Food & Housing, &	Electronic) Repair &
541190 Other Legal Services	services)	Emergency & Other Relief	Maintenance
Accounting, Tax Preparation,	561500 Travel Arrangement &	Services	811410 Home & Garden Equipment &
Bookkeeping, and Payroll Services	Reservation Services	624310 Vocational Rehabilitation	Appliance Repair &
541211 Offices of Certified Public	561600 Investigation & Security	Services	Maintenance
Accountants	Services	624410 Child Day Care Services	811420 Reupholstery & Furniture
541213 Tax Preparation Services	561710 Exterminating & Pest Control	Arts, Entertainment, and	Repair
541214 Payroll Services	Services	Recreation	811430 Footwear & Leather Goods
541219 Other Accounting Services	561720 Janitorial Services	Performing Arts, Spectator Sports,	Repair
Architectural, Engineering, and	561730 Landscaping Services	and Related Industries	811490 Other Personal & Household
Related Services	561740 Carpet & Upholstery Cleaning	711100 Performing Arts Companies	Goods Repair & Maintenance
541310 Architectural Services	Services	711210 Spectator Sports (including	Personal and Laundry Services
541320 Landscape Architecture	561790 Other Services to Buildings &	sports clubs & racetracks)	812111 Barber Shops
Services	Dwellings	711300 Promoters of Performing Arts,	812112 Beauty Salons
541330 Engineering Services	561900 Other Support Services	Sports, & Similar Events	812113 Nail Salons
541340 Drafting Services	(including packaging &	711410 Agents & Managers for	812190 Other Personal Care
541350 Building Inspection Services	labeling services, & convention	Artists, Athletes, Entertainers, &	Services (including diet &
541360 Geophysical Surveying &	& trade show organizers)	Other Public Figures	weight reducing centers)
Mapping Services	Waste Management and	711510 Independent Artists, Writers, &	812210 Funeral Homes & Funeral
541370 Surveying & Mapping (except	Remediation Services	Performers	Services
Geophysical) Services	562000 Waste Management and	Museums, Historical Sites, and Similar	812220 Cemeteries & Crematories
541380 Testing Laboratories	Remediation Services	Institutions	812310 Coin-Operated Laundries &
Specialized Design Services	Educational Services	712100 Museums, Historical Sites, &	Drycleaners
541400 Specialized Design Services	611000 Educational Services	Similar Institutions	812320 Drycleaning & Laundry
(including interior, industrial,	(including schools, colleges,	Amusements, Gambling, and	Services (except
graphic, & fashion design)	& universities)	Recreation Industries	Coin-Operated)
Computer Systems Design and	Health Care and Social Assistance	713100 Amusement Parks & Arcades	812330 Linen & Uniform Supply
Related Services	Offices of Physicians and Dentists	713200 Gambling Industries	812910 Pet Care (except Veterinary)
541511 Custom Computer	621111 Offices of Physicians (except	713900 Other Amusement &	Services
Programming Services	mental health specialists)	Recreation Industries	812920 Photofinishing
541512 Computer Systems Design	621112 Offices of Physicians, Mental	(including golf courses, skiing	812930 Parking Lots & Garages
Services	Health Specialists	facilities, marinas, fitness	812990 All Other Personal Services
541513 Computer Facilities	621210 Offices of Dentists	centers, & bowling centers)	Religious, Grantmaking, Civic,
Management Services	Offices of Other Health Practitioners	Accommodation and Food Services	Professional, and Similar
541519 Other Computer Related	621310 Offices of Chiropractors	Accommodation	Organizations
Services	621320 Offices of Optometrists	721110 Hotels (except Casino Hotels) &	813000 Religious, Grantmaking,
Other Professional, Scientific, and	621330 Offices of Mental Health	Motels	Civic, Professional, & Similar
Technical Services	Practitioners (except	721120 Casino Hotels	Organizations (including
541600 Management, Scientific, &	Physicians)	721191 Bed & Breakfast Inns	condominium and
Technical Consulting Services	621340 Offices of Physical,	721199 All other Traveler	homeowners associations)
541700 Scientific Research &	Occupational & Speech	Accommodation	813930 Labor Unions and Similar
Development Services	Therapists, & Audiologists	721210 RV (Recreational Vehicle)	Labor Organizations
541800 Advertising & Related	621391 Offices of Podiatrists	Parks & Recreational Camps	921000 Governmental Instrumentality
Services	621399 Offices of all Other	721310 Rooming and Boarding Houses,	or Agency
541910 Marketing Research & Public	Miscellaneous Health	Dormitories, and Workers’
Opinion Polling	Practitioners	Camps
541920 Photographic Services	Outpatient Care Centers	Food Services and Drinking Places
541930 Translation & Interpretation	621410 Family Planning Centers	722300 Special Food Services
Services	621420 Outpatient Mental Health &	(including food service
541940 Veterinary Services	Substance Abuse Centers	contractors & caterers)
541990 All Other Professional,	621491 HMO Medical Centers	722410 Drinking Places (Alcoholic
Scientific, & Technical	621492 Kidney Dialysis Centers	Beverages)
Services	621493 Freestanding Ambulatory	722511 Full-Service Restaurants
Management of Companies	Surgical & Emergency Centers	722513 Limited-Service Restaurants
(Holding Companies)	621498 All Other Outpatient Care	722514 Cafeterias and Buffets Beverage Bars
551111 Offices of Bank Holding	Centers	722515 Snack and Non-alcoholic
Companies		Beverage Bars
551112 Offices of Other Holding
Companies

