Form 5500 Schedule Individual Plan Information

Schedule DCG Department of Labor Department of the Treasury Internal Revenue Service	Individual Plan Information This schedule is required to be filed under Section 103 of the Employee Retirement Income Security Act (ERISA) and Section 6058(a) of the Internal Revenue Code (Code) ▶ File as an attachment to Form 5500	OMB Nos. 1210XXXX 1210-XXXX 1210-0089
		2022
		This Form is Open to Public Inspection.

Part I DCG Information

A Name of DCG	B Three-digit plan number for DCG (PN) 
	C EIN for DCG

Part II Individual Plan Identification Information Complete a separate Schedule DCG for each individual plan whose reporting obligations are intended to be satisfied by the DCG’s Form 5500 filing

This Schedule is for X a single-employer plan X a collectively-bargained plan

Part III Basic Individual Plan Information
1a Name of plan ABCDEFGHI CDEFGHI ABCDEFGHI		1b Three-digit plan number (PN) 
		1c Effective date of plan YYYY-MM-DD
2a Plan sponsor’s name (employer, if for a single-employer plan) Mailing address (include room, apt., suite no. and street, or P.O. Box) City or town, state or province, country, and ZIP or foreign postal code (if foreign, see instructions)		2b Employer Identification Number (EIN) 2c Plan sponsor’s telephone number 2d Business code 12345678
3 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, enter the plan sponsor’s name, EIN, the plan name and the plan number from the last return/report:
3a Sponsor’s name 3c Plan Name		3b EIN012345678 3d PN
4a Total number of participants at the beginning of the plan year………………………………………… b Total number of participants as of the end of the plan year …………………………………………. c(1) Total number of active participants at the beginning of the plan year		4a
		4b
		4c(1)
c(2) Total number of active participants at the end of the plan year		4c(2)
d Number of participants with account balances as of the beginning of the plan year		4d
e Number of participants with account balances as of the end of the plan year……………………………. f Number of participants who terminated employment during the plan year with accrued benefits that were less than 100% vested		4e
		4f

Part IV Financial Information

		(a) Beginning of Year	(b) End of Year
5a Total plan assets	5a	-123456789012345	-123456789012345
(1) Participant loans	5a(1)	-123456789012345	-123456789012345
b Total plan liabilities ………………………………………………………………..	5b
c Net assets (subtract line 5b from line 5a) ……………………………………..	5c

6a

Contributions received or receivable in cash from

Amount

(1)

Employers. . . . . . . . . . .

6a(1)

(2)

Participants . . . . . . . . . .

.

.

.

.

6a(2)

(3)

Others (including rollovers) …………………

.

.

.

.

6a(3)

b.

Noncash contributions . . . . . . . . . .

6b

c.

Total contributions (add lines 6a(1)-(3) and line 6(b)) …….

6c

6d Benefit payment and payments to provide benefits:

6d(1)

e Corrective distributions (see instructions)

6e

f Certain deemed distributions of participant loans (see instructions)

6f

g Administrative service provider’s expense (salaries, fees, commissions)………………..

6g

h Other expenses………………………………………………………………………………

6h

i Net income (loss).

6i

j Transfers of assets

6j(1)

(1) To this plan

(2) From this plan

6j(2)

Part V Plan Characteristics

7 Enter the applicable two-character feature codes from the List of Plan Characteristics Codes in the instructions.

Part VI Compliance Questions
			Yes			No	Amount
	8a 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.) b Were there any nonexempt transactions with any party-in-interest?............................................ c Has the plan failed to provide any benefit when due under the plan? ……………………………..
		8a 8b 8c

9a 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.)
9b(1) Name of plan(s)	9b(2) EIN(s)	9b(3) PN(s)
	123456789	123
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFHI	123456789	123

10 Is this a defined contribution plan subject to the minimum funding requirements of section 412 of the Code? Yes No

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11a Does the plan satisfy the coverage and nondiscrimination tests of Code sections 410(b) and 401(a)(4) by combining this plan with any other plans under the permissive aggregation rules? [] Yes [] No

11b If this is a Code section 401(k) plan, check the correct box to indicate how the plan is intended to satisfy the nondiscrimination requirements for employee deferrals and employer matching contributions (as applicable) under Code sections 401(k)(3) and 401(m)(2)?

Design-based safe harbor method “Prior year” ADP test “Current year” ADP test N/A

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12 If the plan sponsor is an adopter of a pre-approved plan that received a favorable IRS Opinion Letter, enter the date of the Opinion Letter __/___/_____ (MMDD YYYYY) and the Opinion Letter serial number__________.

Part VII Accountant Opinion Information for Large Participating Plans

________________________________________________________________________________________________

13 Complete lines 13a through 13c if the report of an independent qualified public accountant is attached to this Schedule DCG.

a The opinion reflected in the attached report of an independent qualified public accountant for this plan is (see instructions):

1. X Unmodified (2) X Qualified (3) X Disclaimer (4) Adverse

b Check the appropriate box(es) to indicate whether the IQPA performed an ERISA section 103(a)(3)(C) audit. Check 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) DOL Regulation 2520.103-12(d) (3) 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: (2) EIN:

___________________________________________________________________________________

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Author	Poppe-Yanez, Gunnar - EBSA
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File Created	2022-05-21