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Department of the Treasury Department of Labor Pension Benefit Guaranty Corporation
Internal Revenue Service Employee Benefits
Security Administration

Instructions for Form 5500
Annual Return/Report of Employee Benefit Plan
Code section references are to the Internal Revenue Code help filers comply with the Form 5500 and Form 5500-SF
unless otherwise noted. ERISA refers to the Employee annual reporting requirements and avoid common reporting
Retirement Income Security Act of 1974. errors.
The Form 5500 must be filed electronically as noted above.
EFAST2 Processing System See Section 3 – Electronic Filing Requirement and the
Under the computerized ERISA Filing Acceptance System EFAST2 website at www.efast.dol.gov. Your Form 5500
(EFAST2), you must electronically file your 2023 Form 5500. entries will be initially screened electronically. Your entries
Your Form 5500 entries will be initially screened electronically. must satisfy this screening for your filing to be received. Once
For more information, see the instructions for Electronic Filing received, your form may be subject to further detailed review,
Requirement and the EFAST2 website at www.efast.dol.gov. and your filing may be rejected based upon this further review.
You cannot file a paper Form 5500 by mail or other delivery ERISA and the Code provide for the assessment or
service. imposition of penalties for not submitting the required
information when due. See Penalties.
About the Form 5500 Annual reports filed under Title I of ERISA must be made
The Form 5500, Annual Return/Report of Employee Benefit available by plan administrators to plan participants and
Plan, including all required schedules and attachments (Form beneficiaries and by the DOL to the public pursuant to ERISA
5500 return/report), is used to report information concerning sections 104 and 106. Pursuant to Section 504 of the Pension
employee benefit plans and Direct Filing Entities (DFEs). Any Protection Act of 2006 (PPA) Pub. L. 109-280, this availability
administrator or sponsor of an employee benefit plan subject to for defined benefit pension plans must include the posting of
ERISA must file information about each benefit plan every year identification and basic plan information and actuarial
(pursuant to Code section 6058 and ERISA sections 104 and information (Form 5500, Schedule SB or MB, and all of the
4065). Some plans participate in certain trusts, accounts, and Schedule SB or MB attachments) on any plan sponsor intranet
other investment arrangements that file a Form 5500 Annual website (or website maintained by the plan administrator on
Return/Report as DFEs. See Who Must File and When To File. behalf of the plan sponsor) that is used for the purpose of
The Internal Revenue Service (IRS), Department of Labor communicating with employees and not the public. Section 504
(DOL), and Pension Benefit Guaranty Corporation (PBGC) also requires DOL to display such information on DOL’s
have consolidated certain returns and report forms to reduce website within 90 days after the filing of the plan’s annual
the filing burden for plan administrators and employers. return/report. To see plan year 2009 and later Forms 5500,
Employers and administrators who comply with the instructions including actuarial information, see www.dol.gov/ebsa. See
for the Form 5500 generally will satisfy the annual reporting www.dol.gov/agencies/ebsa/workers-and-families/preparing-
requirements for the IRS and DOL. for-retirement/pension-plan-actuarial-information-search-
instructions for 2008 and short plan year 2009 actuarial
Defined contribution and defined benefit pension plans may information filed under the previous paper-based system.
have to file additional information with the IRS including Form
5330, Return of Excise Taxes Related to Employee Benefit Changes to Note
Plans, Form 5310-A, Notice of Plan Merger or Consolidation, Schedule DCG for Defined Contribution Group (DCG)
Spinoff, or Transfer of Plan Assets or Liabilities; Notice of Reporting Arrangements. Section 202 of the SECURE Act
Qualified Separate Lines of Business, and Form 8955-SSA, (Pub. L. 116-94, Division O) directed the IRS and DOL to
Annual Registration Statement Identifying Separated modify the Form 5500 to allow certain groups of defined
Participants with Deferred Vested Benefits. See www.irs.gov contribution retirement plans to file a single consolidated
for more information. annual return/report. For 2023, Form 5500 and the filing
Plans covered by the PBGC have special additional instructions have been revised to add a new filing option –
requirements, including premiums and reporting certain Defined Contribution Group (DCG) Reporting Arrangements.
transactions directly with that agency. See PBGC’s website To be eligible to file as a DCG, all plans in the DCG must be
(www.pbgc.gov/practitioners/) for information on premium individual account plans or defined contribution plans that have
payments and reporting and disclosure. the same trustee; the same one or more named fiduciaries; the
Each Form 5500 must accurately reflect the characteristics same plan administrator under ERISA and the Code; the same
and operations that applied during the reporting year of the plan year; and provide the same investments or investment
plan or arrangement. The requirements for completing the options for participants and beneficiaries. The DCG Form 5500
Form 5500 will vary according to the type of plan or generally will be subject to the filing requirements for large
arrangement. The section What To File summarizes what pension plans and direct filing entities (DFEs). A new Schedule
information must be reported for different types of plans and DCG is added that includes individual plan information for
arrangements. The Quick Reference Chart of Form 5500, plans reporting within a DCG. In addition to filing plan level
Schedules and Attachments, gives a brief guide to the annual information with the DCG Form 5500, the Schedule DCG is
return/report requirements of the 2023 Form 5500. See also designed to enable participants and beneficiaries to easily
the “Troubleshooters Guide to Filing the ERISA Annual identify any consolidated Form 5500 filing that includes their
Reports” available on www.dol.gov/ebsa, which is intended to plan and to see individual plan details regarding their plan.

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Each Schedule DCG must include an attached IQPA report for to address a possible, albeit unlikely, situation in which the
a plan that is required to have an audit under generally amount reported on line 6c would not be consistent with IRS
applicable rules. regulations and the statute if the calculation was done in
Small Plan Audits Participant Counting Methodology accordance with the instructions, (2) change the current
Revisions. Both Form 5500 and Form 5500-SF, and their instructions for line 26a to revise a line reference, and (3)
instructions, are revised to reflect a change in the methodology change the current instructions for the Schedule SB, line 26b
for counting the number of participants used to determine attachment (projected benefit payments), for situations where a
when a defined contribution pension plan may file as a small plan assumes some, or all, benefits are paid in a lump sum,
plan, including determining eligibility for the conditional waiver and uses the annuity substitution rule (26 CFR 1.430(d)–
of the independent qualified public accountant (IQPA) audit 1(f)(4)(iii)(B)) to determine the funding target.
requirement. Beginning with 2023 plan year filings, a defined Administrative Penalties. The instructions have been
contribution pension plan counts participants with account updated to reflect an increase in the maximum civil penalty
balances at the beginning of the plan year, except for new amount assessable under Employee Retirement Income
plans which use the number of participants with account Security Act section 502(c)(2), as required by the Federal Civil
balances at the end of the plan year. Penalties Inflation Adjustment Act Improvements Act of 2015.
Plan Characteristics. Form 5500, Part II, line 8a, plan Table of Contents Page
characteristics code 3D is updated to include pre-approved Section 1: Who Must File ............................................... 3
403(b) plans among the listed plans covered by that code. Pension Benefit Plan ..................................................... 3
Schedule H Administrative Expenses Transparency Welfare Benefit Plan ..................................................... 4
Improvements. Schedule H is updated to add new breakout Direct Filing Entity (DFE) ............................................... 4
categories to the “Administrative Expenses” category of the Section 2: When To File .................................................. 4
Income and Expenses section of the Schedule H balance Extension of Time To File ............................................. 5
sheet. This change provides a better picture of plan expenses, Section 3: Electronic Filing Requirement ..................... 5
particularly those related to service providers including fee Amended Return/Report ................................................ 6
categories related to contract administration, recordkeeping, Final Return/Report ....................................................... 7
audit fees, investment advisory and management, trustee and Signature and Date ........................................................ 7
custodial, actuarial, legal, valuation/appraisal and other Change in Plan Year ...................................................... 7
expenses. Penalties ........................................................................ 7
Schedule MEP for Multiple-Employer Plans. A new Administrative Penalties ............................................... 8
Schedule MEP (Multiple-Employer Pension Plan Information) Other Penalties ............................................................ 8
is added to consolidate SECURE Act related and other Section 4: What To File .................................................. 8
multiple-employer plan reporting in one schedule, including Form 5500 Schedules .................................................... 8
ERISA section 103(g) participating employer information and Pension Schedules ................................................... 8
aggregate account information. For 2023, questions intended General Schedules ..................................................... 9
to satisfy the SECURE Act’s reporting requirements for pooled Pension Benefit Plan Filing Requirements ..................... 9
employer plans and questions to link the Form PR (Pooled Limited Pension Plan Reporting ............................... 10
Employer Registration) and the Form 5500 for each plan Welfare Benefit Plan Filing Requirements ................... 10
operated by a pooled plan provider are also found on the Direct Filing Entity (DFE) Filing Requirements............. 11
Schedule MEP. The Schedule MEP requires reporting of Master Trust Investment Account (MTIA) ................. 11
information consistent with that which was required to be Common/Collective Trust (CCT) and Pooled
reported in different formats in prior years, including identifying Separate Account (PSA) .......................................... 11
different types of multiple-employer defined contribution plans 103-12 Investment Entity (103-12 IE) ...................... 12
filing the Form 5500 (pooled employer plans, association Defined Contribution Group Reporting arrangements
retirement plans, PEO multiple-employer plans, and other (DCGs or DCG Report Arrangements) ..................... 12
multiple-employer plans). Finally, a new checkbox is added to Quick Reference Chart of Form 5500, Schedules, and
the Form 5500 (Part II, line 10a(5)) to indicate a Schedule MEP Attachments ............................................................. 14
is attached. Section 5: Line-by-Line Instructions for the 2023
Form 5500 and Schedules......................................... 16
Schedule MB - Schedule MB is revised to add Notes that Part I (Form 5500) – Annual Return/Report Identification
clarify how to report special financial assistance for Information ............................................................... 16
multiemployer plans. Part II (Form 5500) – Basic Plan Information ............... 17
Schedule R. Several new IRS tax compliance questions are M-1 Compliance Information ........................................ 21
being added to Schedule R beginning with the 2023 plan year Schedule A – Insurance Information ............................ 24
reports, The changes add questions in three major areas: non- Schedule C – Service Provider Information ................. 27
discrimination testing, ADP testing and pre-approved plan Schedule D – DFE/Participating Plan Information ....... 32
letters. There are several new changes to Schedule R, line 19 Schedule DCG – Individual Plan Information ............... 34
and its instructions, include the following: (1) modify Schedule Schedule G – Financial Transaction Schedules .......... 41
R, line 19a, to require that all defined benefit pension plans Schedule H – Financial Information ............................. 43
(except DFEs) with 1,000 or more participants at the beginning Schedule I – Financial Information – Small Plan.......... 55
of the plan year show the end-of-year distribution of assets, Schedule MB – Multiemployer Defined Benefit Plan and
broken down in seven reconfigured categories of plan assets, Certain Money Purchase Plan Actuarial
and provide clarification concerning classification of atypical Information ............................................................... 63
investments; (2) modify Schedule R, line 19b, to change the Schedule MEP – Multiple-Employer Retirement Plan
available categories for current average duration; and (3) Information ............................................................... 71
eliminate Schedule R, line 19c. Schedule R – Retirement Plan Information .................. 73
Schedule SB Schedule SB – Single-Employer Defined Benefit Plan
Schedule SB is revised to include the following: (1) change Actuarial Information ................................................ 79
Schedule SB, line 6 (Target Normal Cost), and its instructions,

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Paperwork Reduction Act Notice ............................... 93 of ERISA, see Field Assistance Bulletins 2009-02 and 2010-
Codes for Principal Business Activity ........................ 94 01.
ERISA Compliance Quick Checklist ............................ 97 3. Individual retirement accounts (IRAs) established by an
Index .............................................................................. 98 employer under Code section 408(c).
4. Church pension plans electing coverage under Code
section 410(d).
How To Get Assistance 5. Pension benefit plans that cover residents of Puerto
Rico, the U.S. Virgin Islands, Guam, Wake Island, or American
If you need help completing this form or have related Samoa. This includes a plan that elects to have the provisions
questions, call the EFAST2 Help Desk at 1-866-GO-EFAST of section 1022(i)(2) of ERISA apply.
(1-866-463-3278) (toll-free) or access the EFAST2 or IRS 6. Plans that satisfy the Actual Deferral Percentage
websites. The EFAST2 Help Desk is available Monday through requirements of Code section 401(k)(3)(A)(ii) by adopting the
Friday from 8:00 am to 8:00 pm, Eastern Time. ‘‘SIMPLE’’ provisions of section 401(k)(11).
You can access the EFAST2 website 24 hours a day, 7 See What To File for more information about what must be
days a week at www.efast.dol.gov to: completed for pension plans.
 File the Form 5500-SF or 5500, and any needed schedules Do Not File a Form 5500 for a Pension Benefit
or attachments. Plan That Is Any of the Following:
 Check on the status of a filing you submitted.
 View filings posted by EFAST2. 1. An unfunded excess benefit plan. See ERISA section
 Register for electronic credentials to sign or submit filings. 4(b)(5).
2. An annuity or custodial account arrangement under Code
 View forms and related instructions.
sections 403(b)(1) or (7) not established or maintained by an
 Get information regarding EFAST2, including approved employer as described in DOL Regulation 29 CFR 2510.3-2(f).
software vendors. 3. A Savings Incentive Match Plan for Employees of Small
 See answers to frequently asked questions about the Form Employers (SIMPLE) that involves SIMPLE IRAs under Code
5500-SF, the Form 5500 and its schedules, and EFAST2. section 408(p).
 Access the main EBSA and DOL websites for news, 4. A simplified employee pension (SEP) or a salary
regulations, and publications. reduction SEP described in Code section 408(k) that conforms
You can access the IRS website 24 hours a day, 7 days a to the alternative method of compliance in 29 CFR 2520.104-
week at www.irs.gov to: 48 or 2520.104-49. A SEP is a pension plan that meets certain
 View forms, instructions, and publications. minimum qualifications regarding eligibility and employer
 See answers to frequently asked tax questions. contributions.
5. A church pension benefit plan not electing coverage
 Search publications online by topic or keyword.
under Code section 410(d).
 Send comments or request help by e-mail. 6. A pension plan that is maintained outside the United
 Sign up to receive local and national tax news by e-mail. States primarily for the benefit of persons substantially all of
You can order other IRS forms and publications at whom are nonresident aliens. However, certain foreign plans
www.irs.gov/orderforms. You can order EBSA publications by are required to file the Form 5500-EZ on paper with the IRS or
calling 1-866-444-EBSA (3272). electronically with EFAST2. A foreign plan must file the Form
5500-EZ electronically with EFAST2 instead of filing a paper
Form 5500-EZ with the IRS, if the filer is required to file at least
Section 1: Who Must File 250 returns of any type with the IRS during the calendar year,
including information returns (for example, Forms W-2 and
A return/report must be filed every year for every pension Forms 1099), income tax returns, employment tax returns, and
benefit plan, welfare benefit plan, and for every entity that files excise tax returns. For more information on filing Form 5500-
as a DFE as specified below (pursuant to Code section 6058 EZ, see the Instructions for Form 5500-EZ, or go to
and ERISA sections 104 and 4065). www.irs.gov.
If you are a small plan (generally under 100 participants at 7. An unfunded pension plan for a select group of
the beginning of the plan year), you may be eligible to file the management or highly compensated employees that meets the
Form 5500-SF instead of the Form 5500. For more information, requirements of 29 CFR 2520.104-23, including timely filing of
see the instructions to the Form 5500-SF. a registration statement with the DOL.
Pension Benefit Plan 8. An unfunded dues financed pension benefit plan that
meets the alternative method of compliance provided by 29
All pension benefit plans covered by ERISA must file an annual CFR 2520.104-27.
return/report except as provided in this section. The return/ 9. An individual retirement account or annuity not
report must be filed whether or not the plan is “tax-qualified,” considered a pension plan under 29 CFR 2510.3-2(d).
benefits no longer accrue, contributions were not made this 10. A governmental plan.
plan year, or contributions are no longer made. Pension benefit 11. A “one-participant plan,” as defined below. However,
plans required to file include both defined benefit plans and certain one-participant plans are required to file the Form
defined contribution plans. 5500-EZ, Annual Return of A One-Participant
The following are among the pension benefit plans for (Owners/Partners and Their Spouses) Retirement Plan or A
which a return/report must be filed. Foreign Plan, on paper with the IRS or electronically with
1. Profit-sharing plans, stock bonus plans, money purchase EFAST2. A one-participant plan must file the Form 5500-EZ
plans, 401(k) plans, etc. electronically with EFAST2 instead of filing a paper Form 5500-
2. Annuity arrangements under Code section 403(b)(1) and EZ with the IRS, if the filer is required to file at least 250
custodial accounts established under Code section 403(b)(7) returns of any type with the IRS during the calendar year,
for regulated investment company stock. For more information including information returns (for example, Forms W-2 and
regarding filing requirements for 403(b) plans subject to Title I Forms 1099), income tax returns, employment tax returns, and
excise tax returns. For more information on filing Form 5500-

General Instructions to Form 5500 --3

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EZ, see the Instructions for Form 5500-EZ, or go to contributions by its employees or members (which the
www.irs.gov. For this purpose, a “one-participant plan” is: employer or employee organization forwards within three (3)
a. a pension benefit plan that covers only an individual or months of receipt). The insurance contracts or policies
an individual and their spouse who wholly own a trade or discussed above must be issued by an insurance company or
business, whether incorporated or unincorporated; or similar organization (such as Blue Cross, Blue Shield or a
b. a pension benefit plan for a partnership that covers only health maintenance organization) that is qualified to do
the partners or the partners and the partners’ spouses (treating business in any state.
2% shareholder of an S corporation, as defined in Code c. A combination unfunded/insured welfare benefit plan has
section 1372(b), as a partner). its benefits provided partially as an unfunded plan and partially
See the instructions to the Form 5500-EZ for eligibility as a fully insured plan. An example of such a plan is a welfare
conditions and filing requirements. For more information, go to benefit plan that provides medical benefits as in above and a
www.irs.gov/ep. life insurance benefits as in above. See 29 CFR 2520.104-b
20.
Welfare Benefit Plan 2. A welfare benefit plan maintained outside the United
All welfare benefit plans covered by ERISA are required to file States primarily for persons substantially all of whom are
a Form 5500 except as provided in this section. Welfare benefit nonresident aliens.
plans provide benefits such as medical, dental, life insurance, 3. A governmental plan.
apprenticeship and training, scholarship funds, severance pay, 4. An unfunded or insured welfare benefit plan maintained
disability, etc. See What To File for more information. for a select group of management or highly compensated
Reminder: The administrator of an employee welfare benefit employees, which meets the requirements of 29 CFR
plan that provides benefits wholly or partially through a 2520.104-24.
Multiple-Employer Welfare Arrangement (MEWA) as defined in 5. An employee benefit plan maintained only to comply with
ERISA section 3(40) must file a Form 5500, unless otherwise workers’ compensation, unemployment compensation, or
exempt. Plans required to file a Form M-1, Report for Multiple- disability insurance laws.
Employer Welfare Arrangements (MEWAs) and Certain 6. A welfare benefit plan that participates in a group
Entities Claiming Exception (ECEs), are not eligible for the insurance arrangement that files a Form 5500 on behalf of the
filing exemption in 29 CFR 2520.104-20 described below. Such welfare benefit plan as specified in 29 CFR 2520.103-2. See
plans are required to file the Form 5500 regardless of the plan 29 CFR 2520.104-43.
size or type of funding. 7. An apprenticeship or training plan meeting all of the
conditions specified in 29 CFR 2520.104-22.
Do Not File a Form 5500 for a Welfare Benefit 8. An unfunded dues financed welfare benefit plan
Plan That Is Any of the Following: exempted by 29 CFR 2520.104-26.
1. A welfare benefit plan that covered fewer than 100 9. A church plan under ERISA section 3(33).
participants as of the beginning of the plan year and is 10. A welfare benefit plan maintained solely for (1) an
unfunded, fully insured, or a combination of insured and individual or an individual and their spouse, who wholly own a
unfunded, and which is not subject to the Form M-1 trade or business, whether incorporated or unincorporated, or
requirements under 29 CFR 2520.101-2, as specified in 29 (2) partners or the partners and the partners’ spouses in a
CFR 2520.104-20. partnership. See 29 CFR 2510.3-3(b).
Note. To determine whether the plan covers fewer than 100 Direct Filing Entity (DFE)
participants for purposes of these filing exemptions for insured Some plans participate in certain trusts, accounts, and other
and unfunded welfare plans, see instructions for lines 5 and 6 investment or reporting arrangements that file the Form 5500
on counting participants in a welfare plan. See also 29 CFR Annual Return/Report as a DFE in accordance with the Direct
2510.3-3(d). Filing Entity (DFE) Filing Requirements. A Form 5500 must be
a. An unfunded welfare benefit plan has its benefits paid as filed for a master trust investment account (MTIA). A Form
needed directly from the general assets of the employer or 5500 is not required but may be filed for a common/collective
employee organization that sponsors the plan. trust (CCT), pooled separate account (PSA), 103-12
Note. Plans that are NOT unfunded include those plans that investment entity (103-12 IE), defined contribution group
received employee (or former employee) contributions during reporting arrangement (DCG or DCG reporting arrangement),
the plan year and/or used a trust or separately maintained fund or group insurance arrangement (GIA). Plans that participate in
(including a Code section 501(c)(9) trust) to hold plan assets or CCTs, PSAs, 103-12 IEs, DCGs, or GIAs that file as DFEs,
act as a conduit for the transfer of plan assets during the year. however, generally are eligible for certain annual reporting
A welfare benefit plan with employee contributions that is relief. For reporting purposes, a CCT, PSA, 103-12 IE, DCG, or
associated with a cafeteria plan under Code section 125 may GIA is not considered a DFE unless a Form 5500 and all
be treated for annual reporting purposes as an unfunded required attachments are filed for it in accordance with the
welfare plan if it meets the requirements of DOL Technical Direct Filing Entity (DFE) Filing Requirements.
Release 92-01, 57 Fed. Reg. 23272 (June 2, 1992) and 58 Note. Special requirements also apply to Schedules D and H
Fed. Reg. 45359 (Aug. 27, 1993). The mere receipt of COBRA attached to the Form 5500 filed by plans participating in
contributions or other after-tax participant contributions (e.g., MTIAs, CCTs, PSAs, DCGs, and 103-12 IEs. See these
retiree contributions) by a cafeteria plan would not by itself schedules and their instructions.
affect the availability of the relief provided for cafeteria plans
that otherwise meet the requirements of DOL Technical
Release 92-01. See 61 Fed. Reg. 41220, 41222-23 (Aug. 7, Section 2: When To File
1996).
b. A fully insured welfare benefit plan has its benefits Plans, DCGs and GIAs. File 2023 returns/reports for plan,
provided exclusively through insurance contracts or policies, DCG and GIA years that began in 2023. All required forms,
the premiums of which must be paid directly to the insurance schedules, statements, and attachments must be filed by the
carrier by the employer or employee organization from its last day of the 7th calendar month after the end of the plan,
general assets or partly from its general assets and partly from DCG or GIA year (not to exceed 12 months in length) that

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began in 2023. If the plan, DCG or GIA year differs from the Form 5500 until the extended due date of filing Form 990
2023 calendar year, fill in the fiscal year beginning and ending series if all conditions listed above are met. An extension
dates in the space provided. granted by using this automatic extension procedure cannot be
DFEs other than DCGs and GIAs. File 2023 returns/reports extended beyond a total of 9½ months beyond the close of the
no later than 9½ months after the end of the DFE year that plan year.
ended in 2023. A Form 5500 filed for a DFE (other than DCGs Note. An extension of time to file the Form 5500 does not
and GIAs) must report information for the DFE year (not to operate as an extension of time to file a Form 5500 filed for a
exceed 12 months in length). If the DFE year differs from the DFE (other than a DCG or GIA), to file PBGC premiums or
2023 calendar year, fill in the fiscal year beginning and ending annual financial and actuarial reports (if required by section
dates in the space provided. 4010 of ERISA) or to file the Form 8955-SSA (Annual
Short Years. For a plan year of less than 12 months (short Registration Statement Identifying Separated Participants with
plan year), file the form and applicable schedules by the last Deferred Vested Benefits) (required to be filed with the IRS
day of the 7th calendar month after the short plan year ends or under Code section 6057(a)).
by the extended due date, if filing under an authorized Other Extensions of Time
extension of time. Fill in the short plan year beginning and
ending dates in the space provided and check the appropriate The IRS, DOL, and PBGC may announce special extensions
box in Part I, line B, of the Form 5500. For purposes of this of time under certain circumstances, such as extensions for
return/report, the short plan year ends on the date of the Presidentially-declared disasters or for service in, or in support
change in accounting period or upon the complete distribution of, the Armed Forces of the United States in a combat zone.
of assets of the plan. Also see the instructions for Final Return/ See www.irs.gov, www.efast.dol.gov, and
Report to determine if “the final return/report” box in line B www.pbgc.gov/practitioners for announcements regarding such
should be checked. special extensions. If you are relying on one of these
announced special extensions, check the appropriate box on
Notes. (1) If the filing due date falls on a Saturday, Sunday, or Form 5500, Part I, line D, and enter a description of the
Federal holiday, the return/report may be filed on the next day announced authority for the extension.
that is not a Saturday, Sunday, or Federal holiday. (2) If the
2024 Form 5500 is not available before the plan or DFE filing is Delinquent Filer Voluntary Compliance (DFVC)
due, use the 2023 Form 5500 and enter the 2024 fiscal year Program
beginning and ending dates on the line provided at the top of The DFVC Program facilitates voluntary compliance by plan
the form. administrators who are delinquent in filing annual reports under
Extension of Time To File Using Form 5558 Title I of ERISA by permitting administrators to pay reduced
civil penalties for voluntarily complying with their DOL annual
A plan, GIA, or DCG may obtain a one-time extension of time reporting obligations. If the Form 5500 is being filed under the
to file a Form 5500 Annual Return/Report (up to 2½ months) DFVC Program, check the appropriate box in Form 5500, Part
by filing IRS Form 5558, Application for Extension of Time To I, line D, to indicate that the Form 5500 is being filed under the
File Certain Employee Plan Returns, on or before the normal DFVC Program. See www.efast.dol.gov for additional
due date (not including any extensions) of the return/report. information.
You can file paper Form 5558 with the IRS. Approved paper
copies of the Form 5558 will not be returned to the filer. A copy Plan administrators are reminded that they can use the
of the completed extension request must, however, be retained online calculator available at
with the filer’s records. www.askebsa.dol.gov/dfvcepay/calculator to compute the
penalties due under the program. Payments under the DFVC
File the paper Form 5558 with the Department of the Program also may be submitted electronically. For information
Treasury, Internal Revenue Service Center, Ogden, UT 84201- on how to pay DFVC Program payments online, go to
0045. www.dol.gov/ebsa.
Note. A DCG reporting arrangement can file a single Form Filers who wish to participate in the DFVC Program for
5558 for an extension of time to file a Form 5500 Annual plan years prior to 2021 must use the 2023 version of
Return/Report that includes a list of the individual plans Form 5500 or, if applicable, Form 5500-SF. Use the Form 5500
participating in the DCG reporting arrangement covered by the Version Selection Tool available at www.efast.dol.gov for
single Form 5558 request for an extension. further information.
Using Extension of Time To File Federal Income Tax
Return
An automatic extension of time to file the Form 5500 Annual Section 3: Electronic Filing Requirement
Return/Report until the due date of the federal income tax Under the computerized ERISA Filing Acceptance System
return of the employer will be granted if all of the following (EFAST2), you must file your 2023 Form 5500 Annual Return/
conditions are met: (1) the plan year and the employer’s tax Report electronically. You may file online using EFAST2’s web-
year are the same; (2) the employer has been granted an based filing system or you may file through an EFAST2-
extension of time to file its federal income tax return to a date approved vendor. Detailed information on electronic filing is
later than the normal due date for filing the Form 5500; and (3) available at www.efast.dol.gov. For telephone assistance, call
a copy of the application for extension of time to file the federal the EFAST2 Help Desk at 1-866-GO-EFAST (1-866-463-
income tax return is maintained with the filer’s records. An 3278). The EFAST2 Help Desk is available Monday through
extension granted by using this automatic extension procedure Friday from 8:00 am to 8:00 pm, Eastern Time.
CANNOT be extended further by filing a Form 5558, nor can it Annual returns/reports filed under Title I of ERISA must
be extended beyond a total of 9½ months beyond the close of be made available by plan administrators to plan
the plan year. participants and beneficiaries and by the DOL to the public
Note. A tax-exempt organization is not required to file a federal pursuant to ERISA sections 104 and 106. Even though the
income tax return. However, if the organization uses a Form Form 5500 must be filed electronically, the administrator must
8868 to request an extension for its Form 990 series return, the keep a copy of the Form 5500, including schedules and
filer is automatically granted an extension of time to file the attachments, with all required signatures on file as part of the
General Instructions to Form 5500 --5

- 6 -

plan’s records and must make a paper copy available upon calling the EFAST2 Help Desk at 1-866-GO-EFAST (1-866-
request to participants, beneficiaries, and the DOL as required 463-3278) and using the automated telephone system.
by section 104 of ERISA and 29 CFR 2520.103-1. Filers may To reduce the possibility of correspondence and penalties
use electronic media for record maintenance and retention, so from the DOL, IRS, and/or PBGC, you should do the following:
long as they meet the applicable requirements. (See 29 CFR (1) Before submitting your return/report to EFAST2, check it for
2520.107-1). errors, and (2) after you have submitted it to EFAST2, verify
Note. Effective for plan years beginning after 2019, a one- that you have received a filing status of “Filing Received” and
participant plan or a foreign plan can file Form 5500-EZ attempt to correct and resolve any errors or warnings listed in
electronically using the EFAST2 filing system. Information filed the status report.
on Form 5500-EZ using EFAST2 is required to be made Note. Even after being received by the EFAST2 system, your
available to the public. However, information filed with EFAST2 return/report filing may be subject to further detailed review by
using Form 5500-EZ will not be published on the internet. DOL, IRS, and/or PBGC, and your filing may be deemed
Generally, questions on the Form 5500 relate to the plan deficient based upon this further review. See Penalties on
year entered at the top of the first page of the form. Therefore, Page 7.
answer all questions on the 2023 Form 5500 with respect to Do not enter social security numbers in response to
the 2023 plan year unless otherwise explicitly stated in the questions asking for an employer identification number
instructions or on the form itself. (EIN). Because of privacy concerns, the inclusion of a social
Your entries must be in the proper format in order for the security number or any portion thereof on the Form 5500 or on
EFAST2 system to process your filing. For example, if a a schedule or attachment that is open to public inspection may
question requires you to enter a dollar amount, you cannot result in the rejection of the filing. If you discover a filing
enter a word. Your software will not let you submit your return/ disclosed on the EFAST2 website that contains a social
report unless all entries are in the proper format. To reduce the security number, immediately call the EFAST2 Help Desk at 1-
possibility of correspondence and penalties: 866-GO-EFAST (1-866-463-3278).
 Complete all lines on the Form 5500 unless otherwise Employers without an EIN must apply for one as soon as
specified. Also complete and electronically attach, as required, possible. The EBSA does not issue EINs. To apply for an EIN
applicable schedules and attachments. from the IRS:
 Do not enter “N/A” or “Not Applicable” on the Form 5500  Mail or fax Form SS-4, Application for Employer Identification
unless specifically permitted. “Yes” or “No” questions on the Number, obtained at www.irs.gov/orderforms.
forms and schedules cannot be left blank, unless specifically  See www.IRS.gov/Businesses and click on “Employer ID
permitted. Answer either “Yes” or “No,” but not both. Numbers” for additional information. The EIN is issued
All schedules and attachments to the Form 5500 must be immediately once the application information is validated. (The
properly identified, and must include the name of the plan or online application process is not yet available for corporations
DFE, EIN, and plan number (PN) as found on the Form 5500, with addresses in foreign countries or Puerto Rico.)
lines, 1a, 2b, and 1b, respectively. At the top of each Do not attach a copy of the annual registration statement
attachment, indicate the schedule and line, if any (e.g., (IRS Form 8955-SSA) identifying separated participants with
Schedule H, line 4i) to which the attachment relates. deferred vested benefits, or a previous year’s Schedule SSA
Check your return/report for errors before signing or (Form 5500) to your 2023 Form 5500 Annual Return/Report.
submitting it to EFAST2. Your filing software or, if you are The annual registration statement must be filed directly with
using it, the EFAST2 web-based filing system will allow you to the IRS and cannot be attached to a Form 5500 submission
check your return/report for errors. If, after reasonable attempts with EFAST2.
to correct your filing to eliminate any identified problem or Amended Return/Report
problems, you are unable to address them, or you believe that
you are receiving the message in error, call the EFAST2 Help File an amended return/report to correct errors and/or
Desk at 1-866-GO-EFAST (1-866-463-3278) or contact the omissions in a previously filed annual return/report for the 2023
service provider you used to help prepare and file your annual plan year. The amended Form 5500 and any amended
return/report. schedules and/or attachments must conform to the
requirements in these instructions. See the DOL website at
Once you complete the return/report and finish the www.efast.dol.gov for information on filing amended returns/
electronic signature process, you can electronically submit it to reports for prior years.
EFAST2. When you electronically submit your return/report,
EFAST2 is designed to immediately notify you if your Note. An amended filing must be submitted as a complete
submission was received and whether the return/report is replacement of the previously submitted filing. You will need to
ready to be processed by EFAST2. If EFAST2 does not notify resubmit the entire form, with all required schedules and
you that your submission was successfully received and is attachments, through EFAST2. You cannot submit just the parts
ready to be processed, you will need to take steps to correct of the filing that are being amended. See EFAST2 FAQs
the problem or you may be deemed a non-filer subject to available on the EFAST website at www.efast.dol.gov.
penalties from DOL, IRS, and/or PBGC. If a plan participating in a DCG amended its Schedule DCG
Once EFAST2 receives your return/report, the EFAST2 to correct errors and /or omissions in a previously filed Schedule
system should be able to provide a filing status within 20 DCG, the DCG must resubmit an amended filing as described
minutes. The person submitting the filing should check back above, with all required schedules and attachments, including
into the EFAST2 system to determine the filing status of your Schedules DCG for all participating plans that were submitted
return/report. The filing status message will include a list of any with the original return. The line F box for “an amended
filing errors or warnings that EFAST2 may have identified in Schedule DCG” on the Schedule DCG must be checked only for
your filing. If EFAST2 did not identify any filing errors or those Schedules DCG that have been changed from the original
warnings, EFAST2 will show the filing status of your return/ submission.
report as “Filing Received.” Persons other than the submitter Check the line B box for “an amended return/report” if you
can check whether the filing was received by the system by filed a previous 2023 annual return/report that was given a

-6- General Instructions to Form 5500

- 7 -

“Filing_Received,” “Filing_Error,” or “Filing_Stopped” status by             the service provider has been authorized in writing by the plan 
EFAST2. Do not check the line B box for “an amended                          administrator, plan sponsor/employer, or DFE, as applicable, to 
return/report” if your previous submission attempts were not                 electronically submit the return/report; (2) that a copy of the 
successfully received by EFAST2 because of problems with the                 specific written authorization will be kept in the service 
transmission of your return/report. For more information, go to              provider’s records; (3) that, in addition to any other required 
the EFAST2 website at www.efast.dol.gov or call the EFAST2                   schedules or attachments, the electronic filing includes a true 
Help Desk at 1-866-GO-EFAST (1-866-463-3278).                                and correct PDF copy of the completed Form 5500 (without 
                                                                             schedules or attachments) bearing the manual signature of the 
Final Return/Report                                                          plan administrator, employer/plan sponsor, or DFE, as 
If all assets under the plan (including insurance/annuity                    applicable, under penalty of perjury; (4) that the service 
contracts) have been distributed to the participants and                     provider advised the plan administrator, employer/plan 
beneficiaries or legally transferred to the control of another               sponsor, or DFE, as applicable, that by selecting this electronic 
plan, and when all liabilities for which benefits may be paid                signature option, the image of the plan administrator’s, 
under a welfare benefit plan have been satisfied, check the                  employer/plan sponsor’s, or DFE’s manual signature will be 
final return/report box in Part I, line B at the top of the Form             included with the rest of the return/report posted by the 
5500. Do not mark the final return/report box if you are                     Department of Labor on the Internet for public disclosure; and 
reporting participants and/or assets at the end of the plan year.            (5) that the service provider will communicate to the plan 
If a trustee is appointed for a terminated defined benefit plan              administrator, employer/plan sponsor, or DFE, as applicable, 
pursuant to ERISA section 4042, the last plan year for which a               any inquiries and information received from EFAST2, DOL, 
return/report must be filed is the year in which the trustee is              IRS or PBGC regarding the return/report. 
appointed. If you are in this situation you may contact                      Note. The Code permits either the plan sponsor/employer or 
PBGCTrusteedPlan@dol.gov for further information.                            the administrator to sign the filing. However, any Form 5500 
Examples:                                                                    that is not electronically signed by the plan administrator will be 
                                                                             subject to rejection and civil penalties under Title I of ERISA. 
Mergers/Consolidations 
                                                                             For DFE filings, a person authorized to sign on behalf of the 
A final return/report should be filed for the plan year (12                  DFE must sign for the DFE.  
months or less) that ends when all plan assets were legally 
transferred to the control of another plan.                                  The Form 5500 Annual Return/Report must be filed 
                                                                             electronically and signed. To obtain an electronic signature, go 
Pension and Welfare Plans That Terminated Without                            to www.efast.dol.gov and register in EFAST2 as a signer. You 
Distributing All Assets                                                      will be provided with a UserID and PIN. Both the UserID and 
If the plan was terminated, but all plan assets were not                     PIN are needed to sign the Form 5500. The plan administrator 
distributed, a return/report must be filed for each year the plan            must keep a copy of the Form 5500, including schedules and 
has assets. The return/report must be filed by the plan                      attachments with all required signatures on file as part of the 
administrator, if designated, or by the person or persons who                plan’s records. See 29 CFR 2520.103-1. 
actually control the plan’s assets/property.                                 Electronic signatures on annual returns/reports filed under 
                                                                             EFAST2 are governed by the applicable statutory and 
Welfare Plans Still Liable To Pay Benefits                                   regulatory requirements. 
A welfare plan cannot file a final return/report if the plan is still        Change in Plan Year 
liable to pay benefits for claims that were incurred prior to the 
termination date, but not yet paid. See 29 CFR 2520.104b-                    Generally, only defined benefit pension plans need to get 
2(g)(2)(ii).                                                                 approval for a change in the plan year. See Code section 
                                                                             412(d)(1). However, under Revenue Procedure 87-27, 1987-1 
Signature and Date                                                           C.B. 769, these pension plans may be eligible for automatic 
For purposes of Title I of ERISA, the plan administrator is                  approval of a change in plan year.  
required to file the Form 5500. If the plan administrator does               If a change in plan year for a pension or welfare benefit plan 
not sign a filing, the filing status will indicate that there is an          creates a short plan year, file the form and applicable 
error with your filing, and your filing will be subject to further           schedules by the last day of the 7th calendar month after the 
review, correspondence, rejection, and civil penalties.                      short plan year ends or by the extended due date, if filing 
The plan administrator must electronically sign the Form 5500                under an authorized extension of time. Fill in the short plan 
or 5500-SF submitted to EFAST2.                                              year beginning and ending dates in the space provided in Part 
                                                                             I and check the appropriate box in Part I, line B of the Form 
    After submitting your filing, you must check the Filing                  5500. For purposes of this return/report, the short plan year 
    Status. If the filing status is "Processing Stopped" or                  ends on the date of the change in accounting period or upon 
“Unprocessable”, it is possible your submission was not sent                 the complete distribution of assets of the plan. Also, see the 
with a valid electronic signature as required, and depending on              instructions for the Final Return/Report to determine if “final 
the error, may be considered not to have been filed. By looking              return/report” in line B should be checked. 
closer at the Filing Status, you can see specific error 
messages applicable to the transmitted filing and determine                  Penalties 
whether it was sent with a valid electronic signature and what               Plan administrators and plan sponsors must provide complete 
other errors may need to be corrected.                                       and accurate information and must otherwise comply fully with 
Note. If the plan administrator is an entity, the electronic                 the filing requirements. ERISA and the Code provide for the 
signature must be in the name of a person authorized to sign                 DOL and the IRS, respectively, to assess or impose penalties 
on behalf of the plan administrator.                                         for not giving complete and accurate information and for not 
Authorized Service Provider Signatures. A statement for                      filing complete and accurate statements and returns/reports. 
service providers that use this electronic signature option is in            Certain penalties are administrative (i.e., they may be imposed 
the IFILE application. The statement provides that, by signing               or assessed by one of the governmental agencies delegated to 
the electronic filing, the service provider is attesting: (1) that           administer the collection of the annual return/report data). 
                                                                             Others require a legal conviction. 
General Instructions to Form 5500                                       --7

- 8 -

Administrative Penalties DFEs that are required to file the schedule.
Listed below are various penalties under ERISA and the Code Filing requirements also are listed by type of filer:
that may be assessed or imposed for not meeting the annual (1) Pension Benefit Plan Filing Requirements; (2) Welfare
return/report filing requirements. Generally, whether the Benefit Plan Filing Requirements; and (3) DFE Filing
penalty is under ERISA or the Code, or both, depends upon Requirements (including DCG reporting arrangements). For
the agency for which the information is required to be filed. each filer type there is a separate list of the schedules that
One or more of the following administrative penalties may be must be filed with the Form 5500 (including where applicable,
assessed or imposed in the event of incomplete filings or filings separate lists for large plan filers, small plan filers, and different
received after the due date unless it is determined that your types of DFEs).
failure to file properly is for reasonable cause: The filing requirements also are summarized in a “Quick
1. A penalty of up to $2,586 a day for each day a plan Reference Chart of Form 5500, Schedules, and Attachments.”
administrator fails or refuses to file a complete and accurate Generally, a return/report filed for a pension benefit plan or
report. See ERISA section 502(c)(2), 29 CFR 2560.502c-2, welfare benefit plan that covered fewer than 100 participants
and the Federal Civil Penalties Inflation Adjustment Act of as of the beginning of the plan year should be completed
1990, as amended by the Federal Civil Penalties Inflation following the requirements below for a “small plan,” and a
Adjustment Act Improvements Act of 2015 (2015 Inflation return/report filed for a plan that covered 100 or more
Adjustment Act). Pub. L. No. 114-74; 129 Stat. 599 and the participants as of the beginning of the plan year should be
DOL’s implementing regulation at 88 FR 2210 (Jan. 15, 2023). completed following the requirements below for a “large plan.”
The 2015 Inflation Adjustment Act requires agencies to adjust A plan other than a defined contribution pension plan uses
the levels of civil monetary penalties with an initial catch-up the number of participants required to be entered in line 5 of
adjustment, followed by annual adjustments for the Form 5500 to determine whether a plan is a “small plan” or
inflation. Because the Federal Civil Penalties Inflation “large plan.” Defined contribution pension plans use the
Adjustment Improvements Act of 2015 (Pub. L. No. 114-74; number required to be entered on line 6g(1), except defined
129 Stat. 599), requires the penalty amount to be adjusted contribution pension plans that check the “first return/report”
annually after the Form 5500 and its schedules, attachments, box on Part I, line B use the number entered on line 6g(2).
and instructions are published for filing, be sure to check
DOL’s website for any possible required inflation adjustments Exceptions:
of the maximum penalty amount that may have been published (1) 80-120 Participant Rule: If the number of participants is
in the Federal Register after the instructions have been posted. between 80 and 120, and a Form 5500 Annual Return/Report
2. A penalty of $250 a day (up to $150,000) for not filing was filed for the prior plan year, you may elect to complete the
returns for certain plans of deferred compensation, trusts and return/report in the same category (‘‘large plan’’ or ‘‘small
annuities, and bond purchase plans by the due date(s). See plan’’) as was filed for the prior return/report. Thus, if a Form
Code section 6652(e). 5500-SF or a Form 5500 Annual Return/Report was filed for
3. A penalty of $1,000 for each failure to file an actuarial the 2022 plan year as a small plan, including the Schedule I if
statement (Schedule MB (Form 5500) or Schedule SB (Form applicable, and the participant count for the 2023 Form 5500 is
5500)) required by the applicable instructions. See Code 120 or less, you may elect to complete the 2023 Form 5500
section 6692. and schedules in accordance with the instructions for a small
Other Penalties plan, including for eligible filers, filing the Form 5500-SF
1. Any individual who willfully violates any provision of Part instead of the Form 5500.
1 of Title I of ERISA shall on conviction be fined not more than (2) Short Plan Year Rule: If the plan had a short plan year
$100,000 or imprisoned not more than 10 years, or both. See of seven (7) months or less for either the prior plan year or the
ERISA section 501. plan year being reported on the 2023 Form 5500, an election
2. A penalty up to $10,000, five (5) years imprisonment, or can be made to defer filing the accountant’s report in
both, may be imposed for making any false statement or accordance with 29 CFR 2520.104-50. If such an election was
representation of fact, knowing it to be false, or for knowingly made for the prior plan year, the 2023 Form 5500 must be
concealing or not disclosing any fact required by ERISA. See completed following the requirements for a large plan,
section 1027, Title 18, U.S. Code, as amended by section 111 including the attachment of the Schedule H and the
of ERISA. accountant’s reports, regardless of the number of participants .
(3) DCG Reporting Arrangements: Defined contribution
pension plans included as participating plans in a DCG
reporting arrangement each count participants at the individual
Section 4: What To File plan level to determine whether the plan may be eligible for the
The Form 5500 reporting requirements vary depending on waiver of the annual examination and report of an independent
whether the Form 5500 is being filed for a ‘‘large plan,’’ a qualified public accountant (IQPA) for small plans on the
‘‘small plan,’’ and/or a DFE, and on the particular type of plan Schedule DCG. For additional information, see the Schedule
or DFE involved (e.g., welfare plan, pension plan, DCG instructions.
common/collective trust (CCT), pooled separate account
(PSA), master trust investment account (MTIA), 103-12 IE, Form 5500 Schedules
defined contribution group reporting arrangement (DCG or Pension Schedules
DCG reporting arrangement) or group insurance arrangement
(GIA)). Schedule R (Retirement Plan Information) – is required for a
pension benefit plan that is a defined benefit plan or is
The instructions below provide detailed information about otherwise subject to Code section 412 or ERISA section 302.
each of the Form 5500 schedules and which plans and DFEs Schedule R may also be required for certain other pension
are required to file them. benefit plans unless otherwise specified under limited Pension
The schedules are grouped in the instructions by type: Plan Reporting. For additional information, see the Schedule R
(1) Pension Benefit Schedules and (2) General Schedules. instructions.
Each schedule is listed separately with a description of the
subject matter covered by the schedule and the plans and
-8- General Instructions to Form 5500

- 9 -

Schedule MB (Multiemployer Defined Benefit Plan and information, see the Schedule A instructions.
Certain Money Purchase Plan Actuarial Information) – is Note. Do not file Schedule A for Administrative Services Only
required for most multiemployer defined benefit plans and for (ASO) contracts. Do not file Schedule A if a Schedule A is filed
defined contribution pension plans that currently amortize a for the contract as part of the Form 5500 filed directly by a
waiver of the minimum funding requirements specified in the master trust investment account (MTIA) or 103-12 IE.
instructions for the Schedule MB. For additional information,
see the instructions for the Schedule MB and the Schedule R. Schedule C (Service Provider Information) – is required for
a large plan, MTIA, 103-12 IE, DCG or GIA if (1) any service
Schedule SB (Single-Employer Defined Benefit Plan provider who rendered services to the plan or DFE during the
Actuarial Information) – is required for most single-employer plan or DFE year received $5,000 or more in compensation,
defined benefit plans, including multiple-employer defined directly or indirectly from the plan or DFE, or (2) an accountant
benefit pension plans. For additional information, see the and/or enrolled actuary has been terminated. For additional
instructions for the Schedule SB. information, see the Schedule C instructions.
Schedule MEP (Multiple-Employer Retirement Plan Schedule D (DFE/Participating Plan Information) – Part I is
Information) – is required for multiple-employer pension plans. required for a plan or DFE that invested or participated in any
For additional information, see the instructions for the MTIAs, 103-12 IEs, CCTs, and/or PSAs. Part II is required
Schedule MEP. when the Form 5500 is filed for a DFE, except DCGs. For
Schedule DCG (Individual Plan Information) – is required for additional information, see the Schedule D instructions.
DCGs. Each plan participating in a DCG must individually Schedule G (Financial Transaction Schedules) – is required
complete a Schedule DCG. For additional information, see the for a large plan, MTIA, 103-12 IE, DCG or GIA when Schedule
instructions for the Schedule DCG. H (Financial Information) lines 4b, 4c, and/or 4d are checked
General Schedules ‘‘Yes.’’ Part I of the Schedule G reports loans or fixed income
obligations in default or classified as uncollectible. Part II of the
Schedule H (Financial Information) – is required for pension
Schedule G reports leases in default or classified as
benefit plans and welfare benefit plans filing as “large plans”
uncollectible. Part III of the Schedule G reports nonexempt
and for all DFE filings. Employee benefit plans, 103-12 IEs,
transactions. For additional information, see the Schedule G
and GIAs filing the Schedule H are generally required to
instructions.
engage an independent qualified public accountant (IQPA) and
attach a report of the IQPA pursuant to ERISA section An unfunded, fully insured, or combination unfunded/
103(a)(3)(A). In the case of a DCG reporting arrangement, the insured welfare plan with 100 or more participants
IQPA requirements are determined at the participating plan exempt under 29 CFR 2520.104-44 from completing Schedule
level for each plan participating in the DCG. Plans and DFEs H must still complete Schedule G, Part III, to report nonexempt
filing the Schedule H, including a DCG filer that reports transactions.
financial information on an aggregated basis on behalf of all
Pension Benefit Plan Filing
participating plans, are also generally required to attach to the
Form 5500 a “Schedule of Assets (Held At End of Year),” Requirements
and, if applicable, a “Schedule of Assets (Acquired and Pension benefit plan filers must complete the Form 5500
Disposed of Within Year),” a “Schedule of Reportable Annual Return/Report, including the signature block and,
Transactions,” and a “Schedule of Delinquent Participant unless otherwise specified, attach the following schedules and
Contributions.” For additional information, see the Schedule information:
H instructions.
Small Pension Plan
Exceptions: Insured, unfunded, or combination
unfunded/insured welfare plans, as described in 29 CFR The following schedules (including any additional information
2520.104-44(b)(1) and certain pension plans and required by the instructions to the schedules) must be attached
arrangements, as described in 29 CFR 2520.104-44(b)(2) and to a Form 5500 filed for a small pension plan that is neither
in Limited Pension Plan Reporting, are exempt from exempt from filing nor is filing the Form 5500-SF:
completing the Schedule H. 1. Schedule A (as many as needed), to report insurance,
annuity, and investment contracts held by the plan.
Schedule I (Financial Information - Small Plan) – is 2. Schedule D, Part I, to list any CCTs, PSAs, MTIAs, and
required for all pension benefit plans and welfare benefit plans 103-12 IEs in which the plan participated at any time during the
filing the Form 5500 Annual Return/Report, rather than the plan year.
Form 5500-SF, as ‘‘small plans.’’ Regardless of size, all DFEs 3. Schedule I, to report small plan financial information,
(including DCGs) and certain pension benefit plans and unless exempt.
arrangements described in 29 CFR 2520.104-44(b)(2) and in 4. Schedule MB or SB, to report actuarial information, if
Limited Pension Plan Reporting, file Schedule H not Schedule applicable.
I. For additional information, see the Schedule I and Schedule 5. Schedule MEP, to report information about multiple-
H instructions. employer pension plans, if applicable.
Note. A welfare plan that would have been eligible for the filing 6. Schedule R, to report retirement plan information, if
exemption under 29 CFR 2520.104-20, but for the fact that it is applicable.
required to file a Form M-1, is exempt from completing a If Schedule I, line 4k, is checked “No,” you must attach
Schedule I if it meets the requirements of 29 CFR 2520.104- the report of the independent qualified public accountant
44(b)(1). (IQPA) or a statement that the plan is eligible and elects to
Schedule A (Insurance Information) – is required if any defer attaching the IQPA’s opinion pursuant to 29 CFR
benefits under an employee benefit plan are provided by an 2520.104-50 in connection with a short plan year of seven
insurance company, insurance service or other similar months or less.
organization (such as Blue Cross, Blue Shield, or a health
maintenance organization). This includes investment contracts Large Pension Plan
with insurance companies, such as guaranteed investment The following schedules (including any additional information
contracts and pooled separate accounts. For additional required by the instructions to the schedules) must be attached

General Instructions to Form 5500 --9

- 10 -

to a Form 5500 filed for a large pension plan: other assets should be reported on Schedule H or Schedule I,
1. Schedule A (as many as needed), to report insurance, and any other required schedules. If Schedule H is filed, attach
annuity, and investment contracts held by the plan. an accountant’s report in accordance with the Schedule H
2. Schedule C, if applicable, to report information on service instructions.
providers and, if applicable, any terminated accountants or Note. For purposes of the annual return/report and the
enrolled actuaries. alternative method of compliance set forth in 29 CFR
3. Schedule D, Part I, to list any CCTs, PSAs, MTIAs, and 2520.104-44, a contract is considered to be ‘‘allocated’’ only if
103-12 IEs in which the plan invested at any time during the the insurance company or organization that issued the contract
plan year. unconditionally guarantees, upon receipt of the required
4. Schedule G, to report loans or fixed income obligations in premium or consideration, to provide a retirement benefit of a
default or determined to be uncollectible as of the end of the specified amount. This amount must be provided to each
plan year, leases in default or classified as uncollectible, and participant without adjustment for fluctuations in the market
nonexempt transactions, i.e., file Schedule G if Schedule H value of the underlying assets of the company or organization,
(Form 5500) lines 4b, 4c, and/or 4d are checked ‘‘Yes.’’ and each participant must have a legal right to such benefits,
5. Schedule H, to report large plan financial information, which is legally enforceable directly against the insurance
unless exempt. company or organization. For example, deposit administration,
6. Schedule MB or SB, to report actuarial information, if immediate participation guarantee, and guaranteed investment
applicable. contracts are NOT allocated contracts for Form 5500 Annual
7. Schedule MEP, to report information about multiple- Return/Report purposes.
employer pension plans, if applicable.
8. Schedule R, to report retirement plan information, if Welfare Benefit Plan Filing Requirements
applicable. Welfare benefit plan filers must complete the Form 5500
Eligible Combined Plans Annual Return/Report, including the signature block and,
unless otherwise specified, attach the following schedules and
Section 903 of PPA established rules for a new type of pension information:
plan, an “eligible combined plan,” effective for plan years
beginning after December 31, 2009. See Code section 414(x) Small Welfare Plan
and ERISA section 210(e). An eligible combined plan consists The following schedules (including any additional information
of a defined benefit plan and a defined contribution plan that required by the instructions to the schedules) must be attached
includes a qualified cash or deferred arrangement under Code to a Form 5500 filed for a small welfare plan that is neither
section 401(k), with the assets of the two plans held in a single exempt from filing nor filing the Form 5500-SF:
trust, but clearly identified and allocated between the plans. 1. Schedule A (as many as needed), to report insurance
The eligible combined plan design is available only to contracts held by the plan.
employers that employed an average of at least two, but not 2. Schedule D, Part I, to list any CCTs, PSAs, MTIAs, and
more than 500 employees, on business days during the 103-12 IEs in which the plan participated at any time during the
calendar year preceding the plan year as of which the eligible plan year.
combined plan is established and that employs at least two 3. Schedule I, to report small plan financial information.
employees on the first day of the plan year that the plan is A welfare plan that covered fewer than 100 participants
established. Because an eligible combined plan includes both as of the beginning of the plan year and is required to file
a defined benefit plan and a defined contribution plan, the a Form M-1, Report for Multiple-Employer Welfare
Form 5500 filed for the plan must include all the information, Arrangements (MEWAs) and Certain Entities Claiming
schedules, and attachments that would be required for either a Exception (ECEs), is exempt from attaching Schedule I if the
defined benefit plan (such as a Schedule SB) or a defined plan meets the requirements of 29 CFR 2520.104-44.
contribution plan. However, Schedule G, Part III, must be attached to the Form
Limited Pension Plan Reporting 5500 to report any nonexempt transactions.
The pension benefit plans or arrangements described below Large Welfare Plan
are eligible for limited annual reporting: The following schedules (including any additional information
1. IRA Plans: A pension plan using individual retirement required by the instructions to the schedules) must be attached
accounts or annuities (as described in Code section 408) as to a Form 5500 filed for a large welfare plan:
the sole funding vehicle for providing pension benefits need 1. Schedule A (as many as needed), to report insurance and
complete only Form 5500, Part I and Part II, lines 1 through 4, investment contracts held by the plan.
and 8 (enter pension feature code 2N), and file Schedule MEP, 2. Schedule C, if applicable, to report information on service
in the case of any plan that is a multiple-employer pension plan providers and any terminated accountants or actuaries.
(including a pooled employer plan). 3. Schedule D, Part I, to list any CCTs, PSAs, MTIAs, and
2. Fully Insured Pension Plan: A pension benefit plan 103-12 IEs in which the plan invested at any time during the
providing benefits exclusively through an insurance contract or plan year.
contracts that are fully guaranteed and that meet all of the 4. Schedule G, to report loans or fixed income obligations in
conditions of 29 CFR 2520.104-44(b)(2) during the entire plan default or determined to be uncollectible as of the end of the
year must complete all the requirements listed under this plan year, leases in default or classified as uncollectible, and
Pension Benefit Plan Filing Requirements section, except that nonexempt transactions, i.e., file Schedule G if Schedule H
such a plan is exempt from attaching Schedule H, Schedule I, (Form 5500) lines 4b, 4c, and/or 4d are checked ‘‘Yes’’ or if a
and an independent qualified public accountant’s opinion, and large welfare plan that is not required to file a Schedule H has
from the requirement to engage an IQPA. nonexempt transactions.
A pension benefit plan that has insurance contracts of the 5. Schedule H, to report financial information, unless exempt.
type described in 29 CFR 2520.104-44 as well as other assets Attach the report of the independent qualified public
must complete all requirements for a pension benefit plan, accountant (IQPA) identified on Schedule H, line 3a,
except that the value of the plan’s allocated contracts (see unless line 3d(2) is checked.
below) should not be reported in Part I of Schedule H or I. All

-10- General Instructions to Form 5500

- 11 -

Neither Schedule H nor an IQPA’s opinion should be trust must be treated as a separate MTIA if each plan that has
attached to a Form 5500 filed for an unfunded, fully an interest in the pool has the same fractional interest in each
insured or combination unfunded/insured welfare plan that asset in the pool as its fractional interest in the pool, and if
covered 100 or more participants as of the beginning of the each such plan may not dispose of its interest in any asset in
plan year that meets the requirements of 29 CFR 2520.104-44. the pool without disposing of its interest in the pool. A master
However, Schedule G, Part III, must be attached to the Form trust may also contain assets that are not held in such a pool.
5500 to report any nonexempt transactions. A welfare benefit Each such asset must be treated as a separate MTIA.
plan that uses a ‘‘voluntary employees’ beneficiary Notes. (1) If an MTIA consists solely of one plan’s asset(s)
association’’ (VEBA) under Code section 501(c)(9) is generally during the reporting period, the plan may report the asset(s)
not exempt from the requirement of engaging an IQPA. either as an investment account on an MTIA Form 5500, or as
Direct Filing Entity (DFE) Filing a plan asset(s) that is not part of the master trust (and
therefore subject to all instructions concerning assets not held
Requirements in a master trust) on the plan’s Form 5500. (2) If a master trust
Some plans participate in certain trusts, accounts, and other holds assets attributable to participant or beneficiary directed
investment or reporting arrangements that file the Form 5500 transactions under an individual account plan and the assets
Annual Return/Report as a DFE. A Form 5500 must be filed for are interests in registered investment companies, interests in
a master trust investment account (MTIA). A Form 5500 is not contracts issued by an insurance company licensed to do
required but may be filed for a common/collective trust (CCT), business in any state, interests in common/collective trusts
pooled separate account (PSA), 103-12 investment entity (103- maintained by a bank, trust company or similar institution, or
12 IE), defined contribution group reporting arrangement (DCG the assets have a current value that is readily determinable on
or DCG reporting arrangement) or group insurance an established market, those assets may be treated as a single
arrangement (GIA). MTIA.
Plans that participate in CCTs, PSAs, 103-12 IEs, DCGs or DCGs and multiple-employer pension plans that are
GIAs that file as DFEs generally are eligible for certain annual pooled employer plans cannot participate in an MTIA.
reporting relief. For reporting purposes, a CCT, PSA, 103-12 The Form 5500 submitted for the MTIA must comply with
IE, DCG or GIA is considered a DFE only when a Form 5500 the Form 5500 instructions for a Large Pension Plan, unless
and all required schedules and attachments are filed for it in otherwise specified in the forms and instructions. The MTIA
accordance with the following instructions. must file:
Only one Form 5500 should be filed for each DFE for all 1. Form 5500, except lines C, D, 1c, 2d, and 5 through 9.
plans participating in the DFE; however, the Form 5500 filed Be certain to enter ‘‘M’’ in Part I, line A, as the DFE code.
for the DFE, including all required schedules and attachments, 2. Schedule A (as many as needed) to report insurance,
must report information for the DFE year (not to exceed 12 annuity and investment contracts held by the MTIA.
months in length) that ends with or within the participating 3. Schedule C, if applicable, to report service provider
plan’s year. information. Part III is not required for an MTIA.
Any Form 5500 filed for a DFE is an integral part of the 4. Schedule D, to list CCTs, PSAs, and 103-12 IEs in which
annual report of each participating plan, and the plan the MTIA invested at any time during the MTIA year and to list
administrator may be subject to penalties for failing to file a all plans that participated in the MTIA during its year.
complete annual report unless both the DFE Form 5500 and 5. Schedule G, to report loans or fixed income obligations in
the plan’s Form 5500 are properly filed. The information default or determined to be uncollectible as of the end of the
required for a Form 5500 filed for a DFE varies according to MTIA year, all leases in default or classified as uncollectible,
the type of DFE. The following paragraphs provide specific and nonexempt transactions.
guidance for the reporting requirements for each type of DFE. 6. Schedule H, except lines 1b(1), 1b(2), 1c(8), 1g, 1h, 1i,
2a, 2b(1)(E), 2e, 2f, 2g, 4a, 4e, 4f, 4g, 4h, 4k, 4l, 4m, 4n, and
Master Trust Investment Account (MTIA) 5, to report financial information. An independent qualified
The administrator filing a Form 5500 for an employee benefit public accountant’s (IQPA’s) opinion is not required for an
plan is required to file or have a designee file a Form 5500 for MTIA.
each MTIA in which the plan participated at any time during the 7. Additional information required by the instructions to the
plan year. For reporting purposes, a ‘‘master trust’’ is a trust for above schedules, including, for example, the schedules of
which a regulated financial institution (as defined below) serves assets held for investment and the schedule of reportable
as trustee or custodian (regardless of whether such institution transactions. For purposes of the schedule of reportable
exercises discretionary authority or control with respect to the transactions, the 5% figure shall be determined by comparing
management of assets held in the trust), and in which assets of the current value of the transaction at the transaction date with
more than one plan sponsored by a single employer or by a the current value of the investment account assets at the
group of employers under common control are held. beginning of the applicable fiscal year of the MTIA. All
attachments must be properly labeled.
‘‘Common control’’ is determined on the basis of all relevant
facts and circumstances (whether or not such employers are Common/Collective Trust (CCT) and Pooled
incorporated). Separate Account (PSA)
A ‘‘regulated financial institution’’ means a bank, trust A Form 5500 is not required to be filed for a CCT or PSA.
company, or similar financial institution that is regulated, However, the administrator of a large plan or DFE that
supervised, and subject to periodic examination by a state or participates in a CCT or PSA that files as specified below is
federal agency. A securities brokerage firm is not a ‘‘similar entitled to reporting relief that is not available to plans or DFEs
financial institution’’ as used here. See DOL Advisory Opinion participating in a CCT or PSA for which a Form 5500 is not
93-21A (available at www.dol.gov/ebsa). filed.
The assets of a master trust are considered for reporting For reporting purposes, ‘‘common/collective trust’’ and
purposes to be held in one or more ‘‘investment accounts.’’ A ‘‘pooled separate account’’ are, respectively: (1) a trust
‘‘master trust investment account’’ may consist of a pool of maintained by a bank, trust company, or similar institution or
assets or a single asset. Each pool of assets held in a master (2) an account maintained by an insurance carrier, which is

General Instructions to Form 5500 -11-

- 12 -

regulated, supervised, and subject to periodic examination by a 3. Schedule C, if applicable, to report service provider
state or federal agency in the case of a CCT, or by a state information and any terminated accountants.
agency in the case of a PSA, for the collective investment and 4. Schedule D, to list all CCTs, PSAs, and 103-12 IEs in
reinvestment of assets contributed thereto from employee which the 103-12 IE invested at any time during the
benefit plans maintained by more than one employer or 103-12 IE’s year, and to list all plans that participated in the
controlled group of corporations as that term is used in Code 103-12 IE during its year.
section 1563. See 29 CFR 2520.103-3, 103-4, 103-5, and 5. Schedule G, to report loans or fixed income obligations in
103-9. default or determined to be uncollectible as of the end of the
103-12 IE year, leases in default or classified as uncollectible,
Note. For reporting purposes, a separate account that is not and nonexempt transactions.
considered to be holding plan assets pursuant to 29 CFR 6. Schedule H, except lines 1b(1), 1b(2), 1c(8), 1d, 1e, 1g,
2510.3-101(h)(1)(iii) does not constitute a pooled separate 1h, 1i, 2a, 2b(1)(E), 2e, 2f, 2g, 4a, 4e, 4f, 4g, 4h, 4j, 4k, 4l, 4m,
account. 4n, and 5, to report financial information.
The Form 5500 submitted for a CCT or PSA must comply 7. Additional information required by the instructions to the
with the Form 5500 instructions for a Large Pension Plan, above schedules, including, for example, the report of the
unless otherwise specified in the forms and instructions. independent qualified public accountant (IQPA) identified on
The CCT or PSA must file: Schedule H, line 3a, and the schedule(s) of assets held for
1. Form 5500, except lines C, D, 1c, 2d, and 5 through 9. investment. All attachments must be properly labeled.
Enter ‘‘C’’ or ‘‘P,’’ as appropriate, in Part I, line A, as the DFE Defined Contribution Group Reporting
code. Arrangements (DCGs or DCG Reporting
2. Schedule D, to list all CCTs, PSAs, MTIAs, and
Arrangements)
103-12 IEs in which the CCT or PSA invested at any time
during the CCT or PSA year and to list in Part II all plans that Each defined contribution pension plan that reports as part of a
participated in the CCT or PSA during its year. DCG reporting arrangement is not required to file a separate
3. Schedule H, except lines 1b(1), 1b(2), 1c(8), 1d, 1e, 1g, Form 5500 if a consolidated Form 5500 report for all the plans
1h, 1i, 2a, 2b(1)(E), 2e, 2f, and 2g, to report financial in the DCG is filed by the common plan administrator of the
information. Part IV and an accountant’s (IQPA’s) opinion are plans in accordance with 29 CFR 2510.103-14 and 29 CFR
not required for a CCT or PSA. 2520.104-51, including a Schedule DCG for each participating
plan.
Different requirements apply to the Schedules D and H
attached to the Form 5500 filed by plans and DFEs For reporting purposes, an arrangement is a DCG reporting
participating in CCTs and PSAs, depending upon whether a arrangement only if all plans in a DCG:
DFE Form 5500 has been filed for the CCT or PSA. See the 1. are individual account plans or defined contribution plans;
instructions for these schedules. 2. have the same trustee as described in ERISA section
403(a) (“common trustee”);
103-12 Investment Entity (103-12 IE) 3. have the same one or more named fiduciaries designated
DOL Regulation 2520.103-12 provides an alternative method in accordance with ERISA section 402(a) (“common
of reporting for plans that invest in an entity (other than an fiduciaries”), however an individual employer may be a named
MTIA, CCT, or PSA), whose underlying assets include ‘‘plan fiduciary of each employer’s own plan provided that the other
assets’’ within the meaning of 29 CFR 2510.3-101 of two or named fiduciaries are the same and common to all plans;
more plans that are not members of a ‘‘related group’’ of 4. have a designated plan administrator under ERISA
employee benefit plans. Such an entity for which a Form 5500 section 3(16)(A) that is the same plan administrator for all the
is filed constitutes a ‘‘103-12 IE.’’ A Form 5500 is not required plans in the DCG (“common plan administrator”);
to be filed for such entities; however, filing a Form 5500 as a 5. have plan years beginning on the same date (“common
103-12 IE provides certain reporting relief, including the plan year”);
limitation of the examination and report of the independent 6. provide the same investments or investment options to
qualified public accountant (IQPA) provided by 29 CFR participants and beneficiaries in all the plans (“common
2520.103-12(d), to participating plans and DFEs. For this investments or common investment options”). Certain
reporting purpose, a ‘‘related group’’ of employee benefit plans brokerage window arrangements would qualify as a common
consists of each group of two or more employee benefit plans investment option. See 29 CFR 2520.104-51(c)(3)(ii);
(1) each of which receives 10% or more of its aggregate 7. do not hold any employer securities at any time during the
contributions from the same employer or from a member of the plan year, except this does not prohibit investments in any
same controlled group of corporations (as determined under employer’s publicly traded securities within one of the
Code section 1563(a), without regard to Code section “common investments or investment options” available to
1563(a)(4) thereof); or (2) each of which is either maintained participants and beneficiaries in all the plans;
by, or maintained pursuant to a collective-bargaining 8. either obtain an audit by an IQPA and file the IQPA report
agreement negotiated by, the same employee organization or with the DCG consolidated Form 5500, or be eligible for the
affiliated employee organizations. For purposes of this waiver of the annual examination and report of an IQPA under
paragraph, an ‘‘affiliate’’ of an employee organization means 29 CFR 2520.104-46; and
any person controlling, controlled by, or under common control 9. not be a MEP (including a pooled employer plan) or a
with such organization. See 29 CFR 2520.103-12. multiemployer plan.
The Form 5500 submitted for a 103-12 IE must comply with The Form 5500 submitted for the DCG must comply with the
the Form 5500 instructions for a Large Pension Plan, unless Form 5500 instructions for a Large Pension Plan, unless
otherwise specified in the forms and instructions. The 103-12 otherwise specified in the forms and instructions. The DCG
IE must file: must file:
1. Form 5500, except lines C, D, 1c, 2d, and 5 through 9. 1. Form 5500, except lines C, 2d and 7. Enter ‘‘D’’ in Part I,
Enter ‘‘E’’ in part I, line A, as the DFE code. line A, as the DFE code for the DCG.
2. Schedule A (as many as needed), to report insurance, 2. Schedule A (as many as needed) to report insurance,
annuity and investment contracts held by the 103-12 IE. annuity, and investment contracts held by the plans

-12- General Instructions to Form 5500

- 13 -

participating in a DCG. Group Insurance Arrangement (GIA)
3. Schedule C to report service provider information and any
Each welfare benefit plan that is part of a group insurance
terminated accountants.
arrangement is exempt from the requirement to file a Form
4. Schedule D, Part I only, to list all CCTs, PSAs, and 103-
5500 if a consolidated Form 5500 report for all the plans in the
12 IEs in which DCG participating plans invested at any time
arrangement was filed in accordance with 29 CFR 2520.104-
during the DCG year.
43. For reporting purposes, a ‘‘group insurance arrangement’’
5. Schedule DCG to report individual plan-level information
provides benefits to the employees of two or more unaffiliated
such as the plan sponsor (i.e., employer), plan financial
employers (not in connection with a multiemployer plan or a
information, number of participants, and other information.
collectively-bargained multiple-employer plan), fully insures
6. Schedule G to report loans or fixed income obligations in
one or more welfare plans of each participating employer, uses
default or determined to be uncollectible as of the end of the
a trust or other entity as the holder of the insurance contracts,
DCG year, leases in default or classified as uncollectible, and
and uses a trust as the conduit for payment of premiums to the
nonexempt transactions.
insurance company. The GIA must file:
7. Schedule H, except lines 4e, 4f, 4k, 4l and 5, to report the
DCG’s financial information. 1 . Form 5500, except lines C and 2d. (Enter ‘‘G’’ in Part I,
8. Additional information required by the instructions to the line A, as the DFE code).
above schedules, including, for example, the report of the 2. Schedule A (as many as needed), to report insurance,
independent qualified public accountant (IQPA) identified on annuity and investment contracts held by the GIA.
Schedule DCG, line 14a, unless the plan is eligible for the 3. Schedule C, if applicable, to report service provider
waiver of the annual examination and report of an IQPA under information and any terminated accountants.
29 CFR 2520.104-46. All attachments must be properly 4. Schedule D, to list all CCTs, PSAs, and 103-12 IEs in
labeled. which the GIA invested at any time during the GIA year, and to
list all plans that participated in the GIA during its year.
Note. The information reported on all the Schedules, except
5. Schedule G, to report loans or fixed income obligations in
Schedule DCG, are generally reported for all the plans in the
default or determined to be uncollectible as of the end of the
DCG in the aggregate, except as otherwise provided.
GIA year, leases in default or classified as uncollectible, and
The plan administrator’s information entered on Part III, nonexempt transactions.
line 4 on each individual plan’s Schedule DCG must be 6. Schedule H, except lines 4a, 4e, 4f, 4g, 4h, 4k, 4m, 4n,
the DCG common plan administrator (i.e., the plan and 5, to report financial information.
administrator listed on the Form 5500, Part II, line 3 for the 7. Additional information required by the instructions to the
DCG) in order for the plan to report in the DCG group. above schedules, including, for example, the report of the
independent qualified public accountant (IQPA) identified on
Schedule H, line 3a, the schedules of assets held for
investment and the schedule of reportable transactions. All
attachments must be properly labeled.

