OMB No. 1210-0110 SCHEDULE MB Multiemployer Defined Benefit Plan and Certain (Form 5500) Money Purchase Plan Actuarial Information Department of the Treasury 2022 Internal Revenue Service This schedule is required to be filed under section 104 of the Employee Department of Labor Retirement Income Security Act of 1974 (ERISA) and section 6059 of the Employee Benefits Security Administration Internal Revenue Code (the Code). This Form is Open to Public Pension Benefit Guaranty Corporation Inspection File as an attachment to Form 5500 or 5500-SF. For calendar plan year 2022 or fiscal plan year beginning and ending Round off amounts to nearest dollar. Caution: A penalty of $1,000 will be assessed for late filing of this report unless reasonable cause is established. A Name of plan B Three-digit ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI plan number (PN) 001 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI C Plan sponsor’s name as shown on line 2a of Form 5500 or 5500-SF D Employer Identification Number (EIN) ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 012345678 ABCDEFGHI E Type of plan: (1) XMultiemployer Defined Benefit (2) XMoney Purchase (see instructions) 1a Enter the valuation date: Month _________ Day _________ Year _________ b Assets (1) Current value of assets ...................................................................................................................... 1b(1) (2) Actuarial value of assets for funding standard account ...................................................................... 1b(2) c (1) Accrued liability for plan using immediate gain methods .................................................................... 1c(1) (2) Information for plans using spread gain methods: (a) Unfunded liability for methods with bases ................................................................................... 1c(2)(a) -123456789012345 (b) Accrued liability under entry age normal method ......................................................................... 1c(2)(b) -123456789012345 (c) Normal cost under entry age normal method ............................................................................... 1c(2)(c) -123456789012345 (3) Accrued liability under unit credit cost method ................................................................................... 1c(3) -123456789012345 d Information on current liabilities of the plan: (1) Amount excluded from current liability attributable to pre-participation service (see instructions) ....... 1d(1) -123456789012345 (2) “RPA ‘94” information: (a) Current liability ............................................................................................................................. 1d(2)(a) -123456789012345 (b) Expected increase in current liability due to benefits accruing during the plan year ...................... 1d(2)(b) -123456789012345 (c) Expected release from “RPA ‘94” current liability for the plan year ............................................... 1d(2)(c) -123456789012345 (3) Expected plan disbursements for the plan year .................................................................................. 1d(3) -123456789012345 Statement by Enrolled Actuary To the best of my knowledge, the information supplied in this schedule and accompanying schedules, statements and attachments, if any, is complete and accurate. Each prescribed assumption was applied in accordance with applicable law and regulations. In my opinion, each other assumption is reasonable (taking into account the experience of the plan and reasonable expectations) and such other assumptions, in combination, offer my best estimate of anticipated experience under the plan. SIGN SAMPLE HERE Signature of actuary Date Type or print name of actuary Most recent enrollment number Firm name Telephone number (including area code) 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE UK Address of the firm If the actuary has not fully reflected any regulation or ruling promulgated under the statute in completing this schedule, check the box and see X instructions For Paperwork Reduction Act Notice, see the Instructions for Form 5500 or 5500-SF. Schedule MB (Form 5500) 2022 v. 220413 |
Schedule MB (Form 5500) 2022 Page 2 - 1 x 2 Operational information as of beginning of this plan year: a Current value of assets (see instructions) ................................................................................................... 2a -123456789012345 b “RPA ‘94” current liability/participant count breakdown: (1) Number of participants (2) Current liability (1) For retired participants and beneficiaries receiving payment ................................ 12345678 -123456789012345 (2) For terminated vested participants ....................................................................... 12345678 -123456789012345 (3) For active participants: (a) Non-vested benefits ....................................................................................... -123456789012345 (b) Vested benefits.............................................................................................. -123456789012345 (c) Total active .................................................................................................... -123456789012345 (4) Total .................................................................................................................... 12345678 -123456789012345 percentage ...................................................................................................................................................... 123.12 c If the percentage resulting from dividing line 2a by line 2b(4), column (2), is less than 70%, enter such 2c % 3 Contributions made to the plan for the plan year by employer(s) and employees: (a) Date (b) Amount paid by (c) Amount paid by (a) Date (b) Amount paid by c) Amount paid by (MM-DD-YYYY) employer(s) employees (MM-DD-YYYY) employer(s) employees Totals ► 3(b) 3(c) (d) Total withdrawal liability amounts included in line 3(b) total ............................................................................................... 