OMB No. 1210-0110 
       SCHEDULE I                            Financial Information—Small Plan 
         (Form 5500) 
       Department of the Treasury            This schedule is required to be filed under section 104 of the Employee                                                    2023 
       Internal Revenue Service              Retirement Income Security Act of 1974 (ERISA), and section 6058(a) of the 
         Department of Labor                               Internal Revenue Code (the Code).                                                                       This Form is Open to Public 
   Employee Benefits Security Administration                                                                                                                            Inspection  
                                                           File as an attachment to Form 5500.
     Pension Benefit Guaranty Corporation 
For calendar plan year 2023 or fiscal plan year beginning                                                                                   and ending         
A  Name of plan                                                                                            B                             Three-digit 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI                                                                                        plan number (PN)                            001 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 
C  Plan sponsor’s name as shown on line 2a of Form 5500                                                    D                        Employer Identification Number (EIN)67 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 
ABCDEFGHI
Complete Schedule I if the plan covered fewer than 100 participants as of the beginning of the plan year. You may also complete Schedule I if you are filing as a 
small plan under the 80-120 participant rule (see instructions). Complete Schedule H if reporting as a large plan or DFE. 
Part I   Small Plan Financial Information 
Report below the current value of assets and liabilities, income, expenses, transfers and changes in net assets during the plan year. Combine the value of plan 
assets held in more than one trust. Do not enter the value of the portion of an insurance contract that guarantees during this plan year to pay a specific dollar 
benefit at a future date. Include all income and expenses of the plan including any trust(s) or separately maintained fund(s) and any payments/receipts to/from 
insurance carriers. Round off amounts to the nearest dollar.
1  Plan Assets and Liabilities:                                                                            (a) Beginning of Year                                    (b) End of Year
a  Total plan assets ............................................................................    1a    -123456789012345                                         -123456789012345
b  Total plan liabilities ........................................................................   1b    -123456789012345                                         -123456789012345
c  Net plan assets (subtract line 1b from line 1a) ..............................                    1c    -123456789012345                                         -123456789012345
2  Income, Expenses, and Transfers for this Plan Year:                                                                             (a) Amount                           (b) Total
a  Contributions received or receivable:
   (1) Employers ..............................................................................      2a(1) -123456789012345
   (2) Participants ............................................................................     2a(2) -123456789012345
   (3) Others (including rollovers) ....................................................             2a(3) -123456789012345
b  Noncash contributions ...................................................................         2b    -123456789012345
c  Other income .................................................................................    2c    -123456789012345
d  Total income (add lines 2a(1), 2a(2), 2a(3), 2b, and 2c) ...............                          2d                                                             -123456789012345
e  Benefits paid (including direct rollovers) ........................................               2e    -123456789012345
f  Corrective distributions (see instructions) ......................................                2f    -123456789012345
g   Certain deemed distributions of participant loans
     (see instructions) ...........................................................................  2g    -123456789012345
h  Administrative service providers (salaries, fees, and
     commissions) .................................................................................  2h    -123456789012345
i  Other expenses .............................................................................      2i    -123456789012345
j  Total expenses (add lines 2e, 2f, 2g, 2h, and 2i) ...........................SAMPLE               2j                                                             -123456789012345
k  Net income (loss) (subtract line 2j from line 2d) ............................                    2k                                                             -123456789012345
l  Transfers to (from) the plan (see instructions) ...............................                   2l                                                             -123456789012345
3  Specific Assets: If the plan held assets at any time during the plan year in any of the following categories, check “Yes” and enter the current value of any assets 
   remaining in the plan as of the end of the plan year. Allocate the value of the plan’s interest in a commingled trust containing the assets of more than one plan on a 
   line-by-line basis unless the trust meets one of the specific exceptions described in the instructions. 
                                                                                                                                            Yes      No                 Amount 
a  Partnership/joint venture interests ......................................................................................            3a                         -123456789012345
b  Employer real property .......................................................................................................        3b                         -123456789012345
c  Real estate (other than employer real property) .................................................................                     3c                         -123456789012345
d  Employer securities ............................................................................................................      3d                         -123456789012345
e    Participant loans ................................................................................................................. 3e 
f   Loans (other than to participants)       ......................................................................................      3f 
g   Tangible personal property .................................................................................................         3g 
For Paperwork Reduction Act Notice, see the Instructions for Form 5500.                                                                                             Schedule I (Form 5500) 2023 
                                                                                                                                                                                    v. 230728

          Schedule I (Form 5500) 2023                                                       Page 2-                                               1  x 

Part II    Compliance Questions 
4      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 Correction Program.) .........                                            4a                                   -123456789012345
b     Were any loans by the plan or fixed income obligations due the plan in default as of the
      close of plan year or classified during the year as uncollectible? Disregard participant loans 
      secured by the participant’s account balance. ..........................................................................                    4b                                   -123456789012345
c     Were any leases to which the plan was a party in default or classified during the year as
      uncollectible?  ........................................................................................................................... 4c                                   -123456789012345
d     Were there any nonexempt transactions with any party-in-interest? (Do not include
      transactions reported on line 4a.) .............................................................................................            4d                                   -123456789012345
e     Was the 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 at any time hold 20% or more of its assets in any single security, debt,
      mortgage, parcel of real estate, or partnership/joint venture interest? ......................................                              4i                                   -123456789012345
j     Were all the plan assets either distributed to participants or beneficiaries, transferred to
      another plan, or brought under the control of the PBGC? ........................................................                            4j 
k     Are you claiming a waiver of the annual examination and report of an independent qualified
      public accountant (IQPA) under 29 CFR 2520.104-46? If “No,” attach an IQPA’s report or 
      2520.104-50 statement. (See instructions on waiver eligibility and conditions.) ...............................                             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?........   XYes     NoX                                           - 
      If “Yes,” enter the amount of any plan assets that reverted to the employer this year ____________________________________. 
5b If, during this plan year, any assets or liabilities were transferred from this plan to another plan(s), identify the plan(s) to which assets or liabilities were
      transferred. (See instructions.) 
      5b(1) Name of plan(s)                                                                                                                                                            5b(2) EIN(s)   5b(3) PN(s) 
      ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 
      ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI                                                                                                         123456789         123 
      ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 
      ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI                                                                                                         123456789         123 
      ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI SAMPLE
      ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI                                                                                                         123456789         123 

5c Was the plan a defined benefit plan covered under the PBGC insurance program at any time during this plan year? (See ERISA section 4021 and
      instructions.) …………..................................................................................................................................  XYes       XNo        NotXdetermined     
      If “Yes” is checked, enter the My PAA confirmation number from the PBGC premium filing for this plan year ____________________.