General Instructions to Form 5500 -13-

- 14 -

Quick Reference Chart of Form 5500, Schedules, and Attachments
1
(Not Applicable for Form 5500-SF Filers)
Large Small Large Welfare Small Welfare
Pension Plan Pension Plan2 Plan Plan2 DFE
Form 5500 Must complete. Must complete. Must complete. 3 Must complete. 3 Must complete.

Schedule A Must complete if Must complete if plan Must complete if Must complete if plan Must complete if
(Insurance plan has insurance has insurance plan has insurance has insurance MTIA, 103-12 IE,
Information) contracts. contracts. 4 contracts. contracts. 4 DCG or GIA has
insurance contracts.

Must complete Part I Must complete Part I MTIAs, GIAs, DCGs
if service provider if service provider and 103-12 IEs must
was paid $5,000 or was paid $5,000 or complete Part I if
more, Part II if a more, Part II if a service provider paid
service provider service provider $5,000 or more, and
Schedule C failed to provide failed to provide Part II if a service
(Service Provider information Not required. information Not required. provider failed to
Information) necessary for the necessary for the provide information
completion of Part I, completion of Part I, necessary for the
and Part III if an and Part III if an completion of Part I.
accountant or accountant or GIAs and 103-12 IEs
actuary was actuary was must complete Part
terminated. terminated. III if accountant was
terminated.

All DFEs other than
Schedule D Must complete Part I Must complete Part I Must complete Part I Must complete Part I DCGs must
(DFE/Participating if plan participated in if plan participated in if plan participated in if plan participated in complete Part II, and
Plan Information) a CCT, PSA, MTIA, a CCT, PSA, MTIA, or a CCT, PSA, MTIA, a CCT, PSA, MTIA, DFEs that invest in a
or 103-12 IE. 103-12 IE. 4 or 103-12 IE. or 103-12 IE. 4 CCT, PSA, or
103-12 IE must also
complete Part I.

Individual plans
Schedule DCG participating in a Individual plans Individual plans
(Individual Plan DCG must complete participating in a DCG participating in a
Information) to report individual must complete to Not required. Not required. DCG must complete
plan-level report individual plan- to report individual
information. 9 level information. 9 plan-level
information. 9

Schedule G Must complete if Must complete if Must complete if
(Financial Schedule H, lines Not required. Schedule H, lines Not required . 3 Schedule H, lines
Schedules) 4b, 4c, or 4d are 4b, 4c, or 4d are 4b, 4c, or 4d for a
“Yes.” “Yes.” 3 GIA, DCG, MTIA, or
103-12 IE are “Yes.”

All DFEs must
Schedule H complete Parts I, II,
(Financial Must complete. 5 Not required. Must complete.3, 5 Not required. and III. MTIAs,
Information) 103-12 IEs, DCGs
and GIAs must also
complete Part IV. 5

Schedule I
(Financial Not required. Must complete. 4 Not required. Must complete. 4 Not required.
Information)

-14- General Instructions to Form 5500

- 15 -

Large Small Large Welfare Small Welfare
Pension Plan Pension Plan 2 Plan Plan 2 DFE
Must complete if Must complete if
multiemployer
Schedule MB defined benefit plan multiemployer defined
(Actuarial or money purchase benefit plan or money Not required. Not required. Not required.
Information) plan subject to purchase plan subject
minimum funding to minimum funding
standards. 6 standards. 6

Schedule MEP Must complete if Must complete if
(Multiple-Employer multiple-employer multiple-employer Not required. Not required. Not required.
Retirement Plan pension plan.8 pension plan. 8
Information)

Schedule R
(Pension Plan Must complete. 7 Must complete.4, 7 Not required. Not required. Not required.
Information)

Must complete if Must complete if
single-employer or single-employer or
Schedule SB multiple-employer multiple-employer
(Actuarial defined benefit plan, defined benefit plan, Not required. Not required. Not required.
Information) including an eligible including an eligible
combined plan and combined plan and
subject to minimum subject to minimum
funding standards. funding standards.
Must attach for a
GIA, 103-12 IE, or
Not required unless individual plans
Accountant’s Must attach. Schedule I, line 4k, is Must attach. 3 Not required. participating in a
Report checked “No.” DCG that checked
“Yes” on Schedule
DCG, line 14a. 9

1 This chart provides only general guidance. Not all rules and 5 Schedules of assets and reportable (5%) transactions also must be
requirements are reflected. Refer to specific Form 5500 instructions for filed with the Form 5500 if Schedule H, line 4i or 4j is “Yes.”
complete information on filing requirements (e.g., Who Must File and 6 Money purchase defined contribution plans that are amortizing a
What To File). For example, a pension plan is exempt from filing any funding waiver are required to complete lines 3, 9, and 10 of the
schedules if the plan uses Code section 408 individual retirement Schedule MB in accordance with the instructions. Also see instructions
accounts as the sole funding vehicle for providing benefits. See Limited for line 5 of Schedule R and line 12a of Form 5500-SF.
Pension Plan Reporting. 7 Schedule R should not be completed when the Form 5500 Annual
2 Pension plans and welfare plans with fewer than 100 participants at Return/Report is filed for a pension plan that uses, as the sole funding
the beginning of the plan year that are not exempt from filing an annual vehicle for providing benefits, individual retirement accounts or
return/report may be eligible to file the Form 5500-SF, a simplified annuities (as described in Code section 408). See the Form 5500
report. In addition to the limitation on the number of participants, a instructions for Limited Pension Plan Reporting for more information.
Form 5500-SF may only be filed for a plan that is exempt from the 8 All multiple-employer pension plans must complete Schedule MEP,
requirement that the plan’s books and records be audited by an
independent qualified public accountant (but not by reason of Parts I and II. Multiple-employer pension plans that are pooled
enhanced bonding), has 100 percent of its assets invested in certain employer plans must also complete Schedule MEP, Part III.
secure investments with a readily determinable fair market value, holds 9 Individual plans participating in a DCG must attach the report of an
no employer securities, is not a multiemployer plan, is not required to independent qualified public accountant (IQPA) identified on Schedule
file a Form M-1 (Report for Multiple-Employer Welfare Arrangements DCG, line 14a unless the plan is eligible for the waiver of the annual
(MEWAs) and Certain Entities Claiming Exception (ECEs)) for the plan examination and report of an IQPA under 29 CFR 2520.104-46.
year, and is not a pooled employer plan. See the Form 5500-SF
instructions, Who May File Form 5500-SF.
3 Unfunded, fully insured, or combination unfunded/fully insured
welfare plans covering fewer than 100 participants at the beginning of
the plan year that meet the requirements of 29 CFR 2520.104-20 are
exempt from filing an annual report. See Who Must File. Such a plan
with 100 or more participants must file an annual report, but is exempt
under 29 CFR 2520.104-44 from the accountant’s report requirement
and completing Schedule H, but MUST complete Schedule G, Part III,
to report any nonexempt transactions. See What To File. All Plans
required to file Form M-1 (Report for Multiple-Employer Welfare
Arrangements (MEWAs) and Certain Entities Claiming Exception
(ECEs)) must file a Form 5500 regardless of plan size or type of
funding.
4 Do not complete if filing the Form 5500-SF instead of the Form 5500.
General Instructions to Form 5500 -15-

- 16 -

All multiple-employer pension plans that check this box must
Section 5: Line-by-Line file Schedule MEP, Multiple-Employer Retirement Plan
Instructions for the 2023 Information (see Schedule MEP filing instructions for additional
details) to report information about the participating employers.
Form 5500 and Schedules
Note. Do not check this box if all of the employers maintaining
Part I – Annual Return/Report Identification the plan are members of the same controlled group or affiliated
Information service group under Code sections 414(b), (c), or (m). Do not
check this box for a DCG. See line A Box for Direct Filing
File the 2023 Form 5500 Annual Return/Report for a plan year Entity (DFE).
that began in 2023 or a DFE year that ended in 2023. Enter the
beginning and ending dates in Part I. The 2023 Form 5500 Participating Employer Information. Multiple-employer
Annual Return/Report must be filed electronically. welfare plans required to file a Form 5500 do not file Schedule
MEP but instead must include an attachment using the format
One Form 5500 is generally filed for each plan or entity below. The attachment must be properly identified at the top
described in the instructions to the boxes in line A. Do not with the label “Multiple-Employer Welfare Plan Participating
check more than one box. Employer Information,” and the name of the plan, EIN, and
A separate Form 5500, with line A (single-employer plan) plan number (PN) as found on the plan’s Form 5500. Complete
checked, must be filed by each employer participating in a plan as many entries as needed to report the required information
or program of benefits in which the funds attributable to each for all participating employers in the plan.
employer are available to pay benefits only for that employer’s Except as provided below, all multiple-employer welfare
employees, even if the plan is maintained by a controlled
plans must complete elements 1-3 of the “Multiple-Employer
group. Welfare Plan Participating Employer Information” attachment.
A “controlled group” is generally considered one employer For element 3, enter a good faith estimate of each
for Form 5500 reporting purposes. A “controlled group” is a employer’s percentage of the total contributions (including
controlled group of corporations under Code section 414(b), a
employer and participant contributions) made by all
group of trades or businesses under common control under participating employers during the year. The percentage may
Code section 414(c), or an affiliated service group under Code be rounded to the nearest whole percentage. To the extent the
section 414(m). rounding results in the total reported percentage being either
Line A – Box for Multiemployer Plan. Check this box if the slightly above or slightly below 100 percent, the filer can
Form 5500 is filed for a multiemployer plan. A plan is a indicate that on the attachment. Any employer who was
multiemployer plan if: (a) more than one employer is required obligated to make contributions to the plan for the plan year,
to contribute, (b) the plan is maintained pursuant to one or who made contributions to the plan for the plan year, or whose
more collective bargaining agreements between one or more employees were covered under the plan is a “participating
employee organizations and more than one employer; (c) an employer” for this purpose. If a participating employer made no
election under Code section 414(f)(5) and ERISA section contributions, enter “-0-” in element 3.
3(37)(E) has not been made; and (d) the plan meets any other Multiple-employer welfare plans that are unfunded, fully
applicable conditions of 29 CFR 2510.3-37. A plan that has insured, or a combination of unfunded/insured and exempt
made a proper election under ERISA section 3(37)(G) and under 29 CFR 2520.104-44 from the obligation to file financial
Code section 414(f)(6) on or before August 17, 2007, is also a statements with their annual report are required to complete
multiemployer plan. Participating employers do not file elements 1 and 2 only of the “Multiple-Employer Welfare Plan
individually for these plans. Participating Employer Information” attachment.
Line A – Box for Single-Employer Plan. Check this box if
the Form 5500 is filed for a single-employer plan. A single- Multiple-Employer Welfare Plan Participating Employer
employer plan for this Form 5500 reporting purpose is an Information
employee benefit plan maintained by one employer or one (Insert Name of Plan and EIN/PN as shown on the 5500)
employee organization.
Line A – Box for Multiple-Employer Plan. Check this box if 1. Name of participating 2. EIN 3. Percent of Total
the Form 5500 is being filed for a multiple-employer plan, employer Contributions for
including a multiple-employer 403(b) plan. A multiple-employer Plan Year
plan is a plan that is maintained by more than one employer
and is not one of the plans already described. A multiple- 1. Name of participating 2. EIN 3. Percent of Total
employer plan can be collectively bargained and collectively employer Contributions for
funded, but, if covered by PBGC termination insurance, must Plan Year
have properly elected before September 27, 1981, not to be
treated as a multiemployer plan under Code section 414(f)(5) 1. Name of participating 2. EIN 3. Percent of Total
or ERISA sections 3(37)(E) and 4001(a)(3), and have not employer Contributions for
revoked that election or made an election to be treated as a Plan Year
multiemployer plan under Code section 414(f)(6) or ERISA
section 3(37)(G). A single Form 5500 Annual Return/Report is 1. Name of participating 2. EIN 3. Percent of Total
filed for the multiple-employer plan; participating employers do employer Contributions for
not file individually for this type of plan. Plan Year
A pooled employer plan as defined in ERISA section 3(43)
operated by a “pooled plan provider” that meets the definition
under ERISA section 3(44) is a multiple-employer plan.

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- 17 -

1. Name of participating 2. EIN 3. Percent of Total Form 5500 for the plan year 2024 if the number of participants
employer Contributions for covered as of the beginning of the 2024 plan year drops below
Plan Year 100. See Who Must File. Should the number of participants
covered by such a plan increase to 100 or more in a future
year, the plan must resume filing Form 5500 and enter ‘‘4S’’ on
Complete as many rows as needed to report the line 8b on that year’s Form 5500. See 29 CFR 2520.104-20.
required information for all participating employers in
the plan. Line B – Box for Short Plan Year Return/Report. Check
this box if this Form 5500 is being filed for a plan year period of
Line A –Box for Direct Filing Entity (DFE). Check this box less than 12 months. Provide the dates in Part I, Plan Year
and enter the correct letter from the following chart in the Beginning and Ending.
space provided to indicate the type of entity. Line C – Box for Collectively-Bargained Plan. Check this
Type of entity Enter the letter box when the contributions to the plan and/or the benefits paid
by the plan are subject to the collective bargaining process
(even if the plan is not established and administered by a joint
Master Trust M board of trustees and even if only some of the employees
Investment Account covered by the plan are members of a collective bargaining
Common/Collective Trust C unit that negotiates contributions and/or benefits). The
contributions and/or benefits do not have to be identical for all
Pooled Separate P employees under the plan.
Account
Line D – Box for Extension and DFVC Program. Check the
103-12 Investment E appropriate box here if:
Entity
 You filed for an extension of time to file this form with the
Defined Contribution Group (DCG) D IRS using a completed Form 5558. (A copy of the Form 5558
must be retained with the filer’s records);
Group Insurance G  You are filing using the automatic extension of time to file
Arrangement Form 5500 until the due date of the federal income tax return
Note. A separate annual report with “M” entered as the DFE of the employer (maintain a copy of the employer’s extension
code on Form 5500, line A, must be filed for each MTIA. See of time to file the income tax return with the filer’s records);
instructions on page 11.  You are filing using a special extension of time to file the
Line B – Box for First Return/Report. Check this box if an Form 5500 that has been announced by the IRS, DOL, and
annual return/report has not been previously filed for this plan PBGC. If you checked that you are using a special extension of
or DFE. For the purpose of completing this box, the Form time, enter a description of the extension of time in the space
5500-EZ is not considered an annual return/report. provided.
Line B – Box for Amended Return/Report. Check this box if  You are filing under DOL’s Delinquent Filer Voluntary
Compliance (DFVC) Program.
you have already filed for the 2023 plan year and are now filing
an amended return/report to correct errors and/or omissions on Checking this box does not enter you in the program.
the previously filed return/report. See instructions on page 6. You can enter the program at this site:
www.dol.gov/agencies/ebsa/employers-and-advisers/plan-
Note. If an individual plan amended Schedule DCG to correct
administration-and-compliance/correction-programs/dfvcp
errors and/or omissions in a previously filed Schedule DCG,
the DCG must submit an amended Form 5500, and include all See additional information on the DFVC Program at
Schedules DCG for participating plans that were submitted www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-
with the original return. The line B box for “an amended activities/resource-center/faqs/dfvcp.pdf, including filing by
return/report” on the Form 5500 must be checked. The line F mail.
box for “an amended Schedule DCG” on the Schedule DCG Applying and paying electronically to the DFVC is strongly
must be checked on only those Schedules DCG that have recommended.
been changed from the original submission. Line E – Box for a retroactively adopted plan as permitted
Check the line B box for an “amended return/report” if you by SECURE Act section 201. Check this box if the plan
filed a previous 2023 annual return/report that was given a sponsor adopted the plan during the 2023 plan year (i.e., by
“Filing_Received,” “Filing_Error,” or “Filing_Stopped” status by the due date, including extension, for filing the plan sponsor’s
EFAST2. Do not check the line B box for an “amended tax return for the 2022 taxable year) and elected to treat the
return/report” if your previous submission attempts were not plan as having been adopted before the 2023 plan year began
successfully received by EFAST2 because of problems with the (i.e., at the close as of the last day of the sponsor’s taxable
transmission of your return/report. For more information, go to year) as permitted by section 201 of the Setting Every
the EFAST2 website at www.efast.dol.gov or call the EFAST2 Community Up for Retirement Enhancement Act of 2019
Help Desk at 1-866-GO-EFAST (1-866-463-3278). (SECURE ACT). Plans in this situation are not required to file a
2022 Form 5500. However, if the plan is a defined benefit
Line B – Box for Final Return/Report. Check this box if this pension plan, the 2022 Schedule SB (Form 5500) must be
Form 5500 is the last annual return/report required to be included as an attachment to the 2023 Schedule SB (Form
submitted for this plan. (See Final Return/Report.) 5500) as part of the 2023 Form 5500. Please see Instructions
Note. Do not check box B (Final Return/Report) if “4R” is for Schedule SB for more information.
entered on line 8b for a welfare plan that is not required to file
a Form 5500 for the next plan year because the welfare plan Part II – Basic Plan Information
has become eligible for an annual reporting exemption. For Line 1a. Enter the formal name of the plan or DFE or enough
example, certain unfunded and insured welfare plans may be information to identify the plan or DFE. Abbreviate if
required to file the 2023 Form 5500 and be exempt from filing a necessary. If an annual return/report has previously been filed
on behalf of the plan, regardless of the type of form that was
Instructions for Part I and Part II of Form 5500 -17-

- 18 -

filed (Form 5500, Form 5500-EZ, or Form 5500-SF), use the of a pooled employer plan that meets the definition under
same name or abbreviation as was used on the prior filings. ERISA section 3(43); or
Once you use an abbreviation, continue to use it for that plan  The professional employer organization (PEO), in the case
on all future annual return/report filings with the IRS, DOL, and of a PEO multiple-employer plan that meets the conditions
PBGC. Do not use the same name or abbreviation for any under 29 CFR 2510.3-55(c).
other plan, even if the first plan is terminated. If the plan has Note. In the case of a multiple-employer plan or DCG, file only
changed its name from the prior year filing(s), complete line 4 one annual return/report for the plan or DCG. If an association,
to indicate that the plan was previously identified by a different pooled plan provider, PEO, or other entity listed above is not
name. the sponsor, enter the name of a participating employer as
Line 1b. Enter the three-digit plan or entity number (PN) the sponsor. A plan of a controlled group of corporations should
employer or plan administrator assigned to the plan or DFE. enter the name of one of the sponsoring members. In either
This three-digit number, in conjunction with the employer case, the same name must be used in all subsequent filings of
identification number (EIN) entered on line 2b, is used by the the Form 5500 for the multiple-employer plan or controlled
IRS, DOL, and PBGC as a unique 12-digit number to identify group (see instructions to line 4 concerning change in
the plan or DFE. sponsorship).
Start at 001 for plans providing pension benefits, plans 2. Enter any ‘‘in care of’’ (C/O) name.
providing pension and welfare benefits, or DFEs as illustrated 3. Enter the current street address. A post office box
in the table below. Start at 501 for plans providing only welfare number may be entered if the Post Office does not deliver mail
benefits and GIAs. Do not use 888 or 999. to the sponsor’s street address.
Once you use a plan or DFE number, continue to use it for 4. Enter the name of the city.
that plan or DFE on all future filings with the IRS, DOL, and 5. Enter the two-character abbreviation of the U.S. state or
PBGC. Do not use it for any other plan or DFE, even if the first possession and zip code.
plan or DFE is terminated. 6. Enter the foreign routing code, if applicable. Leave U.S.
state and zip code blank if entering a foreign routing code and
country name.
For each Form 5500 Assign PN 7. Enter the foreign country, if applicable.
with the same EIN 8. Enter the D/B/A (the doing business as) or trade name of
(line 2b), when the sponsor if different from the plan sponsor’s name.
9. Enter any second address. Use only a street address
Part II, line 8a is 001 to the first plan or DFE. here, not a P.O. Box.
completed, or Part I, line A, Consecutively number others
for a DFE is checked and as 002, 003… Note. Use the IRS Form 8822-B, Change of Address or
an M, C, P, D or E is Responsible Party – Business, to notify the IRS if the address
entered provided here is a change in your business mailing address or
your business location.
Part II, line 8b is completed 501 to the first plan or GIA.
and 8a is not checked, or Consecutively number others Line 2b. Enter the nine-digit employer identification number
Part I, line A, for a DFE is as 502, 503… (EIN) assigned to the plan sponsor/employer, for example, 00-
checked and a G is entered 1234567. In the case of a DFE, enter the employer
identification number (EIN) assigned to the CCT, PSA, MTIA,
Exception. If Part II, line 8a is completed and 333 (or a higher 103-12 IE, DCG or GIA.
number in a sequence beginning with 333) was previously Do not use a social security number in lieu of an EIN. The
assigned to the plan, that number may be entered on line 1b. Form 5500 is open to public inspection, and the contents are
Line 1c. Enter the date the plan first became effective. public information and are subject to publication on the
Line 2a. Limit your response to the information required in Internet. Because of privacy concerns, the inclusion of a social
each row as specified below: security number or any portion thereof on this line may result in
the rejection of the filing.
1. Enter the name of the plan sponsor or, in the case of a
Form 5500 filed for a DFE, the name of the insurance Plan sponsor/employers without an EIN must apply for one
company, financial institution, or other sponsor of the DFE as soon as possible. The EBSA does not issue EINs. To apply
(e.g., in the case of a GIA, the trust or other entity that holds for an EIN from the IRS:
the insurance contract, in the case of an MTIA, one of the  Mail or fax Form SS-4, Application for Employer
sponsoring employers, or in the case of a DCG, the DCG Identification Number, obtained at www.irs.gov/orderforms.
sponsor, but, if an individual sponsor cannot be identified,  See www.IRS.gov/Businesses and click on “Employer ID
enter the common plan administrator’s name and be sure to Numbers” for additional information. The EIN is issued
check the box in line 3a). If the plan covers only the employees immediately once the application information is validated. (The
of one employer, enter the employer’s name. online application process is not yet available for corporations
The term ‘‘plan sponsor’’ otherwise means: with addresses in foreign countries or Puerto Rico.)
 The employer, for an employee benefit plan that a single A multiple-employer plan or plan of a controlled group of
employer established or maintains; corporations should use the EIN of the sponsor identified in
 The employee organization, in the case of a plan of an line 2a. The EIN must be used in all subsequent filings of the
employee organization; Form 5500 for these plans (see instructions to line 4
 The association, committee, joint board of trustees, or other concerning change in EIN).
similar group of representatives of the parties who establish or If the plan sponsor is a group of individuals, get a single EIN
maintain the plan, if the plan is established or maintained for the group. When you apply for the EIN, provide the name of
jointly by one or more employers and one or more employee the group, such as ‘‘Joint Board of Trustees of the Local 187
organizations, or by two or more employers; Machinists’ Retirement Plan.’’ (If filing Form SS-4, enter the
 The pooled plan provider that operates the plan, in the case group name on line 1.)

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- 19 -

Note. EINs for funds (trusts or custodial accounts) associated purposes. If the plan administrator does not have an EIN, apply
with plans (other than DFEs) are generally not required to be for one as explained in the instructions for line 2b. One EIN
furnished on the Form 5500; the IRS will issue EINs for such should be entered for a group of individuals who are,
funds for other reporting purposes. EINs may be obtained as collectively, the plan administrator.
explained above. Plan sponsors should use the trust EIN Line 3c. Enter the telephone number for the plan
described above when opening a bank account or conducting administrator. Use numbers only, including area code, and do
other transactions for a trust that require an EIN. not include any special characters.
Line 2c. Enter the telephone number for the plan sponsor. Note. Employees of the plan sponsor who perform
Use numbers only, including area code, and do not include any administrative functions for the plan are generally not the plan
special characters. administrator unless specifically designated in the plan
Line 2d. Enter the six-digit business code from the list of document. If an employee of the plan sponsor is designated as
business codes on pages 94, 95, and 96 that: the plan administrator, that employee must get an EIN.
 In the case of a single-employer plan, best describes the In the case of a pooled employer plan, information for the
primary nature of the plan sponsor’s business, and pooled employer plan and the pooled plan provider
 In the case of a multiemployer plan, best describes the operating the plan reported on the Form 5500 must match the
predominant industry in which the active participants are information reported on the Form PR. Failure to report the
employed (e.g., 484120 - General Freight Trucking, Long- same information could result in correspondence from the
distance, 236110 - Residential Building Construction). Department of Labor or the Internal Revenue Service.
Do not enter code 525100 (Insurance & Employee Benefit Line 4. If the plan sponsor’s or DFE’s name and/or EIN have
Funds) or 813930 (Labor Unions and Similar Labor changed or the plan name has changed since the last
Organizations) unless the predominant industry in which the return/report was filed for this plan or DFE, enter the plan
active participants are employed is the industry of insurance sponsor’s or DFE’s name, EIN, the plan name, and the plan
and employee benefit funds, or labor unions and similar labor number as it appeared on the last return/report filed.
organizations. The failure to indicate on line 4 that a plan sponsor was
Line 3a. Please limit your response to the information previously identified by a different name or a different
required: employer identification number (EIN) or that the plan name has
been changed could result in correspondence from the DOL
1. Enter the name and address of the plan administrator and/or the IRS.
unless the administrator is the sponsor identified in line 2. If
both the plan administrator name and address are the same as Lines 5 and 6. All filers must complete both lines 5 and 6
the plan sponsor name and address, check the “Same as Plan unless the Form 5500 is filed for an IRA Plan described in
Sponsor” box and disregard items 2 through 6 below. If the Limited Pension Plan Reporting, MTIA, CCT, PSA or 103-12
Form 5500 is submitted for a DFE, check the appropriate box IE.
in Part I, line A, and enter the appropriate DFE code. Note. Welfare plans complete only lines 5, 6a(1), 6a(2), 6b, 6c,
The term “plan administrator” means: and 6d.
 The person or group of persons specified as the The description of ‘‘participant’’ in the instructions below is
administrator by the instrument under which the plan is only for purposes of these lines.
operated; An individual becomes a participant covered under an
 The pooled plan provider that operates the plan, in the employee welfare benefit plan on the earliest of:
case of a pooled employer plan that meets the definition  the date designated by the plan as the date on which the
under ERISA section 3(43); individual begins participation in the plan;
 The professional employer organization (PEO), in the case  the date on which the individual becomes eligible under the
of a PEO multiple-employer plan that meets the conditions plan for a benefit subject only to occurrence of the contingency
under 29 CFR 2510.3-55(c); for which the benefit is provided; or
 The common plan administrator that is the same  the date on which the individual makes a contribution to the
administrator for all the plans participating in the DCG, in plan, whether voluntary or mandatory.
the case of a DCG that meets the conditions under 29 See 29 CFR 2510.3-3(d)(1). This includes former
CFR 2520.104-51; employees who are receiving group health continuation
 The plan sponsor/employer if an administrator is not so coverage benefits pursuant to Part 6 of ERISA and who are
designated; or covered by the employee welfare benefit plan. Covered
 Any other person prescribed by regulations if an dependents are not counted as participants. A child who is an
administrator is not designated and a plan sponsor cannot “alternate recipient” entitled to health benefits under a qualified
be identified. medical child support order (QMCSO) should not be counted
2. Enter any “in care of” (C/O) name. as a participant for lines 5 and 6. An individual is not a
3. Enter the current street address. A post office box participant covered under an employee welfare plan on the
number may be entered if the Post Office does not deliver mail earliest date on which the individual (a) is ineligible to receive
to the administrator’s street address. any benefit under the plan even if the contingency for which
4. Enter the name of the city. such benefit is provided should occur, and (b) is not
5. Enter the two-character abbreviation of the U.S. state or designated by the plan as a participant. See 29 CFR 2510.3-
possession and zip code. 3(d)(2).
6. Enter the foreign routing code and foreign country, if Before counting the number of participants, especially in
applicable. Leave U.S. state and zip code blank if entering a welfare benefit plan, it is important to determine
foreign routing code and country information. whether the plan sponsor has established one or more plans
Line 3b. Enter the plan administrator’s nine-digit EIN. A plan for Form 5500/Form 5500-SF reporting purposes. As a matter
administrator must have an EIN for Form 5500 reporting of plan design, plan sponsors can offer benefits through
Instructions for Part I and Part II of Form 5500 -19-

- 20 -

various structures and combinations. For example, a plan counted on line 6f who have made a contribution, or for whom
sponsor could create (i) one plan providing major medical a contribution has been made, to the plan for this plan year or
benefits, dental benefits, and vision benefits, (ii) two plans with any prior plan year. Defined benefit plans do not complete line
one providing major medical benefits and the other providing 6g.
self-insured dental and vision benefits; or (iii) three separate Line 6h. Include any individual who terminated employment
plans. You must review the governing documents and actual during this plan year, whether or not the individual (a) incurred
operations to determine whether welfare benefits are being a break in service, (b) received an irrevocable commitment
provided under a single plan or separate plans. from an insurance company to pay all the benefits to which the
The fact that you have separate insurance policies for each individual is entitled under the plan, and/or (c) received a cash
different welfare benefit does not necessarily mean that you distribution or deemed cash distribution of their nonforfeitable
have separate plans. Some plan sponsors use a “wrap” accrued benefit. Multiemployer plans and multiple-employer
document to incorporate various benefits and insurance plans that are collectively bargained do not have to complete
policies into one comprehensive plan. In addition, whether a line 6h.
benefit arrangement is deemed to be a single plan may be Line 7. Only multiemployer plans should complete line 7.
different for purposes other than Form 5500/Form 5500-SF Multiemployer plans must enter the total number of employers
reporting. For example, special rules may apply for purposes of obligated to contribute to the plan. For purposes of line 7 of the
HIPAA, COBRA, and Internal Revenue Code compliance. If Form 5500, an employer obligated to contribute is defined as
you need help determining whether you have a single welfare an employer who, during the 2023 plan year, is a party to the
benefit plan for Form 5500/Form 5500-SF reporting purposes, collective bargaining agreement(s) pursuant to which the plan
you should consult a qualified benefits consultant or legal is maintained or who may otherwise be subject to withdrawal
counsel. liability pursuant to ERISA section 4203. Any two or more
For pension benefit plans, “alternate payees” entitled to contributing entities (e.g., places of business with separate
benefits under a qualified domestic relations order are not to collective bargaining agreements) that have the same nine-
be counted as participants for this line. digit employer identification number (EIN) must be aggregated
For pension benefit plans, “participant” for this line means and counted as one employer for this purpose.
any individual who is included in one of the categories below: Line 8 - Benefits Provided Under the Plan. Do not leave
1. Active participants (i.e., any individuals who are currently blank. In the boxes for line 8a and 8b, as appropriate, enter all
in employment covered by the plan and who are earning or applicable two-character plan characteristics codes that
retaining credited service under the plan). This includes any applied during the reporting year from the List of Plan
individuals who are eligible to elect to have the employer make Characteristics Codes on pages 22 and 23 that describe the
payments under a Code section 401(k) qualified cash or characteristics of the plan being reported.
deferred arrangement. Active participants also include any Note. In the case of an eligible combined plan under Code
nonvested individuals who are earning or retaining credited section 414(x) and ERISA section 210(e), the codes entered in
service under the plan. This does not include (a) nonvested line 8a must include any codes applicable for either the defined
former employees who have incurred the break in service benefit pension features or the defined contribution pension
period specified in the plan or (b) former employees who have features of the plan.
received a “cash-out” distribution or deemed distribution of For plan sponsors of Puerto Rico plans, enter
their entire nonforfeitable accrued benefit. characteristic code 3C only if:
2. Retired or separated participants receiving benefits (i.e., i. only Puerto Rico residents participate,
individuals who are retired or separated from employment ii. the trust is exempt from income tax under the laws of
covered by the plan and who are receiving benefits under the Puerto Rico, and
plan). This does not include any individual to whom an iii. the plan administrator has not made the election under
insurance company has made an irrevocable commitment to ERISA section 1022(i)(2), and, therefore, the plan is not
pay all the benefits to which the individual is entitled under the intended to qualify under section 401(a) of the Internal
plan. Revenue Code (U.S).
3. Other retired or separated participants entitled to future
benefits (i.e., any individuals who are retired or separated from Line 9 - Funding and Benefit Arrangements. Check all
employment covered by the plan and who are entitled to begin boxes that apply to indicate the funding and benefit
receiving benefits under the plan in the future). This does not arrangements used during the plan year. The ‘‘funding
include any individual to whom an insurance company has arrangement’’ is the method for the receipt, holding,
made an irrevocable commitment to pay all the benefits to investment, and transmittal of plan assets prior to the time the
which the individual is entitled under the plan. plan actually provides benefits. The ‘‘benefit arrangement’’ is
4. Deceased individuals who had one or more beneficiaries the method by which the plan provides benefits to participants.
who are receiving or are entitled to receive benefits under the For purposes of line 9:
plan. This does not include any individual to whom an ‘‘Insurance’’ means the plan has an account, contract, or
insurance company has made an irrevocable commitment to policy with an insurance company, insurance service, or other
pay all the benefits to which the beneficiaries of that individual similar organization (such as Blue Cross, Blue Shield, or a
are entitled under the plan. health maintenance organization) during the plan or DFE year.
Line 6g. Enter in line 6g(1) the total number of participants (This includes investments with insurance companies such as
included on line 5 (total participants at the beginning of the guaranteed investment contracts (GICs).) An annuity account
plan year) who have account balances at the beginning of the arrangement under Code section 403(b)(1) that is required to
plan year. Enter in line 6g(2) the total number of participants complete the Form 5500 should mark “insurance” for both the
included on line 6f (total participants at the end of the plan plan funding arrangement and plan benefit arrangement. Do
year) who have account balances at the end of the plan year. not check ‘‘insurance’’ if the sole function of the insurance
For example, for a Code section 401(k) plan, the number company was to provide administrative services.
entered on line 6g(2) should be the number of participants ‘‘Code section 412(e)(3) insurance contracts’’ are

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- 21 -

contracts that provide retirement benefits under a plan that are Labor under the Form M–1 filing requirements. The Receipt
guaranteed by an insurance carrier. In general, such contracts Confirmation Code is a unique code generated by the Form M–
must provide for level premium payments over the individual’s 1 electronic filing system. You can find this code under the
period of participation in the plan (to retirement age), premiums ‘‘completed filings’’ area when you log into your Form M–1
must be timely paid as currently required under the contract, electronic filing system at www.askebsa.dol.gov/mewa.
no rights under the contract may be subject to a security If a plan that is subject to the Form M-1 filing requirements
interest, and no policy loans may be outstanding. If a plan is was not required to file a 2023 Form M–1 annual report, enter
funded exclusively by the purchase of such contracts, the the Receipt Confirmation Code for the most recent Form M–1
otherwise applicable minimum funding requirements of section that was required to be filed under the Form M–1 filing
412 of the Code and section 302 of ERISA do not apply for the requirements on or before the date of filing the 2023 Form
year and neither the Schedule MB nor the Schedule SB is 5500. (For example, if a plan was not required to file a 2023
required to be filed. Form M–1 annual report by March 1, 2024, for the 2023
‘‘Trust’’ includes any fund or account that receives, holds, calendar year because it experienced a registration event
transmits, or invests plan assets other than an account or between October 1 and December 31, 2023, and made a
policy of an insurance company. A custodial account timely Form M–1 registration filing, the plan must enter on line
arrangement under Code section 403(b)(7) that is required to 11c of the 2023 Form 5500 the Receipt Confirmation Code
complete the Form 5500 should mark “trust” for both the plan issued for the Form M–1 registration filing.)
funding arrangement and the plan benefit arrangement. A welfare benefit plan’s failure to answer line 11a, and if
‘‘General assets of the sponsor’’ means either the plan applicable, lines 11b and 11c, or enter a valid Receipt
had no assets or some assets were commingled with the Confirmation Code in line 11c, will subject the Form 5500 filing
general assets of the plan sponsor prior to the time the plan to rejection as incomplete and civil penalties may be assessed
actually provided the benefits promised. pursuant to ERISA Section 502(c)(2) and 29 CFR 2560.502c-
Example. If the plan holds all its assets invested in registered 2.
investment companies and other non-insurance company
investments until it purchases annuities to pay out the benefits
promised under the plan, box 9a(3) should be checked as the
funding arrangement and box 9b(1) should be checked as the
benefit arrangement.
Note. An employee benefit plan that checks boxes 9a(1),
9a(2), 9b(1), and/or 9b(2) must attach Schedule A (Form
5500), Insurance Information, to provide information
concerning each contract year ending with or within the plan
year. See the instructions to the Schedule A and enter the
number of Schedules A on line 10b(3), if applicable.
Line 10. Check the boxes on line 10 to indicate the schedules
being filed and, where applicable, count the schedules and
enter the number of attached schedules in the space provided.
Form M-1 Compliance Information (to be
provided by all welfare plans).
Line 11a. All plans providing welfare benefits must complete
Part III, line 11a by answering either “Yes” or “No.” Do not
leave the answer blank. If the plan is a multiple-employer
welfare arrangement or an Entity Claiming Exception (ECE)
subject to the Form M-1, Report for Multiple-Employer Welfare
Arrangements (MEWAs) and Certain Entities Claiming
Exception (ECEs) filing requirements, check “Yes” and
complete line 11, elements 11b and 11c. If the answer is “No,”
skip elements 11b and 11c of line 11.
Generally, a Form M-1 must be filed each year by March 1 st
following the calendar year in which a plan operates subject to
the Form M-1 filing requirement. (For example, a plan MEWA
that was operating in 2023 must file the 2023 Form M-1 annual
report by March 1, 2024.) In addition, Form M-1 filings are
necessary in the case of certain registration, origination, or
special events. See the instructions for Form M-1 at
www.askebsa.dol.gov/mewa, and 29 CFR 2520.101-2 for more
information regarding the Form M-1 filing requirements for plan
MEWAs and ECEs.
Line 11b. All plans that answered ‘‘Yes’’ in line 11a must
complete line 11b by answering either ‘‘Yes’’ or ‘‘No.’’ Do not
leave the answer blank.
Line 11c. All plans that answered ‘‘Yes’’ in line 11a must enter
a Receipt Confirmation Code for the 2023 Form M–1 annual
report that was required to be filed with the Department of

Instructions for Part I and Part II of Form 5500 -21-

- 22 -

                     LIST OF PLAN CHARACTERISTICS CODES FOR LINES 8a AND 8b 
                                                                      
 CODE  Defined Benefit Pension Features                                   2F  ERISA section 404(c) plan – This plan, or any part of it, 
                                                                              is intended to meet the conditions of 29 CFR 2550.404c-
 1A    Benefits are primarily pay related.                                    1.  
 1B    Benefits are primarily flat dollar (includes dollars per year      2G  Total participant-directed account plan – Participants 
       of service).                                                           have the opportunity to direct the investment of all the 
                                                                              assets allocated to their individual accounts, regardless 
 1C    Cash balance or similar plan – Plan has a “cash balance”               of whether 29 CFR 2550.404c-1 is intended to be met.  
       formula. For this purpose, a “cash balance” formula is a           2H  Partial participant-directed account plan – Participants 
       benefit formula in a defined benefit plan by whatever                  have the opportunity to direct the investment of a portion 
       name (for example, personal account plan, pension                      of the assets allocated to their individual accounts, 
       equity plan, life cycle plan, cash account plan, etc.) that            regardless of whether 29 CFR 2550.404c-1 is intended 
       rather than, or in addition to, expressing the accrued                 to be met.  
       benefit as a life annuity commencing at normal 
       retirement age, defines benefits for each employee in              2I  Stock bonus. 
       terms more common to a defined contribution plan such              2J  Code section 401(k) feature – A cash or deferred 
       as a single sum distribution amount (for example, 10% of               arrangement described in Code section 401(k) that is 
       final average pay times years of service, or the amount                part of a qualified defined contribution plan that provides 
       of the employee’s hypothetical account balance).                       for an election by employees to defer part of their 
                                                                              compensation or receive these amounts in cash.  
 1D    Floor-offset plan – to offset for retirement benefits              2K  Code section 401(m) arrangement – Employee 
       provided by an employer-sponsored defined contribution                 contributions are allocated to separate accounts under 
       plan.                                                                  the plan or employer contributions are based, in whole or 
                                                                              in part, on employee deferrals or contributions to the 
 1E    Code section 401(h) arrangement – Plan contains                        plan. Not applicable if plan is a Code section 401(k) plan 
       separate accounts under Code section 401(h) to provide                 with only QNECs and/or QMACs. Also not applicable if 
       employee health benefits.                                              plan is a Code section 403(b)(1), 403(b)(7), or 408 
                                                                              arrangement/accounts annuities.  
 1F    Code section 414(k) arrangement – Benefits are based                   An annuity contract purchased by Code section 501(c)(3) 
       partly on the balance of the separate account of the               2L  organization or public school as described in Code 
       participant (also include appropriate defined contribution             section 403(b)(1) arrangement.” 
       pension feature codes).                                                Custodial accounts for regulated investment company 
 1H    Plan covered by PBGC that was terminated and closed                2M  stock as described in Code section 403(b)(7). 
       out for PBGC purposes – Before the end of the plan year                Code section 408 accounts and annuities – See Limited 
       (or a prior plan year), (1) the plan terminated in a                   Pension Plan Reporting instructions for pension plan 
       standard (or distress) termination and completed the               2N  utilizing Code section 408 individual retirement accounts 
       distribution of plan assets in satisfaction of all benefit             or annuities as the funding vehicle for providing benefits. 
       liabilities (or all ERISA Title IV benefits for distress           2O  ESOP other than a leveraged ESOP. 
       termination); or (2) a trustee was appointed for a 
       terminated plan pursuant to ERISA section 4042.                    2P  Leveraged ESOP – An ESOP that acquires employer 
 1I    Frozen plan – As of the last day of the plan year, the plan            securities with borrowed money or other debt-financing 
       provides that no participant will get any new benefit                  techniques. 
       accrual (whether because of service or compensation).              2Q  The employer maintaining this ESOP is an S corporation. 

 CODE  Defined Contribution Pension Features                              2R  Participant-directed brokerage accounts provided as an 
 2A    Use this code if employer contributions in the return year             investment option under the plan.  
       were based on one of the following allocation types:               2S  401(k) plan or 403(b) plan that provides for automatic 
       Age/service weighted or new comparability or similar                   enrollment in plan that has elective contributions 
       plan – Age/service weighted plan: Allocations are based                deducted from payroll. 
       on age, service, or age and service. New comparability 
       or similar plan: Allocations are based on participant              2T  Total or partial participant-directed account plan – plan 
       classifications and a classification(s) consists entirely or           uses default investment account for participants who fail 
       predominantly of highly compensated employees; or the                  to direct assets in their account.  
       plan provides an additional allocation rate on 
       compensation above a specified threshold, and the                  2U  Multiple-employer pension plan sponsored by a bona fide 
       threshold or additional rate exceeds the maximum                       group or association of employers that is an Association 
       threshold or rate allowed under the permitted disparity                Retirement Plan that meets all the conditions under 29 
       rules of Code section 401(l).                                          CFR 2510.3-55(b). 
 2B    Target benefit plan.                                               2V  Multiple-employer pension plan that is a Professional 
                                                                              Employer Organization Plan (PEO Plan) that meets all 
 2C    Money purchase (other than target benefit) plan.                       the conditions under 29 CFR 2510.3-55(c). 
 2D    Offset plan – Plan benefits are subject to offset for 
       retirement benefits provided in another plan or                    2W  Multiple-employer pension plan that is a pooled employer 
       arrangement of the employer.                                           plan that meets the definition under ERISA section 3(43). 

 2E    Profit-sharing plan.  

                                                                     -22-     Instructions for Part I and Part II of Form 5500

- 23 -

LIST OF PLAN CHARACTERISTICS CODES FOR LINES 8a AND 8b (Continued)

2X Multiple-employer defined contribution pension plan that 4K Scholarship (funded).
does not fall under characteristics codes 2U, 2V or 2W. 4L Death benefits (include travel accident but not life
insurance).
CODE Other Pension Benefit Features
4P Taft-Hartley Financial Assistance for Employee Housing
Expenses.
3B Use this code if the plan covered self-employed
individuals in the return year. 4Q Other.
3C Plan not intended to be qualified - A plan not intended to 4R Unfunded, fully insured, or combination unfunded/fully
be qualified under Code sections 401, 403, or 408. insured welfare plan that will not file an annual report for
3D Pre-approved pension plan - A pre-approved plan under next plan year pursuant to 29 CFR 2520.104-20.
sections 401, 403(a), 403(b), and 4975(e)(7) of the Code 4S Unfunded, fully insured, or combination unfunded/fully
that is subject to a favorable opinion letter from the IRS. insured welfare plan that stopped filing annual reports in
3F Plan sponsor(s) received services of leased employees, an earlier plan year pursuant to 29 CFR 2520.104-20.
as defined in Code section 414(n), during the plan year.
4T 10 or more employer plan under Code section
3H Plan sponsor(s) is (are) a member(s) of a controlled 419A(f)(6).
group under Code section 414(b) or (c) or of an affiliated
service group under section 414(m). 4U Collectively-bargained welfare benefit arrangement
3I Plan requiring that all or part of employer contributions under Code section 419A(f)(5).
be invested and held, at least for a limited period, in
employer securities.

3J U.S.-based plan that covers residents of Puerto Rico and
is qualified under both Code section 401 and section
1165 of the Internal Revenue Code of Puerto Rico.
CODE Welfare Benefit Features
4A Health (other than vision or dental).
4B Life insurance.
4C Supplemental unemployment.
4D Dental.
4E Vision.
4F Temporary disability (accident and sickness).
4G Prepaid legal.
4H Long-term disability.
4I Severance pay.
4J Apprenticeship and training.

Instructions for Part I and Part II of Form 5500 23

- 24 -

Lines A, B, C, and D. This information must be the same as
2023 Instructions for Schedule A reported in Part II of the Form 5500 to which this Schedule A is
attached.
(Form 5500) Do not use a social security number in lieu of an EIN. The
Insurance Information Schedule A and its attachments are open to public inspection,
and the contents are public information and are subject to
publication on the Internet. Because of privacy concerns, the
General Instructions inclusion of a social security number or any portion thereof on
Who Must File this Schedule A or any of its attachments may result in the
Schedule A (Form 5500) must be attached to the Form 5500 rejection of the filing.
filed for every defined benefit pension plan, defined You can apply for an EIN from the IRS online, by fax, or by
contribution pension plan, and welfare benefit plan required to mail depending on how soon you need to use the EIN. For
file a Form 5500 if any benefits under the plan are provided by more information, see Section 3: Electronic Filing Requirement
an insurance company, insurance service, or other similar under General Instructions to Form 5500. The EBSA does not
organization (such as Blue Cross, Blue Shield, or a health issue EINs.
maintenance organization). This includes investment contracts Part I – Information Concerning Insurance Contract
with insurance companies such as guaranteed investment Coverage, Fees, and Commissions
contracts (GICs). In addition, Schedule A must be attached to
a Form 5500 filed for GIAs, MTIAs, DCGs and 103-12 IEs for Line 1(c). Enter the code number assigned by the National
each insurance or annuity contract held in the MTIA, or 103-12 Association of Insurance Commissioners (NAIC) to the
IE or by the DCG or GIA. insurance company. If none has been assigned, enter zeros
“0” in the spaces provided.
Note. In the case of a DCG, a Schedule A must be completed
on an aggregate basis for all insurance or annuity contracts Line 1(d). If individual policies with the same carrier are
that constitute one of the investments or investment options grouped as a unit for purposes of this report, and the group
available to all of the participants in a DCG participating plan, does not have one identification number, you may use the
regardless of whether certificates are issued to individual plans contract or identification number of one of the individual
or participants upon selection of that option by a participant. contracts, provided this number is used consistently to report
these contracts as a group and the plan administrator
If Form 5500 line 9a(1), 9a(2), 9b(1), or 9b(2) is maintains the records necessary to disclose all the individual
checked, indicating that either the plan funding contract numbers in the group upon request. Use separate
arrangement or plan benefit arrangement includes an account, Schedules A to report individual contracts that cannot be
policy, or contract with an insurance company (or similar grouped as a unit.
organization), at least one Schedule A would be required to be
attached to the Form 5500 filed for a pension or welfare plan to Line 1(e). Since plan coverage may fluctuate during the year,
provide information concerning the contract year ending with or the administrator should estimate the number of persons that
within the plan year. were covered by the contract at the end of the policy or contract
year. Where contracts covering individual employees are
Do not file Schedule A for a contract that is an Administrative grouped, compute entries as of the end of the plan year.
Services Only (ASO) contract, a fidelity bond or policy, or a
fiduciary liability insurance policy. Also, if a Schedule A for a Line 1(f) and (g). Enter the beginning and ending dates of the
contract or policy is filed as part of a Form 5500 for an MTIA or policy year for the contract identified in 1(d). Leave 1(f) blank if
103-12 IE that holds the contract, do not include a Schedule A separate contracts covering individual employees are grouped.
for the contract or policy on the Form 5500s filed for the plans Line 2. Report on line 2 the total of all insurance fees and
participating in the MTIA or 103-12 IE. commissions directly or indirectly attributable to the contract or
Check the Schedule A box on the Form 5500 (Part II, line policy placed with or retained by the plan.
10b(3)), and enter the number attached in the space provided Totals. Enter on line 2 the total of all such commissions and
if one or more Schedules A are attached to the Form 5500. fees paid to agents, brokers, and other persons listed on line 3.
Complete a separate line 3 item (elements (a) through (e)) for
Specific Instructions each person listed.
Information entered on Schedule A should pertain to the For purposes of lines 2 and 3, commissions and fees
insurance contract or policy year ending with or within the plan include sales and base commissions and all other monetary
year (for reporting purposes, a year cannot exceed 12 and non-monetary forms of compensation where the broker’s
months). agent’s, or other person’s eligibility for the payment or the
Example. If an insurance contract year begins on July 1 and amount of the payment is based, in whole or in part, on the
ends on June 30, and the plan year begins on January 1 and value (e.g., policy amounts, premiums) of contracts or policies
ends on December 31, the information on the Schedule A (or classes thereof) placed with or retained by an ERISA plan,
attached to the 2023 Form 5500 should be for the insurance including, for example, persistency and profitability bonuses.
contract year ending on June 30, 2023. The amount (or pro rata share of the total) of such
Exception. If the insurance company maintains records on the commissions or fees attributable to the contract or policy
basis of a plan year rather than a policy or contract year, the placed with or retained by the plan must be reported in line 2
information entered on Schedule A may pertain to the plan and in line 3, element (b) and/or (c), as appropriate.
year instead of the policy or contract year. Insurers must provide plan administrators with a
Include only the contracts issued to or held by the plan, proportionate allocation of commissions and fees attributable
GIA, MTIA, DCG or 103-12 IE for which the Form 5500 is to each contract. Any reasonable method of allocating
being filed. commissions and fees to policies or contracts is acceptable,
provided the method is disclosed to the plan administrator. A
reasonable allocation method could, in the Department of

-24- Instructions for Schedule A (Form 5500)

- 25 -

Labor’s view, allocate fees and commissions to a Schedule A          though the total cost of the refreshments for all the employees 
based on a calendar year calculation even if the plan year or        would be $120. 
policy year was not a calendar year. For additional information       These thresholds are for purposes of Schedule A reporting. 
on these Schedule A reporting requirements, see ERISA                Filers are cautioned that the payment or receipt of gifts and 
Advisory Opinion 2005-02A, available on the Internet at              gratuities of any amount by plan fiduciaries may violate ERISA 
www.dol.gov/ebsa.                                                    and give rise to civil liabilities and criminal penalties. 
 Where benefits under a plan are purchased from and                  Line 3. Identify agents, brokers, and other persons individually 
guaranteed by an insurance company, insurance service, or            in descending order of the amount paid. Complete as many 
other similar organization, and the contract or policy is reported   entries as necessary to report all required information. 
on a Schedule A, payments of reasonable monetary                     Complete elements (a) through (e) for each person as 
compensation by the insurer out of its general assets to             specified below.  
affiliates or third parties for performing administrative activities 
necessary for the insurer to fulfill its contractual obligation to   Element (a). Enter the name and address of the agents, 
provide benefits, where there is no direct or indirect charge to     brokers, or other persons to whom commissions or fees were 
the plan for the administrative services other than the              paid. 
insurance premium, then the payments for administrative              Element (b). Report all sales and base commissions here. For 
services by the insurer to the affiliates or third parties do not    purposes of this element, sales and/or base commissions are 
need to be reported on lines 2 and 3 of Schedule A. This would       monetary amounts paid by an insurer that are charged directly 
include compensation for services such as recordkeeping and          to the contract or policy and that are paid to a licensed agent or 
claims processing services provided by a third party pursuant        broker for the sale or placement of the contract or policy. All 
to a contract with the insurer to provide those services but         other payments should be reported in element   (c) as fees. 
would not include compensation provided by the insurer               Element (c). Fees to be reported here represent payments by 
incidental to the sale or renewal of a policy, such as finder’s      an insurer attributable directly or indirectly to a contract or 
fees, insurance brokerage commissions and fees, or similar           policy to agents, brokers, and other persons for items other 
fees.                                                                than sales and/or base commissions (e.g., service fees, 
 Schedule A reporting also is not required for compensation          consulting fees, finders fees, profitability and persistency 
paid by the insurer to a “general agent” or “manager” for that       bonuses, awards, prizes, and non-monetary forms of 
general agent’s or manager’s management of an agency or              compensation). Fees paid to persons other than agents and 
performance of administrative functions for the insurer. For this    brokers should be reported here, not in Parts II and III on 
purpose, (1) a “general agent” or “manager” does not include         Schedule A as acquisition costs, administrative charges, etc. 
brokers representing insureds, and (2) payments would not be         Element (d). Enter the purpose(s) for which fees were paid. 
treated as paid for managing an agency or performance of             Element (e). Enter the most appropriate organization code for 
administrative functions where the recipient’s eligibility for the   the broker, agent, or other person entered in element      (a). 
payment or the amount of the payment is dependent or based 
on the value (e.g., policy amounts, premiums) of contracts or        Code   Type of Organization 
policies (or classes thereof) placed with or retained by ERISA       1      Banking, Savings & Loan Association, Credit Union, 
plan(s).                                                                    or other similar financial institution 
 Schedule A reporting is not required for occasional non-            2      Trust Company 
monetary gifts or meals of insubstantial value that are tax          3      Insurance Agent or Broker 
deductible for federal income tax purposes by the person             4      Agent or Broker other than insurance 
providing the gift or meal and would not be taxable income to        5      Third party administrator 
the recipient. For this exemption to be available, the gift or       6      Investment Company/Mutual Fund 
gratuity must be both occasional and insubstantial. For this         7      Investment Manager/Adviser 
exemption to apply, the gift must be valued at less than $50,        8      Labor Union 
the aggregate value of gifts from one source in a calendar year      9      Foreign entity (e.g., an agent or broker, bank, 
must be less than $100, but gifts with a value of less than $10             insurance company, etc., not operating within the 
do not need to be counted toward the $100 annual limit. If the              jurisdictional boundaries of the United States) 
$100 aggregate value limit is exceeded, then the aggregate           0      Other 
value of all the gifts will be reportable. For this purpose, non-     For plans, GIAs, MTIAs, DCGs and 103-12 IEs required to 
monetary gifts of less than $10 also do not need to be included      file Part I of Schedule C, commissions and fees listed on the 
in calculating the aggregate value of all gifts required to be       Schedule A are not required to be reported again on Schedule 
reported if the $100 limit is exceeded.                              C. The amount of the compensation that must be reported on 
 Gifts from multiple employees of one service provider               Schedule A must, however, be taken into account in 
should be treated as originating from a single source when           determining whether the agent’s, broker’s, or other person’s 
calculating whether the $100 threshold applies. On the other         direct or indirect compensation in relation to the plan or DFE is 
hand, in applying the threshold to an occasional gift received       $5,000 or more and, thus, requiring the compensation not 
from one source by multiple employees of a single service            listed on the Schedule A to be reported on the Schedule C. 
provider, the amount received by each employee should be             See FAQs about the Schedule C available on the EBSA 
separately determined in applying the $50 and $100                   website at www.dol.gov/ebsa/faqs . 
thresholds. For example, if six employees of a broker attend a       Part II – Investment and Annuity Contract 
business conference put on by an insurer designed to educate         Information 
and explain the insurer’s products for employee benefit plans, 
and the insurer provides, at no cost to the attendees,               Line 4. Enter the current value of the plan’s interest at year 
refreshments valued at $20 per individual, the gratuities would      end in the contract reported on line 7, e.g., deposit 
not be reportable on lines 2 and 3 of the Schedule A even            administration (DA), immediate participation guarantee (IPG), 
                                                                     or guaranteed investment contracts (GIC). 