3(d) 4 Information on plan status: a Funded percentage for monitoring plan’s status (line 1b(2) divided by line 1c(3)) ........................................... 4a % b Enter code to indicate plan’s status (see instructions for attachment of supporting evidence of plan’s status). 4b If entered code is “N,” go to line 5 ................................................................................................................. c Is the plan making the scheduled progress under any applicable funding improvement or rehabilitation plan? ........................................................ X Yes X No d If the plan is in critical status or critical and declining status, were any benefits reduced (see instructions)? ............................................ X Yes X No e If line d is “Yes,” enter the reduction in liability resulting from the reduction in benefits (see instructions), 4e -123456789012345 measured as of the valuation date ................................................................................................................ f If the plan is in critical status or critical and declining status, and is: • Projected to emerge from critical status within 30 years, enter the plan year in which it is projected to emerge; • Projected to become insolvent within 30 years, enter the plan year in which insolvency is expected and 4f check here………………….…...…...…...…...…...…...…...…...…...…...…...…...…...…...…...…...…...….. X • Neither projected to emerge from critical status nor become insolvent within 30 years, enter “9999.” 5 Actuarial cost method used as the basis for this plan year’s funding standard account computations (check all that apply): a X Attained age normal b X Entry ageSAMPLEnormal c X Accrued benefit (unit credit) d X Aggregate e X Frozen initial liability f X Individual level premium g X Individual aggregate h X Shortfall i X Other (specify):_ ____________________________________________________________________________ j If box h is checked, enter period of use of shortfall method ............................................................................ 5j YYYY-MM-DD k Has a change been made in funding method for this plan year? .............................................................................................................. X Yes X No l If line k is “Yes,” was the change made pursuant to Revenue Procedure 2000-40 or other automatic approval? ...................................... X Yes X No m If line k is “Yes,” and line l is “No,” enter the date (MM-DD-YYYY) of the ruling letter (individual or class) 5m YYYY-MM-DD approving the change in funding method ....................................................................................................... |
Schedule MB (Form 5500) 2022 Page 3 - 1 x 6 Checklist of certain actuarial assumptions: a Interest rate for “RPA ‘94” current liability. ........................................................................................................................... 6a 123.12% Pre-retirement Post-retirement b Rates specified in insurance or annuity contracts .................................... X Yes X No X N/A X Yes X No X N/A c Mortality table code for valuation purposes: (1) Males ............................................................................... 6c(1) (2) Females ........................................................................... 6c(2) d Valuation liability interest rate ................................................. 6d 123.12% 123.12% e Salary scale ............................................................................ 6e 123.12% X N/A f Withdrawal liability interest rate: (1) Type of interest rate .......................................................... 6f(1) X Single rate X ERISA 4044 X Other X N/A (2) If “Single rate” is checked in (1), enter applicable single rate ......................................................... 6f(2) % g Estimated investment return on actuarial value of assets for year ending on the valuation date ........... 6g -123.1 % h Estimated investment return on current value of assets for year ending on the valuation date ............. 6h -123.1 % i Expense load included in normal cost reported in line 9b .................................................................... 6i X N/A (1) If expense load is described as a percentage of normal cost, enter the assumed percentage ........ 6i(1) % (2) If expense load is a dollar amount that varies from year to year, enter the dollar amount included 6i(2) in line 9b ........................................................................................................................................ (3) If neither (1) nor (2) describes the expense load, check the box .................................................... 6i(3) X 7 New amortization bases established in the current plan year: (1) Type of base (2) Initial balance (3) Amortization Charge/Credit A -123456789012345 -123456789012345 A -123456789012345 -123456789012345 A -123456789012345 -123456789012345 8 Miscellaneous information: a If a waiver of a funding deficiency has been approved for this plan year, enter the date (MM-DD- 8a YYYY) of the ruling letter granting the approval ................................................................................... YYYY-MM-DD b Demographic, benefit, and contribution information (1) Is the plan required to provide a projection of expected benefit payments? (See instructions) If “Yes,” see Yes X No instructions for required attachment. ..................................................................................................................... X (2) Is the plan required to provide a Schedule of Active Participant Data? (See instructions). .................................... X Yes X No (3) Is the plan required to provide a projection of employer contributions and withdrawal liability payments? (See Yes X No instructions) If “Yes,” attach a schedule. X c Are any of the plan’s amortization bases operating under an extension of time under section 412(e) (as in effect Yes X No prior to 2008) or section 431(d) of the Code? ............................................................................................................ X d If line c is “Yes,” provide the following additional information: (1) Was an extension granted automatic approval underSAMPLEsection 431(d)(1) of the Code? ................... X Yes X No (2) If line 8d(1) is “Yes,” enter the number of years by which the amortization period was extended .. 