Form 5500 Schedule Financial Transaction Schedules

Annual Information Return/Report of Employee Benefit Plan- SECURE Act

201209 Sch G Clean

OMB: 1210-0170

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SCHEDULE G
(Form 5500)


Department of Treasury
Internal Revenue Service


Department of Labor

Employee Benefits Security Administration

Financial Transaction Schedules


This schedule is required to be filed under section 104 of the Employee Retirement Income Security Act of 1974 (ERISA) and section 6058(a) of the Internal Revenue Code (the Code).

File as an attachment to Form 5500.

OMB No. 1210-0110


2021


This Form is Open to Public Inspection.


For calendar plan year 2021 or fiscal plan year beginning and ending



A Name of plan

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

B Three-digit
plan number (PN)

001




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

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

D Employer Identification Number (EIN)
012345678


Part I

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



(a)

(b) Identity and address of obligor

(c) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan and the terms of the renegotiation, and other material items



X

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE




Amount received during reporting year


Amount overdue

(d) Original amount of loan

(e) Principal

(f) Interest

(g) Unpaid balance at end of year

(h) Principal

(i) Interest

123456789012345

123456789012345

123456789012345

123456789012345

123456789012345

123456789012345







(a)

(b) Identity and address of obligor

(c) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan and the terms of the renegotiation, and other material items

X

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE


Amount received during reporting year


Amount overdue

(d) Original amount of loan

(e) Principal

(f) Interest

(g) Unpaid balance at end of year

(h) Principal

(i) Interest


123456789012345

123456789012345

123456789012345

123456789012345

123456789012345


(a)

(b) Identity and address of obligor

(c) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan and the terms of the renegotiation, and other material items

X

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE


Amount received during reporting year


Amount overdue

(d) Original amount of loan

(e) Principal

(f) Interest

(g) Unpaid balance at end of year

(h) Principal

(i) Interest

123456789012345

123456789012345

123456789012345

123456789012345

123456789012345

123456789012345

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

Schedule G (Form 5500) 2021

v. 201209



(a)

(b) Identity and address of obligor

(c) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan and the terms of the renegotiation, and other material items

X

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE


Amount received during reporting year


Amount overdue


(d) Original amount of loan

(e) Principal

(f) Interest

(g) Unpaid balance at end of year

(h) Principal

(i) Interest


123456789012345

123456789012345

123456789012345

123456789012345

123456789012345

123456789012345




(a)

(b) Identity and address of obligor

(c) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan and the terms of the renegotiation, and other material items

X

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE


Amount received during reporting year


Amount overdue


(d) Original amount of loan

(e) Principal

(f) Interest

(g) Unpaid balance at end of year

(h) Principal

(i) Interest


123456789012345

123456789012345

123456789012345

123456789012345

123456789012345

123456789012345




(a)

(b) Identity and address of obligor

(c) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan and the terms of the renegotiation, and other material items

X

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE


Amount received during reporting year


Amount overdue


(d) Original amount of loan

(e) Principal

(f) Interest

(g) Unpaid balance at end of year

(h) Principal

(i) Interest


123456789012345

123456789012345

123456789012345

123456789012345

123456789012345

123456789012345




(a)

(b) Identity and address of obligor

(c) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan and the terms of the renegotiation, and other material items

X

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE


Amount received during reporting year


Amount overdue


(d) Original amount of loan

(e) Principal

(f) Interest

(g) Unpaid balance at end of year

(h) Principal

(i) Interest


123456789012345

123456789012345

123456789012345

123456789012345

123456789012345

123456789012345




(a)

(b) Identity and address of obligor

(c) Detailed description of loan including dates of making and maturity, interest rate, the type and value of collateral, any renegotiation of the loan and the terms of the renegotiation, and other material items

X

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE


Amount received during reporting year


Amount overdue


(d) Original amount of loan

(e) Principal

(f) Interest

(g) Unpaid balance at end of year

(h) Principal

(i) Interest


123456789012345

123456789012345

123456789012345

123456789012345

123456789012345

123456789012345






Part II

Schedule of Leases in Default or Classified as Uncollectible

Complete as many entries as needed to report all leases in default or classified as uncollectible. Check box (a) if lessor or lessee is known to be a party in interest. Attach Overdue Lease Explanation for each lease listed. (See instructions)



(a)

(b) Identity of lessor/lessee

(c) Relationship to plan, employer, employee organization, or other

party-in-interest

(d) Terms and description (type of property, location and date it was purchased, terms regarding rent, taxes, insurance, repairs,

expenses, renewal options, date property was leased)



X

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD



(e) Original cost

(f) Current value at time of lease

(g) Gross rental receipts during the plan year

(h) Expenses paid during the plan year

(i) Net receipts

(j) Amount in arrears



123456789012345

123456789012345

123456789012345

123456789012345

123456789012345

123456789012345









(a)