Instructions for Schedule A (Form 5500)                         -25-

- 26 -

Exception. Contracts reported on line 7 need not be included Part IV – Provision of Information
on line 4 if (1) the Schedule A is filed for a defined benefit The insurance company, insurance service, or other similar
pension plan and the contract was entered into before March organization is required under ERISA section 103(a)(2) to
20, 1992, or (2) the Schedule A is filed for a defined provide the plan administrator with the information needed to
contribution pension plan and the contract is a fully benefit- complete this return/report. If you do not receive this
responsive contract, i.e., it provides a liquidity guarantee by a information in a timely manner, contact the insurance
financially responsible third party of principal and previously company, insurance service, or other similar organization.
accrued interest for liquidations, transfers, loans, or hardship Lines 11 and 12. If information is missing on Schedule A due
withdrawals initiated by plan participants exercising their rights to a refusal by the insurance company, insurance service, or
to withdraw, borrow, or transfer funds under the terms of a other similar organization to provide information, check “Yes”
defined contribution plan that does not include substantial on line 11 and enter a description of the information not
restrictions to participants’ access to plan funds. provided on line 12. If you received all the information
Important Reminder. Plans may treat multiple individual necessary to complete the Schedule A, check “No” and leave
annuity contracts, including Code section 403(b)(1) annuity line 12 blank.
contracts, issued by the same insurance company as a single As noted above, the insurance company, insurance
group contract for reporting purposes on Schedule A. service, or other similar organization is statutorily
Line 6a. The rate information called for here may be furnished required to provide you with all of the information necessary to
by attaching the appropriate schedules of current rates filed complete the Schedule A but need not provide the information
with the appropriate state insurance department or by on a Schedule A itself.
providing a statement regarding the basis of the rates. Enter
“see attached” if appropriate.
Lines 7a through 7f. Report contracts with unallocated funds.
Do not include portions of these contracts maintained in
separate accounts. Show deposit fund amounts rather than
experience credit records when both are maintained.
Part III – Welfare Benefit Contract Information
Line 8i. Report a stop-loss insurance policy that is an asset of
the plan.
Note. Employers sponsoring welfare plans may purchase a
stop-loss insurance policy with the employer as the insured to
help the employer manage its risk associated with its liabilities
under the plan. These employer contracts with premiums paid
exclusively out of the employer’s general assets without any
employee contributions generally are not plan assets and are
not reportable on Schedule A.

- 26- Instructions for Schedule A (Form 5500)

- 27 -

                                                                   particular plan. The $5,000 threshold is based on the total 
2023 Instructions for Schedule C                                   amount received by the service provider from all sources, not 
(Form 5500)                                                        broken down and measured on a per plan or other allocated 
                                                                   method.   
Service Provider Information 
                                                                         Health and welfare plans that meet the conditions of the 
General Instructions                                                     limited exemption at 29 CFR 2520.104-44 or Technical 
                                                                   Release 92-01 are not required to complete and file a 
Who Must File                                                      Schedule C. 
Schedule C (Form 5500) must be attached to a Form 5500             Lines A, B, C, and D. This information must be the same as 
filed for a large pension or welfare benefit plan, an MTIA, a      reported in Part II of the Form 5500 to which this Schedule C is 
103-12 IE, DCG or a GIA to report certain information              attached. 
concerning service providers. Remember to check the 
Schedule C box on the Form 5500 (Part II, line 10b(4)) if a         Do not use a social security number in line D in lieu of an 
Schedule C is attached to the Form 5500.                           EIN. The Schedule C and its attachments are open to public 
                                                                   inspection, and the contents are public information subject to 
 Part I of the Schedule C must be completed to report              publication on the Internet. Because of privacy concerns, the 
persons who rendered services to or who had transactions with      inclusion of a social security number or any portion thereof on 
the plan (or with the DFE in the case of a Schedule C filed by a   this Schedule C or any of its attachments may result in the 
DFE) during the reporting year if the person received, directly    rejection of the filing.  
or indirectly, $5,000 or more in reportable compensation in 
connection with services rendered or their position with the        You can apply for an EIN from the IRS online, by fax, or by 
plan or DFE, except:                                               mail depending on how soon you need to use the EIN. For 
                                                                   more information, see Section 3: Electronic Filing Requirement 
 1. Employees of the plan whose only compensation in               under General Instructions to Form 5500. The EBSA does not 
relation to the plan was less than $25,000 for the plan year;      issue EINs. 
 2. Employees of the plan sponsor or other business entity 
where the plan sponsor or business entity is reported on the        Do not list the PBGC or the IRS on Schedule C as service 
Schedule C as a service provider, provided the employee did        providers. 
not separately receive reportable direct or indirect                Either the cash or accrual basis may be used for the 
compensation in relation to the plan;                              recognition of transactions reported on the Schedule C as long 
 3. Persons whose only compensation in relation to the plan        as you use one method consistently. 
consists of insurance fees and commissions listed in a              If service provider compensation is reported on a Schedule 
Schedule A filed for the plan; and                                 C filed as a part of a Form 5500 filed for a MTIA or a 103-12 
 4. Payments made directly by the plan sponsor that are not        IE, do not report the same compensation again on the 
reimbursed by the plan. In the case of a multiemployer or          Schedule C filed for the plans that participate in the MTIA or 
multiple-employer plan, where the “plan sponsor” would be the      103-12 IE. 
joint board of trustees for the plan, payments by contributing 
employers, directly or through an employer association, or by      Specific Instructions 
participating employee organizations, should be treated the        Part I  Service Provider Information  – 
same as payments by a plan sponsor.                                You must enter the information required for each person who 
 Only line 1 of Part I of the Schedule C must be completed         rendered services to or had transactions with the plan and 
for persons who received only “eligible indirect compensation”     who received $5,000 or more in total direct or indirect 
as defined below.                                                  compensation in connection with services rendered to the 
 Part II of the Schedule C must be completed to report             plan or the person’s position with the plan during the plan 
service providers who fail or refuse to provide information        year. 
necessary to complete Part I of this Schedule.                      Example. A plan had service providers, A, B, C, and D, 
 Part III of the Schedule C must be completed to report a          who received $12,000, $6,000, $4,500, and $430, 
termination in the appointment of an accountant or enrolled        respectively, in direct and indirect compensation from the 
actuary during the 2023 plan year.                                 plan. Service providers A and B must be identified 
 For plans, GIAs, MTIAs, DCGs and 103-12 IEs required to           separately by name, EIN, etc. As service providers C and D 
file Part I of Schedule C, commissions and fees listed on the      each received less than $5,000, they do not need to be 
Schedule A are not required to be reported again on Schedule       reported on the Schedule C. 
C. The amount of the compensation that must be reported on          For Schedule C purposes, reportable compensation 
Schedule A must, however, be taken into account in                 includes money and any other thing of value (for example, 
determining whether the service provider’s direct or indirect      gifts, awards, trips) received by a person, directly or indirectly, 
compensation in relation to the plan or DFE is $5,000 or more      from the plan (including fees charged as a percentage of 
and, thus, requiring the compensation not listed on the            assets and deducted from investment returns) in connection 
Schedule A to be reported on the Schedule C. See FAQs              with services rendered to the plan, or the person’s position with 
about the Schedule C available on the EBSA website at              the plan. The term “person” for this purpose includes 
www.dol.gov/ebsa/faqs.                                             individuals, trades and businesses (whether incorporated or 
Note: In the case of a DCG, each service provider to the DCG       unincorporated). See ERISA section 3(9). 
and to each of the separate plans in the DCG must be reported       Direct Compensation: Payments made directly by the 
on the Schedule C, even if the service provider did not actually   plan for services rendered to the plan or because of a person’s 
provide services or charge fees to a particular plan because,      position with the plan are reportable as direct compensation. 
for example, the service provider provided investment              Direct payments by the plan would include, for example, direct 
management services with respect to a particular investment        payments by the plan out of a plan account, charges to plan 
option that was not selected by any of the participants in a       forfeiture accounts and fee recapture accounts, charges to a 

Instructions for Schedule C (Form 5500)                       -27-

- 28 -

plan’s trust account before allocations are made to individual           indirect compensation paid to a plan service provider or in 
participant accounts, and direct charges to plan participant             connection with a transaction with the plan. 
individual accounts. Payments made by the plan sponsor,                   Other examples of reportable indirect compensation are 
which are not reimbursed by the plan, are not subject to                 finder’s fees, float revenue, brokerage commissions 
Schedule C reporting requirements even if the sponsor is                 (regardless of whether the broker is granted discretion), 
paying for services rendered to the plan.                                research or other products or services, other than execution, 
 Indirect Compensation: Compensation received from                       received from a broker-dealer or other third party in connection 
sources other than directly from the plan or plan sponsor is             with securities transactions (soft dollars), and other transaction 
reportable on Schedule C as indirect compensation from the               based fees received in connection with transactions or 
plan if the compensation was received in connection with                 services involving the plan whether or not they are capitalized 
services rendered to the plan during the plan year or the                as investment costs. 
person’s position with the plan. For this purpose,                        For more information, see FAQs about the Schedule C, 
compensation is considered to have been received in                      available on the EBSA website at www.dol.gov/ebsa/faqs. 
connection with services rendered to the plan or the person’s 
position with the plan if the person’s eligibility for a payment is      Special rules for non-monetary compensation of 
based, in whole or in part, on services that were rendered to            insubstantial value, guaranteed benefit insurance policies, 
the plan or on a transaction or series of transactions with the          bundled service arrangements, and allocating 
plan. Indirect compensation would not include compensation               compensation among multiple plans: 
that would have been received had the service not been                    Excludable Non-Monetary Compensation: You may 
rendered or the transaction had not taken place and that                 exclude non-monetary compensation of insubstantial value 
cannot be reasonably allocated to the services performed or              (such as gifts or meals of insubstantial value) that is tax 
transaction(s) with the plan.                                            deductible for federal income tax purposes by the person 
 Persons that provide investment management,                             providing the gift or meal and would not be taxable income to 
recordkeeping, claims processing, participant communication,             the recipient. The gift or gratuity must be valued at less than 
brokerage, and other services to the plan as part of an                  $50, and the aggregate value of gifts from one source in a 
investment contract or transaction are considered to be                  calendar year must be less than $100, but gifts with a value of 
providing services to the plan for purposes of Schedule C                less than $10 do not need to be counted toward the $100 limit. 
reporting and would be required to be identified in Part I if they       If the $100 aggregate value limit is exceeded, then the value of 
received $5,000 or more in reportable compensation for                   all the gifts over $10 will be reportable. Gifts received by one 
providing those services.                                                person from multiple employees of one entity must be treated 
 Examples of reportable indirect compensation include fees               as originating from a single source when calculating whether 
and expense reimbursement payments received by a person                  the $100 threshold applies. On the other hand, gifts received 
from mutual funds, bank commingled trusts, insurance                     from one person by multiple employees of one entity can be 
company pooled separate accounts, and other separately                   treated as separate compensation when calculating the $50 
managed accounts and pooled investment funds in which the                and $100 thresholds. For more information, see FAQs about 
plan invests that are charged against the fund or account and            the Schedule C, available on the EBSA website at 
reflected in the value of the plan’s investment (such as                 www.dol.gov/agencies/ebsa/about-ebsa/our-
management fees paid by a mutual fund to its investment                  activities/resource-center/faqs  .
adviser, sub-transfer agency fees, shareholder servicing fees,            These thresholds are for purposes of Schedule C 
account maintenance fees, and 12b-1 distribution fees). The               reporting only. Filers are strongly cautioned that gifts and 
investment of plan assets and payment of premiums for                    gratuities of any amount paid to or received by plan fiduciaries 
insurance contracts, however, are not in and of themselves               may violate ERISA and give rise to civil liabilities and criminal  
payments for services rendered to the plan for purposes of               penalties. 
Schedule C reporting and the investment and payment of 
                                                                          Fully Insured Group Health and Similarly Fully Insured 
premiums themselves are not reportable compensation for 
                                                                         Benefits: Where benefits under a plan are purchased from 
purposes of Part I of the Schedule C. 
                                                                         and guaranteed by an insurance company, insurance service, 
 In the case of charges against an investment fund,                      or other similar organization, and the contract or policy is 
reportable “indirect compensation” includes, for example, the            reported on a Schedule A, payments of reasonable monetary 
fund’s investment adviser asset-based investment                         compensation by the insurer out of its general assets to 
management fee from the fund, brokerage commissions and                  persons for performing administrative activities necessary for 
fees charged in connection with purchases and sales of                   the insurer to fulfill its contractual obligation to provide benefits, 
interests in the fund, fees related to purchases and sales of            where there is no direct or indirect charge to the plan for the 
interests in the fund (including 12b-1 fees), fees for providing         administrative services other than the insurance premium, 
services to plan investors or plan participants such as                  would not be treated as indirect compensation for services 
communication and other shareholder services, and fees                   provided to the plan for Schedule C reporting purposes. This 
relating to the administration of the employee benefit plan such         would include compensation for services such as 
as recordkeeping services, Form 5500 return/report filing and            recordkeeping and claims processing services provided by a 
other compliance services. Amounts charged against the fund              third party pursuant to a contract with the insurer to provide 
for other ordinary operating expenses, such as attorneys’ fees,          those services, but would not include compensation provided 
accountants’ fees, printers fees, are not reportable indirect            by the insurer incidental to the sale or renewal of a policy, such 
compensation for Schedule C purposes. Also, brokerage costs              as finder’s fees, insurance brokerage commissions and fees, 
associated with a broker-dealer effecting securities                     or similar fees. Insurance investment contracts are not eligible 
transactions within the portfolio of a mutual fund or for the            for this exception. 
portfolio of an investment fund that holds “plan assets” for 
                                                                          Bundled Service Arrangements: For Schedule C 
ERISA purposes should be treated for Schedule C purposes 
                                                                         reporting purposes, a bundled service arrangement includes 
as an operating expense of the investment fund, not reportable 
                                                                         any service arrangements where the plan hires one company 
                                                                    -28-                     Instructions for Schedule C (Form 5500)

- 29 -

to provide a range of services either directly from the              you check “Yes” on line 1a, provide as many entries in line 1b 
company, through affiliates or subcontractors, or through a          as necessary to identify the person or persons who provided 
combination, which are priced to the plan as a single package        you with the necessary disclosures regarding the eligible 
rather than on a service-by-service basis. A bundled service         indirect compensation. If any indirect compensation is either 
arrangement would also include an investment transaction in          not of the type described below or if the plan did not receive 
which the plan receives a range of services either directly from     the written disclosures described below, the indirect 
the investment provider, through affiliates or subcontractors, or    compensation is not “eligible indirect compensation” for 
through a combination .                                              purposes of Part 1. 
 Direct payments by the plan to the bundled service provider          (1) Eligible Indirect Compensation: The types of indirect 
should be reported as direct compensation to the bundled             compensation that can be treated as eligible indirect 
service provider. Such direct payments by the plan do not            compensation are indirect compensation that is fees or 
need to be allocated among affiliates or subcontractors and do       expense reimbursement payments charged to investment 
not need to be reported as indirect compensation received by         funds and reflected in the value of the investment or return on 
the affiliates or subcontractors unless the amount paid to the       investment of the participating plan or its participants, finder’s 
affiliate or subcontractor is set on a per transaction basis, e.g.,  fees, “soft dollar” revenue, float revenue, and/or brokerage 
brokerage fees and commissions.                                      commissions or other transaction-based fees for transactions 
 Fees charged to the plan’s investment and reflected in the          or services involving the plan that were not paid directly by the 
net value of the investment, such as management fees paid by         plan or plan sponsor (whether or not they are capitalized as 
mutual funds to their investment advisers, float revenue,            investment costs). 
commissions (including “soft dollars”), finder’s fees, 12b-1          Investment funds or accounts for this purpose would 
distribution fees, account maintenance fees, and shareholder         include mutual funds, bank commingled trusts, including 
servicing fees, must, subject to the alternative reporting option    common and collective trusts, insurance company pooled 
for “eligible indirect compensation,” described below, be            separate accounts, and other separately managed accounts 
treated as separate reportable compensation by the person            and pooled investment vehicles in which the plan invests. 
receiving the fee for purposes of Schedule C reporting.              Investment funds or accounts would also include separately 
 For each person who is a fiduciary to the plan or provides          managed investment accounts that contain assets of individual 
one or more of the following services to the plan  –  contract       plans. 
administrator, consulting, investment advisory (plan or               (2) Required Written Disclosures: For the types of 
participants), investment management, securities brokerage,          indirect compensation described above to be treated as 
or recordkeeping  –  commissions and other transaction based         eligible indirect compensation for purposes of completing line 
fees, finder’s fees, float revenue, soft dollar and other non-       1, you must have received written materials that disclosed and 
monetary compensation, would also be required to be treated          described (a) the existence of the indirect compensation; (b) 
as separate compensation for Schedule C purposes even if             the services provided for the indirect compensation or the 
those fees were paid from mutual fund management fees or             purpose for payment of the indirect compensation; (c) the 
other fees charged to the plan’s investment and reflected in the     amount (or estimate) of the compensation or a description of 
net value of the investment.                                         the formula used to calculate or determine the compensation; 
 Other revenue sharing payments among members of a                   and (d) the identity of the party or parties paying and receiving 
bundled service arrangement do not need to be allocated              the compensation. The written disclosures for a bundled 
among affiliates or subcontractors and treated as indirect           arrangement must separately disclose and describe each 
compensation received by the affiliates or subcontractors in         element or indirect compensation that would be required to be 
determining whether the affiliate or subcontractor must be           separately reported if you were not relying on this alternative 
separately identified on line 2 of the Schedule C.                   reporting option. 
 For more information about bundled arrangements for                   If any person received eligible indirect compensation 
reporting purposes, see FAQs about the Schedule C, available           and either direct compensation and/or indirect 
on the EBSA website at www.dol.gov/ebsa/faqs.                        compensation that does not meet the requirements of this line 
                                                                     to be eligible indirect compensation, you cannot rely on the 
 Allocating Compensation Among Multiple Plans: Where                 alternative reporting option for that person and must complete 
reportable compensation is received by a person in connection        line 2 for each such person who received $5,000 or more in 
with several plans or DFEs, any reasonable method of                 direct and indirect compensation. 
allocating the compensation among the plans or DFEs may be 
used provided that the allocation method is disclosed to the         Line 2. Except for those persons and eligible indirect  
plan administrator. In calculating the $5,000 threshold for          compensation for which you answered “Yes” to line 1 above, 
purposes of determining whether a person must be identified in       complete as many entries as needed to list each person 
Part I, include the amount of compensation received by the           receiving, directly or indirectly, $5,000 or more in total direct 
person that is attributable to the plan or DFE filing the Form       and indirect compensation. Start with the most highly 
5500, not the aggregate amount received in connection with all       compensated and list in descending order of compensation. 
the plans or DFEs.                                                   Enter in element (a) the person’s name and complete elements 
                                                                     (a) through (h) as specified below. Use as many entries as 
 Affiliates: For purposes of Schedule C reporting, an                necessary to list all persons and information required to be 
“affiliate” of a person includes any person, directly or indirectly, reported. 
through one or more intermediaries, controlling, controlled by, 
or under common control with the person applying principles           Element (a). Enter the EIN for the person identified in 
consistent with the regulations prescribed under section 414(c)      element (a). If the name of an individual is entered in element 
of the Code.                                                         (a) and the individual does not have an EIN, enter the EIN of 
                                                                     the individual’s employer. If the person is self-employed and 
Line 1. Check “Yes” or “No” on line 1a to indicate whether you       does not have an EIN, you may enter the person’s address 
are relying on the alternative reporting option for a person or      and telephone number. Do not use a social security number in 
persons who received only “eligible indirect compensation.” If       lieu of an EIN. The Schedule C and its attachments are open 
Instructions for Schedule C (Form 5500)                        -29-

- 30 -

to public inspection and are subject to publication on the                 Element (c).  Enter any relationship of the person 
Internet. Because of privacy concerns, the inclusion of a social          identified in element (a) to the plan sponsor, to the participating 
security number or any portion thereof on this Schedule C or              employer or employee organization, or to any person known to 
any of its attachments may result in the rejection of the filing.         be a party-in-interest, for example, employee of employer, 
 Element (b).  Select from the list below all codes that                  vice-president of employer, union officer, affiliate of plan 
describe both the kind of services provided and the type of               recordkeeper, etc. 
compensation received. Enter as many codes as apply:                       Element (d).  Enter the total amount of compensation 
 Code   Service/Compensation                                              received directly from the plan for services rendered to the plan 
 10  Accounting (including auditing)                                      during the plan year. If a service provider charges the plan a 
 11  Actuarial                                                            fee or commission, but agrees to offset the fee or commission 
 12  Claims processing                                                    with any revenue received from a party other than the plan or 
 13  Contract Administrator                                               plan sponsor, for example, as part of a commission recapture 
 14  Plan Administrator                                                   or other offset arrangement, only the amount paid directly by 
 15  Recordkeeping and information management (computing,                 the plan after any revenue sharing offset should be entered in 
     tabulating, data processing, etc.)                                   element (d). Enter in element (d), as direct payments by the 
 16  Consulting (general)                                                 plan, amounts that a plan sponsor, or contributing employer or 
 17  Consulting (pension)                                                 participating employee organization in the case of a 
 18  Custodial (other than securities)                                    multiemployer or multiple-employer plan, pays a plan third-
 19  Custodial (securities)                                               party service provider that are reimbursed by the plan. 
 20  Trustee (individual)                                                 Note. Do not leave element (d) blank. If no direct 
 21  Trustee (bank, trust company, or similar financial institution)      compensation was received, enter “0”. 
 22  Insurance agents and brokers                                          Element (e).  Check “Yes” if the person identified in 
 23  Insurance services                                                   element (a), or any related person, received during the plan 
 24  Trustee (discretionary)                                              year indirect compensation in connection with the person’s 
 25  Trustee (directed)                                                   position with the plan or services provided to the plan. (See 
 26  Investment advisory (participants)                                   instructions above on definition of indirect compensation.) If 
 27  Investment advisory (plan)                                           the answer is “No,” skip elements (f) through (h) for the person 
 28  Investment management                                                identified in element (a). 
 29  Legal                                                                 Element (f). Check “Yes” if any of the indirect 
 30  Employee (plan)                                                      compensation was eligible indirect compensation for which the 
 31         Named fiduciary                                               plan received the necessary disclosures. See instructions for 
 32  Real estate brokerage                                                line 1 for definition of eligible indirect compensation. Check 
 33  Securities brokerage                                                 “No” if none of the indirect compensation was eligible indirect 
 34  Valuation (appraisals, etc.)                                         compensation. 
 35  Employee (plan sponsor)                                               Element (g). Enter the total of all indirect compensation 
 36  Copying and duplicating                                              that is not eligible indirect compensation for which the plan 
 37  Participant loan processing                                          received the necessary disclosure. Do not leave blank. If none, 
 38  Participant communication                                            enter “0”. 
 40    Foreign entity (e.g., an agent or broker, bank, insurance           Element (h). Check “Yes” if the service provider, instead of 
     company, etc. not operating within jurisdictional boundaries of      an amount or an estimated amount, gave the plan a formula or 
     the United States)                                                   other description of the method used to determine some or all 
 49  Other services                                                       of the indirect compensation received. 
 50  Direct payment from the plan 
 51  Investment management fees paid directly by plan                     Line 3. For each person identified in line 2 who is a fiduciary to 
 52  Investment management fees paid indirectly by plan                   the plan or provides one or more of the following services to 
 53  Insurance brokerage commissions and fees                             the plan  –  contract administrator, consulting custodial, 
 54  Sales loads (front end and deferred)                                 investment advisory (plan or participants), investment 
 55  Other commissions                                                    management, broker, or recordkeeping  –  enter the requested 
 56  Non-monetary compensation                                            information for each source from whom the person received 
 57  Redemption fees                                                      indirect compensation if (1) the amount of the compensation 
                                                                          was $1,000 or more, or (2) the plan was given a formula or 
 58  Product termination fees (surrender charges, etc.) 
                                                                          other description of the method used to determine the indirect 
 59  Shareholder servicing fees                                           compensation rather than an amount or estimated amount of 
 60  Sub-transfer agency fees                                             the indirect compensation. 
 61  Finders’ fees/placement fees 
 62  Float revenue                                                        Part II  Service Providers Who Fail or Refuse To –
 63  Distribution (12b-1) fees                                            Provide Information  
 64  Recordkeeping fees                                                   Line 4.  Provide the requested information for each plan 
 65  Account maintenance fees                                             fiduciary or service provider who you believe failed or refused 
 66  Insurance mortality and expense charge                               to provide any of the information necessary to complete Part I 
 67  Other insurance wrap fees                                            of this schedule. 
 68  “’Soft dollars’ commissions”                                         Important Reminder.  Before identifying a fiduciary or service 
 70  Consulting fees                                                      provider as a person who failed or refused to provide 
 71  Securities brokerage commissions and fees                            information, you should contact the fiduciary or service 
 72  Other investment fees and expenses                                   provider to request the necessary information and tell them 
 73  Other insurance fees and expenses                                    that you will list them on the Schedule C as a fiduciary or 
 99  Other fees 
                                                                     -30-                    Instructions for Schedule C (Form 5500)

- 31 -

service provider who failed or refused to provide information if      an accountant or enrolled actuary. Include a description of any 
they do not provide the necessary information.                        material disputes or matters of disagreement concerning the 
Part III – Termination Information on Accountants                     termination, even if resolved prior to the termination. If an 
                                                                      individual is listed, and the individual does not have an EIN, 
and Enrolled Actuaries 
                                                                      the EIN to be entered should be the EIN of the individual’s 
Complete Part III if there was a termination in the appointment       employer. 
of an accountant or enrolled actuary during the 2023 plan year. 
                                                                      Do not use a social security number in lieu of an EIN. The 
This information must be provided on the Form 5500 for the 
                                                                      Schedule C and its attachments are open to public inspection, 
plan year during which the termination occurred. For example, 
                                                                      and the contents are public information and are subject to 
if an accountant was terminated in the 2023 plan year after 
                                                                      publication on the Internet. Because of privacy concerns, the 
completing work on an audit for the 2022 plan year, the 
                                                                      inclusion of a social security number or any portion thereof on   
termination should be reported on the Schedule C filed with the 
                                                                      this Schedule C or any of its attachments may result in the 
2023 plan year Form 5500. If the accountant is a firm (such as 
                                                                      rejection of the filing. 
a corporation, partnership, etc.), report when the service 
provider (not an individual within the firm) was terminated. An       The plan administrator must also provide the terminated 
enrolled actuary is by definition an individual and not a firm,       accountant or enrolled actuary with a copy of the explanation 
and you must report when the individual is terminated.                for the termination provided in Part III of the Schedule C, along 
                                                                      with a completed copy of the notice below. 
 Provide an explanation of the reasons for the termination of 
        
                                                Notice to Terminated Accountant 
                                                       or Enrolled Actuary 
                                                                      
I, as plan administrator, verify that the explanation that is reproduced below or attached to this notice is the explanation concerning 
your termination reported on the Schedule C (Form 5500) attached to the 2023 Form 5500, Annual Return/Report of Employee 
Benefit Plan, for the  __________________________________________________________(enter name of plan). This Form 5500 
is identified in line 2b by the nine-digit EIN  -                (enter sponsor’s EIN), and in line 1b by the three-digit   
PN________(enter plan number). 
You have the opportunity to comment to the Department of Labor concerning any aspect of this explanation. Comments should 
include the name, EIN, and PN of the plan and be submitted to: Office of Enforcement, Employee Benefits Security Administration, 
U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, DC 20210.  
 
Signed 
Dated 
 
Instructions for Schedule C (Form 5500)                         -31-

- 32 -

                                                                     Element (a). Enter the name of the MTIA, CCT, PSA, or 103-
2023 Instructions for Schedule D                                     12 IE in which the plan or DFE filing the Form 5500 
(Form 5500)                                                          participated at any time during the plan or DFE year.   
DFE  Participating Plan Information /                                Element (b). Enter the name of the sponsor of the MTIA, CCT, 
                                                                     PSA, or 103-12 IE named in element (a).  
General Instructions                                                 Element (c). Enter the nine-digit employer identification 
                                                                     number (EIN) and three-digit plan/entity number (PN) for each 
Purpose of Schedule                                                  MTIA, CCT, PSA, or 103-12 IE named in element     (a)  . This 
When the Form 5500 is filed for a plan or Direct Filing Entity       must be the same DFE EIN/PN as reported on lines 2b and 1b 
(DFE) that invested or participated in any master trust              of the Form 5500 filed for the DFE. If a Form 5500 was not 
investment accounts (MTIAs), 103-12 Investment Entities              filed for a CCT or PSA named in element (a), enter the EIN for 
(103-12 IEs), common/collective trusts (CCTs), and/or pooled         the CCT or PSA and enter 000 for the PN. Do not use a social 
separate accounts (PSAs), Part I provides information about          security number or any portion thereof in lieu of an EIN. The  
these entities. When the Form 5500 is filed for a DFE, Part II       Schedule D and its attachments are open to public inspection, 
provides information about plans participating in the DFE.           and the contents are public information and are subject to 
                                                                     publication on the Internet. Because of privacy concerns, the 
Who Must File  
                                                                     inclusion of a social security number or any portion thereof on 
Employee Benefit Plans: Schedule D (Form 5500) must be               this Schedule D or any of its attachments may result in the  
attached to a Form 5500 filed for an employee benefit plan that      rejection of the filing. 
participated or invested in one or more CCTs, PSAs, MTIAs, or 
                                                                     Element (d). Enter an M, C, P, or E, as appropriate, (see table 
103-12 IEs at any time during the plan year.  
                                                                     below) to identify the type of entity (MTIA, CCT, PSA, or  
Direct Filing Entities: Schedule D (Form 5500) must be 
                                                                     103-12 IE). 
attached to a Form 5500 filed for a CCT, PSA, MTIA, 103-12 
IE, or Group Insurance Arrangement (GIA), as a Direct Filing          
Entity (i.e., when a “DFE” is checked on Part I, line A, of the              Type of entity                      Enter in (d)  
Form 5500). Schedule D (Form 5500) must be attached to a                                                                
Form 5500 filed for a DFE that is a DCG, with Part I                                                               
completed, only if the DCG invested in 103-12 IEs, CCTs or                        MTIA                              M  
PSAs filing as DFEs.                                                              CCT                               C  
For more information, see instructions for Direct Filing Entity 
(DFE) Filing Requirements.                                                        PSA                               P  
      DCGs and multiple-employer pension plans that are                          103-12 IE                          E  
      pooled employer plans cannot participate in an MTIA.  
                                                                     Element (e). Enter the dollar value of the plan’s or DFE’s 
 Check the Schedule D box on the Form 5500 (Part II, line            interest as of the end of the year. If the plan or DFE for which 
10b(5)) if a Schedule D is attached to the Form 5500.                this Schedule D is filed had no interest in the MTIA, CCT, PSA, 
Complete as many repeating entries as necessary to report the        or 103-12 IE listed at the end of the year, enter ‘‘0’’. 
required information.  
                                                                      Example for Part I: If a plan participates in an MTIA, the 
Specific Instructions                                                MTIA is named in element (a); the MTIA’s sponsor is named in 
Lines A, B, C, and D. The information must be the same as            element (b); the MTIA’s EIN and PN are entered in element (c) 
reported in Part II of the Form 5500 to which this Schedule D is     (such as: 12-3456789-001); an ‘‘M’’ is entered in element (d); 
attached.                                                            and the dollar value of the plan’s interest in the MTIA as of the 
 Do not use a social security number in line D in lieu of an         end of plan year is entered in element (e). 
EIN. The Schedule D and its attachments are open to public            If the plan also participates in a CCT for which a Form 5500 
inspection, and the contents are public information and are          was not filed, the CCT is named in another element (a); the 
subject to publication on the Internet. Because of privacy           name of the CCT sponsor is entered in element (b); the EIN for 
concerns, the inclusion of a social security number or any           the CCT, followed by 000 is entered in element (c) (such as: 
portion thereof on this Schedule D or any of its attachments         99-8765432-000); a “C” is entered in element (d); and the 
may result in the rejection of the filing.                           dollar value of the plan’s interest in the CCT is entered in 
 You can apply for an EIN from the IRS online, by fax, or by         element (e). 
mail depending on how soon you need to use the EIN. For               If the plan also participates in a PSA for which a Form 5500 
more information, see Section 3: Electronic Filing Requirement       was filed, the PSA is named in a third element (a); the name of 
under General Instructions to Form 5500. The EBSA does not           the PSA sponsor is entered in element (b); the PSA’s EIN and 
issue EINs.                                                          PN is entered in element (c) (such as: 98-7655555-001); a “P” 
                                                                     is entered in element (d); and the dollar value of the plan’s 
Part I – Information on Interests in MTIAs, CCTs,                    interest in the PSA is entered in element (e). 
PSAs, and 103-12 IEs (To Be Completed by Plans 
and DFEs)                                                            Part II – Information on Participating Plans  
                                                                     (To Be Completed Only by DFEs, Except DCGs) 
Complete as many repeating entries as necessary to enter the 
information specified below for all MTIAs, CCTs, PSAs, and           Complete as many repeating entries as necessary to enter the 
103-12 IEs in which the plan or DFE filing the Form 5500             information specified below for all plans that invested or 
participated at any time during the plan or DFE year.                participated in the DFE at any time during the DFE year. 
                                                                                                  
 Complete a separate item (elements (a) through (e)) for 
each MTIA, CCT, PSA, or 103-12 IE. 

                                                                -32-              Instructions for Schedule D (Form 5500)

- 33 -

Note. DCGs are not required to complete Part II. A DCG’s 
participating plan information must be reported on Schedule 
DCG. See Schedule DCG and related instructions. 
Complete a separate item (elements (a) through (c)) for 
each plan.   
Element (a). Enter the name of each plan that invested or 
participated in the DFE at any time during the DFE year. GIAs 
need not complete element (a).     
Element (b). Enter the name of the sponsor of each and every 
plan investing or participating in the DFE. 
Element (c). Enter the nine-digit EIN and three-digit PN for 
each plan named in element (a)  . This is the EIN and PN 
entered on lines 2b and 1b of the plan’s Form 5500 or Form 
5500-SF. GIAs should enter the EIN of the sponsor listed in 
element (b). Do not use a social security number in lieu of an 
EIN. The Schedule D and its attachments are open to public 
inspection, and the contents are public information and are 
subject to publication on the Internet. Because of privacy 
concerns, the inclusion of a social security number or any  
portion thereof on this Schedule D or any of its attachments  
may result in the rejection of the filing. 

Instructions for Schedule D (Form 5500)                       -33-

- 34 -

submitted as a complete replacement of the previously
2023 Instructions for Schedule DCG submitted filing. If a Schedule DCG needs to be amended, the
(Form 5500) common plan administrator must resubmit the entire annual
Individual Plan Information return/report filing for the DCG, with all required schedules and
attachments, including Schedule DCG for all the plans in the
DCG, through EFAST2. You cannot submit just the Schedule
General Instructions DCG that is being amended. The line F box for “Amended
Purpose of Schedule Schedule” must be checked only for those Schedules DCG
that have been changed from the original submission. See
This schedule is used for a common plan administrator as EFAST2 FAQs available on the EFAST website at
defined in 29 CFR 2520.104-51(c)(2)(iii) to report information www.efast.dol.gov.
regarding each individual plan participating in a Defined
Contribution Group Reporting Arrangement (DCG or DCG Line F Box for the Final Schedule. Check this box if this is
reporting arrangement), as permitted by SECURE Act section the last annual return/report required for this plan.
202. Note. Check this box if all assets under the plan have been
distributed to the participants and beneficiaries or legally
Who Must File
transferred to the control of another plan. Do not check this
Schedule DCG must be attached to a Form 5500 filed for a box if you are reporting participants and/or assets at the end of
DFE that has checked the box in Part I, line A and specified the plan year or if you merely withdraw from a DCG reporting
the report is for a DCG reporting arrangement (i.e., when “D” is arrangement and still have a filing requirement for this plan.
entered as the DFE code on Part I, line A of the Form 5500).
Each plan participating in the DCG must individually complete Part III – Basic Individual Plan Information
a Schedule DCG to be attached to the Form 5500. Remember Line 1a. Enter the formal name of the plan participating in the
to check the Schedule DCG box on the Form 5500 (Part II, line DCG or enough information to identify the plan. Abbreviate if
10(a)(4)) and indicate the number of Schedules DCG that are necessary. If an annual return/report or a schedule has
attached to the Form 5500. previously been filed on behalf of the plan, regardless of the
For more information, see the instructions for DCG filing under type of form or schedule that was filed, use the same name or
Direct Filing Entity (DFE) Filing Requirements. abbreviation that was used on the prior filings. Once you use
an abbreviation, continue to use it for that plan on all future
Specific Instructions annual return/report or schedule filings with the IRS, DOL, and
Part I – DCG Information PBGC. Do not use the same name or abbreviation for any
Lines A, B, C and D. The information must be the same as other plan, even if the first plan is terminated. If the plan has
reported on lines 1a, 1b, 2a, and 2b of Part II of the DCG’s changed its name from the prior year filing(s), complete line 3
Form 5500 to which this schedule is attached. For lines A and to indicate that the plan was previously identified by a different
C, the DCG plan name may be different from the DCG plan name.
sponsor’s name (e.g., in the case of a DCG sponsor that offers Line 1b. Enter the three-digit plan or entity number (PN)
more than one DCG reporting arrangement). assigned to the plan participating in the DCG. This three-digit
number, in conjunction with the EIN entered on line 2b, is used
Part II – Individual Plan Identification Information by the IRS, DOL, and PBGC as a unique 12-digit number to
Line E Box for a Single-Employer Plan. Check this box to identify the plan.
confirm that Schedule DCG is filed for a defined contribution Start at 001 for the first plan providing pension benefits.
pension plan that is a single-employer plan. A single-employer Consecutively number other plans providing pension benefits
plan for this reporting purpose is an employee benefit plan as 002, 003, etc. Once you use a plan number, continue to use
maintained by one employer or one employee organization it for that plan on all future filings with the IRS, DOL, and
(determined on a controlled group basis) in which the funds PBGC. Do not use it for any other plan, even if the first plan or
attributable to each employer are available to pay benefits only DFE is terminated.
for that employer’s employees. A plan that does not meet this
definition is ineligible to participate in the DCG and should not Line 1c. Enter the date the plan first became effective.
complete this Schedule. The plan instead must file a separate Line 2a. Enter the name of the plan sponsor. If the plan covers
Form 5500 or Form 5500-SF (if eligible) in accordance with only the employees of one employer, enter the employer’s
form instructions. name. Enter the current street address, the name of the city,
Line E Box for a Collectively-Bargained, Single-Employer and the two-character abbreviation of the U.S. state or
Plan. Check this box if the contributions to the plan and/or the possession and zip code. Enter a foreign postal code and
benefits paid by the plan are subject to the collective country name, if applicable. Leave U.S. state and zip code
bargaining process. The contributions and/or benefits do not blank if entering a foreign routing code and country name.
have to be identical for all employees under the plan. A post office box number may be entered if the Post Office
Line F Box for the First Schedule. Check this box only if an does not deliver mail to the sponsor’s street address.
annual return/report has not been previously filed for this plan. Note. Use the IRS Form 8822-B, Change of Address or
If a plan participates in a DCG reporting arrangement, it is Responsible Party — Business , to notify the IRS if the address
treated as satisfying its annual return/report requirement under provided here is a change in your business mailing address or
Section 6058 of IRC and Section 104 of ERISA. your business location.
Line F Box for an Amended Schedule. Check this box if an Line 2b. Enter the nine-digit EIN assigned to the plan
annual return/report for the DCG has already been filed for the sponsor/employer. Do not use a SSN in lieu of an EIN.
2023 plan year, including a Schedule DCG for this plan, and Because of privacy concerns, the inclusion of a SSN or any
you are now amending this Schedule DCG to correct errors portion thereof on this line may result in the rejection of the
and/or omissions on the previously filed return/report. filing.
Note. An amended annual return/report filing must be A plan sponsor/employer without an EIN must apply for one

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as soon as possible. To apply for an EIN from the IRS: example, individuals who are retired or separated from
 Mail or fax Form SS-4, “Application for EIN,” obtained at employment covered by the plan and who are receiving
www.irs.gov/orderforms. See www.IRS.gov/Businesses and benefits under the plan). This category does not include any
click on “Employer ID Numbers” for additional information. The individual to whom an insurance company has made an
EIN is issued immediately once the application information is irrevocable commitment to pay all the benefits to which the
validated. (The online application process is not yet available individual is entitled under the plan.
for corporations with addresses in foreign countries or Puerto 3 Other retired or separated participants entitled to future .
Rico.) benefits (for example, any individuals who are retired or
Line 2c. Enter the plan sponsor’s/employer’s telephone separated from employment covered by the plan and who are
number, including the area code. entitled to begin receiving benefits under the plan in the
future). This category does not include any individual to whom
Line 2d. Enter the six-digit business code from the list of an insurance company has made an irrevocable commitment
business codes on pages 94, 95, and 96 that best describes to pay all the benefits to which the individual is entitled under
the primary nature of the plan sponsor’s/employer’s business. the plan.
Do not enter code 525100 (Insurance & Employee Benefit
Funds) or 813930 (Labor Unions and Similar Labor 4 Deceased individuals who had one or more beneficiaries .
Organizations) unless the predominant industry in which the who are receiving or are entitled to receive benefits under the
active participants are employed is the industry of insurance plan. This category does not include any individual to whom an
and employee benefit funds, or the industry of labor unions insurance company has made an irrevocable commitment to
and similar labor organizations. pay all the benefits to which the beneficiaries of that individual
are entitled under the plan.
Lines 3a-d. If the plan sponsor’s/employer’s name and/or EIN
have changed or the plan name has changed since the last Line 5d(1). Enter the number of participants included on line
return/report or schedule was filed for this plan, enter the plan 5a (total number of participants at the beginning of the plan
sponsor’s name and EIN, the plan name, and the plan number year) who have account balances at the beginning of the plan
as it appeared on the last return/report or schedule filed. year.
The failure to indicate on line 3 that a plan sponsor was Line 5d(2). Enter the number of participants included on line
previously identified by a different name or a different 5b (total number of participants at the end of the plan year)
EIN or that the plan name has been changed could result in who have account balances at the end of the plan year. For
correspondence from the DOL and/or the IRS. example, for a section 401(k) plan the number entered on line
5d(2) should be the number of participants counted on line 5b
Line 4a. Enter the name and address of the common plan who have made a contribution, or for whom a contribution has
administrator as shown on the DCG’s Form 5500, Part II, line been made, to the plan for this plan year or any prior plan year.
3a.
Line 5e. Include any individual who terminated employment
Line 4b. Enter the common plan administrator’s nine-digit EIN during this plan year, whether or not the individual (a) incurred
as shown on the DCG’s Form 5500, Part II, line 3b. a break in service, (b) received an irrevocable commitment
Line 4c. Enter the telephone number for the common plan from an insurance company to pay all the benefits to which the
administrator as shown on the DCG’s Form 5500, Part II, line individual is entitled under the plan, and/or (c) received a cash
3c. Use numbers only, including the area code, and do not distribution or deemed cash distribution of their nonforfeitable
include any special characters. accrued benefit.
See Form 5500, Part II, lines 3a-3c for additional information. Part IV – Financial Information
Line 5a. Enter the total number of participants at the beginning Note. The cash, modified cash, or accrual basis accounting
of the plan year. methods may be used for recognition of transactions in Part IV,
Line 5b. Enter the total number of participants at the end of as long as you use one method consistently. If Form 5500 or
the plan year. Form 5500-SF was filed for the previous year, amounts
Line 5c(1). Enter the total number of active participants at the reported on Schedule DCG lines 6a, 6b, and 6c for the
beginning of the plan year. beginning of the plan year must be the same as reported for
the end of the plan year for the corresponding lines on the
Line 5c(2). Enter the total number of active participants at the return/report for the preceding plan year. If Schedule DCG was
end of the plan year. filed in the previous year, the amount reported on lines 6a, 6b,
“Participant” for purpose of lines 5a–5c(2) means any and 6c for the beginning of the plan year must be the same as
individual who is included in one of the categories below. reported for the end of the plan year on the Schedule DCG
1 Active participants (for example, any individuals who are . filed for the previous year. Use whole dollars only.
currently in employment covered by the plan and who are Current value means fair market value where available.
earning or retaining credited service under the plan) including: Otherwise, it means the fair value as determined in good faith
 Any individuals who are eligible to elect to have the employer under the terms of the plan by a trustee or a named fiduciary,
make payments under a section 401(k) qualified cash or assuming an orderly liquidation at the time of the
deferred arrangement, and determination. See ERISA section 3(26).
 Any nonvested individuals who are earning or retaining Line 6a. Enter the total amount of plan assets at the beginning
credited service under the plan. of the plan year in column (a). Do not include contributions
designated for the 2023 plan year in column (a). Enter the total
This category does not include (a) nonvested former amount of plan assets at the end of the plan year in column
employees who have incurred the break in service period (b).
specified in the plan or (b) former employees who have
received a “cash-out” distribution or deemed distribution of Line 6a(1). Enter the current value of all loans to participants,
their entire nonforfeitable accrued benefit. including residential mortgage loans that are subject to Code
section 72(p). Include the sum of the value of the unpaid
2 Retired or separated participants receiving benefits (for .

Instructions for Schedule DCG (Form 5500) -35-

- 36 -

principal balances, plus accrued but unpaid interest, if any, for years before the 2023 plan year on line 7a(1).
participant loans made under an individual account plan with Line 7a(3). Enter the amount of all other contributions
investment experience segregated for each account, which are including transfers or rollovers received from other plans
made in accordance with 29 CFR 2550.408b-1 and secured valued on the date of contribution.
solely by a portion of the participant’s vested accrued benefit.
When applicable, combine this amount with the current value Line 7b. Enter the current value, at date contributed, of
of any other participant loans. Do not include in column (b) a securities or other noncash property.
participant loan that has been deemed distributed during the Line 7c. Enter the total cash, noncash, and other contributions
plan year under the provisions of Code section 72(p) and received and/or receivable by the plan from employers and
Treasury Regulations section 1.72(p)-1, if both of the following participants during the plan year.
circumstances apply: Line 7d. Enter all other plan income for the plan year. Do not
1. Under the plan, the participant loan is treated as a directed include transfers from other plans that are reported on line 7m.
investment solely of the participant’s individual account; and Examples of other income received and/or receivable include:
2. As of the end of the plan year, the participant is not 1 Interest on investments (including money market accounts, .
continuing repayment under the loan. sweep accounts, etc.)
If both of these circumstances apply, report the loan as a 2. Dividends. (Accrual basis plans should include dividends
deemed distribution on line 7h. However, if either of these declared for all stock held by the plan even if the dividends
circumstances does not apply, the current value of the have not been received as of the end of the plan year.)
participant loan (including interest accruing thereon after the 3. Net gain or loss from the sale of assets.
deemed distribution) must be included in column (b) without 4. Other income such as unrealized appreciation (depreciation)
regard to the occurrence of a deemed distribution. in plan assets. To compute this amount, subtract the current
Note. After a participant loan that has been deemed distributed value of all assets at the beginning of the year plus the cost of
is included in the amount reported on line 7h, it is no longer to any assets acquired during the plan year from the current
be reported as an asset on line 6a unless, in a later year, the value of all assets at the end of the year minus assets
participant resumes repayment under the loan. However, such disposed of during the plan year.
a loan (including interest accruing thereon after the deemed Line 7e. Add the total contributions (line 7c) and other plan
distribution) that has not been repaid is still considered income (line 7d) during the plan year. If entering a negative
outstanding for purposes of applying Code section 72(p)(2)(A) number, enter a minus sign (“–”) to the left of the number.
to determine the maximum amount of subsequent loans. Also,
the deemed distribution is not treated as an actual distribution Line 7f. Enter the total amount of benefits paid directly to
for other purposes, such as the qualification requirements of participants or beneficiaries, including payments made (and for
Code section 401, including, for example, the determination of accrual basis filers payments due) to or on behalf of
top- heavy status under Code section 416 and the vesting participants or beneficiaries in cash, securities, or other
requirements of Treasury Regulations section 1.411(a)-7(d)(5). property (including rollovers of an individual’s accrued benefit
See Q&As 12 and 19 of Treasury Regulations section 1.72(p)- or account balance). Include all eligible rollover distributions as
1. defined in Code section 401(a)(31)(D) paid at the participant’s
election to an eligible retirement plan (including an IRA within
The entry on line 6a, column (b) (plan assets at end of the meaning of Code section 401(a)(31)(E)).
year) must include the current value of any participant loan
included as a deemed distribution in the amount reported for Line 7g. Enter total amount of corrective distributions,
any earlier year if, during the plan year, the participant including all distributions paid during the plan year of excess
resumes repayment under the loan. In addition, the amount to deferrals under Code section 402(g)(2)(A)(ii), excess
be entered on line 7h must be reduced by the amount of the contributions under Code section 401(k)(8), excess aggregate
participant loan reported as a deemed distribution for the contributions under Code section 401(m)(6), and allocable
earlier year. income distributed. Also include on this line any elective
deferrals and employee contributions distributed or returned to
Line 6b. Enter the total liabilities at the beginning and end of employees during the plan year as well as any attributable
the plan year. Liabilities to be entered here do not include the income that was also distributed.
value of future pension payments to participants. The amount
to be entered in line 6b for accrual basis filers includes, among Line 7h. Enter the total amount of certain deemed distributions
other things: of participant loans, including a participant loan that has been
deemed distributed during the plan year under the provisions
1 Benefit claims that have been processed and approved for . of Code section 72(p) and Treasury Regulations section
payment by the plan but have not been paid; 1.72(p)-1, only if both of the following circumstances apply:
2 Accounts payable obligations owed by the plan that were . 1 Under the plan, the participant loan is treated as a directed .
incurred in the normal operations of the plan but have not been investment solely of the participant’s individual account; and
paid; and
2 As of the end of the plan year, the participant is not .
3 Other liabilities such as acquisition indebtedness and any . continuing repayment under the loan.
other amount owed by the plan.
If either of these circumstances does not apply, a deemed
Line 6c. Enter the net assets as of the beginning and end of distribution of a participant loan should not be reported on line
the plan year. (Subtract line 6b from 6a). Line 6c, column (b), 7h. Instead, the current value of the participant loan (including
must equal the sum of line 6c, column (a), plus lines 7l(net interest accruing thereon after the deemed distribution) must
income (loss)) and 7m (transfers to (from) the plan). be included on line 6a(1)), column (b) (participant loans – end
Lines 7a(1) and (2). Enter the total cash contributions of year), without regard to the occurrence of a deemed
received and/or receivable by the plan from employers and distribution.
participants during the plan year. Plans using the accrual basis Line 7i. The amount to be reported for expenses involving
of accounting must not include contributions designated for administrative service providers (salaries, fees, and

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commissions) during the plan year includes the total fees paid       Form 5500 filing to satisfy the plan’s reporting requirement in 
(or in the case of accrual basis plans, costs incurred during the    the subsequent year) until the year after the violation has been 
plan year but not paid as of the end of the plan year) by the        fully corrected by payment of the late contributions and 
plan for, among others:                                              reimbursement of the plan for lost earnings or profits. All 
1. Salaries to employees of the plan;                                delinquent participant contributions must be reported on line 9a 
                                                                     at least for the year in which they were delinquent even if 
2. Fees and expenses for accounting, actuarial, legal,               violations have been fully corrected by the close of the plan 
investment management, investment advice, and securities             year. If no participant contributions were received or withheld 
brokerage services;                                                  by the employer during the plan year, answer “No.” 
3. Contract administrator fees; and                                   An employer holding participant contributions commingled 
4. Fees and expenses for individual plan trustees, including         with its general assets after the earliest date on which such 
reimbursement for travel, seminars, and meeting expenses.            contributions can reasonably be segregated from the 
Line 7j. Other expenses (paid and/or payable) include other          employer’s general assets will have engaged in a prohibited 
administrative and miscellaneous expenses paid by or charged         use of plan assets (see ERISA section 406). If such a 
to the plan during the plan year, including among others office      nonexempt prohibited transaction occurred with respect to a 
supplies and equipment, telephone, and postage.                      disqualified person (see Code section 4975(e)(2)), file IRS 
Line 7k. Enter the total of all benefits paid or due reported on     Form 5330, Return of Excise Taxes Related to Employee 
lines 7f, 7g, 7h, and all other plan expenses reported on lines      Benefit Plans, with the IRS to pay any applicable excise tax on 
7i and 7j during the plan year.                                      the transaction. 
Line 7l. Subtract line 7k from line 7e.                               Participant loan repayments paid to and/or withheld by an 
                                                                     employer for purposes of transmittal to the plan that were not 
Line 7m. Include in these figures the value of all transfers of      transmitted to the plan in a timely fashion must be reported 
assets or liabilities into or out of the plan resulting from, among  either on line 9a in accordance with the reporting requirements 
other things, mergers and consolidations. A transfer of assets       that apply to delinquent participant contributions or on line 9b. 
or liabilities occurs when there is a reduction of assets or         See Advisory Opinion 2002-02A, available at 
liabilities with respect to one plan and the receipt of these        www.dol.gov/ebsa. 
assets or the assumption of these liabilities by another plan. A 
transfer is not a shifting of one plan’s assets or liabilities from   For those Schedule DCG filers required to submit an 
one investment to another. A transfer is not a distribution of all    IQPA report, delinquent participant contributions reported 
or part of an individual participant’s account balance that is       on line 9a must be treated as part of the separate schedules 
reportable on IRS Form 1099-R, Distributions From Pensions,          referenced in ERISA section 103(a)(3)(A) and 29 CFR 
Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance       2520.103-1(b) and 2520.103-2(b) for purposes of preparing the 
Contracts, etc., (see the instructions for line 7f). Transfers out   IQPA’s opinion for such individual plan in the DCG, even 
at the end of the year should be reported as occurring during        though they are not required to be listed on Part III of the 
the plan year.                                                       Schedule G that is filed on a consolidated basis at the DCG 
                                                                     level. If the information reported on line 9a is not presented in 
Part V - Plan Characteristics                                        accordance with regulatory requirements, i.e., when the IQPA 
Line 8. Do not leave blank. Enter all applicable pension plan        concludes that the scheduled information required by line 9a 
characteristics codes that applied during the reporting year         does not contain all the required information or contains 
from the List of Plan Characteristics Codes on pages 22 and          information that is inaccurate or is inconsistent with the plan’s 
23 that best describe the characteristics of the plan.               financial statements, the IQPA report must make the 
                                                                     appropriate disclosures in accordance with generally accepted 
Part VI - Compliance Questions                                       auditing standards. For more information, see EBSA’s 
Line 9a. Amounts paid by a participant or beneficiary to an          Frequently Asked Questions about Reporting Delinquent 
employer and/or withheld by an employer for contribution to          Contributions on the Form 5500, available on the Internet at 
the plan are participant contributions that become plan assets       www.dol.gov/ebsa. These Frequently Asked Questions clarify 
as of the earliest date on which such contributions can              that plans have an obligation to include delinquent participant 
reasonably be segregated from the employer’s general assets          contributions on their financial statements and supplemental 
(see 29 CFR 2510.3-102). In the case of a plan with fewer than       schedules and that the IQPA’s report covers such delinquent 
100 participants at the beginning of the plan year, any amount       contributions even though they are no longer required to be 
deposited with such plan not later than the 7th business day   
                                                                     included on Part III of the Schedule G. Although all delinquent 
following the day on which such amount is received by the            participant contributions must be reported on line 9a, 
employer (in the case of amounts that a participant or               delinquent contributions for which the DOL Voluntary Fiduciary 
beneficiary pays to an employer), or the 7th business day   
                                                                     Correction Program (VFCP) requirements and the conditions 
following the day on which such amount would otherwise have          of the Prohibited Transaction Exemption (PTE) 2002-51 have 
been payable to the participant in cash (in the case of amounts      been satisfied do not need to be treated as nonexempt party-
withheld by an employer from a participant’s wages), shall be        in-interest transactions. 
deemed to be contributed or repaid to such plan on the earliest       The VFCP describes the specific transactions covered 
date on which such contributions or participant loan                 (which transactions include delinquent participant contributions 
repayments can reasonably be segregated from the                     to pension and welfare plans) and acceptable methods for 
employer’s general assets. See 29 CFR 2510.3-102(a)(2).              correcting violations. In addition, applicants that satisfy both 
 Plans that check “Yes,” must enter the aggregate amount             the VFCP and the conditions of PTE 2002-51 are eligible for 
of all late contributions for the year. The total amount of the      immediate relief from payment of certain prohibited transaction 
delinquent contributions must be included on line 9a for the         excise taxes for certain corrected transactions and are also 
year in which the contributions were delinquent and must be          relieved from the requirement to file the IRS Form 5330 with 
carried over and reported again on line 9a for each subsequent       the IRS. For more information on the VFCP, the specific 
year (or on line 4a of Schedule H or I of the Form 5500 or line      transactions covered (which transactions include delinquent 
10a of the Form 5500-SF if choosing not to rely on a DCG 
Instructions for Schedule DCG (Form 5500)                       -37-

- 38 -

participant contributions to pension and welfare plans), and and a party-in-interest.
acceptable methods for correcting violations, see 71 Fed. Reg. D. Transfer to, or use by or for the benefit of, a party in-
20261 (Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19, interest, of any income or assets of the plan.
2006). All delinquent participant contributions must be reported
on line 9a at least for the year in which they were delinquent E. Acquisition, on behalf of the plan, of any employer security
even if violations have been fully corrected by the close of the or employer real property in violation of ERISA section 407(a).
plan year. Information about the VFCP is also available on the F. Dealing with the assets of the plan for a fiduciary’s own
Internet at www.dol.gov/ebsa. interest or own account.
Line 9a Schedule. Attach a Schedule of Delinquent G. Acting in a fiduciary’s individual or any other capacity in any
Participant Contributions using the format below if you entered transaction involving the plan on behalf of a party (or represent
“Yes” on line 9a and you are checking “YES” on line 14 a party) whose interests are adverse to the interests of the
because the report of an IQPA for the plan is required. If you plan or the interests of its participants or beneficiaries.
choose to include participant loan repayments on line 9a, you H. Receipt of any consideration for their own personal account
must apply the same supplemental schedule and IQPA by a party-in-interest who is a fiduciary from any party dealing
disclosure requirements to the loan repayments as apply to with the plan in connection with a transaction involving the
delinquent transmittals of participant contributions. income or assets of the plan.
Party-in-Interest. For purposes of this form, party-in interest is
Schedule DCG Line 9a – Schedule of Delinquent deemed to include a disqualified person. See Code section
Participant Contributions 4975(e)(2). The term “party-in-interest” means, as to an
employee benefit plan:
Participant Total that Constitutes Nonexempt Total Fully A. Any fiduciary (including, but not limited to, any
Contributions Prohibited Transactions Corrected administrator, officer, trustee, or custodian), counsel, or
Transferred Under employee of the plan;
Late to Plan VFCP and B. A person providing services to the plan;
PTE
2002-51 C. An employer, any of whose employees are covered by the
Check here if Contributions Contributions Contributions plan;
Late Participant Not Corrected Pending D. An employee organization, any of whose members are
Loan Corrected Outside VFCP Correction in covered by the plan;
Repayments VFCP
are included:  E. An owner, direct or indirect, of 50% or more of:
1 the combined voting power of all classes of stock entitled .
to vote or the total value of shares of all classes of stock of a
corporation;
Line 9b. Check “Yes” if any nonexempt transaction with a
party-in-interest occurred. Do not check “Yes” with respect to 2 the capital interest or the profits interest of a partnership; .
transactions that are: (1) statutorily exempt under Part 4 of or
Title I of ERISA; (2) administratively exempt under ERISA 3 the beneficial interest of a trust or unincorporated .
section 408(a); (3) exempt under Code sections 4975(c) or enterprise which is an employer or an employee organization
4975(d); or (4) delinquent participant contributions or described in C or D;
delinquent loan repayments reported on line 9a. F. A relative of any individual described in A, B, C, or E;
You may indicate that an application for an administrative G. A corporation, partnership, or trust or estate of which (or in
exemption is pending. If you are unsure whether a transaction which) 50% or more of:
is exempt or not, you should consult either with a qualified
public accountant, legal counsel, or both. If the plan is a 1 the combined voting power of all classes of stock entitled .
qualified pension plan and a nonexempt prohibited transaction to vote or the total value of shares of all classes of stock of
occurred with respect to a disqualified person, an IRS Form such corporation,
5330 is required to be filed with the IRS to pay the excise tax 2 the capital interest or profits interest of such partnership, .
on the transaction. Plans that check “Yes” must enter the or
amount. 3 the beneficial interest of such trust or estate, is owned .
Applicants that satisfy the VFCP requirements and the directly or indirectly, or held by persons described in A, B, C,
conditions of PTE 2002-51 (see the instructions for line 9a) are D, or E;
eligible for immediate relief from payment of certain prohibited H. An employee, officer, director (or an individual having
transaction excise taxes for certain corrected transactions, and powers or responsibilities similar to those of officers or
are also relieved from the obligation to file the Form 5330 with directors), or a 10% or more shareholder directly or indirectly,
the IRS. When the conditions of PTE 2002-51 have been of a person described in B, C, D, E, or G, or of the employee
satisfied, the corrected transactions should be treated as benefit plan; or
exempt under Code section 4975(c) for the purposes of I. A 10% or more (directly or indirectly in capital or profits)
answering line 9b. partner or joint venture of a person described in B, C, D, E, or
Nonexempt transactions. Nonexempt transactions with a G.
party-in-interest include any direct or indirect: Line 9c. You must check “Yes” if any benefits due under the
A. Sale or exchange, or lease, of any property between the plan were not timely paid or not paid in full. This would include
plan and a party-in-interest. required minimum distributions to 5% owners who have
B. Lending of money or other extension of credit between the attained the applicable age as described in Code section
plan and a party-in-interest. 401(a)(9)(C)(v) whether or not retired and/or non-5% owners
C. Furnishing of goods, services, or facilities between the plan who have attained the applicable age as described in Code

-38- Instructions for Schedule DCG (Form 5500)

