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Form 5500 Annual Return/Report of Employee Benefit Plan OMB Nos. 1210-0110
1210-0089
This form is required to be filed for employee benefit plans under sections 104
and 4065 of the Employee Retirement Income Security Act of 1974 (ERISA) and
Department of the Treasury
Internal Revenue Service sections 6057(b) and 6058(a) of the Internal Revenue Code (the Code).
2021
Department of Labor  Complete all entries in accordance with
Employee Benefits Security
Administration the instructions to the Form 5500.
Pension Benefit Guaranty Corporation This Form is Open to Public
Inspection
Part I Annual Report Identification Information
0BFor calendar plan year 2021 or fiscal plan year beginning and ending
1BA This return/report is for: Xa multiemployer plan Xa multiple-employer plan (Filers checking this box must attach a list of
participating employer information in accordance with the form instructions.)
Xa single-employer plan Xa DFE (specify) _C_
2BB This return/report is: Xthe first return/report Xthe final return/report
Xan amended return/report Xa short plan year return/report (less than 12 months)
C If the plan is a collectively-bargained plan, check here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  X
D Check box if filing under: XForm 5558 X automatic extension Xthe DFVC program
X special extension (enter description) ABCDEFGHI ABCDE
E If this is a retroactively adopted plan permitted by SECURE Act section 201, check here. . . . . . . . . . . . . . . . . . . . . . . . . ..  X
Part II Basic Plan Information —enter all requested information
1a Name of plan 1b Three-digit plan
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI number (PN)  001
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 1c Effective date of plan
YYYY-MM-DD
2a Plan sponsor’s name (employer, if for a single-employer plan) 2b Employer Identification
Mailing address (include room, apt., suite no. and street, or P.O. Box) Number (EIN)
City or town, state or province, country, and ZIP or foreign postal code (if foreign, see instructions) 012345678
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 2c Plan Sponsor’s telephone
D/B/A ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI number
ABCDEFGHI 0123456789
c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 2d Business code (see
123456789 ABCDEFGHI ABCDEFGHI ABCDE instructions)
123456789 ABCDEFGHI ABCDEFGHI ABCDE 012345
CITYEFGHI ABCDEFGHI AB, ST 012345678901
UK
Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established.
Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return/report, including accompanying schedules,
statements and attachments, as well as the electronic version of this return/report, and to the best of my knowledge and belief, it is true, correct, and complete.
SAMPLE

SIGN YYYY-MM-DD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
HERE
Signature of plan administrator Date Enter name of individual signing as plan administrator

SIGN YYYY-MM-DD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
HERE
Signature of employer/plan sponsor Date Enter name of individual signing as employer or plan sponsor

SIGN YYYY-MM-DD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
HERE
Signature of DFE Date Enter name of individual signing as DFE
For Paperwork Reduction Act Notice, see the Instructions for Form 5500. Form 5500 (2021)
v. 210624

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              Form 5500 (2021)                                                             Page 2                                                                                                                          
 3a      Plan administrator’s name and address    XSame as Plan Sponsor                                                                                                                     3b  Administrator’s EIN 
                                                                                                                                                                                                012345678 
 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI                                                                                                                      3c  Administrator’s telephone 
 c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI                                                                                                                      number 
 123456789 ABCDEFGHI ABCDEFGHI ABCDE                                                                                                                                                            0123456789 
 123456789 ABCDEFGHI ABCDEFGHI ABCDE                                                                                                                                                         
 CITYEFGHI ABCDEFGHI AB, ST 012345678901 
 UK  
 4       If the name and/or EIN of the plan sponsor or the plan name has changed since the last return/report filed for this plan,                                                          4b  EIN012345678 
         enter the plan sponsor’s name, EIN, the plan name and the plan number from the last return/report: 
  a      Sponsor’s name                                                                                                                                                                     4d  PN 
  c      Plan Name                                                                                                                                                                              012 
   
