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Schedule H (Form 5500) 2023 Page 4
Part III Accountant’s Opinion
3 Complete lines 3a through 3c if the opinion of an independent qualified public accountant is attached to this Form 5500. Complete line 3d if an opinion is not
attached.
a The attached opinion of an independent qualified public accountant for this plan is (see instructions):
(1) X Unmodified (2) X Qualified (3) X Disclaimer (4) X Adverse
b Check the appropriate box(es) to indicate whether the IQPA performed an ERISA section 103(a)(3)(C) audit. Check both boxes (1) and (2) if the audit was
performed pursuant to both 29 CFR 2520.103-8 and 29 CFR 2520.103-12(d). Check box (3) if pursuant to neither.
(1) XDOL Regulation 2520.103-8 (2) XDOL Regulation 2520.103-12(d) (3) Xneither DOL Regulation 2520.103-8 nor DOL Regulation 2520.103-12(d).
c Enter the name and EIN of the accountant (or accounting firm) below:
(1) Name: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD (2) EIN: 123456789
d The opinion of an independent qualified public accountant is not attached as part of Schedule H because:
(1) X This form is filed for a CCT, PSA, DCG or MTIA. (2) X It will be attached to the next Form 5500 pursuant to 29 CFR 2520.104-50.
Part IV Compliance Questions
4 CCTs and PSAs do not complete Part IV. MTIAs, 103-12 IEs, and GIAs do not complete lines 4a, 4e, 4f, 4g, 4h, 4k, 4m, 4n, or 5.
103-12 IEs also do not complete lines 4j and 4l. MTIAs also do not complete line 4l. DCGs do not complete lines 4e, 4f, 4k, 4l, and 5, and DCGs generally
complete the rest of Part IV collectively for all plans in the DCG, except as otherwise provided (see instructions).
During the plan year: Yes No Amount
a Was there a failure to transmit to the plan any participant contributions within the time
period described in 29 CFR 2510.3-102? Continue to answer “Yes” for any prior year failures until
fully corrected. (See instructions and DOL’s Voluntary Fiduciary Co rrection Program.) ................... 4a
b Were any loans by the plan or fixed income obligations due the plan in default as of the
close of the plan year or classified during the year as uncollectible? Disregard participant loans
secured by participant’s account balance. (Attach Schedule G (Form 5500) Part I if “Yes” is
checked.) ........................................................................................................................................... 4b
c Were any leases to which the plan was a party in default or classified during the year as
uncollectible? (Attach Schedule G (Form 5500) Part II if “Yes” is checked.) ................................... 4c -123456789012345
d Were there any nonexempt transactions with any party-in-interest? (Do not include transactions
reported on line 4a. Attach Schedule G (Form 5500) Part III if “Yes” is
checked.) ........................................................................................................................................... 4d -123456789012345
e Was this plan covered by a fidelity bond? ......................................................................................... 4e -123456789012345
f Did the plan have a loss, whether or not reimbursed by the plan’s fidelity bond, that was caused
by fraud or dishonesty? .................................................................................................................... 4f -123456789012345
g Did the plan hold any assets whose current value was neither readily determinable on an
established market nor set by an independent third party appraiser? .............................................. 4g -123456789012345
h Did the plan receive any noncash contributions whose value was neither readily
determinable on an established market nor set by an independent third party appraiser? ............... 4h -123456789012345
i Did the plan have assets held for investment? (Attach schedule(s) of assets if “Yes” is checked,
and see instructions for format requirements.) ..................................................................................SAMPLE4i
j Were any plan transactions or series of transactions in excess of 5% of the current
value of plan assets? (Attach schedule of transactions if “Yes” is checked and
see instructions for format requirements.) ......................................................................................... 4j
k Were all the plan assets either distributed to participants or beneficiaries, transferred to another
plan, or brought under the control of the PBGC? .............................................................................. 4k
l Has the plan failed to provide any benefit when due under the plan? .............................................. 4l -123456789012345
m If this is an individual account plan, was there a blackout period? (See instructions and 29 CFR
2520.101-3.) ...................................................................................................................................... 4m
n If 4m was answered “Yes,” check the “Yes” box if you either provided the required notice or one
of the exceptions to providing the notice applied under 29 CFR 2520.101-3. .................................. 4n
5a Has a resolution to terminate the plan been adopted during the plan year or any prior plan year?........ X Yes XNo
If “Yes,” enter the amount of any plan assets that reverted to the employer this year ____________________________________.
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