- 39 -

section 401(a)(9)(C)(v) and have retired or separated from during the plan year. A transfer of assets or liabilities occurs
service; see Code section 401(a)(9). Include in this amount the when there is a reduction of assets or liabilities with respect to
total of any outstanding amounts that were not paid when due one plan and the receipt of these assets or the assumption of
in previous years that have continued to remain unpaid. these liabilities by another plan. Enter the name, plan sponsor
Note: In the absence of other guidance, filers do not need to EIN, and plan number of the transferee plan(s) involved on
report on this line unpaid required minimum distribution (RMD) lines 10a, 10b, and 10c, respectively.
amounts for participants who have retired or separated from Do not use a SSN in place of an EIN or include an
service, or their beneficiaries, who cannot be located after attachment that contains visible SSN.
reasonable efforts or where the plan is in the process of Note. A distribution of all or part of an individual participant’s
engaging in such reasonable efforts at the end of the plan year account balance that is reportable on Form 1099-R should not
reporting period. Plan administrators and employers should be included on line 10.
review their plan documents for written procedures on locating
missing participants. Although the Department of Labor’s Field IRS Form 5310-A, Notice of Plan Merger or
Assistance Bulletin 2014- 01 is specifically applicable to Consolidation, Spinoff, or Transfer of Plan Assets or
terminated defined contribution plans, employers and plan Liabilities; Notice of Qualified Separate Lines of Business,
administrators of ongoing plans may want to consider must be filed at least 30 days before any plan merger or
periodically using one or more of the search methods consolidation or any transfer of plan assets or liabilities to
described in the Field Assistance Bulletin in connection with another plan. There is a penalty for not filing IRS Form 5310-A
making reasonable efforts to locate RMD-eligible missing on time.
participants. Line 11. Check “Yes” if this is a defined contribution plan
Line 9d. Plans that check “Yes” must enter the aggregate subject to the minimum funding requirements of Code section
amount of fidelity bond coverage for all claims. Check ‘‘Yes’’ 412.
only if the plan itself (as opposed to the plan sponsor or Line 12a. Check “Yes” if this plan was permissively
administrator) is a named insured under a fidelity bond from an aggregated with another plan to satisfy the requirements of
approved surety covering plan officials and that protects the Code sections 410(b) and 401(a)(4). Generally, each single
plan from losses due to fraud or dishonesty as described in 29 plan must separately satisfy the coverage and
CFR Part 2580. Generally, every plan official of an employee nondiscrimination requirements. However, generally, an
benefit plan who ‘‘handles’’ funds or other property of such employer may designate two or more separate plans as a
plan must be bonded. Generally, a person shall be deemed to single plan for purposes of applying the ratio percentage test of
be ‘‘handling’’ funds or other property of a plan, so as to Treasury Regulations section 1.410(b)-2(b)(2) or the
require bonding, whenever their duties or activities with respect nondiscriminatory classification test of Treasury Regulations
to given funds are such that there is a risk that such funds section 1.410(b)-4. Two or more plans that are permissively
could be lost in the event of fraud or dishonesty on the part of aggregated and treated as a single plan for purposes of the
such person, acting either alone or in collusion with others. minimum coverage test of Code section 410(b) must also be
ERISA Section 412 and 29 CFR Part 2580 describe the treated as a single plan for purpose of the nondiscrimination
bonding requirements, including the definition of “handling” (29 test under Code section 401(a)(4).
CFR 2580.412-6), the permissible forms of bonds (29 CFR See Treasury Regulations sections 1.410(b)-7(d) and
2580.412-10), the amount of the bond (29 CFR Part 2580, 1.401(a)(4)-(9)(a) for more information.
subpart C), and certain exemptions such as the exemption for Line 12b. Check the applicable method used to satisfy the
unfunded plans, certain banks and insurance companies nondiscrimination requirements of Code section 401(k). A safe
(ERISA section 412), and the exemption allowing plan officials harbor 401(k) plan is similar to a traditional 401(k) plan but,
to purchase bonds from surety companies authorized by the among other things, it must provide for employer contributions.
Secretary of the Treasury as acceptable reinsurers on federal These contributions may be employer matching contributions,
bonds (29 CFR 2580.412-23). Information concerning the list limited to employees who defer, or employer contributions
of approved sureties and reinsurers is available on the Internet made on behalf of all eligible employees, regardless of
at www.fms.treas.gov/c570. For more information on the whether they make elective deferrals. The safe harbor 401(k)
fidelity bonding requirements, see Field Assistance Bulletin plan is not subject to the complex annual nondiscrimination
2008-04, available on the Internet at www.dol.gov/ebsa. tests that apply to traditional 401(k) plans.
Note. Plans are permitted under certain conditions to purchase Check “Design-based safe harbor method” if this is a safe
fiduciary liability insurance. These fiduciary liability insurance harbor 401(k) plan, that is, a SIMPLE 401(k) plan under Code
policies are not written specifically to protect the plan from section 401(k)(11), a safe harbor 401(k) plan under Code
losses due to dishonest acts and cannot be reported as fidelity section 401(k)(12), or a qualified automatic contribution
bonds on line 4e. arrangement under Code section 401(k)(13). If the plan, by its
Line 9e. Check ‘‘Yes,’’ if the plan suffered or discovered any terms, does not satisfy the safe harbor method, it generally
loss as a result of any dishonest or fraudulent act(s) even if the must satisfy the regular nondiscrimination test, known as the
loss was reimbursed by the plan’s fidelity bond or from any actual deferral percentage (ADP) test. Check the appropriate
other source. If ‘‘Yes’’ is checked enter the full amount of the box to indicate if the plan uses the “current year” ADP test or
loss. If the full amount of the loss has not yet been determined, the “prior year” ADP test. Check “current year” ADP test if the
provide an estimate and disclose that the figure is an estimate plan uses the current year testing method under which the
as determined in good faith by a plan fiduciary. You must keep, ADP test is performed by comparing the current plan year’s
in accordance with ERISA section 107, records showing how ADP for highly compensated employees (HCEs) with the
the estimate was determined. current plan year’s (rather than the prior plan year’s) ADP for
Willful failure to report is a criminal offense. See ERISA nonhighly compensated employees (NHCEs). Check all boxes
section 501. that apply for a plan that tests different groups of employees
Line 10. Enter information concerning assets and/or liabilities on a disaggregated basis. Check “N/A” if the plan is not
transferred from this plan to another plan(s) (including spinoffs) required to test for nondiscrimination under Code section

Instructions for Schedule DCG (Form 5500) -39-

- 40 -

401(k)(3), such as a plan in which no HCE is benefiting. or federal agency provided that the statements or information
Line 13. If a plan sponsor or an employer adopted a pre- are prepared by and certified to by the bank or similar
approved plan that relied on a favorable Opinion Letter of a institution or the insurance carrier. The term ‘‘similar institution’’
Pre-approved Plan, enter the date of the most recent favorable as used here does not extend to securities brokerage firms
Opinion Letter issued by the IRS and the Opinion Letter serial (see DOL Advisory Opinion 93-21A). Under 29 CFR 2520.103-
number listed on the letter. A “Pre-approved Plan” is a plan 12, an audit of an employee benefit plan does not need extend
approved by the IRS with a favorable Opinion Letter that is to the investments in a pooled investment fund that files a
made available by a Provider for adoption by employers, separate audited Form 5500 as a 103-12 IE. For more
including a standardized plan or a nonstandardized plan. A information on filing requirements for 103-12 IEs, see Section
Pre-approved Plan may utilize either of two forms: a basic plan 4: What to File. Neither of these regulations exempt the plan
document with an adoption agreement or a single plan administrator from engaging an IQPA nor from attaching the
document. The employer is permitted to make minor IQPA’s report to the Schedule DCG.
modifications to the plan. An “Adopting Employer” is an Line 14a(2). Check if a qualified opinion was issued.
employer that adopts a Pre-approved Plan offered by a Generally, a qualified opinion is issued by an IQPA when (a)
Provider, including a plan that is word-for-word identical to, or the IQPA, having obtained sufficient appropriate audit
a minor modification of, a plan of a Mass Submitter. If a plan evidence, concludes that misstatements, individually or in the
was modified in such a way that negates the Opinion Letter, aggregate, are material but not pervasive to the financial
then the plan sponsor is now no longer an Adopting Employer statements or (b) the IQPA is unable to obtain sufficient
of a Pre-approved Plan, and the plan is treated as an appropriate audit evidence on which to base the opinion, but
individually designed plan. An “Opinion Letter” is a written the auditor concludes that the possible effects on the financial
statement issued by the IRS to a Provider or Mass Submitter statements of undetected misstatements, if any, could be
as an opinion on the qualification in form of a plan under Code material but not pervasive.
section 401(a), Code section 403(a), or both Code sections Line 14a(3). Check if a disclaimer of opinion was issued. A
401(a) or 403(a) and 4975(e)(7). See Revenue Procedure disclaimer of opinion is issued when the IQPA is unable to
2017-41 for more information. The Opinion Letter serial obtain sufficient appropriate audit evidence on which to base
number is a unique combination of a capital letter and a series the opinion, and the IQPA concludes that the possible effects
of six numbers assigned to each Opinion Letter. on the financial statements of undetected misstatements, if
Part VII – Accountant’s Opinion Information for any, could be both material and pervasive.
Large Participating Plans Line 14a(4). Check if the plan received an adverse
Line 14. Each defined contribution plan participating in a DCG accountant’s opinion. Generally, an adverse opinion is issued
determines the number of plan participants used to determine by an IQPA when the IQPA having obtained sufficient
“large plan” or “small plan” status by counting plan participants appropriate audit evidence, concludes that misstatements,
at the individual plan level using information on participants individually or in the aggregate, are both material and
with account balances reported on lines 5d(1) and 5d(2) of pervasive to the financial statements.
Schedule DCG, including the “80 to 120” rule at 29 CFR Line 14b. Check “DOL Regulation 2520.103-8” or “DOL
2520.103-1(d). See Section 4: What to File. Regulation 2520.103-12(d)” (or both boxes, if applicable) if the
A DCG participating plan must be audited and an IQPA IQPA performed an ERISA section 103(a)(3)(C) audit of the
report and audited financial statements for such plan must be plan’s financial statements pursuant to DOL regulations 29
attached to the Schedule DCG for that participating plan CFR 2520.103-8, 29 CFR 2520.103-12(d), or under both. If it
unless the plan is a small plan (plan that covered fewer than was not performed pursuant to 29 CFR 2520.103-8 or 29 CFR
100 participants with account balances as of the beginning of 2520.103-12(d), check box (3). Note. These regulations do not
the plan year) eligible for the waiver of the annual examination exempt the plan administrator from engaging an IQPA or from
and report of an IQPA under 29 CFR 2520.104-46. The audit attaching the IQPA’s report to the Schedule DCG. If you check
and its report must follow the same rules as required for a plan box 103-8 or 103-12(d) or both, you must also check the
that is filing its own Form 5500 Annual Return/Report and not appropriate box on line 14a to identify the type of opinion
having any of its reporting obligations satisfied by the filing of a offered by the IQPA.
Form 5500 by a DCG. See Instructions to Schedule H, line 3. Line 14c. Enter the name and EIN of the accountant (or
Line 14a. These boxes identify the type of opinion offered by accounting firm) in the space provided on line 14c. Do not use
the IQPA. The plan administrator should confirm with the IQPA a SSN or any portion thereof in lieu of an EIN. The Schedule
whether the opinion was an unmodified, qualified, disclaimer DCG is open to public inspection, and the contents are public
of, or adverse opinion before answering line 14a. information and are subject to publication on the Internet.
Because of privacy concerns, the inclusion of a SSN or any
Line 14a(1). Check if an unmodified opinion was issued
portion thereof on this Schedule DCG may result in the
pursuant to SAS 136. Generally, an unmodified opinion is
rejection of the filing.
issued when the IQPA concludes that the plan’s financial
statements are presented fairly, in all material respects, in
accordance with the applicable financial reporting framework
(generally accepted accounting principles (GAAP) or another
basis such as modified cash or cash basis). This also includes
the form of opinion that SAS 136 permits an IQPA to issue
when the IQPA has performed an ERISA section 103(a)(3)(C)
audit pursuant to 29 CFR 2520.103-8 or 29 CFR 2520.103-12,
or both, and had no modifications. Under 29 CFR 2520.103-8,
the examination and report of an IQPA does not need to
extend to statements or information regarding assets held by a
bank, similar institution, or insurance carrier that is regulated
and supervised and subject to periodic examination by a state
-40- Instructions for Schedule DCG (Form 5500)

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Provide, on a separate attachment, an explanation of what
steps have been taken or will be taken to collect overdue
amounts for each loan listed and label the attachment
2023 Instructions for Schedule G
“Schedule G, Part I – Overdue Loan Explanation.”
(Form 5500) The due date, payment amount, and conditions for
Financial Transaction Schedules determining default in the case of a note or loan are usually
contained in the documents establishing the note or loan. A
loan is in default when the borrower is unable to pay the
General Instructions obligation upon maturity. Obligations that require periodic
Who Must File repayment can default at any time. Generally, loans and fixed
Schedule G (Form 5500) must be attached to a Form 5500 income obligations are considered uncollectible when payment
filed for a large plan, MTIA, 103-12 IE, DCG or GIA to report has not been made and there is little probability that payment
loans or fixed income obligations in default or determined to be will be made. A fixed income obligation has a fixed maturity
uncollectible as of the end of the plan year, leases in default or date at a specified interest rate.
classified as uncollectible, and nonexempt transactions. Do not report in Part I participant loans under an individual
Check the Schedule G box on the Form 5500 (Part II, line account plan with investment experience segregated for each
10b(6)) if a Schedule G is attached to the Form 5500. account, that are made in accordance with 29 CFR 2550.408b-
Complete as many entries as necessary to report the required 1, and that are secured solely by a portion of the participant’s
information. vested accrued benefit. Report all other participant loans in
default or classified as uncollectible on Part I, and list each
The Schedule G consists of three parts. Part I of the such loan individually.
Schedule G reports any loans or fixed income obligations in
default or determined to be uncollectible as of the end of the Part II – Leases in Default or Classified as
plan year. Part II of the Schedule G reports any leases in Uncollectible
default or classified as uncollectible. Part III of the Schedule G List any leases in default or classified as uncollectible. A lease
reports nonexempt transactions. is an agreement conveying the right to use property, plant, or
Note. In the case of a DCG, report the required information for equipment for a stated period. A lease is in default when the
all the plans in the DCG, including identifying information for required payment(s) has not been made. An uncollectible
the specific individual plan as provided below. lease is one where the required payments have not been
made and for which there is little probability that payment will
Specific Instructions be made. Provide, on a separate attachment, an explanation of
Lines A, B, C, and D. This information must be the same as what steps have been taken or will be taken to collect overdue
reported in Part II of the Form 5500 to which this Schedule G is amounts for each lease listed and label the attachment
attached. “Schedule G, Part II – Overdue Lease Explanation.”
Do not use a social security number in line D in lieu of an For a DCG, include in the description in element (d) the
EIN. The Schedule G and its attachments are open to public name of the plan or plans involved, the EIN(s) and plan
inspection, and the contents are public information and are number(s). This information must be the same as the
subject to publication on the internet. Because of privacy information reported on Part III of Schedule DCG.
concerns, the inclusion of a social security number or any Part III – Nonexempt Transactions
portion thereof on this Schedule G or any of its attachments
may result in the rejection of the filing. All nonexempt party-in-interest transactions must be reported,
regardless of whether disclosed in the accountant’s report,
You can apply for an EIN from the IRS online, by fax, or by unless the nonexempt transaction is:
mail depending on how soon you need to use the EIN. For
more information, see Section 3: Electronic Filing Requirement 1. Statutorily exempt under Part 4 of Title I of ERISA;
under General Instructions to Form 5500. The EBSA does not 2. Administratively exempt under ERISA section 408(a);
issue EINs. 3. Exempt under Code sections 4975(c) or 4975(d);
4. The holding of participant contributions in the employer’s
Part I – Loans or Fixed Income Obligations in Default general assets for a welfare plan that meets the conditions of
or Classified as Uncollectible ERISA Technical Release 92-01;
List all loans or fixed income obligations in default or 5. A transaction of a 103-12 IE with parties other than
determined to be uncollectible as of the end of the plan year or the plan; or
the fiscal year of the GIA, MTIA, DCG or 103-12 IE. Include: 6. A delinquent participant contribution or a delinquent
 Obligations where the required payments have not been participant loan repayment reported on Schedule H, line 4a.
made by the due date; Note. In the case of a DCG, include in the description in
 Fixed income obligations that have matured, but have not element (c) the plan in the DCG, the name of the plan or plans
been paid, for which it has been determined that payment will involved, EIN(s) and plan number(s). This information must be
not be made; and the same as the information reported on Part III of Schedule
 Loans that were in default even if renegotiated later during DCG.
the year. Nonexempt transactions with a party-in-interest include
Note. Check box (a) and identify in element (b) each obligor any direct or indirect:
known to be a party-in-interest to the plan. For a DCG, include A. Sale or exchange, or lease, of any property between the
in the description in element (c) the name of the plan or plans plan and a party-in-interest.
involved, EIN(s) and plan number(s). This information must be B. Lending of money or other extension of credit between
the same as the information reported on Part III of Schedule the plan and a party-in-interest.
DCG. C. Furnishing of goods, services, or facilities between the
plan and a party-in-interest.

Instructions for Schedule G (Form 5500) -41-

- 42 -

D. Transfer to, or use by or for the benefit of, a party-in- indirectly, of a person described in B, C, D, E, or G, or of the
interest, of any income or assets of the plan. employee benefit plan; or
E. Acquisition, on behalf of the plan, of any employer I. A 10% or more (directly or indirectly in capital or profits)
security or employer real property in violation of ERISA partner or joint venture of a person described in B, C, D, E,
section 407(a). or G.
F. Dealing with the assets of the plan for a fiduciary’s own An unfunded, fully insured, or combination
interest or own account unfunded/insured welfare plan with 100 or more
G. Acting in a fiduciary’s individual or any other capacity in participants exempt under 29 CFR 2520.104-44 from
any transaction involving the plan on behalf of a party (or completing Schedule H must still complete Schedule G, Part
represent a party) whose interests are adverse to the III, to report nonexempt transactions.
interests of the plan or the interests of its participants or
beneficiaries. A plan that is required to file a Form M-1, Report for Multiple-
H. A receipt of any consideration for their own personal Employer Welfare Arrangements (MEWAs) and Certain
account by a party-in-interest who is a fiduciary from any Entities Claiming Exception (ECEs), but that is not required to
party dealing with the plan in connection with a transaction file the Schedule I because it has fewer than 100 participants
involving the income or assets of the plan. and meets the requirements of 29 CFR 2520.104-44, also
For purposes of this form, party-in-interest is deemed to must complete Schedule G, Part III, to report nonexempt
include a disqualified person. See Code section 4975(e)(2). transactions.
The term ‘‘party-in-interest’’ means, as to an employee If you are unsure whether a transaction is exempt or not, you
benefit plan: should consult with either the plan’s independent qualified
A. Any fiduciary (including, but not limited to, any public accountant or legal counsel or both.
administrator, officer, trustee or custodian), counsel, or You may indicate that an application for an administrative
employee of the plan; exemption is pending.
B. A person providing services to the plan; If the plan is a qualified pension plan and a nonexempt
C. An employer, any of whose employees are covered by prohibited transaction occurred with respect to a disqualified
the plan; person, an IRS Form 5330, Return of Excise Taxes Related to
D. An employee organization, any of whose members are Employee Benefit Plans, is required to be filed with the IRS to
covered by the plan; pay the excise tax on the transaction.
E. An owner, direct or indirect, of 50% or more of: (1) the The DOL Voluntary Fiduciary Correction Program
combined voting power of all classes of stock entitled to vote (VFCP) describes how to apply, the specific
or the total value of shares of all classes of stock of a transactions covered (which transactions include delinquent
corporation, (2) the capital interest or the profits interest of a participation contributions to pension and welfare plans), and
partnership, or (3) the beneficial interest of a trust or acceptable methods for correcting violations. In addition,
unincorporated enterprise that is an employer or an applicants that satisfy both the VFCP requirements and the
employee organization described in C or D; conditions of Prohibited Transaction Exemption (PTE) 2002-51
F. A relative of any individual described in A, B, C, or E; are eligible for immediate relief from payment of certain
G. A corporation, partnership, or trust or estate of which (or prohibited excise taxes for certain corrected transactions and
in which) 50% or more of: (1) the combined voting power of are also relieved from the obligation to file the Form 5330 with
all classes of stock entitled to vote or the total value of the IRS. For more information, see 71 Fed. Reg. 20261 (Apr.
shares of all classes of stock of such corporation, (2) the 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19, 2006). If
capital interest or profits interest of such partnership, or (3) conditions of PTE 2002-51 are satisfied, corrected transactions
the beneficial interest of such trust or estate is owned should be treated as exempt under Code section 4975(c) for
directly or indirectly, or held by, persons described in A, B, the purposes of answering Schedule G, Part III. Information
C, D, or E; about the VFCP is also available on the internet at
H. An employee, officer, director (or individual having www.dol.gov/ebsa.
powers or responsibilities similar to those of officers or
directors), or a 10% or more shareholder, directly or

-42- Instructions for Schedule G (Form 5500)

- 43 -

or PSA and expenses that were subtracted from the gross
2023 Instructions for Schedule H income of the CCT or PSA in determining their net investment
(Form 5500) gain (loss). Instead, enter the CCT or PSA net gain (loss) on
line 2b(6) or (7) in accordance with the instructions for these
Financial Information lines.
General Instructions If assets of one plan are maintained in two or more trust
Who Must File funds, report the combined financial information in Parts I and II.
Schedule H (Form 5500) must be attached to a Form 5500 filed Current value means fair market value where available.
for a pension benefit plan or a welfare benefit plan that covered Otherwise, it means the fair value as determined in good faith
100 or more participants as of the beginning of the plan year under the terms of the plan by a trustee or a named fiduciary,
and a Form 5500 filed for an MTIA, CCT, PSA, 103-12 IE, DCG assuming an orderly liquidation at time of the determination.
or GIA. See the instructions to the Form 5500 in Section 4: See ERISA section 3(26).
Direct Filing Entity (DFE) Filing Requirements. Note. For the 2023 plan year, plans that provide participant-
Exceptions: (1) Fully insured, unfunded, or a combination of directed brokerage accounts as an investment alternative (and
unfunded/insured welfare plans and fully insured pension plans have entered pension feature code ‘‘2R’’ on line 8a of the Form
that meet the requirements of 29 CFR 2520.104-44 are exempt 5500) may report investments in assets made through
from completing the Schedule H. (2) If a Schedule I was filed for participant-directed brokerage accounts either:
the plan for the 2022 plan year or a Form 5500-SF and the plan 1. As individual investments on the applicable asset and
covered fewer than 121 participants as of the beginning of the liability categories in Part I and the income and expense
2023 plan year, the Schedule I may be completed instead of a categories in Part II, or
Schedule H. See What To File. If eligible, such a plan may file 2. By including on line 1c(15) the total aggregate value of the
the Form 5500-SF instead of the Form 5500 and its schedules, assets and on line 2c the total aggregate investment income
including the Schedule I. See Instructions for Form 5500-SF. (3) (loss) before expenses, provided the assets are not loans,
Plans that file a Form 5500-SF for the 2023 plan year are not partnership or joint-venture interests, real property, employer
required to file a Schedule H for that year. securities, or investments that could result in a loss in excess of
Check the Schedule H box on the Form 5500 (Part II, line the account balance of the participant or beneficiary who
10b(1)) if a Schedule H is attached to the Form 5500. Do not directed the transaction. Expenses charged to the accounts
attach both a Schedule H and a Schedule I to the same Form must be reported on the applicable expense line items.
5500. Participant-directed brokerage account assets reported in the
aggregate on line 1c(15) should be treated as one asset held for
Note. DCGs report Schedule H information collectively for all investment for purposes of the line 4i schedules, except that
plans in the DCG, except as otherwise provided in the annual investments in tangible personal property must continue to be
reporting regulations or the instructions below. reported as separate assets on the line 4i schedules.
Specific Instructions In the event that investments made through a
Lines A, B, C, and D. This information must be the same as participant-directed brokerage account are loans, partnership or
reported in Part II of the Form 5500 to which this Schedule H is joint venture interests, real property, employer securities, or
attached. investments that could result in a loss in excess of the account
balance of the participant or beneficiary who directed the
Do not use a social security number in line D in lieu of an transaction, such assets must be broken out and treated as
EIN. The Schedule H and its attachments are open to public separate assets on the applicable asset and liability categories
inspection, and the contents are public information and are in Part I, income and expense categories in Part II, and on the
subject to publication on the Internet. Because of privacy line 4i schedules. The remaining assets in the participant-
concerns, the inclusion of a social security number or any directed brokerage account may be reported in the aggregate
portion thereof on this Schedule H or any of its attachments may as set forth in paragraph 2 above.
result in the rejection of the filing.
Columns (a) and (b). Enter the current value on each line as of
You can apply for an EIN from the IRS online, by fax, or by the beginning and end of the plan year.
mail depending on how soon you need to use the
EIN. For more information, see Section 3: Electronic Filing Note. Amounts reported in column (a) must be the same as
Requirement under General Instructions to Form 5500. The reported for the end of the plan year for corresponding line
EBSA does not issue EINs. items of the return/report for the preceding plan year. Do not
include contributions designated for the 2023 plan year in
Part I – Asset and Liability Statement column (a).
Note. The cash, modified cash, or accrual basis may be used Line 1a. Total noninterest bearing cash includes, among other
for recognition of transactions in Parts I and II, as long as you things, cash on hand or cash in a noninterest bearing checking
use one method consistently. Round off all amounts reported account.
on the Schedule H to the nearest dollar. Any other amounts are
subject to rejection. Check all subtotals and totals carefully. Line 1b(1). Noncash basis filers must include contributions due
the plan by the employer but not yet paid. Do not include other
If the assets of two or more plans are maintained in a fund or amounts due from the employer such as the reimbursement of
account that is not a DFE, a registered investment company, or an expense or the repayment of a loan.
the general account of an insurance company under an
unallocated contract (see the instructions for lines 1c(9) through Line 1b(2). Noncash basis filers must include contributions
1c(14)), complete Parts I and II of the Schedule H by entering withheld by the employer from participants and amounts due
the plan’s allocable part of each line item. directly from participants that have not yet been received by the
plan. Do not include the repayment of participant loans.
Exception. When completing Part II of the Schedule H for a
plan or DFE that participates in a CCT or PSA for which a Form Line 1b(3). Noncash basis filers must include amounts due to
5500 has not been filed, do not allocate the income of the CCT the plan that are not includable in lines 1b(1) or 1b(2). These

Instructions for Schedule H (Form 5500) -43-

- 44 -

amounts may include investment income earned but not yet                1. Under the plan, the participant loan is treated as a 
received by the plan and other amounts due to the plan such as         directed investment solely of the participant’s individual account; 
amounts due from the employer or another plan for expense              and  
reimbursement or from a participant for the repayment of an             2. As of the end of the plan year, the participant is not 
overpayment of benefits.                                               continuing repayment under the loan.  
Line 1c(1). Include all assets that earn interest in a financial        If both of these circumstances apply, report the loan as a 
institution account such as interest bearing checking accounts,        deemed distribution on line 2g. However, if either of these 
passbook savings accounts, or in money market accounts.                circumstances does not apply, the current value of the 
Line 1c(2). Include securities issued or guaranteed by the U.S.        participant loan (including interest accruing thereon after the 
Government or its designated agencies such as U.S. Savings             deemed distribution) must be included in column (b) without 
Bonds, Treasury Bonds, Treasury Bills, FNMA, and GNMA.                 regard to the occurrence of a deemed distribution.  
Line 1c(3). Include investment securities (other than employer         Note. After a participant loan that has been deemed distributed 
securities defined below in line 1d(1)) issued by a corporate          is reported on line 2g, it is no longer to be reported as an asset 
entity at a stated interest rate repayable on a particular future      on Schedule H or Schedule I unless, in a later year, the 
date such as most bonds, debentures, convertible debentures,           participant resumes repayment under the loan. However, such a 
commercial paper and zero coupon bonds. Do not include debt            loan (including interest accruing thereon after the deemed 
securities of governmental units that should be reported on line       distribution) that has not been repaid is still considered 
1c(2) or 1c(15).                                                       outstanding for purposes of applying Code section 72(p)(2)(A) 
                                                                       to determine the maximum amount of subsequent loans. Also, 
 ‘‘Preferred’’ means any of the above securities that are              the deemed distribution is not treated as an actual distribution 
publicly traded on a recognized securities exchange and the            for other purposes, such as the qualification requirements of 
securities have a rating of ‘‘A’’ or above. If the securities are not  Code section 401, including, for example, the determination of 
‘‘Preferred,’’ they are listed as ‘‘Other.’’                           top-heavy status under Code section 416 and the vesting 
Line 1c(4)(A). Include stock issued by corporations (other than        requirements of Treasury Regulations section 1.411(a)-7(d)(5). 
employer securities defined in line 1d(1) below) which is              See Q&As 12 and 19 of Treasury Regulations section 1.72(p)-1. 
accompanied by preferential rights such as the right to share in        The entry on line 1c(8), column (b), of Schedule H 
distributions of earnings at a higher rate or which has general        (participant loans - end of year) or on line 1a, column (b), of 
priority over the common stock of the same entity. Include the         Schedule I (plan assets - end of year) must include the current 
value of warrants convertible into preferred stock.                    value of any participant loan that was reported as a deemed 
Line 1c(4)(B). Include any stock (other than employer securities       distribution on line 2g for any earlier year if the participant 
defined in line 1d(1)) that represents regular ownership of the        resumes repayment under the loan during the plan year. In 
corporation and is not accompanied by preferential rights.             addition, the amount to be entered on line 2g must be reduced 
Include the value of warrants convertible into common stock.           by the amount of the participant loan that was reported as a 
Line 1c(5). Include the value of the plan’s participation in a         deemed distribution on line 2g for the earlier year. 
partnership or joint venture if the underlying assets of the           Lines 1c(9), (10), (11), and (12). Enter the total current value of 
partnership or joint venture are not considered to be plan assets      the plan’s or DFE’s interest in DFEs on the appropriate lines as 
under 29 CFR 2510.3-101. Do not include the value of a plan’s          of the beginning and end of the plan or DFE year. The value of 
interest in a partnership or joint venture that is a 103-12            the plan’s or DFE’s interest in each DFE at the end of the plan 
Investment Entity (103-12 IE). Include the value of a 103-12 IE        or DFE year must be reported on the Schedule D (Form 5500).  
in line 1c(12).                                                        The plan’s or DFE’s interest in common/collective trusts (CCTs) 
Line 1c(6). Include the current value of both income and non-                and pooled separate accounts (PSAs) for which a DFE 
income producing real property owned by the plan. Do not                     Form 5500 has not been filed may not be included on 
include the value of property that is employer real property or        lines 1c(9) or 1c(10). The plan’s or DFE’s interest in the 
property used in plan operations that must be reported on lines        underlying assets of such CCTs and PSAs must be allocated 
1d and 1e, respectively.                                               and reported in the appropriate categories on a line-by-line 
Line 1c(7). Enter the current value of all loans made by the           basis on Part I of the Schedule H.  
plan, except participant loans reportable on line 1c(8). Include       Note. For reporting purposes, a separate account that is not 
the sum of the value of loans for construction, securities loans,      considered to be holding plan assets pursuant to 29 CFR 
commercial and/or residential mortgage loans that are not              2510.3-101(h)(1)(iii) does not constitute a PSA. 
subject to Code section 72(p) (either by making or participating       Line 1c(13). A registered investment company is an investment 
in the loans directly or by purchasing loans originated by a third     company registered under the Investment Company Act of 
party), and other miscellaneous loans.                                 1940. These are mutual funds (legally known as open-end 
Line 1c(8). Enter the current value of all loans to participants       companies), closed-end funds (legally known as closed-end 
including residential mortgage loans that are subject to Code          companies), and UITs (legally known as unit investment trusts). 
section 72(p). Include the sum of the value of the unpaid              Line 1c(14). Use the same method for determining the value of 
principal balances, plus accrued but unpaid interest, if any, for      the insurance contracts reported here as you used for line 4 of 
participant loans made under an individual account plan with           Schedule A, or, if line 4 is not required, line 7 of Schedule A. 
investment experience segregated for each account, that are            Line 1c(15). Include all other investments not includable in lines 
made in accordance with 29 CFR 2550.408b-1 and secured                 1c(1) through (14), such as options, index futures, state and 
solely by a portion of the participant’s vested accrued benefit.       municipal securities, collectibles, and other personal property. 
When applicable, combine this amount with the current value of 
any other participant loans. Do not include in column (b) a            Line 1d(1). An employer security is any security issued by an 
participant loan that has been deemed distributed during the           employer (including affiliates) of employees covered by the plan. 
plan year under the provisions of Code section 72(p) and               These may include common stocks, preferred stocks, bonds, 
Treasury Regulations section 1.72(p)-1, if both of the following       zero coupon bonds, debentures, convertible debentures, notes 
circumstances apply:                                                   and commercial paper. 

                                                                  -44-              Instructions for Schedule H (Form 5500)

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Line 1d(2). The term ‘‘employer real property’’ means real              Line 2b(1)(C). Generally, this is the interest earned on 
property (and related personal property) that is leased to an           securities that are reported on lines 1c(3)(A) and (B) and 1d(1).  
employer of employees covered by the plan, or to an affiliate of        Line 2b(2). Generally, the dividends are for investments 
such employer. For purposes of determining the time at which a          reported on lines 1c(4)(A) and (B), 1c(13), and 1d(1). For 
plan acquires employer real property for purposes of this line,         accrual basis plans, include any dividends declared for stock 
such property shall be deemed to be acquired by the plan on             held on the date of record, but not yet received as of the end of 
the date on which the plan acquires the property or on the date         the plan year.  
on which the lease to the employer (or affiliate) is entered into, 
whichever is later.                                                     Line 2b(3). Generally, rents represent the income earned on the 
                                                                        real property that is reported in lines 1c(6) and 1d(2). Enter 
Line 1e. Include the current (not book) value of the buildings          rents as a ‘‘Net’’ figure. Net rents are determined by taking the 
and other property used in the operation of the plan. Buildings         total rent received and subtracting all expenses directly 
or other property held as plan investments should be reported in        associated with the property. If the real property is jointly used 
1c(6) and 1d(2).                                                        as income producing property and for the operation of the plan, 
 Do not include the value of future pension payments on lines           net that portion of the expenses attributable to the income 
1g, h, i, j, or k.                                                      producing portion of the property against the total rents 
Line 1g. Noncash basis plans must include the total amount of           received.  
benefit claims that have been processed and approved for                Line 2b(4). Enter in column (b), the total of net gain (loss) on 
payment by the plan. Include welfare plan ‘‘incurred but not            sale of assets. This equals the sum of the net realized gain (or 
reported’’ (IBNR) benefit claims on this line.                          loss) on each asset held at the beginning of the plan year which 
Line 1h. Noncash basis plans must include the total amount of           was sold or exchanged during the plan year, and on each asset 
obligations owed by the plan which were incurred in the normal          that was both acquired and disposed of within the plan year.  
operations of the plan and have been approved for payment by            Note. As current value reporting is required for the Form 5500, 
the plan but have not been paid.                                        assets are revalued to current value at the end of the plan year. 
Line 1i. ‘‘Acquisition indebtedness,’’ for debt-financed property       For purposes of this form, the increase or decrease in the value 
other than real property, means the outstanding amount of the           of assets since the beginning of the plan year (if held on the first 
principal debt incurred:                                                day of the plan year) or their acquisition date (if purchased 
                                                                        during the plan year) is reported in line 2b(5) below, with two 
 1. By the organization in acquiring or improving the                   exceptions: (1) the realized gain (or loss) on each asset that 
property;                                                               was disposed of during the plan year is reported in line 2b(4) 
 2. Before the acquisition or improvement of the property if            (NOT on line 2b(5)), and (2) the net investment gain (or loss) 
the debt was incurred only to acquire or improve the property; or       from CCTs, PSAs, MTIAs, 103-12 IEs, and registered 
 3. After the acquisition or improvement of the property if the         investment companies is reported in lines 2b(6) through (10). 
debt was incurred only to acquire or improve the property and 
was reasonably foreseeable at the time of such acquisition or            The sum of the realized gain (or loss) of assets sold or 
improvement. For further explanation, see Code section 514(c).          exchanged during the plan year is to be calculated as follows: 
Line 1j. Noncash basis plans must include amounts owed for               1. Enter in line 2b(4)(A), column (a), the sum of the amount 
any liabilities that would not be classified as benefit claims          received for these former assets; 
payable, operating payables, or acquisition indebtedness.                2. Enter in line 2b(4)(B), column (a), the sum of the current 
                                                                        value of these former assets as of the beginning of the plan year 
Line 1l. Enter the net assets as of the beginning and end of the        and the purchase price for assets both acquired and disposed of 
plan year (Subtract line 1k from line 1f.) The entry in column (b)      during the plan year; and 
must equal the sum of the entry in column (a) plus lines 2k and          3. Enter in 2b(4) (C), column (b), the result obtained when 
2l(1), minus 2l(2).                                                     2b(4)(B) is subtracted from 2b(4)(A). If entering a negative 
Part II – Income and Expense Statement                                  number, enter a minus sign “–” to the left of the number. 
Line 2a. Include the total cash contributions received and/or (for      Note. Bond write-offs should be reported as realized losses. 
accrual basis plans) due to be received.                                Line 2b(5). Subtract the current value of assets at the beginning 
Note. Plans using the accrual basis of accounting should not            of the year plus the cost of any assets acquired during the plan 
include contributions designated for years before the 2023 plan         year from the current value of assets at the end of the year to 
year on line 2a.                                                        obtain this figure. If entering a negative number, enter a minus 
Line 2a(1)(B). For welfare plans, report all employee                   sign “–” to the left of the number. Do not include the value of 
contributions, including all elective contributions under a             assets reportable in lines 2b(4) and 2b(6) through 2b(10). 
cafeteria plan (Code section 125). For pension benefit plans,           Lines 2b(6), (7), (8), and (9). Report all earnings, expenses, 
participant contributions, for purposes of this item, also include      gains or losses, and unrealized appreciation or depreciation 
elective contributions under a qualified cash or deferred               included in computing the net investment gain (or loss) from all 
arrangement (Code section 401(k)).                                      CCTs, PSAs, MTIAs, and 103-12 IEs here. If some plan funds 
Line 2a(2). Use the current value, at date contributed, of              are held in any of these entities and other plan funds are held in 
securities or other noncash property.                                   other funding media, complete all applicable subitems of line 2 
                                                                        to report plan earnings and expenses relating to the other 
Line 2b(1)(A). Enter interest earned on interest-bearing cash,          funding media. The net investment gain (or loss) allocated to the 
including earnings from sweep accounts, STIF accounts, money            plan for the plan year from the plan’s investment in these 
market accounts, certificates of deposit, etc. This is the interest     entities is equal to: 
earned on the investments reported on line 1c(1).  
                                                                         1. The sum of the current value of the plan’s interest in each 
Line 2b(1)(B). Enter interest earned on U.S. Government                 entity at the end of the plan year, 
Securities. This is the interest earned on the investments               2. Minus the current value of the plan’s interest in each entity 
reported on line 1c(2).                                                 at the beginning of the plan year, 

Instructions for Schedule H (Form 5500)                             -45-

- 46 -

 3. Plus any amounts transferred out of each entity by the             must then be included in line 1c(8), column (b), of Schedule H 
plan during the plan year, and                                         (participant loans - end of year) or in line 1a, column (b), of 
 4. Minus any amounts transferred into each entity by the              Schedule I (plan assets - end of year).  
plan during the plan year.                                               Although certain participant loans deemed distributed are to 
 Enter the net gain as a positive number or the net loss as a          be reported on line 2g of the Schedule H or Schedule I, and are 
negative number.                                                       not to be reported on the Schedule H or Schedule I as an asset 
Note. Enter the combined net investment gain or loss from all          thereafter (unless the participant resumes repayment under the 
CCTs and PSAs, regardless of whether a DFE Form 5500 was               loan in a later year), they are still considered outstanding loans 
filed for the CCTs and PSAs.                                           and are not treated as actual distributions for certain purposes. 
                                                                       See Q&As 12 and 19 of Treasury Regulations section 1.72(p)-1. 
Line 2b(10). Enter net investment gain (loss) from registered 
investment companies here. Compute in the same manner as               Line 2h.  Interest expense is a monetary charge for the use of 
discussed above for lines 2b(6) through (9), except do not             money borrowed by the plan. This amount should include the 
include dividends reported on line 2b(2)(C).                           total of interest paid or to be paid (for accrual basis plans) 
                                                                       during the plan year. 
Line 2c. Include all other plan income earned that is not included 
in line 2a or 2b. Do not include transfers from other plans that       Line 2i.  Report all administrative expenses (by specified 
should be reported in line 2l.                                         category) paid by or charged to the plan, including those that 
                                                                       were not subtracted from the gross income of CCTs, PSAs, 
Line 2e(1). Include the current value of all cash, securities, or      MTIAs, and 103-12 IEs in determining their net investment 
other property at the date of distribution. Include all eligible       gain(s) or loss(es). Expenses incurred in the general operations 
rollover distributions as defined in Code section 401(a)(31)(D)        of the plan are classified as administrative expenses. 
paid at the participant’s election to an eligible retirement plan 
(including an IRA within the meaning of section 401(a)(31)(E)).          Include, in the appropriate categories in lines 2i(1)-(11), the 
                                                                       total fees paid (or in the case of accrual basis plans, costs 
Line 2e(2).  Include payments to insurance companies and               incurred during the plan year but not paid as of the end of the 
similar organizations such as Blue Cross, Blue Shield, and             plan year) by the plan for plan salaries and allowances, contract 
health maintenance organizations for the provision of plan             administrator fees, recordkeeping fees, investment advisory and 
benefits (e.g., paid-up annuities, accident insurance, health          investment management fees, IQPA audit fees, bank or trust 
insurance, vision care, dental coverage, stop-loss insurance           company trustee/custodial fees, actuarial fees, legal fees, 
whose claims are paid to the plan (or which is otherwise an            valuation/appraisal services, other trustee fees, and other 
asset of the plan)), etc.                                              expenses. 
Line 2e(3).  Include all payments made to other organizations          Line 2i(1).  Report total salaries and allowances for plan 
or individuals providing benefits. Generally, these are individual     employees in line 2i(1). Include plan expenditures such as 
providers of welfare benefits such as legal services, day care         salaries, other compensation, and allowances and employee 
services, training, and apprenticeship services.                       benefits (e.g., payment of premiums to provide health insurance 
Line 2f.  Include on this line all distributions paid during the       benefits to plan employees). Amounts paid to plan employees to 
plan year of excess deferrals under Code section                       perform recordkeeping/bookkeeping/ accounting and similar 
402(g)(2)(A)(ii), excess contributions under Code section              functions should be included in line 2i(1). 
401(k)(8), and excess aggregate contributions under Code               Line 2i(2).  Enter the total fees paid (or in the case of accrual 
section 401(m)(6). Include allocable income distributed. Also          basis plans, costs incurred during the plan year but not paid as 
include on this line any elective deferrals and employee               of the end of the plan year) to a contract administrator for 
contributions distributed or returned to employees during the          performing administrative services for the plan. For purposes of 
plan year, as well as any attributable income that was also            the return/report, a contract administrator is any individual, 
distributed.                                                           partnership, or corporation, responsible for managing the 
Line 2g. Report on line 2g a participant loan that has been            clerical operations (e.g., handling membership rosters, claims 
deemed distributed during the plan year under the provisions of        payments, maintaining books and records) of the plan on a 
Code section 72(p) and Treasury Regulations section 1.72(p)-1          contractual basis. Do not include salaried staff or employees of 
only if both of the following circumstances apply:                     the plan or banks or insurance carriers. 
 1. Under the plan, the participant loan is treated as a               Line 2i(3). Include fees for recordkeeping services and other 
directed investment solely of the participant’s individual account;    accounting fees, such as for payroll audits and other audit fees, 
and                                                                    paid by the plan. Do not include in line 2i(3) amounts paid to a 
 2. As of the end of the plan year, the participant is not             contract administrator that should be included in line 2i(2) or an 
continuing repayment under the loan.                                   IQPA for annual audit and related activities that should be 
 If either of these circumstances does not apply, a deemed             included in line 2i(4).  
distribution of a participant loan should not be reported on line      Line 2i(4). Enter in line 2i(4) fees paid to an independent 
2g. Instead, the current value of the participant loan (including      qualified public accountant (IQPA) for the annual audit of the 
interest accruing thereon after the deemed distribution) must be       plan and related activities. 
included on line 1c(8), column (b) (participant loans – end of         Line 2i(5). Enter the total fees paid to an individual, partnership 
year), without regard to the occurrence of a deemed distribution.      or corporation (or other person) for advice to the plan relating to 
Note. The amount to be reported on line 2g of Schedule H or            its investment portfolio. These may include fees paid to manage 
Schedule I must be reduced if, during the plan year, a                 the plan’s investments, fees for specific advice on a particular 
participant resumes repayment under a participant loan reported        investment, and fees for the evaluation for the plan’s investment 
as a deemed distribution on line 2g for any earlier year. The          performance. 
amount of the required reduction is the amount of the participant      Line 2i(6). Include bank or trust company trustee/custodial fees. 
loan reported as a deemed distribution on line 2g for the earlier 
year. If entering a negative number, enter a minus sign “ – ” to 
the left of the number. The current value of the participant loan 

                                                                  -46-                       Instructions for Schedule H (Form 5500)

- 47 -

Line 2i(7). Include fees for actuarial services rendered to the plan’s Schedule DCG. The IQPA report for each plan must be
plan, including preparation of Schedules MB or SB, as attached to the Schedule DCG unless the plan is eligible for the
applicable. waiver of the annual examination and report of an IQPA under
Line 2i(8). Include payments to a lawyer for rendering legal 29 CFR 2520.104-46. See instructions for Part VII of Schedule
opinions, litigation, and advice and other legal services to the DCG.
plan (but not for providing legal services as a benefit to plan Notes. (1) The Auditing Standards Board’s Statement on
participants). Auditing Standards (SAS) 136, Forming an Opinion and
Line 2i(9). Include the fee(s) for valuations or appraisals to Reporting on Financial Statements of Employee Benefit Plans
determine the cost, quality, or value of an item such as real Subject to ERISA, addresses the IQPA’s responsibility to form
property or personal property (gemstones, coins, etc.), and for an opinion on the financial statements of employee benefit plans
valuations of closely held securities for which there is no ready subject to ERISA. SAS 136 also addresses the form and
market. content of the auditor’s report issued as a result of an audit of
an ERISA plan’s financial statements. The SAS applies to audits
Line 2i(10). Include the total fees and expenses paid to or on of single-employer, multiple-employer, and multiemployer plans
behalf of plan trustees other than bank or trust company fees subject to ERISA. An IQPA Report generally consists of an
reported on line 2i(6). Include direct payment by the plan or Accountant’s Opinion, the plan or DFE Financial Statements,
reimbursement by the plan to trustees of expenses associated Notes to the Financial Statements, and Supplemental
with trustees such as lost time, seminars, travel, meetings, Schedules.
educational conferences, etc.
29 CFR 2520.103-1(b) requires that any separate financial
Line 2i(11). Enter the total other expenses. Other expenses are statements prepared in order for the IQPA to form the opinion
those that cannot be associated definitely with lines 2i(1) and notes to these financial statements must be attached to the
through 2i(10). These may include expenses for office supplies Form 5500. Any separate statements must include the
and equipment, cars, telephone, postage, rent, expenses information required to be disclosed in Parts I and II of the
associated with the ownership of a building used in the Schedule H; however, they may be aggregated into categories
operation of the plan, and all miscellaneous expenses. Include in a manner other than that used on the Schedule H. The
premium payments to the PBGC when paid from plan assets. separate statements must consist of reproductions of Parts I
Line 2i(12). Add all administrative expense amounts in lines and II or statements incorporating by reference Parts I and II.
2i(1) through (11) and enter the total in column (b). See ERISA section 103(a)(3)(A), and the DOL regulations 29
Line 2j. Add all expense amounts in column (b) and enter the CFR 2520.103-1(a)(2) and (b), 2520.103-2, and 2520.104-50.
total in column (b). (2) Delinquent participant contributions reported on line 4a
Line 2l. Include in these reconciliation figures the value of all should be treated as part of the separate schedules referenced
transfers of assets or liabilities into or out of the plan resulting in ERISA section 103(a)(3)(A) and 29 CFR 2520.103-1(b) and
from, among other things, mergers and consolidations. A 2520.103-2(b) for purposes of preparing the IQPA’s opinion
transfer of assets or liabilities occurs when there is a reduction described on line 3 even though they are no longer required to
of assets or liabilities with respect to one plan and the receipt of be listed on Part III of the Schedule G. If the information
these assets or the assumption of these liabilities by another contained on line 4a is not presented in accordance with
plan. A transfer is not a shifting of one plan’s assets or liabilities regulatory requirements, i.e., when the IQPA concludes that the
from one investment to another. A transfer is not a distribution of scheduled information required by line 4a does not contain all
all or part of an individual participant’s account balance that is the required information or contains information that is
reportable on IRS Form 1099-R, Distributions From Pensions, inaccurate or is inconsistent with the plan’s financial statements,
Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance the IQPA report must make the appropriate disclosures in
Contracts, etc., (see the instructions for line 2e). Transfers out accordance with generally accepted auditing standards.
at the end of the year should be reported as occurring during Delinquent participant contributions that are exempt because
the plan year. they satisfy the DOL’s Voluntary Fiduciary Correction Program
Note. If this Schedule H is filed for a CCT, PSA, MTIA, or 103- (VFCP) requirements and the conditions of prohibited
12 IE, report the value of all asset transfers to the CCT, PSA, transaction exemption (PTE) 2002-51 do not need to be treated
MTIA, or 103-12 IE, including those resulting from contributions as part of the schedule of nonexempt party-in-interest
to participating plans on line 2l(1), and report the total value of transactions.
all assets transferred out of the CCT, PSA, MTIA, or 103-12 IE, If the required IQPA’s report is not attached to the Form
including assets withdrawn for disbursement as benefit 5500, the filing is subject to rejection as incomplete and
payments by participating plans, on line 2l(2). Contributions and penalties may be assessed.
benefit payments are considered to be made to/by the plan (not Lines 3a(1) through 3a(4). These boxes identify the type of
to/by a CCT, PSA, MTIA, or 103-12 IE). opinion offered by the IQPA.
Part III – Accountant’s Opinion The Plan Administrator should confirm with their IQPA
Line 3. The administrator of an employee benefit plan who files whether the opinion was an unmodified, qualified,
a Schedule H generally must engage an Independent Qualified disclaimer of, or adverse opinion before answering line 3a.
Public Accountant (IQPA) pursuant to ERISA section Line 3a(1). Check if an unmodified opinion was issued
103(a)(3)(A) and 29 CFR 2520.103-1(b). This requirement also pursuant to SAS 136. Generally, an unmodified opinion is
applies to a Form 5500 filed for a 103-12 IE and for a GIA (see issued when the IQPA concludes that the plan’s financial
29 CFR 2520.103-12 and 29 CFR 2520.103-2). The IQPA’s statements are presented fairly, in all material respects, in
report must be attached to the Form 5500 when a Schedule H is accordance with the applicable financial reporting framework
attached unless line 3d(1) or 3d(2) on the Schedule H is (generally accepted accounting principles (GAAP) or another
checked. For DCGs, the IQPA requirements are determined at basis such as modified cash or cash basis). This also includes
the plan level for each plan participating in the DCG. The the form of opinion that SAS 136 permits an IQPA to issue when
Accountant’s Opinion information must be completed on each the IQPA has performed an ERISA section 103(a)(3)(C) audit

Instructions for Schedule H (Form 5500) -47-

- 48 -

pursuant to 29 CFR 2520.103-8 or 29 CFR 2520.103-12, or must be complete and accurate, with all required attachments,
both, and had no modifications. except for the IQPA’s report, including an attachment explaining
Under 29 CFR 2520.103-8, the examination and report of an why one of the two (2) plan years is of seven (7) or fewer
IQPA does not need to extend to statements or information months duration and stating that the annual report for the
regarding assets held by a bank, similar institution, or insurance immediately following plan year will include a report of an IQPA
carrier that is regulated and supervised and subject to periodic with respect to the financial statements and accompanying
examination by a state or federal agency provided that the schedules for both of the two (2) plan years. The Form 5500 for
statements or information are prepared by and certified to by the the second year must include: (a) financial schedules and
bank or similar institution or the insurance carrier. The term statements for both plan years; (b) a report of an IQPA with
‘‘similar institution’’ as used here does not extend to securities respect to the financial schedules and statements for each of
brokerage firms (see DOL Advisory Opinion 93-21A). Under 29 the two (2) plan years (regardless of the number of participants
CFR 2520.103-12, an audit of an employee benefit plan does covered at the beginning of each plan year); and (c) a statement
not need extend to the investments in a pooled investment fund identifying any material differences between the unaudited
that files a separate audited Form 5500 as a 103-12 IE. For financial information submitted with the first Form 5500 and the
more information on filing requirements for 103-12 IEs, See audited financial information submitted with the second Form
Section 4: What to File. Neither of these regulations exempt the 5500. See 29 CFR 2520.104-50.
plan administrator from engaging an IQPA nor from attaching Note. Do not check the box on line 3d(2) if the Form 5500 is
the IQPA’s report to the Form 5500. filed for a 103-12 IE or a GIA. A deferral of the IQPA’s opinion is
Line 3a(2). Check if a qualified opinion was issued. Generally, not permitted for a 103-12 IE or a GIA. If an “E” or “G” is entered
a qualified opinion is issued by an IQPA when (a) the IQPA, on Form 5500, Part I, line A(4), an IQPA’s opinion must be
having obtained sufficient appropriate audit evidence, concludes attached to the Form 5500 and the type of opinion must be
that misstatements, individually or in the aggregate, are material reported on Schedule H, line 3a.
but not pervasive to the financial statements or (b) the IQPA is Part IV – Compliance Questions
unable to obtain sufficient appropriate audit evidence on which Lines 4a through 4n. Plans completing Schedule H must
to base the opinion, but the auditor concludes that the possible answer all these lines with either ‘‘Yes’’ or ‘‘No.’’ Do not leave
effects on the financial statements of undetected misstatements, any answer blank, unless otherwise directed. For lines 4a
if any, could be material but not pervasive. through 4h and line 4l, if the answer is “Yes,” an amount must
Line 3a(3). Check if a disclaimer of opinion was issued. A be entered.
disclaimer of opinion is issued when the IQPA is unable to Report investments in CCTs, PSAs, MTIAs, and 103-12 IEs,
obtain sufficient appropriate audit evidence on which to base the but not the investments made by these entities. Plans with all of
opinion, and the IQPA concludes that the possible effects on the their funds held in a master trust should check ‘‘No’’ on line 4b,
financial statements of undetected misstatements, if any, could 4c, 4i, and 4j. CCTs and PSAs do not complete Part IV. MTIAs,
be both material and pervasive. 103-12 IEs, and GIAs do not complete lines 4a, 4e, 4f, 4g, 4h,
Line 3a(4). Check if the plan received an adverse accountant’s 4k, 4m, or 4n. 103-12 IEs also do not complete line 4j and 4l.
opinion. Generally, an adverse opinion is issued by an IQPA MTIAs also do not complete line 4l. DCGs do not complete lines
when the IQPA having obtained sufficient appropriate audit 4e, 4f, 4k, or 4l, and generally complete the rest of Part IV
evidence, concludes that misstatements, individually or in the information on a consolidated basis for all individual plans in the
aggregate, are both material and pervasive to the financial DCGs, except as otherwise provided.
statements. Line 4a. Amounts paid by a participant or beneficiary to an
Line 3b. Check “DOL Regulation 2520.103-8” or “DOL employer and/or withheld by an employer for contribution to the
Regulation 2520.103-12(d)” (or both boxes, if applicable) if the plan are participant contributions that become plan assets as of
IQPA performed an ERISA Section 103(a)(3)(C) audit of the the earliest date on which such contributions can reasonably be
plan’s financial statements pursuant to DOL regulations 29 CFR segregated from the employer’s general assets (see 29 CFR
2520.103-8, 29 CFR 2520.103-12(d), or under both. If it was not 2510.3-102). Plans that check “Yes” must enter the aggregate
performed pursuant to 29 CFR 2520.103-8 or 29 CFR 2520 amount of all late contributions for the year. The total amount of
103-12(d), check box (3). the delinquent contributions should be included on line 4a of the
Note. These regulations do not exempt the plan administrator Schedule H or I, as applicable, for the year in which the
from engaging an IQPA or from attaching the IQPA’s report to contributions were delinquent and should be carried over and
the Form 5500. If you check box 103-8 or 103-12(d) or both, you reported again on line 4a of the Schedule H or I, as applicable,
must also check the appropriate box on line 3a to identify the for each subsequent year until the year after the violation has
type of opinion offered by the IQPA. been fully corrected, which correction includes payment of the
Line 3c. Enter the name and EIN of the accountant (or late contributions and reimbursement of the plan for lost
accounting firm) in the space provided on line 3c. Do not use a earnings or profits. If no participant contributions were received
social security number or any portion thereof in lieu of an EIN. or withheld by the employer during the plan year, answer “No.”
The Schedule H is open to public inspection, and the contents An employer holding these assets after that date commingled
are public information and are subject to publication on the with its general assets will have engaged in a prohibited use of
Internet. Because of privacy concerns, the inclusion of a social plan assets (see ERISA section 406). If such a nonexempt
security number or any portion thereof on this Schedule H may prohibited transaction occurred with respect to a disqualified
result in the rejection of the filing. person (see Code section 4975(e)(2)), file IRS Form 5330,
Line 3d(1). Check this box only if the Schedule H is being filed Return of Excise Taxes Related to Employee Benefit Plans, with
for a CCT, PSA, DCG or MTIA. the IRS to pay any applicable excise tax on the transaction.
Line 3d(2). Check this box if the plan has elected to defer Participant loan repayments paid to and/or withheld by an
attaching the IQPA’s opinion for the first of two (2) consecutive employer for purposes of transmittal to the plan that were not
plan years, one of which is a short plan year of seven (7) transmitted to the plan in a timely fashion must be reported
months or fewer. The Form 5500 for the first of the two (2) years either on line 4a in accordance with the reporting requirements

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that apply to delinquent participant contributions or on line 4d. Schedule H Line 4a –Schedule of Delinquent
See Advisory Opinion 2002-02A, available at Participant Contributions
www.dol.gov/ebsa. Participant Total that Constitutes Nonexempt Total Fully
Delinquent participant contributions reported on line 4a Contributions Prohibited Transactions Corrected
should be treated as part of the separate schedules referenced Transferred Under
Late to Plan VFCP and
in ERISA section 103(a)(3)(A) and 29 CFR 2520.103-1(b) and Check here if Contributions Contributions Contributions PTE 2002-
2520.103-2(b) for purposes of preparing the IQPA’s opinion Late Not Corrected Pending 51
described on line 3 even though they are no longer required to
Participant Corrected Outside Correction in
be listed on Part III of the Schedule G. If the information Loan VFCP VFCP
contained on line 4a is not presented in accordance with Repayments
regulatory requirements, i.e., when the IQPA concludes that the are included:
scheduled information required by line 4a does not contain all
the required information or contains information that is
inaccurate or is inconsistent with the plan’s financial statements, Line 4b. Plans that check “Yes” must enter the amount and
the IQPA report must make the appropriate disclosures in complete Part I of Schedule G. The due date, payment amount
accordance with generally accepted auditing standards. For and conditions for determining default of a note or loan are
more information, see EBSA’s Frequently Asked Questions usually contained in the documents establishing the note or
About Reporting Delinquent Contributions on the Form 5500, loan. A loan by the plan is in default when the borrower is
available on the Internet at www.dol.gov/ebsa. These unable to pay the obligation upon maturity. Obligations that
Frequently Asked Questions clarify that plans have an obligation require periodic repayment can default at any time. Generally,
to include delinquent participant contributions on their financial loans and fixed income obligations are considered uncollectible
statements and supplemental schedules and that the IQPA’s when payment has not been made and there is little probability
report covers such delinquent contributions even though they that payment will be made. A fixed income obligation has a fixed
are not required to be included on Part III of the Schedule G. maturity date at a specified interest rate. Do not include
Although all delinquent participant contributions must be participant loans made under an individual account plan with
reported on line 4a, delinquent contributions for which the DOL investment experience segregated for each account that were
VFCP requirements and the conditions of PTE 2002-51 have made in accordance with 29 CFR 2550.408b-1 and secured
been satisfied do not need to be treated as nonexempt party-in- solely by a portion of the participant’s vested accrued benefit.
interest transactions. DCGs must identify the plans involved on the Schedule G. See
the instructions for the Schedule G for more information.
For DCGs, answer “yes” if any plan in the DCG is required to
report delinquent participant contributions on the Schedule DCG Line 4c. Plans that check “Yes” must enter the amount and
for the plan, and report the total amount reported by all such complete Part II of Schedule G. A lease is an agreement
plans on line 4a. DCGs do not need to file a consolidated conveying the right to use property, plant, or equipment for a
Schedule H Line 4a-Schedule of Delinquent Participant stated period. A lease is in default when the required
Contributions for the DCG. However, plans participating in a payment(s) has not been made. An uncollectible lease is one
DCG must report delinquent participant contribution information where the required payments have not been made and for
on the plan’s Schedule DCG and a Schedule DCG Line 9a- which there is little probability that payment will be made. DCGs
Schedule of Delinquent Participant Contributions must be must identify the plans involved on the Schedule G. See the
attached to the Schedule DCG for each plan that is subject to instructions for the Schedule G for more information.
an IQPA audit. As described above, the Schedule should be Line 4d. Plans that check “Yes” must enter the amount and
treated as part of the separate schedules referenced in ERISA complete Part III of Schedule G. Check ‘‘Yes’’ if any nonexempt
section 103(a)(3)(A) and 29 CFR 2520.103-1(b) and 2520.103- transaction with a party-in-interest occurred regardless of
2(b) for purposes of preparing the IQPA’s opinion for the plan whether the transaction is disclosed in the IQPA’s report. Do not
that must be attached to the plan’s Schedule DCG. See check “Yes” or complete Schedule G, Part III, with respect to
Schedule DCG for additional information. transactions that are: (1) statutorily exempt under Part 4 of Title
All delinquent participant contributions must be reported on I of ERISA; (2) administratively exempt under ERISA section
line 4a even if violations have been corrected. The VFCP 408(a); (3) exempt under Code sections 4975(c) or 4975(d); (4)
describes how to apply, the specific transactions covered (which the holding of participant contributions in the employer’s general
transactions include delinquent participant contributions to assets for a welfare plan that meets the conditions of ERISA
pension and welfare plans), and acceptable methods for Technical Release 92-01; (5) a transaction of a 103-12 IE with
correcting violations. In addition, applicants that satisfy both the parties other than the plan; or (6) delinquent participant
VFCP requirements and the conditions of PTE 2002-51 are contributions or delinquent participant loan repayments reported
eligible for immediate relief from payment of certain prohibited on line 4a. DCGs must identify the plans involved on the
transaction excise taxes for certain corrected transactions, and Schedule G. See the instructions for the Schedule G for more
are also relieved from the obligation to file the IRS Form 5330 information. Plans in the DCG must also answer this question
with the IRS. For more information, see 71 Fed. Reg. 20261 for their plan separately on the plan’s Schedule DCG.
(Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19, 2006). Note. See the instructions for Part III of the Schedule G (Form
Information about the VFCP is also available on the Internet at 5500) concerning nonexempt transactions and party-in-interest.
www.dol.gov/ebsa. You may indicate that an application for an administrative
Line 4a Schedule. Attach a Schedule of Delinquent exemption is pending. If you are unsure as to whether a
Participant Contributions using the format below if you entered transaction is exempt or not, you should consult with either the
“Yes.” If you chose to include participant loan repayments on plan’s IQPA or legal counsel or both.
line 4a, you must apply the same supplemental schedule and Applicants that satisfy the VFCP requirements and the
IQPA disclosure requirements to the loan repayments as conditions of PTE 2002-51 (see the instructions for line 4a)
applied to delinquent transmittals of participant contributions. are eligible for immediate relief from payment of certain
prohibited transaction excise taxes for certain corrected

Instructions for Schedule H (Form 5500) -49-

- 50 -

transactions, and are also relieved from the obligation to file the shares in a limited partnership, and collectibles. Do not check
IRS Form 5330 with the IRS. For more information, see 71 Fed. “Yes” on line 4g for mutual fund shares or insurance company
Reg. 20261 (Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19, investment contracts for which the plan receives valuation
2006). When the conditions of PTE 2002-51 have been information at least annually. Also, do not check ‘‘Yes’’ on line
satisfied, the corrected transactions should be treated as 4g if the plan is a defined contribution plan and the only assets
exempt under Code section 4975(c) for the purposes of the plan holds, that do not have a readily determinable value on
answering line 4d. an established market, are: (1) participant loans not in default,
Line 4e. Plans that check “Yes” must enter the aggregate or (2) assets over which the participant exercises control within
amount of fidelity bond coverage for all claims. Check ‘‘Yes’’ the meaning of section 404(c) of ERISA.
only if the plan itself (as opposed to the plan sponsor or Although the current value of plan assets must be determined
administrator) is a named insured under a fidelity bond from an each year, there is no requirement that the assets (other than
approved surety covering plan officials and that protects the certain nonpublicly traded employer securities held in ESOPs)
plan from losses due to fraud or dishonesty as described in 29 be valued every year by independent third-party appraisers.
CFR Part 2580. Generally, every plan official of an employee Enter in the amount column the fair market value of the
benefit plan who ‘‘handles’’ funds or other property of such plan assets referred to on line 4g whose value was not readily
must be bonded. Generally, a person shall be deemed to be determinable on an established market and which were not
‘‘handling’’ funds or other property of a plan, so as to require valued by an independent third-party appraiser in the plan year.
bonding, whenever their duties or activities with respect to given
funds are such that there is a risk that such funds could be lost Generally, as it relates to these questions, an appraisal by an
in the event of fraud or dishonesty on the part of such person, independent third party is an evaluation of the value of an asset
acting either alone or in collusion with others. Section 412 of prepared by an individual or firm who knows how to judge the
ERISA and 29 CFR Part 2580 describe the bonding value of such assets and does not have an ongoing relationship
requirements, including the definition of “handling” (29 CFR with the plan or plan fiduciaries except for preparing the
2580.412-6), the permissible forms of bonds (29 CFR 2580.412- appraisals.
10), the amount of the bond (29 CFR Part 2580, subpart C), and A DCG must check “Yes” on line 4g if any of the plans in the
certain exemptions such as the exemption for unfunded plans, DCG held any assets described in line 4g and “Yes” on line 4h if
certain banks and insurance companies (ERISA section 412), any of the plans in the DCG held any noncash contributions as
and the exemption allowing plan officials to purchase bonds described in line 4h. A DCG checking “Yes” must attach a list
from surety companies authorized by the Secretary of the identifying the plans holding such assets or noncash
Treasury as acceptable reinsurers on federal bonds (29 CFR contributions. The plan information reported must be the same
2580.412-23). Information concerning the list of approved as the information reported on Part III of Schedule DCG for the
sureties and reinsurers is available on the Internet at plan or plans involved. Use the format and label as shown
www.fms.treas.gov/c570. For more information on the fidelity below.
bonding requirements, see Field Assistance Bulletin 2008-04, The attachment for line 4g must be clearly labeled “Schedule
available on the Internet at www.dol.gov/ebsa. H, Line 4g – Plans in a DCG Holding Line 4g Assets. ”
Note. Plans are permitted under certain conditions to purchase
fiduciary liability insurance. These fiduciary liability insurance
Plan EIN Plan Amount
policies are not written specifically to protect the plan from
name Number
losses due to dishonest acts and cannot be reported as fidelity
bonds on line 4e. Plan EIN Plan Amount
Line 4f. Check ‘‘Yes,’’ if the plan suffered or discovered any name Number
loss as a result of any dishonest or fraudulent act(s) even if the Plan EIN Plan Amount
loss was reimbursed by the plan’s fidelity bond or from any name Number
other source. If ‘‘Yes’’ is checked enter the full amount of the
loss. If the full amount of the loss has not yet been determined,
The attachment for line 4h must be clearly labeled
provide an estimate and disclose that the figure is an estimate
“Schedule H, Line 4h – Plans in a DCG Holding Line 4h
as determined in good faith by a plan fiduciary. You must keep,
Noncash Contributions. ”
in accordance with ERISA section 107, records showing how
the estimate was determined.
Willful failure to report is a criminal offense. See ERISA Plan EIN Plan Amount
section 501. name Number
Lines 4g and 4h. Current value means fair market value Plan EIN Plan Amount
where available. Otherwise, it means the fair value as name Number
determined in good faith under the terms of the plan by a trustee Plan EIN Plan Amount
or a named fiduciary, assuming an orderly liquidation at the time name Number
of the determination. See ERISA section 3(26).

