Form 5500 Schedule Financial Information

SCHEDULE H (Form 5500) Department of the Treasury Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation		Financial Information This schedule is required to be filed under section 104 of the Employee Retirement Income Security Act of 1974 (ERISA), and section 6058(a) of the Internal Revenue Code (the Code).  File as an attachment to Form 5500.					OMB No. 1210-0110 2021 This Form is Open to Public Inspection
For calendar plan year 2021 or fiscal plan year beginning and ending
A Name of plan ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI					B Three-digit plan number (PN) 				001
C Plan sponsor’s name as shown on line 2a of Form 5500 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI					D Employer Identification Number (EIN) 012345678
Part I	Asset and Liability Statement
1 Current value of plan assets and liabilities at the beginning and end of the plan year. Combine the value of plan assets held in more than one trust. Report the value of the plan’s interest in a commingled fund containing the assets of more than one plan on a line-by-line basis unless the value is reportable on lines 1c(9) through 1c(14). Do not enter the value of that portion of an insurance contract which guarantees, during this plan year, to pay a specific dollar benefit at a future date. Round off amounts to the nearest dollar. MTIAs, CCTs, PSAs, and 103-12 IEs do not complete lines 1b(1), 1b(2), 1c(8), 1g, 1h, and 1i. CCTs, PSAs, and 103-12 IEs also do not complete lines 1d and 1e. See instructions.
Assets				(a) Beginning of Year				(b) End of Year
a Total noninterest-bearing cash			1a	-123456789012345				-123456789012345
b Receivables (less allowance for doubtful accounts):
(1) Employer contributions			1b(1)	-123456789012345				-123456789012345
(2) Participant contributions			1b(2)	-123456789012345				-123456789012345
(3) Other			1b(3)	-123456789012345				-123456789012345
c General investments:
(1) Interest-bearing cash (include money market accounts & certificates of deposit)			1c(1)	-123456789012345				-123456789012345
(2) U.S. Government securities			1c(2)	-123456789012345				-123456789012345
(3) Corporate debt instruments (other than employer securities):
(A) Preferred			1c(3)(A)	-123456789012345				-123456789012345
(B) All other			1c(3)(B)	-123456789012345				-123456789012345
(4) Corporate stocks (other than employer securities):
(A) Preferred			1c(4)(A)	-123456789012345				-123456789012345
(B) Common			1c(4)(B)	-123456789012345				-123456789012345
(5) Partnership/joint venture interests			1c(5)	-123456789012345				-123456789012345
(6) Real estate (other than employer real property)			1c(6)	-123456789012345				-123456789012345
(7) Loans (other than to participants)			1c(7)	-123456789012345				-123456789012345
(8) Participant loans			1c(8)	-123456789012345				-123456789012345
(9) Value of interest in common/collective trusts			1c(9)	-123456789012345				-123456789012345
(10) Value of interest in pooled separate accounts			1c(10)	-123456789012345				-123456789012345
(11) Value of interest in master trust investment accounts			1c(11)	-123456789012345				-123456789012345
(12) Value of interest in 103-12 investment entities			1c(12)	-123456789012345				-123456789012345
(13) Value of interest in registered investment companies (e.g., mutual funds)			1c(13)	-123456789012345				-123456789012345
(14) Value of funds held in insurance company general account (unallocated contracts)			1c(14)	-123456789012345				-123456789012345
(15) Other			1c(15)	-123456789012345				-123456789012345
For Paperwork Reduction Act Notice, see the Instructions for Form 5500.						Schedule H (Form 5500) 2021 v. 201209