ERISA COMPLIANCE QUICK CHECKLIST

Compliance with the Employee Retirement Income Security Act (ERISA) begins with knowing the rules. Plan administrators and other plan officials can use this checklist as a quick diagnostic tool for assessing a plan’s compliance with certain important ERISA rules; it is not a complete description of all ERISA’s rules and it is not a substitute for a comprehensive compliance review. Use of this checklist is voluntary, and it is not to be filed with your Form 5500.

If you answer “No” to any of the questions below, you should review your plan’s operations because you may not be in full compliance with ERISA’s requirements.

1. Have you provided plan participants with a summary plan description, summaries of any material modifications of the plan, and annual summary financial reports or annual pension funding reports?

2. Do you maintain copies of plan documents at the principal office of the plan administrator for examination by participants and beneficiaries?

3. Do you respond to written participant inquires for copies of plan documents and information within 30 days?

4. Does your plan include written procedures for making benefit claims and appealing denied claims, and are you complying with those procedures?

5. Is your plan covered by fidelity bonds protecting the plan against losses due to fraud or dishonesty by persons who handle plan funds or other property?

6. Are the plan’s investments diversified so as to minimize the risk of large losses?

7. If the plan permits participants to select the investments in their plan accounts, has the plan provided them with enough information to make informed decisions?

8. Has a plan official determined that the investments are prudent and solely in the interest of the plan’s participants and beneficiaries, and evaluated the risks associated with plan investments before making the investments?

9. Did the employer or other plan sponsor send participant contributions to the plan on a timely basis?

10. Did the plan pay participant benefits on time and in the correct amounts?

11. Did the plan give participants and beneficiaries 30 days advance notice before imposing a “blackout period” of at least three consecutive business days during which participants or beneficiaries of a 401(k) or other individual account pension plan were unable to change their plan investments, obtain loans from the plan, or obtain distributions from the plan?

If you answer “Yes” to any of the questions below, you should review your plan’s operations because you may not be in full compliance with ERISA’s requirements.

1. Has the plan engaged in any financial transactions with persons related to the plan or any plan official? (For example, has the plan made a loan to or participated in an investment with the employer?)

2. Has a plan official used the assets of the plan for his/her own interest?

3. Have plan assets been used to pay expenses that were not authorized in the plan document, were not necessary for the proper administration of the plan, or were more than reasonable in amount?

