SCHEDULE D DFE/Participating Plan Information OMB No. 1210-0110
(Form 5500)
Department of the Treasury This schedule is required to be filed under section 104 of the Employee
Internal Revenue Service Retirement Income Security Act of 1974 (ERISA). 2022
Department of Labor File as an attachment to Form 5500.
Employee Benefits Security Administration
This Form is Open to Public
Inspection.
For calendar plan year 2022 or fiscal plan year beginning and ending
A Name of plan B Three-digit
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI plan number (PN) 001
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
C Plan or DFE sponsor’s name as shown on line 2a of Form 5500 D Employer Identification Number (EIN)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 012345678
ABCDEFGHI
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
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
b Name of sponsor of entity listed in (a):
ABCDEFGHI
c EIN-PN d Entity e Dollar value of interest in MTIA, CCT, PSA, or
123456789-123 code 1 103-12 IE at end of year (see instructions) -123456789012345
Name of MTIA, CCT, PSA, or 103-12 IE: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
a
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
b Name of sponsor of entity listed in (a):
ABCDEFGHI
c EIN-PN d Entity e Dollar value of interest in MTIA, CCT, PSA, or
123456789-123 code 1 103-12 IE at end of year (see instructions) -123456789012345
Name of MTIA, CCT, PSA, or 103-12 IE: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
a
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
b Name of sponsor of entity listed in (a):
ABCDEFGHI
c EIN-PN d Entity e Dollar value of interest in MTIA, CCT, PSA, or
123456789-123 code 1 103-12 IE at end of year (see instructions) -123456789012345
Name of MTIA, CCT, PSA, or 103-12 IE: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
a
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
b Name of sponsor of entity listed in (a):
ABCDEFGHI
c EIN-PN d Entity e Dollar value of interest in MTIA, CCT, PSA, or
123456789-123 code 1 103-12 IE at end of year (see instructions) -123456789012345
Name of MTIA, CCT, PSA, or 103-12 IE: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
a
ABCDEFGHISAMPLEABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
b Name of sponsor of entity listed in (a):
ABCDEFGHI
c EIN-PN d Entity e Dollar value of interest in MTIA, CCT, PSA, or
123456789-123 code 1 103-12 IE at end of year (see instructions) -123456789012345
Name of MTIA, CCT, PSA, or 103-12 IE: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
a
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
b Name of sponsor of entity listed in (a):
ABCDEFGHI
c EIN-PN d Entity e Dollar value of interest in MTIA, CCT, PSA, or
123456789-123 code 1 103-12 IE at end of year (see instructions) -123456789012345
Name of MTIA, CCT, PSA, or 103-12 IE: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
a
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
b Name of sponsor of entity listed in (a):
ABCDEFGHI
c EIN-PN d Entity e Dollar value of interest in MTIA, CCT, PSA, or
123456789-123 code 1 103-12 IE at end of year (see instructions) -123456789012345
For Paperwork Reduction Act Notice, see the Instructions for Form 5500. Schedule D (Form 5500) 2022
v. 220413