SFA Template 1

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Version
v20220701p

v20220701p

Date updated
7/1/2022

TEMPLATE 1

File name: Template 1 Plan Name, where "Plan Name" is an abbreviated version of the plan name.

Form 5500 Projection

v20220701p

For an additional submission due to merger under § 4262.4(f)(1)(ii): Template 1 Plan Name Merged, where "Plan Name Merged" is an
abbreviated version of the plan name for the separate plan involved in the merger.

For the 2018 plan year until the most recent plan year for which the Form 5500 is required to be filed by the filing date of the initial application, provide the projection of expected benefit
payments as required to be attached to the Form 5500 Schedule MB if the response to line 8b(1) of the Form 5500 Schedule MB should be "Yes."
PLAN INFORMATION
Abbreviated
Plan Name:
EIN:
PN:
Complete for each Form 5500 that has been filed prior to the date the SFA application is submitted*.
2018 Form 5500

2019 Form 5500

2020 Form 5500

2021 Form 5500

2022 Form 5500

2023 Form 5500

2024 Form 5500

2025 Form 5500

Plan Year Start Date
Plan Year End Date
Expected Benefit Payments

Plan Year
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033

N/A
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2034

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N/A

* Adjust column headers as may be needed due to any changes in the plan year since 2018 and provide supporting explanation. For example, assume the plan has a calendar year plan year, but effective 10/1/2019
the plan year is changed to begin on October 1. For 2019 there will be two 2019 Forms - one for the short plan year from 1/1/2019 to 9/30/2019, and another for the plan year 10/1/2019 to 9/30/2020. For this
example, modify the table to show a separate column for each of the separate Forms 5500, and identify the plan year period for each filing.