An accurate assessment of fair market value is essential to a
pension plan’s ability to comply with the requirements set forth Line 4i. Check “Yes” if the plan had any assets held for
in the Code (e.g., the exclusive benefit rule of Code section investment purposes, and attach a schedule of assets held for
401(a)(2), the limitations on benefits and contributions under investment purposes at end of year, a schedule of assets held
Code section 415, and the minimum funding requirements for investment purposes that were both acquired and disposed
under Code section 412) and must be determined annually. of within the plan year, or both, as applicable. The schedules
must use the format set forth below or a similar format. See 29
Examples of assets that may not have a readily determinable CFR 2520.103-11. A DCG must check “Yes” if any of the plans
value on an established market (e.g., NYSE, AMEX, over the in the DCG had any assets held for investment purposes.
counter, etc.) include real estate, nonpublicly traded securities, Assets held for investment purposes shall include:

-50- Instructions for Schedule H (Form 5500)

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 Any investment asset held by the plan on the last day of the 7. Securities purchased from a broker-dealer
plan year; and registered under the Securities Exchange Act of 1934 and
 Any investment asset purchased during the plan year and sold either: (1) listed on a national securities exchange and
before the end of the plan year except: registered under section 6 of the Securities Exchange Act
1. Debt obligations of the U.S. or any U.S. agency. of 1934 or (2) quoted on NASDAQ.
2. Interests issued by a company registered under the Assets held for investment purposes shall not include any
Investment Company Act of 1940 (e.g., a mutual fund). investment that was not held by the plan on the last day of the
3. Bank certificates of deposit with a maturity of one plan year if that investment is reported in the annual report for
year or less. that plan year in any of the following:
4. Commercial paper with a maturity of 9 months or 1. The schedule of loans or fixed income obligations in
less if it is valued in the highest rating category by at least default required by Schedule G, Part I;
two nationally recognized statistical rating services and is 2. The schedule of leases in default or classified as
issued by a company required to file reports with the uncollectible required by Schedule G, Part II;
Securities and Exchange Commission under section 13 of 3. The schedule of nonexempt transactions required by
the Securities Exchange Act of 1934. Schedule G, Part III; or
5. Participations in a bank common or collective trust. 4. The schedule of reportable transactions required by
6. Participations in an insurance company pooled Schedule H, line 4j.
separate account.

Line 4i schedules. The first schedule r quired to be attached is a schedule of all assets held for investment purposes at the end e
of the plan ye , aggregated and identified by issue, maturity date, rate of inte st, collateral, par or maturity value, cost and current ar re
value, and, in the case of a loan, the payment schedule. In the case of a DCG, the DCGs common plan administrator must attach a
consolidated Schedule of Assets for the entire DCG.
In column (a), place an asterisk (*) on the line of each identified person known to be a party-in-inte st to the plan. In column re
(c), include any restriction on transferability of corporate securities. (Include lending of securities permitted under Prohibi ted
Transactions Exemption 81-6.) A DCG must also include in column (c) the number of plans in the DCG holding the asset.
This schedule must be clearly labeled “Schedule H, line 4i – Schedule of Assets (Held At End of Year).”

(a) (b) Identity of issue, borrower, lessor, or similar (c) Description of investment including maturity date, rate of (d) Cost (e) Current
party interest, collateral, par, or maturity value value

The second schedule r quired to be attached is a schedule of investment assets that we e both acquired and disposed of e r
within the plan ye . A DCG must include in column (b) the name of the plan or plans holding the assets, the EIN(s) and plan ar
number(s). This information must be the same as the information reported on Part III of Schedule DCG for the plan or plans holding
the assets. A DCG should not include in this schedule assets transferred between plans within the DCG.

This schedule must be clearly labeled “Schedule H, line 4i – Schedule of Assets (Acquired and Disposed of Within Year).”
(a) Identity of issue, borrower, lessor, or similar party (b) Description of investment including maturity date, rate of (c) Cost of acquisitions (d) Proceeds
interest, collateral, par, or maturity value of
dispositions

In the case of DCGs, the Schedule DCG for each plan subject to the IQPA audit requirement should include a Schedule of
Assets for each such plan (see Schedule DCG for additional information).
Notes: (1) Participant loans under an individual account plan with investment experience segregated for each account, that are
made in accordance with 29 CFR 2550.408b-1 and that are secured solely by a portion of the participant’s vested accrued benefit,
may be aggregated for reporting purposes in line 4i. Under identity of borrower enter “Participant loans,” under rate of interest
enter the lowest rate and the highest rate charged during the plan year (e.g., 8%–10%), under the cost and proceeds columns enter
zero, and under current value enter the total amount of these loans. (2) Column (d) cost information for the Schedule of Assets
(Held At End of Year) and the column (c) cost of acquisitions information for the Schedule of Assets (Acquired and Disposed
of Within Year) may be omitted when reporting investments of an individual account plan that a participant or beneficiary directed
with respect to assets allocated to their account (including a negative election authorized under the terms of the plan). Likewise, cost
information for investments in Code sections 403(b)(1) annuity contracts and 403(b)(7) custodial accounts may also be omitted.
(3) Participant-directed brokerage account assets reported in the aggregate on line 1c(15) must be treated as one asset held for
investment for purposes of the line 4i schedules, except investments in tangible personal property must continue to be reported as
separate assets on the line 4i schedules. Investments in Code section 403(b)(1) annuity contracts and Code section 403(b)(7) custodial
accounts should also be treated as one asset held for investment for purposes on the line 4i schedules.

Instructions for Schedule H (Form 5500) -51-

- 52 -

Line 4j. Check “Yes” and attach to the Form 5500 the following         except as provided below, the plan’s allocable portion of the 
schedule if the plan had any reportable transactions. A DCG            transactions of the trust shall be combined with the other 
must check “Yes” if any of the plans in the DCG had any                transactions of the plan, if any, to determine which transactions 
reportable transactions. (See 29 CFR 2520.103-6 and the                (or series of transactions) are reportable (5%) transactions. 
examples provided in the regulation for more information on                 For investments in common/collective trusts (CCTs), pooled 
reportable transactions). The schedule must use the format set         separate accounts (PSAs), 103-12 IEs, and registered 
forth below or a similar format. See 29 CFR 2520.103-11.               investment companies, determine the 5% figure by comparing 
A reportable transaction includes:                                     the transaction date value of the acquisition and/or disposition of 
  1.A single transaction within the plan year in excess of 5% of       units of participation or shares in the entity with the current 
the current value of the plan assets;                                  value of the plan assets at the beginning of the plan year. If the 
  2.Any series of transactions with or in conjunction with the         Schedule H is attached to a Form 5500 filed for a plan with all 
same person, involving property other than securities, which           plan funds held in a master trust, check ‘‘No’’ on line 4j. Plans 
amount in the aggregate within the plan year (regardless of the        with assets in a master trust that have other transactions should 
category of asset and the gain or loss on any transaction) to          determine the 5% figure by subtracting the current value of plan 
more than 5% of the current value of plan assets;                      assets held in the master trust from the current value of all plan 
  3.Any transaction within the plan year involving securities of       assets at the beginning of the plan year and check ‘‘Yes’’ or 
the same issue if within the plan year any series of transactions      “No,” as appropriate. Do not include individual transactions of 
with respect to such securities amount in the aggregate to more        (CCTs), (PSAs), master trust investment accounts (MTIAs), 
than 5% of the current value of the plan assets; and                   103-12 IEs, and registered investment companies in which this 
  4.Any transaction within the plan year with respect to               plan or DFE invests.  
securities with, or in conjunction with, a person if any prior or        In the case of a purchase or sale of a security on the market, 
subsequent single transaction within the plan year with such           do not identify the person from whom purchased or to whom 
person, with respect to securities, exceeds 5% of the current          sold. 
value of plan assets.                                                  Special rule for certain participant-directed transactions. 
  The 5% figure is determined by comparing the current value           Transactions under an individual account plan that a participant   
of the transaction at the transaction date with the current value      or beneficiary directed with respect to assets allocated to their 
of the plan assets at the beginning of the plan year. If this is the   account (including a negative election authorized under the      
initial plan year, you may use the current value of the plan           terms of the plan) should not be treated for purposes of line 4j 
assets at the end of the plan year to determine the 5% figure.         as reportable transactions. The current value of all assets of the 
  If the assets of two or more plans are maintained in one trust,      plan, including these participant-directed transactions, should be  
                                                                       included in determining the 5% figure for all other transaction. 

Line 4j schedule. The schedule required to be attached is a schedule of reportable transactions that must be clearly labeled 
“Schedule H, line 4j – Schedule of Reportable Transactions.” A DCG must include in column (b) the name of the plan or plans 
with the reportable transaction(s), the EIN(s) and plan number(s). This information must be the same as the information reported on 
Part III of Schedule DCG for the plan or plans involved. 
 (a) Identity of  (b) Description of  (c)      (d) Selling        (e) Lease   (f) Expense     (g) Cost (h) Current value    (i) Net 
    party         asset (include      Purchase    price              rental   incurred with   of asset    of asset on       gain or 
  involved        interest rate and   price                                   transaction               transaction date     (loss) 
                 maturity in case of 
                     a loan) 
                                                                                                                          
                                                                   52-                      Instructions for Schedule H (Form 5500)

- 53 -

Line 4k. Check “Yes” if all the plan assets (including regarding a participant’s individual account; or (4) by
insurance/annuity contracts) were distributed to the application of federal securities laws. For more information,
participants and beneficiaries, legally transferred to the control see 29 CFR 2520.101-3 (available at www.dol.gov/ebsa).
of another plan, or brought under the control of the PBGC. Line 4n. If there was a blackout period, did you provide the
Check ‘‘No’’ for a welfare benefit plan that is still liable to required notice not less than 30 days nor more than 60 days in
pay benefits for claims incurred before the termination date, advance of restricting the rights of participants and
but not yet paid. See 29 CFR 2520.104b-2(g)(2)(ii). beneficiaries to change their plan investments, obtain loans
Line 4l. You must check “Yes” if any benefits due under the from the plan, or obtain distributions from the plan? If so, check
plan were not timely paid or not paid in full. This would include “Yes.” See 29 CFR 2520.101-3 for specific notice requirements
minimum required distributions to 5% owners who have and for exceptions from the notice requirement. Also, answer
attained the applicable ages as described in Code section “Yes” if one of the exceptions to the notice requirement under
401(a)(9)(C)(v) whether or not retired and/or non-5% owners 29 CFR 2520.101-3 applies. A DCG checking “No” must attach
who have attained the applicable ages as described in Code a list identifying all the plans that failed to provide the required
section 401(a)(9)(C)(v) and have retired or separated from notice on a timely basis. The plan information reported must be
service, see Code section 401(a)(9). Include in this amount the the same as the information reported on Part III of Schedule
total of any outstanding amounts that were not paid when due DCG for the plan or plans involved. Use the format and label
in previous years that have continued to remain unpaid. as shown below.
Note. In the absence of other guidance, filers do not need to The attachment for line 4n must be clearly labeled
report on this line unpaid required minimum distribution (RMD) “Schedule H, Line 4n – Plans in a DCG that Failed to
amounts for participants who have retired or separated from Provide Required Blackout Notice. ”
service, or their beneficiaries, who cannot be located after
reasonable efforts or where the plan is in the process of Plan name EIN Plan Number
engaging in such reasonable efforts at the end of the plan year
reporting period. Plan administrators and employers should Plan name EIN Plan Number
review their plan documents for written procedures on locating Plan name EIN Plan Number
missing participants. Although the Department of Labor’s Field
Assistance Bulletin 2014-01 is specifically applicable to
terminated defined contribution plans, employers and plan Line 5. MTIAs, 103-12 IEs, GIAs and DCGs do not complete
administrators of ongoing plans may want to consider line 5.
periodically using one or more of the search methods Line 5a. Check “Yes” if a resolution to terminate the plan was
described in the FAB in connection with making reasonable adopted during this or any prior plan year, unless the
efforts to locate RMD-eligible missing participants. termination was revoked and no assets reverted to the
Line 4m. Check “Yes” if there was a “blackout period.” A employer. If ‘‘Yes’’ is checked, enter the amount of plan assets
DCG must check “Yes” if there was a “blackout period” for any that reverted to the employer during the plan year in
of the plans in the DCG. A DCG checking “Yes” must attach a connection with the implementation of such termination. Enter
list identifying all the plans that had a “blackout period.” The “0” if no reversion occurred during the current plan year.
plan information reported must be the same as the information A Form 5500 must be filed for each year the plan has
reported on Part III of Schedule DCG for the plan or plans assets, and, for a welfare benefit plan, if the plan is still
involved. Use the format and label as shown below. liable to pay benefits for claims incurred before the termination
The attachment for line 4m must be clearly labeled date, but not yet paid. See 29 CFR 2520.104b-2(g)(2)(ii).
“Schedule H, Line 4m – Plans in a DCG that had Blackout Line 5b. Enter information concerning assets and/or liabilities
Period. ” transferred from this plan to another plan(s) (including spinoffs)
during the plan year. A transfer of assets or liabilities occurs
when there is a reduction of assets or liabilities with respect to
Plan name EIN Plan Number one plan and the receipt of these assets or the assumption of
Plan name EIN Plan Number these liabilities by another plan. Enter the name, plan sponsor
Plan name EIN Plan Number EIN, and PN for the transferee plan(s) involved on lines 5b(1),
(2), and (3).

Do not use a social security number in lieu of an EIN or
A blackout period is a temporary suspension of more than include an attachment that contains visible social security
three (3) consecutive business days during which participants numbers. The Schedule H is open to public inspection, and the
or beneficiaries of a 401(k) or other individual account pension contents are public information and are subject to publication
plan were unable to, or were limited or restricted in their ability on the Internet. Because of privacy concerns, the inclusion of a
to, direct or diversify assets credited to their accounts, obtain social security number or any portion thereof on this Schedule
loans from the plan, or obtain distributions from the plan. A H or the inclusion of a visible social security number or any
“blackout period” generally does not include a temporary portion thereof on an attachment may result in the rejection of
suspension of the right of participants and beneficiaries to the filing.
direct or diversity assets credited to their accounts, obtain
loans from the plan, or obtain distributions from the plan if the Note. A distribution of all or part of an individual participant’s
temporary suspension is: (1) part of the regularly scheduled account balance that is reportable on Form 1099-R should not
operations of the plan that has been disclosed to participants be included on line 5b. Do not submit Form 1099-R with the
and beneficiaries; (2) due to a qualified domestic relations Form 5500.
order (QDRO) or because of a pending determination as to IRS Form 5310-A, Notice of Plan Merger or Consolidation,
whether a domestic relations order is a QDRO; (3) due to an Spinoff, or Transfer of Plan Assets or Liabilities; Notice of
action or a failure to take action by an individual participant or Qualified Separate Lines of Business, may be required to be
because of an action or claim by someone other than the plan filed at least 30 days before any plan merger or consolidation

Instructions for Schedule H (Form 5500) -53-

- 54 -

or any transfer of plan assets or liabilities to another plan.
There is a penalty for not filing IRS Form 5310-A on time. In
addition, a transfer of benefit liabilities involving a plan covered
by PBGC insurance may be reportable to the PBGC. See
PBGC Form 10, Post-Event Notice of Reportable Events, and
PBGC Form 10-Advance, Advance Notice of Reportable
Events.
Line 5c. Check “Yes” if the plan was covered by PBGC at any
time during the plan year to which the Form 5500 relates and
enter the My PAA generated confirmation number for the
premium filing for that plan year reported (see filing receipt).
“Yes” must be checked even if coverage has ceased and/or
final premiums have been paid before the Form 5500 is due.
If you are uncertain whether the plan is covered under the
PBGC termination insurance program, check the box “Not
determined” and contact PBGC either by phone at 1-800-736-
2444, by E-mail at coverage@pbgc.gov. If you amended your
premium filing for this plan year, enter the confirmation number
for that filing and not for the previous filing(s). Defined
contribution plans and welfare plans do not need to complete
this item.
Note: A church defined benefit pension plan that has
made an election under Code section 410(d) should
see www.pbgc.gov for the procedures prescribed by
PBGC on how to notify PBGC that it wishes to have
Title IV of ERISA apply to it.

-54- Instructions for Schedule H (Form 5500)

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assuming an orderly liquidation at time of the determination.
2023 Instructions for Schedule I See ERISA section 3(26).
(Form 5500) Part I – Small Plan Financial Information
Financial Information – Small Plan Amounts reported on lines 1a, 1b, and 1c for the beginning of
the plan year must be the same as reported for the end of the
General Instructions plan year for corresponding lines on the return/report for the
preceding plan year.
Who Must File
Do not include contributions designated for the 2023 plan
Schedule I (Form 5500) must be attached to a Form 5500 filed year in column (a).
for pension benefit plans and welfare benefit plans that
covered fewer than 100 participants as of the beginning of the Line 1a. A plan with assets held in common/collective trusts
plan year and that are not eligible to file Form 5500-SF. (CCTs), pooled separate accounts (PSAs), master trust
investment accounts (MTIAs), and/or 103-12 IEs must also
Note. If a Schedule I or a Form 5500-SF was filed for the plan attach Schedule D.
for the 2022 plan year and the plan covered fewer than 121
participants as of the beginning of the 2023 plan year, the Use the same method for determining the value of the plan’s
Schedule I may be completed instead of a Schedule H. interest in an insurance company general account (unallocated
contracts) that you used for line 4 of Schedule A, or, if line 4 is
Exception. Certain insured, unfunded or combination not required, line 7 of Schedule A.
unfunded/insured welfare plans are exempt from filing the
Form 5500 and the Schedule I. In addition, certain fully insured Note. Do not include in column (b) a participant loan that has
pension benefit plans are exempt from completing the been deemed distributed during the plan year under the
Schedule I. See the Form 5500 instructions for Who Must File provisions of Code section 72(p) and Treasury Regulations
and Limited Pension Plan Reporting for more information. section 1.72(p)-1, if both of the following circumstances apply:
A plan that is required to file a Form M-1, Report for 1. Under the plan, the participant loan is treated as a
Multiple-Employer Welfare Arrangements (MEWAs) and directed investment solely of the participant’s individual
Certain Entities Claiming Exception (ECEs) is not required to account; and
file the Schedule I if it has fewer than 100 participants at the 2. As of the end of the plan year, the participant is not
beginning of the plan year and meets the requirements of 29 continuing repayment under the loan.
CFR 2520.104-44. If the deemed distributed participant loan is included in
Check the Schedule I box on the Form 5500 (Part II, line column (a) and both of these circumstances apply, report the
10b(2)) if a Schedule I is attached to the Form 5500. Do not loan as a deemed distribution on line 2g. However, if either of
attach both a Schedule I and a Schedule H to the same Form these circumstances does not apply, the current value of the
5500. participant loan (including interest accruing thereon after the
deemed distribution) should be included in column (b) without
Specific Instructions regard to the occurrence of a deemed distribution.
Lines A, B, C, and D. This information must be the same as After a participant loan that has been deemed distributed is
reported in Part II of the Form 5500 to which this Schedule I is reported on line 2g, it is no longer to be reported as an asset
attached. on Schedule H or Schedule I unless, in a later year, the
Do not use a social security number in line D in lieu of an participant resumes repayment under the loan. However, such
EIN. The Schedule I and its attachments are open to public a loan (including interest accruing thereon after the deemed
inspection, and the contents are public information and are distribution) that has not been repaid is still considered
subject to publication on the Internet. Because of privacy outstanding for purposes of applying Code section 72(p)(2)(A)
concerns, the inclusion of a social security number or any to determine the maximum amount of subsequent loans. Also,
portion thereof on this Schedule I or any of its attachments the deemed distribution is not treated as an actual distribution
may result in the rejection of the filing. for other purposes, such as the qualification requirements of
You can apply for an EIN from the IRS online, by fax, or by Code section 401, including, for example, the determination of
mail depending on how soon you need to use the EIN. For top-heavy status under Code section 416 and the vesting
more information, see Section 3: Electronic Filing Requirement requirements of Treasury Regulations section 1.411(a)-7(d)(5).
under General Instructions to Form 5500. The EBSA does not See Q&As 12 and 19 of Treasury Regulations section 1.72(p)-
issue EINs. 1.
Note. The cash, modified cash, or accrual basis may be used The entry on line 1a, column (b), of Schedule I (plan assets
for recognition of transactions, as long as you use one method - end of year) or on line 1c(8), column (b), of Schedule H
consistently. Round off all amounts reported on the Schedule I (participant loans - end of year) must include the current value
to the nearest dollar. Any other amounts are subject to of any participant loan reported as a deemed distribution on
rejection. Check all subtotals and totals carefully. line 2g for any earlier year if, during the plan year, the
participant resumes repayment under the loan. In addition, the
If the assets of two or more plans are maintained in one amount to be entered on line 2g must be reduced by the
fund, such as when an employer has two plans funded through amount of the participant loan reported as a deemed
a single trust (except a DFE), complete Parts I and II by distribution on line 2g for the earlier year.
entering the plan’s allocable part of each line item.
Line 1b. Enter the total liabilities at the beginning and end of
If assets of one plan are maintained in two or more trust the plan year. Liabilities to be entered here do not include the
funds, report the combined financial information in Part I. value of future pension payments to plan participants.
Current value means fair market value where available. However, the amount to be entered in line 1b for accrual basis
Otherwise, it means the fair value as determined in good faith filers includes, among other things:
under the terms of the plan by a trustee or a named fiduciary,
Instructions for Schedule I (Form 5500) -55-

- 56 -

 1. Benefit claims that have been processed and approved                 participants or beneficiaries, include the current value on the 
for payment by the plan but have not been paid (including all            date of distribution. 
incurred but not reported welfare benefit claims);                       Line 2f. Include on this line all distributions paid during the 
 2. Accounts payable obligations owed by the plan that were              plan year of excess deferrals under Code section 
incurred in the normal operations of the plan but have not been          402(g)(2)(A)(ii), excess contributions under Code section 
paid; and                                                                401(k)(8), and excess aggregate contributions under Code 
 3. Other liabilities such as acquisition indebtedness and               section 401(m)(6). Include allocable income distributed. Also 
any other amount owed by the plan.                                       include on this line any elective deferrals and employee 
Line 1c. Enter the net assets as of the beginning and end of             contributions distributed or returned to employees during the 
the plan year. (Subtract line 1b from 1a.) Line 1c, column (b)           plan year, as well as any attributable income that was also 
must equal the sum of line 1c, column (a) plus lines 2k and 2l.          distributed. 
Line 2a. Include the total cash contributions received or (for           Line 2g. Report on line 2g a participant loan included in line 
accrual basis plans) due to be received.                                 1a, column (a) (participant loans - beginning of year) and that 
Line 2a(1). Plans using the accrual basis of accounting must             has been deemed distributed during the plan year under the 
not include contributions designated for years before the 2023           provisions of Code section 72(p) and Treasury Regulations 
plan year on line 2a(1).                                                 section 1.72(p)-1 only if both of the following circumstances 
                                                                         apply: 
Line 2a(2). For welfare plans, report all employee 
contributions, including all elective contributions under a              1. Under the plan, the participant loan is treated as a 
cafeteria plan (Code section 125). For pension benefit plans,            directed investment solely of the participant’s individual 
participant contributions, for purposes of this item, also include       account; and 
elective contributions under a qualified cash or deferred                2. As of the end of the plan year, the participant is not 
arrangement (Code section 401(k)).                                       continuing repayment under the loan. 
Line 2b. Use the current value, at date contributed, of                  If either of these circumstances does not apply, a deemed 
securities or other noncash property.                                    distribution of a participant loan should not be reported on line 
                                                                         2g. Instead, the current value of the participant loan (including 
Line 2c. Enter all other plan income for the plan year. Do not           interest accruing thereon after the deemed distribution) should 
include transfers from other plans that are reported on line 2l.         be included on line 1a, column (b) (plan assets – end of year), 
Other income received and/or receivable would include:                   without regard to the occurrence of a deemed distribution. 
 1. Interest on investments (including money market                      Note. The amount to be reported on line 2g of Schedule H or 
accounts, sweep accounts, STIF accounts, etc.).                          Schedule I must be reduced if, during the plan year, a 
 2. Dividends. (Accrual basis plans should include dividends             participant resumes repayment under a participant loan 
declared for all stock held by the plan even if the dividends            reported as a deemed distribution on line 2g for any earlier 
have not been received as of the end of the plan year.)                  year. The amount of the required reduction is the amount of 
 3. Rents from income-producing property owned by the                    the participant loan reported as a deemed distribution on line 
plan.                                                                    2g for the earlier year. If entering a negative number, enter a 
 4. Royalties.                                                           minus sign “-” to the left of the number. The current value of 
 5. Net gain or loss from the sale of assets.                            the participant loan must then be included in line 1c(8), column 
 6. Other income, such as unrealized appreciation                        (b), of Schedule H (participant loans – end of year) or in line 
(depreciation) in plan assets.                                           1a, column (b), of Schedule I (plan assets – end of year). 
  To compute this amount, subtract the current value of all                Although certain participant loans deemed distributed are to 
assets at the beginning of the year plus the cost of any assets          be reported on line 2g of the Schedule H or Schedule I, and 
acquired during the plan year from the current value of all              are not to be reported on the Schedule H or Schedule I as an 
assets at the end of the year minus assets disposed of during            asset thereafter (unless the participant resumes repayment 
the plan year.                                                           under the loan in a later year), they are still considered 
Line 2d. Enter the total of all cash contributions (lines 2a(1)          outstanding loans and are not treated as actual distributions for 
through (3)), noncash contributions (line 2b), and other plan            certain purposes. See Q&As 12 and 19 of Treasury 
income (line 2c) during the plan year. If entering a negative            Regulations section 1.72(p)-1. 
number, enter a minus sign “-” to the left of the number.                Line 2h. The amount to be reported for expenses involving 
Line 2e. Include: (1) payments made (and for accrual basis               administrative service providers (salaries, fees, and 
filers) payments due to or on behalf of participants or                  commissions) includes the total fees paid (or in the case of 
beneficiaries in cash, securities, or other property (including          accrual basis plans, costs incurred during the plan year but not 
rollovers of an individual’s accrued benefit or account balance).        paid as of the end of the plan year) by the plan for, among 
Include all eligible rollover distributions as defined in Code           others: 
section 401(a)(31)(D) paid at the participant’s election to an           1. Salaries to employees of the plan; 
eligible retirement plan (including an IRA within the meaning of         2. Fees and expenses for accounting, actuarial, legal, 
Code section 401(a)(31)(E)); (2) payments to insurance                   investment management, investment advice, and securities 
companies and similar organizations such as Blue Cross, Blue             brokerage services; 
Shield, and health maintenance organizations for the provision           3. Contract administrator fees; 
of plan benefits (e.g., paid-up annuities, accident insurance,           4. Fees and expenses for individual plan trustees, including 
health insurance, vision care, dental coverage, etc.); and (3)           reimbursement for travel, seminars, and meeting expenses; 
payments made to other organizations or individuals providing            and  
benefits. Generally, these payments discussed in (3) are made            5. Fees and expenses paid for valuations and appraisals of 
to individual providers of welfare benefits such as legal                real estate and closely held securities. 
services, day care services, and training and apprenticeship 
services. If securities or other property are distributed to plan        Line 2i. Other expenses (paid and/or payable) include other 
                                                                         administrative and miscellaneous expenses paid by or charged 

                                                                   -56-                        Instructions for Schedule I (Form 5500)

- 57 -

to the plan, including among others, office supplies and 1. Under the plan, the participant loan is treated as a
equipment, telephone, postage, rent and expenses associated directed investment solely of the participant’s individual
with the ownership of a building used in operation of the plan. account; and
Line 2j. Enter the total of all benefits paid or due as reported 2. As of the end of the plan year, the participant is not
on lines 2e, 2f, and 2g and all other plan expenses (lines 2h continuing repayment under the loan.
and 2i) during the year. If both of these circumstances apply, report the loan as a
Line 2l. Enter the net value of all assets transferred to and deemed distribution on line 2g. However, if either of these
from the plan during the plan year including those resulting circumstances does not apply, the current value of the
from mergers and spinoffs. A transfer of assets or liabilities participant loan (including interest accruing thereon after the
occurs when there is a reduction of assets or liabilities with deemed distribution) should be included on line 3e without
respect to one plan and the receipt of these assets or the regard to the occurrence of a deemed distribution.
assumption of these liabilities by another plan. Transfers out at Note. After participant loans have been deemed distributed
the end of the year should be reported as occurring during the and reported on line 2g of the Schedule I or H, they are no
plan year. longer required to be reported as assets on the Schedule I or
Note. A distribution of all or part of an individual participant’s H. However, such loans (including interest accruing thereon
account balance that is reportable on Form 1099-R, after the deemed distribution) that have not been repaid are
Distributions From Pensions, Annuities, Retirement or Profit- still considered outstanding for purposes of applying Code
Sharing Plans, IRAs, Insurance Contracts, etc., should not be section 72(p)(2)(A) to determine the maximum amount of
included on line 2l but must be included in benefit payments subsequent loans. Also, the deemed distribution is not treated
reported on line 2e. Do not submit IRS Form 1099-R with Form as an actual distribution for other purposes, such as the
5500. qualification requirements of Code section 401, including, for
example, the determination of top-heavy status under Code
Lines 3a through 3g. You must check either “Yes” or “No” on section 416 and the vesting requirements of Treasury
each line to report whether the plan held any assets in the Regulations section 1.411(a)-7(d)(5). See Q&As 12 and 19 of
listed categories at any time during the plan year. If “Yes” is Treasury Regulations section 1.72(p)-1.
checked on any line, enter in the amount column for that line
the current value of the assets held at the end of the plan year Line 3f. Enter the current value of all loans made by the plan,
or “0” if no assets remain in the category at the end of the plan except participant loans reportable on line 3e. Include the sum
year. You should allocate the value of the plan’s interest in a of the value of loans for construction, securities loans,
commingled trust containing the assets of more than one plan commercial and/or residential mortgage loans that are not
on a line-by-line basis, except do not include on lines 3a subject to Code section 72(p) (either by making or participating
through 3g the value of the plan’s interest in any CCT, PSA, in the loans directly or by purchasing loans originated by a
MTIA, or 103-12 IE (see instructions definitions of CCT, PSA, third party), and other miscellaneous loans.
MTIA, and 103-12 IE). Line 3g. Include all property that has concrete existence and is
Line 3a. Enter the value of the plan’s participation in a capable of being processed, such as goods, wares,
partnership or joint venture, unless the partnership or joint merchandise, furniture, machines, equipment, animals,
venture is a 103-12 IE. automobiles, etc. This includes collectibles, such as works of
art, rugs, antiques, metals, gems, stamps, coins, alcoholic
Line 3b. The term ‘‘employer real property’’ means real beverages, musical instruments, and historical objects
property (and related personal property) that is leased to an (documents, clothes, etc.). Do not include the value of a plan’s
employer of employees covered by the plan, or to an affiliate of interest in property reported on lines 3a through 3f, or
such employer. For purposes of determining the time at which intangible property, such as patents, copyrights, goodwill,
a plan acquires employer real property for purposes of this franchises, notes, mortgages, stocks, claims, interests, or other
line, such property shall be deemed to be acquired by the plan property that embodies intellectual or legal rights.
on the date on which the plan acquires the property or on the
date on which the lease to the employer (or affiliate) is entered Part II – Compliance Questions
into, whichever is later. Answer all lines with either ‘‘Yes’’ or ‘‘No.’’ Do not leave any
Line 3d. An employer security is any security issued by an answer blank, unless otherwise directed. For lines 4a through
employer (including affiliates) of employees covered by the 4i and line 4l, if the answer is “Yes,” an amount must be
plan. These may include common stocks, preferred stocks, entered. If you check ‘‘No’’ on line 4k you must attach the
bonds, zero coupon bonds, debentures, convertible report of an independent qualified public accountant (IQPA) or
debentures, notes and commercial paper. a statement that the plan is eligible and elects to defer
Line 3e. Enter the current value of all loans to participants attaching the IQPA’s opinion pursuant to 29 CFR 2520.104-50
including residential mortgage loans that are subject to Code in connection with a short plan year of seven months or less.
section 72(p). Include the sum of the value of the unpaid Plans with all of their fund held in a master trust should check
principal balances, plus accrued but unpaid interest, if any, for “No” on Schedule I, lines 4b, c, and i.
participant loans made under an individual account plan with Line 4a. Amounts paid by a participant or beneficiary to an
investment experience segregated for each account, that are employer and/or withheld by an employer for contribution to
made in accordance with 29 CFR 2550.408b-1 and secured the plan are participant contributions that become plan assets
solely by a portion of the participant’s vested accrued benefit. as of the earliest date on which such contributions can
When applicable, combine this amount with the current value reasonably be segregated from the employer’s general assets.
of any other participant loans. Do not include any amount of a See 29 CFR 2510.3-102. In the case of a plan with fewer than
participant loan deemed distributed during the plan year under 100 participants at the beginning of the plan year, any amount
the provisions of Code section 72(p) and Treasury Regulations deposited with such plan not later than the 7 business day th
section 1.72(p)-1, if both of the following circumstances apply: following the day on which such amount is received by the
employer (in the case of amounts that a participant or
beneficiary pays to an employer), or the 7 business day th

Instructions for Schedule I (Form 5500) -57-

- 58 -

following the day on which such amount would otherwise have              contributions to pension and welfare plans), and acceptable 
been payable to the participant in cash (in the case of amount           methods for correcting violations. In addition, applicants that 
withheld by an employer from a participant’s wages), shall be            satisfy both the VFCP requirements and the conditions of 
deemed to be contributed or repaid to such plan on the earliest          Prohibited Transaction Exemption (PTE) 2002-51 are eligible 
date on which such contributions or participant loan                     for immediate relief from payment of certain prohibited 
repayments can reasonably be segregated from the                         transaction excise taxes for certain corrected transactions, and 
employer’s general assets. See 29 CFR 2510.3-102(a)(2).                  are also relieved from the obligation to file the IRS Form 5330 
 Plans that check “Yes” must enter the aggregate amount of               with the IRS. For more information, see 71 Fed. Reg. 20261 
all late contributions for the year. The total amount of the             (Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19, 2006). All 
delinquent contributions must be included on line 4a of the              delinquent participant contributions must be reported on line 4a 
Schedule H or I, as applicable, for the year in which the                even if violations have been corrected. Information about the 
contributions were delinquent and must be carried over and               VFCP is also available on the Internet at www.dol.gov/ebsa. 
reported again on line 4a of the Schedule H or I, as applicable,         Line 4a Schedule. Attach a Schedule of Delinquent 
for each subsequent year until the year after the violation has          Participant Contributions using the format below if you entered 
been fully corrected, which correction includes payment of the           “Yes” on line 4a and you are checking “No” on line 4k because 
late contributions and reimbursement of the plan for lost                you are not claiming the audit waiver for the plan. If you 
earnings or profits. If no participant contributions were received       choose to include participant loan repayments on line 4a, you 
or withheld by the employer during the plan year, answer ‘‘No.’’         must apply the same supplemental schedule and IQPA 
 An employer holding participant contributions commingled                disclosure requirements to the loan repayments as apply to 
with its general assets after the earliest date on which such            delinquent transmittals of participant contributions.  
contributions can reasonably be segregated from the                       
employer’s general assets will have engaged in prohibited use 
of plan assets (see ERISA section 406). If such a nonexempt                   Schedule I Line 4a – Schedule of Delinquent 
prohibited transaction occurred with respect to a disqualified                           Participant Contributions 
person (see Code section 4975(e)(2)), file IRS Form 5330,                Participant        Total that Constitutes Nonexempt        Total 
Return of Excise Taxes Related to Employee Benefit Plans,                Contributions          Prohibited Transactions             Fully 
with the IRS to pay any applicable excise tax on the                     Transferred                                                Corrected 
                                                                         Late to Plan                                               Under 
transaction.                                                             Check here if  Contributions  Contributions  Contributions VFCP 
 Participant loan repayments paid to and/or withheld by an               Late           Not        Corrected Pending                and PTE 
employer for purposes of transmittal to the plan that were not           Participant    Corrected  Outside   Correction in          2002-51 
transmitted to the plan in a timely fashion must be reported             Loan                      VFCP      VFCP 
either on line 4a in accordance with the reporting requirements          Repayments 
that apply to delinquent participant contributions or on line 4d.        are included:  
See Advisory Opinion 2002-02A, available at                              Line 4b. Plans that check “Yes” must enter the amount. The 
www.dol.gov/ebsa.                                                        due date, payment amount and conditions for determining 
  For those Schedule I filers required to submit an IQPA                 default of a note or loan are usually contained in the 
  report, delinquent participant contributions reported on               documents establishing the note or loan. A loan by the plan is 
line 4a must be treated as part of the separate schedules                in default when the borrower is unable to pay the obligation 
referenced in ERISA section 103(a)(3)(A) and 29 CFR                      upon maturity. Obligations that require periodic repayment can 
2520.103-1(b) and 2520.103-2(b) for purposes of preparing the            default at any time. Generally, loans and fixed income 
IQPA’s opinion even though they are not required to be listed            obligations are considered uncollectible when payment has not 
on Part III of the Schedule G. If the information contained on           been made and there is little probability that payment will be 
line 4a is not presented in accordance with regulatory                   made. A fixed income obligation has a fixed maturity date at a 
requirements, i.e., when the IQPA concludes that the                     specified interest rate. Do not include participant loans made 
scheduled information required by line 4a does not contain all           under an individual account plan with investment experience 
the required information or contains information that is                 segregated for each account that were made in accordance 
inaccurate or is inconsistent with the plan’s financial                  with 29 CFR 2550.408b-1 and secured solely by a portion of 
statements, the IQPA report must make the appropriate                    the participant’s vested accrued benefit. 
disclosures in accordance with generally accepted auditing               Line 4c. Plans that check “Yes” must enter the amount. A 
standards. For more information, see EBSA’s Frequently                   lease is an agreement conveying the right to use property, 
Asked Questions about Reporting Delinquent Contributions on              plant or equipment for a stated period. A lease is in default 
the Form 5500, available on the Internet at www.dol.gov/ebsa.            when the required payment(s) has not been made. An 
These Frequently Asked Questions clarify that plans have an              uncollectible lease is one where the required payments have 
obligation to include delinquent participant contributions on            not been made and for which there is little probability that 
their financial statements and supplemental schedules and that           payment will be made. 
the IQPA’s report covers such delinquent contributions even 
though they are no longer required to be included on Part III of         Line 4d. Plans that check “Yes” must enter the amount. Check 
the Schedule G. Although all delinquent participant                      “Yes” if any nonexempt transaction with a party-in-interest 
contributions must be reported on line 4a, delinquent                    occurred regardless of whether the transaction is disclosed in 
contributions for which the DOL Voluntary Fiduciary Correction           the IQPA’s report. Do not check “Yes” with respect to 
Program (VFCP) requirements and the conditions of the                    transactions that are: (1) statutorily exempt under Part 4 of 
Prohibited Transaction Exemption (PTE) 2002-51 have been                 Title I of ERISA; (2) administratively exempt under ERISA 
satisfied do not need to be treated as nonexempt party-in-               section 408(a); (3) exempt under Code sections 4975(c) or 
interest transactions.                                                   4975(d); (4) the holding of participant contributions in the 
                                                                         employer’s general assets for a welfare plan that meets the 
 The VFCP describes how to apply, the specific transactions              conditions of ERISA Technical Release 92-01; (5) a 
covered (which transactions include delinquent participant               transaction of a 103-12 IE with parties other than the plan; or 
                                                                   -58-                       Instructions for Schedule I (Form 5500)

- 59 -

(6) delinquent participant contributions or delinquent participant E. Acquisition, on behalf of the plan, of any employer
loan repayments reported on line 4a. You may indicate that an security or employer real property in violation of ERISA
application for an administrative exemption is pending. If you section 407(a).
are unsure whether a transaction is exempt or not, you should F. Dealing with the assets of the plan for a fiduciary’s own
consult with either a qualified public accountant, legal counsel interest or own account.
or both. If the plan is a qualified pension plan and a nonexempt G. Acting in a fiduciary’s individual or any other capacity in
prohibited transaction occurred with respect to a disqualified any transaction involving the plan on behalf of a party (or
person, an IRS Form 5330 should be filed with the IRS to pay represent a party) whose interests are adverse to the
the excise tax on the transaction. interests of the plan or the interests of its participants or
Applicants that satisfy the VFCP requirements and the beneficiaries.
conditions of PTE 2002-51 (see the instructions for line H. Receipt of any consideration for their own personal
4a) are eligible for immediate relief from payment of certain account by a party-in-interest who is a fiduciary from any
prohibited transaction excise taxes for certain corrected party dealing with the plan in connection with a transaction
transactions, and are also relieved from the obligation to file involving the income or assets of the plan.
the Form 5330 with the IRS. For more information, see 71 Fed. Line 4e. Plans that check “Yes” must enter the aggregate
Reg. 20261 (Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19, amount of fidelity bond coverage for all claims. Check ‘‘Yes’’
2006). When the conditions of PTE 2002-51 have been only if the plan itself (as opposed to the plan sponsor or
satisfied, the corrected transactions should be treated as administrator) is a named insured under a fidelity bond from an
exempt under Code section 4975(c) for the purposes of approved surety covering plan officials and that protects the
answering line 4d. plan from losses due to fraud or dishonesty as described in 29
Party-in-Interest. For purposes of this form, party-in- CFR Part 2580. Generally, every plan official of an employee
interest is deemed to include a disqualified person. See Code benefit plan who ‘‘handles’’ funds or other property of such
section 4975(e)(2). The term ‘‘party-in-interest’’ means, as to plan must be bonded. Generally, a person shall be deemed to
an employee benefit plan: be ‘‘handling’’ funds or other property of a plan, so as to
require bonding, whenever their duties or activities with respect
A. Any fiduciary (including, but not limited to, any to given funds are such that there is a risk that such funds
administrator, officer, trustee, or custodian), counsel, or could be lost in the event of fraud or dishonesty on the part of
employee of the plan; such person, acting either alone or in collusion with others.
B. A person providing services to the plan; Section 412 of ERISA and 29 CFR Part 2580 describe the
C. An employer, any of whose employees are covered by bonding requirements, including the definition of ‘‘handling’’ (29
the plan; CFR 2580.412-6), the permissible forms of bonds (29 CFR
D. An employee organization, any of whose members are 2580.412-10), the amount of the bond (29 CFR Part 2580,
covered by the plan; subpart C), and certain exemptions such as the exemption for
E. An owner, direct or indirect, of 50% or more of: (1) the unfunded plans, certain banks and insurance companies
combined voting power of all classes of stock entitled to vote (ERISA section 412), and the exemption allowing plan officials
or the total value of shares of all classes of stock of a to purchase bonds from surety companies authorized by the
corporation, (2) the capital interest or the profits interest of a Secretary of the Treasury as acceptable reinsurers on federal
partnership, or (3) the beneficial interest of a trust or bonds (29 CFR 2580.412-23). Information concerning the list
unincorporated enterprise that is an employer or an of approved sureties and reinsurers is available on the Internet
employee organization described in C or D; at www.fms.treas.gov/c570. For more information on the
F. A relative of any individual described in A, B, C, or E; fidelity bonding requirements, see Field Assistance Bulletin
G. A corporation, partnership, or trust or estate of which (or 2008-04, available on the Internet at www.dol.gov/ebsa.
in which) 50% or more of: (1) the combined voting power of Note. Plans are permitted under certain conditions to purchase
all classes of stock entitled to vote or the total value of fiduciary liability insurance. These fiduciary liability insurance
shares of all classes of stock of such corporation, (2) the policies are not written specifically to protect the plan from
capital interest or profits interest of such partnership, or (3) losses due to dishonest acts and cannot be reported as fidelity
the beneficial interest of such trust or estate is owned bonds on line 4e.
directly or indirectly, or held by, persons described in A, B, Line 4f. Check ‘‘Yes,’’ if the plan had suffered or discovered
C, D, or E; any loss as a result of any dishonest or fraudulent act(s) even
H. An employee, officer, director (or an individual having if the loss was reimbursed by the plan’s fidelity bond or from
powers or responsibilities similar to those of officers or any other source. If ‘‘Yes’’ is checked enter the full amount of
directors), or a 10% or more shareholder, directly or the loss. If the full amount of the loss has not yet been
indirectly, of a person described in B, C, D, E, or G, or of the determined, provide an estimate as determined in good faith
employee benefit plan; by a plan fiduciary. You must keep, in accordance with ERISA
I. A 10% or more (directly or indirectly in capital or profits) section 107, records showing how the estimate was
partner or joint venture of a person described in B, C, D, E, determined.
or G. Willful failure to report is a criminal offense. See ERISA
Nonexempt transactions with a party-in-interest include section 501.
any direct or indirect: Lines 4g and 4h. Current value means fair market value where
A. Sale or exchange, or lease, of any property between the available. Otherwise, it means the fair value as determined in
plan and a party-in-interest. good faith under the terms of the plan by a trustee or a named
B. Lending of money or other extension of credit between fiduciary, assuming an orderly liquidation at time of the
the plan and a party-in-interest. determination. See ERISA section 3(26).
C. Furnishing of goods, services, or facilities between the An accurate assessment of fair market value is essential to
plan and a party-in-interest. a pension plan’s ability to comply with the requirements set
D. Transfer to, or use by or for the benefit of, a party-in- forth in the Code (e.g., the exclusive benefit rule of Code
interest, of any income or assets of the plan. section 401(a)(2), the limitations on benefits and contributions

Instructions for Schedule I (Form 5500) -59-

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under Code section 415, and the minimum funding instructions for Schedule H, line 3d(2) or call the EFAST2 Help
requirements under Code section 412) and must be Desk at 1-866-GO-EFAST (1-866-463-3278) (toll-free).
determined annually. Note. For plans that check “No,” the IQPA report must make
Examples of assets that may not have a readily the appropriate disclosures in accordance with generally
determinable value on an established market (e.g., NYSE, accepted auditing standards if the information reported on line
AMEX, over the counter, etc.) include real estate, nonpublicly 4a is not presented in accordance with regulatory
traded securities, shares in a limited partnership, and requirements.
collectibles. Do not check “Yes” on line 4g for mutual fund The following summarizes the conditions of 29 CFR
shares or insurance company investment contracts for which 2520.104-46 that must be met for a small pension plan with a
the plan receives valuation information at least annually. Also plan year beginning on or after April 18, 2001, to be eligible for
do not check ‘‘Yes’’ on line 4g if the plan is a defined the waiver. For more information regarding these
contribution plan and the only assets the plan holds, that do requirements, see the EBSA’s Frequently Asked Questions on
not have a readily determinable value on an established the Small Pension Plan Audit Waiver Regulation and 29 CFR
market, are: (1) participant loans not in default, or (2) assets 2520.104-46, which are available at www.dol.gov/ebsa, or call
over which the participant exercises control within the meaning the EFAST2 Help Desk at 1-866-GO-EFAST (1-866-463-3278)
of section 404(c) of ERISA. (toll-free)
Although the current value of plan assets must be Condition 1: At least 95 percent of plan assets are
determined each year, there is no requirement that the assets “qualifying plan assets” as of the end of the preceding plan
(other than certain nonpublicly traded employer securities held year, or any person who handles assets of the plan that do not
in ESOPs) be valued every year by independent third-party constitute qualifying plan assets is bonded in accordance with
appraisers. the requirements of ERISA section 412 (see the instructions
Enter in the amount column the fair market value of the for line 4e), except that the amount of the bond shall not be
assets referred to on line 4g whose value was not readily less than the value of such non-qualifying assets.
determinable on an established market and which were not The determination of the “percent of plan assets” as of the
valued by an independent third-party appraiser in the plan end of the preceding plan year and the amount of any required
year. Generally, as it relates to these questions, an appraisal bond must be made at the beginning of the plan’s reporting
by an independent third party is an evaluation of the value of year for which the waiver is being claimed. For purposes of this
an asset prepared by an individual or firm who knows how to line, you will have satisfied the requirement to make these
judge the value of such assets and does not have an ongoing determinations at the beginning of the plan reporting year for
relationship with the plan or plan fiduciaries except for which the waiver is being claimed if they are made as soon
preparing the appraisals. after the date when such year begins as the necessary
Line 4i. Include as a single security all securities of the same information from the preceding reporting year can practically
issue. An example of a single issue is a certificate of deposit be ascertained. See 29 CFR 2580.412-11, 14 and 19 for
issued by the XYZ Bank on July 1, 2021, which matures on additional guidance on these determinations, and 29 CFR
June 30, 2023, and yields x%. For the purposes of line 4i, do 2580.412-15 for procedures to be used for estimating these
not check ‘‘Yes’’ for securities issued by the U.S. Government amounts if there is no preceding plan year.
or its agencies. Also, do not check “Yes” for securities held as The term ‘‘qualifying plan assets,’’ for purposes of this line,
a result of participant-directed transactions. means:
Line 4j. Check “Yes” if all the plan assets (including 1. Any assets held by any of the following regulated financial
insurance/annuity contracts) were distributed to the institutions:
participants and beneficiaries, legally transferred to the control a. A bank or similar financial institution as defined in 29
of another plan, or brought under the control of the PBGC. CFR 2550.408b-4(c);
Check ‘‘No’’ for a welfare benefit plan that is still liable to pay b. An insurance company qualified to do business under the
benefits for claims that were incurred before the termination laws of a state;
date, but not yet paid. See 29 CFR 2520.104b-2(g)(2)(ii). c. An organization registered as a broker-dealer under the
Line 4k. Check ‘‘Yes’’ if you are claiming a waiver of the Securities Exchange Act of 1934; or
annual examination and report of an independent qualified d. Any other organization authorized to act as a trustee for
public accountant (IQPA) under 29 CFR 2520.104-46. You are individual retirement accounts under Code section 408.
eligible to claim the waiver if the Schedule I is being filed for: 2. Shares issued by an investment company registered
under the Investment Company Act of 1940 (e.g., mutual
1. A small welfare plan, or funds);
2. A small pension plan for a plan year that began on or 3. Investment and annuity contracts issued by any
after April 18, 2001, that complies with the conditions of 29 insurance company qualified to do business under the laws of
CFR 2520.104-46 summarized below. a state;
Check ‘‘No’’ and attach the report of the IQPA meeting the 4. In the case of an individual account plan, any assets in
requirements of 29 CFR 2520.103-1(b) if you are not claiming the individual account of a participant or beneficiary over which
the waiver. Also check ‘‘No,’’ and attach the required IQPA the participant or beneficiary has the opportunity to exercise
reports or the required explanatory statement if you are relying control and with respect to which the participant or beneficiary
on 29 CFR 2520.104-50 in connection with a short plan year of is furnished, at least annually, a statement from a regulated
seven months or less. At the top of any attached 2520.104-50 financial institution referred to above describing the assets held
statement, enter “2520.104-50 Statement, Schedule I, Line or issued by the institution and the amount of such assets;
4k.” 5. Qualifying employer securities, as defined in ERISA
For more information on the requirements for deferring an section 407(d)(5); and
IQPA report pursuant to 29 CFR 2520.104-50 in connection 6. Participant loans meeting the requirements of ERISA
with a short plan year of seven months or less and the section 408(b)(1).
contents of the required explanatory statement, see the
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  Condition 2: The administrator must disclose the following             determined to be needed for the relevant persons for ERISA 
information in the summary annual report (SAR) furnished to              section 412 purposes is at least $42,000). As demonstrated by 
participants and beneficiaries, in accordance with 29 CFR                the foregoing example, where a plan has more than 5% of its 
2520.104b-10. For defined benefit pension plans that are                 assets in non-qualifying plan assets, the required bond is for 
required pursuant to section 101(f) of ERISA to furnish an               the total amount of the non-qualifying plan assets, not just the 
Annual Funding Notice (AFN), the administrator must instead              amount in excess of 5%. 
either provide the information to participants and beneficiaries         If you need further information regarding these 
with the AFN or as a stand-alone notification at the time a SAR          requirements, see 29 CFR 2520.104-46 which is available at 
would have been due and in accordance with the rules for                 www.dol.gov/ebsa or call the EFAST2 Help Desk at 1-866-GO-
furnishing an SAR, although such plans do not have to furnish            EFAST (1-866-463-3278) (toll-free) 
a SAR. 
                                                                         Line 4l.  You must check “Yes” if any benefits due under the 
  1.  The name of each regulated financial institution holding           plan were not timely paid or not paid in full. This would include 
or issuing qualifying plan assets and the amount of such                 required minimum distributions to 5% owners who have 
assets reported by the institution as of the end of the plan year        attained the applicable ages as described in Code section 
(this SAR disclosure requirement does not apply to qualifying            401(a)(9)(C)(v) whether or not retired and/or non-5% owners 
employer securities, participant loans and individual account            who have attained the applicable ages as described in Code 
assets described in paragraphs 4,5 and 6 above);                         section 401(a)(9)(C)(v) and have retired or separated from 
  2. The name of the surety company issuing the fidelity bond,           service, see Code section 401(a)(9). Include in this amount the 
if the plan has more than 5% of its assets in non-qualifying             total of any outstanding amounts that were not paid when due 
plan assets;                                                             in previous years that have continued to remain unpaid. 
  3. A notice that participants and beneficiaries may, upon 
request and without charge, examine or receive from the plan             Note. In the absence of other guidance, filers do not need to 
evidence of the required bond and copies of statements from              report on this line unpaid required minimum distribution (RMD) 
the regulated financial institutions describing the qualifying           amounts for participants who have retired or separated from 
plan assets; and                                                         service, or their beneficiaries, who cannot be located after 
  4. A notice that participants and beneficiaries should contact         reasonable efforts or where the plan is in the process of 
the EBSA Regional Office if they are unable to examine or                engaging in such reasonable efforts at the end of the plan year 
obtain copies of the regulated financial institution statements or       reporting period. Plan administrators and employers should 
evidence of the required bond, if applicable.                            review their plan documents for written procedures on locating 
                                                                         missing participants. Although the Department of Labor’s Field 
  A Model Notice that plans can use to satisfy the enhanced              Assistance Bulletin 2014-01 is specifically applicable to 
SAR (or Annual Funding Notice) disclosure requirements to be             terminated defined contribution plans, employers and plan 
eligible for the audit waiver is available as an Appendix to 29          administrators of ongoing plans may want to consider 
CFR 2520.104-46.                                                         periodically using one or more of the search methods 
  Condition 3: In addition, in response to a request from any            described in the FAB in connection with making reasonable 
participant or beneficiary, the administrator, without charge to         efforts to locate RMD-eligible missing participants. 
the participant or beneficiary, must make available for                  Line 4m.  Check “Yes” if there was a “blackout period.” A 
examination, or upon request furnish copies of, each regulated           blackout period is a temporary suspension of more than three 
financial institution statement and evidence of any required             (3) consecutive business days during which participants or 
bond.                                                                    beneficiaries of a 401(k) or other individual account pension 
  Examples. Plan A, which has a plan year that began on or               plan were unable to, or were limited or restricted in their ability 
after April 18, 2001, had total assets of $600,000 as of the end         to, direct or diversify assets credited to their accounts, obtain 
of the 2000 plan year that included: investments in various              loans from the plan, or obtain distributions from the plan. A 
bank, insurance company and mutual fund products of                      “blackout period” generally does not include a temporary 
$520,000; investments in qualifying employer securities of               suspension of the right of participants and beneficiaries to 
$40,000; participant loans (meeting the requirements of ERISA            direct or diversify assets credited to their accounts, obtain 
section 408(b)(1)), totaling $20,000; and a $20,000 investment           loans from the plan, or obtain distributions from the plan if the 
in a real estate limited partnership. Because the only asset of          temporary suspension is: (1) part of the regularly scheduled 
the plan that did not constitute a ‘‘qualifying plan asset’’ is the      operations of the plan that has been disclosed to participants 
$20,000 real estate limited partnership investment and that              and beneficiaries; (2) due to a qualified domestic relations 
investment represents less than 5% of the plan’s total assets,           order (QDRO) or because of a pending determination as to 
no fidelity bond is required as a condition for the plan to be           whether a domestic relations order is a QDRO; (3) due to an 
eligible for the waiver for the 2001 plan year.                          action or a failure to take action by an individual participant or 
  Plan B is identical to Plan A except that of Plan B’s total            because of an action or claim by someone other than the plan 
assets of $600,000 as of the end of the 2000 plan year,                  regarding a participant’s individual account; (4) by application 
$558,000 constitutes ‘‘qualifying plan assets’’ and $42,000              of federal securities laws. For more information, see 29 CFR 
constitutes non-qualifying plan assets. Because 7%  –  more              2520.101-3 (available at www.dol.gov/ebsa). 
than 5%  –  of Plan B’s assets do not constitute ‘‘qualifying plan       Line 4n. If there was a blackout period, did you provide the 
assets,’’ Plan B, as a condition to be eligible for the waiver for       required notice not less than 30 days nor more than 60 days in 
the 2001 plan year, must ensure that it has a fidelity bond in an        advance of restricting the rights of participants and 
amount equal to at least $42,000 covering persons handling its           beneficiaries to change their plan investments, obtain loans 
non-qualifying plan assets. Inasmuch as compliance with                  from the plan, or obtain distributions from the plan? If so, check 
ERISA section 412 generally requires the amount of the bond              “Yes.” See 29 CFR 2520.101-3 for specific notice requirements 
be not less than 10% of the amount of all the plan’s funds or            and for exceptions from the notice requirement. Also, answer 
other property handled, the bond acquired for ERISA section              “Yes” if one of the exceptions to the notice requirement under 
412 purposes may be adequate to cover the non-qualifying                 29 CFR 2520.101-3 applies. 
plan assets without an increase (i.e., if the amount of the bond         Line 5a. Check “Yes” if a resolution to terminate the plan was 
Instructions for Schedule I (Form 5500)                             -61-

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adopted during this or any prior plan year, unless the with the Form 5500.
termination was revoked and no assets reverted to the IRS Form 5310-A, Notice of Plan Merger or Consolidation,
employer. If ‘‘Yes’’ is checked, enter the amount of plan assets Spinoff, or Transfer of Plan Assets or Liabilities; Notice of
that reverted to the employer during the plan year in Qualified Separate Lines of Business, may be required to be
connection with the implementation of such termination. Enter filed at least 30 days before any plan merger or consolidation
‘‘0’’ if no reversion occurred during the current plan year. or any transfer of plan assets or liabilities to another plan.
A Form 5500 must be filed for each year the plan has There is a penalty of $25 a day (up to a maximum of $15,000)
assets, and, for a welfare benefit plan, if the plan is still for not filing IRS Form 5310-A on time.” In addition, a transfer
liable to pay benefits for claims that were incurred before the of benefit liabilities involving a plan covered by PBGC
termination date, but not yet paid. See 29 CFR 2520.104b- insurance may be reportable to the PBGC. See PBGC Form
2(g)(2)(ii). 10, Post-Event Notice of Reportable Events, and PBGC Form
Line 5b. Enter information concerning assets and/or liabilities 10-Advance, Advance Notice of Reportable Events.
transferred from this plan to another plan(s) (including spinoffs) Line 5c. Check “Yes” if the plan was covered by PBGC at any
during the plan year. A transfer of assets or liabilities occurs time during the plan year to which the Form 5500 relates and
when there is a reduction of assets or liabilities with respect to enter the My PAA generated confirmation number for the
one plan and the receipt of these assets or the assumption of premium filing for that plan year reported (see filing receipt).
these liabilities by another plan. Enter the name, plan sponsor “Yes” must be checked even if coverage has ceased and/or
EIN, and PN for the transferee plan(s) involved on lines 5(b)1, final premiums have been paid before the Form 5500 is due.
(2), and (3). If you are uncertain whether the plan is covered under the
Do not use a social security number in lieu of an EIN or PBGC termination insurance program, check the box “Not
include an attachment that contains visible social security determined” and contact PBGC either by phone at 1-800-736-
numbers. The Schedule I and its attachments are open to 2444, by E-mail at coverage@pbgc.gov. If you amended your
public inspection, and the contents are public information and premium filing for this plan year, enter the confirmation number
are subject to publication on the Internet. Because of privacy for that filing and not for the previous filing(s). Defined
concerns, the inclusion of a social security number or any contribution plans and welfare plans do not need to complete
portion thereof on this Schedule I or the inclusion of a visible this item.
social security number or any portion thereof on an attachment Note: A church defined benefit pension plan that has made an
may result in the rejection of the filing. election under Code section 410(d) should see www.pbgc.gov
Note. A distribution of all or part of an individual participant’s for the procedures prescribed by PBGC on how to notify PBGC
account balance that is reportable on IRS Form 1099-R should that it wishes to have Title IV of ERISA apply to it.
not be included on line 5b. Do not submit IRS Form 1099-R