8d(2) 12 (3) Was an extension approved by the Internal Revenue Service under section 412(e) (as in effect Yes X No prior to 2008) or 431(d)(2) of the Code? ....................................................................................... X (4) If line 8d(3) is “Yes,” enter number of years by which the amortization period was extended (not 8d(4) including the number of years in line (2)) ...................................................................................... 12 (5) If line 8d(3) is “Yes,” enter the date of the ruling letter approving the extension ............................ 8d(5) YYYY-MM-DD (6) If line 8d(3) is “Yes,” is the amortization base eligible for amortization using interest rates applicable under Yes X No section 6621(b) of the Code for years beginning after 2007? .............................................................................. X e If box 5h is checked or line 8c is “Yes,” enter the difference between the minimum required contribution for the year and the minimum that would have been required without using the shortfall 8e method or extending the amortization base(s) ..................................................................................... -123456789012345 9 Funding standard account statement for this plan year: Charges to funding standard account: a Prior year funding deficiency, if any ..................................................................................................... 9a -123456789012345 b Employer’s normal cost for plan year as of valuation date .................................................................... 9b -123456789012345 |
Schedule MB (Form 5500) 2022 Page 4 c Amortization charges as of valuation date: Outstanding balance (1) All bases except funding waivers and certain bases for which the 9c(1) amortization period has been extended ................................................ -123456789012345 -123456789012345 (2) Funding waivers ................................................................................... 9c(2) -123456789012345 -123456789012345 (3) Certain bases for which the amortization period has been extended..... 9c(3) -123456789012345 -123456789012345 d Interest as applicable on lines 9a, 9b, and 9c ....................................................................................... 9d -123456789012345 e Total charges. Add lines 9a through 9d ................................................................................................ 9e -123456789012345 Credits to funding standard account : f Prior year credit balance, if any ............................................................................................................ 9f -123456789012345 g Employer contributions. Total from column (b) of line 3 ........................................................................ 9g -123456789012345 Outstanding balance h Amortization credits as of valuation date .................................................... 9h -123456789012345 -123456789012345 i Interest as applicable to end of plan year on lines 9f, 9g, and 9h ......................................................... 9i -123456789012345 j Full funding limitation (FFL) and credits: (1) ERISA FFL (accrued liability FFL) ...................................................... 9j(1) -123456789012345 (2) “RPA ‘94” override (90% current liability FFL) ................................... 9j(2) -123456789012345 (3) FFL credit .................................................................................................................................... 9j(3) -123456789012345 k (1) Waived funding deficiency ........................................................................................................... 9k(1) -123456789012345 (2) Other credits ................................................................................................................................ 9k(2) -123456789012345 l Total credits. Add lines 9f through 9i, 9j(3), 9k(1), and 9k(2) ................................................................ 9l -123456789012345 m Credit balance: If line 9l is greater than line 9e, enter the difference .................................................... 9m -123456789012345 n Funding deficiency: If line 9e is greater than line 9l, enter the difference .............................................. 9n -123456789012345 o Current year’s accumulated reconciliation account: (1) Due to waived funding deficiency accumulated prior to the 2022 plan year .................................. 9o(1) (2) Due to amortization bases extended and amortized using the interest rate under section 6621(b) of the Code: (a) Reconciliation outstanding balance as of valuation date ........................................................ 9o(2)(a) -123456789012345 (b) Reconciliation amount (line 9c(3) balance minus line 9o(2)(a)) .............................................. 9o(2)(b) -123456789012345 (3) Total as of valuation date ............................................................................................................. 9o(3) -123456789012345 10 Contribution necessary to avoid an accumulated funding deficiency. (see instructions.) .......................... 10 -123456789012345 11 Has a change been made in the actuarial assumptions for the current plan year? If “Yes,” see instructions ................ X Yes X No SAMPLE |