Form 5500 Schedule Retirement Plan Information

SCHEDULE R (Form 5500) Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation		Retirement Plan Information This schedule is required to be filed under sections 104 and 4065 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	Distributions

All references to distributions relate only to payments of benefits during the plan year.

1 Total value of distributions paid in property other than in cash or the forms of property specified in the instructions……………………………………………………………………………………………………………......

1

-123456789012345

2 Enter the EIN(s) of payor(s) who paid benefits on behalf of the plan to participants or beneficiaries during the year (if more than two, enter EINs of the two payors who paid the greatest dollar amounts of benefits):
EIN(s):
Profit-sharing plans, ESOPs, and stock bonus plans, skip line 3.
3 Number of participants (living or deceased) whose benefits were distributed in a single sum, during the plan year	3	12345678

Part II

Funding Information (If the plan is not subject to the minimum funding requirements of section 412 of the Internal Revenue Code or ERISA section 302, skip this Part.)

4 Is the plan administrator making an election under Code section 412(d)(2) or ERISA section 302(d)(2)?		X Yes	X No	X N/A
If the plan is a defined benefit plan, go to line 8.
5 If a waiver of the minimum funding standard for a prior year is being amortized in this plan year, see instructions and enter the date of the ruling letter granting the waiver.
	Date: Month _________ Day _________ Year _________

If you completed line 5, complete lines 3, 9, and 10 of Schedule MB and do not complete the remainder of this schedule.

6 a Enter the minimum required contribution for this plan year (include any prior year accumulated funding deficiency not waived)	6a	-123456789012345
b Enter the amount contributed by the employer to the plan for this plan year	6b	-123456789012345
c Subtract the amount in line 6b from the amount in line 6a. Enter the result (enter a minus sign to the left of a negative amount)	6c	-123456789012345

If you completed line 6c, skip lines 8 and 9.
7 Will the minimum funding amount reported on line 6c be met by the funding deadline?					X Yes	X No		X N/A
8 If a change in actuarial cost method was made for this plan year pursuant to a revenue procedure or other authority providing automatic approval for the change or a class ruling letter, does the plan sponsor or plan administrator agree with the change?
					X Yes	X No		X N/A
Part III	Amendments
9 If this is a defined benefit pension plan, were any amendments adopted during this plan year that increased or decreased the value of benefits? If yes, check the appropriate box. If no, check the “No” box.
		X Increase		X Decrease		X Both		X No
Part IV	ESOPs (see instructions). If this is not a plan described under section 409(a) or 4975(e)(7) of the Internal Revenue Code, skip this Part.
10 Were unallocated employer securities or proceeds from the sale of unallocated securities used to repay any exempt loan?							X Yes		X No
11 a Does the ESOP hold any preferred stock?							X Yes		X No
b If the ESOP has an outstanding exempt loan with the employer as lender, is such loan part of a “back-to-back” loan? (See instructions for definition of “back-to-back” loan.)							X Yes		X No
12 Does the ESOP hold any stock that is not readily tradable on an established securities market?							X Yes		X No
For Paperwork Reduction Act Notice, see the Instructions for Form 5500.			Schedule R (Form 5500) 2021 v. 201209

