Form 5500 Schedule Individual Plan Information

SCHEDULE DCG (Form 5500) Department of the Treasury Internal Revenue Service __________________________

Individual Plan Information This schedule is required to be filed under section 103 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 ____________________________

2023 _____________________________

Department of Labor Employee Benefits Security Administration

This Form is Open to Public Inspection

Part I

DCG Information

A

Name of DCG

B

Three-digit plan number (PN) 4

C

DCG Sponsor’s Name (enter here only if different from Name of DCG)

D

Employer Identification Number (EIN) for DCG

Part II

Individual Schedule DCG Information. Complete a separate Schedule for each individual defined contribution pension plan.

E

This Schedule DCG is for:

a single-employer plan

a collectively-bargained plan

F

This Schedule DCG is:

the first Schedule

the final Schedule

an amended Schedule

Part III

Basic Individual Plan Information

1a

Name of plan

1b

Three-digit plan number (PN)

1c

Effective date of plan

2a

Plan sponsor’s name (employer, if for a single-employer plan) Mailing address (include room, apt., suite no. and street, or P.O. Box), City or town, state or province, country, and ZIP or foreign postal code (if foreign, see instructions)

2b

Employer Identification Number (EIN)

2c

Plan sponsor’s telephone number

2d

Business code

3

If the name and/or EIN of the plan sponsor or the plan name has changed since the last return/report filed for this plan, enter the plan sponsor’s name, EIN, the plan name and the plan number from the last return/report:

3b

EIN

a

Plan sponsor’s name

3d

PN

c

Plan Name

4a

Plan administrator’s name and address

4b

EIN

4c

Administrator’s telephone number

5a

Total number of participants at the beginning of the plan year

5a

b

Total number of participants as of the end of the plan year

5b

c(1)

Total number of active participants at the beginning of the plan year

5c(1)

c(2)

Total number of active participants at the end of the plan year

5c(2)

d(1)

Number of participants with account balances as of the beginning of the plan year

5d(1)

d(2)

Number of participants with account balances as of the end of the plan year

5d(2)

e

Number of participants who terminated employment during the plan year with accrued benefits that were less than 100% vested

5e

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

Schedule DCG (2023) v. 230127

Part IV

Financial Information

6

Plan Assets and Liabilities

(a) Beginning of Year

(b) End of Year

a

Total plan assets

6a

Participant loans

6a(1)

b

Total plan liabilities

6b

c

Net Assets (subtract line 6b from line 6a)

6c

7a

Contributions received or receivable in cash from

Amount

(1) Employers

7a(1)

(2) Participants

7a(2)

(3) Others (including rollovers)

7a(3)

b

Noncash contributions

7b

c

Total Contributions (add lines 7a(1)-(3) and line 7(b)

7c

d

Other income (loss)

7d

e

Total Income (add lines 7c and 7d)

7e

f

Benefit payment and payments to provide benefits

7f

g

Corrective distributions (see instructions)

7g

h

Certain deemed distributions of participant loans (see instructions)

7h

i

Administrative service provider’s expense (salaries, fees, commissions)

7i

j

Other expenses

7j

k

Total expenses (add lines 7f, 7g, 7h, 7i, and 7j)

7k

l

Net income (loss) (subtract line 7k from line 7e)

7l

m

Transfers of assets

(1) To this plan

7m(1)

(2) From this plan

7m(2)

Part V

Plan Characteristics

8

Enter the applicable two-character feature codes from the List of Plan Characteristics Codes in the instructions.

Part VI

Compliance Questions

Yes

No

Amount

9a

Was there a failure to transmit to the plan any participant contributions within the time period described in 29 CFR 2510.3-102? Continue to answer “Yes” for any prior year failures until fully corrected. (See instructions and DOL’s Voluntary Fiduciary Correction Program.)

9a

b

Were there any nonexempt transactions with any party-in-interest?

9b

c

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

9c

d

Was the plan covered by a fidelity bond?

9d

e

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

9e

10		If, during this plan year, any assets or liabilities were transferred from this plan to another plan(s), identify the plan(s) to which assets or liabilities were transferred. (See instructions)
10a Name of plan(s)						10b EIN(s)		10c PN(s)
11			Is this a defined contribution plan subject to the minimum funding requirements of section 412 of the Code?						Yes No
12a			Does the plan satisfy the coverage and nondiscrimination tests of Code sections 410(b) and 401(a)(4) by combining this plan with any other plans under the permissive aggregation rules?						Yes No
12b			If this is a Code section 401(k) plan, check all boxes that apply to indicate how the plan is intended to satisfy the nondiscrimination requirements for employee deferrals and employer matching contributions (as applicable) under Code sections 401(k)(3) and 401(m)(2)?
			Design-based safe harbor method “Prior year” ADP test “Current year” ADP test N/A
13			If the plan sponsor is an adopter of a pre-approved plan that received a favorable IRS Opinion Letter, enter the date of the Opinion Letter ___/___/______ (MM/DD/YYYY) and the Opinion Letter serial number ____________.
Part VII				Accountant Opinion Information for Participating Plans
14			Is the plan required to attach a report of an independent qualified public accountant (IQPA)? (See instructions on eligibility and condition for waiver of the annual examination and report of an IQPA under 29 CFR 2520.104-46): Yes No Complete lines 14a through 14c if you checked “YES” and the report of an IQPA for the plan is required to be attached to this Schedule DCG.
a			The opinion reflected in the attached report of an IQPA accountant for this plan is (see instructions):
			(1) Unmodified (2) Qualified (3) Disclaimer (4) Adverse
b			Check the appropriate box(es) to indicate whether the IQPA performed an ERISA section 103(a)(3)(C) audit. Check both boxes (1) and (2) if the audit was performed pursuant to both 29 CFR 2520.103-8 and 29 CFR 2520.103-12(d). Check box (3) if pursuant to neither.
	(1) X DOL Regulation 2520.103-8				(2) X DOL Regulation 2520.103-12(d)		(3) X neither DOL Regulation 2520.103-8 nor DOL Regulation 2520.103-12(d).
c			Enter the name and EIN of the accountant (or accounting firm) below:
			(1) Name: (2) EIN: