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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 2022 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/ebsa/actuarialsearch.html for 2008 and short plan
requirements for the IRS and DOL. year 2009 actuarial information filed under the previous paper-
Defined contribution and defined benefit pension plans may based system.
have to file additional information with the IRS including Form Changes to Note
5330, Return of Excise Taxes Related to Employee Benefit
Plans, Form 5310-A, Notice of Plan Merger or Consolidation, Multiple-Employer Plans.
Spinoff, or Transfer of Plan Assets or Liabilities; Notice of • New plan characteristics codes have been added for Form
Qualified Separate Lines of Business, and Form 8955-SSA, 5500, Part II, line 8a, to identify different types of multiple-
Annual Registration Statement Identifying Separated employer defined contribution plans filing the Form 5500
Participants with Deferred Vested Benefits. See www.irs.gov (pooled employer plans, association retirement plans, PEO
for more information. multiple-employer plans, and other multiple-employer
Plans covered by the PBGC have special additional plans).
requirements, including premiums and reporting certain • Technical and conforming changes have been made to the
transactions directly with that agency. See PBGC’s website instructions for multiple-employer plan reporting (e.g.,
(www.pbgc.gov/practitioners/) for information on premium revising the instructions on identifying the “plan sponsor”
payments and reporting and disclosure. and “plan administrator”).
Each Form 5500 must accurately reflect the characteristics Administrative Penalties. The instructions have been
and operations that applied during the reporting year of the updated to reflect an increase in the maximum civil penalty
plan or arrangement. The requirements for completing the amount assessable under Employee Retirement Income
Form 5500 will vary according to the type of plan or Security Act section 502(c)(2), as required by the Federal Civil
arrangement. The section What To File summarizes what Penalties Inflation Adjustment Act Improvements Act of 2015.
information must be reported for different types of plans and Schedule MB. The instructions for line 3 have been revised to
arrangements. The Quick Reference Chart of Form 5500, require an attachment that breaks down total withdrawal
Schedules and Attachments, gives a brief guide to the annual liability payments made to the plan by date, specifying periodic
return/report requirements of the 2022 Form 5500. See also withdrawal liability amounts and lump sum withdrawal liability
the “Troubleshooters Guide to Filing the ERISA Annual amounts. Line 4f and its instructions have been clarified. Line
Reports” available on www.dol.gov/ebsa, which is intended to 6e and its instructions have been revised to reflect the

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movement of the salary scale item to line 6e from line 6f. Line Part II (Form 5500) – Basic Plan Information ............... 16
6f and its instructions have been revised to require the M-1 Compliance Information ........................................ 19
reporting of the interest rate used to determine the present Schedule A – Insurance Information ............................ 22
value of vested benefits for withdrawal liability determinations. Schedule C – Service Provider Information ................. 25
Line 6i and its instructions were moved from line 6e and Schedule D – DFE/Participating Plan Information ....... 30
revised to better understand how expense loads are Schedule G – Financial Transaction Schedules .......... 32
determined. The instructions for line 8b(1) have been revised Schedule H – Financial Information ............................. 34
to increase the projection period in the attachment to 50 years, Schedule I – Financial Information – Small Plan.......... 44
for plans with 1,000 or more participants. In addition, benefits Schedule MB – Multiemployer Defined Benefit Plan and
projections are broken down between active participants, Certain Money Purchase Plan Actuarial
terminated vested participants and participants in pay-status. Information ............................................................... 52
The instructions for line 8b(2) have been revised to require Schedule R – Retirement Plan Information .................. 60
plans to report average accrued monthly benefits as of the Schedule SB – Single-Employer Defined Benefit Plan
valuation date and removed the requirement to provide cash Actuarial Information ................................................ 65
balance account information. Line 8b(3) and its instructions Paperwork Reduction Act Notice ................................ 79
have been added to require plans with 1,000 or more Codes for Principal Business Activity ......................... 80
participants as of the beginning of the plan year to attach a 10- ERISA Compliance Quick Checklist ............................ 83
year projection of employer contributions and withdrawal Index ............................................................................... 84
liability payments. The attachments for lines 3 and 8b may be
provided in a spreadsheet file (CSV format).
Schedule R. Part V, Line 13 has been revised to require plans How To Get Assistance
to report identifying information about any participating If you need help completing this form or have related
employer who either contributed more than five percent of the questions, call the EFAST2 Help Desk at 1-866-GO-EFAST
plan’s total contributions or was one of the top-ten highest
contributors. (1-866-463-3278) (toll-free) or access the EFAST2 or IRS
websites. The EFAST2 Help Desk is available Monday through
Schedule SB. Part VI, Line 26 has been revised and now Friday from 8:00 am to 8:00 pm, Eastern Time.
consists of line 26a and a new line 26b. Line 26a is the same
as line 26 from the prior year. Line 26b requires an attachment You can access the EFAST2 website 24 hours a day, 7
of a projection of expected benefit payments. The attachments days a week at www.efast.dol.gov to:
for line 26 may be provided in a spreadsheet file (CSV format). • File the Form 5500-SF or 5500, and any needed schedules
Part IX, line 41 and its instructions, have been replaced to or attachments.
require filers to indicate the first plan year that the extended • Check on the status of a filing you submitted.
amortization rule was applied under American Rescue Plan Act • View filings posted by EFAST2.
of 2021. • Register for electronic credentials to sign or submit filings.
Table of Contents Page • View forms and related instructions.
Section 1: Who Must File ............................................... 2 • Get information regarding EFAST2, including approved
Pension Benefit Plan ..................................................... 2 software vendors.
Welfare Benefit Plan ..................................................... 3 • See answers to frequently asked questions about the Form
Direct Filing Entity (DFE) ............................................... 4 5500-SF, the Form 5500 and its schedules, and EFAST2.
Section 2: When To File.................................................. 4 • Access the main EBSA and DOL websites for news,
Extension of Time To File ............................................. 4 regulations, and publications.
Section 3: Electronic Filing Requirement ..................... 5 You can access the IRS website 24 hours a day, 7 days a
Amended Return/Report................................................ 6 week at www.irs.gov to:
Final Return/Report ....................................................... 6 • View forms, instructions, and publications.
Signature and Date ....................................................... 6 • See answers to frequently asked tax questions.
Change in Plan Year ..................................................... 7
Penalties........................................................................ 7 • Search publications online by topic or keyword.
Administrative Penalties .............................................. 7 • Send comments or request help by e-mail.
Other Penalties ............................................................ 7 • Sign up to receive local and national tax news by e-mail.
Section 4: What To File .................................................. 7 You can order other IRS forms and publications at
Form 5500 Schedules ................................................... 8 http://www.irs.gov/orderforms. You can order EBSA
Pension Schedules ................................................... 8 publications by calling 1-866-444-EBSA (3272).
General Schedules .................................................... 8
Pension Benefit Plan Filing Requirements .................... 8
Limited Pension Plan Reporting ................................. 9
Section 1: Who Must File
Welfare Benefit Plan Filing Requirements ..................... 9
Direct Filing Entity (DFE) Filing Requirements ............ 10 A return/report must be filed every year for every pension
Master Trust Investment Account (MTIA) ................ 10 benefit plan, welfare benefit plan, and for every entity that files
Common/Collective Trust (CCT) and Pooled as a DFE as specified below (pursuant to Code section 6058
Separate Account (PSA) .......................................... 11 and ERISA sections 104 and 4065).
103-12 Investment Entity (103-12 IE) ...................... 11 If you are a small plan (generally under 100 participants at
Group Insurance Arrangement (GIA)....................... 11 the beginning of the plan year), you may be eligible to file the
Quick Reference Chart of Form 5500, Schedules, and Form 5500-SF instead of the Form 5500. For more information,
Attachments ............................................................. 12 see the instructions to the Form 5500-SF.
Section 5: Line-by-Line Instructions for the 2022
Form 5500 and Schedules ........................................ 14 Pension Benefit Plan
Part I (Form 5500) – Annual Return/Report Identification All pension benefit plans covered by ERISA must file an annual
Information ............................................................... 14 return/report except as provided in this section. The return/

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report must be filed whether or not the plan is “tax-qualified,” 9. An individual retirement account or annuity not
benefits no longer accrue, contributions were not made this considered a pension plan under 29 CFR 2510.3-2(d).
plan year, or contributions are no longer made. Pension benefit 10. A governmental plan.
plans required to file include both defined benefit plans and 11. A “one-participant plan,” as defined below. However,
defined contribution plans. certain one-participant plans are required to file the Form
The following are among the pension benefit plans for 5500-EZ, Annual Return of A One-Participant
which a return/report must be filed. (Owners/Partners and Their Spouses) Retirement Plan or A
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 10 returns
custodial accounts established under Code section 403(b)(7) of any type with the IRS during the calendar year, including
for regulated investment company stock. For more information information returns (for example, Forms W-2 and Forms 1099),
regarding filing requirements for 403(b) plans subject to Title I income tax returns, employment tax returns, and excise tax
of ERISA, see Field Assistance Bulletins 2009-02 and 2010- returns. For more information on filing Form 5500-EZ, see the
01. Instructions for Form 5500-EZ, or go to www.irs.gov. For this
3. Individual retirement accounts (IRAs) established by an purpose, a “one-participant plan” is:
employer under Code section 408(c). a. a pension benefit plan that covers only an individual or
4. Church pension plans electing coverage under Code an individual and his or her spouse who wholly own a trade or
section 410(d). business, whether incorporated or unincorporated; or
5. Pension benefit plans that cover residents of Puerto b. a pension benefit plan for a partnership that covers only
Rico, the U.S. Virgin Islands, Guam, Wake Island, or American the partners or the partners and the partners’ spouses (treating
Samoa. This includes a plan that elects to have the provisions 2% shareholder of an S corporation, as defined in IRC
of section 1022(i)(2) of ERISA apply.
6. Plans that satisfy the Actual Deferral Percentage §1372(b), as a partner).
requirements of Code section 401(k)(3)(A)(ii) by adopting the See the instructions to the Form 5500-EZ for eligibility
‘‘SIMPLE’’ provisions of section 401(k)(11). conditions and filing requirements. For more information, go to
See What To File for more information about what must be www.irs.gov/ep.
completed for pension plans. Welfare Benefit Plan
Do Not File a Form 5500 for a Pension Benefit All welfare benefit plans covered by ERISA are required to file
Plan That Is Any of the Following: a Form 5500 except as provided in this section. Welfare benefit
1. An unfunded excess benefit plan. See ERISA section plans provide benefits such as medical, dental, life insurance,
4(b)(5). apprenticeship and training, scholarship funds, severance pay,
2. An annuity or custodial account arrangement under Code disability, etc. See What To File for more information.
sections 403(b)(1) or (7) not established or maintained by an Reminder: The administrator of an employee welfare benefit
employer as described in DOL Regulation 29 CFR 2510.3-2(f). plan that provides benefits wholly or partially through a
3. A Savings Incentive Match Plan for Employees of Small Multiple-Employer Welfare Arrangement (MEWA) as defined in
Employers (SIMPLE) that involves SIMPLE IRAs under Code ERISA section 3(40) must file a Form 5500, unless otherwise
section 408(p). exempt. Plans required to file a Form M-1, Report for Multiple-
4. A simplified employee pension (SEP) or a salary Employer Welfare Arrangements (MEWAs) and Certain
reduction SEP described in Code section 408(k) that conforms Entities Claiming Exception (ECEs), are not eligible for the
to the alternative method of compliance in 29 CFR 2520.104- filing exemption in 29 CFR 2520.104-20 described below.
48 or 2520.104-49. A SEP is a pension plan that meets certain Such plans are required to file the Form 5500 regardless of the
minimum qualifications regarding eligibility and employer plan size or type of funding.
contributions. Do Not File a Form 5500 for a Welfare Benefit
5. A church pension benefit plan not electing coverage
under Code section 410(d). Plan That Is Any of the Following:
6. A pension plan that is maintained outside the United 1. A welfare benefit plan that covered fewer than 100
States primarily for the benefit of persons substantially all of participants as of the beginning of the plan year and is
whom are nonresident aliens. However, certain foreign plans unfunded, fully insured, or a combination of insured and
are required to file the Form 5500-EZ on paper with the IRS or unfunded, and which is not subject to the Form M-1
electronically with EFAST2. A foreign plan must file the Form requirements under § 2520.101-2, as specified in 29 CFR
5500-EZ electronically with EFAST2 instead of filing a paper 2520.104-20.
Form 5500-EZ with the IRS, if the filer is required to file at least Note. To determine whether the plan covers fewer than 100
10 returns of any type with the IRS during the calendar year, participants for purposes of these filing exemptions for insured
including information returns (for example, Forms W-2 and and unfunded welfare plans, see instructions for lines 5 and 6
Forms 1099), income tax returns, employment tax returns, and on counting participants in a welfare plan. See also 29 CFR
excise tax returns. For more information on filing Form 5500- 2510.3-3(d).
EZ, see the Instructions for Form 5500-EZ, or go to a. An unfunded welfare benefit plan has its benefits paid as
www.irs.gov. needed directly from the general assets of the employer or
7. An unfunded pension plan for a select group of employee organization that sponsors the plan.
management or highly compensated employees that meets the Note. Plans that are NOT unfunded include those plans that
requirements of 29 CFR 2520.104-23, including timely filing of received employee (or former employee) contributions during
a registration statement with the DOL. the plan year and/or used a trust or separately maintained fund
8. An unfunded dues financed pension benefit plan that (including a Code section 501(c)(9) trust) to hold plan assets or
meets the alternative method of compliance provided by 29 act as a conduit for the transfer of plan assets during the year.
CFR 2520.104-27. A welfare benefit plan with employee contributions that is
associated with a cafeteria plan under Code section 125 may

General Instructions to Form 5500 --3

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be treated for annual reporting purposes as an unfunded Note. Special requirements also apply to Schedules D and H
welfare plan if it meets the requirements of DOL Technical attached to the Form 5500 filed by plans participating in
Release 92-01, 57 Fed. Reg. 23272 (June 2, 1992) and 58 MTIAs, CCTs, PSAs, and 103-12 IEs. See these schedules
Fed. Reg. 45359 (Aug. 27, 1993). The mere receipt of COBRA and their instructions.
contributions or other after-tax participant contributions (e.g.,
retiree contributions) by a cafeteria plan would not by itself
affect the availability of the relief provided for cafeteria plans Section 2: When To File
that otherwise meet the requirements of DOL Technical
Release 92-01. See 61 Fed. Reg. 41220, 41222-23 (Aug. 7, Plans and GIAs. File 2022 returns/reports for plan and GIA
1996). years that began in 2022. All required forms, schedules,
b. A fully insured welfare benefit plan has its benefits statements, and attachments must be filed by the last day of
provided exclusively through insurance contracts or policies, the 7th calendar month after the end of the plan or GIA year
the premiums of which must be paid directly to the insurance (not to exceed 12 months in length) that began in 2022. If the
carrier by the employer or employee organization from its plan or GIA year differs from the 2022 calendar year, fill in the
general assets or partly from its general assets and partly from fiscal year beginning and ending dates in the space provided.
contributions by its employees or members (which the DFEs other than GIAs. File 2022 returns/reports no later than
employer or employee organization forwards within three (3) 9½ months after the end of the DFE year that ended in 2022. A
months of receipt). The insurance contracts or policies Form 5500 filed for a DFE must report information for the DFE
discussed above must be issued by an insurance company or year (not to exceed 12 months in length). If the DFE year
similar organization (such as Blue Cross, Blue Shield or a differs from the 2022 calendar year, fill in the fiscal year
health maintenance organization) that is qualified to do beginning and ending dates in the space provided.
business in any state. Short Years. For a plan year of less than 12 months (short
c. A combination unfunded/insured welfare benefit plan has plan year), file the form and applicable schedules by the last
its benefits provided partially as an unfunded plan and partially day of the 7th calendar month after the short plan year ends or
as a fully insured plan. An example of such a plan is a welfare by the extended due date, if filing under an authorized
benefit plan that provides medical benefits as in aabove and extension of time. Fill in the short plan year beginning and
life insurance benefits as in babove. See 29 CFR 2520.104- ending dates in the space provided and check the appropriate
20. box in Part I, line B, of the Form 5500. For purposes of this
2. A welfare benefit plan maintained outside the United return/report, the short plan year ends on the date of the
States primarily for persons substantially all of whom are change in accounting period or upon the complete distribution
nonresident aliens. of assets of the plan. Also see the instructions for Final Return/
3. A governmental plan. Report to determine if “the final return/report” box in line B
4. An unfunded or insured welfare benefit plan maintained should be checked.
for a select group of management or highly compensated
employees, which meets the requirements of 29 CFR Notes. (1)If the filing due date falls on a Saturday, Sunday, or
Federal holiday, the return/report may be filed on the next day
2520.104-24.
that is not a Saturday, Sunday, or Federal holiday.
5. An employee benefit plan maintained only to comply with (2) If the
2023 Form 5500 is not available before the plan or DFE filing is
workers’ compensation, unemployment compensation, or
due, use the 2022 Form 5500 and enter the 2023 fiscal year
disability insurance laws.
beginning and ending dates on the line provided at the top of
6. A welfare benefit plan that participates in a group
the form.
insurance arrangement that files a Form 5500 on behalf of the
welfare benefit plan as specified in 29 CFR 2520.103-2. See Extension of Time To File Using Form 5558
29 CFR 2520.104-43. A plan or GIA may obtain a one-time extension of time to file a
7. An apprenticeship or training plan meeting all of the Form 5500 Annual Return/Report (up to 2½ months) by filing
conditions specified in 29 CFR 2520.104-22. IRS Form 5558, Application for Extension of Time To File
8. An unfunded dues financed welfare benefit plan Certain Employee Plan Returns, on or before the normal due
exempted by 29 CFR 2520.104-26. date (not including any extensions) of the return/report. You
9. A church plan under ERISA section 3(33). MUST file Form 5558 with the IRS. Approved copies of the
10. A welfare benefit plan maintained solely for (1) an Form 5558 will not be returned to the filer. A copy of the
individual or an individual and his or her spouse, who wholly completed extension request must, however, be retained withe
own a trade or business, whether incorporated or the filer’s records.
unincorporated, or (2) partners or the partners and the
partners’ spouses in a partnership. See 29 CFR 2510.3-3(b). File Form 5558 with the Department of the Treasury,
Internal Revenue Service Center, Ogden, UT 84201-0045.
Direct Filing Entity (DFE) Using Extension of Time To File Federal Income Tax
Some plans participate in certain trusts, accounts, and other Return
investment arrangements that file the Form 5500 Annual
Return/Report as a DFE in accordance with the Direct Filing An automatic extension of time to file the Form 5500 Annual
Entity (DFE) Filing Requirements. A Form 5500 must be filed Return/Report until the due date of the federal income tax
for a master trust investment account (MTIA). A Form 5500 is return of the employer will be granted if all of the following
not required but may be filed for a common/collective trust conditions are met: (1) the plan year and the employer’s tax
(CCT), pooled separate account (PSA), 103-12 investment year are the same; (2) the employer has been granted an
entity (103-12 IE), or group insurance arrangement (GIA). extension of time to file its federal income tax return to a date
Plans that participate in CCTs, PSAs, 103-12 IEs, or GIAs that later than the normal due date for filing the Form 5500; and (3)
file as DFEs, however, generally are eligible for certain annual a copy of the application for extension of time to file the federal
reporting relief. For reporting purposes, a CCT, PSA, income tax return is maintained with the filer’s records. An
103-12 IE, or GIA is not considered a DFE unless a Form 5500 extension granted by using this automatic extension procedure
and all required attachments are filed for it in accordance with CANNOT be extended further by filing a Form 5558, nor can it
the Direct Filing Entity (DFE) Filing Requirements. be extended beyond a total of 9½ months beyond the close of
the plan year.
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Note. A tax-exempt organization is not required to file a pursuant to ERISA sections 104 and 106. Even though the
federal income tax return. However, if the organization uses a Form 5500 must be filed electronically, the administrator must
Form 8868 to request an extension for its Form 990 series keep a copy of the Form 5500, including schedules and
return, the filer is automatically granted an extension of time to attachments, with all required signatures on file as part of the
file the Form 5500 until the extended due date of filing Form plan’s records and must make a paper copy available upon
990 series if all conditions listed above are met. An extension request to participants, beneficiaries, and the DOL as required
granted by using this automatic extension procedure cannot be by section 104 of ERISA and 29 CFR 2520.103-1. Filers may
extended beyond a total of 9½ months beyond the close of the use electronic media for record maintenance and retention, so
plan year. long as they meet the applicable requirements. (See 29 CFR
Note. An extension of time to file the Form 5500 does not 2520.107-1).
operate as an extension of time to file a Form 5500 filed for a Note. Effective for plan years beginning after 2019, a one-
DFE (other than a GIA), to file PBGC premiums or annual participant plan or a foreign plan can file Form 5500-EZ
financial and actuarial reports (if required by section 4010 of electronically using the EFAST2 filing system. Information filed
ERISA) or to file the Form 8955-SSA (Annual Registration on Form 5500-EZ using EFAST2 is required to be made
Statement Identifying Separated Participants with Deferred available to the public. However, information filed with EFAST2
Vested Benefits) (required to be filed with the IRS under Code using Form 5500-EZ will not be published on the internet.
section 6057(a)). Generally, questions on the Form 5500 relate to the plan
Other Extensions of Time year entered at the top of the first page of the form. Therefore,
answer all questions on the 2022 Form 5500 with respect to
The IRS, DOL, and PBGC may announce special extensions the 2022 plan year unless otherwise explicitly stated in the
of time under certain circumstances, such as extensions for instructions or on the form itself.
Presidentially-declared disasters or for service in, or in support
of, the Armed Forces of the United States in a combat zone. Your entries must be in the proper format in order for the
See www.irs.gov, www.efast.dol.gov, and EFAST2 system to process your filing. For example, if a
www.pbgc.gov/practitioners for announcements regarding such question requires you to enter a dollar amount, you cannot
special extensions. If you are relying on one of these enter a word. Your software will not let you submit your return/
announced special extensions, check the appropriate box on report unless all entries are in the proper format. To reduce the
Form 5500, Part I, line D, and enter a description of the possibility of correspondence and penalties:
announced authority for the extension. • Complete all lines on the Form 5500 unless otherwise
Delinquent Filer Voluntary Compliance (DFVC) specified. Also complete and electronically attach, as required,
applicable schedules and attachments.
Program • Do not enter “N/A” or “Not Applicable” on the Form 5500
The DFVC Program facilitates voluntary compliance by plan unless specifically permitted. “Yes” or “No” questions on the
administrators who are delinquent in filing annual reports under forms and schedules cannot be left blank, unless specifically
Title I of ERISA by permitting administrators to pay reduced permitted. Answer either “Yes” or “No,” but not both.
civil penalties for voluntarily complying with their DOL annual
reporting obligations. If the Form 5500 is being filed under the All schedules and attachments to the Form 5500 must be
DFVC Program, check the appropriate box in Form 5500, Part properly identified, and must include the name of the plan or
I, line D, to indicate that the Form 5500 is being filed under the DFE, EIN, and plan number (PN) as found on the Form 5500,
DFVC Program. See www.efast.dol.gov for additional lines, 1a, 2b, and 1b, respectively. At the top of each
information. attachment, indicate the schedule and line, if any (e.g.,
Schedule H, line 4i) to which the attachment relates.
Plan administrators are reminded that they can use the
online calculator available at Check your return/report for errors before signing or
www.dol.gov/ebsa/calculator/dfvcpmain.html to compute the submitting it to EFAST2. Your filing software or, if you are
penalties due under the program. Payments under the DFVC using it, the EFAST2 web-based filing system will allow you to
Program also may be submitted electronically. For information check your return/report for errors. If, after reasonable attempts
on how to pay DFVC Program payments online, go to to correct your filing to eliminate any identified problem or
www.dol.gov/ebsa. problems, you are unable to address them, or you believe that
you are receiving the message in error, call the EFAST2 Help
Filers who wish to participate in the DFVC Program for Desk at 1-866-GO-EFAST (1-866-463-3278) or contact the
plan years prior to 2020 must use the 2022 version of service provider you used to help prepare and file your annual
Form 5500 or, if applicable, Form 5500-SF. Use the Form 5500 return/report.
Version Selection Tool available at www.efast.dol.gov for
further information. Once you complete the return/report and finish the
electronic signature process, you can electronically submit it to
EFAST2. When you electronically submit your return/report,
EFAST2 is designed to immediately notify you if your
Section 3: Electronic Filing Requirement submission was received and whether the return/report is
Under the computerized ERISA Filing Acceptance System ready to be processed by EFAST2. If EFAST2 does not notify
(EFAST2), you must file your 2022 Form 5500 Annual Return/ you that your submission was successfully received and is
Report electronically. You may file online using EFAST2’s web- ready to be processed, you will need to take steps to correct
based filing system or you may file through an EFAST2- the problem or you may be deemed a non-filer subject to
approved vendor. Detailed information on electronic filing is penalties from DOL, IRS, and/or PBGC.
available at www.efast.dol.gov. For telephone assistance, call Once EFAST2 receives your return/report, the EFAST2
the EFAST2 Help Desk at 1-866-GO-EFAST (1-866-463- system should be able to provide a filing status within 20
3278). The EFAST2 Help Desk is available Monday through minutes. The person submitting the filing should check back
Friday from 8:00 am to 8:00 pm, Eastern Time. into the EFAST2 system to determine the filing status of your
Annual returns/reports filed under Title I of ERISA must return/report. The filing status message will include a list of any
be made available by plan administrators to plan filing errors or warnings that EFAST2 may have identified in
participants and beneficiaries and by the DOL to the public your filing. If EFAST2 did not identify any filing errors or
General Instructions to Form 5500 --5

- 6 -

warnings, EFAST2 will show the filing status of your return/          under a welfare benefit plan have been satisfied, check the 
report as “Filing Received.” Persons other than the submitter         final return/report box in Part I, line B at the top of the Form 
can check whether the filing was received by the system by            5500. Do not mark the final return/report box if you are 
calling the EFAST2 Help Desk at 1-866-GO-EFAST (1-866-                reporting participants and/or assets at the end of the plan year. 
463-3278) and using the automated telephone system.                   If a trustee is appointed for a terminated defined benefit plan 
  To reduce the possibility of correspondence and penalties           pursuant to ERISA section 4042, the last plan year for which a 
from the DOL, IRS, and/or PBGC, you should do the following:          return/report must be filed is the year in which the trustee is 
(1) Before submitting your return/report to EFAST2, check it for      appointed. If you are in this situation you may contact 
errors, and (2) after you have submitted it to EFAST2, verify         PBGCTrusteedPlan@dol.gov for further information. 
that you have received a filing status of “Filing Received” and       Examples: 
attempt to correct and resolve any errors or warnings listed in 
the status report.                                                    Mergers/Consolidations 
Note. Even after being received by the EFAST2 system, your            A final return/report should be filed for the plan year (12 
return/report filing may be subject to further detailed review by     months or less) that ends when all plan assets were legally 
DOL, IRS, and/or PBGC, and your filing may be deemed                  transferred to the control of another plan. 
deficient based upon this further review. See Penalties on            Pension and Welfare Plans That Terminated Without  
Page 7.                                                               Distributing All Assets 
       Do not enter social security numbers in response to            If the plan was terminated, but all plan assets were not 
       questions asking for an employer identification number         distributed, a return/report must be filed for each year the plan 
(EIN). Because of privacy concerns, the inclusion of a social         has assets. The return/report must be filed by the plan 
security number or any portion thereof on the Form 5500 or on         administrator, if designated, or by the person or persons who 
a schedule or attachment that is open to public inspection may        actually control the plan’s assets/property. 
result in the rejection of the filing. If you discover a filing        
disclosed on the EFAST2 website that contains a social                Welfare Plans Still Liable To Pay Benefits 
security number, immediately call the EFAST2 Help Desk at 1-
866-GO-EFAST (1-866-463-3278).                                        A welfare plan cannot file a final return/report if the plan is still 
                                                                      liable to pay benefits for claims that were incurred prior to the 
    Employers without an EIN must apply for one as soon as            termination date, but not yet paid. See 29 CFR 2520.104b-
possible. The EBSA does not issue EINs. To apply for an EIN           2(g)(2)(ii). 
from the IRS:  
• Mail or fax Form SS-4, Application for Employer Identification      Signature and Date 
Number, obtained at http://www.irs.gov/orderforms.                    For purposes of Title I of ERISA, the plan administrator is 
• See https://www.IRS.gov/Businesses and click on “Employer           required to file the Form 5500. If the plan administrator does 
ID Numbers” for additional information. The EIN is issued             not sign a filing, the filing status will indicate that there is an 
immediately once the application information is validated. (The       error with your filing, and your filing will be subject to further 
online application process is not yet available for corporations      review, correspondence, rejection, and civil penalties.  
with addresses in foreign countries or Puerto Rico.) 
                                                                      The plan administrator must electronically sign the Form 5500 
  Do not attach a copy of the annual registration statement           or 5500-SF submitted to EFAST2.   
(IRS Form 8955-SSA) identifying separated participants with 
deferred vested benefits, or a previous year’s Schedule SSA                After submitting your filing, you must check the Filing 
(Form 5500) to your 2022 Form 5500 Annual Return/Report.                   Status. If the filing status is "Processing Stopped" or 
The annual registration statement must be filed directly with         “Unprocessable”, it is possible your submission was not sent 
the IRS and cannot be attached to a Form 5500 submission              with a valid electronic signature as required, and depending on 
with EFAST2.                                                          the error, may be considered not to have been filed. By looking 
                                                                      closer at the Filing Status, you can see specific error 
Amended Return/Report                                                 messages applicable to the transmitted filing and determine 
File an amended return/report to correct errors and/or                whether it was sent with a valid electronic signature and what 
omissions in a previously filed annual return/report for the 2022     other errors may need to be corrected. 
plan year. The amended Form 5500 and any amended                      Note. If the plan administrator is an entity, the electronic 
schedules and/or attachments must conform to the                      signature must be in the name of a person authorized to sign 
requirements in these instructions. See the DOL website at            on behalf of the plan administrator. 
www.efast.dol.gov for information on filing amended returns/          Authorized Service Provider Signatures. A statement for 
reports for prior years.                                              service providers that use this electronic signature option is in 
     Check the line B box for “an amended return/report” if you       the IFILE application. The statement provides that, by signing 
     filed a previous 2022 annual return/report that was given a      the electronic filing, the service provider is attesting: (1) that 
“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, 

                                                                  -6-                         General Instructions to Form 5500

- 7 -

employer/plan sponsor’s, or DFE’s manual signature will be report. See ERISA section 502(c)(2), 29 CFR 2560.502c-2,
included with the rest of the return/report posted by the and the Federal Civil Penalties Inflation Adjustment Act of
Department of Labor on the Internet for public disclosure; and 1990, as amended by the Federal Civil Penalties Inflation
(5) that the service provider will communicate to the plan Adjustment Act Improvements Act of 2015 (2015 Inflation
administrator, employer/plan sponsor, or DFE, as applicable, Adjustment Act). Pub. L. No. 114-74; 129 Stat. 599 and the
any inquiries and information received from EFAST2, DOL, DOL’s implementing regulation at 87 FR 2328 (Jan. 14, 2022).
IRS or PBGC regarding the return/report. The 2015 Inflation Adjustment Act requires agencies to adjust
Note. The Code permits either the plan sponsor/employer or the levels of civil monetary penalties with an initial catch-up
the administrator to sign the filing. However, any Form 5500 adjustment, followed by annual adjustments for
that is not electronically signed by the plan administrator will be inflation. Because the Federal Civil Penalties Inflation
subject to rejection and civil penalties under Title I of ERISA. Adjustment Improvements Act of 2015 (Pub. L. No. 114-74;
129 Stat. 599), requires the penalty amount to be adjusted
For DFE filings, a person authorized to sign on behalf of the annually after the Form 5500 and its schedules, attachments,
DFE must sign for the DFE. and instructions are published for filing, be sure to check
The Form 5500 Annual Return/Report must be filed DOL’s website for any possible required inflation adjustments
electronically and signed. To obtain an electronic signature, go of the maximum penalty amount that may have been published
to www.efast.dol.gov and register in EFAST2 as a signer. You in the Federal Register after the instructions have been posted.
will be provided with a UserID and PIN. Both the UserID and 2. A penalty of $250 a day (up to $150,000) for not filing
PIN are needed to sign the Form 5500. The plan administrator returns for certain plans of deferred compensation, trusts and
must keep a copy of the Form 5500, including schedules and annuities, and bond purchase plans by the due date(s). See
attachments with all required signatures on file as part of the Code section 6652(e).
plan’s records. See 29 CFR 2520.103-1. 3. A penalty of $1,000 for each failure to file an actuarial
Electronic signatures on annual returns/reports filed under statement (Schedule MB (Form 5500) or Schedule SB (Form
EFAST2 are governed by the applicable statutory and 5500)) required by the applicable instructions. See Code
regulatory requirements. section 6692.
Other Penalties
Change in Plan Year 1. Any individual who willfully violates any provision of Part
Generally, only defined benefit pension plans need to get 1 of Title I of ERISA shall on conviction be fined not more than
approval for a change in the plan year. See Code section $100,000 or imprisoned not more than 10 years, or both. See
412(d)(1). However, under Revenue Procedure 87-27, 1987-1 ERISA section 501.
C.B. 769, these pension plans may be eligible for automatic 2. A penalty up to $10,000, five (5) years imprisonment, or
approval of a change in plan year. both, may be imposed for making any false statement or
If a change in plan year for a pension or welfare benefit plan representation of fact, knowing it to be false, or for knowingly
creates a short plan year, file the form and applicable concealing or not disclosing any fact required by ERISA. See
schedules by the last day of the 7th calendar month after the section 1027, Title 18, U.S. Code, as amended by section 111
short plan year ends or by the extended due date, if filing of ERISA.
under an authorized extension of time. Fill in the short plan
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 Section 4: What To File
5500. For purposes of this return/report, the short plan year
ends on the date of the change in accounting period or upon The Form 5500 reporting requirements vary depending on
the complete distribution of assets of the plan. Also, see the whether the Form 5500 is being filed for a ‘‘large plan,’’ a
instructions for the Final Return/Report to determine if “final ‘‘small plan,’’ and/or a DFE, and on the particular type of plan
return/report” in line B should be checked. or DFE involved (e.g., welfare plan, pension plan,
common/collective trust (CCT), pooled separate account
Penalties (PSA), master trust investment account (MTIA), 103-12 IE, or
Plan administrators and plan sponsors must provide complete group insurance arrangement (GIA)).
and accurate information and must otherwise comply fully with The instructions below provide detailed information about
the filing requirements. ERISA and the Code provide for the each of the Form 5500 schedules and which plans and DFEs
DOL and the IRS, respectively, to assess or impose penalties are required to file them.
for not giving complete and accurate information and for not The schedules are grouped in the instructions by type:
filing complete and accurate statements and returns/reports. (1) Pension Benefit Schedules and (2) General Schedules.
Certain penalties are administrative (i.e., they may be imposed Each schedule is listed separately with a description of the
or assessed by one of the governmental agencies delegated to subject matter covered by the schedule and the plans and
administer the collection of the annual return/report data). DFEs that are required to file the schedule.
Others require a legal conviction.
Filing requirements also are listed by type of filer:
Administrative Penalties (1) Pension Benefit Plan Filing Requirements; (2) Welfare
Listed below are various penalties under ERISA and the Code Benefit Plan Filing Requirements; and (3) DFE Filing
that may be assessed or imposed for not meeting the annual Requirements. For each filer type there is a separate list of the
return/report filing requirements. Generally, whether the schedules that must be filed with the Form 5500 (including
penalty is under ERISA or the Code, or both, depends upon where applicable, separate lists for large plan filers, small plan
the agency for which the information is required to be filed. filers, and different types of DFEs).
One or more of the following administrative penalties may be The filing requirements also are summarized in a “Quick
assessed or imposed in the event of incomplete filings or filings Reference Chart of Form 5500, Schedules, and Attachments.”
received after the due date unless it is determined that your Generally, a return/report filed for a pension benefit plan or
failure to file properly is for reasonable cause: welfare benefit plan that covered fewer than 100 participants
1. A penalty of up to $2,400 a day for each day a plan as of the beginning of the plan year should be completed
administrator fails or refuses to file a complete and accurate following the requirements below for a “small plan,” and a
General Instructions to Form 5500 --7

- 8 -

return/report filed for a plan that covered 100 or more                  unfunded/insured welfare plans, as described in 29 CFR 
participants as of the beginning of the plan year should be              2520.104-44(b)(1) and certain pension plans and 
completed following the requirements below for a “large plan.”           arrangements, as described in 29 CFR 2520.104-44(b)(2) and 
 Use the number of participants required to be entered in line           in Limited Pension Plan Reporting, are exempt from 
5 of the Form 5500 to determine whether a plan is a “small               completing the Schedule H. 
plan” or “large plan.”                                                   Schedule I (Financial Information - Small Plan) – is 
Exceptions:                                                              required for all pension benefit plans and welfare benefit plans 
                                                                         filing the Form 5500 Annual Return/Report, rather than the 
 (1) 80-120 Participant Rule: If the number of participants              Form 5500-SF, as ‘‘small plans,’’ except for certain pension 
reported on line 5 is between 80 and 120, and a Form 5500                benefit plans and arrangements described in 29 CFR 
Annual Return/Report was filed for the prior plan year, you may          2520.104-44(b)(2) and Limited Pension Plan Reporting. For 
elect to complete the return/report in the same category (‘‘large        additional information, see the Schedule I instructions. 
plan’’ or ‘‘small plan’’) as was filed for the prior return/report. 
Thus, if a Form 5500-SF or a Form 5500 Annual Return/Report              Note. A welfare plan that would have been eligible for the filing 
was filed for the 2021 plan year as a small plan, including the          exemption under 29 CFR 2520.104-20, but for the fact that it is 
Schedule I if applicable, and the number entered on line 5 of            required to file a Form M-1, is exempt from completing a 
the 2022 Form 5500 is 120 or less, you may elect to complete             Schedule I if it meets the requirements of 29 CFR 2520.104-
the 2022 Form 5500 and schedules in accordance with the                  44(b)(1). 
instructions for a small plan, including for eligible filers, filing     Schedule A (Insurance Information) – is required if any 
the Form 5500-SF instead of the Form 5500.                               benefits under an employee benefit plan are provided by an 
 (2) Short Plan Year Rule: If the plan had a short plan year             insurance company, insurance service or other similar 
of seven (7) months or less for either the prior plan year or the        organization (such as Blue Cross, Blue Shield, or a health 
plan year being reported on the 2022 Form 5500, an election              maintenance organization). This includes investment contracts 
can be made to defer filing the accountant’s report in                   with insurance companies, such as guaranteed investment 
accordance with 29 CFR 2520.104-50. If such an election was              contracts and pooled separate accounts. For additional 
made for the prior plan year, the 2022 Form 5500 must be                 information, see the Schedule A instructions. 
completed following the requirements for a large plan,                   Note. Do not file Schedule A for Administrative Services Only 
including the attachment of the Schedule H and the                       (ASO) contracts. Do not file Schedule A if a Schedule A is filed 
accountant’s reports, regardless of the number of participants           for the contract as part of the Form 5500 filed directly by a 
entered in Part II, line 5.                                              master trust investment account (MTIA) or 103-12 IE. 
Form 5500 Schedules                                                      Schedule C (Service Provider Information) – is required for 
                                                                         a large plan, MTIA, 103-12 IE, or GIA if (1) any service 
Pension Schedules                                                        provider who rendered services to the plan or DFE during the 
Schedule R (Retirement Plan Information) – is required for a             plan or DFE year received $5,000 or more in compensation, 
pension benefit plan that is a defined benefit plan or is                directly or indirectly from the plan or DFE, or (2) an accountant 
otherwise subject to Code section 412 or ERISA section 302.              and/or enrolled actuary has been terminated. For additional 
Schedule R may also be required for certain other pension                information, see the Schedule C instructions. 
benefit plans unless otherwise specified under limited Pension           Schedule D (DFE/Participating Plan Information) – Part I is 
Plan Reporting. For additional information, see the Schedule R           required for a plan or DFE that invested or participated in any 
instructions.                                                            MTIAs, 103-12 IEs, CCTs, and/or PSAs. Part II is required 
Schedule MB (Multiemployer Defined Benefit Plan and                      when the Form 5500 is filed for a DFE. For additional 
Certain Money Purchase Plan Actuarial Information) – is                  information, see the Schedule D instructions. 
required for most multiemployer defined benefit plans and for            Schedule G (Financial Transaction Schedules) – is required 
defined contribution pension plans that currently amortize a             for a large plan, MTIA, 103-12 IE, or GIA when Schedule H 
waiver of the minimum funding requirements specified in the              (Financial Information) lines 4b, 4c, and/or 4d are checked 
instructions for the Schedule MB. For additional information,            ‘‘Yes.’’ Part I of the Schedule G reports loans or fixed income 
see the instructions for the Schedule MB and the Schedule R.             obligations in default or classified as uncollectible. Part II of the 
Schedule SB (Single-Employer Defined Benefit Plan                        Schedule G reports leases in default or classified as 
Actuarial Information) – is required for most single-employer            uncollectible. Part III of the Schedule G reports nonexempt 
defined benefit plans, including multiple-employer defined               transactions. For additional information, see the Schedule G 
benefit pension plans. For additional information, see the               instructions. 
instructions for the Schedule SB.                                             An unfunded, fully insured, or combination unfunded/ 
General Schedules                                                             insured welfare plan with 100 or more participants 
                                                                         exempt under 29 CFR 2520.104-44 from completing Schedule 
Schedule H (Financial Information) – is required for pension             H must still complete Schedule G, Part III, to report nonexempt 
benefit plans and welfare benefit plans filing as “large plans”          transactions. 
and for all DFE filings. Employee benefit plans, 103-12 IEs, 
and GIAs filing the Schedule H are generally required to                 Pension Benefit Plan Filing 
engage an independent qualified public accountant (IQPA) and 
attach a report of the IQPA pursuant to ERISA section                    Requirements 
103(a)(3)(A). These plans and DFEs are also generally                    Pension benefit plan filers must complete the Form 5500 
required to attach to the Form 5500 a “Schedule of Assets                Annual Return/Report, including the signature block and, 
(Held At End of Year),” and, if applicable, a “Schedule of               unless otherwise specified, attach the following schedules and 
Assets (Acquired and Disposed of Within Year),” a                        information: 
“Schedule of Reportable Transactions,” and a “Schedule                   Small Pension Plan 
of Delinquent Participant Contributions.” For additional 
information, see the Schedule H instructions.                            The following schedules (including any additional information 
                                                                         required by the instructions to the schedules) must be attached 
Exceptions: Insured, unfunded, or combination 
                                                                     -8-                       General Instructions to Form 5500

- 9 -

to a Form 5500 filed for a small pension plan that is neither              accounts or annuities (as described in Code section 408) as 
exempt from filing nor is filing the Form 5500-SF:                         the sole funding vehicle for providing pension benefits need 
1.  Schedule A (as many as needed), to report insurance,                   complete only Form 5500, Part I and Part II, lines 1 through 4, 
annuity, and investment contracts held by the plan.                        and 8 (enter pension feature code 2N). 
2.  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 participated 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 
3.  Schedule I, to report small plan financial information,                conditions of 29 CFR 2520.104-44(b)(2) during the entire plan 
unless exempt.                                                             year must complete all the requirements listed under this 
4.  Schedule MB or SB, to report actuarial information, if                 Pension Benefit Plan Filing Requirements section, except that 
applicable.                                                                such a plan is exempt from attaching Schedule H, Schedule I, 
5.  Schedule R, to report retirement plan information, if                  and an independent qualified public accountant’s opinion, and 
applicable.                                                                from the requirement to engage an IQPA.  
   If Schedule I, line 4k, is checked “No,” you must attach                  A pension benefit plan that has insurance contracts of the 
   the report of the independent qualified public accountant               type described in 29 CFR 2520.104-44 as well as other assets 
(IQPA) or a statement that the plan is eligible and elects to              must complete all requirements for a pension benefit plan, 
defer attaching the IQPA’s opinion pursuant to 29 CFR                      except that the value of the plan’s allocated contracts (see 
2520.104-50 in connection with a short plan year of seven                  below) should not be reported in Part I of Schedule H or I. All 
months or less.                                                            other assets should be reported on Schedule H or Schedule I, 
                                                                           and any other required schedules. If Schedule H is filed, attach 
Large Pension Plan                                                         an accountant’s report in accordance with the Schedule H 
The following schedules (including any additional information              instructions. 
required by the instructions to the schedules) must be attached 
to a Form 5500 filed for a large pension plan:                             Note. For purposes of the annual return/report and the 
                                                                           alternative method of compliance set forth in 29 CFR 
1.  Schedule A (as many as needed), to report insurance, 
                                                                           2520.104-44, a contract is considered to be ‘‘allocated’’ only if 
annuity, and investment contracts held by the plan.  
                                                                           the insurance company or organization that issued the contract 
2.  Schedule C, if applicable, to report information on service 
                                                                           unconditionally guarantees, upon receipt of the required 
providers and, if applicable, any terminated accountants or 
                                                                           premium or consideration, to provide a retirement benefit of a 
enrolled actuaries.  
                                                                           specified amount. This amount must be provided to each 
3.  Schedule D, Part I, to list any CCTs, PSAs, MTIAs, and 
                                                                           participant without adjustment for fluctuations in the market 
103-12 IEs in which the plan invested at any time during the 
                                                                           value of the underlying assets of the company or organization, 
plan year. 
                                                                           and each participant must have a legal right to such benefits, 
4.  Schedule G, to report loans or fixed income obligations in 
                                                                           which is legally enforceable directly against the insurance 
default or determined to be uncollectible as of the end of the 
                                                                           company or organization. For example, deposit administration, 
plan year, leases in default or classified as uncollectible, and 
                                                                           immediate participation guarantee, and guaranteed investment 
nonexempt transactions, i.e., file Schedule G if Schedule H 
                                                                           contracts are NOT allocated contracts for Form 5500 Annual 
(Form 5500) lines 4b, 4c, and/or 4d are checked ‘‘Yes.’’ 
                                                                           Return/Report purposes. 
5.  Schedule H, to report large plan financial information, 
unless exempt.                                                             Welfare Benefit Plan Filing Requirements 
6.  Schedule MB or SB, to report actuarial information, if                 Welfare benefit plan filers must complete the Form 5500 
applicable.                                                                Annual Return/Report, including the signature block and, 
7.  Schedule R, to report retirement plan information, if                  unless otherwise specified, attach the following schedules and 
applicable.                                                                information: 
Eligible Combined Plans                                                    Small Welfare Plan 
Section 903 of PPA established rules for a new type of pension             The following schedules (including any additional information 
plan, an “eligible combined plan,” effective for plan years                required by the instructions to the schedules) must be attached 
beginning after December 31, 2009. See Code section 414(x)                 to a Form 5500 filed for a small welfare plan that is neither 
and ERISA section 210(e). An eligible combined plan consists               exempt from filing nor filing the Form 5500-SF:  
of a defined benefit plan and a defined contribution plan that               1.  Schedule A (as many as needed), to report insurance 
includes a qualified cash or deferred arrangement under Code               contracts held by the plan. 
section 401(k), with the assets of the two plans held in a single            2.  Schedule D, Part I, to list any CCTs, PSAs, MTIAs, and 
trust, but clearly identified and allocated between the plans.             103-12 IEs in which the plan participated at any time during the 
The eligible combined plan design is available only to                     plan year. 
employers that employed an average of at least two, but not                  3.  Schedule I, to report small plan financial information. 
more than 500 employees, on business days during the 
                                                                                A welfare plan that covered fewer than 100 participants 
calendar year preceding the plan year as of which the eligible 
                                                                                as of the beginning of the plan year and is required to file 
combined plan is established and that employs at least two 
                                                                           a Form M-1, Report for Multiple-Employer Welfare 
employees on the first day of the plan year that the plan is 
established. Because an eligible combined plan includes both               Arrangements (MEWAs) and Certain Entities Claiming 
                                                                           Exception (ECEs), is exempt from attaching Schedule I if the 
a defined benefit plan and a defined contribution plan, the 
                                                                           plan meets the requirements of 29 CFR 2520.104-44. 
Form 5500 filed for the plan must include all the information, 
                                                                           However, Schedule G, Part III, must be attached to the Form 
schedules, and attachments that would be required for either a 
defined benefit plan (such as a Schedule SB) or a defined                  5500 to report any nonexempt transactions.  
contribution plan.                                                         Large Welfare Plan  
Limited Pension Plan Reporting                                             The following schedules (including any additional information 
The pension benefit plans or arrangements described below                  required by the instructions to the schedules) must be attached 
are eligible for limited annual reporting:                                 to a Form 5500 filed for a large welfare plan: 
                                                                             1. Schedule A (as many as needed), to report insurance and 
1. IRA Plans: A pension plan using individual retirement 
General Instructions to Form 5500                                      --9

- 10 -

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

-10- General Instructions to Form 5500

- 11 -

attachments must be properly labeled. by, or maintained pursuant to a collective-bargaining
agreement negotiated by, the same employee organization or
Common/Collective Trust (CCT) and Pooled affiliated employee organizations. For purposes of this
Separate Account (PSA) paragraph, an ‘‘affiliate’’ of an employee organization means
A Form 5500 is not required to be filed for a CCT or PSA. any person controlling, controlled by, or under common control
However, the administrator of a large plan or DFE that with such organization. See 29 CFR 2520.103-12.
participates in a CCT or PSA that files as specified below is The Form 5500 submitted for a 103-12 IE must comply with
entitled to reporting relief that is not available to plans or DFEs the Form 5500 instructions for a Large Pension Plan, unless
participating in a CCT or PSA for which a Form 5500 is not otherwise specified in the forms and instructions. The
filed. 103-12 IE must file:
For reporting purposes, ‘‘common/collective trust’’ and 1. Form 5500, except lines C, D, 1c, 2d, and 5 through 9.
‘‘pooled separate account’’ are, respectively: (1) a trust Enter ‘‘E’’ in part I, line A, as the DFE code.
maintained by a bank, trust company, or similar institution or 2. Schedule A (as many as needed), to report insurance,
(2) an account maintained by an insurance carrier, which is annuity and investment contracts held by the 103-12 IE.
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
Note. For reporting purposes, a separate account that is not 103-12 IE year, leases in default or classified as uncollectible,
considered to be holding plan assets pursuant to 29 CFR and nonexempt transactions.
2510.3-101(h)(1)(iii) does not constitute a pooled separate 6. Schedule H, except lines 1b(1), 1b(2), 1c(8), 1d, 1e, 1g,
account. 1h, 1i, 2a, 2b(1)(E), 2e, 2f, 2g, 4a, 4e, 4f, 4g, 4h, 4j, 4k, 4l, 4m,
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 3c, 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 Group Insurance Arrangement (GIA)
code.
2. Schedule D, to list all CCTs, PSAs, MTIAs, and Each welfare benefit plan that is part of a group insurance
103-12 IEs in which the CCT or PSA invested at any time arrangement is exempt from the requirement to file a Form
during the CCT or PSA year and to list in Part II all plans that 5500 if a consolidated Form 5500 report for all the plans in the
participated in the CCT or PSA during its year. arrangement was filed in accordance with 29 CFR 2520.104-
3. Schedule H, except lines 1b(1), 1b(2), 1c(8), 1d, 1e, 1g, 43. For reporting purposes, a ‘‘group insurance arrangement’’
1h, 1i, 2a, 2b(1)(E), 2e, 2f, and 2g, to report financial provides benefits to the employees of two or more unaffiliated
information. Part IV and an accountant’s (IQPA’s) opinion are employers (not in connection with a multiemployer plan or a
not required for a CCT or PSA. collectively-bargained multiple-employer plan), fully insures
one or more welfare plans of each participating employer, uses
Different requirements apply to the Schedules D and H a trust or other entity as the holder of the insurance contracts,
attached to the Form 5500 filed by plans and DFEs and uses a trust as the conduit for payment of premiums to the
participating in CCTs and PSAs, depending upon whether a insurance company. The GIA must file:
DFE Form 5500 has been filed for the CCT or PSA. See the
instructions for these schedules. 1 . Form 5500, except lines C and 2d. (Enter ‘‘G’’ in Part I,
line A, as the DFE code).
103-12 Investment Entity (103-12 IE) 2. Schedule A (as many as needed), to report insurance,
DOL Regulation 2520.103-12 provides an alternative method annuity and investment contracts held by the GIA.
of reporting for plans that invest in an entity (other than an 3. Schedule C, if applicable, to report service provider
MTIA, CCT, or PSA), whose underlying assets include ‘‘plan information and any terminated accountants.
assets’’ within the meaning of 29 CFR 2510.3-101 of two or 4. Schedule D, to list all CCTs, PSAs, and 103-12 IEs in
more plans that are not members of a ‘‘related group’’ of which the GIA invested at any time during the GIA year, and to
employee benefit plans. Such an entity for which a Form 5500 list all plans that participated in the GIA during its year.
is filed constitutes a ‘‘103-12 IE.’’ A Form 5500 is not required 5. Schedule G, to report loans or fixed income obligations in
to be filed for such entities; however, filing a Form 5500 as a default or determined to be uncollectible as of the end of the
103-12 IE provides certain reporting relief, including the GIA year, leases in default or classified as uncollectible, and
limitation of the examination and report of the independent nonexempt transactions.
qualified public accountant (IQPA) provided by 29 CFR 6. Schedule H, except lines 4a, 4e, 4f, 4g, 4h, 4k, 4m, 4n,
2520.103-12(d), to participating plans and DFEs. For this and 5, to report financial information.
reporting purpose, a ‘‘related group’’ of employee benefit plans 7. Additional information required by the instructions to the
consists of each group of two or more employee benefit plans above schedules, including, for example, the report of the
(1) each of which receives 10% or more of its aggregate independent qualified public accountant (IQPA) identified on
contributions from the same employer or from a member of the Schedule H, line 3c, the schedules of assets held for
same controlled group of corporations (as determined under investment and the schedule of reportable transactions. All
Code section 1563(a), without regard to Code section attachments must be properly labeled.
1563(a)(4) thereof); or (2) each of which is either maintained

General Instructions to Form 5500 -11-

- 12 -

Quick Reference Chart of Form 5500, Schedules, and Attachments (Not
1
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, or
Information) contracts. contracts. 4 contracts. contracts. 4 GIA has insurance
contracts.

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

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

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

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

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

-12- General Instructions to Form 5500

- 13 -

Large Small Large Welfare Small Welfare
Pension Plan Pension Plan2 Plan Plan2 DFE

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
multiple-employer multiple-employer
Schedule SB defined benefit plan, defined benefit plan, Not required. Not required. Not required.
(Actuarial including an eligible including an eligible
Information) combined plan and combined plan and
subject to minimum subject to minimum
funding standards. funding standards.

Not required unless
Accountant’s Must attach. Schedule I, line 4k, is Must attach. 3 Not required. Must attach for a
Report checked “No.” GIA or 103-12 IE.

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

General Instructions to Form 5500 -13-

- 14 -

Section 5: Line-by-Line Note. Do not check this box if all of the employers maintaining
the plan are members of the same controlled group or affiliated
Instructions for the 2022 service group under Code sections 414(b), (c), or (m).
Form 5500 and Schedules Participating Employer Information. Multiple-employer plans
required to file a Form 5500 must include an attachment using
Part I – Annual Return/Report Identification the format below. The attachment must be properly identified
Information at the top with the label “Multiple-Employer Plan Participating
File the 2022 Form 5500 Annual Return/Report for a plan year Employer Information,” and the name of the plan, EIN, and
that began in 2022 or a DFE year that ended in 2022. Enter the plan number (PN) as found on the plan’s Form 5500. Complete
beginning and ending dates in Part I. The 2022 Form 5500 as many entries as needed to report the required information
Annual Return/Report must be filed electronically. for all participating employers in the plan.
One Form 5500 is generally filed for each plan or entity • Except as provided below, all multiple-employer plans must
described in the instructions to the boxes in line A. Do not complete elements 1-3 of the “Multiple-Employer Plan
check more than one box. Participating Employer Information” attachment. For element
3, enter a good faith estimate of each employer’s percentage
A separate Form 5500, with line A (single-employer plan) of the total contributions (including employer and participant
checked, must be filed by each employer participating in a plan contributions) made by all participating employers during the
or program of benefits in which the funds attributable to each year. The percentage may be rounded to be nearest whole
employer are available to pay benefits only for that employer’s percentage. To the extent the rounding results in the total
employees, even if the plan is maintained by a controlled reported percentage being either slightly above or slightly
group. below 100 percent, the filer can indicate that on the
A “controlled group” is generally considered one employer attachment. Any employer who was obligated to make
for Form 5500 reporting purposes. A “controlled group” is a contributions to the plan for the plan year, made
controlled group of corporations under Code section 414(b), a contributions to the plan for the plan year, or whose
group of trades or businesses under common control under employees were covered under the plan is a “participating
Code section 414(c), or an affiliated service group under Code employer” for this purpose. If a participating employer made
section 414(m). no contributions, enter “-0-” in element 3.
Line A – Box for Multiemployer Plan. Check this box if the • Multiple-employer pension plans that are defined
Form 5500 is filed for a multiemployer plan. A plan is a contribution plans must also complete element 4 of the
multiemployer plan if: (a) more than one employer is required “Multiple-Employer Plan Participating Employer Information”
to contribute, (b) the plan is maintained pursuant to one or attachment to report the aggregate account balances for
more collective bargaining agreements between one or more each participating employer determined as the sum of the
employee organizations and more than one employer; (c) an account balances of the employees of such employer (and
election under Code section 414(f)(5) and ERISA section the beneficiaries of such employees). For element 4, the
3(37)(E) has not been made; and (d) the plan meets any other aggregate account balance attributable to each employer is
applicable conditions of 29 CFR 2510.3-37. A plan that has the sum of the account balances of the employees of such
made a proper election under ERISA section 3(37)(G) and employer and their beneficiaries at the end of the year.
Code section 414(f)(6) on or before August 17, 2007, is also a Consistent with the information on the schedules of assets
multiemployer plan. Participating employers do not file for the plan as a whole, use the end of year valuation to
individually for these plans. calculate the amount of assets by employer. The amounts
Line A – Box for Single-Employer Plan. Check this box if can be rounded to the nearest dollar, consistent with other
the Form 5500 is filed for a single-employer plan. A single- asset reporting on the forms and schedules.
employer plan for this Form 5500 reporting purpose is an • Multiple-employer welfare plans that are unfunded, fully
employee benefit plan maintained by one employer or one insured, or a combination of unfunded/insured and exempt
employee organization. under 29 CFR 2520.104-44 from the obligation to file
Line A – Box for Multiple-Employer Plan. Check this box if financial statements with their annual report are required to
the Form 5500 is being filed for a multiple-employer plan. A complete elements 1 and 2 only of the “Multiple-Employer
multiple-employer plan is a plan that is maintained by more Plan Participating Employer Information” attachment.
than one employer and is not one of the plans already • Multiple-employer pension plans that are pooled employer
described. A multiple-employer plan can be collectively plans must also complete the “Pooled Employer Plan/Pooled
bargained and collectively funded, but if covered by PBGC Plan Provider Information” attachment. The attachment may
termination insurance, must have properly elected before be attached as part of the “Multiple-Employer Plan
September 27, 1981, not to be treated as a multiemployer plan Participating Employer Information” attachment or as a
under Code section 414(f)(5) or ERISA sections 3(37)(E) and separate attachment entitled “Pooled Employer Plan
4001(a)(3), and have not revoked that election or made an Information.” For element 1b, AckID is the acknowledgement
election to be treated as a multiemployer plan under Code code generated by the system in response to a completed
section 414(f)(6) or ERISA section 3(37)(G). A single Form Form PR submitted. The instructions to the Form PR advise
5500 Annual Return/Report is filed for the multiple-employer the pooled plan provider that it must keep, under ERISA
plan; participating employers do not file individually for this type section 107, the electronic receipt for the Form PR filing as
of plan. part of the records of the pooled employer plans operated by
A pooled employer plan as defined in ERISA section 3(44) the pooled plan provider.
operated by a “pooled plan provider” that meets the definition
under ERISA section 3(43) is a multiple-employer plan.

-14- Instructions for Part I and Part II of Form 5500

- 15 -

Multiple-Employer Plan Participating Employer Type of entity Enter the letter
Information

(Insert Name of Plan and EIN/PN as shown on the 5500) Master Trust M
1. Name of 2. 3. Percent of 4. Aggregate Investment Account
participating EIN Total Account Balances at Common/Collective Trust C
employer Contributions End of Year
for Plan Year Attributable to Pooled Separate P
Participating Account
Employer 103-12 Investment E
Entity
Group Insurance
1. Name of 2. 3. Percent of 4. Aggregate Arrangement G
participating EIN Total Account Balances at
employer Contributions End of Year Note. A separate annual report with “M” entered as the DFE
for Plan Year Attributable to code on Form 5500, line A, must be filed for each MTIA. See
Participating instructions on page 10.
Employer Line B – Box for First Return/Report. Check this box if an
annual return/report has not been previously filed for this plan
1. Name of 2. 3. Percent of 4. Aggregate or DFE. For the purpose of completing this box, the Form
participating EIN Total Account Balances at 5500-EZ is not considered an annual return/report.
employer Contributions End of Year Line B – Box for Amended Return/Report. Check this box if
for Plan Year Attributable to you have already filed for the 2022 plan year and are now filing
Participating an amended return/report to correct errors and/or omissions on
Employer the previously filed return/report. See instructions on page 6.
Check the line B box for an “amended return/report” if you
filed a previous 2022 annual return/report that was given a
1. Name of 2. 3. Percent of 4. Aggregate
participating EIN Total Account Balances at “Filing_Received,” “Filing_Error,” or “Filing_Stopped” status by
employer Contributions End of Year EFAST2. Do not check the line B box for an “amended
return/report” if your previous submission attempts were not
for the Plan Attributable to
successfully received by EFAST2 because of problems with the
Year Participating
Employer transmission of your return/report. For more information, go to
the EFAST2 website at www.efast.dol.gov or call the EFAST2
Help Desk at 1-866-GO-EFAST (1-866-463-3278).
1. Name of 2. 3. Percent of 4. Aggregate Line B – Box for Final Return/Report. Check this box if this
participating EIN Total Account Balances at Form 5500 is the last annual return/report required to be
employer Contributions End of Year submitted for this plan. (See Final Return/Report.)
for the Plan Attributable to Do not check box B (Final Return/Report) if “4R” is
Note.
Year Participating entered on line 8b for a welfare plan that is not required to file
Employer a Form 5500 for the next plan year because the welfare plan
has become eligible for an annual reporting exemption. For
Complete as many rows as needed to report the example, certain unfunded and insured welfare plans may be
required information for all participating employers in required to file the 2022 Form 5500 and be exempt from filing a
the plan. Form 5500 for the plan year 2023 if the number of participants
covered as of the beginning of the 2023 plan year drops below
100. See Who Must File. Should the number of participants
Pooled Employer Plan/Pooled Plan Provider Information covered by such a plan increase to 100 or more in a future
(Insert Name of Plan and EIN/PN as shown on the year, the plan must resume filing Form 5500 and enter ‘‘4S’’ on
Form 5500) line 8b on that year’s Form 5500. See 29 CFR 2520.104-20.
Only pooled employer plans complete . 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
1a. Is the pooled plan provider currently in compliance with less than 12 months. Provide the dates in Part I, Plan Year
the requirements for filing the Form PR (Pooled Plan Beginning and Ending.
Provider Registration Statement)? (See Form PR
Instructions and 29 CFR 2510.3-44.) [] Yes [] No Line C – Box for Collectively-Bargained Plan. Check this
box when the contributions to the plan and/or the benefits paid
1b. If “Yes” is checked in line 1a, enter the AckID for the by the plan are subject to the collective bargaining process
most recent Form PR that was required to be filed under the (even if the plan is not established and administered by a joint
Form PR filing requirements. (Failure to enter a valid AckID board of trustees and even if only some of the employees
will subject the Form 5500 filing to rejection as incomplete.) covered by the plan are members of a collective bargaining
AckID ______________________ unit that negotiates contributions and/or benefits). The
contributions and/or benefits do not have to be identical for all
employees under the plan.
Line A –Box for Direct Filing Entity (DFE). Check this box Line D – Box for Extension and DFVC Program. Check the
and enter the correct letter from the following chart in the appropriate box here if:
space provided to indicate the type of entity.
• You filed for an extension of time to file this form with the

Instructions for Part I and Part II of Form 5500 -15-

- 16 -

IRS using a completed Form 5558, Application for Extension Part II, line 8b is completed 501 to the first plan or GIA.
of Time To File Certain Employee Plan Returns (maintain a and 8a is not checked, or Consecutively number others
copy of the Form 5558 with the filer’s records); Part I, line A, for a DFE is as 502, 503…
• You are filing using the automatic extension of time to file checked and a G is entered
Form 5500 until the due date of the federal income tax return
of the employer (maintain a copy of the employer’s extension Exception. If Part II, line 8a is completed and 333 (or a higher
of time to file the income tax return with the filer’s records); number in a sequence beginning with 333) was previously
• You are filing using a special extension of time to file the assigned to the plan, that number may be entered on line 1b.
Form 5500 that has been announced by the IRS, DOL, and Line 1c. Enter the date the plan first became effective.
PBGC. If you checked that you are using a special extension of Limit your response to the information required in
Line 2a.
time, enter a description of the extension of time in the space each row as specified below:
provided.
• You are filing under DOL’s Delinquent Filer Voluntary 1. Enter the name of the plan sponsor or, in the case of a
Compliance (DFVC) Program. Form 5500 filed for a DFE, the name of the insurance
company, financial institution, or other sponsor of the DFE
Line E – Box for a retroactively adopted plan as permitted (e.g., in the case of a GIA, the trust or other entity that holds
by SECURE Act section 201. Check this box if the plan the insurance contract, or in the case of an MTIA, one of the
sponsor adopted the plan during the 2022 plan year (i.e., by
the due date, including extension, for filing the plan sponsor’s sponsoring employers). If the plan covers only the employees
tax return for the 2021 taxable year) and elected to treat the of one employer, enter the employer’s name.
plan as having been adopted before the 2022 plan year began The term ‘‘plan sponsor’’ means:
(i.e., at the close as of the last day of the sponsor’s taxable • The employer, for an employee benefit plan that a single
year) as permitted by section 201 of the Setting Every employer established or maintains;
Community Up for Retirement Enhancement Act of 2019 • The employee organization, in the case of a plan of an
(SECURE ACT). Plans in this situation are not required to file a employee organization;
2021 Form 5500. However, if the plan is a defined benefit • The association, committee, joint board of trustees, or other
pension plan, the 2021 Schedule SB (Form 5500) must be
included as an attachment to the 2022 Schedule SB (Form similar group of representatives of the parties who establish or
5500) as part of the 2022 Form 5500. Please see Instructions maintain the plan, if the plan is established or maintained
for Schedule SB for more information. jointly by one or more employers and one or more employee
organizations, or by two or more employers;
Part II – Basic Plan Information • The pooled plan provider that operates the plan, in the case
Line 1a. Enter the formal name of the plan or DFE or enough of a pooled employer plan that meets the definition under
information to identify the plan or DFE. Abbreviate if ERISA section 3(43); or
necessary. If an annual return/report has previously been filed • The professional employer organization (PEO), in the case
on behalf of the plan, regardless of the type of form that was of a PEO multiple-employer plan that meets the conditions
filed (Form 5500, Form 5500-EZ, or Form 5500-SF), use the under 29 CFR 2510.3-55(c).
same name or abbreviation as was used on the prior filings. Note. In the case of a multiple-employer plan, file only one
Once you use an abbreviation, continue to use it for that plan annual return/report for the plan. If an association, pooled plan
on all future annual return/report filings with the IRS, DOL, and provider, PEO or other entity is not the sponsor, enter the
PBGC. Do not use the same name or abbreviation for any name of a participating employer as sponsor. A plan of a
other plan, even if the first plan is terminated. If the plan has controlled group of corporations should enter the name of one
changed its name from the prior year filing(s), complete line 4 of the sponsoring members. In either case, the same name
to indicate that the plan was previously identified by a different must be used in all subsequent filings of the Form 5500 for the
name. multiple-employer plan or controlled group (see instructions to
Line 1b. Enter the three-digit plan or entity number (PN) the line 4 concerning change in sponsorship).
employer or plan administrator assigned to the plan or DFE. 2. Enter any ‘‘in care of’’ (C/O) name.
This three-digit number, in conjunction with the employer 3. Enter the current street address. A post office box
identification number (EIN) entered on line 2b, is used by the number may be entered if the Post Office does not deliver mail
IRS, DOL, and PBGC as a unique 12-digit number to identify to the sponsor’s street address.
the plan or DFE. 4. Enter the name of the city.
Start at 001 for plans providing pension benefits, plans 5. Enter the two-character abbreviation of the U.S. state or
providing pension and welfare benefits, or DFEs as illustrated possession and zip code.
in the table below. Start at 501 for plans providing only welfare 6. Enter the foreign routing code, if applicable. Leave U.S.
benefits and GIAs. Do not use 888 or 999. state and zip code blank if entering a foreign routing code and
Once you use a plan or DFE number, continue to use it for country name.
that plan or DFE on all future filings with the IRS, DOL, and 7. Enter the foreign country, if applicable.
PBGC. Do not use it for any other plan or DFE, even if the first 8. Enter the D/B/A (the doing business as) or trade name of
plan or DFE is terminated. the sponsor if different from the plan sponsor’s name.
9. Enter any second address. Use only a street address

here, not a P.O. Box.
For each Form 5500 Assign PN
Note. Use the IRS Form 8822-B, Change of Address or
with the same EIN Responsible Party – Business, to notify the IRS if the address
(line 2b), when
provided here is a change in your business mailing address or
your business location.
Part II, line 8a is 001 to the first plan or DFE.
completed, or Part I, line A, Consecutively number others Line 2b. Enter the nine-digit employer identification number
for a DFE is checked and as 002, 003… (EIN) assigned to the plan sponsor/employer, for example, 00-
an M, C, P, or E is entered 1234567. In the case of a DFE, enter the employer

-16- Instructions for Part I and Part II of Form 5500

- 17 -

identification number (EIN) assigned to the CCT, PSA, MTIA, • The person or group of persons specified as the
103-12 IE, or GIA. administrator by the instrument under which the plan is
Do not use a social security number in lieu of an EIN. The operated;
Form 5500 is open to public inspection, and the contents are • The pooled plan provider that operates the plan, in the
public information and are subject to publication on the case of a pooled employer plan that meets the definition
Internet. Because of privacy concerns, the inclusion of a social under ERISA section 3(43);
security number or any portion thereof on this line may result in • The professional employer organization (PEO), in the case
the rejection of the filing. of a PEO multiple-employer plan that meets the conditions
Employers without an EIN must apply for one as soon as under 29 CFR 2510.3-55(c);
possible. The EBSA does not issue EINs. To apply for an EIN • The plan sponsor/employer if an administrator is not so
from the IRS: designated; or
• Any other person prescribed by regulations if an
• Mail or fax Form SS-4, Application for Employer administrator is not designated and a plan sponsor cannot
Identification Number, obtained at www.irs.gov/orderforms. be identified.
• See https://www.IRS.gov/Businesses and click on
“Employer ID Numbers” for additional information. The EIN is 2. Enter any “in care of” (C/O) name.
issued immediately once the application information is 3. Enter the current street address. A post office box
validated. (The online application process is not yet available number may be entered if the Post Office does not deliver mail
for corporations with addresses in foreign countries or Puerto to the administrator’s street address.
Rico.) 4. Enter the name of the city.
5. Enter the two-character abbreviation of the U.S. state or
A multiple-employer plan or plan of a controlled group of possession and zip code.
corporations should use the EIN of the sponsor identified in 6. Enter the foreign routing code and foreign country, if
line 2a. The EIN must be used in all subsequent filings of the applicable. Leave U.S. state and zip code blank if entering
Form 5500 for these plans (see instructions to line 4 foreign routing code and country information.
concerning change in EIN).
Line 3b. Enter the plan administrator’s nine-digit EIN. A plan
If the plan sponsor is a group of individuals, get a single EIN administrator must have an EIN for Form 5500 reporting
for the group. When you apply for the EIN, provide the name of purposes. If the plan administrator does not have an EIN, apply
the group, such as ‘‘Joint Board of Trustees of the Local 187 for one as explained in the instructions for line 2b. One EIN
Machinists’ Retirement Plan.’’ (If filing Form SS-4, enter the should be entered for a group of individuals who are,
group name on line 1.) collectively, the plan administrator.
Note. EINs for funds (trusts or custodial accounts) associated Line 3c. Enter the telephone number for the plan
with plans (other than DFEs) are generally not required to be administrator. Use numbers only, including area code, and do
furnished on the Form 5500; the IRS will issue EINs for such not include any special characters.
funds for other reporting purposes. EINs may be obtained as
explained above. Plan sponsors should use the trust EIN Note. Employees of the plan sponsor who perform
described above when opening a bank account or conducting administrative functions for the plan are generally not the plan
other transactions for a trust that require an EIN. administrator unless specifically designated in the plan
document. If an employee of the plan sponsor is designated as
Line 2c. Enter the telephone number for the plan sponsor. the plan administrator, that employee must get an EIN.
Use numbers only, including area code, and do not include any
special characters. In the case of a pooled employer plan, information for the
pooled employer plan and the pooled plan provider
Line 2d. Enter the six-digit business code from the list of operating the plan reported on the Form 5500 must match the
business codes on pages 80, 81, and 82 that: information reported on the Form PR. Failure to report the
• In the case of a single-employer plan, best describes the same information could result in correspondence from the
primary nature of the plan sponsor’s business, and Department of Labor or the Internal Revenue Service.
• In the case of a multiemployer plan, best describes the Line 4. If the plan sponsor’s or DFE’s name and/or EIN have
predominant industry in which the active participants are changed or the plan name has changed since the last
employed (e.g., 484120 - General Freight Trucking, Long- return/report was filed for this plan or DFE, enter the plan
distance, 236110 - Residential Building Construction). sponsor’s or DFE’s name, EIN, the plan name, and the plan
Do not enter code 525100 (Insurance & Employee Benefit number as it appeared on the last return/report filed.
Funds) or 813930 (Labor Unions and Similar Labor The failure to indicate on line 4 that a plan sponsor was
Organizations) unless the predominant industry in which the previously identified by a different name or a different
active participants are employed is the industry of insurance employer identification number (EIN) or that the plan name has
and employee benefit funds, or labor unions and similar labor been changed could result in correspondence from the DOL
organizations. and/or the IRS.
Line 3a. Please limit your response to the information Lines 5 and 6. All filers must complete both lines 5 and 6
required: unless the Form 5500 is filed for an IRA Plan described in
1. Enter the name and address of the plan administrator Limited Pension Plan Reporting or for a DFE. Note. Welfare
unless the administrator is the sponsor identified in line 2. If plans complete only lines 5, 6a(1), 6a(2), 6b, 6c, and 6d.
both the plan administrator name and address are the same as The description of ‘‘participant’’ in the instructions below is
the plan sponsor name and address, check the “Same as Plan only for purposes of these lines.
Sponsor” box and disregard items 2 through 6 below. If the An individual becomes a participant covered under an
Form 5500 is submitted for a DFE, check the appropriate box employee welfare benefit plan on the earliest of:
in Part I, line A, and enter the appropriate DFE code. • the date designated by the plan as the date on which the
The term “plan administrator” means: individual begins participation in the plan;

Instructions for Part I and Part II of Form 5500 -17-

- 18 -

• the date on which the individual becomes eligible under the insurance company has made an irrevocable commitment to
plan for a benefit subject only to occurrence of the contingency pay all the benefits to which the individual is entitled under the
for which the benefit is provided; or plan.
• the date on which the individual makes a contribution to the 3. Other retired or separated participants entitled to future
plan, whether voluntary or mandatory. benefits (i.e., any individuals who are retired or separated from
See 29 CFR 2510.3-3(d)(1). This includes former employment covered by the plan and who are entitled to begin
employees who are receiving group health continuation receiving benefits under the plan in the future). This does not
coverage benefits pursuant to Part 6 of ERISA and who are include any individual to whom an insurance company has
covered by the employee welfare benefit plan. Covered made an irrevocable commitment to pay all the benefits to
dependents are not counted as participants. A child who is an which the individual is entitled under the plan.
“alternate recipient” entitled to health benefits under a qualified 4. Deceased individuals who had one or more beneficiaries
medical child support order (QMCSO) should not be counted who are receiving or are entitled to receive benefits under the
as a participant for lines 5 and 6. An individual is not a plan. This does not include any individual to whom an
participant covered under an employee welfare plan on the insurance company has made an irrevocable commitment to
earliest date on which the individual (a) is ineligible to receive pay all the benefits to which the beneficiaries of that individual
any benefit under the plan even if the contingency for which are entitled under the plan.
such benefit is provided should occur, and (b) is not Line 6g. Enter the number of participants included on line 6f
designated by the plan as a participant. See 29 CFR 2510.3- (total participants at the end of the plan year) who have
3(d)(2). account balances. For example, for a Code section 401(k) plan
Before counting the number of participants, especially in the number entered on line 6g should be the number of
a welfare benefit plan, it is important to determine participants counted on line 6f who have made a contribution,
whether the plan sponsor has established one or more plans or for whom a contribution has been made, to the plan for this
for Form 5500/Form 5500-SF reporting purposes. As a matter plan year or any prior plan year. Defined benefit plans should
of plan design, plan sponsors can offer benefits through leave line 6g blank.
various structures and combinations. For example, a plan Line 6h. Include any individual who terminated employment
sponsor could create (i) one plan providing major medical during this plan year, whether or not he or she (a) incurred a
benefits, dental benefits, and vision benefits, (ii) two plans with break in service, (b) received an irrevocable commitment from
one providing major medical benefits and the other providing an insurance company to pay all the benefits to which he or
self-insured dental and vision benefits; or (iii) three separate she is entitled under the plan, and/or (c) received a cash
plans. You must review the governing documents and actual distribution or deemed cash distribution of his or her
operations to determine whether welfare benefits are being nonforfeitable accrued benefit. Multiemployer plans and
provided under a single plan or separate plans. multiple-employer plans that are collectively bargained do not
The fact that you have separate insurance policies for each have to complete line 6h.
different welfare benefit does not necessarily mean that you Line 7. Only multiemployer plans should complete line 7.
have separate plans. Some plan sponsors use a “wrap” Multiemployer plans must enter the total number of employers
document to incorporate various benefits and insurance obligated to contribute to the plan. For purposes of line 7 of the
policies into one comprehensive plan. In addition, whether a Form 5500, an employer obligated to contribute is defined as
benefit arrangement is deemed to be a single plan may be an employer who, during the 2022 plan year, is a party to the
different for purposes other than Form 5500/Form 5500-SF collective bargaining agreement(s) pursuant to which the plan
reporting. For example, special rules may apply for purposes of is maintained or who may otherwise be subject to withdrawal
HIPAA, COBRA, and Internal Revenue Code compliance. If liability pursuant to ERISA section 4203. Any two or more
you need help determining whether you have a single welfare contributing entities (e.g., places of business with separate
benefit plan for Form 5500/Form 5500-SF reporting purposes, collective bargaining agreements) that have the same nine-
you should consult a qualified benefits consultant or legal digit employer identification number (EIN) must be aggregated
counsel. and counted as one employer for this purpose.
For pension benefit plans, “alternate payees” entitled to Line 8 - Benefits Provided Under the Plan. Do not leave
benefits under a qualified domestic relations order are not to blank. In the boxes for line 8a and 8b, as appropriate, enter all
be counted as participants for this line. applicable two-character plan characteristics codes that
For pension benefit plans, “participant” for this line means applied during the reporting year from the List of Plan
any individual who is included in one of the categories below: Characteristics Codes on pages 20 and 21 that describe the
characteristics of the plan being reported.
1. Active participants (i.e., any individuals who are currently
in employment covered by the plan and who are earning or Note. In the case of an eligible combined plan under Code
retaining credited service under the plan). This includes any section 414(x) and ERISA section 210(e), the codes entered in
individuals who are eligible to elect to have the employer make line 8a must include any codes applicable for either the defined
payments under a Code section 401(k) qualified cash or benefit pension features or the defined contribution pension
deferred arrangement. Active participants also include any features of the plan.
nonvested individuals who are earning or retaining credited For plan sponsors of Puerto Rico plans, enter
service under the plan. This does not include (a) nonvested characteristic code 3C only if:
former employees who have incurred the break in service i. only Puerto Rico residents participate,
period specified in the plan or (b) former employees who have ii. the trust is exempt from income tax under the laws of
received a “cash-out” distribution or deemed distribution of Puerto Rico, and
their entire nonforfeitable accrued benefit. iii. the plan administrator has not made the election under
2. Retired or separated participants receiving benefits (i.e., ERISA section 1022(i)(2), and, therefore, the plan is not
individuals who are retired or separated from employment intended to qualify under section 401(a) of the Internal
covered by the plan and who are receiving benefits under the Revenue Code (U.S).
plan). This does not include any individual to whom an
-18- Instructions for Part I and Part II of Form 5500

- 19 -

Line 9 - Funding and Benefit Arrangements.  Check all                    Arrangements (MEWAs) and Certain Entities Claiming 
boxes that apply to indicate the funding and benefit                     Exception (ECEs) filing requirements, check “Yes” and 
arrangements used during the plan year. The ‘‘funding                    complete line 11, elements 11b and 11c. If the answer is “No,” 
arrangement’’ is the method for the receipt, holding,                    skip elements 11b and 11c of line 11. 
investment, and transmittal of plan assets prior to the time the             Generally, a Form M-1 must be filed each year by March 
plan actually provides benefits. The ‘‘benefit arrangement’’ is          1 stfollowing the calendar year in which a plan operates subject 
the method by which the plan provides benefits to participants.          to the Form M-1 filing requirement. (For example, a plan 
For purposes of line 9:                                                  MEWA that was operating in 2022 must file the 2022 Form M-1 
‘‘Insurance’’ means the plan has an account, contract, or                annual report by March 1, 2023.) In addition, Form M-1 filings 
policy with an insurance company, insurance service, or other            are necessary in the case of certain registration, origination, or 
similar organization (such as Blue Cross, Blue Shield, or a              special events. See the instructions for Form M-1 at 
health maintenance organization) during the plan or DFE year.            http://www.askebsa.dol.gov/mewa, and 29 CFR 2520.101-2 for 
(This includes investments with insurance companies such as              more information regarding the Form M-1 filing requirements 
guaranteed investment contracts (GICs).) An annuity account              for plan MEWAs and ECEs.  
arrangement under Code section 403(b)(1) that is required to             Line 11b. All plans that answered ‘‘Yes’’ in line 11a must 
complete the Form 5500 should mark “insurance” for both the              complete line 11b by answering either ‘‘Yes’’ or ‘‘No.’’ Do not 
plan funding arrangement and plan benefit arrangement. Do                leave the answer blank.  
not check ‘‘insurance’’ if the sole function of the insurance 
company was to provide administrative services.                          Line 11c. All plans that answered ‘‘Yes’’ in line 11a must enter 
                                                                         a Receipt Confirmation Code for the 2022 Form M–1 annual 
‘‘Code section 412(e)(3) insurance contracts’’ are                       report that was required to be filed with the Department of 
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 http://www.askebsa.dol.gov/mewa.  
no rights under the contract may be subject to a security 
interest, and no policy loans may be outstanding. If a plan is               If a plan that is subject to the Form M-1 filing requirements 
funded exclusively by the purchase of such contracts, the                was not required to file a 2022 Form M–1 annual report, enter 
otherwise applicable minimum funding requirements of section             the Receipt Confirmation Code for the most recent Form M–1 
412 of the Code and section 302 of ERISA do not apply for the            that was required to be filed under the Form M–1 filing 
year and neither the Schedule MB nor the Schedule SB is                  requirements on or before the date of filing the 2022 Form 
required to be filed.                                                    5500. (For example, if a plan was not required to file a 2022 
                                                                         Form M–1 annual report by March 1, 2023 for the 2022 
‘‘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, 2022, 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 2022 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 

Instructions for Part I and Part II of Form 5500                    -19-

- 20 -

                     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.  

                                                                     -20-     Instructions for Part I and Part II of Form 5500

- 21 -

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), and 4975(e)(7) of the Code that is 4S Unfunded, fully insured, or combination unfunded/fully
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 -21-

- 22 -

inclusion of a social security number or any portion thereof on
this Schedule A or any of its attachments may result in the
2022 Instructions for Schedule A rejection of the filing.
(Form 5500) You can apply for an EIN from the IRS online, by fax, or by
Insurance Information mail depending on how soon you need to use the EIN. For
more information, see Section 3: Electronic Filing Requirement
under General Instructions to Form 5500. The EBSA does not
General Instructions issue EINs.
Who Must File Part I – Information Concerning Insurance Contract
Schedule A (Form 5500) must be attached to the Form 5500 Coverage, Fees, and Commissions
filed for every defined benefit pension plan, defined Line 1(c). Enter the code number assigned by the National
contribution pension plan, and welfare benefit plan required to Association of Insurance Commissioners (NAIC) to the
file a Form 5500 if any benefits under the plan are provided by insurance company. If none has been assigned, enter zeros
an insurance company, insurance service, or other similar “0” in the spaces provided.
organization (such as Blue Cross, Blue Shield, or a health
maintenance organization). This includes investment contracts Line 1(d). If individual policies with the same carrier are
with insurance companies such as guaranteed investment grouped as a unit for purposes of this report, and the group
contracts (GICs). In addition, Schedules A must be attached to does not have one identification number, you may use the
a Form 5500 filed for GIAs, MTIAs, and 103-12 IEs for each contract or identification number of one of the individual
insurance or annuity contract held in the MTIA, or 103-12 IE or contracts, provided this number is used consistently to report
by the GIA. these contracts as a group and the plan administrator
maintains the records necessary to disclose all the individual
If Form 5500 line 9a(1), 9a(2), 9b(1), or 9b(2) is contract numbers in the group upon request. Use separate
checked, indicating that either the plan funding Schedules A to report individual contracts that cannot be
arrangement or plan benefit arrangement includes an account, grouped as a unit.
policy, or contract with an insurance company (or similar
organization), at least one Schedule A would be required to be Line 1(e). Since plan coverage may fluctuate during the year,
attached to the Form 5500 filed for a pension or welfare plan to the administrator should estimate the number of persons that
provide information concerning the contract year ending with or were covered by the contract at the end of the policy or contract
within the plan year. year. Where contracts covering individual employees are
grouped, compute entries as of the end of the plan year.
Do not file Schedule A for a contract that is an Administrative
Services Only (ASO) contract, a fidelity bond or policy, or a Line 1(f) and (g). Enter the beginning and ending dates of the
fiduciary liability insurance policy. Also, if a Schedule A for a policy year for the contract identified in 1(d). Leave 1(f) blank if
contract or policy is filed as part of a Form 5500 for an MTIA or separate contracts covering individual employees are grouped.
103-12 IE that holds the contract, do not include a Schedule A Line 2. Report on line 2 the total of all insurance fees and
for the contract or policy on the Form 5500s filed for the plans commissions directly or indirectly attributable to the contract or
participating in the MTIA or 103-12 IE. policy placed with or retained by the plan.
Check the Schedule A box on the Form 5500 (Part II, line Totals. Enter on line 2 the total of all such commissions and
10b(3)), and enter the number attached in the space provided fees paid to agents, brokers, and other persons listed on line 3.
if one or more Schedules A are attached to the Form 5500. Complete a separate line 3 item (elements (a) through (e)) for
each person listed.
Specific Instructions
For purposes of lines 2 and 3, commissions and fees
Information entered on Schedule A should pertain to the include sales and base commissions and all other monetary
insurance contract or policy year ending with or within the plan and non-monetary forms of compensation where the broker’s
year (for reporting purposes, a year cannot exceed 12 agent’s, or other person’s eligibility for the payment or the
months). amount of the payment is based, in whole or in part, on the
Example. If an insurance contract year begins on July 1 and value (e.g., policy amounts, premiums) of contracts or policies
ends on June 30, and the plan year begins on January 1 and (or classes thereof) placed with or retained by an ERISA plan,
ends on December 31, the information on the Schedule A including, for example, persistency and profitability bonuses.
attached to the 2022 Form 5500 should be for the insurance The amount (or pro rata share of the total) of such
contract year ending on June 30, 2022. commissions or fees attributable to the contract or policy
Exception. If the insurance company maintains records on the placed with or retained by the plan must be reported in line 2
basis of a plan year rather than a policy or contract year, the and in line 3, element (b) and/or (c), as appropriate.
information entered on Schedule A may pertain to the plan Insurers must provide plan administrators with a
year instead of the policy or contract year. proportionate allocation of commissions and fees attributable
Include only the contracts issued to or held by the plan, to each contract. Any reasonable method of allocating
GIA, MTIA, or 103-12 IE for which the Form 5500 is being filed. commissions and fees to policies or contracts is acceptable,
Lines A, B, C, and D. This information must be the same as provided the method is disclosed to the plan administrator. A
reported in Part II of the Form 5500 to which this Schedule A is reasonable allocation method could, in the Department of
attached. Labor’s view, allocate fees and commissions to a Schedule A
based on a calendar year calculation even if the plan year or
Do not use a social security number in lieu of an EIN. The policy year was not a calendar year. For additional information
Schedule A and its attachments are open to public inspection, on these Schedule A reporting requirements, see ERISA
and the contents are public information and are subject to Advisory Opinion 2005-02A, available on the Internet at
publication on the Internet. Because of privacy concerns, the www.dol.gov/ebsa.

-22- Instructions for Schedule A (Form 5500)

- 23 -

 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 Element (a). Enter the name and address of the agents, 
necessary for the insurer to fulfill its contractual obligation to   brokers, or other persons to whom commissions or fees were 
provide benefits, where there is no direct or indirect charge to     paid. 
the plan for the administrative services other than the 
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 
                                                                     Code   Type of Organization 
on the value (e.g., policy amounts, premiums) of contracts or 
policies (or classes thereof) placed with or retained by ERISA       1      Banking, Savings & Loan Association, Credit Union, 
plan(s).                                                                    or other similar financial institution 
                                                                     2      Trust Company 
 Schedule A reporting is not required for occasional non-                   Insurance Agent or Broker 
                                                                     3
monetary gifts or meals of insubstantial value that are tax                 Agent or Broker other than insurance 
                                                                     4
deductible for federal income tax purposes by the person                    Third party administrator 
                                                                     5
providing the gift or meal and would not be taxable income to               Investment Company/Mutual Fund 
                                                                     6
the recipient. For this exemption to be available, the gift or              Investment Manager/Adviser 
                                                                     7
gratuity must be both occasional and insubstantial. For this                Labor Union 
                                                                     8
exemption to apply, the gift must be valued at less than $50,               Foreign entity (e.g., an agent or broker, bank, 
                                                                     9
the aggregate value of gifts from one source in a calendar year             insurance company, etc., not operating within the 
must be less than $100, but gifts with a value of less than $10             jurisdictional boundaries of the United States) 
do not need to be counted toward the $100 annual limit. If the              Other 
                                                                     0
$100 aggregate value limit is exceeded, then the aggregate 
value of all the gifts will be reportable. For this purpose, non-     For plans, GIAs, MTIAs, and 103-12 IEs required to file Part 
monetary gifts of less than $10 also do not need to be included      I of Schedule C, commissions and fees listed on the Schedule 
in calculating the aggregate value of all gifts required to be       A are not required to be reported again on Schedule C. The 
reported if the $100 limit is exceeded.                              amount of the compensation that must be reported on 
                                                                     Schedule A must, however, be taken into account in 
 Gifts from multiple employees of one service provider               determining whether the agent’s, broker’s, or other person’s 
should be treated as originating from a single source when           direct or indirect compensation in relation to the plan or DFE is 
calculating whether the $100 threshold applies. On the other         $5,000 or more and, thus, requiring the compensation not 
hand, in applying the threshold to an occasional gift received       listed on the Schedule A to be reported on the Schedule C. 
from one source by multiple employees of a single service            See FAQs about the Schedule C available on the EBSA 
provider, the amount received by each employee should be             website at www.dol.gov/ebsa/faqs . 
separately determined in applying the $50 and $100 
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,       Line 4. Enter the current value of the plan’s interest at year 
and the insurer provides, at no cost to the attendees,               end in the contract reported on line 7, e.g., deposit 
refreshments valued at $20 per individual, the gratuities would      administration (DA), immediate participation guarantee (IPG), 
not be reportable on lines 2 and 3 of the Schedule A even            or guaranteed investment contracts (GIC). 
though the total cost of the refreshments for all the employees 
would be $120.                                                       Exception. Contracts reported on line 7 need not be included 
                                                                     on line 4 if (1) the Schedule A is filed for a defined benefit 
 These thresholds are for purposes of Schedule A reporting.          pension plan and the contract was entered into before March 
Filers are cautioned that the payment or receipt of gifts and        20, 1992, or (2) the Schedule A is filed for a defined 
gratuities of any amount by plan fiduciaries may violate ERISA       contribution pension plan and the contract is a fully benefit-
and give rise to civil liabilities and criminal penalties.           responsive contract, i.e., it provides a liquidity guarantee by a 
                                                                     financially responsible third party of principal and previously 

Instructions for Schedule A (Form 5500)                        -23-

- 24 -

accrued interest for liquidations, transfers, loans, or hardship Part IV – Provision of Information
withdrawals initiated by plan participants exercising their rights The insurance company, insurance service, or other similar
to withdraw, borrow, or transfer funds under the terms of a organization is required under ERISA section 103(a)(2) to
defined contribution plan that does not include substantial provide the plan administrator with the information needed to
restrictions to participants’ access to plan funds. complete this return/report. If you do not receive this
Important Reminder. Plans may treat multiple individual information in a timely manner, contact the insurance
annuity contracts, including Code section 403(b)(1) annuity company, insurance service, or other similar organization.
contracts, issued by the same insurance company as a single Lines 11 and 12. If information is missing on Schedule A due
group contract for reporting purposes on Schedule A. to a refusal by the insurance company, insurance service, or
Line 6a. The rate information called for here may be furnished other similar organization to provide information, check “Yes”
by attaching the appropriate schedules of current rates filed on line 11 and enter a description of the information not
with the appropriate state insurance department or by provided on line 12. If you received all the information
providing a statement regarding the basis of the rates. Enter necessary to receive the Schedule A, check “No” and leave
“see attached” if appropriate. line 12 blank.
Lines 7a through 7f. Report contracts with unallocated funds. As noted above, the insurance company, insurance
Do not include portions of these contracts maintained in service, or other similar organization is statutorily
separate accounts. Show deposit fund amounts rather than required to provide you with all of the information necessary to
experience credit records when both are maintained. complete the Schedule A but need not provide the information
on a Schedule A itself.
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.

-24- Instructions for Schedule A (Form 5500)

- 25 -

                                                                   Lines A, B, C, and D. This information must be the same as 
2022 Instructions for Schedule C                                   reported in Part II of the Form 5500 to which this Schedule C is 
                                                                   attached. 
(Form 5500)                                                         Do not use a social security number in line D in lieu of an 
Service Provider Information                                       EIN. The Schedule C and its attachments are open to public 
                                                                   inspection, and the contents are public information subject to 
General Instructions                                               publication on the Internet. Because of privacy concerns, the 
Who Must File                                                      inclusion of a social security number or any portion thereof on 
                                                                   this Schedule C or any of its attachments may result in the 
Schedule C (Form 5500) must be attached to a Form 5500             rejection of the filing.  
filed for a large pension or welfare benefit plan, an MTIA, a 
103-12 IE, or a GIA to report certain information concerning        You can apply for an EIN from the IRS online, by fax, or by 
service providers. Remember to check the Schedule C box on         mail depending on how soon you need to use the EIN. For 
the Form 5500 (Part II, line 10b(4)) if a Schedule C is attached   more information, see Section 3: Electronic Filing Requirement 
to the Form 5500.                                                  under General Instructions to Form 5500. The EBSA does not 
                                                                   issue EINs. 
 Part I of the Schedule C must be completed to report 
persons who rendered services to or who had transactions with       Do not list the PBGC or the IRS on Schedule C as service 
the plan (or with the DFE in the case of a Schedule C filed by a   providers. 
DFE) during the reporting year if the person received, directly     Either the cash or accrual basis may be used for the 
or indirectly, $5,000 or more in reportable compensation in        recognition of transactions reported on the Schedule C as long 
connection with services rendered or their position with the       as you use one method consistently. 
plan or DFE, except:                                                If service provider compensation is reported on a Schedule 
 1. Employees of the plan whose only compensation in               C filed as a part of a Form 5500 filed for a MTIA or a            
relation to the plan was less than $25,000 for the plan year;      103-12 IE, do not report the same compensation again on the 
 2. Employees of the plan sponsor or other business entity         Schedule C filed for the plans that participate in the MTIA or 
where the plan sponsor or business entity is reported on the       103-12 IE. 
Schedule C as a service provider, provided the employee did 
not separately receive reportable direct or indirect               Specific Instructions 
compensation in relation to the plan;                              Part I –Service Provider Information  
 3. Persons whose only compensation in relation to the plan        You must enter the information required for each person who 
consists of insurance fees and commissions listed in a             rendered services to or had transactions with the plan and 
Schedule A filed for the plan; and                                 who received $5,000 or more in total direct or indirect 
 4. Payments made directly by the plan sponsor that are not        compensation in connection with services rendered to the 
reimbursed by the plan. In the case of a multiemployer or          plan or the person’s position with the plan during the plan 
multiple-employer plan, where the “plan sponsor” would be the      year. 
joint board of trustees for the plan, payments by contributing 
employers, directly or through an employer association, or by       Example. A plan had service providers, A, B, C, and D, 
participating employee organizations, should be treated the        who received $12,000, $6,000, $4,500, and $430, 
same as payments by a plan sponsor.                                respectively, in direct and indirect compensation from the 
                                                                   plan. Service providers A and B must be identified 
 Only line 1 of Part I of the Schedule C must be completed         separately by name, EIN, etc. As service providers C and D 
for persons who received only “eligible indirect compensation”     each received less than $5,000, they do not need to be 
as defined below.                                                  reported on the Schedule C. 
 Part II of the Schedule C must be completed to report              For Schedule C purposes, reportable compensation 
service providers who fail or refuse to provide information        includes money and any other thing of value (for example, 
necessary to complete Part I of this Schedule.                     gifts, awards, trips) received by a person, directly or indirectly, 
 Part III of the Schedule C must be completed to report a          from the plan (including fees charged as a percentage of 
termination in the appointment of an accountant or enrolled        assets and deducted from investment returns) in connection 
actuary during the 2022 plan year.                                 with services rendered to the plan, or the person’s position with 
 For plans, GIAs, MTIAs, and 103-12 IEs required to file Part      the plan. The term “person” for this purpose includes 
I of Schedule C, commissions and fees listed on the Schedule       individuals, trades and businesses (whether incorporated or 
A are not required to be reported again on Schedule C. The         unincorporated). See ERISA section 3(9). 
amount of the compensation that must be reported on                 Direct Compensation: Payments made directly by the 
Schedule A must, however, be taken into account in                 plan for services rendered to the plan or because of a person’s 
determining whether the service provider’s direct or indirect      position with the plan are reportable as direct compensation. 
compensation in relation to the plan or DFE is $5,000 or more      Direct payments by the plan would include, for example, direct 
and, thus, requiring the compensation not listed on the            payments by the plan out of a plan account, charges to plan 
Schedule A to be reported on the Schedule C. See FAQs              forfeiture accounts and fee recapture accounts, charges to a 
about the Schedule C available on the EBSA website at              plan’s trust account before allocations are made to individual 
www.dol.gov/ebsa/faqs.                                             participant accounts, and direct charges to plan participant 
  Health and welfare plans that meet the conditions of the         individual accounts. Payments made by the plan sponsor, 
  limited exemption at 29 CFR 2520.104-44 or Technical             which are not reimbursed by the plan, are not subject to 
Release 92-01 are not required to complete and file a              Schedule C reporting requirements even if the sponsor is 
Schedule C.                                                        paying for services rendered to the plan. 
                                                                    Indirect Compensation: Compensation received from 
                                                                   sources other than directly from the plan or plan sponsor is 
                                                                   reportable on Schedule C as indirect compensation from the 
Instructions for Schedule C (Form 5500)                       -25-

- 26 -

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 
                                                                         as originating from a single source when calculating whether 
 Examples of reportable indirect compensation include fees               the $100 threshold applies. On the other hand, gifts received 
and expense reimbursement payments received by a person                  from one person by multiple employees of one entity can be 
from mutual funds, bank commingled trusts, insurance                     treated as separate compensation when calculating the $50 
company pooled separate accounts, and other separately                   and $100 thresholds. For more information, see FAQs about 
managed accounts and pooled investment funds in which the                the Schedule C, available on the EBSA website at 
plan invests that are charged against the fund or account and            www.dol.gov/ebsa/faqs. 
reflected in the value of the plan’s investment (such as 
management fees paid by a mutual fund to its investment                      These thresholds are for purposes of Schedule C 
adviser, sub-transfer agency fees, shareholder servicing fees,               reporting only. Filers are strongly cautioned that gifts and 
account maintenance fees, and 12b-1 distribution fees). The              gratuities of any amount paid to or received by plan fiduciaries 
investment of plan assets and payment of premiums for                    may violate ERISA and give rise to civil liabilities and criminal 
insurance contracts, however, are not in and of themselves               penalties. 
payments for services rendered to the plan for purposes of                Fully Insured Group Health and Similarly Fully Insured 
Schedule C reporting and the investment and payment of                   Benefits: Where benefits under a plan are purchased from 
premiums themselves are not reportable compensation for                  and guaranteed by an insurance company, insurance service, 
purposes of Part I of the Schedule C.                                    or other similar organization, and the contract or policy is 
 In the case of charges against an investment fund,                      reported on a Schedule A, payments of reasonable monetary 
reportable “indirect compensation” includes, for example, the            compensation by the insurer out of its general assets to 
fund’s investment adviser asset-based investment                         persons for performing administrative activities necessary for 
management fee from the fund, brokerage commissions and                  the insurer to fulfill its contractual obligation to provide benefits, 
fees charged in connection with purchases and sales of                   where there is no direct or indirect charge to the plan for the 
interests in the fund, fees related to purchases and sales of            administrative services other than the insurance premium, 
interests in the fund (including 12b-1 fees), fees for providing         would not be treated as indirect compensation for services 
services to plan investors or plan participants such as                  provided to the plan for Schedule C reporting purposes. This 
communication and other shareholder services, and fees                   would include compensation for services such as 
relating to the administration of the employee benefit plan such         recordkeeping and claims processing services provided by a 
as recordkeeping services, Form 5500 return/report filing and            third party pursuant to a contract with the insurer to provide 
other compliance services. Amounts charged against the fund              those services, but would not include compensation provided 
for other ordinary operating expenses, such as attorneys’ fees,          by the insurer incidental to the sale or renewal of a policy, such 
accountants’ fees, printers fees, are not reportable indirect            as finder’s fees, insurance brokerage commissions and fees, 
compensation for Schedule C purposes. Also, brokerage costs              or similar fees. Insurance investment contracts are not eligible 
associated with a broker-dealer effecting securities                     for this exception. 
transactions within the portfolio of a mutual fund or for the             Bundled Service Arrangements: For Schedule C 
portfolio of an investment fund that holds “plan assets” for             reporting purposes, a bundled service arrangement includes 
ERISA purposes should be treated for Schedule C purposes                 any service arrangements where the plan hires one company 
as an operating expense of the investment fund, not reportable           to provide a range of services either directly from the 
indirect compensation paid to a plan service provider or in              company, through affiliates or subcontractors, or through a 
connection with a transaction with the plan.                             combination, which are priced to the plan as a single package 
 Other examples of reportable indirect compensation are                  rather than on a service-by-service basis. A bundled service 
finder’s fees, float revenue, brokerage commissions                      arrangement would also include an investment transaction in 
(regardless of whether the broker is granted discretion),                which the plan receives a range of services either directly from 
research or other products or services, other than execution,            the investment provider, through affiliates or subcontractors, or 
received from a broker-dealer or other third party in connection         through a combination. 
with securities transactions (soft dollars), and other transaction        Direct payments by the plan to the bundled service provider 
based fees received in connection with transactions or                   should be reported as direct compensation to the bundled 

                                                                    -26-                     Instructions for Schedule C (Form 5500)

- 27 -

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

Instructions for Schedule C (Form 5500)                        -27-

- 28 -

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

                                                                     -28-                   Instructions for Schedule C (Form 5500)

- 29 -

Part III – Termination Information on Accountants                     material disputes or matters of disagreement concerning the 
and Enrolled Actuaries                                                termination, even if resolved prior to the termination. If an 
                                                                      individual is listed, and the individual does not have an EIN, 
Complete Part III if there was a termination in the appointment 
                                                                      the EIN to be entered should be the EIN of the individual’s 
of an accountant or enrolled actuary during the 2022 plan year. 
                                                                      employer. 
This information must be provided on the Form 5500 for the 
plan year during which the termination occurred. For example,         Do not use a social security number in lieu of an EIN. The 
if an accountant was terminated in the 2022 plan year after           Schedule C and its attachments are open to public inspection, 
completing work on an audit for the 2021 plan year, the               and the contents are public information and are subject to 
termination should be reported on the Schedule C filed with the       publication on the Internet. Because of privacy concerns, the 
2022 plan year Form 5500. If the accountant is a firm (such as        inclusion of a social security number or any portion thereof on 
a corporation, partnership, etc.), report when the service            this Schedule C or any of its attachments may result in the 
provider (not an individual within the firm) was terminated. An       rejection of the filing. 
enrolled actuary is by definition an individual and not a firm,       The plan administrator must also provide the terminated 
and you must report when the individual is terminated.                accountant or enrolled actuary with a copy of the explanation 
 Provide an explanation of the reasons for the termination of         for the termination provided in Part III of the Schedule C, along 
an accountant or enrolled actuary. Include a description of any       with a completed copy of the notice below. 
           
                                                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 2022 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)                         -29-

- 30 -

                                                                        Element (c). Enter the nine-digit employer identification 
2022 Instructions for Schedule D                                        number (EIN) and three-digit plan/entity number (PN) for each 
                                                                        MTIA, CCT, PSA, or 103-12 IE named in element (a)  . This 
(Form 5500)                                                             must be the same DFE EIN/PN as reported on lines 2b and 1b 
DFE /Participating Plan Information                                     of the Form 5500 filed for the DFE. If a Form 5500 was not 
                                                                        filed for a CCT or PSA named in element (a), enter the EIN for 
                                                                        the CCT or PSA and enter 000 for the PN. Do not use a social 
General Instructions                                                    security number or any portion thereof in lieu of an EIN. The 
Purpose of Schedule                                                     Schedule D and its attachments are open to public inspection, 
                                                                        and the contents are public information and are subject to 
When the Form 5500 is filed for a plan or Direct Filing Entity          publication on the Internet. Because of privacy concerns, the 
(DFE) that invested or participated in any master trust                 inclusion of a social security number or any portion thereof on 
investment accounts (MTIAs), 103-12 Investment Entities                 this Schedule D or any of its attachments may result in the 
(103-12 IEs), common/collective trusts (CCTs), and/or pooled            rejection of the filing. 
separate accounts (PSAs), Part I provides information about 
these entities. When the Form 5500 is filed for a DFE, Part II          Element (d). Enter an M, C, P, or E, as appropriate, (see table 
provides information about plans participating in the DFE.              below) to identify the type of entity (MTIA, CCT, PSA, or  
Who Must File                                                           103-12 IE). 
Employee Benefit Plans:  Schedule D (Form 5500) must be                  
attached to a Form 5500 filed for an employee benefit plan that                  Type of entity                     Enter in (d)  
participated or invested in one or more CCTs, PSAs, MTIAs, or                                                          
103-12 IEs at anytime during the plan year.  
                                                                                      MTIA                                M  
Direct Filing Entities:  Schedule D (Form 5500) must be 
attached to a Form 5500 filed for a CCT, PSA, MTIA,                                   CCT                                 C  
103-12 IE, or Group Insurance Arrangement (GIA), as a Direct 
                                                                                      PSA                                 P  
Filing Entity (i.e., when a “DFE” is checked on Part I, line A, of 
the Form 5500). For more information, see instructions for                           103-12 IE                            E  
Direct Filing Entity (DFE) Filing Requirements.  
                                                                        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” 
Part I – Information on Interests in MTIAs, CCTs,                       is entered in element (d); and the dollar value of the plan’s 
                                                                        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  
Complete as many repeating entries as necessary to enter the            (To Be Completed Only by DFEs) 
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 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                 Complete a separate item (elements (a) through (c)) for 
each MTIA, CCT, PSA, or 103-12 IE.                                      each plan.   
Element (a). Enter the name of the MTIA, CCT, PSA, or                   Element (a). Enter the name of each plan that invested or 
103-12 IE in which the plan or DFE filing the Form 5500                 participated in the DFE at any time during the DFE year. GIAs 
participated at any time during the plan or DFE year.                   need not complete element (a).     
Element (b). Enter the name of the sponsor of the MTIA, CCT,            Element (b). Enter the name of the sponsor of each and every 
PSA, or 103-12 IE named in element (a).                                 plan investing or participating in the DFE. 

                                                                   -30-                    Instructions for Schedule D (Form 5500)

- 31 -

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)                      -31-

- 32 -

loan is in default when the borrower is unable to pay the
2022 Instructions for Schedule G obligation upon maturity. Obligations that require periodic
repayment can default at any time. Generally loans and fixed
(Form 5500) income obligations are considered uncollectible when payment
Financial Transaction Schedules has not been made and there is little probability that payment
will be made. A fixed income obligation has a fixed maturity
date at a specified interest rate.
General Instructions
Do not report in Part I participant loans under an individual
Who Must File account plan with investment experience segregated for each
Schedule G (Form 5500) must be attached to a Form 5500 account, that are made in accordance with 29 CFR 2550.408b-
filed for a large plan, MTIA, 103-12 IE, or GIA to report loans or 1, and that are secured solely by a portion of the participant’s
fixed income obligations in default or determined to be vested accrued benefit. Report all other participant loans in
uncollectible as of the end of the plan year, leases in default or default or classified as uncollectible on Part I, and list each
classified as uncollectible, and nonexempt transactions. such loan individually.
Check the Schedule G box on the Form 5500 (Part II, line Part II – Leases in Default or Classified as
10b(6)) if a Schedule G is attached to the Form 5500. Uncollectible
Complete as many entries as necessary to report the required
List any leases in default or classified as uncollectible. A lease
information.
is an agreement conveying the right to use property, plant, or
The Schedule G consists of three parts. Part I of the equipment for a stated period. A lease is in default when the
Schedule G reports any loans or fixed income obligations in required payment(s) has not been made. An uncollectible
default or determined to be uncollectible as of the end of the lease is one where the required payments have not been
plan year. Part II of the Schedule G reports any leases in made and for which there is little probability that payment will
default or classified as uncollectible. Part III of the Schedule G be made. Provide, on a separate attachment, an explanation of
reports nonexempt transactions. what steps have been taken or will be taken to collect overdue
Specific Instructions amounts for each lease listed and label the attachment
“Schedule G, Part II – Overdue Lease Explanation.”
Lines A, B, C, and D. This information must be the same as
reported in Part II of the Form 5500 to which this Schedule G is Part III – Nonexempt Transactions
attached. All nonexempt party-in-interest transactions must be reported,
Do not use a social security number in line D in lieu of an regardless of whether disclosed in the accountant’s report,
EIN. The Schedule G and its attachments are open to public unless the nonexempt transaction is:
inspection, and the contents are public information and are 1. Statutorily exempt under Part 4 of Title I of ERISA;
subject to publication on the internet. Because of privacy 2. Administratively exempt under ERISA section 408(a);
concerns, the inclusion of a social security number or any 3. Exempt under Code sections 4975(c) or 4975(d);
portion thereof on this Schedule G or any of its attachments 4. The holding of participant contributions in the employer’s
may result in the rejection of the filing. general assets for a welfare plan that meets the conditions of
You can apply for an EIN from the IRS online, by fax, or by ERISA Technical Release 92-01;
mail depending on how soon you need to use the EIN. For 5. A transaction of a 103-12 IE with parties other than
more information, see Section 3: Electronic Filing Requirement the plan; or
under General Instructions to Form 5500. The EBSA does not 6. A delinquent participant contribution or a delinquent
issue EINs. participant loan repayment reported on Schedule H, line 4a.
Part I – Loans or Fixed Income Obligations in Default Nonexempt transactions with a party-in-interest include
or Classified as Uncollectible any direct or indirect:
List all loans or fixed income obligations in default or A. Sale or exchange, or lease, of any property between the
determined to be uncollectible as of the end of the plan year or plan and a party-in-interest.
the fiscal year of the GIA, MTIA, or 103-12 IE. Include: B. Lending of money or other extension of credit between
• Obligations where the required payments have not been the plan and a party-in-interest.
made by the due date; C. Furnishing of goods, services, or facilities between the
plan and a party-in-interest.
• Fixed income obligations that have matured, but have not Transfer to, or use by or for the benefit of, a party-in-
been paid, for which it has been determined that payment will D.
interest, of any income or assets of the plan.
not be made; and
E. Acquisition, on behalf of the plan, of any employer
• Loans that were in default even if renegotiated later during security or employer real property in violation of ERISA
the year. section 407(a).
Note. Identify in element (a) each obligor known to be a party- F. Dealing with the assets of the plan for a fiduciary’s own
in-interest to the plan. interest or own account
Provide, on a separate attachment, an explanation of what G. Acting in a fiduciary’s individual or any other capacity in
steps have been taken or will be taken to collect overdue any transaction involving the plan on behalf of a party (or
amounts for each loan listed and label the attachment represent a party) whose interests are adverse to the
“Schedule G, Part I – Overdue Loan Explanation.” interests of the plan or the interests of its participants or
The due date, payment amount, and conditions for beneficiaries.
determining default in the case of a note or loan are usually H. A receipt of any consideration for his or her own personal
contained in the documents establishing the note or loan. A account by a party-in-interest who is a fiduciary from any

-32- Instructions for Schedule G (Form 5500)

- 33 -

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

Instructions for Schedule G (Form 5500) -33-

- 34 -

income of the CCT or PSA in determining their net investment
2022 Instructions for Schedule H gain (loss). Instead, enter the CCT or PSA net gain (loss) on
line 2b(6) or (7) in accordance with the instructions for these
(Form 5500) lines.
Financial Information If assets of one plan are maintained in two or more trust
funds, report the combined financial information in Parts I and II.
General Instructions Current value means fair market value where available.
Who Must File Otherwise, it means the fair value as determined in good faith
Schedule H (Form 5500) must be attached to a Form 5500 filed under the terms of the plan by a trustee or a named fiduciary,
for a pension benefit plan or a welfare benefit plan that covered assuming an orderly liquidation at time of the determination.
100 or more participants as of the beginning of the plan year See ERISA section 3(26).
and a Form 5500 filed for an MTIA, CCT, PSA, 103-12 IE, or Note. For the 2022 plan year, plans that provide participant-
GIA. See the instructions to the Form 5500 in Section 4: Direct directed brokerage accounts as an investment alternative (and
Filing Entity (DFE) Filing Requirements. have entered pension feature code ‘‘2R’’ on line 8a of the Form
Exceptions: (1) Fully insured, unfunded, or a combination of 5500) may report investments in assets made through
unfunded/insured welfare plans and fully insured pension plans participant-directed brokerage accounts either:
that meet the requirements of 29 CFR 2520.104-44 are exempt 1. As individual investments on the applicable asset and
from completing the Schedule H. (2) If a Schedule I was filed for liability categories in Part I and the income and expense
the plan for the 2021 plan year or a Form 5500-SF and the plan categories in Part II, or
covered fewer than 121 participants as of the beginning of the 2. By including on line 1c(15) the total aggregate value of the
2022 plan year, the Schedule I may be completed instead of a assets and on line 2c the total aggregate investment income
Schedule H. See What To File. If eligible, such a plan may file (loss) before expenses, provided the assets are not loans,
the Form 5500-SF instead of the Form 5500 and its schedules, partnership or joint-venture interests, real property, employer
including the Schedule I. See Instructions for Form 5500-SF. (3) securities, or investments that could result in a loss in excess of
Plans that file a Form 5500-SF for the 2022 plan year are not the account balance of the participant or beneficiary who
required to file a Schedule H for that year. directed the transaction. Expenses charged to the accounts
Check the Schedule H box on the Form 5500 (Part II, line must be reported on the applicable expense line items.
10b(1)) if a Schedule H is attached to the Form 5500. Do not Participant-directed brokerage account assets reported in the
attach both a Schedule H and a Schedule I to the same Form aggregate on line 1c(15) should be treated as one asset held for
5500. investment for purposes of the line 4i schedules, except that
investments in tangible personal property must continue to be
Specific Instructions reported as separate assets on the line 4i schedules.
Lines A, B, C, and D. This information must be the same as In the event that investments made through a
reported in Part II of the Form 5500 to which this Schedule H is participant-directed brokerage account are loans, partnership or
attached. joint venture interests, real property, employer securities, or
Do not use a social security number in line D in lieu of an investments that could result in a loss in excess of the account
EIN. The Schedule H and its attachments are open to public balance of the participant or beneficiary who directed the
inspection, and the contents are public information and are transaction, such assets must be broken out and treated as
subject to publication on the Internet. Because of privacy separate assets on the applicable asset and liability categories
concerns, the inclusion of a social security number or any in Part I, income and expense categories in Part II, and on the
portion thereof on this Schedule H or any of its attachments may line 4i schedules. The remaining assets in the participant-
result in the rejection of the filing. directed brokerage account may be reported in the aggregate
You can apply for an EIN from the IRS online, by fax, or by as set forth in paragraph 2 above.
mail depending on how soon you need to use the Columns (a) and (b). Enter the current value on each line as of
EIN. For more information, see Section 3: Electronic Filing the beginning and end of the plan year.
Requirement under General Instructions to Form 5500. The Note. Amounts reported in column (a) must be the same as
EBSA does not issue EINs. reported for the end of the plan year for corresponding line
Part I – Asset and Liability Statement items of the return/report for the preceding plan year. Do not
include contributions designated for the 2022 plan year in
Note. The cash, modified cash, or accrual basis may be used column (a).
for recognition of transactions in Parts I and II, as long as you
use one method consistently. Round off all amounts reported Line 1a. Total noninterest bearing cash includes, among other
on the Schedule H to the nearest dollar. Any other amounts are things, cash on hand or cash in a noninterest bearing checking
subject to rejection. Check all subtotals and totals carefully. account.
If the assets of two or more plans are maintained in a fund or Line 1b(1). Noncash basis filers must include contributions due
account that is not a DFE, a registered investment company, or the plan by the employer but not yet paid. Do not include other
the general account of an insurance company under an amounts due from the employer such as the reimbursement of
unallocated contract (see the instructions for lines 1c(9) through an expense or the repayment of a loan.
1c(14)), complete Parts I and II of the Schedule H by entering Line 1b(2). Noncash basis filers must include contributions
the plan’s allocable part of each line item. withheld by the employer from participants and amounts due
Exception. When completing Part II of the Schedule H for a directly from participants that have not yet been received by the
plan or DFE that participates in a CCT or PSA for which a Form plan. Do not include the repayment of participant loans.
5500 has not been filed, do not allocate the income of the CCT Line 1b(3). Noncash basis filers must include amounts due to
or PSA and expenses that were subtracted from the gross the plan that are not includable in lines 1b(1) or 1b(2). These
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- 35 -

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
Line 1c(6). Include the current value of both income and non- (CCTs) and pooled separate accounts (PSAs) for which a
income producing real property owned by the plan. Do not DFE Form 5500 has not been filed may not be included on lines
include the value of property that is employer real property or 1c(9) or 1c(10). The plan’s or DFE’s interest in the underlying
property used in plan operations that must be reported on lines assets of such CCTs and PSAs must be allocated and reported
1d and 1e, respectively. in the appropriate categories on a line-by-line basis on Part I of
Line 1c(7). Enter the current value of all loans made by the 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.

Instructions for Schedule H (Form 5500) -35-

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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 2022 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, 

                                                                   -36-                       Instructions for Schedule H (Form 5500)

- 37 -

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)). Line 2i(1). Include the total fees paid (or in the case of accrual
basis plans, costs incurred during the plan year but not paid as
Line 2e(2). Include payments to insurance companies and of the end of the plan year) by the plan for outside accounting,
similar organizations such as Blue Cross, Blue Shield, and actuarial, legal, and valuation/appraisal services. Include fees
health maintenance organizations for the provision of plan for the annual audit of the plan by an independent qualified
benefits (e.g., paid-up annuities, accident insurance, health public accountant (IQPA); for payroll audits; for
insurance, vision care, dental coverage, stop-loss insurance accounting/bookkeeping services; for actuarial services
whose claims are paid to the plan (or which is otherwise an rendered to the plan; and to a lawyer for rendering legal
asset of the plan)), etc. opinions, litigation, and advice (but not for providing legal
Line 2e(3). Include all payments made to other organizations services as a benefit to plan participants). Report here fees and
or individuals providing benefits. Generally, these are individual expenses for corporate trustees and individual plan trustees,
providers of welfare benefits such as legal services, day care including reimbursement of expenses associated with trustees,
services, training, and apprenticeship services. such as lost time, seminars, travel, meetings, etc. Include the
Line 2f. Include on this line all distributions paid during the fee(s) for valuations or appraisals to determine the cost, quality,
plan year of excess deferrals under Code section or value of an item such as real property, personal property
402(g)(2)(A)(ii), excess contributions under Code section (gemstones, coins, etc.), and for valuations of closely held
401(k)(8), and excess aggregate contributions under Code securities for which there is no ready market. Do not include
section 401(m)(6). Include allocable income distributed. Also amounts paid to plan employees to perform bookkeeping/
include on this line any elective deferrals and employee accounting functions that should be included in line 2i(4).
contributions distributed or returned to employees during the Line 2i(2). Enter the total fees paid (or in the case of accrual
plan year, as well as any attributable income that was also basis plans, costs incurred during the plan year but not paid as
distributed. of the end of the plan year) to a contract administrator for
Line 2g. Report on line 2g a participant loan that has been performing administrative services for the plan. For purposes of
deemed distributed during the plan year under the provisions of the return/report, a contract administrator is any individual,
Code section 72(p) and Treasury Regulations section 1.72(p)-1 partnership, or corporation, responsible for managing the
only if both of the following circumstances apply: clerical operations (e.g., handling membership rosters, claims
1. Under the plan, the participant loan is treated as a payments, maintaining books and records) of the plan on a
directed investment solely of the participant’s individual account; contractual basis. Do not include salaried staff or employees of
and the plan or banks or insurance carriers.
2. As of the end of the plan year, the participant is not Line 2i(3). Enter the total fees paid (or in the case of accrual
continuing repayment under the loan. basis plans, costs incurred during the plan year but not paid as
If either of these circumstances does not apply, a deemed of the end of the plan year) to an individual, partnership or
distribution of a participant loan should not be reported on line corporation (or other person) for advice to the plan relating to its
2g. Instead, the current value of the participant loan (including investment portfolio. These may include fees paid to manage
interest accruing thereon after the deemed distribution) must be the plan’s investments, fees for specific advice on a particular
included on line 1c(8), column (b) (participant loans – end of investment, and fees for the evaluation for the plan’s investment
year), without regard to the occurrence of a deemed distribution. performance.
Note. The amount to be reported on line 2g of Schedule H or Line 2i(4). Other expenses are those that cannot be included in
Schedule I must be reduced if, during the plan year, a 2i(1) through 2i(3). These may include plan expenditures such
participant resumes repayment under a participant loan reported as salaries and other compensation and allowances (e.g.,
as a deemed distribution on line 2g for any earlier year. The payment of premiums to provide health insurance benefits to
amount of the required reduction is the amount of the participant plan employees), expenses for office supplies and equipment,
loan reported as a deemed distribution on line 2g for the earlier cars, telephone, postage, rent, expenses associated with the
year. If entering a negative number, enter a minus sign “ – ” to ownership of a building used in the operation of the plan, and all
the left of the number. The current value of the participant loan

Instructions for Schedule H (Form 5500) -37-

- 38 -

miscellaneous expenses. Include premium payments to the contained on line 4a is not presented in accordance with
PBGC when paid from plan assets. regulatory requirements, i.e., when the IQPA concludes that the
Line 2l. Include in these reconciliation figures the value of all scheduled information required by line 4a does not contain all
transfers of assets or liabilities into or out of the plan resulting the required information or contains information that is
from, among other things, mergers and consolidations. A inaccurate or is inconsistent with the plan’s financial statements,
transfer of assets or liabilities occurs when there is a reduction the IQPA report must make the appropriate disclosures in
of assets or liabilities with respect to one plan and the receipt of accordance with generally accepted auditing standards.
these assets or the assumption of these liabilities by another Delinquent participant contributions that are exempt because
plan. A transfer is not a shifting of one plan’s assets or liabilities they satisfy the DOL’s Voluntary Fiduciary Correction Program
from one investment to another. A transfer is not a distribution of (VFCP) requirements and the conditions of prohibited
all or part of an individual participant’s account balance that is transaction exemption (PTE) 2002-51 do not need to be treated
reportable on IRS Form 1099-R, Distributions From Pensions, as part of the schedule of nonexempt party-in-interest
Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance transactions.
Contracts, etc., (see the instructions for line 2e). Transfers out If the required IQPA’s report is not attached to the Form
at the end of the year should be reported as occurring during 5500, the filing is subject to rejection as incomplete and
the plan year. penalties may be assessed.
Note. If this Schedule H is filed for a CCT, PSA, MTIA, or Lines 3a(1) through 3a(4). These boxes identify the type of
103-12 IE, report the value of all asset transfers to the CCT, opinion offered by the IQPA.
PSA, MTIA, or 103-12 IE, including those resulting from The Plan Administrator should confirm with their IQPA
contributions to participating plans on line 2l(1), and report the whether the opinion was an unmodified, qualified,
total value of all assets transferred out of the CCT, PSA, MTIA, disclaimer of, or adverse opinion before answering Line 3a.
or 103-12 IE, including assets withdrawn for disbursement as
benefit payments by participating plans, on line 2l(2). Line 3a(1). Check if an unmodified opinion was issued
Contributions and benefit payments are considered to be made pursuant to SAS 136. Generally, an unmodified opinion is
to/by the plan (not to/by a CCT, PSA, MTIA, or 103-12 IE). issued when the IQPA concludes that the plan’s financial
statements are presented fairly, in all material respects, in
Part III – Accountant’s Opinion accordance with the applicable financial reporting framework
Line 3. The administrator of an employee benefit plan who files (generally accepted accounting principles (GAAP) or another
a Schedule H generally must engage an Independent Qualified basis such as modified cash or cash basis). This also includes
Public Accountant (IQPA) pursuant to ERISA section the form of opinion that SAS 136 permits an IQPA to issue when
103(a)(3)(A) and 29 CFR 2520.103-1(b). This requirement also the IQPA has performed an ERISA section 103(a)(3)(C) audit
applies to a Form 5500 filed for a 103-12 IE and for a GIA (see pursuant to 29 CFR 2520.103-8 or 29 CFR 2520.103-12, or
29 CFR 2520.103-12 and 29 CFR 2520.103-2). The IQPA’s both, and had no modifications.
report must be attached to the Form 5500 when a Schedule H is Under 29 CFR 2520.103-8, the examination and report of an
attached unless line 3d(1) or 3d(2) on the Schedule H is IQPA does not need to extend to statements or information
checked. regarding assets held by a bank, similar institution, or insurance
Notes. (1) The Auditing Standards Board’s Statement on carrier that is regulated and supervised and subject to periodic
Auditing Standards (SAS) 136, Forming an Opinion and examination by a state or federal agency provided that the
Reporting on Financial Statements of Employee Benefit Plans statements or information are prepared by and certified to by the
Subject to ERISA, addresses the IQPA’s responsibility to form bank or similar institution or the insurance carrier. The term
an opinion on the financial statements of employee benefit plans ‘‘similar institution’’ as used here does not extend to securities
subject to ERISA. SAS 136 also addresses the form and brokerage firms (see DOL Advisory Opinion 93-21A). Under 29
content of the auditor’s report issued as a result of an audit of CFR 2520.103-12, an audit of an employee benefit plan does
an ERISA plan’s financial statements. The SAS applies to audits not need extend to the investments in a pooled investment fund
of single employer, multiple-employer, and multiemployer plans that files a separate audited Form 5500 as a 103-12 IE. For
subject to ERISA. An IQPA Report generally consists of an more information on filing requirements for 103-12 IEs, See
Accountant’s Opinion, the plan or DFE Financial Statements, Section 4: What to File. Neither of these regulations exempt
Notes to the Financial Statements, and Supplemental the plan administrator from engaging an IQPA nor from
Schedules. attaching the IQPA’s report to the Form 5500.
29 CFR 2520.103-1(b) requires that any separate financial Line 3a(2). Check if a qualified opinion was issued. Generally,
statements prepared in order for the IQPA to form the opinion a qualified opinion is issued by an IQPA when (a) the IQPA,
and notes to these financial statements must be attached to the having obtained sufficient appropriate audit evidence, concludes
Form 5500. Any separate statements must include the that misstatements, individually or in the aggregate, are material
information required to be disclosed in Parts I and II of the but not pervasive to the financial statements or (b) the IQPA is
Schedule H; however, they may be aggregated into categories unable to obtain sufficient appropriate audit evidence on which
in a manner other than that used on the Schedule H. The to base the opinion, but the auditor concludes that the possible
separate statements must consist of reproductions of Parts I effects on the financial statements of undetected misstatements,
and II or statements incorporating by reference Parts I and II. if any, could be material but not pervasive.
See ERISA section 103(a)(3)(A), and the DOL regulations 29 Line 3a(3). Check if a disclaimer of opinion was issued. A
CFR 2520.103-1(a)(2) and (b), 2520.103-2, and 2520.104-50. disclaimer of opinion is issued when the IQPA is unable to
(2) Delinquent participant contributions reported on line 4a obtain sufficient appropriate audit evidence on which to base the
should be treated as part of the separate schedules referenced opinion, and the IQPA concludes that the possible effects on the
in ERISA section 103(a)(3)(A) and 29 CFR 2520.103-1(b) and financial statements of undetected misstatements, if any, could
2520.103-2(b) for purposes of preparing the IQPA’s opinion be both material and pervasive.
described on line 3 even though they are no longer required to Line 3a(4). Check if the plan received an adverse accountant’s
be listed on Part III of the Schedule G. If the information opinion. Generally, an adverse opinion is issued by an IQPA

-38- Instructions for Schedule H (Form 5500)

- 39 -

when the IQPA having obtained sufficient appropriate audit Line 4a. Amounts paid by a participant or beneficiary to an
evidence, concludes that misstatements, individually or in the employer and/or withheld by an employer for contribution to the
aggregate, are both material and pervasive to the financial plan are participant contributions that become plan assets as of
statements. the earliest date on which such contributions can reasonably be
Line 3b. Check “DOL Regulation 2520.103-8” or “DOL segregated from the employer’s general assets (see 29 CFR
Regulation 2520.103-12(d)” (or both boxes, if applicable) if the 2510.3-102). Plans that check “Yes” must enter the aggregate
IQPA performed an ERISA Section 103(a)(3)(C) audit of the amount of all late contributions for the year. The total amount of
plan’s financial statements pursuant to DOL regulations 29 CFR the delinquent contributions should be included on line 4a of the
2520.103-8, 29 CFR 2520.103-12(d), or under both. If it was not Schedule H or I, as applicable, for the year in which the
performed pursuant to 29 CFR 2520.103-8 or 29 CFR 2520 contributions were delinquent and should be carried over and
103-12(d), check box (3). reported again on line 4a of the Schedule H or I, as applicable,
for each subsequent year until the year after the violation has
Note. These regulations do not exempt the plan administrator been fully corrected, which correction includes payment of the
from engaging an IQPA or from attaching the IQPA’s report to late contributions and reimbursement of the plan for lost
the Form 5500. If you check box 103-8 or 103-12(d) or both, you earnings or profits. If no participant contributions were received
must also check the appropriate box on line 3a to identify the or withheld by the employer during the plan year, answer “No.”
type of opinion offered by the IQPA.
An employer holding these assets after that date commingled
Line 3c. Enter the name and EIN of the accountant (or with its general assets will have engaged in a prohibited use of
accounting firm) in the space provided on line 3c. Do not use a plan assets (see ERISA section 406). If such a nonexempt
social security number or any portion thereof in lieu of an EIN. prohibited transaction occurred with respect to a disqualified
The Schedule H is open to public inspection, and the contents person (see Code section 4975(e)(2)), file IRS Form 5330,
are public information and are subject to publication on the Return of Excise Taxes Related to Employee Benefit Plans, with
Internet. Because of privacy concerns, the inclusion of a social the IRS to pay any applicable excise tax on the transaction.
security number or any portion thereof on this Schedule H may
result in the rejection of the filing. Participant loan repayments paid to and/or withheld by an
employer for purposes of transmittal to the plan that were not
Line 3d(1). Check this box only if the Schedule H is being filed transmitted to the plan in a timely fashion must be reported
for a CCT, PSA, or MTIA. either on line 4a in accordance with the reporting requirements
Line 3d(2). Check this box if the plan has elected to defer that apply to delinquent participant contributions or on line 4d.
attaching the IQPA’s opinion for the first of two (2) consecutive See Advisory Opinion 2002-02A, available at
plan years, one of which is a short plan year of seven (7) www.dol.gov/ebsa.
months or fewer. The Form 5500 for the first of the two (2) years
must be complete and accurate, with all required attachments, Delinquent participant contributions reported on line 4a
except for the IQPA’s report, including an attachment explaining should be treated as part of the separate schedules
why one of the two (2) plan years is of seven (7) or fewer referenced in ERISA section 103(a)(3)(A) and 29 CFR
months duration and stating that the annual report for the 2520.103-1(b) and 2520.103-2(b) for purposes of preparing the
immediately following plan year will include a report of an IQPA IQPA’s opinion described on line 3 even though they are no
with respect to the financial statements and accompanying longer required to be listed on Part III of the Schedule G. If the
schedules for both of the two (2) plan years. The Form 5500 for information contained on line 4a is not presented in accordance
the second year must include: (a) financial schedules and with regulatory requirements, i.e., when the IQPA concludes
statements for both plan years; (b) a report of an IQPA with that the scheduled information required by line 4a does not
respect to the financial schedules and statements for each of contain all the required information or contains information that
the two (2) plan years (regardless of the number of participants is inaccurate or is inconsistent with the plan’s financial
covered at the beginning of each plan year); and (c) a statement statements, the IQPA report must make the appropriate
identifying any material differences between the unaudited disclosures in accordance with generally accepted auditing
financial information submitted with the first Form 5500 and the standards. For more information, see EBSA’s Frequently Asked
audited financial information submitted with the second Form Questions About Reporting Delinquent Contributions on the
5500. See 29 CFR 2520.104-50. Form 5500, available on the Internet at www.dol.gov/ebsa.
These Frequently Asked Questions clarify that plans have an
Note. Do not check the box on line 3d(2) if the Form 5500 is obligation to include delinquent participant contributions on their
filed for a 103-12 IE or a GIA. A deferral of the IQPA’s opinion is financial statements and supplemental schedules and that the
not permitted for a 103-12 IE or a GIA. If an “E” or “G” is entered IQPA’s report covers such delinquent contributions even though
on Form 5500, Part I, line A(4), an IQPA’s opinion must be they are not required to be included on Part III of the Schedule
attached to the Form 5500 and the type of opinion must be G. Although all delinquent participant contributions must be
reported on Schedule H, line 3a. reported on line 4a, delinquent contributions for which the DOL
Part IV – Compliance Questions VFCP requirements and the conditions of PTE 2002-51 have
Lines 4a through 4n. Plans completing Schedule H must been satisfied do not need to be treated as nonexempt party-in-
answer all these lines with either ‘‘Yes’’ or ‘‘No.’’ Do not leave interest transactions.
any answer blank, unless otherwise directed. For lines 4a The VFCP describes how to apply, the specific transactions
through 4h and line 4l, if the answer is “Yes,” an amount must covered (which transactions include delinquent participant
be entered. contributions to pension and welfare plans), and acceptable
Report investments in CCTs, PSAs, MTIAs, and 103-12 IEs, methods for correcting violations. In addition, applicants that
but not the investments made by these entities. Plans with all of satisfy both the VFCP requirements and the conditions of PTE
their funds held in a master trust should check ‘‘No’’ on line 4b, 2002-51 are eligible for immediate relief from payment of certain
4c, 4i, and 4j. CCTs and PSAs do not complete Part IV. MTIAs, prohibited transaction excise taxes for certain corrected
103-12 IEs, and GIAs do not complete lines 4a, 4e, 4f, 4g, 4h, transactions, and are also relieved from the obligation to file the
4k, 4m, or 4n. 103-12 IEs also do not complete line 4j and 4l. IRS Form 5330 with the IRS. For more information, see 71 Fed.
MTIAs also do not complete line 4l. Reg. 20261 (Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19,

Instructions for Schedule H (Form 5500) -39-

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2006). Information about the VFCP is also available on the Applicants that satisfy the VFCP requirements and the
Internet at www.dol.gov/ebsa. conditions of PTE 2002-51 (see the instructions for line 4a)
All delinquent participant contributions must be reported on are eligible for immediate relief from payment of certain
line 4a even if violations have been corrected. prohibited transaction excise taxes for certain corrected
transactions, and are also relieved from the obligation to file the
Line 4a Schedule. Attach a Schedule of Delinquent IRS Form 5330 with the IRS. For more information, see 71 Fed.
Participant Contributions using the format below if you entered Reg. 20261 (Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19,
“Yes.” If you chose to include participant loan repayments on 2006). When the conditions of PTE 2002-51 have been
line 4a, you must apply the same supplemental schedule and satisfied, the corrected transactions should be treated as
IQPA disclosure requirements to the loan repayments as exempt under Code section 4975(c) for the purposes of
applied to delinquent transmittals of participant contributions. answering line 4d.
Schedule H Line 4a –Schedule of Delinquent Line 4e. Plans that check “Yes” must enter the aggregate
Participant Contributions amount of fidelity bond coverage for all claims. Check ‘‘Yes’’
Participant Total that Constitute Nonexempt Total Fully only if the plan itself (as opposed to the plan sponsor or
Contributions Prohibited Transactions Corrected administrator) is a named insured under a fidelity bond from an
Transferred Under approved surety covering plan officials and that protects the
Late to Plan VFCP and plan from losses due to fraud or dishonesty as described in 29
Check here if Contributions Contributions Contributions PTE 2002- CFR Part 2580. Generally, every plan official of an employee
Late Not Corrected Pending 51 benefit plan who ‘‘handles’’ funds or other property of such plan
Participant Corrected Outside Correction in must be bonded. Generally, a person shall be deemed to be
Loan VFCP VFCP ‘‘handling’’ funds or other property of a plan, so as to require
Repayments bonding, whenever his or her duties or activities with respect to
are included: given funds are such that there is a risk that such funds could
be lost in the event of fraud or dishonesty on the part of such
Line 4b. Plans that check “Yes” must enter the amount and person, acting either alone or in collusion with others. Section
complete Part I of Schedule G. The due date, payment amount 412 of ERISA and 29 CFR Part 2580 describe the bonding
and conditions for determining default of a note or loan are requirements, including the definition of “handling” (29 CFR
usually contained in the documents establishing the note or 2580.412-6), the permissible forms of bonds (29 CFR 2580.412-
loan. A loan by the plan is in default when the borrower is 10), the amount of the bond (29 CFR Part 2580, subpart C), and
unable to pay the obligation upon maturity. Obligations that certain exemptions such as the exemption for unfunded plans,
require periodic repayment can default at any time. Generally, certain banks and insurance companies (ERISA section 412),
loans and fixed income obligations are considered uncollectible and the exemption allowing plan officials to purchase bonds
when payment has not been made and there is little probability from surety companies authorized by the Secretary of the
that payment will be made. A fixed income obligation has a fixed Treasury as acceptable reinsurers on federal bonds (29 CFR
maturity date at a specified interest rate. Do not include 2580.412-23). Information concerning the list of approved
participant loans made under an individual account plan with sureties and reinsures is available on the Internet at
investment experience segregated for each account that were www.fms.treas.gov/c570. For more information on the fidelity
made in accordance with 29 CFR 2550.408b-1 and secured bonding requirements, see Field Assistance Bulletin 2008-04,
solely by a portion of the participant’s vested accrued benefit. available on the Internet at www.dol.gov/ebsa.
Line 4c. Plans that check “Yes” must enter the amount and Note. Plans are permitted under certain conditions to purchase
complete Part II of Schedule G. A lease is an agreement fiduciary liability insurance. These fiduciary liability insurance
conveying the right to use property, plant, or equipment for a policies are not written specifically to protect the plan from
stated period. A lease is in default when the required losses due to dishonest acts and cannot be reported as fidelity
payment(s) has not been made. An uncollectible lease is one bonds on line 4e.
where the required payments have not been made and for Line 4f. Check ‘‘Yes,’’ if the plan suffered or discovered any
which there is little probability that payment will be made. loss as a result of any dishonest or fraudulent act(s) even if the
Line 4d. Plans that check “Yes” must enter the amount and loss was reimbursed by the plan’s fidelity bond or from any
complete Part III of Schedule G. Check ‘‘Yes’’ if any nonexempt other source. If ‘‘Yes’’ is checked enter the full amount of the
transaction with a party-in-interest occurred regardless of loss. If the full amount of the loss has not yet been determined,
whether the transaction is disclosed in the IQPA’s report. Do not provide an estimate and disclose that the figure is an estimate
check “Yes” or complete Schedule G, Part III, with respect to as determined in good faith by a plan fiduciary. You must keep,
transactions that are: (1) statutorily exempt under Part 4 of Title in accordance with ERISA section 107, records showing how
I of ERISA; (2) administratively exempt under ERISA section the estimate was determined.
408(a); (3) exempt under Code sections 4975(c) or 4975(d);(4) Willful failure to report is a criminal offense. See ERISA
the holding of participant contributions in the employer’s general section 501.
assets for a welfare plan that meets the conditions of ERISA
Technical Release 92-01; (5) a transaction of a 103-12 IE with Lines 4g and 4h. Current value means fair market value
parties other than the plan; or (6) delinquent participant where available. Otherwise, it means the fair value as
contributions or delinquent participant loan repayments reported determined in good faith under the terms of the plan by a trustee
on line 4a. or a named fiduciary, assuming an orderly liquidation at the time
of the determination. See ERISA section 3(26).
Note. See the instructions for Part III of the Schedule G (Form
5500) concerning nonexempt transactions and party-in-interest. An accurate assessment of fair market value is essential to a
pension plan’s ability to comply with the requirements set forth
You may indicate that an application for an administrative in the Code (e.g., the exclusive benefit rule of Code section
exemption is pending. If you are unsure as to whether a 401(a)(2), the limitations on benefits and contributions under
transaction is exempt or not, you should consult with either the Code section 415, and the minimum funding requirements
plan’s IQPA or legal counsel or both. under Code section 412) and must be determined annually.
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Examples of assets that may not have a readily determinable • Any investment asset held by the plan on the last day of the
value on an established market (e.g., NYSE, AMEX, over the plan year; and
counter, etc.) include real estate, nonpublicly traded securities, • Any investment asset purchased during the plan year and sold
shares in a limited partnership, and collectibles. Do not check before the end of the plan year except:
“Yes” on line 4g for mutual fund shares or insurance company 1. Debt obligations of the U.S. or any U.S. agency.
investment contracts for which the plan receives valuation 2. Interests issued by a company registered under the
information at least annually. Also, do not check ‘‘Yes’’ on line Investment Company Act of 1940 (e.g., a mutual fund).
4g if the plan is a defined contribution plan and the only assets 3. Bank certificates of deposit with a maturity of one
the plan holds, that do not have a readily determinable value on year or less.
an established market, are: (1) participant loans not in default, 4. Commercial paper with a maturity of 9 months or
or (2) assets over which the participant exercises control within less if it is valued in the highest rating category by at least
the meaning of section 404(c) of ERISA. two nationally recognized statistical rating services and is
Although the current value of plan assets must be determined issued by a company required to file reports with the
each year, there is no requirement that the assets (other than Securities and Exchange Commission under section 13 of
certain nonpublicly traded employer securities held in ESOPs) the Securities Exchange Act of 1934.
be valued every year by independent third-party appraisers. 5. Participations in a bank common or collective trust.
Enter in the amount column the fair market value of the 6. Participations in an insurance company pooled
assets referred to on line 4g whose value was not readily separate account.
determinable on an established market and which were not 7. Securities purchased from a broker-dealer
valued by an independent third-party appraiser in the plan year. registered under the Securities Exchange Act of 1934 and
Generally, as it relates to these questions, an appraisal by an either: (1) listed on a national securities exchange and
independent third party is an evaluation of the value of an asset registered under section 6 of the Securities Exchange Act
prepared by an individual or firm who knows how to judge the of 1934 or (2) quoted on NASDAQ.
value of such assets and does not have an ongoing relationship Assets held for investment purposes shall not include any
with the plan or plan fiduciaries except for preparing the investment that was not held by the plan on the last day of the
appraisals. plan year if that investment is reported in the annual report for
Line 4i. Check “Yes” if the plan had any assets held for that plan year in any of the following:
investment purposes, and attach a schedule of assets held for 1. The schedule of loans or fixed income obligations in
investment purposes at end of year, a schedule of assets held default required by Schedule G, Part I;
for investment purposes that were both acquired and disposed 2. The schedule of leases in default or classified as
of within the plan year, or both, as applicable. The schedules uncollectible required by Schedule G, Part II;
must use the format set forth below or a similar format. See 29 3. The schedule of nonexempt transactions required by
CFR 2520.103-11. Schedule G, Part III; or
Assets held for investment purposes shall include: 4. The schedule of reportable transactions required by
Schedule H, line 4j.

Line 4i schedules. The first schedule required to be attached is a schedule of all assets held for investment purposes at the end
of the plan year, aggregated and identified by issue, maturity date, rate of inte st,recollateral, par or maturity value, cost and current
value, and, in the case of a loan, the payment schedule.
In column (a), place an asterisk (*) on the line of each identified person known to be a party-in-inte streto the plan. In column
(c), include any restriction on transferability of corporate securities. (Include lending of securities permitted under Prohibited
Transactions Exemption 81-6.)
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 required to be attached is a schedule of investment assets that were both acquired and disposed of within
the plan year. This schedule must be cle arly 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

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

Instructions for Schedule H (Form 5500) -41-

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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 his or her 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. 
 
Line 4j. Check “Yes” and attach to the Form 5500 the following          transactions of the trust shall be combined with the other 
schedule if the plan had any reportable transactions (see 29            transactions of the plan, if any, to determine which transactions 
CFR 2520.103-6 and the examples provided in the regulation).            (or series of transactions) are reportable (5%) transactions. 
The schedule must use the format set forth below or a similar                For investments in common/collective trusts (CCTs), pooled 
format. See 29 CFR 2520.103-11.                                         separate accounts (PSAs), 103-12 IEs, and registered 
A reportable transaction includes:                                      investment companies, determine the 5% figure by comparing 
  1.A single transaction within the plan year in excess of 5% of        the transaction date value of the acquisition and/or disposition of 
the current value of the plan assets;                                   units of participation or shares in the entity with the current 
  2.Any series of transactions with or in conjunction with the          value of the plan assets at the beginning of the plan year. If the 
same person, involving property other than securities, which            Schedule H is attached to a Form 5500 filed for a plan with all 
amount in the aggregate within the plan year (regardless of the         plan funds held in a master trust, check ‘‘No’’ on line 4j. Plans 
category of asset and the gain or loss on any transaction) to           with assets in a master trust that have other transactions should 
more than 5% of the current value of plan assets;                       determine the 5% figure by subtracting the current value of plan 
  3.Any transaction within the plan year involving securities of        assets held in the master trust from the current value of all plan 
the same issue if within the plan year any series of transactions       assets at the beginning of the plan year and check ‘‘Yes’’ or 
with respect to such securities amount in the aggregate to more         “No,” as appropriate. Do not include individual transactions of 
than 5% of the current value of the plan assets; and                    (CCTs), (PSAs), master trust investment accounts (MTIAs), 
  4.Any transaction within the plan year with respect to                103-12 IEs, and registered investment companies in which this 
securities with, or in conjunction with, a person if any prior or       plan or DFE invests.  
subsequent single transaction within the plan year with such              In the case of a purchase or sale of a security on the market, 
person, with respect to securities, exceeds 5% of the current           do not identify the person from whom purchased or to whom 
value of plan assets.                                                   sold. 
  The 5% figure is determined by comparing the current value            Special rule for certain participant-directed transactions. 
of the transaction at the transaction date with the current value       Transactions under an individual account plan that a participant 
of the plan assets at the beginning of the plan year. If this is the    or beneficiary directed with respect to assets allocated to his or 
initial plan year, you may use the current value of the plan            her account (including a negative election authorized under the 
assets at the end of the plan year to determine the 5% figure.          terms of the plan) should not be treated for purposes of line 4j 
  If the assets of two or more plans are maintained in one trust,       as reportable transactions. The current value of all assets of the 
except as provided below, the plan’s allocable portion of the           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) 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) 
                                                                                                                                
Line 4k. Check “Yes” if all the plan assets (including                      see Code section 401(a)(9). Include in this amount the total of 
insurance/annuity contracts) were distributed to the                        any outstanding amounts that were not paid when due in 
participants and beneficiaries, legally transferred to the control          previous years that have continued to remain unpaid. 
of another plan, or brought under the control of the PBGC.                  Note. In the absence of other guidance, filers do not need to 
  Check ‘‘No’’ for a welfare benefit plan that is still liable to           report on this line unpaid required minimum distribution (RMD) 
pay benefits for claims incurred before the termination date,               amounts for participants who have retired or separated from 
but not yet paid. See 29 CFR 2520.104b-2(g)(2)(ii).                         service, or their beneficiaries, who cannot be located after 
Line 4l. You must check “Yes” if any benefits due under the                 reasonable efforts or where the plan is in the process of 
plan were not timely paid or not paid in full. This would include           engaging in such reasonable efforts at the end of the plan year 
minimum required distributions to 5% owners who have                        reporting period. Plan administrators and employers should 
attained 72 whether or not retired and/or non-5% owners who                 review their plan documents for written procedures on locating 
have attained 72 and have retired or separated from service,                missing participants. Although the Department of Labor’s Field 
                                                                            Assistance Bulletin 2014-01 is specifically applicable to 
                                                                   -42-                        Instructions for Schedule H (Form 5500)

- 43 -

terminated defined contribution plans, employers and plan when there is a reduction of assets or liabilities with respect to
administrators of ongoing plans may want to consider one plan and the receipt of these assets or the assumption of
periodically using one or more of the search methods these liabilities by another plan. Enter the name, plan sponsor
described in the FAB in connection with making reasonable EIN, and PN for the transferee plan(s) involved on lines 5b(1),
efforts to locate RMD-eligible missing participants. (2), and (3).
Line 4m. Check “Yes” if there was a “blackout period.” A Do not use a social security number in lieu of an EIN or
blackout period is a temporary suspension of more than three include an attachment that contains visible social security
(3) consecutive business days during which participants or numbers. The Schedule H is open to public inspection, and the
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 Note. A distribution of all or part of an individual participant’s
loans from the plan, or obtain distributions from the plan if the account balance that is reportable on Form 1099-R should not
temporary suspension is: (1) part of the regularly scheduled be included on line 5b. Do not submit Form 1099-R with the
operations of the plan that has been disclosed to participants Form 5500.
and beneficiaries; (2) due to a qualified domestic relations
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
regarding a participant’s individual account; or (4) by or any transfer of plan assets or liabilities to another plan.
application of federal securities laws. For more information, There is a penalty for not filing IRS Form 5310-A on time. In
see 29 CFR 2520.101-3 (available at www.dol.gov/ebsa). addition, a transfer of benefit liabilities involving a plan covered
by PBGC insurance may be reportable to the PBGC. See
Line 4n. If there was a blackout period, did you provide the PBGC Form 10, Post-Event Notice of Reportable Events, and
required notice not less than 30 days nor more than 60 days in PBGC Form 10-Advance, Advance Notice of Reportable
advance of restricting the rights of participants and Events.
beneficiaries to change their plan investments, obtain loans
from the plan, or obtain distributions from the plan? If so, check Line 5c. Check “Yes” if the plan was covered by PBGC at any
“Yes.” See 29 CFR 2520.101-3 for specific notice requirements time during the plan year to which the Form 5500 relates and
and for exceptions from the notice requirement. Also, answer enter the My PAA generated confirmation number for the
“Yes” if one of the exceptions to the notice requirement under premium filing for that plan year reported (see filing receipt).
29 CFR 2520.101-3 applies. “Yes” must be checked even if coverage has ceased and/or
final premiums have been paid before the Form 5500 is due.
Line 5a. Check “Yes” if a resolution to terminate the plan was
adopted during this or any prior plan year, unless the If you are uncertain whether the plan is covered under the
termination was revoked and no assets reverted to the PBGC termination insurance program, check the box “Not
employer. If ‘‘Yes’’ is checked, enter the amount of plan assets determined” and contact PBGC either by phone at 1-800-736-
that reverted to the employer during the plan year in 2444, by E-mail at coverage@pbgc.gov. If you amended your
connection with the implementation of such termination. Enter premium filing for this plan year, enter the confirmation number
“0” if no reversion occurred during the current plan year. for that filing and not for the previous filing(s). Defined
contribution plans and welfare plans do not need to complete
A Form 5500 must be filed for each year the plan has this item.
assets, and, for a welfare benefit plan, if the plan is still
liable to pay benefits for claims incurred before the termination Note: A church defined benefit pension plan that has
date, but not yet paid. See 29 CFR 2520.104b-2(g)(2)(ii). made an election under Code section 410(d) should
see www.pbgc.gov for the procedures prescribed by
Line 5b. Enter information concerning assets and/or liabilities PBGC on how to notify PBGC that it wishes to have
transferred from this plan to another plan(s) (including spinoffs) title IV of ERISA apply to it.
during the plan year. A transfer of assets or liabilities occurs

Instructions for Schedule H (Form 5500) -43-

- 44 -

under the terms of the plan by a trustee or a named fiduciary,
2022 Instructions for Schedule I assuming an orderly liquidation at time of the determination.
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
Who Must File preceding plan year.
Schedule I (Form 5500) must be attached to a Form 5500 filed Do not include contributions designated for the 2022 plan
for pension benefit plans and welfare benefit plans that year in column (a).
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
Note. If a Schedule I or a Form 5500-SF was filed for the plan investment accounts (MTIAs), and/or 103-12 IEs must also
for the 2021 plan year and the plan covered fewer than 121 attach Schedule D.
participants as of the beginning of the 2022 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
Exception. Certain insured, unfunded or combination contracts) that you used for line 4 of Schedule A, or, if line 4 is
unfunded/insured welfare plans are exempt from filing the not required, line 7 of Schedule A.
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
Specific Instructions deemed distribution) should be included in column (b) without
regard to the occurrence of a deemed distribution.
Lines A, B, C, and D. This information must be the same as
reported in Part II of the Form 5500 to which this Schedule I is After a participant loan that has been deemed distributed is
attached. reported on line 2g, it is no longer to be reported as an asset
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
If the assets of two or more plans are maintained in one participant resumes repayment under the loan. In addition, the
fund, such as when an employer has two plans funded through amount to be entered on line 2g must be reduced by the
a single trust (except a DFE), complete Parts I and II by amount of the participant loan reported as a deemed
entering the plan’s allocable part of each line item. distribution on line 2g for the earlier year.
If assets of one plan are maintained in two or more trust Line 1b. Enter the total liabilities at the beginning and end of
funds, report the combined financial information in Part I. the plan year. Liabilities to be entered here do not include the
value of future pension payments to plan participants.
Current value means fair market value where available.
Otherwise, it means the fair value as determined in good faith

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However, the amount to be entered in line 1b for accrual basis          services, day care services, and training and apprenticeship 
filers includes, among other things:                                    services. If securities or other property are distributed to plan 
 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 
                                                                        has been deemed distributed during the plan year under the 
Line 2a(1). Plans using the accrual basis of accounting must            provisions of Code section 72(p) and Treasury Regulations 
not include contributions designated for years before the 2022          section 1.72(p)-1 only if both of the following circumstances 
plan year on line 2a(1).                                                apply: 
Line 2a(2). For welfare plans, report all employee                      1. Under the plan, the participant loan is treated as a 
contributions, including all elective contributions under a             directed investment solely of the participant’s individual 
cafeteria plan (Code section 125). For pension benefit plans,           account; and 
participant contributions, for purposes of this item, also include      2. As of the end of the plan year, the participant is not 
elective contributions under a qualified cash or deferred               continuing repayment under the loan. 
arrangement (Code section 401(k)). 
                                                                        If either of these circumstances does not apply, a deemed 
Line 2b. Use the current value, at date contributed, of                 distribution of a participant loan should not be reported on line 
securities or other noncash property.                                   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. 

Instructions for Schedule I (Form 5500)                            -45-

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

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- 47 -

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 2510.3102(a)(2).                  are also relieved from the obligation to file the IRS Form 5330 
Plans that check “Yes” must enter the aggregate amount of all           with the IRS. For more information, see 71 Fed. Reg. 20261 
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 Constitute 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 
Instructions for Schedule I (Form 5500)                            -47-

- 48 -

(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 his or her 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 his or her duties or activities with
A. Any fiduciary (including, but not limited to, any respect to given funds are such that there is a risk that such
administrator, officer, trustee, or custodian), counsel, or funds could be lost in the event of fraud or dishonesty on the
employee of the plan; part of such person, acting either alone or in collusion with
B. A person providing services to the plan; others. Section 412 of ERISA and 29 CFR Part 2580 describe
C. An employer, any of whose employees are covered by the bonding requirements, including the definition of ‘‘handling’’
the plan; (29 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 venturer 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

-48- Instructions for Schedule I (Form 5500)

- 49 -

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, 2020, which matures on additional guidance on these determinations, and 29 CFR
June 30, 2022, 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
Instructions for Schedule I (Form 5500) -49-

- 50 -

  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 72 whether or not retired and/or non-5% owners who 
(this SAR disclosure requirement does not apply to qualifying             have attained 72 and have retired or separated from service, 
employer securities, participant loans and individual account             see Code section 401(a)(9). Include in this amount the total of 
assets described in paragraphs 4,5 and 6 above);                          any outstanding amounts that were not paid when due in 
  2. The name of the surety company issuing the fidelity bond,            previous years that have continued to remain unpaid. 
if the plan has more than 5% of its assets in non-qualifying 
plan assets;                                                              Note. In the absence of other guidance, filers do not need to 
  3. A notice that participants and beneficiaries may, upon               report on this line unpaid required minimum distribution (RMD) 
request and without charge, examine or receive from the plan              amounts for participants who have retired or separated from 
evidence of the required bond and copies of statements from               service, or their beneficiaries, who cannot be located after 
the regulated financial institutions describing the qualifying            reasonable efforts or where the plan is in the process of 
plan assets; and                                                          engaging in such reasonable efforts at the end of the plan year 
  4. A notice that participants and beneficiaries should contact          reporting period. Plan administrators and employers should 
the EBSA Regional Office if they are unable to examine or                 review their plan documents for written procedures on locating 
obtain copies of the regulated financial institution statements or        missing participants. Although the Department of Labor’s Field 
evidence of the required bond, if applicable.                             Assistance Bulletin 2014-01 is specifically applicable to 
                                                                          terminated defined contribution plans, employers and plan 
  A Model Notice that plans can use to satisfy the enhanced               administrators of ongoing plans may want to consider 
SAR (or Annual Funding Notice) disclosure requirements to be              periodically using one or more of the search methods 
eligible for the audit waiver is available as an Appendix to 29           described in the FAB in connection with making reasonable 
CFR 2520.104-46.                                                          efforts to locate RMD-eligible missing participants. 
  Condition 3: In addition, in response to a request from any             Line 4m.  Check “Yes” if there was a “blackout period.” A 
participant or beneficiary, the administrator, without charge to          blackout period is a temporary suspension of more than three 
the participant or beneficiary, must make available for                   (3) consecutive business days during which participants or 
examination, or upon request furnish copies of, each regulated            beneficiaries of a 401(k) or other individual account pension 
financial institution statement and evidence of any required              plan were unable to, or were limited or restricted in their ability 
bond.                                                                     to, direct or diversify assets credited to their accounts, obtain 
  Examples. Plan A, which has a plan year that began on or                loans from the plan, or obtain distributions from the plan. A 
after April 18, 2001, had total assets of $600,000 as of the end          “blackout period” generally does not include a temporary 
of the 2000 plan year that included: investments in various               suspension of the right of participants and beneficiaries to 
bank, insurance company and mutual fund products of                       direct or diversify assets credited to their accounts, obtain 
$520,000; investments in qualifying employer securities of                loans from the plan, or obtain distributions from the plan if the 
$40,000; participant loans (meeting the requirements of ERISA             temporary suspension is: (1) part of the regularly scheduled 
section 408(b)(1)), totaling $20,000; and a $20,000 investment            operations of the plan that has been disclosed to participants 
in a real estate limited partnership. Because the only asset of           and beneficiaries; (2) due to a qualified domestic relations 
the plan that did not constitute a ‘‘qualifying plan asset’’ is the       order (QDRO) or because of a pending determination as to 
$20,000 real estate limited partnership investment and that               whether a domestic relations order is a QDRO; (3) due to an 
investment represents less than 5% of the plan’s total assets,            action or a failure to take action by an individual participant or 
no fidelity bond is required as a condition for the plan to be            because of an action or claim by someone other than the plan 
eligible for the waiver for the 2001 plan year.                           regarding a participant’s individual account; (4) by application 
  Plan B is identical to Plan A except that of Plan B’s total             of federal securities laws. For more information, see 29 CFR 
assets of $600,000 as of the end of the 2000 plan year,                   2520.101-3 (available at www.dol.gov/ebsa). 
$558,000 constitutes ‘‘qualifying plan assets’’ and $42,000               Line 4n. If there was a blackout period, did you provide the 
constitutes non-qualifying plan assets. Because 7%  –  more               required notice not less than 30 days nor more than 60 days in 
than 5%  –  of Plan B’s assets do not constitute ‘‘qualifying plan        advance of restricting the rights of participants and 
assets,’’ Plan B, as a condition to be eligible for the waiver for        beneficiaries to change their plan investments, obtain loans 
the 2001 plan year, must ensure that it has a fidelity bond in an         from the plan, or obtain distributions from the plan? If so, check 
amount equal to at least $42,000 covering persons handling its            “Yes.” See 29 CFR 2520.101-3 for specific notice requirements 
non-qualifying plan assets. Inasmuch as compliance with                   and for exceptions from the notice requirement. Also, answer 
ERISA section 412 generally requires the amount of the bond               “Yes” if one of the exceptions to the notice requirement under 
be not less than 10% of the amount of all the plan’s funds or             29 CFR 2520.101-3 applies. 
other property handled, the bond acquired for ERISA section               Line 5a. Check “Yes” if a resolution to terminate the plan was 
412 purposes may be adequate to cover the non-qualifying                  adopted during this or any prior plan year, unless the 
plan assets without an increase (i.e., if the amount of the bond          termination was revoked and no assets reverted to the 
                                                                    -50-                  Instructions for Schedule I (Form 5500)

- 51 -

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

Instructions for Schedule I (Form 5500) -51-

- 52 -

You can apply for an EIN from the IRS online, by fax, or by
2022 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
contents are public information and are subject to publication Specific Instructions
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

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within the period specified by Code section 431(c)(7) and               account rates of early retirement and the plan’s early 
ERISA section 304(c)(7).                                                retirement and turnover provisions as they relate to benefits, 
Line 1b(1). Current Value of Assets. Enter the current value            where these would significantly affect the results. 
of assets as of the valuation date. The current value is the            Regardless of the valuation date, current liability is computed 
same as the fair market value. Do not adjust for items such as          taking into account only credited service through the end of 
the existing credit balance or the outstanding balances of              the prior plan year. No salary scale projections should be 
certain amortization bases. Contributions designated for 2022           used in these computations. Do not include the expected 
should not be included in this amount. Note that this entry may         increase in current liability due to benefits accruing during 
be different from the entry in line 2a. Such a difference may           the plan year reported on line 1d(2)(b) in these 
result, for example, if the valuation date is not the first day of      computations. 
the plan year, or if insurance contracts are excluded from              Line 1d(2)(b). Expected Increase in Current Liability. 
assets reported on line 1b(1) but not on line 2a.                       Enter the amount by which the current liability is expected to 
 Rollover amounts or other assets held in individual                    increase due to benefits accruing during the plan year on 
accounts that are not available to provide defined benefits             account of credited service and/or salary changes for the 
under the plan should not be included on line 1b(1), regardless         current year. One year’s salary scale may be reflected. 
of whether they are reported on the 2022 Schedule H (Form               Line 1d(2)(c). Expected Release From Current Liability 
5500) (line 1I, column (a)) or Schedule I (Form 5500) (line 1c,         for the Plan Year. Enter the expected release from current 
column (a)). Additionally, asset and liability amounts must be          liability on account of disbursements (including single-sum 
determined in a consistent manner. Therefore, if the value of           distributions) from the plan expected to be paid after the 
any insurance contracts have been excluded from the amount              valuation date but prior to the end of the plan year (see also 
reported on line 1b(1), liabilities satisfied by such contracts         Q&A-7 of Revenue Ruling 96-21, 1996-1 C.B. 64). 
should also be excluded from the liability values reported on           Line 1d(3). Expected Plan Disbursements. Enter the 
lines 1c(1), 1c(2), and 1d(2) of the Schedule MB.                       amount of plan disbursements expected to be paid for the 
Line 1b(2). Actuarial Value of Assets. Enter the value of               plan year. 
assets determined in accordance with Code section 431(c)(2)             Line 2. All entries must be reported as of the beginning of 
and ERISA section 304(c)(2). Do not adjust for items such as            the 2022 plan year. Lines 2a and 2b should include all 
the existing credit balance or the outstanding balances of              assets and liabilities under the plan except for assets and 
certain amortization bases, and do not include contributions            liabilities attributable to: (1) rollover amounts or other 
designated for 2022 in this amount.                                     amounts in individual accounts that are not available to 
Line 1c(1). Accrued Liability for Immediate Gain Methods.               provide defined benefits, or (2) benefits for which an insurer 
Complete this line only if you use an immediate gain method             has made an irrevocable commitment as defined in 29 CFR 
(see Revenue Ruling 81-213, 1981-2 C.B. 101, for a definition           4001.2. 
of immediate gain method).                                              Line 2a. Current Value of Assets. Enter the current value 
Lines 1c(2)(a), (b), and (c). Information for Plans Using               of net assets as of the first day of the plan year. Except for 
Spread Gain Methods. Complete these lines only if you use a             plans with excluded assets as described above, this entry 
spread gain method (see Revenue Ruling 81-213 for a                     should be the same as reported on the 2022 Schedule H 
definition of spread gain method).                                      (Form 5500) (line 1l, column (a)) or Schedule I (Form 5500) 
Line 1c(2)(a). Unfunded Liability for Methods with Bases.               (line 1c, column (a)). Note that contributions designated for 
Complete this line only if you use the frozen initial liability or      the 2022 plan year are not included on those lines.  
attained age normal cost method.                                        Line 2b. Current Liability (beginning of plan year). Enter 
Lines 1c(2)(b) and (c). Entry Age Normal Accrued Liability              the current liability as of the first day of the plan year. Do not 
and Normal Cost. For spread gain methods, these                         include the expected increase in current liability due to 
calculations are used for purposes of the full funding limitation       benefits accruing during the plan year. See the instructions 
(see Revenue Ruling 81-13, 1981-1 C.B. 229).                            for line 1d(2)(a) for actuarial assumptions used in 
                                                                        determining current liability. 
Line 1d(1). Amount Excluded from Current Liability. 
Leave line 1(d)(1) blank.                                                Column (1) – Enter the number of participants and 
                                                                        beneficiaries as of the beginning of the plan year in each 
Line 1d(2)(a). Current Liability. All multiemployer plans,              category (e.g., terminated vested participants). Enter “0” if no 
regardless of the number of participants, must provide the              participants fall into the category. If the current liability 
information indicated in accordance with these instructions.            figures are derived from a valuation that follows the first day 
The interest rate used to compute the current liability must be         of the plan year, the participant and beneficiary count entries 
in accordance with guidelines issued by the IRS and, pursuant           should be derived from the counts used in that valuation in a 
to the Pension Protection Act of 2006 (PPA), must not be more           manner consistent with the derivation of the current liability 
than 5 percent above and must not be more than 10 percent               reported in column (2). 
below the weighted average of the rates of interest, as set forth 
by the Treasury Department, on 30-year Treasury securities               Column (2) – Enter the current liability attributable to all 
during the 4-year period ending on the last day before the              benefits, with subtotals for vested and nonvested benefits in 
beginning of the 2022 plan year.                                        the case of active participants. Enter “0” if there is no current 
                                                                        liability attributable to a particular category of participants. 
 The current liability must be computed using the mortality 
tables referenced in section 1.431(c)(6)-1 of the Treasury              Line 2c. This calculation is required under ERISA section 
Regulations.                                                            103(d)(11). Do not complete if line 2a divided by line 2b(4), 
                                                                        column (2), is 70% or greater.  
 Each other actuarial assumption used in calculating the 
current liability must be the same assumption used for                  Line 3. Contributions Made to Plan. Show all employer 
calculating other costs for the funding standard account. See           and employee contributions for the plan year. Include 
Notice 90-11, 1990-1 C.B. 319. The actuary must take into               employer contributions made not later than 2½ months (or 
                                                                        the later date allowed under Code section 431(c)(8) and 
Instructions for Schedule MB (Form 5500)                           -53-

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ERISA section 304(c)(8)) after the end of the plan year.                 Line 4c. If, in the plan year in which the Schedule MB is filed, a 
Show only contributions actually made to the plan by the                 certification was required to be made under Code section 
date this Schedule MB is signed.                                         432(b)(3)(A)(ii) and ERISA section 305(b)(3)(A)(ii) with respect 
   Add the amounts in both columns (b) and (c) and enter                 to scheduled progress during the plan year for which the 
both results on the total line. All contributions must be                Schedule MB is filed, check “Yes” or “No” to reflect the 
credited toward a particular plan year.                                  certification. Attach documentation comparing the current 
                                                                         status of the plan to the scheduled progress under the 
   If any of the contributions reported in line 3 include                applicable funding improvement or rehabilitation plan to this 
amounts owed for withdrawal liability, report in line 3(d) the           Schedule MB. Label the documentation “Schedule MB, line 
total withdrawal liability amounts included in line 3(b).                4c – Documentation Regarding Progress Under Funding 
   Attach a list showing the date and amount of each                     Improvement or Rehabilitation Plan.” 
withdrawal liability amount included, broken down between                Lines 4d and 4e. If Code C (Critical Status) or Code D (Critical 
periodic amounts and lump sum amounts. For this purpose,                 and Declining Status) was entered on line 4b, an entry on line 
include a withdrawal liability payment as a lump sum only if             4d is required. For purposes of lines 4d and 4e, in determining 
the entire liability is paid in one lump sum or if the payment           whether benefits have been reduced, only adjustable benefits 
from an employer that paid its assessed withdrawal liability             that would otherwise be protected under Code section 
in periodic installments (e.g., monthly or quarterly) in prior           411(d)(6) and ERISA section 204(g) are taken into account if 
years settled the remaining liability via one lump sum                   the plan is certified as being in critical status. Plans that are 
payment during the plan year. Use the format shown below                 certified as being in critical and declining status should 
and label this attachment “Schedule MB, Line 3(d) –                      determine whether benefits have been reduced, including all 
Withdrawal Liability Amounts.” The attachment may be                     benefits that were adjusted (only adjustable benefits that would 
provided in a spreadsheet file (CSV format).                             otherwise be protected under Code section 411(d)(6) and 
   Schedule MB, Line 3(d) - Withdrawal Liability Amounts                 ERISA section 204(g) are taken into account), any benefits that 
                                                                         have been suspended under Code section 432(e)(9), and any 
  Payment        Periodic        Lump Sum       Total                    benefit reductions due to a partition under ERISA section 4233. 
   Date          Amounts         Amounts        Amounts 
                                                                         For a plan that has benefits suspended under Code section 
                                                                         432(e)(9) and/or partitioned under ERISA section 4233, attach 
                                                                         a full description of the transaction and label the attachment 
                                                                         “Schedule MB, Lines 4d and 4e – Description of Benefit 
                                                                         Reductions Due to Suspension or Partition.” In addition, 
                                                                         only benefit reductions that are first reflected in line 1c(3) for 
                                                                         the current year's Schedule MB should be reported, and this 
Line 4. Information on Plan Status. All multiemployer plans              amount should not include any amounts previously reported on 
regardless of the number of participants must provide the                any prior year's Schedule MB. 
information indicated in accordance with these instructions.             Line 4f. If Code C (Critical Status) or Code D (Critical and 
Line 4a. All plans enter the funded percentage for monitoring            Declining Status) was entered on line 4b you must complete 
the plan’s status. This is line 1b(2) divided by line 1c(3).             line 4f as follows:  
Line 4b. Enter the code for the status of the multiemployer              If the projections underlying the actuarial certification for the 
plan for the plan year, as certified by the plan actuary, (or as         plan year indicate that the plan is: 
elected by the plan sponsor in accordance with Code section               • Projected to emerge from critical status within 30 years, 
432(b)(4)(A) and ERISA section 305(b)(4)(A)) using one of                  enter the plan year in which the plan is projected to emerge 
the following codes:                                                       from critical status. 
   Code  Plan Status                                                      • Projected to become insolvent within 30 years, check the 
   E      Endangered Status                                                box provided and enter the plan year in which the 
   S      Seriously Endangered Status                                      insolvency is expected. In addition, attach an illustration 
   C      Critical Status                                                  showing year-by-year cash flow projections for the period 
   D      Critical and Declining Status                                    beginning with the plan year and ending with the year the 
   N      Not in Endangered or Critical Status                             plan is projected to become insolvent (or, if earlier, the 19 th
                                                                           year after the plan year) and a summary of the 
  If the plan is certified to be in endangered status, seriously           assumptions underlying the projections. Label this 
endangered status, critical status, or critical and declining              attachment “Schedule MB, line 4f – Cash Flow 
status, attach a copy of the actuarial certification of such status        Projections.” 
to this Schedule MB. Also attach an illustration showing the              • Neither projected to emerge from critical status nor become 
details (including year-by-year cash flow projections                      insolvent within 30 years, enter “9999.” In addition, attach 
demonstrating the solvency of the plan over the relevant period            an illustration showing year-by-year cash flow projections 
if the plan is certified as being in critical and declining status)        for the 20-year period beginning with the plan year and a 
providing support for the actuarial certification of status and            summary of the assumptions underlying the projections. 
label the illustration “Schedule MB, line 4b – Illustration                Label this attachment “Schedule MB, line 4f – Cash Flow 
Supporting Actuarial Certification of Status.” For example,                Projections.” 
if a plan is certified as being in critical status based on Code         Line 5. Actuarial Cost Method. Enter the primary method 
section 432(b)(2)(B), show the funded percentage (if                     used. If the plan uses one actuarial cost method in one year as 
applicable) and the projection of the funding standard account           the basis of establishing an accrued liability for use under the 
for the year in which the accumulated funding deficiency                 frozen initial liability method in subsequent years, answer as if 
occurs. All supporting documentation should include                      the frozen initial liability method was used in all years. The 
descriptions of the assumptions used.                                    projected unit credit method is included in the “Accrued benefit 

                                                                    -54-               Instructions for Schedule MB (Form 5500)

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(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
methods and justifications for any such change (see section
Changes in funding methods include changes in actuarial 103(d) of ERISA). Label the summary “Schedule MB, line 6
cost method, changes in asset valuation method, and changes
– Summary of Plan Provisions.”
in the valuation date of plan costs and liabilities or of plan
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 2022 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 section 1.431(c)(6)-1 of the Treasury Regulations must be used
412 applies. In addition, pursuant to PPA section 201(b), a in the calculation of current liability for non-disabled lives. Enter
plan does NOT need advance approval from the IRS to the mortality table code for non-disabled lives used for valuation
adopt or cease using the shortfall method if the plan (1) has 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 Mortality Table Code
amortization period extension and did not operate under Mortality Tables with Base Year in 1970s or Earlier ............. 1
such an extension during such 5-year period. In such a case,
check “Yes” for line 5l. If a plan utilizes this automatic Mortality Tables with Base Year in 1980s ........................... 2
approval to apply the shortfall method, the benefit increase Mortality Tables with Base Year in 1990s ........................... 3
limitations of Code section 412(c)(7) apply. Mortality table applicable to current plan year under
If a plan is not eligible for automatic approval as set forth
in the preceding paragraph, advance approval from the IRS section 1.431(c)(6)-1 of the Income Tax Regulations .......... 4
is required if the shortfall funding method is adopted at a RP-2014 ………………...………………….….…………....5
later time, if a specific computation method is changed, or if
RP-2014 (Blue Collar) ……………………………….........6
the shortfall method is discontinued. In such a case there is
no automatic limitation on benefit increases. RP-2014 (adjusted to 2006 Base Year) …………….…...7
Line 6. Actuarial Assumptions. If gender-based Pri-2012 .......................................................................... .8
assumptions are used in developing plan costs, enter those
rates where appropriate in line 6. Note that requests for Pri-2012 (Blue Collar) ..................................................... 9
gender-based cost information do not suggest that gender- Other ................................................................................... A
based benefits are legal. If unisex tables are used, enter the
values in both “Male” and “Female” lines. Check “N/A” for None ................................................................................... 0
line 6b if the question is not applicable. Where an indicated table consists of separate tables for
Attach a statement of actuarial assumptions (if not fully males and females, add F to the female table (e.g., 1F).
described by line 6) and actuarial methods used to calculate When a projection is used with a table, follow the code with
the figures shown in lines 1 and 9 (if not fully described by “P” and the year of projection (omit the year if the projection
line 5), and label the statement “Schedule MB, line 6 – is unrelated to a single calendar year). The identity of the
Statement of Actuarial Assumptions/Methods.” The projection scale should be omitted from line 6c, but a
statement must describe all actuarial assumptions used to description of projection techniques, including the projection
determine the liabilities. For example, the statement for non- scales used, should be included in the Schedule MB, line 6
traditional plans (e.g., cash balance plans) must include the – Statement of Actuarial Assumptions/Methods. When
assumptions used to convert balances to annuities. an age setback or set forward is used, indicate with “ – ” or

Instructions for Schedule MB (Form 5500) -55-

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“+” and the number of years. For example, if for females the            value of the assets one year ago, and B is the current value of 
1983 G.A.M. Table (solely per Revenue Ruling 95-28) with                the assets on the current valuation date. Enter rates to the 
projection to 2021 is used with a 5-year setback, enter                 nearest .1 percent. If entering a negative number, enter a 
“2P21-5.” If the table is not one of those listed, enter “A” with       minus sign (“ – ”) to the left of the number. 
no further notation. If the valuation assumes a maturity value           Note. Use the above formula even if the actuary feels that the 
to provide the post-retirement income without separately                result of using the formula does not represent the true 
identifying the mortality, interest and expense elements,               estimated rate of return on the current value of plan assets for 
enter on line 6c, under “Post-retirement,” the value of $1.00           the 1-year period ending on the valuation date. The actuary 
of monthly pension beginning at the plan’s weighted average             may attach a statement showing both the actuary’s estimate of 
retirement age, assuming the normal form of annuity for an              the rate of return and the actuary’s calculations of that rate, 
unmarried person. In such a case, leave lines 6d and 6e                 and label the statement “Schedule MB, line 6h – Estimated 
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 
Line 6e. Salary Scale. If a uniform level annual rate of                percentage of normal cost, the reported percentage in line 
salary increase is used, enter that annual rate. Otherwise,             6i(1) should be the expense load as a percent of the 
enter the level annual rate of salary increase that is                  unloaded normal cost.  For example, if the expense load is 
equivalent to the rate(s) of salary increase used. Enter the            5% of the normal cost, the unloaded normal cost is $100,000 
annual rate as a percentage to the nearest .01 percent, used            and the reported normal cost is $105,000, enter 5%, not 
for a participant from age 25 to assumed retirement age. If             4.8% (i.e., $5,000/$105,000). Enter rates to the nearest .1 
the plan’s benefit formula is not related to compensation,              percent. 
check the “N/A” box.                                                    Line 7. New Amortization Bases Established. List all new 
Lines 6f(1) and 6(f)(2). Withdrawal Liability Interest Rate.            amortization bases established in the current plan year (before 
In line 6f(1), check the box that describes the type of interest        the combining of bases, if bases were combined). Use the 
rate assumption used to determine the present value of                  following table to indicate the type of base established and 
vested benefits for withdrawal liability determinations for             enter the appropriate code under “Type of base.” List 
employers withdrawing during the plan year.  If the present             amortization bases and charges and/or credits as of the 
value of vested benefits noted above was not determined by              valuation date. Bases that are considered fully amortized 
the time the Form 5500 is filed, check “N/A”. In addition:              because there is a credit for the plan year on line 9j(3) should 
•  If “Single rate” is checked, enter the single rate in line           be listed. If entering a negative number, enter a minus sign (“–
6f(2).                                                                  ”) to the left of the number. 
•  If “Other” is checked, attach a description of the interest 
rate used for this purpose and label this attachment                    Code  Type of Amortization Base 
“Schedule MB, line 6f(1) – Description of Withdrawal                    1     Experience gain or loss  
Liability Interest Rate.”                                               2     Shortfall gain or loss 
Line 6g. Estimated Investment Return – Actuarial Value.                 3     Change in unfunded liability due to plan 
Enter the estimated rate of return on the actuarial value of                  amendment 
plan assets for the 1-year period ending on the valuation               4     Change in unfunded liability due to change in 
date. For this purpose, the rate of return is determined by                   actuarial assumptions  
using the formula 2I/(A + B  –  I), where I is the dollar amount        5     Change in unfunded liability due to change in 
of the investment return under the asset valuation method                     actuarial cost method 
used for the plan, A is the actuarial value of the assets one           6     Waiver of the minimum funding standard 
year ago, and B is the actuarial value of the assets on the             7     Initial unfunded liability (for new plan) 
current valuation date. Enter rates to the nearest .1 percent.          8     Net investment losses and other losses related to 
If entering a negative number, enter a minus sign (“ – ”) to                  the virus SARS-CoV-2 or coronavirus disease 
the left of the number.                                                       2019 (COVID) incurred in either or both of the first 
Note. Use the above formula even if the actuary feels that the                two plan years ending after February 29, 2020 
result of using the formula does not represent the true                  
estimated rate of return on the actuarial value of plan assets for      For purposes of Code 8, other losses related to COVID-19 
the 1-year period ending on the valuation date. The actuary             include (but are not limited to) losses related to reductions in 
may attach a statement showing both the actuary’s estimate of           contributions, reductions in employment, and deviations from 
the rate of return and the actuary’s calculations of that rate,         anticipated retirement rates, as determined by the plan 
and label the statement “Schedule MB, line 6g – Estimated               sponsor. 
Rate of Investment Return (Actuarial Value).”                           Line 8a and 8d. Funding Waivers or Extensions. If a 
Line 6h. Estimated Investment Return – Current (Market)                 funding waiver or extension request is approved after the 
Value. Enter the estimated rate of return on the current value          Schedule MB is filed, an amended Schedule MB must be 
of plan assets for the 1-year period ending on the valuation            filed with Form 5500 to report the waiver or extension 
date. (The current value is the same as the fair market value —         approval (also see instructions for line 9k(1)).  
see line 1b(1) instructions.) For this purpose, the rate of return      Line 8b(1). Schedule of Projection of Expected Benefit 
is determined by using the formula 2I/(A + B  –  I), where I is         Payments. Check “Yes” only if this is a multiemployer plan 
the dollar amount of the investment return, A is the current            covered by Title IV of ERISA that has 1,000 or more total 
                                                                   -56-          Instructions for Schedule MB (Form 5500)

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participants as of the beginning of the plan year (i.e., the format shown below and label the attachment “Schedule
reported on line 2b(4), column (1)). MB, line 8b(2) – Schedule of Active Participant Data.”
If line 8b(1) is “Yes,” in an attachment, provide a The attachment may be provided in a spreadsheet file (CSV
projection of benefits expected to be paid separately for format).
active participants, terminated vested participants, and Expand this schedule by adding columns after the “5 to
retired participants and beneficiaries receiving payments, 9” column and before the “40 & up” column for active
and for the entire plan (not to include expected expenses) in participants with total years of credited service in the
each of the next fifty years starting with the plan year and following ranges: 10 to 14; 15 to 19; 20 to 24; 25 to 29; 30 to
based on the participant’s status as of the valuation date. 34; and 35 to 39. For each column, enter the number of
For purposes of this projection, assume (1) no additional active participants with the specified number of years of
accruals, (2) experience (e.g., termination, mortality, and credited service divided according to age group. For
retirement) is in line with valuation assumptions, (3) no new participants with partial years of credited service, truncate
entrants, and (4) benefits are paid in the form assumed for the total number of years of credited service. Years of
valuation purposes. credited service are the years credited under the plan’s
Use the format shown below and label the schedule benefit formula.
“Schedule MB, line 8b(1) – Schedule of Projection of Plans reporting 1,000 or more active participants on line
Expected Benefit Payments.” The attachment may be 2b(3)(c), column (1), and using compensation to determine
provided in a spreadsheet file (CSV format). benefits must also provide average compensation data. For
Schedule MB, line 8b(1) – Schedule of Projection of Expected each grouping, enter the average compensation of the active
Benefit Payments participants in that group. For this purpose, compensation is
the compensation taken into account for each participant
Retired under the plan’s benefit formula, limited to the amount
Participants
and defined under section 401(a)(17) of the Code. Do not enter
Terminated Beneficiaries the average compensation in any grouping that contains
Active Vested Receiving
Plan Year Participants Participants Payments Total fewer than 20 participants.
Plans reporting 1,000 or more active participants on line
Current 2b(3)(c), column (1), must also provide average accrued
Plan Year
monthly benefits, as of the valuation date, that are payable
at normal retirement age. For each grouping, enter the
Current average accrued monthly benefit that is payable at normal
Plan Year retirement age for the active participants in that group. Do
+ 1
not enter the average accrued monthly benefit in any
Etc. grouping that contains fewer than 20 participants.
General Rule. In general, data to be shown in each
Current age/service bin includes:
Plan Year 1. the number of active participants in the age/service
+ 49 bin,
2. the average compensation of the active participants in

the age/service bin, and
Line 8b(2). Schedule of Active Participant Data. Check 3. the average accrued monthly benefit payable at
“Yes” only if this is a multiemployer plan covered by Title IV normal retirement age of the active participants in the
of ERISA that has active participants. age/service bin, using $0 for anyone who has no accrued
monthly benefit.

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

If line 8b(2) is “Yes,” attach a schedule of the active plan
participant data used in the valuation for this plan year. Use
Instructions for Schedule MB (Form 5500) -57-

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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
Line 8b(3). Schedule of Projection of Employer credit balances or funding deficiencies are not equal, attach
Contributions and Withdrawal Liability Payments. Check an explanation and label the attachment “Schedule MB, line
“Yes” only if this is a multiemployer plan covered by Title IV 9f – Explanation of Prior Year Credit Balance/Funding
of ERISA that has 1,000 or more total participants as of the Deficiency Discrepancy.” For example, if the difference is
beginning of the plan year (i.e., reported on line 2b(4), because contributions for a prior year that were not
column (1)). If line 8b(3) is “Yes,” in an attachment, previously reported are received this plan year, attach a
separately provide a projection of employer contributions listing of the amounts and dates of such contributions. As
and withdrawal liability payments expected to be received for another example, if the difference is due to the application of
the entire plan in each of the next ten plan year starting with funding relief under the Preservation of Access to Care for
the plan year. For purposes of this projection, use the Medicare Beneficiaries and Pension Relief Act of 2010 (PRA
assumption used to determine the plan’s status under line 2010), Pub. L. No. 111-192, the attachment should show
4b. Use the format shown below and label the schedule how the information on the Schedule MB filed for any
“Schedule MB, line 8b(3) – Schedule of Projection of previous plan year would have differed if it had reflected
Employer Contributions and Withdrawal Liability application of the special funding relief in accordance with
Payments.” The attachment may be provided in a published guidance (to the extent that the plan sponsor has
spreadsheet file (CSV format). applied the special funding relief).
Line 9j(1). ERISA Full Funding Limitation. Instructions for
Schedule MB, line 8b(3) – Schedule of Projection of Employer this line are reserved pending published guidance.
Contributions and Withdrawal Liability Payments
Line 9j(2). “RPA ’94” Override. Instructions for this line are
Withdrawal reserved pending published guidance.
Employer Liability
Plan Year Contributions Payments Total Line 9j(3). Full Funding Credit. Enter the excess of (1) the
accumulated funding deficiency, disregarding the credit
Current balance and contributions for the current year, if any, over
Plan Year (2) the greater of lines 9j(1) or 9j(2).
Line 9k(1). Waived Funding Deficiency Credit. Enter a
Current credit for a waived funding deficiency for the current plan
Plan Year +
1 year (Code section 431(b)(3)(C)). If a waiver of a funding
deficiency is pending, report a funding deficiency. If the
waiver is granted after Form 5500 or Form 5500-SF is filed,
Etc. file an amended Form 5500 or Form 5500-SF, as applicable,
with an amended Schedule MB to report the funding waiver
Current (see Amended Return/Report in the instructions for Form
plan year + 5500 or line B – Box for Amended Return/Report in the
9 instructions for Form 5500-SF, as applicable).
Line 9. Shortfall Method. Under the shortfall method of Line 9k(2). Other Credits. Enter a credit in the case of a
funding, the normal cost in the funding standard account is plan for which the accumulated funding deficiency is
the charge per unit of production (or per unit of service) determined under the funding standard account if such plan
multiplied by the actual number of units of production (or year follows a plan year for which such deficiency was
units of service) that occurred during the plan year. Each determined under the alternative minimum funding standard.
amortization installment in the funding standard account is Line 9o. Reconciliation Account. The reconciliation
similarly calculated. account is made up of those components that upset the
Lines 9c and 9h. Amortization Charges and Credits. If balance equation of Treasury Regulations section
there are any amortization charges or credits, attach a 1.412(c)(3)-1(b). Valuation assets must not be adjusted by
maintenance schedule of funding standard account bases the reconciliation account balance when computing the
and label the schedule “Schedule MB, lines 9c and 9h – required minimum funding.
Schedule of Funding Standard Account Bases.” The Line 9o(1). This amount is equal to the prior year’s
attachment should clearly indicate the type of base (i.e., accumulated reconciliation amount due to prior waived
original unfunded liability, amendments, actuarial losses, funding deficiencies, increased with interest at the valuation
etc.), the outstanding balance of each base, the number of rate to the current valuation date.
years remaining in the amortization period, and the Line 9o(2)(a). If an amortization extension is being
amortization amount. If bases were combined in the current amortized at an interest rate that differs from the valuation
year, the attachment should show information on bases both rate, enter the prior year’s “reconciliation amortization
prior to and after the combining of bases. extension outstanding balance,” increased with interest at
The outstanding balance and amortization charges and the valuation interest rate to the current valuation date, and
credits must be calculated as of the valuation date for the decreased by the year end amortization amount based on
plan year. the amortization interest rate from the prior plan year.
Line 9c(3) should only include information related to the Line 9o(3). Enter the sum of lines 9o(1) and 9o(2)(b) (each
amortization bases extended and amortized using the adjusted with interest at the valuation rate to the current
interest rate under section 6621(b) of the Code. valuation date, if necessary).

-58- Instructions for Schedule MB (Form 5500)

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Note. The net outstanding balance of amortization charges        Plans, with the IRS to pay the excise tax on the funding 
and credits minus the prior year’s credit balance minus the      deficiency. There is a penalty for not filing the Form 5330 on 
amount on line 9o(3) (each adjusted with interest at the         time. 
valuation rate, if necessary) must equal the unfunded            Line 11. In accordance with ERISA section 103(d)(3), attach 
liability.                                                       a justification for any change in actuarial assumptions for the 
Line 10. Contribution Necessary to Avoid Deficiency.             current plan year and label the attachment “Schedule MB, 
Enter the amount from line 9n. If applicable, file IRS Form      line 11 – Justification for Change in Actuarial 
5330, Return of Excise Taxes Related to Employee Benefit         Assumptions.”
 
Instructions for Schedule MB (Form 5500)                    -59-

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Specific Instructions
2022 Instructions for Schedule R Lines A, B, C, and D. This information must be the same as
(Form 5500) reported in Part II of the Form 5500 to which this Schedule R is
attached.
Retirement Plan Information
Do not use a social security number in line D instead of an
EIN. Schedule R and its attachments are open to public
General Instructions inspection, and the contents are public information and are
Purpose of Schedule subject to publication on the Internet. Because of privacy
Schedule R (Form 5500) reports certain information on concerns, the inclusion of a social security number or any portion
retirement plan distributions, funding, nondiscrimination, thereof on Schedule R or any of its attachments may result in the
coverage, and the adoption of amendments, as well as certain rejection of the filing.
information on single employer and multiemployer defined You can apply for an EIN from the IRS online, by fax,
benefit plans. or by mail depending on how soon you need to use the
Electronic Attachments. All attachments to Schedule R must EIN. For more information, see Section 3: Electronic Filing
be properly identified, must include the name of the plan, plan Requirement. The EBSA does not issue EINs.
sponsor’s EIN, and plan number. Place “Schedule R” and the “Participant” for purposes of Schedule R, means any
Schedule R line number at the top of each attachment to present or former employee who at any time during the
identify the information to which the attachment relates. Do not plan year had an accrued benefit in the plan (account
include attachments that contain a visible social security balance in a defined contribution plan).
number. The Schedule R and its attachments are open to Part I – Distributions
public inspection, and the contents are subject to publication
on the Internet. Because of privacy concerns, the inclusion of a “Distribution” includes only payments of benefits during the
visible social security number or any portion thereof on an plan year, in cash, in kind, by purchase for the distributee of an
attachment may result in the rejection of the filing. annuity contract from an insurance company, or by distribution
of life insurance contracts. It does not include:
Who Must File 1. Corrective distributions of excess deferrals, excess
Schedule R must be attached to a Form 5500 filed for both tax- contributions, or excess aggregate contributions, or the income
qualified and nonqualified pension benefit plans. The parts of allocable to any of these amounts;
Schedule R that must be completed depend on whether the 2. Distributions of automatic contributions pursuant to Code
plan is subject to the minimum funding standards of Code section 414(w);
section 412 or ERISA section 302 and the type of plan. See 3. The distribution of elective deferrals or the return of
line item requirements under Specific Instructions for more employee contributions to correct excess annual additions
details. under Code section 415, or the gains attributable to these
Exceptions: (1) Schedule R should not be completed when amounts; and
the Form 5500 Annual Return/Report is filed for a pension plan 4. A loan deemed as a distribution under Code section
that uses, as the sole funding vehicle for providing benefits, 72(p).
individual retirement accounts or annuities (as described in Note. It does, however, include a distribution of a plan loan
Code section 408). See the Form 5500 instructions for Limited offset amount as defined in Treasury Regulations section
Pension Plan Reporting for more information. 1.402(c)-2, Q&A 9(b).
(2) Schedule R also should not be completed if all of the Line 1. Enter the total value of all distributions made during the
following conditions are met: year (regardless of when the distribution began) in any form
• The plan is not a defined benefit plan or otherwise subject to other than cash, annuity contracts issued by an insurance
the minimum funding standards of Code Section 412 or ERISA company, distribution of life insurance contracts, marketable
section 302. securities within the meaning of Code section 731(c)(2), or
• No plan benefits that would be reportable on Line 1 of Part I plan loan offset amounts. Do not include eligible rollover
of this schedule R were distributed during the plan year. See distributions paid directly to eligible retirement plans in a direct
instructions for Part I, Line 1 below. rollover under Code section 401(a)(31) unless such direct
• No benefits, as described in the instructions Part I, line 2, rollovers include property other than that enumerated in the
below, were paid during the plan year other than by the plan preceding sentence.
sponsor or plan administrator. (This condition is not met if Line 2. Enter the EIN(s) of any payor(s) (other than the plan
benefits were paid by the trust or any other payor(s) which are sponsor or plan administrator on line 2b or 3b of the Form
reportable on IRS Form 1099-R, Distributions from Pensions, 5500) who paid benefits reportable on IRS Form 1099-R on
Annuities, Retirement, or Profit-Sharing Plans, IRAs, Insurance behalf of the plan to participants or beneficiaries during the
contracts, etc, using an EIN other than that of the plan sponsor plan year. This is the EIN that appears on the IRS Forms
or plan administrator reported on line 2b or 3b of form 5500.) 1099-R that are issued to report the payments. Include the EIN
• Unless the plan is a profit-sharing, ESOP, or stock bonus of the trust if different than that of the sponsor or plan
plan, no plan benefits of living or deceased participants were administrator. If more than two payors made such payments
distributed during the plan year in the form of a single-sum during the year, enter the EINs of the two payors who paid the
distribution. See the instructions for Part I, line 3, below. greatest dollar amounts during the year. For purposes of this
• The plan is not an ESOP. line 2, take into account all payments made during the plan
• The plan is not a multiemployer defined benefit plan. year, in cash or in kind, that are reportable on IRS Form 1099-
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.

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Line 3. Enter the number of living or deceased participants amortized, complete lines 3, 9, and 10 of Schedule MB. See
whose benefits under the plan were distributed during the plan instructions for Schedule MB. Attach Schedule MB to Form
year in the form of a single-sum distribution. For this purpose, 5500. The Schedule MB for a money purchase defined
a distribution of a participant’s benefits will not fail to be a contribution plan does not need to be signed by an enrolled
single-sum distribution merely because, after the date of the actuary.
distribution, the plan makes a supplemental distribution as a Line 6a. The minimum required contribution for a money
result of earnings or other adjustments made after the date of purchase defined contribution plan (including a target benefit
the single-sum distribution. Also include any participants plan) for a plan year is the amount required to be contributed
whose benefits were distributed in the form of a direct rollover for the year under the formula set forth in the plan document. If
to the trustee or custodian of a qualified plan or individual there is an accumulated funding deficiency for a prior year that
retirement account. has not been waived, that amount should also be included as
Part II – Funding Information part of the contribution required for the current year.
Complete Part II only if the plan is subject to the minimum Line 6b. Include all contributions for the plan year made not
funding requirements of Code section 412 or ERISA section later than 8 ½ months after the end of the plan year. Show only
302. contributions actually made to the plan by the date the form is
All qualified defined benefit and defined contribution plans filed. For example, do not include receivable contributions for
are subject to the minimum funding requirements of Code this purpose.
section 412 unless they are described in the exceptions listed Line 6c. If the minimum required contribution exceeds the
under Code section 412(e)(2). These exceptions include profit- contributions for the plan year made not later than 81/ 2months
sharing or stock bonus plans, insurance contract plans after the end of the plan year, the excess is an accumulated
described in Code section 412(e)(3), and certain plans to funding deficiency for the plan year. File IRS Form 5330,
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 • Check “Increase” if an amendment was adopted during
either approved the amendment or failed to disapprove the 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

Instructions for Schedule R (Form 5500) -61-

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of the plan to new employees, or accruals being frozen for “Schedule R,Summary of Rehabilitation Plan ” as
some or all participants. appropriate, and if applicable, “Schedule R, Update of
• If the amendments that were adopted increased the Funding Improvement Plan or Rehabilitation Plan.” Each
value of some benefits but decreased the value of others, attachment must also include the plan name, the plan
check “Both.” sponsor’s name and EIN, and the plan number.
Part IV – ESOP Information Line 13. This line should be completed only by multiemployer
Line 11b. A loan is a “back-to-back loan” if the following defined benefit pension plans that are subject to the minimum
requirements are satisfied: funding standards (see Code section 412 and Part 3 of Title I
of ERISA). Enter the information on lines 13a through 13e for
1. The loan from the employer corporation to the ESOP any employer that, for the plan year, (1) contributed more than
qualifies as an exempt loan under DOL regulations at 29 CFR five (5) percent of the plan’s total contributions or (2) was one
2550.408b-3 and under Treasury Regulations sections of the top-ten highest contributors. List employers in
54.4975-7 and 54.4975-11; and descending order according to the dollar amount of their
2. The repayment terms of the loan from the sponsoring contributions to the plan. Complete as many entries as are
corporation to the ESOP are substantially similar to the necessary to list all employers that are required to be reported.
repayment terms of the loan from the commercial lender to the Line 13a. Enter the name of the employer contributing to the
sponsoring employer. plan.
Part V – Additional Employer Information for Line 13b. Enter the EIN of the employer contributing to the
Multiemployer Defined Benefit Pension Plans plan. Do not enter a social security number in lieu of an EIN;
If this is not a multiemployer plan, skip this Part. therefore, ensure that you have the employer’s EIN and not a
social security number. The Form 5500 is open to public
Required attachments. Multiemployer defined benefit plans inspection, and the contents are public information and are
that are in Endangered Status, Critical Status, or Critical and subject to publication on the Internet. Because of privacy
Declining Status must attach a summary of their Funding concerns, the inclusion of a social security number or any
Improvement Plan or Rehabilitation Plan (as updated, if portion thereof on this line may result in the rejection of the
applicable) and also any update to a Funding Improvement filing.
Plan or Rehabilitation Plan.
EINs can be obtained from the IRS online, by fax, or by
The summary of any Funding Improvement Plan or mail depending on when you need to use the EIN. For more
Rehabilitation Plan must reflect such plan in effect at the end of information, see Section 3: Electronic Filing Requirement. The
the plan year (whether the original Funding Improvement Plan EBSA does not issue EINs.
or Rehabilitation Plan or as updated) and must include a
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 Line 13d. Collective Bargaining Agreement Expiration
extended Funding Improvement Period (of 13 or 18 years) or Date. Enter the date on which the employer’s collective
Rehabilitation Period (of 13 years) applies because of an bargaining agreement expires. If the employer has more than
election under section 205 of the Worker, Retiree, and one collective bargaining agreement requiring contributions to
Employer Recovery Act of 2008 (“WRERA”), the summary the plan, check the box and include, as an attachment, the
must include a statement to that effect and the date that the expiration date of each collective bargaining agreement
election was filed with the IRS. (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 Line 13e. Contribution Rate Information. Enter the
has determined that, based on reasonable actuarial contribution rate (in dollars and cents) per contribution base
assumptions and upon exhaustion of all reasonable measures, unit in line 13e(1) and the base unit measure in line 13e(2).
the plan cannot emerge from Critical Status by the end of the Indicate whether the base unit is measured on an hourly,
Rehabilitation Period as described in Code section weekly, unit-of-production, or other basis. If “other,” specify the
432(e)(3)(A)(ii), the summary must include an explanation of base unit measure used. If the contribution rate changed
the alternatives considered, why the plan is not reasonably during the plan year, enter the last contribution rate in effect for
expected to emerge from Critical Status by the end of the the plan year.
Rehabilitation Period, and when, if ever, it is expected to If the employer has different contribution rates for different
emerge from Critical Status under the Rehabilitation Plan. classifications of employees or different places of business,
The plan sponsor is required to annually update a Funding check the box in the first line of line 13e and list in an
Improvement Plan or Rehabilitation Plan that was adopted in a attachment each contribution rate and corresponding base unit
prior year. The update must be filed as an attachment to the measure under which the employer made contributions
Schedule R. The update attachment must identify the (regardless of the amount of contributions resulting from each
modifications made to the Funding Improvement Plan or rate). Label the attachment: “Schedule R, line 13e –
Rehabilitation Plan during the plan year, including contribution Information on Contribution Rates and Base Units.” Include
increases, benefit reductions, or other actions. the plan name and the sponsor’s name and EIN.
The attachment described above must be labeled Line 14. Enter the number of deferred vested and retired
“Schedule R, Summary of Funding Improvement Plan,” or participants (inactive participants), as of the beginning of the

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plan year, whose contributing employer is no longer making of employers still active in the plan (unless the collective
contributions to the plan. Generally, if there has been a prior bargaining agreement specifically requires the employer to
withdrawal, unless all former vested participants of the make contributions for such participants).
withdrawn employer have been reemployed with a currently Line 15a. Enter the ratio of the number of participants as
contributing employer, this line should not be zero. Plans must described in the line 15 instructions for the 2022 plan year to
use one of the following counting methods to count these the number for the 2021 plan year.
inactive participants.
Line 15b. Enter the ratio of the number of participants as
1. Under the last contributing employer method, count described on the line 15 instructions for the 2022 plan year to
only those inactive participants whose last contributing the number for the 2020 plan year.
employer had withdrawn from the plan by the beginning of the
relevant plan year. Disregard any inactive participants whose Note. Withdrawal liability payments are not to be treated as
most recent employers had not withdrawn from the plan. Thus, contributions for determining the number of participants on line
for the limited purposes of line 14 and notwithstanding any 15.
contrary definition of such inactive participants applicable Line 16a. Enter the number of employers that withdrew from
elsewhere, inactive participants of employers who have not the plan during the 2021 plan year.
withdrawn from the plan should not be included in these Line 16b. If line 16a is greater than zero, enter the aggregate
numbers; amount of withdrawal liability assessed against these
2. Under the alternative method count only those inactive employers. If the withdrawal liability for one or more
participants whose last contributing employer and all prior withdrawing employers has not yet been determined, include
contributing employers had withdrawn from the plan by the the amounts estimated to be assessed against them in the
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 2022 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 2022 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 2022 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 2021 plan year. For single-employer plans, the funded
change. percentage is the funding target attainment percentage, where
the numerator is the value of plan assets reduced by the sum
For any required attachment for line 14, label the attachment
of the amount of the prefunding balance and the funding
“Schedule R, Line 14 – Information on Inactive standard carryover balance, and the denominator is the
Participants Whose Contributing Employer is No Longer funding target for the plan (for this purpose, if the plan is in at
Making Contributions to the Plan.”
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 2022 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
Instructions for Schedule R (Form 5500) -63-

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have been reported. Label the attachment “Schedule R, line Line 20b. In general, a PBGC-insured single-employer plan
18 –Funded Percentage of Plans Contributing to the must notify PBGC if a required contribution is not made by its
Liabilities of Plan Participants” and include the plan name due date. With the exception of situations where the
and the plan sponsor’s name and EIN. accumulated value of missed contributions exceeds $1 million,
Line 19. This line must be completed for all defined benefit PBGC waives reporting if contributions equal to or exceeding
pension plans (except DFEs) with 1,000 or more participants at the missed amount are made by the 30 thday after the due
the beginning of the plan year. To determine if the plan has date. For more information, see 29 CFR 4043.25 and 4043.81
1,000 or more participants, use the participant count shown on and the filing instructions for PBGC Forms 10 and 200.
line 3d(1) of the Schedule SB for single-employer plans or on If PBGC has been notified of the missed contribution, check
line 2b(4)(1) of the Schedule MB for multiemployer plans. the “Yes” box. Otherwise, check the box that best explains why
Line 19a. Show the beginning-of-year distribution of assets for PBGC wasn’t notified. If the “No. Other. Provide explanation”
the categories shown. Use the market value of assets and do box is checked, provide an explanation as to why PBGC wasn’t
not include the value of any receivables. These percentages, notified (e.g., “The due date for filing Form 10 has not yet
expressed to the nearest whole percent, should reflect the total passed; the plan administrator intends to file Form 10 with
assets held in stocks, investment-grade debt instruments, high- PBGC shortly” or “Reporting was waived under 29 CFR
yield debt instruments, real estate, or other asset classes, 4043.25(c)(3) because the unpaid contribution resulted solely
regardless of how they are listed on the Schedule H. The from an administrative error related to an election to use a pre-
percentages in the five categories should sum to 100 percent. funding balance”).
Assets held in trusts, accounts, mutual funds, and other
investment arrangements should be disaggregated and
properly distributed among the five asset components. The
assets in these trusts, accounts, mutual funds, and investment
arrangements should not be included in the “Other” component
unless these investments contain no stocks, bonds, or real
estate holdings. The same methodology should be used in
disaggregating trust assets as is used when disclosing the
allocation of plan assets on the sponsor’s 10-K filings to the
Securities and Exchange Commission. Real estate investment
trusts (REITs) should be listed with stocks, while real estate
limited partnerships should be included in the Real Estate
category.
Investment-grade debt-instruments are those with an S&P
rating of BBB – or higher, a Moody’s rating of Baa3 or higher, or
an equivalent rating from another rating agency. High-yield
debt instruments are those that have ratings below these rating
levels. If the debt does not have a rating, it should be included
in the “high-yield” category if it does not have the backing of a
government entity. Unrated debt with the backing of a
government entity would generally be included in the
“investment-grade” category unless it is generally accepted
that the debt should be considered as “high-yield.” Use the
ratings in effect as of the beginning of the plan year.
Line 19b. Check the box that shows the average duration of
the plan’s combined investment-grade and high-yield debt
portfolio. If the average duration falls exactly on the boundary
of two boxes, check the box with the lower duration. To
determine the average duration, use the “effective duration” or
any other generally accepted measure of duration. Report the
duration measure used in line 19c. If debt instruments are held
in multiple debt portfolios, report the weighted average of the
average durations of the various portfolios where the weights
are the dollar values of the individual portfolios.
Line 20. This line must be completed for all single-employer
defined benefit plans that are covered by PBGC.
Line 20a. If the amount reported on Schedule SB (Form 5500)
line 40 is greater than $0, check the “Yes” box and complete
line 20b. Otherwise, check “No” and skip line 20b.

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instructions in the Note above, pertaining to “one-participant
2022 Instructions for Schedule SB plans”).
(Form 5500) Note. This schedule is not filed for a multiemployer plan nor for
a money purchase defined contribution plan (including a target
Single-Employer Defined Benefit Plan benefit plan) for which a waiver of the minimum funding
Actuarial Information requirements is currently being amortized. Information for
these plans must be filed using Schedule MB (Form 5500).
General Instructions Specific Instructions
Note.To the extent that regulations and other items of Lines A through F. Identifying Information. Lines A – F
published guidance under Code sections 430 and 436 do not must be completed for all plans. Lines A through D should
take into account statutory changes since those regulations include the same information as reported in corresponding
were issued, plan sponsors must take into account the lines in Part II of the Form 5500, Form 5500-SF, or Form 5500-
provisions of the Worker, Retiree, and Employer Recovery Act EZ filed for the plan. You may abbreviate the plan name (if
of 2008 (“WRERA”), Pub. L. No. 110-458, the Preservation of necessary) to fit in the space provided.
Access to Care for Medicare Beneficiaries and Pension Relief Do not use a social security number in line D instead of an
Act of 2010 (“PRA 2010”), Pub. L. No. 111-192, Moving Ahead EIN. The Schedule SB and its attachments are open to public
for Progress in the 21 stCentury Act (“MAP-21”), Pub. L. No.
inspection if filed with a Form 5500 or Form 5500-SF, and the
112-141, the Cooperative and Small Employer Charity Pension contents are public information and are generally subject to
Flexibility Act of 2014 (“CSEC Act”), Pub. L. No. 113-97, the publication on the Internet. Because of privacy concerns, the
Highway and Transportation Funding Act of 2014 (HATFA), inclusion of a social security number or any portion thereof on
Pub. L. No. 113-159, and the Bipartisan Budget Act of 2015 the Schedule SB or any of its attachments may result in the
(BBA’15), Pub. L. No. 114-74, and any other amendments to rejection of the filing.
the funding rules that are enacted.
You can apply for an EIN from the IRS online, by fax, or by
Who Must File mail depending on how soon you need to use the EIN. For
As the first step, the plan administrator of any single-employer more information, see Section 3: Electronic Filing Requirement
defined benefit plan (including a multiple-employer defined under General Instructions to Form 5500. The EBSA does not
benefit plan) that is subject to the minimum funding standards issue EINs.
(see Code section 412 and Part 3 of Title I of ERISA) must Line E. Type of Plan. Check the applicable box to indicate the
obtain a completed Schedule SB (including attachments) that type of plan. A single-employer plan for this reporting purpose
is prepared and signed by the plan’s enrolled actuary as is an employee benefit plan maintained by one employer or
discussed below in the Statement by Enrolled Actuary section. one employee organization. A multiple-employer plan is a plan
The plan administrator must retain with the plan records the that is maintained by more than one employer, but is not a
Schedule SB that is prepared and signed by the plan’s actuary. multiemployer plan. (See the Instructions for Form 5500, box A
Next, the plan administrator must ensure that the for additional information on the definition of a multiemployer
information from the actuary’s Schedule SB is entered plan.)
electronically into the annual return/report being submitted. ● Check “Single” if the Form 5500, Form 5500-SF, or Form
When entering the information, whether using EFAST2- 5500-EZ is filed for a single-employer plan (including a plan
approved software or EFAST2’s web-based filing system, all maintained by more than one member of the same controlled
the fields required for the type of plan must be completed (see group).
instructions for fields that need to be completed). ● Check “Multiple-A” if the Form 5500 or Form 5500-SF is
Further, the plan administrator of a single-employer defined being filed for a multiple-employer plan and the plan is subject
benefit plan must attach to the Form 5500 or Form 5500-SF an to the rules of Code section 413(c)(4)(A) (i.e., it is funded as if
electronic reproduction of the Schedule SB (including each employer were maintaining a separate plan). This
attachments) prepared and signed by the plan’s enrolled includes plans established before January 1, 1989, for which
actuary. This electronic reproduction must be labeled “SB an election was made to fund in accordance with Code section
Actuary Signature” and must be included as a Portable 413(c)(4)(A).
Document Format (PDF) attachment or any alternative ● Check “Multiple-B” if the Form 5500 or Form 5500-SF is
electronic attachment allowable under EFAST2. being filed for a multiple-employer plan and the plan is subject
Note. The Schedule SB (Form 5500) does not have to be filed to the rules of Code section 413(c)(4)(B) (i.e., it is funded as if
with the Form 5500-EZ regardless of whether it is filed on all participants were employed by a single employer).
paper with the IRS or electronically with EFAST2, but it must If “Multiple-A” is checked, with the exception of Part III, the
be retained in accordance with the Instructions for Form 5500- data entered on Schedule SB should be the sum of the
EZ under the What to File section. The enrolled actuary must individual amounts computed for each employer. The
complete and sign the Schedule SB and forward it to the percentages reported in Part III should be calculated based on
person responsible for filing the Form 5500-EZ, even if the the reported aggregate numbers rather than by summing up
Schedule SB is not filed. the individual percentages. The Schedule SB data for each
Check the Schedule SB box on the Form 5500 (Part II, line employer’s portion of the plan must be submitted as an
10a(3)) if a Schedule SB is attached to Form 5500. Check attachment. This is accomplished by completing and attaching
“Yes” on line 11 in Part VI of the Form 5500-SF if a Schedule a Schedule SB for each employer or by attaching a document
SB is required to be prepared for the plan, even if Schedule SB containing that information (e.g., a table showing a row for
is not required to be attached to Form 5500-SF (see each Schedule SB data item and a column for each

Instructions for Schedule SB (Form 5500) -65-

- 66 -

employer). Label the attachment “Schedule SB – Information                 under insurance contracts held by the plan and whether to 
for Each Individual Employer.”                                             include the value of the insurance contracts in plan assets. 
Line F. Prior Year Plan Size. Check the applicable box based                (2) For terminating plans, Revenue Ruling 79-237, 1979-2 
on the highest number of participants (both active and inactive)           C.B. 190, provides that minimum funding standards apply until 
on any day of the preceding plan year, taking into account                 the end of the plan year that includes the termination date. 
participants in all defined benefit plans maintained by the same           Accordingly, the Schedule SB is not required to be filed for any 
employer (or any member of such employer’s controlled group)               later plan year. However, if a termination fails to occur — 
who are or were also employees of that employer or member.                 whether because assets remain in the plan’s related trust (see 
For this purpose, participants whose only defined benefit plan             Revenue Ruling 89-87, 1989-2 C.B. 81) or for any other 
is a multiemployer plan (as defined in Code section 414(f)) are            reason (e.g., the PBGC issues a notice of noncompliance 
not counted, and participants who are covered in more than                 pursuant to 29 CFR section 4041.31 for a standard 
one of the defined benefit plans described above are counted               termination) — there is no termination date, and therefore, 
only once. Inactive participants include vested terminated and             minimum funding standards continue to apply and a Schedule 
retired employees as well as beneficiaries of deceased                     SB continues to be required. 
participants. If this is the first plan year that a plan described in 
                                                                           Statement by Enrolled Actuary 
this paragraph exists, complete this line based on the highest 
number of participants that the plan was reasonably expected               An enrolled actuary must sign Schedule SB. The signature of 
to have on any day during the first plan year.                             the enrolled actuary may be qualified to state that it is subject 
                                                                           to attached qualifications. See Treasury Regulations section 
General Instructions, Parts I through IX, Statement                        301.6059-1(d) for permitted qualifications. If the actuary has 
by Enrolled Actuary, and Attachments                                       not fully reflected any final or temporary regulation, revenue 
Except as noted below, Parts I through VIII must be completed              ruling, or notice promulgated under the statute in completing 
for all single and multiple-employer defined benefit plans,                the Schedule SB, check the box on the last line of page 1. If 
regardless of size or type. See instructions for line 27 for               this box is checked, indicate on an attachment whether any 
additional information to be provided for certain plans with               unpaid required contribution or a contribution that is not wholly 
special circumstances. Part IX is completed only for those                 deductible would result if the actuary had fully reflected such 
plans for which an alternative amortization schedule was                   regulation, revenue ruling, or notice, and label this attachment 
elected under section 430(c)(2)(D) of the Code or section                  “Schedule SB – Statement by Enrolled Actuary.” In 
303(c)(2)(D) of ERISA, as amended by PRA 2010.                             addition, the actuary may offer any other comments related to 
 PPA provides funding relief for certain defined benefit plans             the information contained in Schedule SB. Except as otherwise 
(other than multiemployer plans) maintained by a commercial                provided in these instructions, a stamped or machine produced 
passenger airline or by an employer whose principal business               signature is not acceptable. 
is providing catering services to a commercial passenger                       The actuary must provide the completed and signed 
airline, based on an alternative 17-year funding schedule.                 Schedule SB to the plan administrator to be retained with the 
Plans using this funding relief do not need to complete the                plan records and included (in accordance with these 
entire Schedule SB, but are required to provide supplemental               instructions) with the Form 5500 or Form 5500-SF that is 
information as an attachment to Schedule SB. See the                       submitted under EFAST2. The plan’s actuary is permitted to 
instructions for line 27 for more information about which lines            sign the Schedule SB on page one using the actuary’s 
of Schedule SB need to be completed and what additional                    signature or by inserting the actuary’s typed name in the 
attachments are required.                                                  signature line followed by the actuary’s handwritten initials. 
 Code section 430(h)(2)(C)(iv) and ERISA section                           The actuary’s most recent enrollment number must be entered 
302(h)(2)(C)(iv) provide that, for certain purposes, each of the           on the Schedule SB that is prepared and signed by the plan’s 
three segment rates described in those sections is adjusted as             actuary. 
necessary to fall within a specified range that is determined              Attachments 
based on an average of the corresponding segment rates for                 All attachments to the Schedule SB must be properly identified 
the 25-year period ending on September 30 of the calendar                  as attachments to the Schedule SB, and must include the 
year preceding the first day of the plan year. Accordingly, if the         name of the plan, plan sponsor’s EIN, plan number, and line 
funding target and target normal cost for a plan are determined            number to which the schedule relates. 
using the segment rates, the segment rates used to determine 
the minimum required contribution and the adjusted funding                  Do not include attachments that contain a visible social 
target attainment percentage (“AFTAP”) used to apply funding-              security number. Except for certain one-participant plans, the 
based benefit restrictions under Code section 436 and ERISA                Schedule SB and its attachments are open to public 
section 206(g) may be different from those used for other                  inspection, and the contents are public information and are 
purposes (such as the segment rates used to determine the                  subject to publication on the Internet. Because of privacy 
deductible limit under Code section 404(o)). In such cases,                concerns, the inclusion of a visible social security number or 
report all information on Schedule SB reflecting the                       any portion thereof on an attachment may result in the 
assumptions used to determine the minimum required                         rejection of the filing. 
contribution and the AFTAP used to apply funding-based                      The first year Schedule SB attachment for a plan 
benefit restrictions.                                                      retroactively adopted pursuant to SECURE Act section 201. If 
Note. (1) For a plan funded with insurance (other than a plan              a plan sponsor adopted a defined benefit pension plan in 2022 
described in Code section 412(e)(3) or ERISA section 301(b)),              (i.e., by the due date, including extension, for filing the plan 
refer to section 1.430(d)-1(c)(2) of the Income Tax Regulations            sponsor’s tax return for the 2021 taxable year) and elected to 
regarding whether to include the liabilities for benefits covered          treat the plan as having been adopted before the 2022 plan 
                                                                           year began as permitted under SECURE Act section 201, then 
                                                                           the enrolled actuary must complete and sign the 2021 
                                                                      -66-             Instructions for Schedule SB (Form 5500)

- 67 -

Schedule SB (Form 5500). If the plan sponsor is required to             If an averaging method is used to value plan assets (as 
file Schedule SB (see instructions for Schedule SB under “Who          permitted under Code section 430(g)(3)(B) and ERISA section 
Must File”), attach the 2021 Schedule SB (Form 5500) as a              303(g)(3)(B), as amended by WRERA), enter the value as of 
Portable Document Format (PDF) attachment to the 2022                  the valuation date taking into account the requirement that 
Schedule SB when filing the 2022 Form 5500. Label the                  such value must be within 90% to 110% of the fair market 
attachment “The first year Schedule SB attachment for a plan           value of assets. 
retroactively adopted pursuant to SECURE Act 201”.                     Note. Under Code section 430(g)(3)(B), the use of averaging 
Part I – Basic Information                                             methods in determining the value of plan assets is permitted 
Note. All entries in Part I must be reported as of the valuation       only in accordance with methods prescribed in Treasury 
date, reflecting the assumptions and amounts generally used            regulations. Accordingly, taxpayers cannot use asset valuation 
to determine the minimum required contribution. In the case of         methods other than fair market value (as described in Code 
a plan described in section 104 of PPA, the information should         section 430(g)(3)(A)), except as provided under Notice 2009-
be reported as if PPA provisions were effective for all plan           22, 2009-14 IRB 741, or Treasury regulations.  
years beginning after December 31, 2007.                               Line 3. Funding Target/Participant Count Breakdown. All 
Line 1. Valuation Date. The valuation date for a plan year             amounts should be reported as of the valuation date.  
must be the first day of the plan year unless the plan meets the       •  Column (1)—Enter the number of participants in each 
small-plan exception of Code section 430(g)(2)(B) and ERISA            category (e.g., terminated vested participants). Enter “0” if no 
section 303(g)(2)(B). For plans that qualify for the exception,        participants fall into the category. Include beneficiaries of 
the valuation date may be any date in the plan year, including         deceased participants who are or who will be entitled to 
the first or last day of the plan year.                                benefits under the plan. 
 A plan qualifies for this small-plan exception if there were          •  Column (2)—Enter the portion of the funding target 
100 or fewer participants on each day of the prior plan year.          attributable to vested benefits. If no portion of the funding 
For the definition of participant as it applies in this case, see      target for a particular category is attributable to vested 
the instructions for line F.                                           benefits, enter “0.” For this purpose, benefits considered to be 
Line 2a. Market Value of Assets. Enter the fair market value           vested for PBGC premium purposes must be included.  
of assets as of the valuation date. Include contributions              •  Column (3)—Enter the funding target attributable to all 
designated for any previous plan year that are made after the          benefits, both vested and nonvested. Enter “0” if no portion of 
valuation date (but within the 8½-month period after the end of        the funding target is for participants in a particular category.  
the immediately preceding plan year), adjusted for interest for        For columns (2) and (3), the funding target must be calculated 
the period between the date of payment and the valuation date          using the methods and assumptions provided in Code sections 
as provided in the applicable regulations.                             430(h) and (i), ERISA sections 303(h) and (i), and other related 
 Contributions made for the current plan year must be                  guidance. 
excluded from the amount reported in line 2a. If these                  Unless the plan sponsor has received approval to use 
contributions were made prior to the valuation date (which can         substitute mortality tables in accordance with Code section 
only occur for small plans with a valuation date other than the        430(h)(3)(C) and ERISA section 303(h)(3)(C), the funding 
first day of the plan year), the asset value must be adjusted to       target must be computed using the mortality tables for non-
exclude not only the contribution amounts, but interest on the         disabled lives, as described in section 1.430(h)(3)-1 of the 
contributions from the date of payment to the valuation date,          regulations. If substitute mortality tables have been approved 
using the current-year effective interest rate.                        (or deemed to have been approved) by the IRS, such tables 
 Do not adjust for items such as the funding standard                  must be used instead of the mortality tables described in the 
carryover balance, prefunding balance, any unpaid minimum              previous sentence, subject to the rules of Code section 
required contributions, or the present value of remaining              430(h)(3) and ERISA section 303(h)(3). The funding target 
shortfall or waiver amortization installments. Rollover amounts        may be computed taking into account the mortality tables for 
or other assets held in individual accounts that are not               disabled lives published in Revenue Ruling 96-7, 1996-1 C.B. 
available to provide defined benefits under the plan should not        59, and as provided in Notice 2008-29, 2008-12 IRB 637. 
be included on line 2a regardless of whether they are reported          Special rules for plans that are in at-risk status. If a plan 
on the Schedule H (Form 5500) (line 1l, column (a)) or                 is in at-risk status, report the amount reflecting the additional 
Schedule I (Form 5500) (line 1c, column (a)), or Form 5500-SF          assumptions required in Code section 430(i)(1)(B) and ERISA 
(line 7c, column (a)). Additionally, asset and liability amounts       section 303(i)(1)(B). 
must be determined in a consistent manner. Therefore, if the 
value of any insurance contracts has been excluded from the             If the plan has been in at-risk status for any two or more of 
amount reported in line 2a, liabilities satisfied by such              the preceding four plan years, also include the loading factor 
contracts should also be excluded from the funding target              required in Code section 430(i)(1)(C) and ERISA section 
values reported in lines 3 and 4.                                      303(i)(1)(C). If the plan is in at-risk status and has been in at-
                                                                       risk status for fewer than five consecutive years, report the 
Line 2b. Actuarial Value of Assets. Do not adjust the                  funding target amounts after reflecting the transition rule 
actuarial value of assets for items such as the funding                provided in Code section 430(i)(5) and ERISA section 
standard carryover balance, the prefunding balance, any                303(i)(5). For example, the funding target for a plan that is in 
unpaid minimum required contributions, or the present value of         at-risk status for 2022 and was in at-risk status for the 2019, 
any remaining shortfall or waiver amortization installments.           2020 and 2021 plan years (but not the 2018 plan year) will 
Treat contributions designated for a current or prior plan year,       reflect 80% of the funding target using the special at-risk 
rollover amounts, insurance contracts, and other items in the          assumptions and 20% of the funding target determined without 
same manner as for line 2a.                                            regard to the at-risk assumptions. 

Instructions for Schedule SB (Form 5500)                          -67-

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Determining whether a plan is in at-risk status. Refer to ERISA section 303(h)(2)(A), and the applicable regulations.
Code section 430(i)(4) and ERISA section 303(i)(4) to Enter rate to the nearest .01% (e.g., 5.26%).
determine whether the plan is in at-risk status. Generally, a If the funding target calculation includes some benefits for
plan is in at-risk status for a plan year if it had more than 500 which the present value is calculated using the 8.00% segment
participants on any day during the preceding plan year (see interest rates and other benefits for which present value is
instructions for line F for the definition of participants) and the calculated using the applicable United States Treasury
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 2022 Line 6. Target Normal Cost.
if both:
Line 6a. Present Value of Current Year Accruals. Enter the
• the FTAP for 2021 (line 14 of the 2021 Schedule SB) is less present value of all benefits which have been accrued or have
than 80%, and been earned (or that are expected to accrue or to be earned)
• the at-risk funding target attainment percentage for 2021 is under the plan during the plan year, decreased (but not below
less than 70%. zero) by any mandatory employee contributions expected to be
In general, the at-risk funding target attainment percentage made during the plan year. Include any increase in benefits
is determined in the same manner as the FTAP (as described during the plan year that is a result of any actual or projected
in the instructions for line 14), except that the funding target is increase in compensation during the current plan year, even if
determined using the additional assumptions for plans in at- that increase in benefits is with respect to benefits attributable
risk status. For this purpose, the at-risk funding target is to services performed in a preceding plan year. This amount
determined by disregarding the transition rule of Code section must be calculated as of the valuation date and must generally
430(i)(5) and ERISA section 303(i)(5) for plans that have been be based on the same assumptions used to determine the
in at-risk status for fewer than five consecutive years, and funding target reported in line 3c, column (3), reflecting the
disregarding the loading factor in Code section 430(i)(1)(C) special assumptions and the loading factor for at-risk plans, if
and ERISA section 303(i)(1)(C). For plans that were in at-risk applicable. If the plan is in at-risk status for the current plan
status for the 2021 plan year, the at-risk funding target used to year and has been in at-risk status for fewer than five
determine whether the plan is in at-risk status for the 2022 plan consecutive years, report the target normal cost after reflecting
year is the amount reported in line 4b of the 2021 Schedule the transition rule provided in Code section 430(i)(5) and
SB. ERISA section 303(i)(5).
Refer to the regulations under section 430(i) of the Code for Line 6b. Expected Plan-related Expenses. Enter the
rules pertaining to new plans and other special situations. aggregate amount of any plan-related expenses expected to
Line 4. Additional Information for Plans in At-Risk Status. be paid from plan assets during the plan year.
If the plan is in at-risk status as provided under Code section Line 6c. Total. Enter the sum of lines 6a and 6b.
430(i)(4) and ERISA section 303(i)(4), check the box, complete Part II – Beginning of Year Carryover Prefunding
lines 4a and 4b, and include as an attachment the information Balances
described below. Do not complete line 4 if the plan is not in at-
risk status for the current plan year for purposes of determining Line 7. Balance at Beginning of Prior Plan Year After
the minimum required contribution. Applicable Adjustments. In general, report the amount in the
corresponding columns of line 13 of the prior-year Schedule
● Line 4a – Enter the amount of the funding target determined SB. However, if the balance from the prior year has been
as if the plan were not in at-risk status. adjusted so that it does not match the corresponding amount in
● Line 4b – Report the funding target disregarding the line 13 of the prior-year Schedule SB, attach an explanation
transition rule of Code section 430(i)(5) and ERISA section and label the attachment “Schedule SB, line 7 – Explanation
303(i)(5), and disregarding the loading factor in Code section of Discrepancy in Prior Year Funding Standard Carryover
430(i)(1)(C) and ERISA section 303(i)(1)(C). Balance or Prefunding Balance.” Note that elections to add
If the plan is in at-risk status for the current plan year, excess contributions or reduce balances have specific
attach a description of the at-risk assumptions for the assumed deadlines, and generally cannot be changed once they have
form of payment (e.g., the optional form resulting in the highest been made.
present value). Label the attachment “Schedule SB, line 4 – If this is the first year for which the plan is subject to the
Additional Information for Plans in At-Risk Status.” minimum funding rules of Code section 430 or ERISA section
Line 5. Effective Interest Rate. Enter the single rate of 303, leave both columns blank.
interest which, if used instead of the interest rate(s) reported in Line 8. Portion Elected for Use To Offset Prior Year’s
line 21 to determine the present value of the benefits that are Funding Requirement. Report the amount for each column
taken into account in determining the plan’s funding target for a from the corresponding column of line 35 of the prior-year
plan year, would result in an amount equal to the plan’s Schedule SB. If the valuation date is not the first day of the
funding target determined for the plan year, without regard to plan year, report the amounts from line 35 of the prior-year
calculations for plans in at-risk status. (This is the funding Schedule SB, discounted to the beginning of the prior plan
target reported in line 3d, column (3) for plans not in at-risk year using the effective interest rate for the prior plan year.
status, or in line 4a for plans in at-risk status.) However, if the
funding target for the plan year is zero, the effective interest Reflect the full amount reported in line 35 of the prior-year
rate is determined as the single rate that would result in an Schedule SB even if the amount is larger than the minimum
amount equal to the plan’s target normal cost determined for required contribution reported for that year on line 34 of the
the plan year, without regard to calculations for plans in at-risk prior-year Schedule SB. This can occur under the special rule
status. See the provisions of Code section 430(h)(2)(A), for elections to use balances in excess of the minimum
required contribution under section 1.430(f)-1(f)(1)(ii) of the

-68- Instructions for Schedule SB (Form 5500)

- 69 -

regulations, if no timely election is made to revoke the excess Step 3: Multiply the result in Step 2 by the prior year’s
amount. effective interest rate in line 11(b)(1), and
If this is the first year for which the plan is subject to the Step 4: Reduce the result in Step 3 by interest on the
minimum funding rules of Code section 430 or ERISA section result in Step 2 of this paragraph for the period between the
303, leave both columns blank. first day of the prior plan year and the prior-year valuation date
Special rule for late election to apply balances to using the effective interest rate for the prior year.
quarterly installments. If an election was made to use the The amount reported in line 11(b)(1) is zero if the prior
funding standard carryover balance or the prefunding balance year’s valuation date was the last day of the prior plan year.
to offset the amount of a required quarterly installment, but the Line 11(b)(2). In column (b), enter the product of the prior
election was made after the due date of the installment, the year’s actual rate of return (from line 10) and the present value
amount reported on line 8 may not be the same as the amount of excess contributions reported on line 38b for the prior year.
reported on line 35 for the prior year. Refer to the regulations
under section 430 of the Code for additional information. An However, if the valuation date for the prior plan year was
attachment to Schedule SB should explain why the amount is not the first day of the plan year (permitted for small plans
different. Label the attachment “Schedule SB, line 8 – Late only), enter the result of the following calculation:
Election to Apply Balances to Quarterly Installments.” Step 1: Adjust the prior-year amount reported in line 38b
Line 9. Amount Remaining. Enter the amount equal to line 7 to the first day of the prior year, using the effective interest rate
minus line 8 in each column. for the prior year,
If this is the first year that the plan is subject to the Step 2: Multiply the result in Step 1 by the prior year’s
minimum funding requirements of Code section 430 or ERISA actual rate of return (from line 10), and
section 303, enter the amount of any credit balance at the end Step 3: Reduce the result in Step 2 by interest on the
of the prior year (the “pre-effective plan year”) on line 9, result in Step 1 for the period between the first day of the
column (a) and leave line 9, column (b) blank. The amount prior plan year and the prior-year valuation date using the
entered on line 9, column (a) is generally the amount reported effective interest rate for the prior year.
for the pre-effective plan year on line 9o of the 2007 version of Line 11c. Enter the sum of lines 11a, 11b(1) and 11(b)(2).
the Schedule B form that was submitted as an attachment to Enter the amount of the excess contributions for the
Line 11d.
the Schedule SB for that pre-effective plan year. If there has prior year (with interest) that the plan sponsor elected to use to
been any adjustment to this amount so that it does not match increase the prefunding balance. This amount cannot be
the amount so reported for the pre-effective plan year, attach greater than the amount reported on line 11c.
an explanation and label the attachment “Schedule SB, line 9
– Explanation of Credit Balance Discrepancy.” If this is the first year for which the plan is subject to the
minimum funding rules of Code section 430 or ERISA section
Line 10. Interest on Line 9. Enter the actual rate of return on 303, leave lines 11a–d blank.
plan assets during the preceding plan year in the space
provided. Enter the rate to the nearest .01% (e.g., 6.53%). If Line 12. Other Reductions in Balances Due to Elections or
entering a negative number, enter a minus sign (“–”) to the left Deemed Elections. In each column, enter the amount by
of the number. In each column, enter the product of this which the employer elects to reduce (or is deemed to elect to
interest rate and the amount reported in the corresponding reduce, per Code section 436(f)(3) and ERISA section
column of line 9. 206(g)(5)(C)) the funding standard carryover balance or
prefunding balance, as applicable, under Code section 430(f)
If this is the first year for which the plan is subject to the and ERISA section 303(f), other than any amount reported in
minimum funding rules of Code section 430 or ERISA section line 8 that is treated as a reduction in these balances under the
303, leave both columns blank. special rule in section 1.430(f)-1(f)(3)(ii) (relating to amounts
Line 11. Prior Year’s Excess Contributions to be Added to elected for use to offset the minimum required contribution that
Prefunding Balance. exceed the minimum required contribution for the plan for the
Line 11a. Enter the amount reported in line 38a on the plan year, and which are not revoked by the plan sponsor).
Schedule SB for the prior plan year. This amount cannot be greater than the sum of the amounts
Line 11b(1). Enter the effective interest rate for the prior plan reported in the corresponding column of lines 9, 10 and, if
year, as reported on line 5 of the Schedule SB for the prior applicable, 11d. Note that an election (or deemed election)
plan year, in the space provided. Enter the rate to the nearest cannot be made to reduce the prefunding balance in column
.01% (e.g., 6.35%). (b) until the funding standard carryover balance in column (a)
has been reduced to zero.
In column (b), enter the product of the prior year’s effective
interest rate in line 11b(1) and the excess (if any) of the If the valuation date is not the first day of the plan year,
amount reported on line 38a for the prior year over the amount adjust the amounts reported in line 12 to the first day of the
reported on line 38b for the prior year. plan year, using the effective interest rate for the current plan
year. If the plan did not exist in the prior year and is not a
However, if the valuation date for the prior plan year was successor plan, leave both columns blank.
not the first day of the plan year (permitted for small plans
only), enter the result of the following calculation: If this is the first year for which the plan is subject to the
minimum funding rules of Code section 430 or ERISA section
Step 1: Determine the excess (if any) of the amount 303, leave column (b) blank.
reported on line 38a for the prior year over the amount
reported on line 38b for the prior year, Line 13. Balance at Beginning of Current Year.
Step 2: Adjust the result in Step 1 to the first day of the ● Column (a) - Enter the sum of the amounts reported on lines
prior year using the effective interest rate for the prior year, 9 and 10 of column (a), minus the amount reported on line 12
of column (a).

Instructions for Schedule SB (Form 5500) -69-

- 70 -

● Column (b) - Enter the sum of the amounts reported on lines              other adjustments as described in applicable guidance), even if 
9, 10 and 11d of column (b), minus the amount reported on                  that AFTAP is not used to apply the restrictions under Code 
line 12 of column (b).                                                     section 436 and ERISA section 206(g) until the following plan 
  If this is the first year for which the plan is subject to the           year. 
minimum funding rules of Code section 430 or ERISA section                   If the AFTAP reported on line 15 does not correspond to 
303, leave column (b) blank.                                               the valuation results reported on this Schedule SB (for 
                                                                           instance, if any adjustments pertaining to the plan year were 
                                                                           made subsequent to the valuation), attach a schedule showing 
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 
Line 14. Funding Target Attainment Percentage. Enter the                   target, actuarial value of assets, funding standard carryover 
funding target attainment percentage (FTAP) determined in                  balance and prefunding balance used to determine the 
accordance with Code section 430(d)(2) and ERISA section                   corresponding AFTAP. Label the attachment, “Line 15, 
303(d)(2). The FTAP is the ratio (expressed as a percentage)               Reconciliation of differences between valuation results 
which the actuarial value of plan assets (reduced by the                   and amounts used to calculate AFTAP.”  It is not necessary 
funding standard carryover balance and prefunding balance)                 to include any information pertaining to a range certification in 
bears to the funding target determined without regard to the               this attachment. 
additional rules for plans in at-risk status.                              Line 16. Prior Year’s Funding Percentage for Purposes of 
  This percentage is determined by subtracting the sum of                  Determining Whether Carryover/Prefunding Balances May 
the amounts reported in line 13 from line 2b and dividing the              Be Used to Offset Current Year’s Funding Requirement. 
result by the funding target. The funding target used for this             Under Code section 430(f)(3) and ERISA section 303(f)(3), the 
purpose is the number reported in line 3d, column (3) for plans            funding standard carryover balance and prefunding balance 
that are not in at-risk status and line 4a for plans that are in at-       may not be applied toward minimum contribution requirements 
risk status. If the plan’s valuation date is not the first day of the      unless the ratio of plan assets for the preceding plan year to 
plan year, subtract the sum of the amounts reported in line 13,            the funding target for the preceding plan year (as described in 
adjusted for interest between the beginning of the plan year               Code section 430(f)(3)(C) and ERISA section 303(f)(3)(C)) is 
and the valuation date using the effective interest rate for the           80% or more. 
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 
Line 15. Adjusted Funding Target Attainment Percentage.                    general, the percentage is the ratio that the prior-year actuarial 
Enter the adjusted funding target attainment percentage                    value of plan assets (reduced by the amount of any prefunding 
(AFTAP) determined in accordance with Code section 436(j)(2)               balance, but not the funding standard carryover balance) bears 
and ERISA section 206(g)(9)(B). The AFTAP is calculated in                 to the prior-year funding target determined without regard to 
the same manner as the FTAP reported in line 14, except that               the additional rules for plans in at-risk status. This percentage 
both the assets and the funding target used to calculate the               is determined as follows, with all amounts taken from the prior 
AFTAP are increased by the aggregate amount of purchases                   year’s Schedule SB: 
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 
  See Code section 436(j)(3) and ERISA section 206(g)(9)(C)                plan year) from the amount reported on line 2b, and divide the 
for rules regarding circumstances in which the actuarial value             result by the funding target reported on line 3d, column (3). 
of plan assets is not reduced by the funding standard carryover            ● For plans that are in at-risk status, subtract the amount 
balance and prefunding balance for certain fully-funded plans              reported on line 13, column (b) (adjusted for interest as 
when determining the AFTAP. Note that this special rule                    described below, if the valuation date is not the first day of the 
applies only to the calculation of the AFTAP and not to the                plan year) from the amount reported on line 2b, and divide the 
FTAP reported in line 14.                                                  result by the funding target reported on line 4a.  
  Report the final certified AFTAP for the plan year, even if it             If the valuation date for the prior plan year was not the 
does not correspond to the valuation results reported on this              first day of that plan year, the amount subtracted from the 
Schedule SB (for instance, if any adjustments pertaining to the            assets for the purpose of the above calculations is the amount 
plan year were made subsequent to the valuation or the                     reported on line 13, column(b), adjusted for interest between 
AFTAP). If no AFTAP was certified for the plan year, attach an             the beginning of the prior plan year and the prior year’s 
explanation and (1) report 100%, if the plan's adjusted funding            valuation date, using the effective interest rate for the prior 
target for the plan year is zero, as described in section 1.436-           plan year. 
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 
the current plan year at the time that the Schedule SB is filed            Line 18. Contributions Made to the Plan. Show all employer 
(reflecting contributions for the current plan year and reflecting         and employee contributions either designated for this plan year 
                                                                           or those allocated to unpaid minimum required contributions 

                                                                      -70-                  Instructions for Schedule SB (Form 5500)

- 71 -

for a prior plan year. Do not adjust contributions to reflect date for the installment and the end of that quarter, regardless
interest. Show only employer contributions actually made to of when the contribution is actually paid.
the plan within 8½ months after the end of the plan year for Interest adjustment for contributions representing late
which this Schedule SB is filed (or actually made before the required quarterly installments — small plans with
Schedule SB is signed, if earlier). valuation dates after the beginning of the plan year -
Certain employer contributions must be made in quarterly installments due prior to the valuation date. See the
installments. See Code section 430(j) and ERISA section regulations under section 430 for rules regarding interest
303(j). Contributions made to meet the liquidity requirement of adjustments for late quarterly contributions for quarterly
Code section 430(j)(4) and ERISA section 303(j)(4) should be contributions due before the valuation date.
reported. Include contributions made to avoid benefit Line 19a. Contributions Allocated Toward Unpaid
restrictions under Code section 436 and ERISA section 206(g). Minimum Required Contributions from Prior Plan Years.
Add the amounts in both columns 18(b) and 18(c) Under code section 4971(c)(4)(B), if a plan has an unpaid
separately and enter each result in the corresponding column minimum required contribution that has not been corrected at
on the total line. All contributions except those made to avoid the time a payment is made (i.e., the deadline for making the
benefit restrictions under Code section 436 and ERISA section minimum required contribution for a prior plan year had passed
206(g) must be credited toward minimum funding requirements and the minimum required contribution for that year was not
for a particular plan year. yet paid) that payment is allocated first to plan years with
Line 19. Discounted Employer Contributions. Employer unpaid minimum required contributions, beginning with the
contributions reported in line 18 that were made on a date earliest such plan year, and then to the minimum required
other than the valuation date must be adjusted to reflect contribution for the current plan year. Within a given plan year,
interest for the time period between the valuation date for the payments are credited first to the earliest unpaid installment
plan year to which the contribution is allocated and the date until the minimum required contribution for that plan year is
the contribution was made. In general, adjust each contribution satisfied. Report any contributions from line 18 that are
using the effective interest rate for the plan year to which the allocated toward unpaid minimum required contributions from
contribution is allocated, as reported on line 5. prior plan years, discounted for interest from the date the
contribution was made to the valuation date for the plan year
Allocate the interest-adjusted employer contributions to for which the contribution was originally required as described
lines 19a, 19b, and 19c to report the purpose for which they above. Increase the effective interest rate for the applicable
were made (as described below). plan year by 5 percentage points for any portion of the unpaid
Attach a schedule showing the dates and amounts of minimum required contribution that represents a late quarterly
individual contributions, the year to which the contributions (or installment, for the period between the due date for the
the portion of individual contributions) are applied, the interest installment and the date of payment. Reflect the increased
rate(s) used to adjust the contributions (i.e., the effective interest rate for any portion of the unpaid minimum required
interest rate for timely contributions and the applicable contribution that represents a late liquidity shortfall installment,
effective interest rate plus 5% for late quarterly installments) for the period corresponding to the time between the date the
and the periods during which each rate applies, and the installment was due and the end of the quarter during which it
interest-adjusted contribution. It is not necessary to include was due. The amount reported in line 19a cannot be larger
information regarding interest-adjusted contributions allocated than the amount reported in line 28.
toward the minimum required contribution for the current year For the purpose of allocating contribution amounts to
(reported in line 19c) in this schedule, unless any of those unpaid minimum required contributions, any unpaid minimum
contributions represent late quarterly installments. However, if required contribution attributable to an accumulated funding
any of the contributions reported in line 19c represent late deficiency at the end of the last plan year before Code section
quarterly installments, include all contributions reported in line 430 or ERISA section 303 applied to the plan (the “pre-
19c on this schedule. Label the attachment “Schedule SB, effective plan year”) is treated as a single contribution due on
line 19 –Discounted Employer Contributions.” the last day of the pre-effective plan year (without separately
Special note for small plans with valuation dates after identifying any portion of the accumulated funding deficiency
the beginning of the plan year. If the valuation date is after attributable to late quarterly installments or late liquidity
the beginning of the plan year and contributions for the current shortfall installments), and the associated effective interest rate
year were made during the plan year but before the valuation is deemed to be the valuation interest rate for the pre-effective
date, such contributions are increased with interest to the plan year.
valuation date using the effective interest rate for the current Line 19b. Contributions Made To Avoid Benefit
plan year. These contributions and the interest calculated as Restrictions. Include in this category current year
described in the preceding sentence are excluded from the contributions made to avoid or terminate benefit restrictions
value of assets reported in lines 2a and 2b. under Code section 436 and ERISA section 206(g). Adjust
Interest adjustment for contributions representing late each contribution for interest from the date the contribution
required quarterly installments — installments due after was made to the valuation date as described above.
the valuation date. If the full amount of a required installment
Line 19c. Contributions Allocated Toward Minimum
due after the valuation date for the current plan year is not paid Required Contribution for Current Year. Include in this
by the due date for that installment, increase the effective category contributions (including any contributions made in
interest rate used to discount the contribution by 5 percentage excess of the minimum required contribution) that are not
points for the period between the due date for the required included in line 19a or 19b. Adjust each contribution for interest
installment and the date on which the payment is made. If all from the date the contribution was made to the valuation date
or a portion of the late required quarterly installment is due to a as described above.
liquidity shortfall, the increased interest rate is used for a
period of time corresponding to the period between the due Line 20. Quarterly Contributions and Liquidity Shortfalls.

Instructions for Schedule SB (Form 5500) -71-

- 72 -

Line 20a. Did the Plan Have a Funding Shortfall for the                  section 430(h)(2)(C) and ERISA section 303(h)(2)(C) and as 
Prior Plan Year? In accordance with Code section 430(j)(3)               published by the IRS, unless the plan sponsor has elected to 
and ERISA section 303(j)(3), only plans that have a funding              use the full yield curve. If the sponsor has elected to use the 
shortfall for the preceding plan year are subject to an                  full yield curve, check the “N/A, full yield curve used” box. 
accelerated quarterly contribution schedule. For this purpose,           If an election under Code section 430(m)(2) applies to the 
a plan is considered to have a funding shortfall for the prior           plan for a plan year, enter 8.00% in each of the three segment 
year if the funding target reported on line 3d, column (3) is            rates. Do not check the full yield curve box, even if some or all 
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 
Line 20b. If line 20a is “No” (i.e., if the plan did not have a          preceding months. For example, if the valuation date is 
funding shortfall in the prior plan year), the plan is not subject       January 1 and the funding target and target normal cost were 
to the quarterly contribution rules, and this line should not be         determined based on rates published for November, enter “2.” 
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 
Target and Target Normal Cost                                            compute the weighted average retirement age, including a 
                                                                         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 
and used as published by the IRS, and are to be applied as                                                “Schedule SB, line 22 – 
annual rates without adjustment.                                         Description of Weighted Average Retirement Age.” 
Line 21a. Enter the three segment rates used to calculate the            Line 23. Mortality Tables. Mortality tables described in Code 
                                                                         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 

                                                                    -72-          Instructions for Schedule SB (Form 5500)

- 73 -

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

Instructions for Schedule SB (Form 5500)                                 -73-

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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 in a spreadsheet file If the accrued benefit is the greater of a cash balance benefit or
(CSV format). some other benefit, average in only the cash balance account. If
Expand this schedule by adding columns after the “5 to 9” the accrued benefit is the sum of a cash balance account
column and before the “40 & up” column for active participants benefit and some other benefit, average in only the cash
with total years of credited service in the following ranges: 10 to balance account. For both the average compensation and the
14; 15 to 19; 20 to 24; 25 to 29; 30 to 34; and 35 to 39. For each 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 3d, 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.

-74- Instructions for Schedule SB (Form 5500)

- 75 -

 Participant Data” for each participating employer in the                        430(f)(4)(B)(ii) and ERISA section 
 multiple-employer plan.                                                         303(f)(4)(B)(ii) 
 Line 26b.  Schedule of Projection of Expected Benefit                    5      This code, formerly used by airlines using 10-
 Payments. Check “Yes” only if this plan is covered by Title IV                  year amortization period for initial post-PPA 
 of ERISA and has 1,000 or more total participants as of the                     shortfall amortization base under section 
 valuation date.                                                                 402(a)(2) of PPA (as amended), is no longer 
                                                                                 applicable and should not be used. 
 If line 26b is “Yes,” in an attachment, provide a projection of          6      Airlines with frozen plans using alternative 17-
 benefits expected to be paid separately for active participants,                year funding schedule under section 402(a)(1) 
 terminated vested participants, and retired participants and                    of PPA 
 beneficiaries receiving payments, and for the entire plan (not to        7      Interstate transit company described in section 
 include expected expenses) in each of the next fifty years                      115 of PPA 
 starting with the plan year and based on the participant’s               8      This code, formerly used by a plan subject to 
 status as of the valuation date. For purposes of this projection,               section 104 of PPA (as amended) that is not a 
 assume (1) no additional accruals, (2) experience (e.g.,                        CSEC plan, is no longer applicable and should 
 termination, mortality, and retirement) is in line with valuation               not be used.  
 assumptions, (3) no new entrants, and (4) benefits are paid in           9      Community Newspaper plans and plans within 
 the form assumed for valuation purposes.                                        the controlled group, as described in SECURE 
 Use the format shown below and label this attachment                            Act section 115. 
 “Schedule SB, line 26b – Schedule of Projection of                       
 Expected Benefit Payments.” The attachment may be                        Special Instructions for codes 1 through 9 
 provided in a spreadsheet file (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 
                          Participants    and                               •    Part I (including signature of enrolled actuary), 
                                       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 
 Line 27. Alternative Funding Rules. If one of the alternative           Plans.” Each attachment must include the plan name, the plan 
 funding rules was used for this plan year, enter the appropriate        sponsor’s name and EIN, and the plan number. Complete all 
 code from the table below and follow the special instructions           items from the 2007 Schedule B, excluding line 9f and Part II, 
                                                                         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 § 430(h)(2)(C)(iii) and 
 Code          Alternative Funding Rule                                  ERISA section 303(h)(2)(C)(iii) is substituted for the current 
                                                                         liability interest rate under § 412(b)(5)(B) and ERISA section 
 1             A CSEC plan that is described in Code section             302(b)(5)(B) (as in effect before PPA ‘06).  
               414(y). This includes certain multiple-employer 
               plans maintained by rural cooperatives and                 If the plan’s funded percentage (as defined in § 
               other specified cooperative organizations and             433(j)(5)(B)) as of the beginning of the plan year is less than 
               certain plans maintained by more than 1                   80%, then the plan is in funding restoration status. If the plan’s 
               employer (determined after application of Code            enrolled actuary certifies that the plan is in funding restoration 
               section 414(b) and (c)), all of which are                 status for a plan year, include the following additional 
               described in Code section 501(c)(3). Do not use           information in the attachment “Schedule SB, line 27 – 
               Code 1 for a plan that satisfies the definition of a      Actuarial Information for CSEC Plans:” (a) the annual 
               CSEC plan that has made the election to not be            certification by the enrolled actuary for the plan; and (b) the 
               treated as a CSEC plan.                                   value of plan assets and the funding liability, including any 
 2             This code, formerly used by certain plans                 adjustments to these amounts as specified in § 433(j)(4) and 
               maintained by PBGC settlements as described               ERISA section 306(j)(4). 
               in section 105 of PPA, is no longer applicable             If a plan in funding restoration status has an accumulated 
               and should not be used                                    funding deficiency based on the excess of the employer’s 
 3             Reserved                                                  normal cost determined under line 9b, over the amount 
 4             Plans with binding agreements with PBGC to                actually contributed to the plan for the plan year, as 
               maintain prefunding and/or funding standard               determined under § 433(j)(1) and ERISA section 306(j)(1), 
               carryover balances described in Code section              then the details of this calculation must be included in the 

 Instructions for Schedule SB (Form 5500)                           -75-

- 76 -

attachment “Schedule SB, line 27 – Actuarial Information disregarding the attachment required for plans reporting the use
for CSEC Plans.” In the case of a plan for which a spread of the substitute mortality table in line 23.
gain funding method is used, the normal cost that is used to Part VII – Reconciliation of Unpaid Minimum
apply this rule is the normal cost determined under the entry
age normal cost funding method. Required Contributions for Prior Years
Line 28. Unpaid Minimum Required Contributions for Prior
Plans with binding agreements with the PBGC to Enter the total amount of any unpaid minimum required
Years.
maintain prefunding and/or carryover balances (code 4). contributions for all years from line 40 of the Schedule SB for
Complete the entire Schedule SB and attachments as outlined
the prior plan year.
in these instructions. In addition, report on an attachment the
amount subject to the binding agreement with the PBGC, If this is the first year that the plan is subject to the minimum
reported separately for the funding standard carryover balance funding requirements of Code section 430 or ERISA section
and prefunding balance. Label the attachment “Schedule SB, 303, enter the amount of any accumulated funding deficiency at
line 27 – Balances Subject to Binding Agreement with the end of the prior year (the pre-effective plan year). This is the
PBGC.” amount reported on line 9p of the 2007 Schedule B form that
was submitted as an attachment to the Schedule SB for the pre-
Airlines with frozen plans using alternative 17-year effective plan year.
funding schedule (code 6). Complete the following lines on
Schedule SB and provide associated attachments: Line 29. Employer Contributions Allocated Toward Unpaid
● Lines A through F. Minimum Required Contributions from Prior Years. Enter
the total amount of discounted contributions made for the
● Part I (including signature of enrolled actuary) – complete all
current plan year allocated toward unpaid minimum required
lines.
contributions from prior years as reported in line 19a.
● Parts III through VII – complete all lines.
For this purpose, disregard the special funding rules under Line 30. Remaining Unpaid Minimum Required
section 402(e) of PPA except for the information reported on the Contributions. Enter the amount in line 28 minus the amount
in line 29.
following lines:
● Line 19 – Discount contributions to the applicable valuation Part VIII – Minimum
date using the 8.85% discount rate provided under section Required Contribution for Current Year
402(e)(4)(B) of PPA. Line 31. Target Normal Cost and Excess Assets.
● Line 20 – Reflect required quarterly installments based on Line 31a.Target Normal Cost (line 6c). Enter the target
the minimum required contribution determined under section normal cost as reported in line 6c.
402(e) of PPA to the extent applicable (i.e., for purposes of
calculating the required annual payment under Code section Line 31b. Excess Assets. Enter the excess, if any, of the
430(j)(3)(D)(ii)(l) and ERISA section 303(j)(3)(D)(ii)(l)). value of assets reported on line 2b reduced by any funding
● Line 29 – Reflect the minimum required contribution standard carryover balance and prefunding balance on line 13,
determined under section 402(e) of PPA when determining the columns (a) and (b), over the funding target reported on line
unpaid minimum required contribution. 3d, column (3). If the valuation date is not the first day of the
plan year, excess assets are determined as the value of assets
Also, attach a worksheet showing the information below, reported on line 2b reduced by any funding standard carryover
determined in accordance with section 402(e) of PPA. Label this balance and prefunding balance reported on line 13, columns
worksheet “Schedule SB, line 27 – Alternative 17-Year (a) and (b), adjusted for interest at the effective interest rate for
Funding Schedule for Airlines.” the period between the beginning of the plan year and the
● Date as of which plan benefits were frozen as required under valuation date, minus the funding target reported on line 3d,
section 402(b)(2) of PPA. column (3) (but not less than zero). Limit the amount reported
● Date on which the first applicable plan year began. in line 31b so that it is not greater than the target normal cost
● Accrued liability under the unit credit method calculated as of reported in line 31a.
the first day of the plan year, using an interest rate of 8.85%. Line 32. Amortization Installments.
● A summary of all other assumptions used to calculate the
unit credit accrued liability. Line 32a. Shortfall Amortization Bases and Amortization
● Fair market value of assets as of the first day of the plan Installments. Outstanding balance — If the plan’s funding
year. shortfall (determined under Code section 430(c)(4) and ERISA
● Unfunded liability under section 402(e)(3)(A) of PPA. section 303(c)(4)) is zero, all amortization bases and related
● Alternative funding schedule: installments are considered fully amortized. In this case, enter
zero. Otherwise, enter the sum (but not less than zero) of the
1. Contribution necessary to amortize the unfunded liability outstanding balances of all shortfall amortization bases
over the remaining number of years, assuming payments at (including any new shortfall amortization base established for
the valuation date for each plan year and using an interest rate the current plan year). The outstanding balance for each
of 8.85%; amortization base established in past years is equal to the
2. Employer contributions for the plan year, discounted for present value as of the valuation date of any remaining
interest to the valuation date for the plan year, and using a rate amortization installments for each base (including the
of 8.85%; and amortization installment for the current plan year), using the
3. Contribution shortfall, if any ((1)-(2) but not less than interest rates reported on line 21.
zero).
A plan is generally exempt from the requirement to establish
Interstate transit company (code 7). Complete the entire a new shortfall amortization base for the current plan year if the
Schedule SB, reflecting the modifications to the otherwise- funding target reported on line 3d, column (3), is less than or
required funding rules under section 115(b) of PPA, and equal to the reduced value of assets as described below.

-76- Instructions for Schedule SB (Form 5500)

- 77 -

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

Instructions for Schedule SB (Form 5500)                             -77-

- 78 -

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

-78- Instructions for Schedule SB (Form 5500)

- 79 -

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., 54 min.   1 hr., 19 min.                                                  1 hr., 45 min. 1 hr., 14 min. 
 Schedule A                   2 hr., 52 min.   2 hr., 51 min.                                                  3 hr., 39 min. 2 hr., 43 min. 
 Schedule C                    3 hr., 4 min             N/A                                                    3 hr., 38 min.               N/A 
 Schedule D                   1 hr., 39 min.       20 min.                                                     1 hr., 52 min.               20 min. 
 Schedule G                   11 hr., 29 min.           N/A                                                    11 hr.                       N/A 
 Schedule H                   7 hr., 42 min.            N/A                                                    8 hr., 35 min.               N/A 
 Schedule I                    N/A             2 hr., 5 min.                                                          N/A     1 hr., 55 min. 
 Schedule MB                  7 hr., 52 min.   4 hr., 14 min.                                                         N/A                   N/A 
 Schedule R                   1 hr., 43 min.   1 hr., 5 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. 
 
                                                   -79-

- 80 -

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 
                                             is designed to classify an enterprise by  the type of  activity in    Industry Classification System. 
5500-EZ Codes for Principal                  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                      
                                                                                                                        
                                                                               -80-

- 81 -

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)                      
                                                                                     
                                                                                    -81-

- 82 -

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                                                                                                                 
                                                                                                                                
                                                                               -82-

- 83 -

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.

-83-

- 84 -

Pooled Separate Account (PSA) 11
Index I Provision of Information .............. 23
Information Concerning Insurance
Contract Coverage, Fees, and
Commissions ........................... 21 Q
80-120 Participant Rule ………. ...... 8 Instructions to Form 5500 … ....... 14 Quick Reference Chart of Form
103-12 Investment Entity Instructions for Schedule A: 5500, Schedules, and
(103-12 IE) ............................... 11 Who Must File .......................... 22 Attachments…..………………12
Instructions for Schedule C:
A Who Must File .......................... 25
About the Form 5500 .................... 1 Instructions for Schedule D: R
Additional Employer Information Who Must File .......................... 30 Reportable Transaction .............. 42
for Multiemployer Defined Instructions for Schedule G:
Benefit Pension Plans .......... 62 Who Must File .......................... 32 S
Additional Information for Instructions for Schedule H: Schedule of Reportable
Single-Employer and Who Must File .......................... 34 Transactions ....................... 42
Multiemployer Defined Instructions for Schedule I: Service Provider Information ...... 24
Benefit Pension Plans ......... 62 Who Must File .......................... 44 Service Providers Who Fail or
Amended Return/Report ............... 6 Instructions for Schedule MB: Refuse To Provide
Amendments .............................. 61 Statement by Enrolled Information .......................... 27
Actuary ................................. 52 Short Plan Year Rule ................... 8
Who Must File .......................... 52 Signature and Date ...................... 6
C Instructions for Schedule R: Small Plan Financial
Change in Plan Year ..................... 7 Who Must File .......................... 60 Information .......................... 44
Changes to Note ........................... 1 Instructions for Schedule SB: Special rule for certain
Combination Unfunded/Insured Statement by Enrolled participant-directed
Welfare Plan .............................. 4 Actuary ................................. 65 transactions ......................... 42
Common/Collective Trust ............ 11 Who Must File .......................... 65 Statement by Enrolled
Investment and Annuity Actuary ................................ 66
D Contract Information ................ 23
Delinquent Filer Voluntary
T
Compliance (DFVC) Program ...... 5 L Telephone Assistance .................. 2
Direct Filing Entity (DFE) – Who Leases in Default or Classified Termination Information on
Must File .................................... 4 As Uncollectible ……………… . 32 Accountants and Enrolled
Direct Filing Entity (DFE) – Filing Limited Pension Plan Reporting .... 9 Actuaries ............................. 29
Requirements .......................... 10 List of Plan Characteristic Codes 20
Distributions ................................ 60 Loans or Fixed Income
Obligations in Default or U
E Classified As Uncollectible....... 32 Unfunded Welfare Benefit Plan .... 3
EFAST2 Processing System ......... 1
W
Electronic Filing Requirement ....... 5 M Welfare Benefit Contract
ESOP Information ....................... 62 M-1 Compliance Information ....... 19
Information .......................... 24
Extension of Time to File............... 4 Master Trust Investment
Welfare Benefit Plan – Who
Account (MTIA) ........................ 10
Must File ................................ 3
F
Welfare Benefit Plan Filing
Final Return/Report: N Requirements ....................... 9
Mergers/Consolidations ............. 6 Nonexempt Transactions ............ 32 What To File ................................. 7
Pension and Welfare Plans Notice to Terminated Accountant When To File:
Terminated Without or Enrolled Actuary .................. 29 DFEs other than GIAs ........... 4
Distributing All Assets ............ 6 Extensions ............................ 4
Welfare Plans Still Liable to Pay Plans and GIAs ..................... 4
Benefits .................................. 6 O Short Years ........................... 4
Form 5500 Schedules ................... 8 On-Line Assistance……………….2 Who Must File .............................. 2
Fully Insured Welfare Benefit
Plan ........................................... 4
P
Funding Information .................... 61 Party-In-Interest ......................... 48
Penalties:
G Administrative ........................... 7
General Schedules ....................... 8 Other ......................................... 7
Group Insurance Arrangement Pension Benefit Plan - Who
(GIA) ........................................ 11 Must File ................................... 2
Pension Benefit Plan Filing
Requirements ........................... 8
H Pension Schedule………….…… .. 8
How to get assistance ................... 2 Plan Administrator ...................... 16
Plan Sponsor .............................. 15
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