Part V	Additional Information for Multiemployer Defined Benefit Pension Plans
13 Enter the following information for each employer that contributed more than 5% of total contributions to the plan during the plan year (measured in dollars). See instructions. Complete as many entries as needed to report all applicable employers.
a Name of contributing employer
b EIN		c Dollar amount contributed by employer
d Date collective bargaining agreement expires (If employer contributes under more than one collective bargaining agreement, check box X and see instructions regarding required attachment. Otherwise, enter the applicable date.) Month _______ Day _______ Year _______
e Contribution rate information (If more than one rate applies, check this box X and see instructions regarding required attachment. Otherwise, complete lines 13e(1) and 13e(2).) (1) Contribution rate (in dollars and cents) _____________ (2) Base unit measure: X Hourly X Weekly X Unit of production X Other (specify):
a Name of contributing employer
b EIN		c Dollar amount contributed by employer
d Date collective bargaining agreement expires (If employer contributes under more than one collective bargaining agreement, check box X and see instructions regarding required attachment. Otherwise, enter the applicable date.) Month _______ Day _______ Year _______
e Contribution rate information (If more than one rate applies, check this box X and see instructions regarding required attachment. Otherwise, complete lines 13e(1) and 13e(2).) (1) Contribution rate (in dollars and cents) _____________ (2) Base unit measure: X Hourly X Weekly X Unit of production X Other (specify): _______________________________
a Name of contributing employer
b EIN		c Dollar amount contributed by employer
d Date collective bargaining agreement expires (If employer contributes under more than one collective bargaining agreement, check box X and see instructions regarding required attachment. Otherwise, enter the applicable date.) Month _______ Day _______ Year _______
e Contribution rate information (If more than one rate applies, check this box X and see instructions regarding required attachment. Otherwise, complete lines 13e(1) and 13e(2).) (1) Contribution rate (in dollars and cents) _____________ (2) Base unit measure: X Hourly X Weekly X Unit of production X Other (specify): _______________________________
a Name of contributing employer
b EIN		c Dollar amount contributed by employer
d Date collective bargaining agreement expires (If employer contributes under more than one collective bargaining agreement, check box X and see instructions regarding required attachment. Otherwise, enter the applicable date.) Month _______ Day _______ Year _______
e Contribution rate information (If more than one rate applies, check this box X and see instructions regarding required attachment. Otherwise, complete lines 13e(1) and 13e(2).) (1) Contribution rate (in dollars and cents) _____________ (2) Base unit measure: X Hourly X Weekly X Unit of production X Other (specify): _______________________________
a Name of contributing employer
b EIN		c Dollar amount contributed by employer
d Date collective bargaining agreement expires (If employer contributes under more than one collective bargaining agreement, check box X and see instructions regarding required attachment. Otherwise, enter the applicable date.) Month _______ Day _______ Year _______
e Contribution rate information (If more than one rate applies, check this box X and see instructions regarding required attachment. Otherwise, complete lines 13e(1) and 13e(2).) (1) Contribution rate (in dollars and cents) _____________ (2) Base unit measure: X Hourly X Weekly X Unit of production X Other (specify): _______________________________
a Name of contributing employer
b EIN		c Dollar amount contributed by employer
d Date collective bargaining agreement expires (If employer contributes under more than one collective bargaining agreement, check box X and see instructions regarding required attachment. Otherwise, enter the applicable date.) Month _______ Day _______ Year _______
e Contribution rate information (If more than one rate applies, check this box X and see instructions regarding required attachment. Otherwise, complete lines 13e(1) and 13e(2).) (1) Contribution rate (in dollars and cents) _____________ (2) Base unit measure: X Hourly X Weekly X Unit of production X Other (specify): _______________________________

14 Enter the number of deferred vested and retired participants (inactive participants), as of the beginning of the plan year, whose contributing employer is no longer making contributions to the plan for: a The current plan year. Check the box to indicate the counting method used to determine the number of inactive participants: X last contributing employer X alternative X reasonable approximation (see instructions for required attachment)				123456789012345
		14a
b The plan year immediately preceding the current plan year. X Check the box if the number reported is a change from what was previously reported (see instructions for required attachment)		14b		123456789012345
c The second preceding plan year. X Check the box if the number reported is a change from what was previously reported (see instructions for required attachment)		14c		123456789012345
15 Enter the ratio of the number of participants under the plan on whose behalf no employer had an obligation to make an employer contribution during the current plan year to:
a The corresponding number for the plan year immediately preceding the current plan year		15a		123456789012345
b The corresponding number for the second preceding plan year		15b		123456789012345
16 Information with respect to any employers who withdrew from the plan during the preceding plan year:
a Enter the number of employers who withdrew during the preceding plan year		16a		123456789012345
b If line 16a is greater than 0, enter the aggregate amount of withdrawal liability assessed or estimated to be assessed against such withdrawn employers		16b		123456789012345
17 If assets and liabilities from another plan have been transferred to or merged with this plan during the plan year, check box and see instructions regarding supplemental information to be included as an attachment. X
Part VI	Additional Information for Single-Employer and Multiemployer Defined Benefit Pension Plans
18 If any liabilities to participants or their beneficiaries under the plan as of the end of the plan year consist (in whole or in part) of liabilities to such participants and beneficiaries under two or more pension plans as of immediately before such plan year, check box and see instructions regarding supplemental information to be included as an attachment X
19 If the total number of participants is 1,000 or more, complete lines (a) through (c)
a Enter the percentage of plan assets held as: Stock: _____% Investment-Grade Debt: _____% High-Yield Debt: _____% Real Estate: _____% Other: _____%
b Provide the average duration of the combined investment-grade and high-yield debt: X 0-3 years X 3-6 years X 6-9 years X 9-12 years X 12-15 years X 15-18 years X 18-21 years X 21 years or more
c What duration measure was used to calculate line 19(b)? X Effective duration X Macaulay duration X Modified duration X Other (specify):

20 PBGC missed contribution reporting requirements. If this is a multiemployer plan or a single-employer plan that is not covered by PBGC, skip line 20.

a Is the amount of unpaid minimum required contributions for all years from Schedule SB (Form 5500) line 40 greater than zero? Yes No

b If line 20a is “Yes,” has PBGC been notified as required by ERISA sections 4043(c)(5) and/or 303(k)(4)? Check the applicable box:

Yes.

_ No. Reporting was waived under 29 CFR 4043.25(c)(2) because contributions equal to or exceeding the unpaid minimum required contribution were made by the 30th day after the due date.

_ No. The 30-day period referenced in 29 CFR 4043.25(c)(2) has not yet ended, and the sponsor intends to make a contribution equal to or exceeding the unpaid minimum required contribution by the 30th day after the due date.

_ No. Other. Provide explanation__________________________________________________________________________________________