 5       Total number of participants at the beginning of the plan year                                                                                                                      5         123456789012 
 6       Number of participants as of the end of the plan year unless otherwise stated (welfare plans complete only lines 6a(1),    
         6a(2), 6b, 6c, and 6d).                                                                                                                                                                        
   
  a(1)  Total number of active participants at the beginning of the plan year  ..............................................................................   6a(1)                                                       
     
  a(2)  Total number of active participants at the end of  the plan year  ......................................................................................   6a(2)                                                    
    
  b      Retired or separated participants receiving benefits .............................................................................................................                  6b        123456789012 
   
  c      Other retired or separated participants entitled to future benefits .........................................................................................                       6c        123456789012 
    
  d      Subtotal. Add lines6a(2),6b, and6c. ..................................................................................................................................              6d        123456789012 
    
  e      Deceased participants whose beneficiaries are receiving or are entitled to receive benefits. ...............................................                                        6e        123456789012 
    
  f      Total.  Add lines 6d and 6e. .................................................................................................................................................      6f        123456789012 
    
  g      Number of participants with account balances as of the end of the plan year (only defined contribution plans  
          complete this item) ............................................................................................................................................................   6g        123456789012 
    
  h      Number of participants who terminated employment during the plan year with accrued benefits that were  
        less than 100% vested ........................................................................................................................................................       6h        123456789012 
 7       Enter the total number of employers obligated to contribute to the plan (only multiemployer plans complete this item) ........                                                      7   
 8a      If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristics Codes in the instructions: 
     
  b      If the plan provides welfare benefits, enter the applicable welfare feature codes from the List of Plan Characteristics Codes in the instructions:  
           
 9a      Plan funding arrangement (check all that apply)                            9b Plan benefit arrangement (check all that apply) 
         (1)  X        Insurance                         SAMPLE(1)                          X      Insurance 
         (2)  X        Code section 412(e)(3) insurance contracts                      (2)  X      Code section 412(e)(3) insurance contracts 
         (3)  X        Trust                                                           (3)  X      Trust  
         (4)  X        General assets of the sponsor                                   (4)  X      General assets of the sponsor 
 10      Check all applicable boxes in 10a and 10b to indicate which schedules are attached, and, where indicated, enter the number attached.  (See instructions) 
   a  Pension Schedules                                                             b  General Schedules 
         (1)  X       R  (Retirement Plan Information)                                 (1)  X               H  (Financial Information) 
                                                                                       (2)  X               I   (Financial Information – Small Plan) 
         (2)  X        MB  (Multiemployer Defined Benefit Plan and Certain Money 
                       Purchase Plan Actuarial Information) - signed by the plan       (3)  X       ___     A  (Insurance Information) 
                       actuary                                                         (4)  X               C  (Service Provider Information) 
         (3)  X        SB  (Single-Employer Defined Benefit Plan Actuarial             (5)  X               D  (DFE/Participating Plan Information) 
                       Information) - signed by the plan actuary                       (6)  X               G  (Financial Transaction Schedules)

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         Form 5500 (2021)                                                            Page 3                                                                    

Part III   Form M-1 Compliance Information (to be completed by welfare benefit plans) 
11a If the plan provides welfare benefits, was the plan subject to the Form M-1 filing requirements during the plan year? (See instructions and 29 CFR 
   2520.101-2.) ........................………..….      X Yes           XNo 
 
         If “Yes” is checked, complete lines 11b and 11c. 
 
11b Is the plan currently in compliance with the Form M-1 filing requirements? (See instructions and 29 CFR 2520.101-2.) …….....   XYes       XNo  
11c Enter the Receipt Confirmation Code for the 2021 Form M-1 annual report.  If the plan was not required to file the 2021 Form M-1 annual report, enter the 
   Receipt Confirmation Code for the most recent Form M-1 that was required to be filed under the Form M-1 filing requirements. (Failure to enter a valid 
   Receipt Confirmation Code will subject the Form 5500 filing to rejection as incomplete.)   
 
         Receipt Confirmation Code______________________                             
                                            
                                                          SAMPLE

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