(b) Identity of lessor/lessee

(c) Relationship to plan, employer, employee organization, or other

party-in-interest

(d) Terms and description (type of property, location and date it was purchased, terms regarding rent, taxes, insurance, repairs,

expenses, renewal options, date property was leased)



X

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD



(e) Original cost

(f) Current value at time of lease

(g) Gross rental receipts during the plan year

(h) Expenses paid during the plan year

(i) Net receipts

(j) Amount in arrears



123456789012345

123456789012345

123456789012345

123456789012345

123456789012345

123456789012345









(a)

(b) Identity of lessor/lessee

(c) Relationship to plan, employer, employee organization, or other

party-in-interest

(d) Terms and description (type of property, location and date it was purchased, terms regarding rent, taxes, insurance, repairs,

expenses, renewal options, date property was leased)



X

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD



(e) Original cost

(f) Current value at time of lease

(g) Gross rental receipts during the plan year

(h) Expenses paid during the plan year

(i) Net receipts

(j) Amount in arrears



123456789012345

123456789012345

123456789012345

123456789012345

123456789012345

123456789012345









(a)

(b) Identity of lessor/lessee

(c) Relationship to plan, employer, employee organization, or other

party-in-interest

(d) Terms and description (type of property, location and date it was purchased, terms regarding rent, taxes, insurance, repairs,

expenses, renewal options, date property was leased)



X

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD



(e) Original cost

(f) Current value at time of lease

(g) Gross rental receipts during the plan year

(h) Expenses paid during the plan year

(i) Net receipts

(j) Amount in arrears



123456789012345

123456789012345

123456789012345

123456789012345

123456789012345

123456789012345









(a)

(b) Identity of lessor/lessee

(c) Relationship to plan, employer, employee organization, or other

party-in-interest

(d) Terms and description (type of property, location and date it was purchased, terms regarding rent, taxes, insurance, repairs,

expenses, renewal options, date property was leased)



X

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD



(e) Original cost

(f) Current value at time of lease

(g) Gross rental receipts during the plan year

(h) Expenses paid during the plan year

(i) Net receipts

(j) Amount in arrears



123456789012345

123456789012345

123456789012345

123456789012345

123456789012345

123456789012345









(a)

(b) Identity of lessor/lessee

(c) Relationship to plan, employer, employee organization, or other

party-in-interest

(d) Terms and description (type of property, location and date it was purchased, terms regarding rent, taxes, insurance, repairs,

expenses, renewal options, date property was leased)



X

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD



(e) Original cost

(f) Current value at time of lease

(g) Gross rental receipts during the plan year

(h) Expenses paid during the plan year

(i) Net receipts

(j) Amount in arrears



123456789012345

123456789012345

123456789012345

123456789012345

123456789012345

123456789012345








Part III

Nonexempt Transactions

Complete as many entries as needed to report all nonexempt transactions. Caution: If a nonexempt prohibited transaction occurred with respect to a disqualified person, file Form 5330 with the IRS to pay the excise tax on the transaction.


(a) Identity of party involved

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

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

(d) Purchase price


ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

123456789012345

(e) Selling price

(f) Lease rental

(g) Transaction expenses

(h) Cost of asset

(i) Current value of asset

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


123456789012345

123456789012345

123456789012345

123456789012345

12345678901235

-1234567890123455





(a) Identity of party involved

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

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

(d) Purchase price


ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

123456789012345

(e) Selling price

(f) Lease rental

(g) Transaction expenses

(h) Cost of asset

(i) Current value of asset

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












(a) Identity of party involved

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

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

(d) Purchase price


ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

123456789012345

(e) Selling price

(f) Lease rental

(g) Transaction expenses

(h) Cost of asset

(i) Current value of asset

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


123456789012345

123456789012345

123456789012345

123456789012345

12345678901235

-1234567890123455





(a) Identity of party involved

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

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

(d) Purchase price


ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

123456789012345

(e) Selling price

(f) Lease rental

(g) Transaction expenses

(h) Cost of asset

(i) Current value of asset

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












(a) Identity of party involved

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

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

(d) Purchase price


ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

123456789012345

(e) Selling price

(f) Lease rental

(g) Transaction expenses

(h) Cost of asset

(i) Current value of asset

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


123456789012345

123456789012345

123456789012345

123456789012345

12345678901235

-1234567890123455





(a) Identity of party involved

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

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

(d) Purchase price


ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

123456789012345

(e) Selling price

(f) Lease rental

(g) Transaction expenses

(h) Cost of asset

(i) Current value of asset

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


123456789012345

123456789012345

123456789012345

123456789012345

12345678901235

-1234567890123455



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title2020 Sch G
AuthorBruce Silver
File Modified0000-00-00
File Created2022-05-25

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