Sch D (Form 5500) DFE/Participating Plan Information

Annual Return/Report of Employee Benefit Plan

230127 Sch D-Clean

OMB: 1545-1610

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SCHEDULE D

(Form 5500)


Department of the Treasury

Internal Revenue Service


Department of Labor

Employee Benefits Security Administration

DFE/Participating Plan Information


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

File as an attachment to Form 5500.



OMB No. 1210-0110


2023


This Form is Open to Public Inspection.

For calendar plan year 2023 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 or DFE 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

Information on interests in MTIAs, CCTs, PSAs, and 103-12 IEs (to be completed by plans and DFEs)
(Complete as many entries as needed to report all interests in DFEs)

a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345




a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345




a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345




a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


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


Schedule D (Form 5500) 2023

v. 230127



a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


a Name of MTIA, CCT, PSA, or 103-12 IE:

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

d Entity code

1

e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions)

-123456789012345


6

Part II

Information on Participating Plans (to be completed by DFEs, other than DCGs)
(Complete as many entries as needed to report all participating plans. DCGs must report each participating plan using Schedule DCG.)

a Plan name

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

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123


a Plan name

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

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123

a Plan name

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

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123


a Plan name

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

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123


a Plan name

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

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123


a Plan name

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

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123


a Plan name

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

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123


a Plan name

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

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123


a Plan name

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

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123


a Plan name

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

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123


a Plan name

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

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123


a Plan name

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

b Name of
plan sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN

123456789-123



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title2020 Sch D
AuthorBruce Silver
File Modified0000-00-00
File Created2023-08-29
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