1d Employer-related investments:			(a) Beginning of Year	(b) End of Year
(1) Employer securities		1d(1)	-123456789012345	-123456789012345
(2) Employer real property		1d(2)	-123456789012345	-123456789012345
1e Buildings and other property used in plan operation		1e	-123456789012345	-123456789012345
1f Total assets (add all amounts in lines 1a through 1e)		1f	-123456789012345	-123456789012345
Liabilities
1g Benefit claims payable		1g	-123456789012345	-123456789012345
1h Operating payables		1h	-123456789012345	-123456789012345
1i Acquisition indebtedness		1i	-123456789012345	-123456789012345
1j Other liabilities		1j	-123456789012345	-123456789012345
1k Total liabilities (add all amounts in lines 1g through1j)		1k	-123456789012345	-123456789012345
Net Assets
1l Net assets (subtract line 1k from line 1f)		1l	-123456789012345	-123456789012345
Part II	Income and Expense Statement
2 Plan income, expenses, and changes in net assets for the year. 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. MTIAs, CCTs, PSAs, and 103-12 IEs do not complete lines 2a, 2b(1)(E), 2e, 2f, and 2g.
Income			(a) Amount	(b) Total
a Contributions:
(1) Received or receivable in cash from: (A) Employers		2a(1)(A)	-123456789012345
(B) Participants		2a(1)(B)	-123456789012345
(C) Others (including rollovers)		2a(1)(C)	-123456789012345
(2) Noncash contributions		2a(2)	-123456789012345
(3) Total contributions. Add lines 2a(1)(A), (B), (C), and line 2a(2)		2a(3)		-123456789012345
b Earnings on investments:
(1) Interest:
(A) Interest-bearing cash (including money market accounts and certificates of deposit)		2b(1)(A)	-123456789012345
(B) U.S. Government securities		2b(1)(B)	-123456789012345
(C) Corporate debt instruments		2b(1)(C)	-123456789012345
(D) Loans (other than to participants)		2b(1)(D)	-123456789012345
(E) Participant loans		2b(1)(E)	-123456789012345
(F) Other		2b(1)(F)	-123456789012345
(G) Total interest. Add lines 2b(1)(A) through (F)		2b(1)(G)		-123456789012345
(2) Dividends: (A) Preferred stock		2b(2)(A)	-123456789012345
(B) Common stock		2b(2)(B)	-123456789012345
(C) Registered investment company shares (e.g. mutual funds)		2b(2)(C)
(D) Total dividends. Add lines 2b(2)(A), (B), and (C)		2b(2)(D)		-123456789012345
(3) Rents		2b(3)		-123456789012345
(4) Net gain (loss) on sale of assets: (A) Aggregate proceeds		2b(4)(A)	-123456789012345
(B) Aggregate carrying amount (see instructions)		2b(4)(B)	-123456789012345
(C) Subtract line 2b(4)(B) from line 2b(4)(A) and enter result		2b(4)(C)		-123456789012345
(5) Unrealized appreciation (depreciation) of assets: (A) Real estate		2b(5)(A)
(B) Other		2b(5)(B)
(C) Total unrealized appreciation of assets. Add lines 2b(5)(A) and (B)		2b(5)(C)

		(a) Amount	(b) Total
(6) Net investment gain (loss) from common/collective trusts	2b(6)		123456789012345
(7) Net investment gain (loss) from pooled separate accounts	2b(7)		-123456789012345-123456789012345
(8) Net investment gain (loss) from master trust investment accounts	2b(8)		-123456789012345-123456789012345
(9) Net investment gain (loss) from 103-12 investment entities	2b(9)		-123456789012345-123456789012345
(10) Net investment gain (loss) from registered investment companies (e.g., mutual funds)	2b(10)		-123456789012345-123456789012345
c Other income	2c		-123456789012345
d Total income. Add all income amounts in column (b) and enter total	2d
Expenses
e Benefit payment and payments to provide benefits:
(1) Directly to participants or beneficiaries, including direct rollovers	2e(1)	-123456789012345
(2) To insurance carriers for the provision of benefits	2e(2)	-123456789012345
(3) Other	2e(3)	-123456789012345
(4) Total benefit payments. Add lines 2e(1) through (3)	2e(4)
f Corrective distributions (see instructions)	2f
g Certain deemed distributions of participant loans (see instructions)	2g
h Interest expense	2h
i Administrative expenses: (1) Professional fees	2i(1)	-123456789012345
(2) Contract administrator fees	2i(2)	-123456789012345
(3) Investment advisory and management fees	2i(3)	-123456789012345
(4) Other	2i(4)	-123456789012345
(5) Total administrative expenses. Add lines 2i(1) through (4)	2i(5)		-123456789012345
j Total expenses. Add all expense amounts in column (b) and enter total	2j		-123456789012345
Net Income and Reconciliation
k Net income (loss). Subtract line 2j from line 2d	2k
l Transfers of assets:
(1) To this plan	2l(1)		-123456789012345
(2) From this plan	2l(2)		-123456789012345

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) X DOL Regulation 2520.103-8 (2) X DOL Regulation 2520.103-12(d) (3) X neither 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 because: (1) X This form is filed for a CCT, PSA, 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.
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

		Yes	No		Amount
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.)
	4i
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 X No 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)
				123456789		123
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				123456789		123
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFHI				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.) ………………………………………………………………………………………………………….. X Yes X No X Not determined If “Yes” is checked, enter the My PAA confirmation number from the PBGC premium filing for this plan year ____________________.