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You can apply for an EIN from the IRS online, by fax, or by
2023 Instructions for Schedule MB mail depending on how soon you need to use the EIN. For
(Form 5500) more information, see Section 3: Electronic Filing Requirement
under the General Instructions to Form 5500 and How to File –
Multiemployer Defined Benefit Plan and Electronic Filing Requirement under the General Instructions to
Certain Money Purchase Plan Actuarial Form 5500-SF. The EBSA does not issue EINs.
Information Note. (1) For split-funded plans, the costs and contributions
reported on Schedule MB must include those relating to both
General Instructions trust funds and insurance carriers. (2) For plans with funding
Who Must File standard account amortization charges and credits, see the
instructions for lines 9c and 9h. (3) For terminating
As the first step, the plan administrator of any multiemployer multiemployer plans, Code section 412(e)(4) and ERISA
defined benefit plan that is subject to the minimum funding section 301(c) provide that minimum funding standards apply
standards (see Code sections 412 and 431 and Part 3 of Title I until the last day of the plan year in which the plan terminates
of ERISA) must obtain a completed Schedule MB (Form 5500) within the meaning of section 4041A(a)(2) of ERISA.
that is prepared and signed by the plan’s enrolled actuary as Accordingly, the Schedule MB is not required to be filed for any
discussed below in the Statement by Enrolled Actuary section. later plan year.
The plan administrator must retain with the plan records the
Schedule MB that is prepared and signed by the plan’s actuary. Statement by Enrolled Actuary
Next, the plan administrator of a multiemployer defined An enrolled actuary must sign Schedule MB unless, as
benefit plan must ensure that the information from the described above, the plan is a money purchase defined
actuary’s Schedule MB is entered electronically into the annual contribution plan that has received a waiver of the minimum
return/report being submitted. When entering the information, funding standard. The signature of the enrolled actuary may be
whether using EFAST2-approved software or EFAST2’s web- qualified to state that it is subject to attached qualifications.
based filing system, all the fields required for the type of plan See Treasury Regulations section 301.6059-1(d) for permitted
must be completed (see instructions for fields that need to be qualifications. Except as otherwise provided in these
completed). instructions, a stamped or machine produced signature is not
acceptable. If the actuary has not fully reflected any final or
Further, the plan administrator of a multiemployer defined temporary regulation, revenue ruling, or notice promulgated
benefit plan must attach to the Form 5500 an electronic under the statute in completing the Schedule MB, check the
reproduction of the Schedule MB prepared and signed by the box on the last line of page 1. If this box is checked, indicate
plan’s enrolled actuary. This electronic reproduction must be on an attachment whether an accumulated funding deficiency
labeled “MB Actuary Signature” and must be included as a or a contribution that is not wholly deductible would result if the
Portable Document Format (PDF) attachment or any actuary had fully reflected such regulation, revenue ruling, or
alternative electronic attachment allowable under EFAST2. notice, and label this attachment “Schedule MB – Statement
If a money purchase defined contribution plan (including a by Enrolled Actuary.” In addition, the actuary may offer any
target benefit plan) has received a waiver of the minimum other comments related to the information contained in
funding standard, and the waiver is currently being amortized, Schedule MB.
lines 3, 9, and 10 of Schedule MB must be completed but it The actuary must provide the completed and signed
need not be signed by an enrolled actuary. In such a case, the Schedule MB to the plan administrator to be retained with the
Form 5500 or the Form 5500-SF that is submitted under plan records and included (in accordance with these
EFAST2 must include the Schedule MB with lines 3, 9, and 10 instructions) with the Form 5500 that is submitted under
completed, but is not required to include a PDF attachment of a EFAST2. The plan’s actuary is permitted to sign the Schedule
signed Schedule MB. MB on page one using the actuary’s signature or by inserting
Note. Schedule MB does not have to be filed with the Form the actuary’s typed name in the signature line followed by the
5500-EZ regardless of whether it is filed on paper with the IRS actuary’s handwritten initials. The actuary’s most recent
or electronically with EFAST2, but, if required, it must be enrollment number must be entered on the Schedule MB that
retained (in accordance with the instructions for the Form is prepared and signed by the plan’s actuary.
5500-EZ under the What to File section). Also, the funding
standard account for the plan must continue to be maintained, Attachments
even if the Schedule MB is not filed. All attachments to the Schedule MB must be properly
Check the Schedule MB box on the Form 5500 (Part II, line identified, and must include the name of the plan, the plan
10a(2)) if a Schedule MB is attached to the Form 5500. sponsor’s EIN, and the plan number. Put “Schedule MB” and
the line number to which the attachment relates at the top of
Lines A through E must be completed for ALL plans. If the each attachment. Do not include attachments that contain a
Schedule MB is attached to a Form 5500 or Form 5500-SF, visible social security number. The Schedule MB and its
lines A, B, C, and D should include the same information as attachments are open to public inspection, and the contents
reported in Part II of the Form 5500 or Form 5500-SF. You are public information and are subject to publication on the
may abbreviate the plan name. Internet. Because of privacy concerns, the inclusion of a visible
Do not use a social security number in line D in lieu of an social security number or any portion thereof on an attachment
EIN. The Schedule MB and its attachments are open to public may result in the rejection of the filing.
inspection if filed with a Form 5500 or Form 5500-SF, and the
Specific Instructions
contents are public information and are subject to publication
on the Internet. Because of privacy concerns, the inclusion of a Line 1. All entries must be reported as of the valuation date.
social security number or any portion thereof on this Schedule Line 1a. Actuarial Valuation Date. The valuation for a plan
MB or any of its attachments may result in the rejection of the year may be as of any date in the plan year, including the first
filing. or last day of the plan year. Valuations must be performed

Instructions for Schedule MB (Form 5500) -63-

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within the period specified by Code section 431(c)(7) and                 The current liability must be computed using the mortality 
ERISA section 304(c)(7).                                                 tables referenced in section 1.431(c)(6)-1 of the Treasury 
Line 1b(1). Current Value of Assets. Enter the current value             Regulations. 
of assets as of the valuation date. The current value is the              Each other actuarial assumption used in calculating the 
same as the fair market value. Do not adjust for items such as           current liability must be the same assumption used for 
the existing credit balance or the outstanding balances of               calculating other costs for the funding standard account. See 
certain amortization bases. Contributions designated for 2023            Notice 90-11, 1990-1 C.B. 319. The actuary must take into 
should not be included in this amount. Note that this entry may          account rates of early retirement and the plan’s early 
be different from the entry in line 2a. Such a difference may            retirement and turnover provisions as they relate to benefits, 
result, for example, if the valuation date is not the first day of       where these would significantly affect the results. 
the plan year, or if insurance contracts are excluded from               Regardless of the valuation date, current liability is computed 
assets reported on line 1b(1) but not on line 2a.                        taking into account only credited service through the end of 
   Rollover amounts or other assets held in individual                   the prior plan year. No salary scale projections should be 
accounts that are not available to provide defined benefits              used in these computations. Do not include the expected 
under the plan should not be included on line 1b(1), regardless          increase in current liability due to benefits accruing during 
of whether they are reported on the 2023 Schedule H (Form                the plan year reported on line 1d(2)(b) in these 
5500) (line 1I, column (a)) or Schedule I (Form 5500) (line 1c,          computations. 
column (a)). Additionally, asset and liability amounts must be           Line 1d(2)(b). Expected Increase in Current Liability. 
determined in a consistent manner. Therefore, if the value of            Enter the amount by which the current liability is expected to 
any insurance contracts has been excluded from the amount                increase due to benefits accruing during the plan year on 
reported on line 1b(1), liabilities satisfied by such contracts          account of credited service and/or salary changes for the 
should also be excluded from the liability values reported on            current year. One year’s salary scale may be reflected. 
lines 1c(1), 1c(2), and 1d(2) of the Schedule MB. 
                                                                         Line 1d(2)(c). Expected Release From Current Liability 
Note. If the plan received special financial assistance under            for the Plan Year. Enter the expected release from current 
ERISA section 4262 on or before the valuation date, exclude              liability on account of disbursements (including single-sum 
the value of the special financial assistance account (as                distributions) from the plan expected to be paid after the 
described in IRS Notice 2021-38) as of the valuation date.               valuation date but prior to the end of the plan year (see also 
Line 1b(2). Actuarial Value of Assets. Enter the value of                Q&A-7 of Revenue Ruling 96-21, 1996-1 C.B. 64). 
assets determined in accordance with Code section 431(c)(2)              Line 1d(3). Expected Plan Disbursements. Enter the 
and ERISA section 304(c)(2). Do not adjust for items such as             amount of plan disbursements expected to be paid for the 
the existing credit balance or the outstanding balances of               plan year. 
certain amortization bases, and do not include contributions 
designated for 2023 in this amount.                                      Line 2. All entries must be reported as of the beginning of 
                                                                         the 2023 plan year. Lines 2a and 2b should include all 
Note. If the plan received special financial assistance under            assets and liabilities under the plan except for assets and 
ERISA section 4262 on or before the valuation date, exclude              liabilities attributable to: (1) rollover amounts or other 
the value of the special financial assistance account (as                amounts in individual accounts that are not available to 
described in IRS Notice 2021-38) as of the valuation date.               provide defined benefits, or (2) benefits for which an insurer 
Line 1c(1). Accrued Liability for Immediate Gain Methods.                has made an irrevocable commitment as defined in 29 CFR 
Complete this line only if you use an immediate gain method              4001.2. 
(see Revenue Ruling 81-213, 1981-2 C.B. 101, for a definition            Line 2a. Current Value of Assets. Enter the current value 
of immediate gain method).                                               of net assets as of the first day of the plan year. Except for 
Lines 1c(2)(a), (b), and (c). Information for Plans Using                plans with excluded assets as described above, this entry 
Spread Gain Methods. Complete these lines only if you use a              should be the same as reported on the 2023 Schedule H 
spread gain method (see Revenue Ruling 81-213 for a                      (Form 5500) (line 1l, column (a)) or Schedule I (Form 5500) 
definition of spread gain method).                                       (line 1c, column (a)). Note that contributions designated for 
Line 1c(2)(a). Unfunded Liability for Methods with Bases.                the 2023 plan year are not included on those lines.  
Complete this line only if you use the frozen initial liability or       Note. If the plan received special financial assistance under 
attained age normal cost method.                                         ERISA section 4262 on or before the first day of the plan 
Lines 1c(2)(b) and (c). Entry Age Normal Accrued Liability               year, exclude the value of the special financial assistance 
and Normal Cost. For spread gain methods, these                          account (as described in IRS Notice 2021-38) as of the first 
calculations are used for purposes of the full funding limitation        day of the plan year. 
(see Revenue Ruling 81-13, 1981-1 C.B. 229).                             Line 2b. Current Liability (beginning of plan year). Enter 
Line 1d(1). Amount Excluded from Current Liability.                      the current liability as of the first day of the plan year. Do not 
Leave line 1(d)(1) blank.                                                include the expected increase in current liability due to 
                                                                         benefits accruing during the plan year. See the instructions 
Line 1d(2)(a). Current Liability. All multiemployer plans,               for line 1d(2)(a) for actuarial assumptions used in 
regardless of the number of participants, must provide the               determining current liability. 
information indicated in accordance with these instructions. 
The interest rate used to compute the current liability must be           Column (1) – Enter the number of participants and 
in accordance with guidelines issued by the IRS and, pursuant            beneficiaries as of the beginning of the plan year in each 
to the Pension Protection Act of 2006 (PPA), must not be more            category (e.g., terminated vested participants). Enter “0” if no 
than 5 percent above and must not be more than 10 percent                participants fall into the category. If the current liability 
below the weighted average of the rates of interest, as set forth        figures are derived from a valuation that follows the first day 
by the Treasury Department, on 30-year Treasury securities               of the plan year, the participant and beneficiary count entries 
during the 4-year period ending on the last day before the               should be derived from the counts used in that valuation in a 
beginning of the 2023 plan year. 
                                                                    -64-               Instructions for Schedule MB (Form 5500)

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manner consistent with the derivation of the current liability         status, attach a copy of the actuarial certification of such status 
reported in column (2).                                                to this Schedule MB. Also attach an illustration showing the 
   Column (2) – Enter the current liability attributable to all        details (including year-by-year cash flow projections 
benefits, with subtotals for vested and nonvested benefits in          demonstrating the solvency of the plan over the relevant period 
the case of active participants. Enter “0” if there is no current      if the plan is certified as being in critical and declining status) 
liability attributable to a particular category of participants.       providing support for the actuarial certification of status and 
                                                                       label the illustration “Schedule MB, line 4b – Illustration 
Line 2c. This calculation is required under ERISA section              Supporting Actuarial Certification of Status.” For example, 
103(d)(11). Do not complete if line 2a divided by line 2b(4),          if a plan is certified as being in critical status based on Code 
column (2), is 70% or greater.                                         section 432(b)(2)(B), show the funded percentage (if 
Line 3. Contributions Made to Plan. Show all employer                  applicable) and the projection of the funding standard account 
and employee contributions for the plan year. Include                  for the year in which the accumulated funding deficiency 
employer contributions made not later than 2½ months (or               occurs. All supporting documentation should include 
the later date allowed under Code section 431(c)(8) and                descriptions of the assumptions used. 
ERISA section 304(c)(8)) after the end of the plan year.               Note. If the plan received special financial assistance under 
Show only contributions actually made to the plan by the               ERISA section 4262, the plan is deemed to be in critical status 
date this Schedule MB is signed.                                       for plan years beginning with the plan year in which the 
   Add the amounts in both columns (b) and (c) and enter               effective date for such assistance occurs and ending with the 
both results on the total line. All contributions must be              last plan year ending in 2051 in accordance with Code section 
credited toward a particular plan year.                                432(b)(7). 
   If any of the contributions reported in line 3 include              Line 4c. If, in the plan year in which the Schedule MB is filed, a 
amounts owed for withdrawal liability, report in line 3(d) the         certification was required to be made under Code section 
total withdrawal liability amounts included in line 3(b).              432(b)(3)(A)(ii) and ERISA section 305(b)(3)(A)(ii) with respect 
   Attach a list showing the date and amount of each                   to scheduled progress during the plan year for which the 
withdrawal liability amount included, broken down between              Schedule MB is filed, check “Yes” or “No” to reflect the 
periodic amounts and lump sum amounts. For this purpose,               certification. Attach documentation comparing the current 
include a withdrawal liability payment as a lump sum only if           status of the plan to the scheduled progress under the 
the entire liability is paid in one lump sum or if the payment         applicable funding improvement or rehabilitation plan to this 
from an employer that paid its assessed withdrawal liability           Schedule MB. Label the documentation “Schedule MB, line 
in periodic installments (e.g., monthly or quarterly) in prior         4c – Documentation Regarding Progress Under Funding 
years settled the remaining liability via one lump sum                 Improvement or Rehabilitation Plan.” 
payment during the plan year. Use the format shown below               Lines 4d and 4e. If Code C (Critical Status) or Code D (Critical 
and label this attachment “Schedule MB, Line 3(d) –                    and Declining Status) was entered on line 4b, an entry on line 
Withdrawal Liability Amounts.” The attachment may be                   4d is required. For purposes of lines 4d and 4e, in determining 
provided as a structured attachment, e.g., in a spreadsheet            whether benefits have been reduced, only adjustable benefits 
file (CSV format).                                                     that would otherwise be protected under Code section 
   Schedule MB, Line 3(d) - Withdrawal Liability Amounts               411(d)(6) and ERISA section 204(g) are taken into account if 
                                                                       the plan is certified as being in critical status. Plans that are 
  Payment          Periodic      Lump Sum       Total                  certified as being in critical and declining status should 
   Date            Amounts       Amounts        Amounts                determine whether benefits have been reduced, including all 
                                                                       benefits that were adjusted (only adjustable benefits that would 
                                                                       otherwise be protected under Code section 411(d)(6) and 
                                                                       ERISA section 204(g) are taken into account), any benefits that 
                                                                       have been suspended under Code section 432(e)(9), and any 
                                                                       benefit reductions due to a partition under ERISA section 4233. 
                                                                       For a plan that has benefits suspended under Code section 
Line 4. Information on Plan Status. All multiemployer plans            432(e)(9) and/or partitioned under ERISA section 4233, attach 
regardless of the number of participants must provide the              a full description of the transaction and label the attachment 
information indicated in accordance with these instructions.           “Schedule MB, Lines 4d and 4e – Description of Benefit 
                                                                       Reductions Due to Suspension or Partition.” In addition, 
Line 4a. All plans enter the funded percentage for monitoring 
                                                                       only benefit reductions that are first reflected in line 1c(3) for 
the plan’s status. This is line 1b(2) divided by line 1c(3). 
                                                                       the current year's Schedule MB should be reported, and this 
Line 4b. Enter the code for the status of the multiemployer            amount should not include any amounts previously reported on 
plan for the plan year, as certified by the plan actuary, (or as       any prior year's Schedule MB. 
elected by the plan sponsor in accordance with Code section 
                                                                       Line 4f. If Code C (Critical Status) or Code D (Critical and 
432(b)(4)(A) and ERISA section 305(b)(4)(A)) using one of 
                                                                       Declining Status) was entered on line 4b you must complete 
the following codes: 
                                                                       line 4f as follows:  
   Code  Plan Status                                                   If the projections underlying the actuarial certification for the 
   E      Endangered Status                                            plan year indicate that the plan is: 
   S      Seriously Endangered Status                                    Projected to emerge from critical status within 30 years, 
   C      Critical Status                                                enter the plan year in which the plan is projected to emerge 
   D      Critical and Declining Status                                  from critical status. 
   N      Not in Endangered or Critical Status                           Projected to become insolvent within 30 years, check the 
                                                                         box provided and enter the plan year in which the 
  If the plan is certified to be in endangered status, seriously         insolvency is expected. In addition, attach an illustration 
endangered status, critical status, or critical and declining 
Instructions for Schedule MB (Form 5500)                          -65-

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showing year-by-year cash flow projections for the period is required if the shortfall funding method is adopted at a
beginning with the plan year and ending with the year the later time, if a specific computation method is changed, or if
plan is projected to become insolvent (or, if earlier, the 19 th the shortfall method is discontinued. In such a case there is
year after the plan year) and a summary of the no automatic limitation on benefit increases.
assumptions underlying the projections. Label this Line 6. Actuarial Assumptions. If gender-based
attachment “Schedule MB, line 4f – Cash Flow assumptions are used in developing plan costs, enter those
Projections.” rates where appropriate in line 6. Note that requests for
 Neither projected to emerge from critical status nor become gender-based cost information do not suggest that gender-
insolvent within 30 years, enter “9999.” In addition, attach based benefits are legal. If unisex tables are used, enter the
an illustration showing year-by-year cash flow projections values in both “Male” and “Female” lines. Check “N/A” for
for the 20-year period beginning with the plan year and a line 6b if the question is not applicable.
summary of the assumptions underlying the projections. Attach a statement of actuarial assumptions (if not fully
Label this attachment “Schedule MB, line 4f – Cash Flow described by line 6) and actuarial methods used to calculate
Projections.” the figures shown in lines 1 and 9 (if not fully described by
Line 5. Actuarial Cost Method. Enter the primary method line 5), and label the statement “Schedule MB, line 6 –
used. If the plan uses one actuarial cost method in one year as Statement of Actuarial Assumptions/Methods.” The
the basis of establishing an accrued liability for use under the statement must describe all actuarial assumptions used to
frozen initial liability method in subsequent years, answer as if determine the liabilities. For example, the statement for non-
the frozen initial liability method was used in all years. The traditional plans (e.g., cash balance plans) must include the
projected unit credit method is included in the “Accrued benefit assumptions used to convert balances to annuities.
(unit credit)” category of line 5c. If a method other than a Also attach a summary of the principal eligibility and
method listed on lines 5a through 5g is used, check the box for benefit provisions on which the valuation was based,
line 5i and specify the method. For example, if a modified including the status of the plan (e.g., eligibility frozen,
individual level premium method for which actuarial gains and service/pay frozen, benefits frozen), optional forms of
losses are spread as a part of future normal cost is used, benefits, special plan provisions, including those that apply
check the box for 5i and describe the cost method. only to a subgroup of employees (e.g., those with imputed
Check the appropriate box for the underlying actuarial service), supplemental benefits, an identification of benefits
cost method used as the basis for this plan year’s funding not included in the valuation (e.g., shutdown benefits), a
standard account computation. If box 5h is checked, enter description of any significant events that occurred during the
the period of use of the shortfall method in line 5j. For this year, a summary of any changes in principal eligibility or
purpose, enter the calendar year (YY) which includes the benefit provisions since the last valuation, a description (or
first day of the plan year in which the shortfall method was reasonably representative sample) of plan early retirement
first used. factors, and any change in actuarial assumptions or cost
Changes in funding methods include changes in actuarial methods and justifications for any such change (see section
cost method, changes in asset valuation method, and changes 103(d) of ERISA). Label the summary “Schedule MB, line 6
in the valuation date of plan costs and liabilities or of plan – Summary of Plan Provisions.”
assets. Changes in the funding method of a plan include not Also, include any other information needed to disclose the
only changes to the overall funding method used by the plan, actuarial position of the plan fully and fairly, including the
but also changes to each specific method of computation used weighted average retirement age.
in applying the overall method. Generally, these changes Line 6a. Current Liability Interest Rate. Enter the interest
require IRS approval. If the change was made pursuant to rate used to determine current liability. The interest rate used
Revenue Procedure 2000-40, 2000-2 C.B. 357, or pursuant must be in accordance with the guidelines issued by the IRS
to other automatic approval, check “Yes” for line 5l. If approval and, pursuant to PPA, must not be more than 5 percent
was granted for this plan by either an individual ruling letter or above and must not be more than 10 percent below the
a class ruling letter, enter the date of the applicable ruling letter weighted average of the rates of interest, as set forth by the
in line 5m. Note that the plan sponsor's agreement to certain Treasury Department, on 30-year Treasury securities during
changes in funding methods should be reported on line 8 of the 4-year period ending on the last day before the
Schedule R (Form 5500). beginning of the 2023 plan year. Enter the rate to the
Shortfall Method: Only certain plans may elect the shortfall nearest .01 percent.
funding method (see Treasury Regulations section Line 6b. Check “Yes,” if the rates in the contract were used
1.412(c)(1)-2). Advance approval from the IRS for the (e.g., purchase rates at retirement).
election of the shortfall method of funding is NOT required if
Line 6c. Mortality Table. The mortality table published in
it is first adopted for the first plan year to which Code section
412 applies. In addition, pursuant to PPA section 201(b), a section 1.431(c)(6)-1 of the Treasury Regulations must be used
plan does NOT need advance approval from the IRS to in the calculation of current liability for non-disabled lives. Enter
adopt or cease using the shortfall method if the plan (1) has the mortality table code for non-disabled lives used for valuation
purposes as follows:
not adopted or ceased using the shortfall method during the
5-year period ending on the day before the date the plan is
to use the method, and (2) is not operating under an
amortization period extension and did not operate under
such an extension during such 5-year period. In such a case,
check “Yes” for line 5l. If a plan utilizes this automatic
approval to apply the shortfall method, the benefit increase
limitations of Code section 412(c)(7) apply.
If a plan is not eligible for automatic approval as set forth
in the preceding paragraph, advance approval from the IRS
-66- Instructions for Schedule MB (Form 5500)

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                                                                                                 •  If “Other” is checked, attach a description of the interest 
                                                                                                 rate used for this purpose and label this attachment 
                                                                                                 “Schedule MB, line 6f(1) – Description of Withdrawal 
 Mortality Table                                       Code                                      Liability Interest Rate.” 
Mortality Tables with Base Year in 1970s or Earlier ............. 1                              Line 6g. Estimated Investment Return – Actuarial Value. 
Mortality Tables with Base Year in 1980s  ............................ 2                         Enter the estimated rate of return on the actuarial value of 
Mortality Tables with Base Year in 1990s  ............................ 3                         plan assets for the 1-year period ending on the valuation 
                                                                                                 date. For this purpose, the rate of return is determined by 
Mortality table applicable to current plan year under                                            using the formula 2I/(A + B  –  I), where I is the dollar amount 
section 1.431(c)(6)-1 of the Income Tax Regulations  .......... 4                                of the investment return under the asset valuation method 
                                                                                                 used for the plan, A is the actuarial value of the assets one 
RP-2014  ………………...………………….….…………....5                                                            year ago, and B is the actuarial value of the assets on the 
RP-2014 (Blue Collar)   ……………………………….........6                                                   current valuation date. Enter rates to the nearest .1 percent. 
                                                                                                 If entering a negative number, enter a minus sign (“ – ”) to 
RP-2014 (adjusted to 2006 Base Year)  …………….…...7                                                the left of the number. 
Pri-2012 ......................................................................... .8            Note. Use the above formula even if the actuary feels that the 
Pri-2012 (Blue Collar)  .................................................... 9                   result of using the formula does not represent the true 
                                                                                                 estimated rate of return on the actuarial value of plan assets for 
Other  ...................................................................................A      the 1-year period ending on the valuation date. The actuary 
None  ................................................................................... 0      may attach a statement showing both the actuary’s estimate of 
                                                                                                 the rate of return and the actuary’s calculations of that rate, 
 Where an indicated table consists of separate tables for                                        and label the statement “Schedule MB, line 6g – Estimated 
males and females, add F to the female table (e.g., 1F).                                         Rate of Investment Return (Actuarial Value).”   
When a projection is used with a table, follow the code with 
                                                                                                 Line 6h. Estimated Investment Return – Current (Market) 
“P” and the year of projection (omit the year if the projection 
                                                                                                 Value. Enter the estimated rate of return on the current value 
is unrelated to a single calendar year). The identity of the 
                                                                                                 of plan assets for the 1-year period ending on the valuation 
projection scale should be omitted from line 6c, but a 
                                                                                                 date. (The current value is the same as the fair market value — 
description of projection techniques, including the projection 
                                                                                                 see line 1b(1) instructions.) For this purpose, the rate of return 
scales used, should be included in the Schedule MB, line 6 
                                                                                                 is determined by using the formula 2I/(A + B  –  I), where I is 
– Statement of Actuarial Assumptions/Methods. When 
                                                                                                 the dollar amount of the investment return, A is the current 
an age setback or set forward is used, indicate with “ – ” or 
                                                                                                 value of the assets one year ago, and B is the current value of 
“+” and the number of years. For example, if for females the 
                                                                                                 the assets on the current valuation date. Enter rates to the 
1983 G.A.M. Table (solely per Revenue Ruling 95-28) with 
                                                                                                 nearest .1 percent. If entering a negative number, enter a 
projection to 2022 is used with a 5-year setback, enter 
                                                                                                 minus sign (“ – ”) to the left of the number. 
“2FP22-5.” If the table is not one of those listed, enter “A” 
with no further notation. If the valuation assumes a maturity                                     Note. Use the above formula even if the actuary feels that the 
value to provide the post-retirement income without                                              result of using the formula does not represent the true 
separately identifying the mortality, interest and expense                                       estimated rate of return on the current value of plan assets for 
elements, enter on line 6c, under “Post-retirement,” the value                                   the 1-year period ending on the valuation date. The actuary 
of $1.00 of monthly pension beginning at the plan’s weighted                                     may attach a statement showing both the actuary’s estimate of 
average retirement age, assuming the normal form of                                              the rate of return and the actuary’s calculations of that rate, 
annuity for an unmarried person. In such a case, leave lines                                     and label the statement “Schedule MB, line 6h – Estimated 
6d and 6e blank.                                                                                 Rate of Investment Return (Current Value).”    
Line 6d. Valuation Liability Interest Rate. Enter the                                            Line 6i. Expense Load Included in Normal Cost. If the 
assumption as to the interest rate used to determine all the                                     normal cost reported in line 9b does not include a load for 
calculated values except for current liability. If the assumed                                   administrative or investment expenses, check the “N/A” box.  
rate varies with the year, enter the weighted average of the                                     Otherwise, provide information in lines 6i(1), 6i(2), or 6i(3), 
assumed rate for 20 years following the valuation date. Enter                                    whichever is applicable, about the expense load included in 
rates to the nearest .01 percent.                                                                the normal cost. If the expense load is described as a 
                                                                                                 percentage of normal cost, the reported percentage in line 
Line 6e. Salary Scale. If a uniform level annual rate of 
                                                                                                 6i(1) should be the expense load as a percent of the 
salary increase is used, enter that annual rate. Otherwise, 
                                                                                                 unloaded normal cost. For example, if the expense load is 
enter the level annual rate of salary increase that is 
                                                                                                 5% of the normal cost, the unloaded normal cost is $100,000 
equivalent to the rate(s) of salary increase used. Enter the 
                                                                                                 and the reported normal cost is $105,000, enter 5%, not 
annual rate as a percentage to the nearest .01 percent, used 
                                                                                                 4.8% (i.e., $5,000/$105,000). Enter rates to the nearest .1 
for a participant from age 25 to assumed retirement age. If 
                                                                                                 percent. 
the plan’s benefit formula is not related to compensation, 
check the “N/A” box.                                                                             Line 7. New Amortization Bases Established. List all new 
                                                                                                 amortization bases established in the current plan year (before 
Lines 6f(1) and 6(f)(2). Withdrawal Liability Interest Rate. 
                                                                                                 the combining of bases, if bases were combined). Use the 
In line 6f(1), check the box that describes the type of interest 
                                                                                                 following table to indicate the type of base established and 
rate assumption used to determine the present value of 
                                                                                                 enter the appropriate code under “Type of base.” List 
vested benefits for withdrawal liability determinations for 
                                                                                                 amortization bases and charges and/or credits as of the 
employers withdrawing during the plan year. If the present 
                                                                                                 valuation date. Bases that are considered fully amortized 
value of vested benefits noted above was not determined by 
                                                                                                 because there is a credit for the plan year on line 9j(3) should 
the time the Form 5500 is filed, check “N/A”. In addition: 
                                                                                                 be listed. If entering a negative number, enter a minus sign (“–
•  If “Single rate” is checked, enter the single rate in line                                    ”) to the left of the number. 
6f(2). 

Instructions for Schedule MB (Form 5500)                                                    -67-

- 68 -

Use the format shown below and label the schedule
Code Type of Amortization Base “Schedule MB, line 8b(1) – Schedule of Projection of
1 Experience gain or loss Expected Benefit Payments.” The attachment may be
2 Shortfall gain or loss provided as a structured attachment, e.g., in a spreadsheet
3 Change in unfunded liability due to plan file (CSV format).
amendment
4 Change in unfunded liability due to change in Schedule MB, line 8b(1) – Schedule of Projection of Expected
actuarial assumptions Benefit Payments
5 Change in unfunded liability due to change in Retired
actuarial cost method Participants
6 Waiver of the minimum funding standard and
Terminated Beneficiaries
7 Initial unfunded liability (for new plan) Active Vested Receiving
8 Net investment losses and other losses related to Plan Year Participants Participants Payments Total
the virus SARS-CoV-2 or coronavirus disease
2019 (COVID) incurred in either or both of the first Current
Plan Year
two plan years ending after February 29, 2020
Current
Plan Year
For purposes of Code 8, other losses related to COVID- + 1
19 include (but are not limited to) losses related to
reductions in contributions, reductions in employment, and Etc.
deviations from anticipated retirement rates, as determined
by the plan sponsor. Current
Plan Year
Line 8a and 8d. Funding Waivers or Extensions. If a + 49
funding waiver or extension request is approved after the
Schedule MB is filed, an amended Schedule MB must be Line 8b(2). Schedule of Active Participant Data. Check
filed with Form 5500 to report the waiver or extension “Yes” only if this is a multiemployer plan covered by Title IV
approval (also see instructions for line 9k(1)). of ERISA that has active participants.
Line 8b(1). Schedule of Projection of Expected Benefit If line 8b(2) is “Yes,” attach a schedule of the active plan
Payments. Check “Yes” only if this is a multiemployer plan participant data used in the valuation for this plan year. Use
covered by Title IV of ERISA that has 1,000 or more total the format shown below and label the attachment “Schedule
participants as of the beginning of the plan year (i.e., MB, line 8b(2) – Schedule of Active Participant Data.”
reported on line 2b(4), column (1)). The attachment may be provided as a structured
If line 8b(1) is “Yes,” in an attachment, provide a attachment, e.g., in a spreadsheet file (CSV format).
projection of benefits expected to be paid separately for Expand this schedule by adding columns after the “5 to
active participants, terminated vested participants, and 9” column and before the “40 & up” column for active
retired participants and beneficiaries receiving payments, participants with total years of credited service in the
and for the entire plan (not to include expected expenses) in following ranges: 10 to 14; 15 to 19; 20 to 24; 25 to 29; 30 to
each of the next fifty years starting with the plan year and 34; and 35 to 39. For each column, enter the number of
based on the participant’s status as of the valuation date. active participants with the specified number of years of
For purposes of this projection, assume (1) no additional credited service divided according to age group. For
accruals, (2) experience (e.g., termination, mortality, and participants with partial years of credited service, truncate
retirement) is in line with valuation assumptions, (3) no new the total number of years of credited service. Years of
entrants, and (4) benefits are paid in the form assumed for credited service are the years credited under the plan’s
valuation purposes. benefit formula.

Schedule MB, line 8b(2) – Schedule of Active Participant Data

YEARS OF CREDITED SERVICE
Under 1 1 to 4 5 to 9 40 & up
Average Average Average Average
Attained N
Age No. Comp. Accrued No. Comp. Accrued No. Comp. Accrued No. Comp. Accrued
Mon. Ben. Mon. Ben. Mon. Ben. Mon. Ben.
Under 25
25 to 29
30 to 34
35 to 39
40 to 44
45 to 49
50 to 54
55 to 59
60 to 64
65 to 69
70 & up

-68- Instructions for Schedule MB (Form 5500)

- 69 -

Plans reporting 1,000 or more active participants on line Current
2b(3)(c), column (1), and using compensation to determine plan year +
9
benefits must also provide average compensation data. For
each grouping, enter the average compensation of the active Line 9. Shortfall Method. Under the shortfall method of
participants in that group. For this purpose, compensation is funding, the normal cost in the funding standard account is
the compensation taken into account for each participant the charge per unit of production (or per unit of service)
under the plan’s benefit formula, limited to the amount multiplied by the actual number of units of production (or
defined under section 401(a)(17) of the Code. Do not enter units of service) that occurred during the plan year. Each
the average compensation in any grouping that contains amortization installment in the funding standard account is
fewer than 20 participants. similarly calculated.
Plans reporting 1,000 or more active participants on line Lines 9c and 9h. Amortization Charges and Credits. If
2b(3)(c), column (1), must also provide average accrued there are any amortization charges or credits, attach a
monthly benefits, as of the valuation date, that are payable maintenance schedule of funding standard account bases
at normal retirement age. For each grouping, enter the and label the schedule “Schedule MB, lines 9c and 9h –
average accrued monthly benefit that is payable at normal Schedule of Funding Standard Account Bases.” The
retirement age for the active participants in that group. Do attachment should clearly indicate the type of base (i.e.,
not enter the average accrued monthly benefit in any original unfunded liability, amendments, actuarial losses,
grouping that contains fewer than 20 participants. etc.), the outstanding balance of each base, the number of
years remaining in the amortization period, and the
General Rule. In general, data to be shown in each amortization amount. If bases were combined in the current
age/service bin includes: year, the attachment should show information on bases both
1. the number of active participants in the age/service prior to and after the combining of bases.
bin, The outstanding balance and amortization charges and
2. the average compensation of the active participants in credits must be calculated as of the valuation date for the
the age/service bin, and plan year.
3. the average accrued monthly benefit payable at
normal retirement age of the active participants in the Line 9c(3) should only include information related to the
age/service bin, using $0 for anyone who has no accrued amortization bases extended and amortized using the
monthly benefit. interest rate under section 6621(b) of the Code.
In general, information should be determined as of the Line 9d. Interest as Applicable. Interest as applicable
valuation date. Average accrued monthly benefits may be should be charged to the last day of the plan year.
determined as of either: Line 9f. Note that the credit balance or funding deficiency at
1. the valuation date or the end of “Year X” should be equal to the credit balance or
2. the day immediately preceding the valuation date. funding deficiency at the beginning of “Year X+1.” If such
credit balances or funding deficiencies are not equal, attach
Line 8b(3). Schedule of Projection of Employer an explanation and label the attachment “Schedule MB, line
Contributions and Withdrawal Liability Payments. Check 9f – Explanation of Prior Year Credit Balance/Funding
“Yes” only if this is a multiemployer plan covered by Title IV Deficiency Discrepancy.” For example, if the difference is
of ERISA that has 1,000 or more total participants as of the because contributions for a prior year that were not
beginning of the plan year (i.e., reported on line 2b(4), previously reported are received this plan year, attach a
column (1)). If line 8b(3) is “Yes,” in an attachment, listing of the amounts and dates of such contributions. As
separately provide a projection of employer contributions another example, if the difference is due to the application of
and withdrawal liability payments expected to be received for funding relief under the Preservation of Access to Care for
the entire plan in each of the next ten plan year starting with Medicare Beneficiaries and Pension Relief Act of 2010 (PRA
the plan year. For purposes of this projection, use the 2010), Pub. L. No. 111-192, the attachment should show
assumption used to determine the plan’s status under line how the information on the Schedule MB filed for any
4b. Use the format shown below and label the schedule previous plan year would have differed if it had reflected
“Schedule MB, line 8b(3) – Schedule of Projection of application of the special funding relief in accordance with
Employer Contributions and Withdrawal Liability published guidance (to the extent that the plan sponsor has
Payments.” The attachment may be provided as a applied the special funding relief).
structured attachment, e.g., in a spreadsheet file (CSV
format). Line 9j(1). ERISA Full Funding Limitation. Instructions for
this line are reserved pending published guidance.
Schedule MB, line 8b(3) – Schedule of Projection of Employer Line 9j(2). “RPA ’94” Override. Instructions for this line are
Contributions and Withdrawal Liability Payments reserved pending published guidance.
Withdrawal
Employer Liability Line 9j(3). Full Funding Credit. Enter the excess of (1) the
Plan Year Contributions Payments Total accumulated funding deficiency, disregarding the credit
balance and contributions for the current year, if any, over
Current (2) the greater of lines 9j(1) or 9j(2).
Plan Year
Current Line 9k(1). Waived Funding Deficiency Credit. Enter a
Plan Year + credit for a waived funding deficiency for the current plan
1 year (Code section 431(b)(3)(C)). If a waiver of a funding
deficiency is pending, report a funding deficiency. If the
Etc.
waiver is granted after Form 5500 or Form 5500-SF is filed,
file an amended Form 5500 or Form 5500-SF, as applicable,
with an amended Schedule MB to report the funding waiver

Instructions for Schedule MB (Form 5500) -69-

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(see Amended Return/Report in the instructions for Form decreased by the year end amortization amount based on
5500 or line B – Box for Amended Return/Report in the the amortization interest rate from the prior plan year.
instructions for Form 5500-SF, as applicable). Line 9o(3). Enter the sum of lines 9o(1) and 9o(2)(b) (each
Line 9k(2). Other Credits. Enter a credit in the case of a adjusted with interest at the valuation rate to the current
plan for which the accumulated funding deficiency is valuation date, if necessary).
determined under the funding standard account if such plan Note. The net outstanding balance of amortization charges
year follows a plan year for which such deficiency was and credits minus the prior year’s credit balance minus the
determined under the alternative minimum funding standard. amount on line 9o(3) (each adjusted with interest at the
Line 9o. Reconciliation Account. The reconciliation valuation rate, if necessary) generally equals the unfunded
account is made up of those components that upset the liability.
balance equation of Treasury Regulations section Line 10. Contribution Necessary to Avoid Deficiency.
1.412(c)(3)-1(b). Valuation assets must not be adjusted by Enter the amount from line 9n. If applicable, file IRS Form
the reconciliation account balance when computing the 5330, Return of Excise Taxes Related to Employee Benefit
required minimum funding. Plans, with the IRS to pay the excise tax on the funding
Line 9o(1). This amount is equal to the prior year’s deficiency. There is a penalty for not filing the Form 5330 on
accumulated reconciliation amount due to prior waived time.
funding deficiencies, increased with interest at the valuation Line 11. In accordance with ERISA section 103(d)(3), attach
rate to the current valuation date. a justification for any change in actuarial assumptions for the
Line 9o(2)(a). If an amortization extension is being current plan year and label the attachment “Schedule MB,
amortized at an interest rate that differs from the valuation line 11 – Justification for Change in Actuarial
rate, enter the prior year’s “reconciliation amortization Assumptions.”
extension outstanding balance,” increased with interest at
the valuation interest rate to the current valuation date, and

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                                                                            (b) Professional Employer Organization Plan (PEO Plan). 
2023 Instructions for Schedule MEP                                          Check this box if the Schedule MEP is being filed for a defined 
(Form 5500)                                                                 contribution MEP that is a Professional Employer Organization 
                                                                            Plan (PEO Plan) and complete Part II. For this purpose, a 
Multiple-Employer Retirement Plan                                           professional employer organization (PEO) is a human-resource 
Information                                                                 company that contractually assumes certain employer 
                                                                            responsibilities of its client employers. A defined contribution 
General Instructions                                                        pension plan sponsored by a PEO is a MEP that is a PEO Plan 
                                                                            if the PEO: (1) performs substantial employment functions on 
The Schedule MEP provides information about multiple-                       behalf of its client employers and maintains adequate records 
employer pension plans (MEPs). It consists of three parts. All              relating to such functions; (2) has substantial control over the 
MEPs must complete Parts I and II to indicate the specific type             functions and activities of the MEP as the plan sponsor, the plan 
of plan or arrangement, to complete a list of participating                 administrator, and a named fiduciary and continues to have plan 
employers, and to provide certain required information.                     obligations to MEP participants after the client employer no 
 Part III only needs to be completed by pooled employer                     longer contracts with the organization; (3) ensures that each 
plans to answer questions specific to pooled employer plans.                client employer that adopts the MEP acts directly as an 
 Remember to check the Schedule MEP box on the Form                         employer of at least one employee that is a participant covered 
5500 (Part II, line 10a(5)) if a Schedule MEP is attached to the            under the MEP; (4) ensures that participation in the MEP is 
Form 5500.                                                                  available only to employees and former employees of the PEO 
                                                                            and client employers and to employees and former employees 
Who Must File                                                               of former client employers who became participants during the 
Schedule MEP (Form 5500) must be attached to a Form 5500                    contract period between the PEO and former client employers, 
or Form 5500-SF filed for a pension plan that checks the                    and their beneficiaries; and (5) meets any other applicable 
“multiple-employer plan” box on Part I of Form 5500 or Form                 conditions under 29 CFR 2510.3-55(c). 
5500-SF, to provide information specific to such plan, including              Do not check this box for a defined benefit plan sponsored 
a list of participating employers and related information.                    by a PEO. See instructions for element (d) Other Multiple-
Multiple-employer welfare plans are not required to file the                Employer Pension Plan. 
Schedule MEP but must include an attachment to report the                   (c) Pooled Employer Plan. Check this box if the Schedule MEP 
participating employer information in accordance with the                   is being filed for a defined contribution MEP that is a pooled 
instructions for the “multiple-employer plan” box on Part I of              employer plan and complete Parts II and III. A plan operated by 
Form 5500.                                                                  a “pooled plan provider” is a pooled employer plan if: (1) the 
Specific Instructions                                                       plan is an individual account plan established or maintained for 
                                                                            the purpose of providing benefits to the employees of two or 
Part I Type of Multiple-Employer Pension Plan                               more employers; (2) the plan is a qualified retirement plan, a 
Line 1. For purposes of completing the Schedule MEP, from                   plan that consists of annuity contracts described in Code section 
among (a) to (d) described below, check the box on line 1 that              403(b) that also meets the requirements of Code section 
best describes the type of plan. Filers must check one of the               403(b)(15), or a plan funded entirely with individual retirement 
four boxes.                                                                 accounts (IRA-based plan); and (3) the terms of the plan meet 
(a) Association Retirement Plan. Check this box if the                      certain requirements set forth in ERISA section 3(43). 
Schedule MEP is being filed for a defined contribution MEP that              A “pooled plan provider” with respect to a pooled employer 
is an Association Retirement Plan and complete Part II. A                   plan is defined in ERISA section 3(44) and Code section 413(e) 
defined contribution pension plan sponsored by a bona fide                  to mean a person that: 
group or association of employers is a MEP that is an                        1. is designated by the terms of the plan as a named 
Association Retirement Plan if: (1) the group or association has            fiduciary under ERISA, as the plan administrator, and as the 
at least one substantial business purpose unrelated to offering             person responsible for performing all administrative duties that 
and providing employee benefits to its employer members and                 are reasonably necessary to ensure that the plan meets the 
their employees; (2) each employer member directly acts as an               Code requirements for tax-favored treatment and the 
employer of at least one employee participating in the MEP; (3)             requirements of ERISA and for ensuring that each employer in 
the group or association has a formal organizational structure;             the plan takes actions as the Secretary of Labor or the pooled 
(4) the group or association is controlled by its employer                  plan provider determines necessary for the plan to meet Code 
members; (5) employer members of the group or association                   and ERISA requirements, including providing to the pooled plan 
have a commonality of interest; (6) plan participation is limited to        provider any disclosures or other information that the Secretary 
employees and former employees of its employer members, and                 may require or that the pooled plan provider otherwise 
their beneficiaries; (7) the group or association must not be a             determines are necessary to administer the plan or to allow the 
bank or trust company, insurance issuer, broker-dealer, or other            plan to meet Code and ERISA requirements; 
similar financial services firm (including a pension record keeper 
or third-party administrator) or owned or controlled by such an              2. acknowledges in writing its status as a named fiduciary 
entity or any subsidiary or affiliate of such an entity, other than         under ERISA and as the plan administrator; 
to the extent such an entity, subsidiary, or affiliate participates in       3  is responsible for ensuring that all persons who handle .
the group or association in its capacity as an employer member;             plan assets or are plan fiduciaries are bonded in accordance 
and (8) the group or association meets any other applicable                 with ERISA requirements; and 
conditions under 29 CFR 2510.3-55(b).                                        4. registers as a pooled plan provider by filing a Form PR in 
 Do not check this box for a defined benefit plan sponsored                 accordance with 29 CFR 2510.3-44. 
 by a bona fide group or association of employers. See                      Note. The term “pooled employer plan” does not include a 
instructions for (d) Other Multiple-Employer Pension Plan.                  multiemployer plan or plan maintained by employers that have a 
                                                                            commonality of interest other than having adopted the plan. The 

Instructions for Schedule MEP (Form 5500)                              -71-

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term also does not include a plan established before January 1, employer and participant contributions) made by all participating
2021, which is the effective date of the SECURE Act provisions employers during the plan year. The percentage may be
allowing pooled employer plans to begin operating, unless the rounded to the nearest whole percentage. Any employer that
plan administrator elects to have the plan treated as a pooled was obligated to make contributions to the plan for the plan
employer plan and the plan meets the Code and ERISA year, who made contributions to the plan for the plan year, or
requirements applicable to a pooled employer plan established whose employees were covered under the plan for the plan year
on or after such date, including the requirement that the pooled is a “participating employer” for this purpose. If a participating
plan provider file a Form PR with the Department of Labor employer made no contributions for the plan year (including
before beginning to operate any pooled employer plan(s). participant contributions), enter “-0-” on line 2c.
The pooled plan provider must be the same as the person Line 2d. If this filing is for a defined contribution MEP, enter the
identified as the plan sponsor and administrator in Part II of aggregate account balances for each participating employer,
the Form 5500 and plan administrator on line C of Schedule determined as the sum of the account balances of the
MEP. All information for the pooled employer plan and the employees of such employer (and the beneficiaries of such
pooled plan provider operating the plan reported on the Form employees). For line 2d, the aggregate account balance
5500, including Schedule MEP, must match the information attributable to each employer is the sum of the account
reported on the Form PR. Failure to use consistent identifying balances of the employees of such employer and their
information could result in correspondence from the Department beneficiaries at the end of the year. Consistent with the
of Labor or the Internal Revenue Service. information on the schedule of the assets for the plan as a
(d) Other Multiple-Employer Pension Plan. Check this box, whole, use the end-of-year valuation to calculate the amount of
describe the type of MEP (e.g., defined benefit MEP or the aggregate account balances of each employer. The
collectively-bargained multiple-employer pension plan that did amounts can be rounded to the nearest dollar, consistent with
not elect to be treated as a multiemployer plan) and complete other asset reporting on the forms and schedules.
Part II of the Schedule MEP if the Schedule MEP is being filed Line 2e. If the plan includes any individuals not participating
for a plan that is maintained by more than one employer and is through an employer or who are individual working owners,
not one of the plans already described. answer “Yes” to line 2e and complete lines 2f and 2g. Do not
Note. A MEP can be collectively bargained and collectively identify such individuals on line 2a. For purposes of completing
funded, but if covered by PBGC termination insurance, must this schedule, a “working owner” has the same meaning as in 29
have properly elected before September 27, 1981, not to be CFR 2510.3-55(d)(2).
treated as a multiemployer plan under Code section 414(f)(5) or Line 2f. If the answer to line 2e is “Yes,” enter a good faith
ERISA sections 3(37)(E) and 4001(a)(3) and have not revoked estimate of the percentage of total contributions made by all
that election or made an election to be treated as a such individuals that are not listed on line 2a. The amounts
multiemployer plan under Code section 414(f)(6) or ERISA listed in line 2c and line 2f must equal 100 percent (with a
section 3(37)(G). permitted variance of less than 1 percent due to rounding).
Part II Multiple-Employer Plan Participating Employer Line 2g. If the answer to line 2e is “Yes,” enter the aggregate
Information. account balances for all individuals who are not listed on line 2a.
All MEPs (including association retirement plans, PEO plans, Part III. Pooled Employer Plan Information.
pooled employer plans, and other multiple-employer pension If this filing is for a pooled employer plan, you must complete
plans) must complete Part II to report the information for each Part III.
participating employer in the MEP filing the Form 5500. All Line 3. To be able to operate one or more pooled employer
MEPs complete lines 2a-2c. Defined contribution MEPs also plans, pooled plan providers must satisfy a number of
complete line 2d. conditions, including compliance with the Form PR (Pooled Plan
Complete as many entries as needed to list the required Provider Registration) requirements. See 29 CFR 2510.3-44.
information for each participating employer that is not an Line 3a. Pooled employer plans must answer whether the
individual person. pooled plan provider (identified as the plan sponsor and
Note. If there are any working owners without employees administrator in Part II of the Form 5500 and line C of Schedule
participating in the plan, answer “Yes” to line 2e and provide the MEP) has complied with the Form PR registration requirements.
percentage of total contribution and aggregate account balance Line 3b. If line 3a is “Yes,” enter in line 3b the Receipt
information for all such individuals on lines 2f and 2g, without Confirmation Code (ACK ID) for the most recent Form PR that
providing names or other identifying information. was required to be filed under the Form PR filing requirements.
Line 2a. Enter the name of each participating employer in line The ACK ID is the acknowledgement code generated by the
2a. system in response to a completed Form PR being submitted.
Line 2b. Enter the EIN of each participating employer. The instructions to the Form PR advise the pooled plan
Do not enter an SSN in lieu of an EIN. The Schedule MEP provider that it must keep, under ERISA section 107, the
is open to public inspection, and the contents are public electronic receipt for the Form PR filing as part of the records of
information and are subject to publication on the Internet. the pooled employer plans operated by the pooled plan
Because of privacy concerns, the inclusion of an SSN or any provider.
portion thereof on a Schedule MEP may result in the rejection of Failure to enter a valid Receipt Confirmation Code (ACK ID)
the filing. for the pooled plan provider’s most recent Form PR will subject
Line 2c. Enter a good faith estimate of each participating the Form 5500 filing to rejection as incomplete.
employer’s percentage of the total contributions (including

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Part I – Distributions
2023 Instructions for Schedule R “Distribution” includes only payments of benefits during the
(Form 5500) plan year, in cash, in kind, by purchase for the distributee of an
annuity contract from an insurance company, or by distribution
Retirement Plan Information of life insurance contracts. It does not include:

1. Corrective distributions of excess deferrals, excess
General Instructions contributions, or excess aggregate contributions, or the income
Purpose of Schedule allocable to any of these amounts;
Schedule R (Form 5500) reports certain information on 2. Distributions of automatic contributions pursuant to Code
retirement plan distributions, funding, nondiscrimination, section 414(w);
coverage, and the adoption of amendments, as well as certain 3. The distribution of elective deferrals or the return of
information on single-employer and multiemployer defined employee contributions to correct excess annual additions
benefit plans. under Code section 415, or the gains attributable to these
amounts; and
Electronic Attachments. All attachments to Schedule R must 4. A loan deemed as a distribution under Code section
be properly identified, must include the name of the plan, plan 72(p).
sponsor’s EIN, and plan number. Place “Schedule R” and the
Schedule R line number at the top of each attachment to Note. It does, however, include a distribution of a plan loan
identify the information to which the attachment relates. Do not offset amount as defined in Treasury Regulations section
include attachments that contain a visible social security 1.402(c)-2, Q&A 9(b).
number. The Schedule R and its attachments are open to Line 1. Enter the total value of all distributions made during the
public inspection, and the contents are subject to publication year (regardless of when the distribution began) in any form
on the Internet. Because of privacy concerns, the inclusion of a other than cash, annuity contracts issued by an insurance
visible social security number or any portion thereof on an company, distribution of life insurance contracts, marketable
attachment may result in the rejection of the filing. securities within the meaning of Code section 731(c)(2), or
Who Must File plan loan offset amounts. Do not include eligible rollover
distributions paid directly to eligible retirement plans in a direct
Schedule R must be attached to a Form 5500 filed for both tax- rollover under Code section 401(a)(31) unless such direct
qualified and nonqualified pension benefit plans. Schedule R rollovers include property other than that enumerated in the
should not be completed for a DCG reporting group as each preceding sentence.
individual plan participating in a DCG reports Part VII IRS
Compliance information on Schedule DCG. The parts of Line 2. Enter the EIN(s) of any payor(s) (other than the plan
Schedule R that must be completed depend on whether the sponsor or plan administrator on line 2b or 3b of the Form
plan is subject to the minimum funding standards of Code 5500) who paid benefits reportable on IRS Form 1099-R on
section 412 or ERISA section 302 and the type of plan. See behalf of the plan to participants or beneficiaries during the
line item requirements under Specific Instructions for more plan year. This is the EIN that appears on the IRS Forms
details. 1099-R that are issued to report the payments. Include the EIN
of the trust if different than that of the sponsor or plan
Exception: Schedule R should not be completed when the administrator. If more than two payors made such payments
Form 5500 Annual Return/Report is filed for a pension plan during the year, enter the EINs of the two payors who paid the
that uses, as the sole funding vehicle for providing benefits, greatest dollar amounts during the year. For purposes of this
individual retirement accounts or annuities (as described in line 2, take into account all payments made during the plan
Code section 408). See the Form 5500 instructions for Limited year, in cash or in kind, that are reportable on IRS Form 1099-
Pension Plan Reporting for more information. R, regardless of when the payments began, but take into
Check the Schedule R box on the Form 5500 (Part II, line account payments from an insurance company under an
10a(1)) if a Schedule R is attached to the Form 5500. annuity only in the year the contract was purchased.
Specific Instructions Line 3. Enter the number of living or deceased participants
whose benefits under the plan were distributed during the plan
Lines A, B, C, and D. This information must be the same as year in the form of a single-sum distribution. For this purpose,
reported in Part II of the Form 5500 to which this Schedule R is a distribution of a participant’s benefits will not fail to be a
attached. single-sum distribution merely because, after the date of the
Do not use a social security number in line D instead of an distribution, the plan makes a supplemental distribution as a
EIN. Schedule R and its attachments are open to public result of earnings or other adjustments made after the date of
inspection, and the contents are public information and are the single-sum distribution. Also include any participants
subject to publication on the Internet. Because of privacy whose benefits were distributed in the form of a direct rollover
concerns, the inclusion of a social security number or any portion to the trustee or custodian of a qualified plan or individual
thereof on Schedule R or any of its attachments may result in the retirement account.
rejection of the filing.
You can apply for an EIN from the IRS online, by fax, Part II – Funding Information
or by mail depending on how soon you need to use the Complete Part II only if the plan is subject to the minimum
EIN. For more information, see Section 3: Electronic Filing funding requirements of Code section 412 or ERISA section
Requirement. The EBSA does not issue EINs. 302.
“Participant” for purposes of Schedule R, means any All qualified defined benefit and defined contribution plans
present or former employee who at any time during the are subject to the minimum funding requirements of Code
plan year had an accrued benefit in the plan (account section 412 unless they are described in the exceptions listed
balance in a defined contribution plan). under Code section 412(e)(2). These exceptions include profit-
sharing or stock bonus plans, insurance contract plans
described in Code section 412(e)(3), and certain plans to
Instructions for Schedule R (Form 5500) -73-

- 74 -

which no employer contributions are made. Return of Excise Taxes Related to Employee Benefit Plans,
Nonqualified employee pension benefit plans are subject to with the IRS to pay the excise tax on the deficiency. There is a
the minimum funding requirements of ERISA section 302 penalty for not filing IRS Form 5330 on time.
unless specifically exempted under ERISA sections 4(a) or Line 7. Check “Yes” if the minimum required contribution
301(a). remaining in line 6c will be made not later than 8 ½ months
The employer or plan administrator of a single-employer or after the end of the plan year. If “Yes,” and contributions are
multiple-employer defined benefit plan that is subject to the actually made by this date, then there will be no reportable
minimum funding requirements must file Schedule SB as an deficiency and IRS Form 5330 will not need to be filed.
attachment to Form 5500. Schedule MB is filed for Line 8. Revenue Procedure 2017-56, 2017-44 IRB 465 and
multiemployer defined benefit plans and certain money Revenue Procedure 2000-40, 2000-2 C.B. 357, providing for
purchase defined contribution plans (whether they are single- automatic approval for a change in funding method for a plan
employer or multiemployer plans). However, Schedule MB is year, generally do not apply unless the plan administrator or an
not required to be filed for a money purchase defined authorized representative of the plan sponsor explicitly agrees
contribution plan that is subject to the minimum funding to the change. If a change in funding method made pursuant to
requirements unless the plan is currently amortizing a waiver of such a revenue procedure (or a class ruling letter) is to be
the minimum funding requirements. applicable for the current plan year, this line generally must be
Line 4. Check ‘‘Yes’’ if, for purposes of computing the checked ‘‘Yes.” In certain situations, however, the requirement
minimum funding requirements for the plan year, the plan that the plan administrator or an authorized representative of
administrator is making an election intended to satisfy the the plan sponsor agree to the change in funding method will be
requirements of Code section 412(d)(2) or ERISA section satisfied if the plan administrator or an authorized
302(d)(2). Under Code section 412(d)(2) and ERISA section representative of the plan sponsor is made aware of the
302(d)(2), a plan administrator may elect to have any change. In these situations, this line must be checked “N/A.”
amendment, adopted after the close of the plan year for which See section 6.01 of Revenue Procedure 2017-56 and section
it applies, treated as having been made on the first day of the 6.01(2) of Revenue Procedure 2000-40. If the plan’s change in
plan year if all of the following requirements are met: funding method is not made pursuant to a revenue procedure
or other authority providing automatic approval which requires
1. The amendment is adopted no later than two and one- plan sponsor agreement, or to a class ruling letter (e.g., it is
half months (two years for a multiemployer plan) after the close pursuant to a regulation, then this line should be checked
of such plan year; “N/A.”
2. The amendment does not reduce the accrued benefit of
any participant determined as of the beginning of such plan Part III – Amendments
year; and Line 9.
3. The amendment does not reduce the accrued benefit of  Check “No” if no amendments were adopted during this
any participant determined as of the adoption of the plan year that increased or decreased the value of
amendment unless the plan administrator notified the benefits.
Secretary of the Treasury of the amendment and the Secretary
either approved the amendment or failed to disapprove the  Check “Increase” if an amendment was adopted during
the plan year that increased the value of benefits in any
amendment within 90 days after the date the notice was filed.
way. This includes an amendment providing for an
See Treasury Temporary Regulations section 11.412(c)- increase in the amount of benefits or rate of accrual, more
7(b) for details on when and how to make the election and generous lump sum factors, COLAs, more rapid vesting,
what information to include on the statement of election, which additional payment forms, or earlier eligibility for some
must be filed with the Form 5500 Annual Return/Report. benefits.
Line 5. If a money purchase defined contribution plan  Check “Decrease” if an amendment was adopted during
(including a target benefit plan) has received a waiver of the the plan year that decreased the value of benefits in any
minimum funding standard, and the waiver is currently being way. This includes a decrease in future accruals, closure
amortized, complete lines 3, 9, and 10 of Schedule MB. See of the plan to new employees, or accruals being frozen for
instructions for Schedule MB. Attach Schedule MB to Form some or all participants.
5500. The Schedule MB for a money purchase defined  If the amendments that were adopted increased the
contribution plan does not need to be signed by an enrolled value of some benefits but decreased the value of others,
actuary. check “Both.”
Line 6a. The minimum required contribution for a money Part IV – ESOP Information
purchase defined contribution plan (including a target benefit Line 11b. A loan is a “back-to-back loan” if the following
plan) for a plan year is the amount required to be contributed requirements are satisfied:
for the year under the formula set forth in the plan document. If
there is an accumulated funding deficiency for a prior year that 1. The loan from the employer corporation to the ESOP
has not been waived, that amount should also be included as qualifies as an exempt loan under DOL regulations at 29 CFR
part of the contribution required for the current year. 2550.408b-3 and under Treasury Regulations sections
54.4975-7 and 54.4975-11; and
Line 6b. Include all contributions for the plan year made not
later than 8 ½ months after the end of the plan year. Show only 2. The repayment terms of the loan from the sponsoring
contributions actually made to the plan by the date the form is corporation to the ESOP are substantially similar to the
filed. For example, do not include receivable contributions for repayment terms of the loan from the commercial lender to the
this purpose. sponsoring employer.
Line 6c. If the minimum required contribution exceeds the Part V – Additional Employer Information for
contributions for the plan year made not later than 8 / months 1 2 Multiemployer Defined Benefit Pension Plans
after the end of the plan year, the excess is an accumulated If this is not a multiemployer plan, skip this Part.
funding deficiency for the plan year. File IRS Form 5330,

-74- Instructions for Schedule R (Form 5500)

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Required attachments. Multiemployer defined benefit plans social security number. The Form 5500 is open to public
that are in Endangered Status, Critical Status, or Critical and inspection, and the contents are public information and are
Declining Status must attach a summary of their Funding subject to publication on the Internet. Because of privacy
Improvement Plan or Rehabilitation Plan (as updated, if concerns, the inclusion of a social security number or any
applicable) and also any update to a Funding Improvement portion thereof on this line may result in the rejection of the
Plan or Rehabilitation Plan. filing.
The summary of any Funding Improvement Plan or EINs can be obtained from the IRS online, by fax, or by
Rehabilitation Plan must reflect such plan in effect at the end of mail depending on when you need to use the EIN. For more
the plan year (whether the original Funding Improvement Plan information, see Section 3: Electronic Filing Requirement. The
or Rehabilitation Plan or as updated) and must include a EBSA does not issue EINs.
description of the various contribution and benefit schedules Line 13c. Dollar Amount Contributed. Enter the total dollar
that are being provided to the bargaining parties and any other amount contributed to the plan by the employer for all covered
actions taken in connection with the Funding Improvement workers in all locations for the plan year. Do not include the
Plan or Rehabilitation Plan, such as use of the shortfall funding portion of an aggregated contribution that is for another plan,
method or extension of an amortization period. The summary such as a welfare benefit plan, a defined contribution pension
must also identify the first year and the last year of the Funding plan or another defined benefit pension plan.
Improvement Period or the Rehabilitation Period. If an
extended Funding Improvement Period (of 13 or 18 years) or Line 13d. Collective Bargaining Agreement Expiration
Rehabilitation Period (of 13 years) applies because of an Date. Enter the date on which the employer’s collective
election under section 205 of the Worker, Retiree, and bargaining agreement expires. If the employer has more than
Employer Recovery Act of 2008 (“WRERA”), the summary one collective bargaining agreement requiring contributions to
must include a statement to that effect and the date that the the plan, check the box and include, as an attachment, the
election was filed with the IRS. expiration date of each collective bargaining agreement
(regardless of the amount of contributions arising from such
The summary must also include a schedule of the expected agreement). Label the attachment: “Schedule R, line 13d –
annual progress for the funded percentage or other relevant Collective Bargaining Agreement Expiration Date.” Include
factors under the Funding Improvement Plan or Rehabilitation the plan name and the sponsor’s name and EIN.
Plan. If the sponsor of a multiemployer plan in Critical Status
has determined that, based on reasonable actuarial Line 13e. Contribution Rate Information. Enter the
assumptions and upon exhaustion of all reasonable measures, contribution rate (in dollars and cents) per contribution base
the plan cannot emerge from Critical Status by the end of the unit in line 13e(1) and the base unit measure in line 13e(2).
Rehabilitation Period as described in Code section Indicate whether the base unit is measured on an hourly,
432(e)(3)(A)(ii), the summary must include an explanation of weekly, unit-of-production, or other basis. If “other,” specify the
the alternatives considered, why the plan is not reasonably base unit measure used. If the contribution rate changed
expected to emerge from Critical Status by the end of the during the plan year, enter the last contribution rate in effect for
Rehabilitation Period, and when, if ever, it is expected to the plan year.
emerge from Critical Status under the Rehabilitation Plan. If the employer has different contribution rates for different
The plan sponsor is required to annually update a Funding classifications of employees or different places of business,
Improvement Plan or Rehabilitation Plan that was adopted in a check the box in the first line of line 13e and list in an
prior year. The update must be filed as an attachment to the attachment each contribution rate and corresponding base unit
Schedule R. The update attachment must identify the measure under which the employer made contributions
modifications made to the Funding Improvement Plan or (regardless of the amount of contributions resulting from each
Rehabilitation Plan during the plan year, including contribution rate). Label the attachment: “Schedule R, line 13e –
increases, benefit reductions, or other actions. Information on Contribution Rates and Base Units.” Include
the plan name and the sponsor’s name and EIN.
The attachment described above must be labeled
“Schedule R, Summary of Funding Improvement Plan,” or Line 14. Enter the number of deferred vested and retired
“Schedule R Summary of Rehabilitation Plan, ” as participants (inactive participants), as of the beginning of the
appropriate, and if applicable, “Schedule R, Update of plan year, whose contributing employer is no longer making
Funding Improvement Plan or Rehabilitation Plan.” Each contributions to the plan. Generally, if there has been a prior
attachment must also include the plan name, the plan withdrawal, unless all former vested participants of the
sponsor’s name and EIN, and the plan number. withdrawn employer have been reemployed with a currently
contributing employer, this line should not be zero. Plans must
Line 13. This line should be completed only by multiemployer use one of the following counting methods to count these
defined benefit pension plans that are subject to the minimum inactive participants.
funding standards (see Code section 412 and Part 3 of Title I
of ERISA). Enter the information on lines 13a through 13e for 1. Under the last contributing employer method, count
any employer that, for the plan year, (1) contributed more than only those inactive participants whose last contributing
five (5) percent of the plan’s total contributions or (2) was one employer had withdrawn from the plan by the beginning of the
of the top-ten highest contributors. List employers in relevant plan year. Disregard any inactive participants whose
descending order according to the dollar amount of their most recent employers had not withdrawn from the plan. Thus,
contributions to the plan. Complete as many entries as are for the limited purposes of line 14 and notwithstanding any
necessary to list all employers that are required to be reported. contrary definition of such inactive participants applicable
elsewhere, inactive participants of employers who have not
Line 13a. Enter the name of the employer contributing to the withdrawn from the plan should not be included in these
plan. numbers;
Line 13b. Enter the EIN of the employer contributing to the 2. Under the alternative method count only those inactive
plan. Do not enter a social security number in lieu of an EIN; participants whose last contributing employer and all prior
therefore, ensure that you have the employer’s EIN and not a contributing employers had withdrawn from the plan by the