If you need help answering these questions or want additional guidance about ERISA requirements, a plan official should contact the U.S. Department of Labor Employee Benefits Security Administration office in your region or consult with the plan’s legal counsel or professional employee benefit advisor.

Index

80-120 Participant Rule ………. 8

103-12 Investment Entity
(103-12 IE) 11

About the Form 5500 1

Additional Employer Information

for Multiemployer Defined

Benefit Pension Plans 60

Additional Information for

Single-Employer and

Multiemployer Defined

Benefit Pension Plans 61

Amended Return/Report 6

Amendments 59

Change in Plan Year 7

Changes to Note 1

Combination Unfunded/Insured

Welfare Plan 3

Common/Collective Trust 11

Delinquent Filer Voluntary Compliance (DFVC) Program 5

Direct Filing Entity (DFE) – Who

Must File 4

Direct Filing Entity (DFE) – Filing

Requirements 10

Distributions 58

EFAST2 Processing System 1

Electronic Filing Requirement 5

ESOP Information 60

Extension of Time to File 4

Final Return/Report:

Mergers/Consolidations 6

Pension and Welfare Plans

Terminated Without Distributing All Assets 6

Welfare Plans Still Liable to Pay

Benefits 6

Form 5500 Schedules 8

Fully Insured Welfare Benefit

Plan 4

Funding Information 59

General Schedules 8

Group Insurance Arrangement

(GIA) 11

How to get assistance 2

Information Concerning Insurance

Contract Coverage, Fees, and

Commissions 21

Instructions to Form 5500 … 14

Instructions for Schedule A:

Who Must File 21

Instructions for Schedule C:

Who Must File 24

Instructions for Schedule D:

Who Must File 29

Instructions for Schedule G:

Who Must File 31

Instructions for Schedule H:

Who Must File 33

Instructions for Schedule I:

Who Must File 43

Instructions for Schedule MB:

Statement by Enrolled

Actuary 51

Who Must File 51

Instructions for Schedule R:

Who Must File 58

Instructions for Schedule SB:

Statement by Enrolled

Actuary 63

Who Must File 63

Investment and Annuity

Contract Information 22

Leases in Default or Classified

As Uncollectible ……………… 31

Limited Pension Plan Reporting 9

List of Plan Characteristic Codes 19

Loans or Fixed Income

Obligations in Default or

Classified As Uncollectible 31

M-1 Compliance Information 18

Master Trust Investment

Account (MTIA) 10

Nonexempt Transactions 31, 47

Notice to Terminated Accountant

or Enrolled Actuary 28

On-Line Assistance……………….2

Party-In-Interest 31, 47

Penalties:

Administrative 7

Other 7

Pension Benefit Plan - Who

Must File 2

Pension Benefit Plan Filing

Requirements 8

Pension Schedule………….…… 8

Plan Administrator 16

Plan Sponsor 15

Pooled Separate Account (PSA) 11

Provision of Information 23

Quick Reference Chart of Form

5500, Schedules, and

Attachments…..………………12

Reportable Transaction 41

Schedule of Reportable

Transactions 41

Service Provider Information 24

Service Providers Who Fail or

Refuse To Provide

Information 27

Short Plan Year Rule 8

Signature and Date 6

Small Plan Financial

Information 43

Special rule for certain

participant-directed

transactions 41

Statement by Enrolled

Actuary 64

Telephone Assistance 2

Termination Information on

Accountants and Enrolled

Actuaries 28

Unfunded Welfare Benefit Plan 3

Welfare Benefit Contract

Information 23

Welfare Benefit Plan – Who

Must File 3

Welfare Benefit Plan Filing

Requirements 9

What To File 7

When To File:

DFEs other than GIAs 4

Extensions 4

Plans and GIAs 4

Short Years 4

Who Must File 2

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	2020 Form 5500 Instructions 020420
Author	Emily St. Onge
File Modified	0000-00-00
File Created	2021-03-31