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                                                    2022 
        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 2022 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) 2022 
                                                                                                                                                                                                   v. 220413 
  

         Schedule I (Form 5500) 2022                                                       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 
     close of plan year or classified during the year as uncollectible? Disregard participant loans                                             
   b Were any loans by the plan or fixed income obligations due the plan in default as of the                                                                                                                
     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                                                            
     public accountant (IQPA) under 29 CFR 2520.104-46? If “No,” attach an IQPA’s report or                                                     
   k Are you claiming a waiver of the annual examination and report of an independent qualified                                                                                                              
     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    XNo                                            - 
     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        NotX determined                        
       If “Yes” is checked, enter the My PAA confirmation number from the PBGC premium filing for this plan year ____________________.