Instructions for Schedule R (Form 5500) -75-

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beginning of the relevant plan year. Under this method, the aggregate amount.
plan would review the list of all contributing employers The definitions of withdrawal are those contained in Section
(employers that had not withdrawn from the plan by the 4203 of ERISA. If the plan is in the building and construction,
beginning of the relevant plan year), and include on line 14 entertainment, or another industry that has special withdrawal
only those inactive participants who had no covered service rules, withdrawing employers should only be counted if the
with any of these employers; withdrawal adheres to the special rules applying to its specific
3. Under the reasonable approximation method, a plan industry.
that is unable to use the last contributing employer method or Line 17. If assets and liabilities from another plan were
the alternative method, must make a reasonable, good faith transferred to or merged with the assets and liabilities of this
effort to count inactive participants to satisfy the requirements plan during the 2023 plan year, check the box and provide the
of section 103(f)(2)(C) of ERISA and provide an attachment following information as an attachment. The attachment should
that explains the plan’s approximation method. The include the names and employer identification numbers of all
explanation must include a description of the data and a plans that transferred assets and liabilities to, or merged with,
breakdown describing the number of clearly identified inactive this plan. For each plan, including this plan, the attachment
participants and the number of estimated inactive participants. should also include the actuarial valuation of the total assets
Note. Withdrawal liability payments are not to be treated as and total liabilities for the year preceding the transfer or
contributions for the purpose of determining the number of merger, based on the most recent data available as of the day
inactive participants for line 14. before the first day of the 2023 plan year. Label the attachment
Line 14a. Enter the number of inactive participants described “Schedule R, line 17 – Information on Assets and
in the line 14 instructions for the current plan year. The current Liabilities Transferred to or Merged with This Plan” and
plan year is the plan year to which the Form 5500 relates. include the plan name and the plan sponsor’s name and EIN.
Line 14b. Enter the number of inactive participants described Part VI – Additional Information for Single-Employer
in the line 14 instructions for the plan year immediately and Multiemployer Defined Benefit Pension Plans
preceding the current plan year. Check the box if the number Line 18. If any liabilities to participants or their beneficiaries
reported on line 14b differs from the number reported on line under the plan at the end of the plan year consist of liabilities
14a for the plan year immediately preceding the current plan under two (2) or more plans as of the last day of the plan year
year. If the box is checked, provide an attachment with an immediately before the 2023 plan year, check the box and
explanation of the reason for the change. provide the following information as an attachment. The
Line 14c. Enter the number of inactive participants described attachment should include the names, employer identification
in the line 14 instructions for the second preceding plan year. numbers, and plan numbers of all plans, including the current
Check the box if the number reported on line 14c differs from plan, that provided a portion of liabilities of the participants and
the number reported on line 14b for the plan year immediately beneficiaries in question. The attachment should also include
preceding the current plan year. If the box is checked, provide the funded percentage of each plan as of the last day of the
an attachment with an explanation of the reason for the 2022 plan year. For single-employer plans, the funded
change. percentage is the funding target attainment percentage, where
For any required attachment for line 14, label the attachment the numerator is the value of plan assets reduced by the sum
“Schedule R, Line 14 – Information on Inactive of the amount of the prefunding balance and the funding
Participants Whose Contributing Employer is No Longer standard carryover balance, and the denominator is the
Making Contributions to the Plan.” funding target for the plan (for this purpose, if the plan is in at
risk status, then the funding target is determined as if the plan
Line 15. Enter the ratio of number of participants on whose were not in at risk status). For multiemployer plans, the funded
behalf no employer had an obligation to make a contribution for percentage is the ratio where the numerator is the actuarial
the 2023 plan year to the corresponding number for each of value of the plan’s assets and the denominator is the accrued
the two preceding plan years. For the purpose of these ratios, liability of the plan. For a terminated plan for which the funded
count all participants whose employers have withdrawn from percentage is required to be reported, write “Terminated” in the
the plan as well as all deferred vested and retired participants space where the plan’s funded percentage would otherwise
of employers still active in the plan (unless the collective have been reported. Label the attachment “Schedule R, line
bargaining agreement specifically requires the employer to 18 –Funded Percentage of Plans Contributing to the
make contributions for such participants). Liabilities of Plan Participants” and include the plan name
Line 15a. Enter the ratio of the number of participants as and the plan sponsor’s name and EIN.
described in the line 15 instructions for the 2023 plan year to Line 19. This line must be completed for all defined benefit
the number for the 2022 plan year. pension plans (except DFEs) with 1,000 or more participants at
Line 15b. Enter the ratio of the number of participants as the beginning of the plan year. To determine if the plan has
described on the line 15 instructions for the 2023 plan year to 1,000 or more participants, use the participant count shown on
the number for the 2021 plan year. line 3d(1) of the Schedule SB for single-employer plans or on
Note. Withdrawal liability payments are not to be treated as line 2b(4)(1) of the Schedule MB for multiemployer plans.
contributions for determining the number of participants on line Line 19a. Show the end-of-year distribution of assets for the
15. categories shown. Use the market value of assets (not notional
Line 16a. Enter the number of employers that withdrew from or book value) and do not include the value of any receivables.
the plan during the 2022 plan year. These percentages, expressed to the nearest whole percent,
should reflect the total assets held regardless of how they are
Line 16b. If line 16a is greater than zero, enter the aggregate
listed on the Schedule H and the sum of the percentages in the
amount of withdrawal liability assessed against these seven categories should sum to 100 percent. Assets held in
employers. If the withdrawal liability for one or more trusts, accounts, mutual funds, and other investment
withdrawing employers has not yet been determined, include
arrangements should be disaggregated among the seven
the amounts estimated to be assessed against them in the
asset categories. The same methodology should be used in
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disaggregating trust assets as is used when disclosing the If PBGC has been notified of the missed contribution, check
allocation of plan assets on the sponsor’s 10-K filings to the the “Yes” box. Otherwise, check the box that best explains why
Securities and Exchange Commission. Split assets between PBGC wasn’t notified. If the “No. Other. Provide explanation”
the following seven categories: box is checked, provide an explanation as to why PBGC wasn’t
● Public Equity - Publicly traded U.S. and non-U.S. equity notified (e.g., “The due date for filing Form 10 has not yet
securities and the approximate portion of mutual funds or passed; the plan administrator intends to file Form 10 with
collective trusts invested in public equities. PBGC shortly” or “Reporting was waived under 29 CFR
4043.25(c)(3) because the unpaid contribution resulted solely
● Private Equity – Direct ownership, co-investment, limited from an administrative error related to an election to use a pre-
partnerships, fund of funds or other investments in equity funding balance”).
ownership not included in the Public Equity category.
Part VII IRS Compliance Questions
● Investment-Grade Debt and Interest Rate Hedging Assets – –
Investment-grade dollar denominated debt securities (fixed Line 21a. A multiple-employer plan or a pooled employer plan
income) traded publicly or privately, and the approximate can skip this question. Check "Yes" if this plan was
portion of the mutual funds or collective trusts invested in such permissively aggregated with another plan to satisfy the
securities. Investment-grade debt-instruments are those with requirements of Code sections 410(b) and 401(a)(4).
an S&P rating of BBB- or higher, a Moody’s rating of Baa3 or Generally, each single plan must separately satisfy the
higher, an equivalent rating from another rating agency, or coverage and nondiscrimination requirements. However,
generally considered to be of equivalent credit quality. Include generally, an employer may designate two or more separate
preferred equity in this category. Unrated debt with the backing plans as a single plan for purposes of applying the ratio
of a government entity would be included in the “investment- percentage test of Treasury Regulations section 1.410(b)-
grade” category unless it is generally accepted that the debt 2(b)(2) or the nondiscriminatory classification test of Treasury
should be considered as “high-yield.” Use the ratings in effect Regulations section 1.410(b)-4. Two or more plans that are
as of the end of the plan year. Include the market value (not permissively aggregated and treated as a single plan for
notional value) of interest rate swaps, futures and other purposes of the minimum coverage test of Code section 410(b)
derivates designed to be interest rate sensitive in this category. must also be treated as a single plan for purposes of the
● High-Yield Debt – Debt securities not included in Investment- nondiscrimination test under Code section 401(a)(4). See
Grade Debt as described above or in Cash and Cash Treasury Regulations sections 1.410(b)-7(d) and 1.401(a)(4)-
Equivalents as described below. Include the approximate (9)(a) for more information.
portion of the mutual funds or collective trusts invested in high- Line 21b. A multiple-employer plan or a pooled employer plan
yield debt securities. can skip this question. Check the applicable method used to
● Real Assets - Direct ownership, co-investments, or shares of satisfy the nondiscrimination requirements of Code section
funds with direct ownership in income-producing assets such 401(k). A safe harbor 401(k) plan is similar to a traditional
as real estate, infrastructure, or land (e.g., farmland or 401(k) plan, but it must provide for employer contributions.
timberland). Real estate investment trusts (REITs) should be These contributions may be employer matching contributions,
included with Public Equity. limited to employees who defer, or employer contributions
made on behalf of all eligible employees, regardless of whether
● Cash and Cash Equivalents – Non-interest-bearing cash they make elective deferrals. A safe harbor 401(k) plan is not
(Schedule H item 1(a)) and accounts at financial institutions subject to the complex annual nondiscrimination tests that
that earn interest (Schedule H item 1(c)(1)). apply to traditional 401(k) plans.
● Other – Any investments not included in the categories as Check "Design-based safe harbor method" if this is a safe
described above, such as hedge funds, commodities, and harbor 401(k) plan, that is, a SIMPLE 401(k) plan under Code
collectibles. section 401(k)(11), a safe harbor 401(k) plan under Code
Line 19b. Check the box that shows the average duration of section 401(k)(12), or a qualified automatic contribution
the plan’s combined investment-grade debt and interest rate arrangement under Code section 401(k)(13). If the plan, by its
hedging assets portfolio. If the average duration falls exactly on terms, does not satisfy the safe harbor method, it generally
the boundary of two boxes, check the box with the lower must satisfy the regular nondiscrimination test, known as the
duration. To determine the average duration, use the “effective actual deferral percentage (ADP) test.
duration” or any other generally accepted measure of duration. Check the appropriate box to indicate if the plan uses the
If debt instruments are held in multiple debt portfolios, report "current year" ADP test or the "prior year" ADP test.
the weighted average of the average durations of the various
portfolios where the weights are the dollar values of the Check "current year" ADP test if the plan uses the current
individual portfolios. year testing method under which the ADP test is performed by
comparing the current plan year's ADP for highly compensated
Line 20. This line must be completed for all single-employer employees (HCEs) with the current plan year's (rather than the
defined benefit plans that are covered by PBGC. prior plan year's) ADP for nonhighly compensated employees
Line 20a. If the amount reported on Schedule SB (Form 5500) (NHCEs).
line 40 is greater than $0, check the “Yes” box and complete Check all boxes that apply for a plan that tests different
line 20b. Otherwise, check “No” and skip line 20b. groups of employees on a disaggregated basis or uses
Line 20b. In general, a PBGC-insured single-employer plan different testing methods for different portions of the plan. For
must notify PBGC if a required contribution is not made by its example, a plan that allows for immediate eligibility for elective
due date. With the exception of situations where the deferrals and statutory eligibility for safe harbor contributions
accumulated value of missed contributions exceeds $1 million, would be a safe harbor plan for statutory employees. However,
PBGC waives reporting if contributions equal to or exceeding the plan would be subject to ADP testing for non-statutory
the missed amount are made by the 30 day after the due th employees.
date. For more information, see 29 CFR 4043.25 and 4043.81 Check "N/A" if the plan is not required to test for
and the filing instructions for PBGC Forms 10 and 200. nondiscrimination under Code section 401(k)(3), such as a

Instructions for Schedule R (Form 5500) -77-

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plan in which no HCE is benefiting. word-for-word identical to, or a minor modification of, a plan of
Line 22. If a plan sponsor or an employer adopted a Pre- a Mass Submitter. If a plan was modified in such a way that
approved Plan that had received a favorable IRS Opinion negates the Opinion Letter, then the plan sponsor is no longer
Letter, enter the date of the most recent favorable Opinion an Adopting Employer of a Pre-approved Plan, and the plan is
Letter issued by the IRS and the Opinion Letter serial number treated as an individually designed plan. An “Opinion Letter” is
listed on the letter. A “Pre-approved Plan” is a plan approved a written statement issued by the IRS to a Provider or Mass
by the IRS with a favorable Opinion Letter that is made Submitter as an opinion on the qualification in form of a plan
available by a Provider for adoption by employers, including a under Code section 401(a), Code section 403(a), or both Code
standardized plan or a nonstandardized plan. A Pre-approved sections 401(a) or 403(a) and 4975(e)(7). See Revenue
Plan may utilize either of two forms: a basic plan document Procedure 2017-41 for more information. The Opinion Letter
with an adoption agreement or a single plan document. The serial number is a unique combination of a capital letter and a
employer is permitted to make minor modifications to the plan. series of six numbers assigned to each Opinion Letter.
An “Adopting Employer” is an employer that adopts a Pre-
approved Plan offered by a Provider, including a plan that is

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Note. This schedule is not filed for a multiemployer plan nor for
2023 Instructions for Schedule SB a money purchase defined contribution plan (including a target
(Form 5500) benefit plan) for which a waiver of the minimum funding
requirements is currently being amortized. Information for
Single-Employer Defined Benefit Plan these plans must be filed using Schedule MB (Form 5500).
Actuarial Information Specific Instructions

Lines A through F. Identifying Information. Lines A – F
General Instructions must be completed for all plans. Lines A through D should
Note. To the extent that regulations and other items of include the same information as reported in corresponding
published guidance under Code sections 430 and 436 do not lines in Part II of the Form 5500, Form 5500-SF, or Form 5500-
take into account statutory changes since those regulations EZ filed for the plan. You may abbreviate the plan name (if
were issued, plan sponsors must take into account the necessary) to fit in the space provided.
provisions of the Worker, Retiree, and Employer Recovery Act Do not use a social security number in line D instead of an
of 2008 (“WRERA”), Pub. L. No. 110-458, the Preservation of EIN. The Schedule SB and its attachments are open to public
Access to Care for Medicare Beneficiaries and Pension Relief inspection if filed with a Form 5500 or Form 5500-SF, and the
Act of 2010 (“PRA 2010”), Pub. L. No. 111-192, Moving Ahead contents are public information and are generally subject to
for Progress in the 21 Century Act (“MAP-21”), Pub. L. No. st
publication on the Internet. Because of privacy concerns, the
112-141, the Cooperative and Small Employer Charity Pension inclusion of a social security number or any portion thereof on
Flexibility Act of 2014 (“CSEC Act”), Pub. L. No. 113-97, the the Schedule SB or any of its attachments may result in the
Highway and Transportation Funding Act of 2014 (HATFA), rejection of the filing.
Pub. L. No. 113-159, and the Bipartisan Budget Act of 2015
(BBA’15), Pub. L. No. 114-74, and any other amendments to You can apply for an EIN from the IRS online, by fax, or by
the funding rules that are enacted. mail depending on how soon you need to use the EIN. For
more information, see Section 3: Electronic Filing Requirement
Who Must File under General Instructions to Form 5500. The EBSA does not
As the first step, the plan administrator of any single-employer issue EINs.
defined benefit plan (including a multiple-employer defined Line E. Type of Plan. Check the applicable box to indicate the
benefit plan) that is subject to the minimum funding standards type of plan. A single-employer plan for this reporting purpose
(see Code section 412 and Part 3 of Title I of ERISA) must is an employee benefit plan maintained by one employer or
obtain a completed Schedule SB (including attachments) that one employee organization. A multiple-employer plan is a plan
is prepared and signed by the plan’s enrolled actuary as that is maintained by more than one employer, but is not a
discussed below in the Statement by Enrolled Actuary section. multiemployer plan. (See the Instructions for Form 5500, box A
The plan administrator must retain with the plan records the for additional information on the definition of a multiemployer
Schedule SB that is prepared and signed by the plan’s actuary. plan.)
Next, the plan administrator must ensure that the ● Check “Single” if the Form 5500, Form 5500-SF, or Form
information from the actuary’s Schedule SB is entered 5500-EZ is filed for a single-employer plan (including a plan
electronically into the annual return/report being submitted. maintained by more than one member of the same controlled
When entering the information, whether using EFAST2- group).
approved software or EFAST2’s web-based filing system, all ● Check “Multiple-A” if the Form 5500 or Form 5500-SF is
the fields required for the type of plan must be completed (see being filed for a multiple-employer plan and the plan is subject
instructions for fields that need to be completed). to the rules of Code section 413(c)(4)(A) (i.e., it is funded as if
Further, the plan administrator of a single-employer defined each employer were maintaining a separate plan). This
benefit plan must attach to the Form 5500 or Form 5500-SF an includes plans established before January 1, 1989, for which
electronic reproduction of the Schedule SB (including an election was made to fund in accordance with Code section
attachments) prepared and signed by the plan’s enrolled 413(c)(4)(A).
actuary. This electronic reproduction must be labeled “SB ● Check “Multiple-B” if the Form 5500 or Form 5500-SF is
Actuary Signature” and must be included as a Portable being filed for a multiple-employer plan and the plan is subject
Document Format (PDF) attachment or any alternative to the rules of Code section 413(c)(4)(B) (i.e., it is funded as if
electronic attachment allowable under EFAST2. all participants were employed by a single employer).
Note. The Schedule SB (Form 5500) does not have to be filed If “Multiple-A” is checked, with the exception of Part III, the
with the Form 5500-EZ regardless of whether it is filed on data entered on Schedule SB should be the sum of the
paper with the IRS or electronically with EFAST2, but it must individual amounts computed for each employer. The
be retained in accordance with the Instructions for Form 5500- percentages reported in Part III should be calculated based on
EZ under the What to File section. The enrolled actuary must the reported aggregate numbers rather than by summing up
complete and sign the Schedule SB and forward it to the the individual percentages. The Schedule SB data for each
person responsible for filing the Form 5500-EZ, even if the employer’s portion of the plan must be submitted as an
Schedule SB is not filed. attachment. This is accomplished by completing and attaching
Check the Schedule SB box on the Form 5500 (Part II, line a Schedule SB for each employer or by attaching a document
10a(3)) if a Schedule SB is attached to Form 5500. Check containing that information (e.g., a table showing a row for
“Yes” on line 11 in Part VI of the Form 5500-SF if a Schedule each Schedule SB data item and a column for each
SB is required to be prepared for the plan, even if Schedule SB employer). Label the attachment “Schedule SB – Information
is not required to be attached to Form 5500-SF (see for Each Individual Employer.”
instructions in the Note above, pertaining to “one-participant Line F. Prior Year Plan Size. Check the applicable box based
plans”). on the highest number of participants (both active and inactive)

Instructions for Schedule SB (Form 5500) -79-

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on any day of the preceding plan year, taking into account                 Accordingly, the Schedule SB is not required to be filed for any 
participants in all defined benefit plans maintained by the same           later plan year. However, if a termination fails to occur — 
employer (or any member of such employer’s controlled group)               whether because assets remain in the plan’s related trust (see 
who are or were also employees of that employer or member.                 Revenue Ruling 89-87, 1989-2 C.B. 81) or for any other 
For this purpose, participants whose only defined benefit plan             reason (e.g., the PBGC issues a notice of noncompliance 
is a multiemployer plan (as defined in Code section 414(f)) are            pursuant to 29 CFR section 4041.31 for a standard 
not counted, and participants who are covered in more than                 termination) — there is no termination date, and therefore, 
one of the defined benefit plans described above are counted               minimum funding standards continue to apply and a Schedule 
only once. Inactive participants include vested terminated and             SB continues to be required. 
retired employees as well as beneficiaries of deceased                     Statement by Enrolled Actuary 
participants. If this is the first plan year that a plan described in 
this paragraph exists, complete this line based on the highest             An enrolled actuary must sign Schedule SB. The signature of 
number of participants that the plan was reasonably expected               the enrolled actuary may be qualified to state that it is subject 
to have on any day during the first plan year.                             to attached qualifications. See Treasury Regulations section 
                                                                           301.6059-1(d) for permitted qualifications. If the actuary has 
General Instructions, Parts I through IX, Statement                        not fully reflected any final or temporary regulation, revenue 
by Enrolled Actuary, and Attachments                                       ruling, or notice promulgated under the statute in completing 
Except as noted below, Parts I through VIII must be completed              the Schedule SB, check the box on the last line of page 1. If 
for all single and multiple-employer defined benefit plans,                this box is checked, indicate on an attachment whether any 
regardless of size or type. See instructions for line 27 for               unpaid required contribution or a contribution that is not wholly 
additional information to be provided for certain plans with               deductible would result if the actuary had fully reflected such 
special circumstances. Part IX is completed for those plans for            regulation, revenue ruling, or notice, and label this attachment 
which the extended amortization rule, under the American                   “Schedule SB – Statement by Enrolled Actuary.” In 
Rescue Plan Act of 2021, was elected to apply before the 2022              addition, the actuary may offer any other comments related to 
plan year.                                                                 the information contained in Schedule SB. Except as otherwise 
  PPA provides funding relief for certain defined benefit plans            provided in these instructions, a stamped or machine produced 
(other than multiemployer plans) maintained by a commercial                signature is not acceptable. 
passenger airline or by an employer whose principal business                The actuary must provide the completed and signed 
is providing catering services to a commercial passenger                   Schedule SB to the plan administrator to be retained with the 
airline, based on an alternative 17-year funding schedule.                 plan records and included (in accordance with these 
Plans using this funding relief do not need to complete the                instructions) with the Form 5500 or Form 5500-SF that is 
entire Schedule SB, but are required to provide supplemental               submitted under EFAST2. The plan’s actuary is permitted to 
information as an attachment to Schedule SB. See the                       sign the Schedule SB on page one using the actuary’s 
instructions for line 27 for more information about which lines            signature or by inserting the actuary’s typed name in the 
of Schedule SB need to be completed and what additional                    signature line followed by the actuary’s handwritten initials. 
attachments are required.                                                  The actuary’s most recent enrollment number must be entered 
  Code section 430(h)(2)(C)(iv) and ERISA section                          on the Schedule SB that is prepared and signed by the plan’s 
302(h)(2)(C)(iv) provide that, for certain purposes, each of the           actuary. 
three segment rates described in those sections is adjusted as             Attachments 
necessary to fall within a specified range that is determined              All attachments to the Schedule SB must be properly identified 
based on an average of the corresponding segment rates for                 as attachments to the Schedule SB, and must include the 
the 25-year period ending on September 30 of the calendar                  name of the plan, plan sponsor’s EIN, plan number, and line 
year preceding the first day of the plan year. Accordingly, if the         number to which the schedule relates. 
funding target and target normal cost for a plan are determined 
using the segment rates, the segment rates used to determine                Do not include attachments that contain a visible social 
the minimum required contribution and the adjusted funding                 security number. Except for certain one-participant plans, the 
target attainment percentage (“AFTAP”) used to apply funding-              Schedule SB and its attachments are open to public 
based benefit restrictions under Code section 436 and ERISA                inspection, and the contents are public information and are 
section 206(g) may be different from those used for other                  subject to publication on the Internet. Because of privacy 
purposes (such as the segment rates used to determine the                  concerns, the inclusion of a visible social security number or 
deductible limit under Code section 404(o)). In such cases,                any portion thereof on an attachment may result in the  
report all information on Schedule SB reflecting the                       rejection of the filing. 
assumptions used to determine the minimum required                          The first year Schedule SB attachment for a plan 
contribution and the AFTAP used to apply funding-based                     retroactively adopted pursuant to SECURE Act section 201. If 
benefit restrictions.                                                      a plan sponsor adopted a defined benefit pension plan in 2023 
Note. (1) For a plan funded with insurance (other than a plan              (i.e., by the due date, including extension, for filing the plan 
described in Code section 412(e)(3) or ERISA section 301(b)),              sponsor’s tax return for the 2022 taxable year) and elected to 
refer to section 1.430(d)-1(c)(2) of the Income Tax Regulations            treat the plan as having been adopted before the 2023 plan 
regarding whether to include the liabilities for benefits covered          year began as permitted under SECURE Act section 201, then 
under insurance contracts held by the plan and whether to                  the enrolled actuary must complete and sign the 2022 
include the value of the insurance contracts in plan assets.               Schedule SB (Form 5500). If the plan sponsor is required to 
                                                                           file Schedule SB (see instructions for Schedule SB under “Who 
 (2) For terminating plans, Revenue Ruling 79-237, 1979-2                  Must File”), attach the 2022 Schedule SB (Form 5500) as a 
C.B. 190, provides that minimum funding standards apply until              Portable Document Format (PDF) attachment to the 2023 
the end of the plan year that includes the termination date.               Schedule SB when filing the 2023 Form 5500. Label the 

                                                                      -80-             Instructions for Schedule SB (Form 5500)

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attachment “The first year Schedule SB attachment for a plan           Note. Under Code section 430(g)(3)(B), the use of averaging 
retroactively adopted pursuant to SECURE Act 201”.                     methods in determining the value of plan assets is permitted 
Part I – Basic Information                                             only in accordance with methods prescribed in Treasury 
                                                                       regulations. Accordingly, taxpayers cannot use asset valuation 
Note. All entries in Part I must be reported as of the valuation       methods other than fair market value (as described in Code 
date, reflecting the assumptions and amounts generally used            section 430(g)(3)(A)), except as provided under Notice 2009-
to determine the minimum required contribution. In the case of         22, 2009-14 IRB 741, or Treasury regulations.  
a plan described in section 104 of PPA, the information should 
be reported as if PPA provisions were effective for all plan           Line 3. Funding Target/Participant Count Breakdown. All 
years beginning after December 31, 2007.                               amounts should be reported as of the valuation date.  
Line 1. Valuation Date. The valuation date for a plan year               Column (1)—Enter the number of participants in each 
must be the first day of the plan year unless the plan meets the       category (e.g., terminated vested participants). Enter “0” if no 
small-plan exception of Code section 430(g)(2)(B) and ERISA            participants fall into the category. Include beneficiaries of 
section 303(g)(2)(B). For plans that qualify for the exception,        deceased participants who are or who will be entitled to 
the valuation date may be any date in the plan year, including         benefits under the plan. 
the first or last day of the plan year.                                  Column (2)—Enter the portion of the funding target 
 A plan qualifies for this small-plan exception if there were          attributable to vested benefits. If no portion of the funding 
100 or fewer participants on each day of the prior plan year.          target for a particular category is attributable to vested 
For the definition of participant as it applies in this case, see      benefits, enter “0.” For this purpose, benefits considered to be 
the instructions for line F.                                           vested for PBGC premium purposes must be included.  
Line 2a. Market Value of Assets. Enter the fair market value             Column (3)—Enter the funding target attributable to all 
of assets as of the valuation date. Include contributions              benefits, both vested and nonvested. Enter “0” if no portion of 
designated for any previous plan year that are made after the          the funding target is for participants in a particular category.  
valuation date (but within the 8½-month period after the end of        For columns (2) and (3), the funding target must be calculated 
the immediately preceding plan year), adjusted for interest for        using the methods and assumptions provided in Code sections 
the period between the date of payment and the valuation date          430(h) and (i), ERISA sections 303(h) and (i), and other related 
as provided in the applicable regulations.                             guidance. 
 Contributions made for the current plan year must be                   Unless the plan sponsor has received approval to use 
excluded from the amount reported in line 2a. If these                 substitute mortality tables in accordance with Code section 
contributions were made prior to the valuation date (which can         430(h)(3)(C) and ERISA section 303(h)(3)(C), the funding 
only occur for small plans with a valuation date other than the        target must be computed using the mortality tables for non-
first day of the plan year), the asset value must be adjusted to       disabled lives, as described in section 1.430(h)(3)-1 of the 
exclude not only the contribution amounts, but interest on the         regulations. If substitute mortality tables have been approved 
contributions from the date of payment to the valuation date,          (or deemed to have been approved) by the IRS, such tables 
using the current-year effective interest rate.                        must be used instead of the mortality tables described in the 
 Do not adjust for items such as the funding standard                  previous sentence, subject to the rules of Code section 
carryover balance, prefunding balance, any unpaid minimum              430(h)(3) and ERISA section 303(h)(3). The funding target 
required contributions, or the present value of remaining              may be computed taking into account the mortality tables for 
shortfall or waiver amortization installments. Rollover amounts        disabled lives published in Revenue Ruling 96-7, 1996-1 C.B. 
or other assets held in individual accounts that are not               59, and as provided in Notice 2008-29, 2008-12 IRB 637. 
available to provide defined benefits under the plan should not         Special rules for plans that are in at-risk status. If a plan 
be included on line 2a regardless of whether they are reported         is in at-risk status, report the amount reflecting the additional 
on the Schedule H (Form 5500) (line 1l, column (a)) or                 assumptions required in Code section 430(i)(1)(B) and ERISA 
Schedule I (Form 5500) (line 1c, column (a)), or Form 5500-SF          section 303(i)(1)(B). 
(line 7c, column (a)). Additionally, asset and liability amounts        If the plan has been in at-risk status for any two or more of 
must be determined in a consistent manner. Therefore, if the           the preceding four plan years, also include the loading factor 
value of any insurance contracts has been excluded from the            required in Code section 430(i)(1)(C) and ERISA section 
amount reported in line 2a, liabilities satisfied by such              303(i)(1)(C). If the plan is in at-risk status and has been in at-
contracts should also be excluded from the funding target              risk status for fewer than five consecutive years, report the 
values reported in lines 3 and 4.                                      funding target amounts after reflecting the transition rule 
Line 2b. Actuarial Value of Assets. Do not adjust the                  provided in Code section 430(i)(5) and ERISA section 
actuarial value of assets for items such as the funding                303(i)(5). For example, the funding target for a plan that is in 
standard carryover balance, the prefunding balance, any                at-risk status for 2023 and was in at-risk status for the 2020, 
unpaid minimum required contributions, or the present value of         2021 and 2022 plan years (but not the 2019 plan year) will 
any remaining shortfall or waiver amortization installments.           reflect 80% of the funding target using the special at-risk 
Treat contributions designated for a current or prior plan year,       assumptions and 20% of the funding target determined without 
rollover amounts, insurance contracts, and other items in the          regard to the at-risk assumptions. 
same manner as for line 2a.                                             Determining whether a plan is in at-risk status. Refer to 
 If an averaging method is used to value plan assets (as               Code section 430(i)(4) and ERISA section 303(i)(4) to 
permitted under Code section 430(g)(3)(B) and ERISA section            determine whether the plan is in at-risk status. Generally, a 
303(g)(3)(B), as amended by WRERA), enter the value as of              plan is in at-risk status for a plan year if it had more than 500 
the valuation date taking into account the requirement that            participants on any day during the preceding plan year (see 
such value must be within 90% to 110% of the fair market               instructions for line F for the definition of participants) and the 
value of assets. 

Instructions for Schedule SB (Form 5500)                          -81-

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plan’s funding target attainment percentage (“FTAP”) for the obligation yield curve, the effective interest rate must reflect
preceding plan year fell below specified thresholds. both sets of rates.
A plan with over 500 participants is in at-risk status for 2023
if both: Line 6. Target Normal Cost.
 the FTAP for 2022 (line 14 of the 2022 Schedule SB) is less Line 6a. Present Value of Current Year Accruals. Enter the
than 80%, and present value of all benefits which have been accrued or have
 the at-risk funding target attainment percentage for 2022 is been earned (or that are expected to accrue or to be earned)
less than 70%. under the plan during the plan year. Include any increase in
In general, the at-risk funding target attainment percentage benefits during the plan year that is a result of any actual or
is determined in the same manner as the FTAP (as described projected increase in compensation during the current plan
in the instructions for line 14), except that the funding target is year, even if that increase in benefits is with respect to benefits
determined using the additional assumptions for plans in at- attributable to services performed in a preceding plan year.
risk status. For this purpose, the at-risk funding target is This amount must be calculated as of the valuation date and
determined by disregarding the transition rule of Code section must generally be based on the same assumptions used to
430(i)(5) and ERISA section 303(i)(5) for plans that have been determine the funding target reported in line 3c, column (3),
in at-risk status for fewer than five consecutive years, and reflecting the special assumptions and the loading factor for at-
disregarding the loading factor in Code section 430(i)(1)(C) risk plans, if applicable. If the plan is in at-risk status for the
and ERISA section 303(i)(1)(C). For plans that were in at-risk current plan year and has been in at-risk status for fewer than
status for the 2022 plan year, the at-risk funding target used to five consecutive years, report this amount after reflecting the
determine whether the plan is in at-risk status for the 2023 plan transition rule provided in Code section 430(i)(5) and ERISA
year is the amount reported in line 4b of the 2022 Schedule section 303(i)(5).
SB. Line 6b. Expected Plan-related Expenses. Enter the
Refer to the regulations under section 430(i) of the Code for aggregate amount of any plan-related expenses expected to
rules pertaining to new plans and other special situations. be paid from plan assets during the plan year.
Line 4. Additional Information for Plans in At-Risk Status. Line 6c. Target Normal Cost. Enter the sum of lines 6a and
If the plan is in at-risk status as provided under Code section 6b, reduced (but not below zero) by any mandatory employee
430(i)(4) and ERISA section 303(i)(4), check the box, complete contributions expected to be made during the plan year.
lines 4a and 4b, and include as an attachment the information Part II – Beginning of Year Carryover Prefunding
described below. Do not complete line 4 if the plan is not in at- Balances
risk status for the current plan year for purposes of determining
the minimum required contribution. Line 7. Balance at Beginning of Prior Plan Year After
Applicable Adjustments. In general, report the amount in the
● Line 4a – Enter the amount of the funding target determined corresponding columns of line 13 of the prior-year Schedule
as if the plan were not in at-risk status. SB. However, if the balance from the prior year has been
● Line 4b – Report the funding target disregarding the adjusted so that it does not match the corresponding amount in
transition rule of Code section 430(i)(5) and ERISA section line 13 of the prior-year Schedule SB, attach an explanation
303(i)(5), and disregarding the loading factor in Code section and label the attachment “Schedule SB, line 7 – Explanation
430(i)(1)(C) and ERISA section 303(i)(1)(C). of Discrepancy in Prior Year Funding Standard Carryover
If the plan is in at-risk status for the current plan year, attach Balance or Prefunding Balance.” Note that elections to add
a description of the at-risk assumptions for the assumed form excess contributions or reduce balances have specific
of payment (e.g., the optional form resulting in the highest deadlines, and generally cannot be changed once they have
present value). Label the attachment “Schedule SB, line 4 – been made.
Additional Information for Plans in At-Risk Status.” If this is the first year for which the plan is subject to the
Line 5. Effective Interest Rate. Enter the single rate of minimum funding rules of Code section 430 or ERISA section
interest which, if used instead of the interest rate(s) reported in 303, leave both columns blank.
line 21 to determine the present value of the benefits that are Line 8. Portion Elected for Use To Offset Prior Year’s
taken into account in determining the plan’s funding target for a Funding Requirement. Report the amount for each column
plan year, would result in an amount equal to the plan’s from the corresponding column of line 35 of the prior-year
funding target determined for the plan year, without regard to Schedule SB. If the valuation date is not the first day of the
calculations for plans in at-risk status. (This is the funding plan year, report the amounts from line 35 of the prior-year
target reported in line 3d, column (3) for plans not in at-risk Schedule SB, discounted to the beginning of the prior plan
status, or in line 4a for plans in at-risk status.) However, if the year using the effective interest rate for the prior plan year.
funding target for the plan year is zero, the effective interest
rate is determined as the single rate that would result in an Reflect the full amount reported in line 35 of the prior-year
amount equal to the plan’s target normal cost determined for Schedule SB even if the amount is larger than the minimum
the plan year, without regard to calculations for plans in at-risk required contribution reported for that year on line 34 of the
status. See the provisions of Code section 430(h)(2)(A), prior-year Schedule SB. This can occur under the special rule
ERISA section 303(h)(2)(A), and the applicable regulations. for elections to use balances in excess of the minimum
Enter rate to the nearest .01% (e.g., 5.26%). required contribution under section 1.430(f)-1(f)(1)(ii) of the
regulations, if no timely election is made to revoke the excess
If the funding target calculation includes some benefits for amount.
which the present value is calculated using the 8.00% segment
interest rates and other benefits for which present value is If this is the first year for which the plan is subject to the
calculated using the applicable United States Treasury minimum funding rules of Code section 430 or ERISA section
303, leave both columns blank.

-82- Instructions for Schedule SB (Form 5500)

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Special rule for late election to apply balances to The amount reported in line 11(b)(1) is zero if the prior
quarterly installments. If an election was made to use the year’s valuation date was the last day of the prior plan year.
funding standard carryover balance or the prefunding balance Line 11(b)(2). In column (b), enter the product of the prior
to offset the amount of a required quarterly installment, but the year’s actual rate of return (from line 10) and the present value
election was made after the due date of the installment, the of excess contributions reported on line 38b for the prior year.
amount reported on line 8 may not be the same as the amount
reported on line 35 for the prior year. Refer to the regulations However, if the valuation date for the prior plan year was
under section 430 of the Code for additional information. An not the first day of the plan year (permitted for small plans
attachment to Schedule SB should explain why the amount is only), enter the result of the following calculation:
different. Label the attachment “Schedule SB, line 8 – Late Step 1: Adjust the prior-year amount reported in line 38b
Election to Apply Balances to Quarterly Installments.” to the first day of the prior year, using the effective interest rate
Line 9. Amount Remaining. Enter the amount equal to line 7 for the prior year,
minus line 8 in each column. Step 2: Multiply the result in Step 1 by the prior year’s
If this is the first year that the plan is subject to the minimum actual rate of return (from line 10), and
funding requirements of Code section 430 or ERISA section Step 3: Reduce the result in Step 2 by interest on the
303, enter the amount of any credit balance at the end of the result in Step 1 for the period between the first day of the
prior year (the “pre-effective plan year”) on line 9, column (a) prior plan year and the prior-year valuation date using the
and leave line 9, column (b) blank. The amount entered on line effective interest rate for the prior year.
9, column (a) is generally the amount reported for the pre- Line 11c. Enter the sum of lines 11a, 11b(1) and 11(b)(2).
effective plan year on line 9o of the 2007 version of the Line 11d. Enter the amount of the excess contributions for the
Schedule B form that was submitted as an attachment to the prior year (with interest) that the plan sponsor elected to use to
Schedule SB for that pre-effective plan year. If there has been increase the prefunding balance. This amount cannot be
any adjustment to this amount so that it does not match the greater than the amount reported on line 11c.
amount so reported for the pre-effective plan year, attach an
explanation and label the attachment “Schedule SB, line 9 – If this is the first year for which the plan is subject to the
Explanation of Credit Balance Discrepancy.” minimum funding rules of Code section 430 or ERISA section
303, leave lines 11a–d blank.
Line 10. Interest on Line 9. Enter the actual rate of return on
plan assets during the preceding plan year in the space Line 12. Other Reductions in Balances Due to Elections or
provided. Enter the rate to the nearest .01% (e.g., 6.53%). If Deemed Elections. In each column, enter the amount by
entering a negative number, enter a minus sign (“–”) to the left which the employer elects to reduce (or is deemed to elect to
of the number. In each column, enter the product of this reduce, per Code section 436(f)(3) and ERISA section
interest rate and the amount reported in the corresponding 206(g)(5)(C)) the funding standard carryover balance or
column of line 9. prefunding balance, as applicable, under Code section 430(f)
and ERISA section 303(f), other than any amount reported in
If this is the first year for which the plan is subject to the line 8 that is treated as a reduction in these balances under the
minimum funding rules of Code section 430 or ERISA section special rule in section 1.430(f)-1(f)(3)(ii) (relating to amounts
303, leave both columns blank. elected for use to offset the minimum required contribution that
Line 11. Prior Year’s Excess Contributions to be Added to exceed the minimum required contribution for the plan for the
Prefunding Balance. plan year, and which are not revoked by the plan sponsor).
Line 11a. Enter the amount reported in line 38a on the This amount cannot be greater than the sum of the amounts
Schedule SB for the prior plan year. reported in the corresponding column of lines 9, 10 and, if
Line 11b(1). Enter the effective interest rate for the prior plan applicable, 11d. Note that an election (or deemed election)
year, as reported on line 5 of the Schedule SB for the prior cannot be made to reduce the prefunding balance in column
plan year, in the space provided. Enter the rate to the nearest (b) until the funding standard carryover balance in column (a)
.01% (e.g., 6.35%). has been reduced to zero.
In column (b), enter the product of the prior year’s effective If the valuation date is not the first day of the plan year,
interest rate in line 11b(1) and the excess (if any) of the adjust the amounts reported in line 12 to the first day of the
amount reported on line 38a for the prior year over the amount plan year, using the effective interest rate for the current plan
reported on line 38b for the prior year. year. If the plan did not exist in the prior year and is not a
successor plan, leave both columns blank.
However, if the valuation date for the prior plan year was
not the first day of the plan year (permitted for small plans If this is the first year for which the plan is subject to the
only), enter the result of the following calculation: minimum funding rules of Code section 430 or ERISA section
303, leave column (b) blank.
Step 1: Determine the excess (if any) of the amount
reported on line 38a for the prior year over the amount Line 13. Balance at Beginning of Current Year.
reported on line 38b for the prior year, ● Column (a) - Enter the sum of the amounts reported on lines
Step 2: Adjust the result in Step 1 to the first day of the 9 and 10 of column (a), minus the amount reported on line 12
prior year using the effective interest rate for the prior year, of column (a).
● Column (b) - Enter the sum of the amounts reported on lines
Step 3: Multiply the result in Step 2 by the prior year’s 9, 10 and 11d of column (b), minus the amount reported on
effective interest rate in line 11(b)(1), and line 12 of column (b).
Step 4: Reduce the result in Step 3 by interest on the If this is the first year for which the plan is subject to the
result in Step 2 of this paragraph for the period between the minimum funding rules of Code section 430 or ERISA section
first day of the prior plan year and the prior-year valuation date 303, leave column (b) blank.
using the effective interest rate for the prior year.

Instructions for Schedule SB (Form 5500) -83-

- 84 -

Part III – Funding Percentages                                             each AFTAP that was certified or recertified for the plan year, 
Enter all percentages in this section by truncating at .01%                the date of the certification (or recertification), and a 
(e.g., report 82.649% as 82.64%).                                          description and the amount of each adjustment to the funding 
                                                                           target, actuarial value of assets, funding standard carryover 
Line 14. Funding Target Attainment Percentage. Enter the                   balance and prefunding balance used to determine the 
funding target attainment percentage (FTAP) determined in                  corresponding AFTAP. Label the attachment, “Line 15, 
accordance with Code section 430(d)(2) and ERISA section                   Reconciliation of differences between valuation results 
303(d)(2). The FTAP is the ratio (expressed as a percentage)               and amounts used to calculate AFTAP.” It is not necessary 
which the actuarial value of plan assets (reduced by the                   to include any information pertaining to a range certification in 
funding standard carryover balance and prefunding balance)                 this attachment. 
bears to the funding target determined without regard to the 
additional rules for plans in at-risk status.                              Line 16. Prior Year’s Funding Percentage for Purposes of 
                                                                           Determining Whether Carryover/Prefunding Balances May 
 This percentage is determined by subtracting the sum of                   Be Used to Offset Current Year’s Funding Requirement. 
the amounts reported in line 13 from line 2b and dividing the              Under Code section 430(f)(3) and ERISA section 303(f)(3), the 
result by the funding target. The funding target used for this             funding standard carryover balance and prefunding balance 
purpose is the number reported in line 3d, column (3) for plans            may not be applied toward minimum contribution requirements 
that are not in at-risk status and line 4a for plans that are in at-       unless the ratio of plan assets for the preceding plan year to 
risk status. If the plan’s valuation date is not the first day of the      the funding target for the preceding plan year (as described in 
plan year, subtract the sum of the amounts reported in line 13,            Code section 430(f)(3)(C) and ERISA section 303(f)(3)(C)) is 
adjusted for interest between the beginning of the plan year               80% or more. 
and the valuation date using the effective interest rate for the 
current plan year, from the amount reported in line 2b; and                 Enter the applicable percentage as described below, 
divide by the funding target.                                              truncated at .01% (e.g., report 81.239% as 81.23%). In 
                                                                           general, the percentage is the ratio that the prior-year actuarial 
Line 15. Adjusted Funding Target Attainment Percentage.                    value of plan assets (reduced by the amount of any prefunding 
Enter the adjusted funding target attainment percentage                    balance, but not the funding standard carryover balance) bears 
(AFTAP) determined in accordance with Code section 436(j)(2)               to the prior-year funding target determined without regard to 
and ERISA section 206(g)(9)(B). The AFTAP is calculated in                 the additional rules for plans in at-risk status. This percentage 
the same manner as the FTAP reported in line 14, except that               is determined as follows, with all amounts taken from the prior 
both the assets and the funding target used to calculate the               year’s Schedule SB: 
AFTAP are increased by the aggregate amount of purchases 
of annuities for employees other than highly compensated                   ● For plans that are not in at-risk status, subtract the amount 
employees (as defined in Code section 414(q)) which were                   reported on line 13, column (b) (adjusted for interest as 
made by the plan during the preceding two plan years.                      described below, if the valuation date is not the first day of the 
                                                                           plan year) from the amount reported on line 2b, and divide the 
 See Code section 436(j)(3) and ERISA section 206(g)(9)(C)                 result by the funding target reported on line 3d, column (3). 
for rules regarding circumstances in which the actuarial value             ● For plans that are in at-risk status, subtract the amount 
of plan assets is not reduced by the funding standard carryover            reported on line 13, column (b) (adjusted for interest as 
balance and prefunding balance for certain fully-funded plans              described below, if the valuation date is not the first day of the 
when determining the AFTAP. Note that this special rule                    plan year) from the amount reported on line 2b, and divide the 
applies only to the calculation of the AFTAP and not to the                result by the funding target reported on line 4a.  
FTAP reported in line 14. 
                                                                            If the valuation date for the prior plan year was not the 
 Report the final certified AFTAP for the plan year, even if it            first day of that plan year, the amount subtracted from the 
does not correspond to the valuation results reported on this              assets for the purpose of the above calculations is the amount 
Schedule SB (for instance, if any adjustments pertaining to the            reported on line 13, column(b), adjusted for interest between 
plan year were made subsequent to the valuation or the                     the beginning of the prior plan year and the prior year’s 
AFTAP). If no AFTAP was certified for the plan year, attach an             valuation date, using the effective interest rate for the prior 
explanation and (1) report 100%, if the plan's adjusted funding            plan year. 
target for the plan year is zero, as described in section 1.436-
1(j)(1)(iv) of the Treasury regulations, or (2) leave line 15 blank        Line 17. Ratio of Current Value of Assets to Funding 
if the plan's adjusted funding target for the plan year is not             Target if Below 70%. This calculation is required under ERISA 
equal to zero. Label the attachment, "Line 15, Reconciliation              section 103(d)(11). If line 2a divided by the funding target 
of differences between valuation results and amounts                       reported in line 3d, column (3), is less than 70%, enter such 
used to calculate AFTAP.” For plans with valuation dates                   percentage. Otherwise, leave this line blank. 
other than the first day of the plan year, report the AFTAP that           Part IV – Contributions and Liquidity Shortfalls 
is the final certified AFTAP based on the valuation results for            Line 18. Contributions Made to the Plan. Show all employer 
the current plan year at the time that the Schedule SB is filed            and employee contributions either designated for this plan year 
(reflecting contributions for the current plan year and reflecting         or those allocated to unpaid minimum required contributions 
other adjustments as described in applicable guidance), even if            for a prior plan year. Do not adjust contributions to reflect 
that AFTAP is not used to apply the restrictions under Code                interest. Show only employer contributions actually made to 
section 436 and ERISA section 206(g) until the following plan              the plan within 8½ months after the end of the plan year for 
year.                                                                      which this Schedule SB is filed (or actually made before the 
 If the AFTAP reported on line 15 does not correspond to                   Schedule SB is signed, if earlier). 
the valuation results reported on this Schedule SB (for                     Certain employer contributions must be made in quarterly 
instance, if any adjustments pertaining to the plan year were              installments. See Code section 430(j) and ERISA section 
made subsequent to the valuation), attach a schedule showing               303(j). Contributions made to meet the liquidity requirement of 

                                                                      -84-                  Instructions for Schedule SB (Form 5500)

- 85 -

Code section 430(j)(4) and ERISA section 303(j)(4) should be             adjustments for late quarterly contributions for quarterly 
reported. Include contributions made to avoid benefit                    contributions due before the valuation date. 
restrictions under Code section 436 and ERISA section 206(g).            Line 19a. Contributions Allocated Toward Unpaid 
Add the amounts in both columns 18(b) and 18(c)                          Minimum Required Contributions from Prior Plan Years.           
separately and enter each result in the corresponding column             Under code section 4971(c)(4)(B), if a plan has an unpaid 
on the total line. All contributions except those made to avoid          minimum required contribution that has not been corrected at 
benefit restrictions under Code section 436 and ERISA section            the time a payment is made (i.e., the deadline for making the 
206(g) must be credited toward minimum funding requirements              minimum required contribution for a prior plan year had passed 
for a particular plan year.                                              and the minimum required contribution for that year was not 
Line 19. Discounted Employer Contributions. Employer                     yet paid) that payment is allocated first to plan years with 
contributions reported in line 18 that were made on a date               unpaid minimum required contributions, beginning with the 
other than the valuation date must be adjusted to reflect                earliest such plan year, and then to the minimum required 
interest for the time period between the valuation date for the          contribution for the current plan year. Within a given plan year, 
plan year to which the contribution is allocated and the date            payments are credited first to the earliest unpaid installment 
the contribution was made. In general, adjust each contribution          until the minimum required contribution for that plan year is 
using the effective interest rate for the plan year to which the         satisfied. Report any contributions from line 18 that are 
contribution is allocated, as reported on line 5.                        allocated toward unpaid minimum required contributions from 
                                                                         prior plan years, discounted for interest from the date the 
Allocate the interest-adjusted employer contributions to                 contribution was made to the valuation date for the plan year 
lines 19a, 19b, and 19c to report the purpose for which they             for which the contribution was originally required as described 
were made (as described below).                                          above. Increase the effective interest rate for the applicable 
Attach a schedule showing the dates and amounts of                       plan year by 5 percentage points for any portion of the unpaid 
individual contributions, the year to which the contributions (or        minimum required contribution that represents a late quarterly 
the portion of individual contributions) are applied, the interest       installment, for the period between the due date for the 
rate(s) used to adjust the contributions (i.e., the effective            installment and the date of payment. Reflect the increased 
interest rate for timely contributions and the applicable                interest rate for any portion of the unpaid minimum required 
effective interest rate plus 5% for late quarterly installments)         contribution that represents a late liquidity shortfall installment, 
and the periods during which each rate applies, and the                  for the period corresponding to the time between the date the 
interest-adjusted contribution. It is not necessary to include           installment was due and the end of the quarter during which it 
information regarding interest-adjusted contributions allocated          was due. The amount reported in line 19a cannot be larger 
toward the minimum required contribution for the current year            than the amount reported in line 28. 
(reported in line 19c) in this schedule, unless any of those             For the purpose of allocating contribution amounts to 
contributions represent late quarterly installments. However, if         unpaid minimum required contributions, any unpaid minimum 
any of the contributions reported in line 19c represent late             required contribution attributable to an accumulated funding 
quarterly installments, include all contributions reported in line       deficiency at the end of the last plan year before Code section 
19c on this schedule. Label the attachment “Schedule SB,                 430 or ERISA section 303 applied to the plan (the “pre-
line 19 –Discounted Employer Contributions.”                             effective plan year”) is treated as a single contribution due on 
Special note for small plans with valuation dates after                  the last day of the pre-effective plan year (without separately 
the beginning of the plan year. If the valuation date is after           identifying any portion of the accumulated funding deficiency 
the beginning of the plan year and contributions for the current         attributable to late quarterly installments or late liquidity 
year were made during the plan year but before the valuation             shortfall installments), and the associated effective interest rate 
date, such contributions are increased with interest to the              is deemed to be the valuation interest rate for the pre-effective 
valuation date using the effective interest rate for the current         plan year. 
plan year. These contributions and the interest calculated as            Line 19b. Contributions Made To Avoid Benefit 
described in the preceding sentence are excluded from the                Restrictions. Include in this category current year 
value of assets reported in lines 2a and 2b.                             contributions made to avoid or terminate benefit restrictions 
Interest adjustment for contributions representing late                  under Code section 436 and ERISA section 206(g). Adjust 
required quarterly installments — installments due after                 each contribution for interest from the date the contribution 
the valuation date. If the full amount of a required installment         was made to the valuation date as described above. 
due after the valuation date for the current plan year is not paid       Line 19c. Contributions Allocated Toward Minimum 
by the due date for that installment, increase the effective             Required Contribution for Current Year. Include in this 
interest rate used to discount the contribution by 5 percentage          category contributions (including any contributions made in 
points for the period between the due date for the required              excess of the minimum required contribution) that are not 
installment and the date on which the payment is made. If all            included in line 19a or 19b. Adjust each contribution for interest 
or a portion of the late required quarterly installment is due to a      from the date the contribution was made to the valuation date 
liquidity shortfall, the increased interest rate is used for a           as described above. 
period of time corresponding to the period between the due 
date for the installment and the end of that quarter, regardless         Line 20. Quarterly Contributions and Liquidity Shortfalls. 
of when the contribution is actually paid.                               Line 20a. Did the Plan Have a Funding Shortfall for the 
Interest adjustment for contributions representing late                  Prior Plan Year? In accordance with Code section 430(j)(3) 
required quarterly installments — small plans with                       and ERISA section 303(j)(3), only plans that have a funding 
valuation dates after the beginning of the plan year -                   shortfall for the preceding plan year are subject to an 
installments due prior to the valuation date. See the                    accelerated quarterly contribution schedule. For this purpose, 
regulations under section 430 for rules regarding interest               a plan is considered to have a funding shortfall for the prior 
                                                                         year if the funding target reported on line 3d, column (3) is 

Instructions for Schedule SB (Form 5500)                            -85-

- 86 -

greater than the actuarial value of assets reported on line 2b,          of the funding target or the target normal cost is calculated 
reduced by the sum of the funding standard carryover balance             using the applicable United States Treasury obligation yield 
and prefunding balance reported on line 13, columns (a) and              curve. 
(b), with all figures taken from the prior year’s Schedule SB.           Line 21b. Code section 430(h)(2)(E) and ERISA section 
 If the valuation date for the prior plan year was not the first         303(h)(2)(E) provide that the segment rate(s) used to measure 
day of that plan year, the amount subtracted from the actuarial          the funding target and target normal cost are those published 
value of assets for the above calculation is the sum of the              by Treasury for the month that includes the valuation date 
amounts reported on line 13, columns (a) and (b) of the prior-           (based on the average of the monthly corporate bond yield 
year Schedule SB, but adjusted for interest between the                  curves for the 24-month period ending with the month 
beginning of the prior plan year and the prior year’s valuation          preceding that month). Alternatively, at the election of the plan 
date using the effective interest rate for the plan for the prior        sponsor, the segment rate(s) used to measure the funding 
plan year.                                                               target and target normal cost may be those published by 
 However, see Code section 430(f)(4)(B)(ii) and ERISA                    Treasury for any of the four months that precede the month 
section 303(f)(4)(B)(ii) for special rules in the case of a binding      that includes the valuation date. 
agreement with the PBGC providing that all or a portion of the           Enter the applicable month to indicate which segment rates 
funding standard carryover balance and/or prefunding balance             were used to determine the funding target and target normal 
is not available to offset the minimum required contribution for         cost. Enter “0” if the rates used to determine the funding target 
the prior plan year.                                                     and target normal cost were published for the month that 
 Please note that a plan may be considered to have a                     includes the valuation date. Enter “1” if the rates were 
funding shortfall for this purpose even if it is exempt from             published for the month immediately preceding the month that 
establishing a shortfall amortization base under the provisions          includes the valuation date, “2” for the second preceding 
of Code section 430(c)(5) and ERISA section 303(c)(5).                   month, and “3” or “4,” respectively, for the third or fourth 
                                                                         preceding months. For example, if the valuation date is 
Line 20b. If line 20a is “No” (i.e., if the plan did not have a          January 1 and the funding target and target normal cost were 
funding shortfall in the prior plan year), the plan is not subject       determined based on rates published for November, enter “2.” 
to the quarterly contribution rules, and this line should not be 
completed. If line 20a is “Yes,” check the “Yes” box on line 20b         If an election under Code section 430(m)(2) applies to the 
if required installments for the current plan year were made in          plan for a plan year, enter “0”. 
a timely manner; otherwise, check “No.”                                  Note. The plan sponsor’s interest rate election under Code 
Line 20c. If line 20a is “No,” or the plan had 100 or fewer              section 430(h)(2) or ERISA section 303(h)(2) (an election to use 
participants on every day of the preceding plan year (as                 the yield curve or an election to use an applicable month other 
defined for line F), the plan is not subject to the liquidity            than the default month) generally may not be changed unless 
requirement of Code section 430(j)(4) and ERISA section                  the plan sponsor obtains approval from the IRS. However, see 
303(j)(4) and this line should not be completed. Attach a                the regulations under section 430(h)(2) for circumstances in 
certification by the enrolled actuary if the special rule for            which a change in interest rate may be made without obtaining 
nonrecurring circumstances is used, and label the certification          approval from the IRS. 
“Schedule SB, line 20c –Liquidity Requirement                            Line 22. Weighted Average Retirement Age. Enter the 
Certification.” See Code section 430(j)(4)(E)(ii)(II) and ERISA          weighted average retirement age for active participants. If the 
section 303(j)(4)(E)(ii)(II).                                            plan is in at-risk status, enter the weighted average retirement 
If the plan is subject to the liquidity requirement and has a            age as if the plan were not in at-risk status. If each participant 
liquidity shortfall for any quarter of the plan year (see Code           is assumed to retire at his/her normal retirement age, enter the 
section 430(j)(4)(E) and ERISA section 303(j)(4)(E)), enter the          age specified in the plan as normal retirement age. If the 
amount of the liquidity shortfall for each such quarter. If the          normal retirement age differs for individual participants, enter 
plan was subject to the liquidity requirement but did not have a         the age that is the weighted average normal retirement age; do 
liquidity shortfall, enter zero. File IRS Form 5330, Return of           not enter “NRA.” Otherwise, enter the assumed retirement age. 
Excise Taxes Related to Employee Benefit Plans, with the IRS             If the valuation uses rates of retirement at various ages, enter 
to pay the 10% excise tax(es) if there is a failure to pay any           the nearest whole age that is the weighted average retirement 
liquidity shortfall by the required due date, unless a waiver of         age. 
the 10% tax has been granted under Code section 4971(f)(4)               On an attachment to Schedule SB, list the rate of 
Part V – Assumptions Used To Determine Funding                           retirement at each age and describe the methodology used to 
                                                                         compute the weighted average retirement age, including a 
Target and Target Normal Cost 
                                                                         description of the weight applied at each potential retirement 
Line 21. Discount Rate. All discount rates are to be reported            age, and label the attachment “Schedule SB, line 22 – 
and used as published by the IRS, and are to be applied as               Description of Weighted Average Retirement Age.” 
annual rates without adjustment.  
                                                                         Line 23. Mortality Tables. Mortality tables described in Code 
Line 21a. Enter the three segment rates used to calculate the            section 430(h)(3), ERISA section 303(h)(3), and section 
funding target and target normal cost as provided under Code             1.430(h)(3)-1 of the regulations as published by the IRS must 
section 430(h)(2)(C) and ERISA section 303(h)(2)(C) and as               be used to determine the funding target and target normal cost 
published by the IRS, unless the plan sponsor has elected to             for non-disabled participants and may be used to determine 
use the full yield curve. If the sponsor has elected to use the          the funding target and target normal cost for disabled 
full yield curve, check the “N/A, full yield curve used” box.            participants, unless the IRS has approved (or was deemed to 
 If an election under Code section 430(m)(2) applies to the              have approved) the use of a substitute mortality table for the 
plan for a plan year, enter 8.00% in each of the three segment           plan. Standard mortality tables must be either applied on a 
rates. Do not check the full yield curve box, even if some or all        generational basis, or the tables must be updated to reflect the 

                                                                    -86-          Instructions for Schedule SB (Form 5500)

- 87 -

static tables published for the year in which the valuation date              determining the Schedule SB entries that are not prescribed by 
occurs. Substitute mortality tables must be applied in                        law. 
accordance with the terms of the IRS ruling letter.                           Also attach a summary of the principal eligibility and benefit 
Separate standard mortality tables were published by the                      provisions on which the valuation was based, including the 
IRS for annuitants (rates applying for periods when a                         status of the plan (e.g., frozen eligibility, service/pay, or 
participant is assumed to receive a benefit under the plan) and               benefits), optional forms of benefits, special plan provisions, 
nonannuitants (rates applying to periods before a participant is              including those that apply only to a subgroup of employees 
assumed to receive a benefit under the plan). If a plan has 500               (e.g., those with imputed service), supplemental benefits, and 
or fewer participants as of the valuation date for the current                identification of benefits not included in the valuation, a 
plan year as reported in line 3d, column (1), the plan sponsor                description of any significant events that occurred during the 
can elect to use the combined mortality tables published by the               year, a summary of any changes in principal eligibility or benefit 
IRS, which reflect combined rates for both annuitants and                     provisions since the last valuation, and a description (or 
nonannuitants.                                                                reasonably representative sample) of plan early retirement 
Check the applicable box to indicate which set of mortality                   reduction factors and optional form conversion factors. Label the 
tables was used to determine the funding target and target                    summary “Schedule SB, Part V – Summary of Plan 
normal cost. If one set of mortality tables was used for certain              Provisions.” 
populations within the plan and a different set of mortality                  Also, include any other information needed to disclose the 
tables was used for other populations, check the box for the                  actuarial position of the plan fully and fairly. 
set of mortality tables that applied to the largest population. If            Part VI – Miscellaneous Items 
more than one set of mortality tables were used (other than for 
disabled lives pursuant to section 430(h)(3)(D)), attach a                    Line 24. Change in Non-Prescribed Actuarial Assumptions          . 
statement describing the mortality tables used for each                       If a change has been made in the non-prescribed actuarial 
population and the size of that population. Label the                         assumptions for the current plan year, check “Yes.” If the only 
attachment “Schedule SB, line 23 – Information on Use of                      assumption changes are statutorily required changes in the 
Multiple Sets of Mortality Tables.”                                           discount or mortality rates, or changes required for plans in at-
                                                                              risk status, check “No.” Include as an attachment a description 
● Check “Prescribed–combined” if the funding target and target                of any change in non-prescribed actuarial assumptions and 
normal cost are based on the prescribed tables with combined                  justifications for any such change. (See section 103(d) of 
annuitant/nonannuitant mortality rates.                                       ERISA.) Label the attachment “Schedule SB, line 24 – 
● Check “Prescribed–separate” if the funding target and target                Change in Actuarial Assumptions.” 
normal cost are based on the prescribed tables with separate 
mortality rates for nonannuitants and annuitants.                             If the “Yes” box is checked and the non-prescribed 
● Check “Substitute” if the funding target and target normal                  assumptions have been changed in a way that decreases the 
cost are based on substitute mortality tables. If substitute                  funding shortfall for the current plan year, approval for such a 
mortality tables are used, attach a statement including a                     change may be required.  
summary of plan populations for which substitute mortality                    Line 25. Change in Method. If a change in the method has 
tables are used, plan populations for which the prescribed                    been made for the current plan year, check “Yes.” For this 
tables are used, the mortality ratio used to develop the table                purpose, a change in funding method refers to not only a 
for any population, whether the table is constructed based on                 change in the overall method used by the plan, but also each 
full or partial credibility, the partial credibility weighting factor if      specific method of computation used in applying the overall 
applicable, plan populations for which the prescribed tables are              method. Accordingly, funding method changes include 
used, and the last plan year for which the IRS approval of the                modifications such as a change in the method for calculating the 
substitute mortality tables applies. Label the attachment                     actuarial value of assets or a change in the valuation date (not 
“Schedule SB, line 23 – Information on Use of Substitute                      an exclusive list). Also check "Yes" if there has been a change 
Mortality Tables.”                                                            in the method for determining the discount rates reported in line 
Attach a statement of actuarial assumptions and funding                       21. In general, any changes in a plan’s method must be 
methods used to calculate the Schedule SB entries and label                   approved by the IRS. However, see the regulations under Code 
the statement “Schedule SB, Part V – Statement of Actuarial                   section 430 and Revenue Procedure 2017-56, 2017-44 IRB 
Assumptions/Methods.” The statement must describe all non-                    465, for circumstances in which a change in method may be 
prescribed actuarial assumptions (e.g., retirement, withdrawal                made without obtaining approval from the IRS. 
rates) used to determine the funding target and target normal                 Include, as an attachment, a description of the change. 
cost, including the assumption as to the frequency with which                 Label the attachment “Schedule SB, line 25 – Change in 
participants are assumed to elect each optional form of benefit               Method.” 
(including lump sum distributions), whether mortality tables are  
applied on a static or generational basis, whether combined                   Note. The plan sponsor’s agreement to certain changes in 
mortality tables are used instead of separate annuitant and                   funding method should be reported on line 8 of Schedule R 
nonannuitant mortality tables (for plans with 500 or fewer                    (Form 5500). 
participants as of the valuation date), and (for target normal 
cost) expected plan-related expenses and increases in 
compensation. For applicable defined benefit plans under Code 
section 411(a)(13)(C) and ERISA section 203(f)(3) (e.g., cash 
balance plans) the statement must include the assumptions 
used to convert balances to annuities. In addition, the statement 
must describe the method for determining the actuarial value of 
assets and any other aspects of the funding method for 

Instructions for Schedule SB (Form 5500)                                 -87-

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Schedule SB, line 26a –Schedule of Active Participant Data

YEARS OF CREDITED SERVICE
Under 1 1 to 4 5 to 9 40 & up
Attained Average Average Average Average
Age
No. Comp. Cash Bal. No. Comp. Cash Bal. No. Comp. Cash Bal. No. Comp. Cash Bal.
Under 25
25 to 29
30 to 34
35 to 39
40 to 44
45 to 49
50 to 54
55 to 59
60 to 64
65 to 69
70 & up

Line 26a. Schedule of Active Participant Data. Check “Yes” General Rule. When all active participants in the plan have
only if (a) the plan is covered by Title IV of ERISA and (b) the a cash balance account, data to be shown in each bin includes:
plan has active participants. 1. The number of active participants in the age/service bin,
If line 26a is “Yes,” attach a schedule of the active plan 2. The average compensation of the active participants in
participant data used in the valuation for this plan year. Use the the age/service bin, and
format shown on the following page and label the schedule 3. The average cash balance account of the active
“Schedule SB, line 26a – Schedule of Active Participant participants in the age/service bin.
Data.” The attachment may be provided as a structured If the accrued benefit is the greater of a cash balance benefit
attachment, e.g., in a spreadsheet file (CSV format). or some other benefit, average in only the cash balance
Expand this schedule by adding columns after the “5 to 9” account. If the accrued benefit is the sum of a cash balance
column and before the “40 & up” column for active participants account benefit and some other benefit, average in only the
with total years of credited service in the following ranges: 10 to cash balance account. For both the average compensation and
14; 15 to 19; 20 to 24; 25 to 29; 30 to 34; and 35 to 39. For each the average cash balance account, do not enter an amount for
column, enter the number of active participants with the age/service bins with fewer than 20 active participants.
specified number of years of credited service divided according When some active participants do not have cash balance
to age group. For participants with partial years of credited accounts, an alternative is provided for showing compensation
service, truncate the total number of years of credited. Years of and cash balance accounts, requiring two age/service scatters
credited service are the years credited under the plan’s benefit as follows:
formula.
● Scatter 1 – Provide participant count and average
Plans reporting 1,000 or more active participants on line 3c, compensation for all active participants.
column (1), must also provide average compensation data. For ● Scatter 2 – Provide participant count and average cash
each grouping, enter the average compensation of the active balance account for only those active participants with
participants in that group. For this purpose, compensation is the account-based benefits. If the number of participants with
compensation taken into account for each participant under the account-based benefits in a bin is fewer than 20, the average
plan’s benefit formula, limited to the amount defined under account should not be shown even if there are 20 or more
section 401(a)(17) of the Code. Do not enter the average active participants in this bin on Scatter 1.
compensation in any grouping that contains fewer than 20
participants. In general, information should be determined as of the
valuation date. Average cash balance accounts may be
In the case of a plan under which benefits are primarily pay- determined as of either:
related and under which no future accruals are granted (i.e., a
“hard-frozen” plan as defined in the instructions for plan 1. The valuation date or
characteristic “1I” applicable to line 8a of the Form 5500), report 2. The day immediately preceding the valuation date.
the average annual accrued benefit in lieu of average Average cash balance accounts that are offset by amounts
compensation. Include a note on the scatter indicating that the from another plan may be reported either as amounts prior to
plan is “hard frozen” and the average accrued benefits are in taking into account the offset or as amounts after taking into
lieu of compensation. account the offset. Do not report the offset amount. For this or
Cash balance plans (or any plans using characteristic code any other unusual or unique situation, the attachment should
1C on line 8a of Form 5500) reporting 1,000 or more active include an explanation of what is being provided.
participants on line 3d, column (1), must also provide average If the plan is a multiple-employer plan, complete one or more
cash balance account data, regardless of whether all active schedules of active-participant data in a manner consistent with
participants have cash balance accounts. For each age/service the computations for the funding requirements reported in Part
bin, enter the average cash balance account of the active VIII. For example, if the funding requirements are computed as if
participants in that bin. Do not enter the average cash balance each participating employer maintained a separate plan, attach
account in any age/service bin that contains fewer than 20 a separate “Schedule SB, line 26a – Schedule of Active
active participants.

