Form 5500 Schedule Multiple-Employer Retirement Plan Information

SCHEDULE MEP

(Form 5500)

Department of the Treasury

Internal Revenue Service

Department of Labor
Employee Benefits Security Administration

MULTIPLE-EMPLOYER RETIREMENT

PLAN INFORMATION

This schedule is required to be filed under section 104 of the
Employee Retirement Income Security Act of 1974 (ERISA) and

Section 6058(a) of the Internal Revenue Code (the Code)

File as an attachment to Form 5500.



OMB Nos. 1210-XXXX

1210-XXXX

202

This Form is Open to Public Inspection

For calendar plan year 202X or fiscal plan year beginning and ending

A Name of plan

ABCDEBCDEFGHI ABCDEFGHI ABCDE

FGHI

B Three-digit
plan number (PN) 

001

C Plan administrator’s name as shown on line 2a of Form 5500
ABCDEFGHI CDEFGHI ABCDEFGHI ABCDE

FGHI ABCDEFGHI

EIN
012345678

Part I

Type of Multiple-Employer Pension Plan. All multiple-employer pension plans must complete.

Line 1 Check the appropriate box to indicate type of multiple-employer pension plan. (See Instructions)

a [] association retirement plan (See 29 CFR 2510.3-55) (Complete Part II)

b [] professional employer organization (PEO) plan (See 29 CFR 29 CFR 2510.3-55) (Complete Part II)

c [] pooled employer plan (PEP) (See 29 CFR 2510.3-44) (Complete Parts II and III)

d [] other multiple-employer pension plan (Describe)_______________________________ (Complete Part II)

Part II

Participating Employer Information.

All multiple-employer pension plans that are subject to section 210(a) of ERISA (see instructions for filing the Form 5500) must complete Part II, in addition to Part I, in accordance with the instructions, to report the information for each employer participating in the MEP.

Line 2 Participating Employer Information. Complete as many entries as needed to list the required information for each participating employer that is not an individual person (See instructions).

2a. Name of Participating Employer	2b. EIN	2c. Percentage of Total Contributions for the Plan Year	2d. Aggregate Account Balances Attributable to Participating Employer
2a. Name of Participating Employer	2b. EIN	2c. Percentage of Total Contributions for the Plan Year	2d. Aggregate Account Balances Attributable to Participating Employer

CAUTION Do not individually list information for working owners (see instructions and 29 CFR 2510.3-55(d)(2)) or other individuals who are participants or beneficiaries in the plan or arrangement that are no longer associated with a particular participating employer or participating employer plan. (See instructions). Providing identifying information for individuals may result in rejection of this filing. If there are any such individuals in the plan, answer “Yes” to line 2e and provide the total information for all such individuals, without providing names or other identifying information.

2e. Does the plan include any individuals not participating through an employer or who are individual working owners?

[] Yes [] No

2f. If you answer “Yes” in line 2e, enter a good faith estimate of percentage of total contributions made by all such individuals that are not listed on line 2a during the plan year.

2g. If you answer “Yes” in Line 2e, enter the aggregate account balances for all such individuals that are not listed on

line 2a.

Part III

Pooled Employer Plan Information.

Pooled employer plans must answer all of the questions in Part III, in addition to completing all of Parts I and II.

Line 3. Has the pooled plan provider (identified as the plan sponsor and administrator in Part II of the Form 5500) acknowledged in writing that it is the named fiduciary and plan administrator? [] Yes [] No

Line 4. Has the pooled plan provider (identified as the plan sponsor and administrator in Part II of the Form 5500) acknowledged in writing its administrative responsibilities for the plan? [] Yes [] No

Line 5. Is the pooled plan provider currently in compliance with the Form PR (Pooled Plan Provider Registration Statement) requirements? (See instructions and 29 CFR 2510.3-44)[] Yes [] No

5a If “Yes” is checked, enter the ACK ID for the most recent Form PR that was required to be filed under the Form PR filing requirements. (Failure to enter a valid ACK ID will subject the Form 5500 filing for any PEP operated by the pooled plan provider to be rejected as incomplete.)

ACK ID ______________________________

Line 6. Have services been provided to the plan through affiliates or other related parties to the pooled plan provider?

[] Yes [] No

6a If “Yes,” are you relying on a prohibited transaction exemption? If you answer yes, enter the PTE(s) on which you are relying. [] Yes (enter PTE _______) [] No

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

DRAFT Schedule MEP (Form 5500) 2021 v. XX