Model Summary Annual Report Relating to Welfare Plans 2-24-2023 ROCIS

Cover Page

Behind this cover page is the Summary Annual Report form for the disclosure requirement set forth in 29 CFR § 2520.104b-10(d). Except as otherwise provided in the regulation, the summary annual report furnished to participant and beneficiaries of an employee pension benefit plan must consist of a completed copy of the form.

Paperwork Reduction Act Statement

OMB Control Number 1210-0040; expires 07/31/2023

According to the Paperwork Reduction Act of 1995, no person is required to respond to a collection of information unless such collection displays a valid OMB control number.

The Summary Annual Report is a collection of information instrument subject to the Paperwork Reduction Act. Collection of this information is authorized by 29 USC § 1024(b)(3), 29 USC § 1029(c) and 29 CFR § 2520.104b-10. The obligation to respond to this collection is mandatory. The Department of Labor estimates that it will take less than one minute per notice (approximately 1 hours and 19 minutes per plan) to complete the form. Please send comments regarding the burden estimates or any other aspect of this collection of information, including suggestions for reducing burden to: US Department of Labor, Office of Research and Analysis, Attention: PRA Officer, 200 Constitution Avenue, NW, Room N-5718, Washington, DC 20210 or by email to ebsa.opr@dol.gov, and reference OMB Control Number 1210-0040. The disclosure requirements in 29 CFR § 2520.104b-10(d), referenced above, are also a collection of information under the PRA.

Note: Please do not return the completed Summary Annual Report to this address.

Do not include this Paperwork Reduction Act banner in notices to participants and beneficiaries.

Form for Summary Annual Report Relating to Welfare Plans.

Summary Annual Report for (name of plan)

This is a summary of the annual report of the (name of plan, EIN and type of welfare plan) for (period covered by this report). The annual report has been filed with the Employee Benefits Security Administration, as required under the Employee Retirement Income Security Act of 1974 (ERISA).

[If any benefits under the plan are provided on an uninsured basis:]

(Name of sponsor) has committed itself to pay (all, certain) (state type of) claims incurred under the terms of the plan.

[If any of the funds are used to purchase insurance contracts:]

Insurance Information

The plan has (a) contract(s) with (name of insurance carrier(s)) to pay (all, certain) (state type of) claims incurred under the terms of the plan. The total premiums paid for the plan year ending (date) were ($ ).

[If applicable add:]

Because (it is a) (they are) so called "experience-rated" contract(s), the premium costs are affected by, among other things, the number and size of claims. Of the total insurance premiums paid for the plan year ending (date), the premiums paid under such "experience-rated" contract(s) were ($ ) and the total of all benefit claims paid under the(se) experience-rated contract(s) during the plan year was ($ ).

[If any funds of the plan are held in trust or in a separately maintained fund:]

Basic Financial Statement

The value of plan assets, after subtracting liabilities of the plan, was ($ ) as of (the end of plan year), compared to ($ ) as of (the beginning of the plan year). During the plan year the plan experienced an (increase) (decrease) in its net assets of ($ ). This (increase) (decrease) includes unrealized appreciation and depreciation in the value of plan assets; that is, the difference between the value of the plan's assets at the end of the year and the value of the assets at the beginning of the year or the cost of assets acquired during the year. During the plan year, the plan had total income of ($ ) including employer contributions of ($ ), employee contributions of ($ ), realized (gains) (losses) of ($ ) from the sale of assets, and earnings from investments of ($ ). Plan expenses were ($ ). These expenses included ($ ) in administrative expenses, ($ ) in benefits paid to participants and beneficiaries, and ($ ) in other expenses.

Your Rights to Additional Information

You have the right to receive a copy of the full annual report, or any part thereof, on request. The items listed below are included in that report: [Note-list only those items which are actually included in the latest annual report].

1. an accountant's report;

2. financial information and information on payments to service providers;

3. assets held for investment;

4. fiduciary information, including non-exempt transactions between the plan and parties-in-interest (that is, persons who have certain relationships with the plan);

5. loans or other obligations in default or classified as uncollectible;

6. leases in default or classified as uncollectible;

7. transactions in excess of 5 percent of the plan assets;

8. insurance information including sales commissions paid by insurance carriers; and

9. information regarding any common or collective trusts, pooled separate accounts, master trusts or103-12 investment entities in which the plan participates.

To obtain a copy of the full annual report, or any part thereof, write or call the office of (name), who is (state title: e.g., the plan administrator), (business address and telephone number). The charge to cover copying costs will be ($ ) for the full annual report, or ($ ) per page for any part thereof.

You also have the right to receive from the plan administrator, on request and at no charge, a statement of the assets and liabilities of the plan and accompanying notes, or a statement of income and expenses of the plan and accompanying notes, or both. If you request a copy of the full annual report from the plan administrator, these two statements and accompanying notes will be included as part of that report. The charge to cover copying costs given above does not include a charge for the copying of these portions of the report because these portions are furnished without charge.

You also have the legally protected right to examine the annual report at the main office of the plan (address), (at any other location where the report is available for examination), and at the U.S. Department of Labor in Washington, D.C. or to obtain a copy from the U.S. Department of Labor upon payment of copying costs. Requests to the Department should be addressed to: Public Disclosure Room, Room N-1513, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210.