| TEMPLATE 3 |
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File name: Template 3 Plan Name, where "Plan Name" is an abbreviated version of the plan name. |
v20230427p |
| Historical Plan Information |
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For additional submission due to merger under § 4262.4(f)(1)(ii): Template 3 Plan Name Merged, where "Plan Name Merged" is an abbreviated version of the plan name for the separate plan involved in the merger. |
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Provide historical plan information for the 2010 plan year through the plan year immediately preceding the date the plan's initial application was filed that separately identifies: total contributions, total contribution base units (including identification of the base unit used (i.e., hourly, weekly)), average contribution rates, and number of active participants at the beginning of each plan year. Also show separately for each of the plan years in the same period all other sources of non-investment income, including, if applicable, withdrawal liability payments collected, reciprocity contributions (if applicable), additional contributions from the rehabilitation plan (if any), and other identifiable contribution streams.
If the contributions and withdrawal liabilities shown on this table do not equal the amount shown as credited to the funding standard account on the plan year Schedule MB of Form 5500, include an explanation as a footnote to this table. |
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| PLAN INFORMATION |
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Abbreviated
Plan Name: |
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| EIN: |
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| PN: |
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| Unit (e.g. hourly, weekly) |
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All Other Sources of Non-Investment Income |
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| Plan Year (in order from oldest to most recent) |
Plan Year Start Date |
Plan Year End Date |
Total Contributions*, ** |
Total Contribution Base Units |
Average Contribution Rate |
Reciprocity Contributions (if applicable) |
Additional Rehab Plan Contributions (if applicable) |
Other - Explain if Applicable |
Withdrawal Liability Payments Collected** |
Number of Active Participants at Beginning of Plan Year |
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| * Total contributions shown here should be contributions based upon CBUs and should not include items separately shown in any columns under "All Other Sources of Non-Investment Income." |
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| ** If the contributions and withdrawal liabilities shown on this table do not equal the amounts shown as credited to the funding standard account on the plan year Schedule MB of Form 5500, include an explanation as a footnote to this table. |
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