-88- Instructions for Schedule SB (Form 5500)

- 89 -

 Participant Data” for each participating employer in the                 2      This code, formerly used by certain plans 
 multiple-employer plan.                                                         maintained by PBGC settlements as described 
 Line 26b.  Schedule of Projection of Expected Benefit                           in section 105 of PPA, is no longer applicable 
 Payments. Check “Yes” only if this plan is covered by Title IV                  and should not be used 
 of ERISA and has 1,000 or more total participants as of the              3      Reserved 
 valuation date.                                                          4      Plans with binding agreements with PBGC to 
                                                                                 maintain prefunding and/or funding standard 
 If line 26b is “Yes,” in an attachment, provide a projection of                 carryover balances described in Code section 
 benefits expected to be paid separately for active participants,                430(f)(4)(B)(ii) and ERISA section 
 terminated vested participants, and retired participants and                    303(f)(4)(B)(ii) 
 beneficiaries receiving payments, and for the entire plan (not to        5      This code, formerly used by airlines using 10-
 include expected expenses) in each of the next fifty years                      year amortization period for initial post-PPA 
 starting with the plan year and based on the participant’s                      shortfall amortization base under section 
 status as of the valuation date. For purposes of this projection,               402(a)(2) of PPA (as amended), is no longer 
 assume (1) no additional accruals, (2) experience (e.g.,                        applicable and should not be used. 
 termination, mortality, and retirement) is in line with valuation        6      Airlines with frozen plans using alternative 17-
 assumptions, (3) no new entrants, and (4) benefits are paid in                  year funding schedule under section 402(a)(1) 
 the form assumed for valuation purposes.                                        of PPA 
 Note. If the plan is using the annuity substitution rule provided        7      Interstate transit company described in section 
 in Treasury Regulations section 1.430(d)-1(f)(4)(iii)(B) to                     115 of PPA 
 determine the funding target, for purposes of this attachment,           8      This code, formerly used by a plan subject to 
 instead of assuming benefits are paid in the form assumed for                   section 104 of PPA (as amended) that is not a 
 valuation purposes, you may assume benefits are paid as an                      CSEC plan, is no longer applicable and should 
 annuity (i.e., you may report the projected benefits that are                   not be used.  
 used to determine the funding target).                                   9      Community Newspaper plans and plans within 
 Use the format shown below and label this attachment                            the controlled group, as described in SECURE 
 “Schedule SB, line 26b – Schedule of Projection of                              Act section 115. 
                                                                          
 Expected Benefit Payments.” The attachment may be 
 provided as a structured attachment, e.g., in a spreadsheet file         Special Instructions for codes 1 through 9 
 (CSV format).                                                            CSEC Plans, as described in Code section 414(y) and 
           Schedule SB, line 26b – Schedule of Projection of             subject to Code section 433 (code 1).  
                   Expected Benefit Payments                             Complete only the following on Schedule SB: 
 Plan       Active        Terminated     Retired              Total             Lines A through F 
 Year       Participants  Vested         Participants                           Part I (including signature of enrolled actuary), 
                          Participants    and 
                                        Beneficiaries                            determined as if PPA ’06 provisions were effective for 
                                         Receiving                               all plan years beginning after December 31, 2007. 
                                         Payments                               Part III, line 14, determined as if PPA ‘06 provisions 
 Current                                                                         were effective for all plan years beginning after 
 Plan Year                                                                       December 31, 2007. 
 Current                                                                        Part IV, line 18. 
 Plan Year                                                                      Part V, determined as if PPA ‘06 provisions were 
 + 1                                                                             effective for all plan years beginning after December 
 Etc.                                                                            31, 2007. 
 Current                                                                  Also, report other information for the current plan year 
 Plan Year                                                               using a 2007 Schedule B (Form 5500). Label this attachment 
 + 49                                                                    “Schedule SB, line 27 – Actuarial Information for CSEC 
                                                                         Plans.” Each attachment must include the plan name, the plan 
 Line 27. Alternative Funding Rules. If one of the alternative           sponsor’s name and EIN, and the plan number. Complete all 
 funding rules was used for this plan year, enter the appropriate        items from the 2007 Schedule B, excluding line 9f and Part II, 
 code from the table below and follow the special instructions           and attach the 2007 Schedule B and all applicable 
 applicable to that code, including completion of any required           attachments to the Schedule SB. Note that under PPA ‘06, the 
 attachments.                                                            third segment rate determined under Code 
 Code          Alternative Funding Rule                                  section 430(h)(2)(C)(iii) and ERISA section 303(h)(2)(C)(iii) is 
 1             A CSEC plan that is described in Code section             substituted for the current liability interest rate under Code 
               414(y). This includes certain multiple-employer           section 412(b)(5)(B) and ERISA section 302(b)(5)(B) (as in 
               plans maintained by rural cooperatives and                effect before PPA ‘06).  
               other specified cooperative organizations and              If the plan’s funded percentage (as defined in Code section 
               certain plans maintained by more than 1                   433(j)(5)(B)) as of the beginning of the plan year is less than 
               employer (determined after application of Code            80%, then the plan is in funding restoration status. If the plan’s 
               section 414(b) and (c)), all of which are                 enrolled actuary certifies that the plan is in funding restoration 
               described in Code section 501(c)(3). Do not use           status for a plan year, include the following additional 
               Code 1 for a plan that satisfies the definition of a      information in the attachment “Schedule SB, line 27 – 
               CSEC plan that has made the election to not be            Actuarial Information for CSEC Plans:” (a) the annual 
               treated as a CSEC plan.                                   certification by the enrolled actuary for the plan; and (b) the 

 Instructions for Schedule SB (Form 5500)                           -89-

- 90 -

value of plan assets and the funding liability, including any 2. Employer contributions for the plan year, discounted for
adjustments to these amounts as specified in Code section interest to the valuation date for the plan year, and using a rate
433(j)(4) and ERISA section 306(j)(4). of 8.85%; and
If a plan in funding restoration status has an accumulated 3. Contribution shortfall, if any ((1)-(2) but not less than
funding deficiency based on the excess of the employer’s zero).
normal cost determined under line 9b, over the amount Interstate transit company (code 7). Complete the entire
actually contributed to the plan for the plan year, as Schedule SB, reflecting the modifications to the otherwise-
determined under Code section 433(j)(1) and ERISA section required funding rules under section 115(b) of PPA, and
306(j)(1), then the details of this calculation must be included disregarding the attachment required for plans reporting the use
in the attachment “Schedule SB, line 27 – Actuarial of the substitute mortality table in line 23.
Information for CSEC Plans.” In the case of a plan for which Part VII – Reconciliation of Unpaid Minimum
a spread gain funding method is used, the normal cost that is
Required Contributions for Prior Years
used to apply this rule is the normal cost determined under the
entry age normal cost funding method. Line 28. Unpaid Minimum Required Contributions for Prior
Years. Enter the total amount of any unpaid minimum required
Plans with binding agreements with the PBGC to
contributions for all years from line 40 of the Schedule SB for
maintain prefunding and/or carryover balances (code 4).
the prior plan year.
Complete the entire Schedule SB and attachments as outlined
in these instructions. In addition, report on an attachment the If this is the first year that the plan is subject to the minimum
amount subject to the binding agreement with the PBGC, funding requirements of Code section 430 or ERISA section
reported separately for the funding standard carryover balance 303, enter the amount of any accumulated funding deficiency at
and prefunding balance. Label the attachment “Schedule SB, the end of the prior year (the pre-effective plan year). This is the
line 27 – Balances Subject to Binding Agreement with amount reported on line 9p of the 2007 Schedule B form that
PBGC.” was submitted as an attachment to the Schedule SB for the pre-
effective plan year.
Airlines with frozen plans using alternative 17-year
funding schedule (code 6). Complete the following lines on Line 29. Employer Contributions Allocated Toward Unpaid
Schedule SB and provide associated attachments: Minimum Required Contributions from Prior Years. Enter
the total amount of discounted contributions made for the
● Lines A through F.
current plan year allocated toward unpaid minimum required
● Part I (including signature of enrolled actuary) – complete all
contributions from prior years as reported in line 19a.
lines.
● Parts III through VII – complete all lines. Line 30. Remaining Unpaid Minimum Required
Contributions. Enter the amount in line 28 minus the amount
For this purpose, disregard the special funding rules under
in line 29.
section 402(e) of PPA except for the information reported on the
following lines: Part VIII – Minimum
● Line 19 – Discount contributions to the applicable valuation Required Contribution for Current Year
date using the 8.85% discount rate provided under section Line 31. Target Normal Cost and Excess Assets.
402(e)(4)(B) of PPA. Line 31a Target Normal Cost (line 6c).. Enter the target
● Line 20 – Reflect required quarterly installments based on normal cost as reported in line 6c.
the minimum required contribution determined under section
402(e) of PPA to the extent applicable (i.e., for purposes of Line 31b. Excess Assets. Enter the excess, if any, of the
calculating the required annual payment under Code section value of assets reported on line 2b reduced by any funding
430(j)(3)(D)(ii)(l) and ERISA section 303(j)(3)(D)(ii)(l)). standard carryover balance and prefunding balance on line 13,
● Line 29 – Reflect the minimum required contribution columns (a) and (b), over the funding target reported on line
determined under section 402(e) of PPA when determining the 3d, column (3). If the valuation date is not the first day of the
unpaid minimum required contribution. plan year, excess assets are determined as the value of assets
reported on line 2b reduced by any funding standard carryover
Also, attach a worksheet showing the information below, balance and prefunding balance reported on line 13, columns
determined in accordance with section 402(e) of PPA. Label this (a) and (b), adjusted for interest at the effective interest rate for
worksheet “Schedule SB, line 27 – Alternative 17-Year the period between the beginning of the plan year and the
Funding Schedule for Airlines.” valuation date, minus the funding target reported on line 3d,
● Date as of which plan benefits were frozen as required under column (3) (but not less than zero). Limit the amount reported
section 402(b)(2) of PPA. in line 31b so that it is not greater than the target normal cost
● Date on which the first applicable plan year began. reported in line 31a.
● Accrued liability under the unit credit method calculated as of Line 32. Amortization Installments.
the first day of the plan year, using an interest rate of 8.85%.
● A summary of all other assumptions used to calculate the Line 32a. Shortfall Amortization Bases and Amortization
unit credit accrued liability. Installments. Outstanding balance — If the plan’s funding
● Fair market value of assets as of the first day of the plan shortfall (determined under Code section 430(c)(4) and ERISA
year. section 303(c)(4)) is zero, all amortization bases and related
● Unfunded liability under section 402(e)(3)(A) of PPA. installments are considered fully amortized. In this case, enter
● Alternative funding schedule: zero. Otherwise, enter the sum (but not less than zero) of the
outstanding balances of all shortfall amortization bases
1. Contribution necessary to amortize the unfunded liability (including any new shortfall amortization base established for
over the remaining number of years, assuming payments at the current plan year). The outstanding balance for each
the valuation date for each plan year and using an interest rate amortization base established in past years is equal to the
of 8.85%;
-90- Instructions for Schedule SB (Form 5500)

- 91 -

present value as of the valuation date of any remaining                   2. The shortfall amortization installment that corresponds to 
amortization installments for each base (including the                    any new shortfall amortization base established for the current 
amortization installment for the current plan year), using the            plan year. This amount is the level amortization payment that 
interest rates reported on line 21.                                       will amortize the new shortfall amortization base over 15 
A plan is generally exempt from the requirement to establish              annual payments, using the interest rates reported in line 21 
a new shortfall amortization base for the current plan year if the        for the current plan year. 
funding target reported on line 3d, column (3), is less than or           Note. Shortfall amortization installments for a given shortfall 
equal to the reduced value of assets as described below.                  amortization base are not re-determined from year to year 
For the purpose of determining whether a plan is exempt                   regardless of any changes in interest rates or valuation dates. 
from the requirement to establish a new shortfall amortization            Note. If an election was made to use an alternative shortfall 
base for the current plan year, the reduced value of assets is the        amortization schedule under Code section 430(c)(2)(D) and 
amount reported on line 2b, reduced by the full value of the              ERISA section 303(c)(2)(D) added by PRA 2010, the shortfall 
prefunding balance reported on line 13, column (b), adjusted for          amortization installment is the amount determined in 
interest for the period between the beginning of the plan year            accordance with the shortfall amortization schedule chosen 
and the valuation date using the effective interest rate for the          and guidance issued by Treasury and the IRS. Include any 
current plan year, if the valuation date is not the first day of the      increase to the shortfall amortization installment for this year 
plan year. However, the assets are reduced by the prefunding              due to the installment acceleration amount, as provided in 
balance if and only if the plan sponsor has elected to use any            Code section 430(c)(7) and ERISA section 303(c)(7). 
portion of the prefunding balance to offset the minimum required          Line 32b. Waiver Amortization Bases and Amortization 
contribution for the current plan year, as reported on line 35.           Installments. Outstanding balance — If the plan’s funding 
The assets are not reduced by the amount of any funding                   shortfall (determined under Code section 430(c)(4) and ERISA 
standard carryover balance for this calculation regardless of             section 303(c)(4)) is zero, all waiver amortization bases and 
whether any portion of the funding standard carryover balance             related installments are considered fully amortized. In this 
is used to offset the minimum required contribution for the plan          case, enter zero. Otherwise, enter the present value as of the 
year.                                                                     valuation date of all remaining waiver amortization installments 
If the plan is not exempt from the requirement to establish a             (including any installment for the current plan year), using the 
new shortfall amortization base for the current plan year, the            interest rates reported on line 21. Do not include any new 
amount of that base is generally equal to the difference between          waiver amortization base established for a waiver of minimum 
the funding shortfall as of the valuation date (determined under          funding requirements for the current plan year. 
Code section 430(c)(4) and ERISA section 303(c)(4)) and the               Waiver amortization installments — Enter the sum of any 
sum of any outstanding balances of any previously established             remaining waiver amortization installments that were 
shortfall and waiver amortization bases. The new shortfall                established to amortize any waiver amortization bases for prior 
amortization base may be either greater than or less than zero.           plan years, unless such bases have been or are deemed to be 
For the purpose of determining the amount of any new                      fully amortized. Do not include an amortization installment for 
shortfall amortization base, the funding shortfall is equal to the        any new waiver amortization base established for a waiver of 
amount of the funding target reported on line 3d, column (3),             minimum funding requirements for the current plan year. 
minus the reduced value of assets, but not less than zero.                Note. If a waiver of minimum funding requirements has been 
If the plan’s valuation date is the first day of the plan year,           granted for the current plan year, a waiver amortization base is 
then the reduced value of assets for the purpose of determining           established as of the valuation date for the current plan year 
the amount of any new shortfall amortization base is the amount           equal to the amount of the funding waiver reported in line 33. 
reported on line 2b, reduced by the sum of the funding standard           The waiver amortization installment that corresponds to any 
carryover balance and the prefunding balance reported on line             waiver amortization base established for the current year is the 
13, columns (a) and (b). However, if the plan’s valuation date is         level amortization payment that will amortize the new waiver 
not the first day of the plan year, then the reduced value of             amortization base over 5 annual payments, using the same 
assets for the purpose of determining the amount of any new               segment interest rates or rates from the full yield curve 
shortfall amortization base is the amount reported on line 2b,            reported on line 21 for the current plan year, but with the first 
reduced by the sum of the funding standard carryover balance              payment due on the valuation date for the following plan year. 
and the prefunding balance reported on line 13, columns (a) and           The amount of the waiver amortization base and the waiver 
(b), adjusted for interest for the period between the beginning of        amortization installments for this base are not reported in line 
the plan year and the valuation date (using the effective interest        32b for the year in which they are established. Rather, these 
rate for the current plan year). See Code section 430(f)(4)(B)(ii)        are included in the entries for line 32b on the Schedule SB for 
and ERISA section 303(f)(4)(B)(ii) for special rules in the case of       the following plan year. 
a binding agreement with the PBGC providing that all or a                 Note. Waiver amortization installments (including the waiver 
portion of the funding standard carryover balance and/or                  amortization installments of any waiver amortization base 
prefunding balance is not available to offset the minimum                 established for the prior plan year) are not re-determined from 
required contribution for the plan year.                                  year to year regardless of any changes in interest rates or 
Shortfall amortization installment — Enter the sum (but not               valuation dates. 
less than zero) of:                                                       Required attachment.        If there are any shortfall or waiver 
1. Any shortfall amortization installments that were                      amortization bases, include as an attachment a listing of all 
established to amortize shortfall amortization bases                      bases (other than a base established for a funding waiver for the 
established in prior years, excluding amortization installments           current plan year) showing for each base: 
for bases that have been or are deemed to be fully amortized,             1. The type of base (shortfall or waiver), 
and                                                                       2. The present value of any remaining installments 
                                                                          (including the installment for the current plan year), 

Instructions for Schedule SB (Form 5500)                             -91-

- 92 -

3. The valuation date as of which the base was established, Refer to the regulations under Section 430 of the Code for
4. The number of years remaining in the amortization additional information.
period, and Special rule for elections to use balances in excess of
5. The amortization installment. the minimum required contribution. Section 1.430(f)-1(f)(3)(ii)
If a base is negative (i.e., a “gain base”), show amounts in of the regulations provides an exception to the general rule
parentheses or with a negative sign in front of them. All requiring that any elections to use the funding standard
amounts must be calculated as of the valuation date for the carryover balance and/or prefunding balance to offset the
plan year. minimum required contribution are irrevocable. Under this
If any of the shortfall amortization bases shown on this exception, such an election may be revoked to the extent that
attachment are being amortized using an alternative the amount of the election exceeds the minimum required
amortization schedule in accordance with Code section contribution for the plan year as reported in line 34. If a timely
430(c)(2)(D) or ERISA section 303(c)(2)(D), identify the election is made to revoke the excess amount, report only the
amortization schedule being used and show separately the amount of the election used to offset the minimum required
amount of any installment acceleration amount added to the contribution on line 35. If the excess amount is not revoked by
shortfall amortization installment for the current plan year means of a timely election, report the full amount of the election
under Code section 430(c)(7) or ERISA section 303(c)(7). on line 35 even if it exceeds the minimum required contribution
Label the schedule “Schedule SB, line 32 – Schedule of reported on line 34.
Amortization Bases.” Line 36. Additional Cash Requirement. Enter the amount in
Line 33. Funding Waiver. If a waiver of minimum funding line 34 minus the amount in the “Total Balance” column in line
requirements has been approved for the current plan year, 35. (The result cannot be less than zero.) This represents the
enter the date of the ruling letter granting the approval and the contribution needed to satisfy the minimum funding
waived amount (reported as of the valuation date) in the requirement for the current year, adjusted for interest to the
spaces provided. If a waiver is pending, do not complete this valuation date.
line. If a pending waiver is granted after Form 5500 is filed, file Line 37. Contributions Allocated Toward Minimum
an amended Form 5500 with an amended Schedule SB. Required Contribution for Current Year, Adjusted to
Line 34. Total Funding Requirement Before Reflecting Valuation Date. Enter the amount reported in line 19c.
Carryover/Prefunding Balances. Enter the target normal cost Line 38. Present Value of Excess Contributions for Current
in line 31a, minus the excess assets in line 31b, plus the Year.
amortization installments reported in lines 32a and 32b, Line 38a. If line 37 is greater than line 36, enter the amount by
reduced by any waived amounts reported in line 33. which line 37 exceeds line 36. Otherwise, enter “0.” This
Line 35. Balances Elected for Use to Offset Funding amount (plus interest, if applicable) is the maximum amount by
Requirement. If the percentage reported on line 16 is at least which the plan sponsor may elect to increase the prefunding
80%, and the plan has a funding standard carryover balance balance.
and/or prefunding balance (as reported on line 13, columns (a) Line 38b. Enter the amount of any portion of the amount
and (b)), the plan sponsor may elect to credit all or a portion of shown on line 38a that results solely from the use of the
such balances against the minimum required contribution. funding standard carryover balance and/or prefunding balance
Enter the amount of any balance elected for use for this to offset the minimum required contribution.
purpose in the applicable column of line 35, and enter the total
in the column headed “Total Balance.” No portion of the Line 39. Unpaid Minimum Required Contribution for
prefunding balance can be used for this purpose unless the full Current Year. If line 37 is less than line 36, enter the amount
amount of any remaining funding standard carryover balance by which line 36 exceeds line 37. Otherwise, enter “0”.
(line 13, column (a)) is used. The amounts entered on line 35 Line 40. Unpaid Minimum Required Contributions for All
cannot be larger than the corresponding amounts on line 13 Years. Enter the sum of the remaining unpaid minimum
(unless the plan’s valuation date is not the first day of the plan required contributions from line 30 and the unpaid minimum
year, as discussed below). required contribution for the current year from line 39. If this
If the plan’s valuation date is not the first day of the plan amount is greater than zero, file IRS Form 5330, Return of
year, adjust the portion of the funding standard carryover Excise Taxes Related to Employee Benefit Plans and pay the
balance and prefunding balance used to offset the minimum 10% excise tax on the unpaid minimum required contributions.
required contribution for interest between the beginning of the In addition, if this is a PBGC-covered plan and reporting to
plan year and the valuation date using the effective interest rate PBGC is not waived under 29 CFR 4043.25(c), file PBGC
for the current plan year. Form 10 or PBGC Form 200, whichever is applicable.
Special rule for late election to apply balances to Part IX –Pension Funding Relief under the American
quarterly installments. If an election was made to use the Rescue Plan Act of 2021
funding standard carryover balance or the prefunding balance to Line 41. If an election was made under Code section 430(c)(8)
offset the amount of a required quarterly installment, but the or ERISA section 303(c)(8) to apply the extended amortization
election was made after the due date of the installment, the rule for a plan year beginning on or before December 31,
amount reported on line 35 may not be the same amount that is 2021, check the box to indicate the first plan year for which the
subtracted from the plan’s balances in the following plan year (to rule applies (i.e., the box for the 2019, 2020, or 2021 plan
be reported in line 8 of Schedule SB for the following plan year). year).

-92- Instructions for Schedule SB (Form 5500)

- 93 -

OMB Control Numbers                            
Agency                                                                  OMB Number 
Employee Benefits Security Administration...............................................1210 - 0110 and 1210 - 0089 
Pension Benefit Guaranty Corporation .....................................................1212 - 0057 
Internal Revenue Service ..........................................................................1545 - 1610 
 
Paperwork Reduction Act Notice 
 
We ask for the information on this form to carry out the law as specified in ERISA and in Code sections 6047(e), 6058(a), and 
6059(a). You are required to give us the information. We need it to determine whether the plan is operating according to the law.  
  You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form 
displays a valid OMB control number. Books and records relating to a form or its instructions must be retained as long as their 
contents may become material in the administration of the Internal Revenue Code or are required to be maintained pursuant to Title I 
or IV of ERISA. Generally, the Form 5500 return/reports are open to public inspection and are subject to publication on the Internet.  
  The time needed to complete and file the forms listed below reflects the combined requirements of the Internal Revenue Service, 
Department of Labor, and Pension Benefit Guaranty Corporation. These times will vary depending on individual circumstances. The 
estimated average times are:  
 
                                     Pension Plans                                                                            Welfare Plans 
  
                               Large               Small                                                       Large                        Small 
 Form 5500                    1 hr., 50 min.   1 hr., 19 min.                                                  1 hr., 45 min. 1 hr., 14 min. 
 Schedule A                   2 hr., 52 min.   2 hr., 52 min.                                                  3 hr., 40 min. 2 hr., 43 min. 
 Schedule C                   2 hr., 51 min             N/A                                                    3 hr., 38 min.               N/A 
 Schedule D                   1 hr., 39 min.       20 min.                                                     1 hr., 52 min.               20 min. 
 Schedule DCG                 1 hr., 33 min.            N/A                                                    N/A                          N/A 
 Schedule G                   14 hr., 49 min.           N/A                11 hr., 0 min.                                                   N/A 
 Schedule H                   7 hr., 40 min.            N/A                                                    8 hr., 36 min.               N/A 
 Schedule I                    N/A             2 hr., 6 min.                                                   N/A            1 hr., 56 min. 
 Schedule MB                  8 hr., 52 min.   8 hr., 40 min.                                                  N/A                          N/A 
 Schedule MEP                  14 min.             10 min.                                                     N/A                          N/A 
 Schedule R                   1 hr., 43 min.   1 hr., 7 min.                                                   N/A                          N/A 
 Schedule SB                  6 hr., 38 min.   6 hr., 49 min.                                                  N/A                          N/A 

  If you have comments concerning the accuracy of these time estimates or suggestions for making these forms simpler, we would 
be happy to hear from you. You can write to the Internal Revenue Service, Tax Products Coordinating Committee, 
SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave NW, IR-6526, Washington, DC 20224. Do not send any of these forms or schedules to 
this address. The forms and schedules must be filed electronically. See How To File – Electronic Filing Requirement. 
 
                                                   -93-

- 94 -

Forms 5500, 5500-SF, and                     This list of principal business activities and their associated codes       These principal activity codes are based on the North American 
5500-EZ Codes for Principal                  is  designed  to  classify  an  enterprise  by  the  type  of  activity  in Industry Classification System. 
                                             which it is engaged. 
Business Activity 
 Code                                   Code                                    Code                                      Code 
Agriculture, Forestry, Fishing         Specialty Trade Contractors             Printing and Related Support              Computer and Electronic Product 
and Hunting                            238100  Foundation, Structure, &        Activities                                Manufacturing 
Crop Production                              Building Exterior Contractors     323100  Printing & Related Support        334110  Computer & Peripheral 
111100  Oilseed & Grain Farming              (including framing carpentry,           Activities                                Equipment Mfg 
111210  Vegetable & Melon Farming            masonry, glass, roofing, &        Petroleum and Coal Products               334200  Communications Equipment 
          (including potatoes & yams)        siding)                           Manufacturing                                   Mfg 
111300  Fruit & Tree Nut Farming       238210  Electrical Contractors          324110  Petroleum Refineries              334310  Audio & Video Equipment Mfg 
111400  Greenhouse, Nursery, &         238220  Plumbing, Heating, &                  (including integrated)              334410  Semiconductor & Other 
          Floriculture Production            Air-Conditioning Contractors      324120  Asphalt Paving, Roofing, &              Electronic Component Mfg 
111900  Other Crop Farming             238290  Other Building Equipment              Saturated Materials Mfg             334500  Navigational, Measuring, 
          (including tobacco, cotton,        Contractors                       324190  Other Petroleum & Coal                  Electromedical, & Control 
          sugarcane, hay, peanut,      238300  Building Finishing                    Products Mfg                              Instruments Mfg 
          sugar beet, & all other crop       Contractors (including            Chemical Manufacturing                    334610  Manufacturing & Reproducing 
          farming)                           drywall, insulation, painting,    325100  Basic Chemical Mfg                      Magnetic & Optical Media 
Animal Production                            wallcovering, flooring, tile, &   325200  Resin, Synthetic Rubber, &        Electrical Equipment, Appliance, and 
112111  Beef Cattle Ranching &               finish carpentry)                       Artificial & Synthetic Fibers &     Component Manufacturing 
          Farming                      238900  Other Specialty Trade                 Filaments Mfg                       335100  Electric Lighting Equipment  
112112  Cattle Feedlots                      Contractors (including site       325300  Pesticide, Fertilizer, & Other          Mfg 
112120  Dairy Cattle & Milk                  preparation)                            Agricultural Chemical Mfg           335200  Major Household Appliance Mfg 
          Production                   Manufacturing                           325410  Pharmaceutical & Medicine Mfg     335310  Electrical Equipment Mfg 
112210  Hog & Pig Farming              Food Manufacturing                      325500  Paint, Coating, & Adhesive Mfg    335900  Other Electrical Equipment & 
112300  Poultry & Egg Production       311110  Animal Food Mfg                 325600  Soap, Cleaning Compound, &              Component Mfg 
112400  Sheep & Goat Farming           311200  Grain & Oilseed Milling               Toilet Preparation Mfg              Transportation Equipment 
112510  Aquaculture (including         311300  Sugar & Confectionary           325900  Other Chemical Product &          Manufacturing 
          shellfish & finfish farms &        Product Mfg                             Preparation Mfg                     336100  Motor Vehicle Mfg 
          hatcheries)                  311400  Fruit & Vegetable Preserving    Plastics and Rubber Products              336210  Motor Vehicle Body & Trailer  
112900  Other Animal Production              & Specialty Food Mfg              Manufacturing                                   Mfg 
Forestry and Logging                   311500  Dairy Product Mfg               326100  Plastics Product Mfg              336300  Motor Vehicle Parts Mfg 
113110  Timber Tract Operations        311610  Animal Slaughtering and         326200  Rubber Product Mfg                336410  Aerospace Product & Parts  
113210  Forest Nurseries & Gathering         Processing                        Nonmetallic Mineral Product                     Mfg 
          of Forest Products           311710  Seafood Product Preparation     Manufacturing                             336510  Railroad Rolling Stock Mfg 
113310  Logging                              & Packaging                       327100  Clay Product & Refractory Mfg     336610  Ship & Boat Building 
Fishing, Hunting and Trapping          311800  Bakeries, Tortilla & Dry Pasta  327210  Glass & Glass Product Mfg         336990  Other Transportation 
114110  Fishing                               Mfg                              327300  Cement & Concrete Product Mfg           Equipment Mfg 
114210  Hunting & Trapping             311900  Other Food Mfg (including       327400  Lime & Gypsum Product Mfg         Furniture and Related Product 
Support Activities for Agriculture           coffee, tea, flavorings &         327900  Other Nonmetallic Mineral         Manufacturing 
and Forestry                                 seasonings)                             Product Mfg                         337000  Furniture & Related Product 
115110  Support Activities for Crop    Beverage and Tobacco Product            Primary Metal Manufacturing                     Manufacturing 
          Production (including cotton Manufacturing                           331110  Iron & Steel Mills & Ferroalloy   Miscellaneous Manufacturing 
          ginning, soil preparation,   312110  Soft Drink & Ice Mfg                  Mfg                                 339110  Medical Equipment &  
          planting, & cultivating)     312120  Breweries                       331200  Steel Product Mfg from                  Supplies Mfg 
115210  Support Activities for Animal  312130  Wineries                              Purchased Steel                     339900  Other Miscellaneous Mfg 
          Production                   312140  Distilleries                    331310  Alumina & Aluminum                Wholesale Trade 
115310  Support Activities for         312200  Tobacco Manufacturing                 Production & Processing             Merchant Wholesalers, Durable 
          Forestry                     Textile Mills and Textile Product       331400  Nonferrous Metal (except          Goods 
Mining                                 Mills                                         Aluminum) Production &              423100  Motor Vehicle, & Motor  
211120  Crude Petroleum Extraction     313000  Textile Mills                         Processing                                Vehicle Parts & Supplies 
211130  Natural Gas Extraction         314000  Textile Product Mills           331500  Foundries                         423200  Furniture & Home Furnishings 
212110  Coal Mining                    Apparel Manufacturing                   Fabricated Metal Product                  423300  Lumber & Other Construction 
212200  Metal Ore Mining               315100  Apparel Knitting Mills          Manufacturing                                   Materials 
212310  Stone Mining & Quarrying       315210  Cut & Sew Apparel               332110  Forging & Stamping                423400  Professional & Commercial 
212320  Sand, Gravel, Clay, &                Contractors                       332210  Cutlery & Handtool Mfg                  Equipment & Supplies 
          Ceramic & Refractory         315220  Men’s & Boys’ Cut & Sew         332300  Architectural & Structural        423500  Metal & Mineral (except 
          Minerals Mining, & Quarrying       Apparel Mfg.                            Metals Mfg                                petroleum) 
212390  Other Nonmetallic Mineral      315240  Women’s, Girls’ and Infants’    332400  Boiler, Tank, & Shipping          423600  Household Appliances and  
                Mining & Quarrying            Cut & Sew Apparel Mfg.                 Container Mfg                              Electrical & Electronic Goods 
213110  Support Activities for Mining  315280  Other Cut & Sew Apparel Mfg     332510  Hardware Mfg                      423700  Hardware, Plumbing, & 
Utilities                              315990  Apparel Accessories & Other     332610  Spring & Wire Product Mfg               Heating Equipment &  
221100  Electric Power Generation,           Apparel Mfg                       332700  Machine Shops; Turned                   Supplies 
          Transmission & Distribution  Leather and Allied Product                    Product; & Screw, Nut, & Bolt       423800  Machinery, Equipment, & 
221210  Natural Gas Distribution       Manufacturing                                 Mfg                                       Supplies 
221300  Water, Sewage & Other          316110  Leather & Hide Tanning, &       332810  Coating, Engraving, Heat          423910  Sporting & Recreational 
          Systems                            Finishing                               Treating, & Allied Activities             Goods & Supplies 
221500  Combination Gas & Electric     316210  Footwear Mfg (including         332900  Other Fabricated Metal            423920  Toy, & Hobby Goods, & 
Construction                                 rubber & plastics)                      Product Mfg                               Supplies 
Construction of Buildings              316990  Other Leather & Allied          Machinery Manufacturing                   423930  Recyclable Materials 
236110  Residential Building                 Product Mfg                       333100  Agriculture, Construction, &      423940  Jewelry, Watch, Precious 
          Construction                 Wood Product Manufacturing                    Mining Machinery Mfg                      Stone, & Precious Metals 
236200  Nonresidential Building        321110  Sawmills & Wood                 333200  Industrial Machinery Mfg          423990  Other Miscellaneous Durable 
          Construction                       Preservation                      333310  Commercial & Service                    Goods 
Heavy and Civil Engineering            321210  Veneer, Plywood, &                    Industry Machinery Mfg              Merchant Wholesalers, Nondurable 
Construction                                 Engineered Wood Product           333410  Ventilation, Heating,             Goods 
237100  Utility System Construction          Mfg                                     Air-Conditioning, &                 424100  Paper & Paper Products 
237210  Land Subdivision               321900  Other Wood Product Mfg                Commercial Refrigeration            424210  Drugs & Druggists’ Sundries 
237310  Highway, Street, & Bridge      Paper Manufacturing                           Equipment Mfg                       424300  Apparel, Piece Goods, & 
                                       322100  Pulp, Paper, & Paperboard       333510  Metalworking Machinery Mfg              Notions 
237990  Other Heavy & Civil                  Mills                             333610  Engine, Turbine & Power           424400  Grocery & Related Products 
          Engineering Construction     322200  Converted Paper Product Mfg           Transmission Equipment Mfg          424500  Farm Product Raw Materials 
                                                                               333900  Other General Purpose             424600  Chemical & Allied Products 
                                                                                     Machinery Mfg                        
                                                                                                                          
                                                                               -94-

- 95 -

Forms 5500, 5500-SF, and 5500-EZ Codes for Principal Business Activity (continued) 
Code                                   Code                                         Code                                          Code 
424700  Petroleum & Petroleum          448140  Family Clothing Stores               Support Activities for Transportation         Securities, Commodity Contracts, 
        Products                       448150  Clothing Accessories Stores          488100  Support Activities for Air            and Other Financial Investments and 
424800  Beer, Wine, & Distilled        448190  Other Clothing Stores                      Transportation                          Related Activities 
        Alcoholic Beverages            448210  Shoe Stores                          488210  Support Activities for Rail           523110  Investment Banking & 
424910  Farm Supplies                  448310  Jewelry Stores                             Transportation                                   Securities Dealing 
424920  Book, Periodical, &            448320  Luggage & Leather Goods              488300  Support Activities for Water          523120  Securities Brokerage 
        Newspapers                          Stores                                        Transportation                          523130  Commodity Contracts Dealing 
424930  Flower, Nursery Stock, &       Sporting Goods, Hobby, Book, and             488410  Motor Vehicle Towing                  523140  Commodity Contracts  
        Florists’ Supplies             Music Stores                                 488490  Other Support Activities for                   Brokerage 
424940  Tobacco & Tobacco Products     451110  Sporting Goods Stores                      Road Transportation                     523210  Securities & Commodity  
424950  Paint, Varnish, & Supplies     451120  Hobby, Toy, & Game Stores            488510  Freight Transportation                         Exchanges 
424990  Other Miscellaneous            451130  Sewing, Needlework, & Piece                Arrangement                             523900  Other Financial Investment 
        Nondurable Goods                    Goods Stores                            488990  Other Support Activities for                   Activities (including portfolio 
Wholesale Electronic Markets and       451140  Musical Instrument &                       Transportation                                   management & investment 
Agents and Brokers                          Supplies Stores                         Couriers and Messengers                                advice) 
425110  Business to Business           451211  Book Stores                          492110  Couriers                              Insurance Carriers and Related  
        Electronic Markets             451212  News Dealers & Newsstands            492210  Local Messengers & Local              Activities 
425120  Wholesale Trade Agents &       General Merchandise Stores                         Delivery                                524130    Reinsurance Carriers 
        Brokers                        452200  Department Stores                    Warehousing and Storage                       524140  Direct Life, Health, & Medical 
Retail Trade                           452300  General Merchandise Stores,          493100  Warehousing & Storage                          Insurance Carriers 
Motor Vehicle and Parts Dealers             incl. Warehouse Clubs &                       (except lessors of                      524150   Direct Insurance (except Life,                
                                            Supercenters                                            miniwarehouses & self-storage                 Health & Medical) Carriers 
441110  New Car Dealers                                                                   units)                                  524210  Insurance Agencies & 
441120  Used Car Dealers               Miscellaneous Store Retailers                                                                       Brokerages 
441210  Recreational Vehicle Dealers   453110  Florists                             Information                                   524290  Other Insurance Related 
441222  Boat Dealers                   453210  Office Supplies & Stationery         Publishing Industries (except Internet)                Activities (including third- 
441228  Motorcycle, ATV, and All            Stores                                  511110  Newspaper Publishers                           party administration of 
        Other Motor Vehicle Dealers    453220  Gift, Novelty, & Souvenir            511120  Periodical Publishers                          Insurance and pension funds) 
441300  Automotive Parts,                   Stores                                  511130  Book Publishers                       Funds, Trusts, and Other Financial 
        Accessories, & Tire Stores     453310  Used Merchandise Stores              511140  Directory & Mailing List              Vehicles 
Furniture and Home Furnishings         453910  Pet & Pet Supplies Stores                  Publishers                              525100  Insurance & Employee 
Stores                                 453920  Art Dealers                          511190  Other Publishers                               Benefit Funds 
442110  Furniture Stores               453930  Manufactured (Mobile) Home           511210  Software Publishers                   525910  Open-End Investment Funds 
442210  Floor Covering Stores               Dealers                                 Motion Picture and Sound Recording                     (Form 1120-RIC) 
442291  Window Treatment Stores        453990  All Other Miscellaneous Store        Industries                                    525920  Trusts, Estates, & Agency 
442299  All Other Home Furnishings          Retailers (including tobacco,           512100  Motion Picture & Video                         Accounts 
        Stores                              candle, & trophy shops)                       Industries (except video rental)        525990  Other Financial Vehicles 
Electronics and Appliance Stores       Nonstore Retailers                           512200  Sound Recording Industries                     (including mortgage REITs & 
443141  Household Appliance Stores     454110  Electronic Shopping &                Broadcasting (except Internet)                         closed-end investment funds) 
443142  Electronics Stores (including       Mail-Order Houses                       515100  Radio & Television                    “Offices of Bank Holding Companies” 
        Audio, Video, Computer, and    454210  Vending Machine Operators                  Broadcasting                            and “Offices of Other Holding Companies” 
        Camera Stores)                 454310  Fuel Dealers (including Heating      515210  Cable & Other Subscription            are located under Management 
Building Material and Garden                           Oil and Liquefied Petroleum)       Programming                             of Companies (Holding Companies). 
Equipment and Supplies Dealers         454390  Other Direct Selling                 Telecommunications                            Real Estate and Rental and  
444110  Home Centers                        Establishments (including               517000  Telecommunications                    Leasing 
444120  Paint & Wallpaper Stores            door-to-door retailing, frozen                (including paging, cellular,            Real Estate 
                                            food plan providers, party                    satellite, cable & other program        531110  Lessors of Residential 
444130  Hardware Stores                     plan merchandisers, &                         distribution, resellers, other                   Buildings & Dwellings 
444190  Other Building Material             coffee-break service providers)               telecommunications, &                            (including equity REITs) 
        Dealers                        Transportation and                                 internet service providers)             531120  Lessors of Nonresidential 
444200  Lawn & Garden Equipment &      Warehousing                                  Data Processing Services                               Buildings (except 
        Supplies Stores                Air, Rail, and Water Transportation          518210  Data Processing, Hosting, &                    Miniwarehouses) (including 
Food and Beverage Stores               481000  Air Transportation                         Related Services                                 equity REITs) 
445110  Supermarkets and Other         482110  Rail Transportation                  Other Information Services                    531130  Lessors of Miniwarehouses & 
        Grocery (except                483000  Water Transportation                 519100  Other Information Services                     Self-Storage Units (including 
        Convenience) Stores            Truck Transportation                               (including news syndicates,                      equity REITs) 
445120  Convenience Stores             484110  General Freight Trucking,                  libraries, internet publishing &        531190  Lessors of Other Real Estate 
445210  Meat Markets                        Local                                         broadcasting)                                    Property (including equity  
445220  Fish & Seafood Markets         484120  General Freight Trucking,            Finance and Insurance                                  REITs) 
445230  Fruit & Vegetable Markets           Long-distance                           Depository Credit Intermediation              531210  Offices of Real Estate Agents 
445291  Baked Goods Stores             484200  Specialized Freight Trucking         522110  Commercial Banking                             & Brokers 
445292  Confectionery & Nut Stores     Transit and Ground Passenger                 522120  Savings Institutions                  531310  Real Estate Property 
445299  All Other Specialty Food       Transportation                               522130  Credit Unions                                  Managers 
        Stores                         485110  Urban Transit Systems                522190  Other Depository Credit               531320  Offices of Real Estate 
445310  Beer, Wine, & Liquor Stores    485210  Interurban & Rural Bus                     Intermediation                                   Appraisers 
Health and Personal Care Stores             Transportation                          Nondepository Credit Intermediation           531390  Other Activities Related to 
446110  Pharmacies & Drug Stores       485310  Taxi Service                         522210  Credit Card Issuing                            Real Estate 
446120  Cosmetics, Beauty Supplies,    485320  Limousine Service                    522220  Sales Financing                       Rental and Leasing Services 
        & Perfume Stores               485410  School & Employee Bus                522291  Consumer Lending                      532100  Automotive Equipment Rental & 
446130  Optical Goods Stores                Transportation                          522292  Real Estate Credit                             Leasing 
446190  Other Health & Personal        485510  Charter Bus Industry                       (including mortgage bankers &           532210  Consumer Electronics & 
        Care Stores                    485990  Other Transit & Ground                     originators)                                     Appliances Rental 
Gasoline Stations                           Passenger Transportation                522293  International Trade Financing         532281  Formal Wear & Costume Rental 
447100  Gasoline Stations (including   Pipeline Transportation                      522294  Secondary Market Financing            532282  Video Tape & Disc Rental 
        convenience stores with gas)   486000  Pipeline Transportation              522298  All Other Nondepository                
Clothing and Clothing Accessories      Scenic & Sightseeing Transportation                Credit Intermediation                    
Stores                                 487000  Scenic & Sightseeing                 Activities Related to Credit                   
448110  Men’s Clothing Stores               Transportation                          Intermediation                                 
448120  Women’s Clothing Stores                                                     522300  Activities Related to Credit           
448130  Children’s & Infants’ Clothing                                                    Intermediation (including loan           
        Stores                                                                            brokers, check clearing, &               
                                                                                          money transmitting)                      
                                                                                     
                                                                                    -95-

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Forms 5500, 5500-SF, and 5500-EZ Codes for Principal Business Activity (continued) 
Code                                    Code                                   Code                                            Code 
532283  Home Health Equipment           Administrative and Support and         Medical and Diagnostic Laboratories             Other Services 
      Rental                            Waste Management and                   621510  Medical & Diagnostic                    Repair and Maintenance 
532284  Recreational Goods Rental       Remediation Services                        Laboratories                               811110  Automotive Mechanical, & 
532289  All Other Consumer Goods        Administration and Support Services    Home Health Care Services                            Electrical Repair & 
      Rental                            561110  Office Administrative Services 621610  Home Health Care Services                    Maintenance 
532310  General Rental Centers          561210  Facilities Support Services    Other Ambulatory Health Care Services           811120  Automotive Body, Paint, 
532400  Commercial & Industrial         561300  Employment Services            621900  Other Ambulatory Health Care                 Interior, & Glass Repair 
      Machinery & Equipment             561410  Document Preparation Services       Services (including ambulance              811190  Other Automotive Repair & 
      Rental & Leasing                  561420  Telephone Call Centers              services & blood & organ banks)                 Maintenance (including oil 
Lessors of Nonfinancial Intangible      561430  Business Service Centers       Hospitals                                            change & lubrication shops & 
Assets (except copyrighted works)            (including private mail centers   622000  Hospitals                                    car washes) 
533110  Lessors of Nonfinancial              & copy shops)                     Nursing and Residential Care                    811210  Electronic & Precision 
      Intangible Assets (except         561440  Collection Agencies            Facilities                                           Equipment Repair & 
      copyrighted works)                561450  Credit Bureaus                 623000  Nursing & Residential Care                   Maintenance 
Professional, Scientific, and           561490  Other Business Support              Facilities                                 811310  Commercial & Industrial 
Technical Services                           Services (including               Social Assistance                                    Machinery & Equipment 
Legal Services                               repossession services, court      624100  Individual & Family Services                 (except Automotive & 
541110  Offices of Lawyers                   reporting, & stenotype            624200  Community Food & Housing, &                  Electronic) Repair & 
541190  Other Legal Services                 services)                              Emergency & Other Relief                        Maintenance 
Accounting, Tax Preparation,            561500  Travel Arrangement &                Services                                   811410  Home & Garden Equipment & 
Bookkeeping, and Payroll Services            Reservation Services              624310  Vocational Rehabilitation                    Appliance Repair & 
541211  Offices of Certified Public     561600  Investigation & Security            Services                                        Maintenance 
      Accountants                            Services                          624410  Child Day Care Services                 811420  Reupholstery & Furniture 
541213  Tax Preparation Services        561710  Exterminating & Pest Control   Arts, Entertainment, and                             Repair 
541214  Payroll Services                     Services                          Recreation                                      811430  Footwear & Leather Goods 
541219  Other Accounting Services       561720  Janitorial Services            Performing Arts, Spectator Sports,                   Repair 
Architectural, Engineering, and         561730  Landscaping Services           and Related Industries                          811490  Other Personal & Household 
Related Services                        561740  Carpet & Upholstery Cleaning   711100  Performing Arts Companies                    Goods Repair & Maintenance 
541310  Architectural Services               Services                          711210  Spectator Sports (including             Personal and Laundry Services 
541320  Landscape Architecture          561790  Other Services to Buildings &       sports clubs & racetracks)                 812111  Barber Shops 
      Services                               Dwellings                         711300  Promoters of Performing Arts,           812112  Beauty Salons 
541330  Engineering Services            561900  Other Support Services              Sports, & Similar Events                   812113  Nail Salons 
541340  Drafting Services                    (including packaging &            711410  Agents & Managers for                   812190  Other Personal Care 
541350  Building Inspection Services         labeling services, & convention        Artists, Athletes, Entertainers, &              Services (including diet & 
541360  Geophysical Surveying &              & trade show organizers)               Other Public Figures                            weight reducing centers) 
      Mapping Services                  Waste Management and                   711510  Independent Artists, Writers, &         812210  Funeral Homes & Funeral 
541370  Surveying & Mapping (except     Remediation Services                        Performers                                      Services 
      Geophysical) Services             562000  Waste Management and           Museums, Historical Sites, and Similar          812220  Cemeteries & Crematories 
541380  Testing Laboratories                 Remediation Services              Institutions                                    812310  Coin-Operated Laundries & 
Specialized Design Services             Educational Services                   712100  Museums, Historical Sites, &                 Drycleaners 
541400  Specialized Design Services     611000  Educational Services                Similar Institutions                       812320  Drycleaning & Laundry 
      (including interior, industrial,       (including schools, colleges,     Amusements, Gambling, and                            Services (except 
      graphic, & fashion design)             & universities)                   Recreation Industries                                Coin-Operated) 
Computer Systems Design and             Health Care and Social Assistance      713100  Amusement Parks & Arcades               812330  Linen & Uniform Supply 
Related Services                        Offices of Physicians and Dentists     713200  Gambling Industries                     812910  Pet Care (except Veterinary) 
541511  Custom Computer                 621111  Offices of Physicians (except  713900  Other Amusement &                            Services 
      Programming Services                   mental health specialists)             Recreation Industries                      812920  Photofinishing 
541512  Computer Systems Design         621112  Offices of Physicians, Mental       (including golf courses, skiing            812930  Parking Lots & Garages 
      Services                               Health Specialists                     facilities, marinas, fitness               812990  All Other Personal Services 
541513  Computer Facilities             621210  Offices of Dentists                 centers, & bowling centers)                Religious, Grantmaking, Civic, 
      Management Services               Offices of Other Health Practitioners  Accommodation and Food Services                 Professional, and Similar 
541519  Other Computer Related          621310  Offices of Chiropractors       Accommodation                                   Organizations 
      Services                          621320  Offices of Optometrists        721110  Hotels (except Casino Hotels) &         813000  Religious, Grantmaking, 
Other Professional, Scientific, and     621330  Offices of Mental Health            Motels                                          Civic, Professional, & Similar 
Technical Services                           Practitioners (except             721120  Casino Hotels                                Organizations (including 
541600  Management, Scientific, &            Physicians)                       721191  Bed & Breakfast Inns                         condominium and 
      Technical Consulting Services     621340  Offices of Physical,           721199  All other Traveler                           homeowners associations) 
541700  Scientific Research &                Occupational & Speech                  Accommodation                              813930  Labor Unions and Similar 
      Development Services                   Therapists, & Audiologists        721210  RV (Recreational Vehicle)                    Labor Organizations 
541800  Advertising & Related           621391  Offices of Podiatrists              Parks & Recreational Camps                 921000  Governmental Instrumentality 
      Services                          621399  Offices of all Other           721310  Rooming and Boarding Houses,                 or Agency 
541910  Marketing Research & Public          Miscellaneous Health                   Dormitories, and Workers’                   
      Opinion Polling                        Practitioners                          Camps                                       
541920  Photographic Services           Outpatient Care Centers                Food Services and Drinking Places                
541930  Translation & Interpretation    621410  Family Planning Centers        722300  Special Food Services                    
      Services                          621420  Outpatient Mental Health &                     (including food service          
541940  Veterinary Services                  Substance Abuse Centers                           contractors & caterers)          
541990  All Other Professional,         621491  HMO Medical Centers            722410  Drinking Places (Alcoholic               
      Scientific, & Technical           621492  Kidney Dialysis Centers                        Beverages)                       
      Services                          621493  Freestanding Ambulatory        722511  Full-Service Restaurants                 
Management of Companies                      Surgical & Emergency Centers      722513  Limited-Service Restaurants              
(Holding Companies)                     621498  All Other Outpatient Care      722514    Cafeterias and Buffets                 
                                                                               Beverage Bars 
551111  Offices of Bank Holding              Centers                           722515    Snack and Non-alcoholic                
      Companies                                                                                Beverage Bars                    
551112  Offices of Other Holding                                                                                                
      Companies                                                                                                                 
                                                                                                                                
                                                                               -96-

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ERISA COMPLIANCE QUICK CHECKLIST

Compliance with the Employee Retirement Income Security Act (ERISA) begins with knowing the rules. Plan administrators and
other plan officials can use this checklist as a quick diagnostic tool for assessing a plan’s compliance with certain important
ERISA rules; it is not a complete description of all ERISA’s rules and it is not a substitute for a comprehensive compliance
review. Use of this checklist is voluntary, and it is not to be filed with your Form 5500.

If you answer “No” to any of the questions below, you should review your plan’s operations because you may not be in
full compliance with ERISA’s requirements.

1. Have you provided plan participants with a summary plan description, summaries of any material modifications of the
plan, and annual summary financial reports or annual pension funding reports?

2. Do you maintain copies of plan documents at the principal office of the plan administrator for examination by
participants and beneficiaries?

3. Do you respond to written participant inquires for copies of plan documents and information within 30 days?

4. Does your plan include written procedures for making benefit claims and appealing denied claims, and are you
complying with those procedures?

5. Is your plan covered by fidelity bonds protecting the plan against losses due to fraud or dishonesty by persons who
handle plan funds or other property?

6. Are the plan’s investments diversified so as to minimize the risk of large losses?

7. If the plan permits participants to select the investments in their plan accounts, has the plan provided them with
enough information to make informed decisions?

8. Has a plan official determined that the investments are prudent and solely in the interest of the plan’s participants and
beneficiaries, and evaluated the risks associated with plan investments before making the investments?

9. Did the employer or other plan sponsor send participant contributions to the plan on a timely basis?

10. Did the plan pay participant benefits on time and in the correct amounts?

11. Did the plan give participants and beneficiaries 30 days advance notice before imposing a “blackout period” of at least
three consecutive business days during which participants or beneficiaries of a 401(k) or other individual account
pension plan were unable to change their plan investments, obtain loans from the plan, or obtain distributions from
the plan?

If you answer “Yes” to any of the questions below, you should review your plan’s operations because you may not be
in full compliance with ERISA’s requirements.

1. Has the plan engaged in any financial transactions with persons related to the plan or any plan official? (For example,
has the plan made a loan to or participated in an investment with the employer?)

2. Has a plan official used the assets of the plan for his/her own interest?

3. Have plan assets been used to pay expenses that were not authorized in the plan document, were not necessary for
the proper administration of the plan, or were more than reasonable in amount?

If you need help answering these questions or want additional guidance about ERISA requirements, a plan official
should contact the U.S. Department of Labor Employee Benefits Security Administration office in your region or consult
with the plan’s legal counsel or professional employee benefit advisor.

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- 98 -

Pension Benefit Plan - Who
Index H Must File ................................... 3
How to get assistance ................... 3 Pension Benefit Plan Filing
I Requirements ........................... 9
80-120 Participant Rule ………. ...... 8 Information Concerning Insurance Pension Schedule………….…… .. 8
103-12 Investment Entity Contract Coverage, Fees, and Plan Administrator ...................... 19
(103-12 IE) ............................... 12 Commissions ........................... 24 Plan Sponsor .............................. 18
Instructions to Form 5500 … ....... 16 Pooled Separate Account (PSA) 11
Instructions for Schedule A: Provision of Information .............. 26
A Who Must File .......................... 24
About the Form 5500 .................... 1 Instructions for Schedule C: Q
Additional Employer Information Who Must File .......................... 27 Quick Reference Chart of Form
for Multiemployer Defined Instructions for Schedule D: 5500, Schedules, and
Benefit Pension Plans .......... 74 Who Must File .......................... 32 Attachments…..………………14
Additional Information for Instructions for Schedule DCG:
Single-Employer and Who Must File .......................... 34
Multiemployer Defined Instructions for Schedule G: R
Benefit Pension Plans ......... 76 Who Must File .......................... 41 Reportable Transaction .............. 52
Amended Return/Report ............... 6 Instructions for Schedule H:
Amendments .............................. 74 Who Must File .......................... 43
Instructions for Schedule I: S
C Who Must File .......................... 55 Schedule of Reportable
Change in Plan Year ..................... 7 Instructions for Schedule MB: Transactions ....................... 52
Changes to Note ........................... 1 Statement by Enrolled Service Provider Information ...... 27
Combination Unfunded/Insured Actuary ................................. 63 Service Providers Who Fail or
Welfare Plan .............................. 4 Who Must File .......................... 63 Refuse To Provide
Common/Collective Trust ............ 11 Instructions for Schedule MEP: Information .......................... 30
Who Must File .......................... 71 Short Plan Year Rule ................... 8
Instructions for Schedule R: Signature and Date ...................... 7
D Who Must File .......................... 73 Small Plan Financial
Delinquent Filer Voluntary Instructions for Schedule SB: Information .......................... 55
Compliance (DFVC) Program ...... 5 Statement by Enrolled Special rule for certain
Defined Contribution Group Actuary ................................. 80 participant-directed
Reporting Arrangements (DCGs or Who Must File .......................... 79 transactions ......................... 52
DCG Report Arrangements ......... 12 Investment and Annuity Statement by Enrolled
Direct Filing Entity (DFE) – Who Contract Information ................ 25 Actuary ................................ 63
Must File .................................... 4
Direct Filing Entity (DFE) – Filing T
Requirements .......................... 11 L
Distributions ................................ 73 Leases in Default or Classified Telephone Assistance .................. 5
As Uncollectible ……………… . 41 Termination Information on
Limited Pension Plan Reporting .. 10 Accountants and Enrolled
E List of Plan Characteristic Codes 22 Actuaries ............................. 31
EFAST2 Processing System ......... 1 Loans or Fixed Income
Electronic Filing Requirement ....... 5 Obligations in Default or U
ESOP Information ....................... 74 Classified As Uncollectible....... 41 Unfunded Welfare Benefit Plan .... 4
Extension of Time to File............... 5

M W
F M-1 Compliance Information ....... 21 Welfare Benefit Contract
Final Return/Report: Master Trust Investment Information .......................... 26
Mergers/Consolidations ............. 7 Account (MTIA) ........................ 11 Welfare Benefit Plan – Who
Pension and Welfare Plans Must File ................................ 4
Terminated Without Welfare Benefit Plan Filing
Distributing All Assets ............ 7 N Requirements ..................... 10
Welfare Plans Still Liable to Pay Nonexempt Transactions ............ 38 What To File ................................. 8
Benefits .................................. 7 Notice to Terminated Accountant When To File:
Form 5500 Schedules ................... 8 or Enrolled Actuary .................. 31 DFEs other than GIAs ........... 5
Fully Insured Welfare Benefit Extensions ............................ 5
Plan ........................................... 4 O Plans and GIAs ..................... 5
Funding Information .................... 73 On-Line Assistance……………….3 Short Years ........................... 5
Who Must File .............................. 3

G P
General Schedules ....................... 9 Party-In-Interest ......................... 59
Group Insurance Arrangement Penalties:
(GIA) ........................................ 13 Administrative ........................... 8
Other ......................................... 8

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