Annual Return/Report of Employee Benefit Plan

D epartment of the Treasury Department of Labor Pension Benefit Guaranty Corporation

Internal Revenue Service Employee Benefits

Security Administration

2023

Instructions for Form 5500-SF

Short Form Annual Return/Report of Small Employee Benefit Plan

Code section references are to the Internal Revenue Code unless otherwise noted. ERISA refers to the Employee Retirement Income Security Act of 1974.

_{Changes to Note}

Defined Contribution Group (DCG) Reporting Arrangements Must Use Form 5500. Section 202 of the SECURE Act (Pub. L. 116-94, Division O) directed the IRS and DOL to modify the Form 5500 to allow certain groups of defined contribution retirement plans to file a single consolidated annual return/report. For 2023, Form 5500 and the filing instructions have been revised to add a new filing option – Defined Contribution Group Reporting Arrangements (DCG or DCG reporting arrangement). All DCGs and individual plans within a DCG reporting arrangement must report using a consolidated Form 5500, in accordance with that form’s filing instructions, and are precluded from using Form 5500-SF for DCG reporting regardless of DCG size or the size of plans within the DCG reporting arrangement. See Who May File Form 5500-SF for full details.

Small Plan Audits Participant Counting Methodology Revisions. Both Form 5500 and 5500-SF and their instructions are revised to reflect a change in the reporting methodology related to the number of participants used in the current threshold (i.e., less than 100 participants) for determining when a defined contribution pension plan may file as a small plan. This change in methodology also includes eligibility for the waiver of the requirement for small plans to have an audit and include the report of an independent qualified public accountant (IQPA) with their annual report. For 2023, generally, a defined contribution pension plan counts participants with account balances at the beginning of the year, except for new plans that measure based on end of year participants with account balances.

Schedule MEP for Multiple-Employer Plans. A new Schedule MEP (Multiple-Employer Pension Plan Information) is added for use with both Form 5500 and Form 5500-SF. Schedule MEP generally consolidates SECURE Act related reporting for a MEP filer in one easily identifiable schedule, including the ERISA section 103(g) participating employer information and aggregate account information. For Form 5500-SF filers, a new checkbox is added to Part I, line A to indicate that a Schedule MEP is attached. Schedule MEP requires information consistent with that which was required to be reported via attachment for the 2021 and 2022 forms , including identifying different types of multiple-employer defined contribution plans filing the Form 5500-SF (association retirement plans, PEO multiple-employer plans, and other multiple-employer plans). Pooled employer plans may not file Form 5500-SF. Instead, all pooled employer plans, regardless of size, must file Form 5500 and include Schedule MEP in that filing.

Collectively-bargained plans. Part I is revised to renumber Line “D” as Line “E” and to add a new Line D collectively-bargained plan box to improve identification of plans, and/or the benefits paid by plans, that are subject to the collective bargaining process.

Plan characteristics. Part IV, line 9a, plan characteristics code 3D is updated to include pre-approved 403(b) plans among the listed plans covered by that code.

Compliance Questions. Part V, question 10a is updated to remind filers to continue to check the box “yes” if there is a failure to transmit participant contributions for any prior year failures until fully corrected.

IRS Compliance Questions. A new Part VIII is added, regarding whether the plan uses the permissive aggregation rules to satisfy coverage and nondiscrimination tests, how the 401(k) plan intends to satisfy the nondiscrimination requirement, and whether the plan sponsor is an adopter of a pre-approved plan.

Administrative Penalties. The instructions have been updated to reflect an increase in the maximum civil penalty amount assessable under Employee Retirement Income Security Act section 502(c)(2), as required by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015.

Table of Contents Page

EFAST2 Processing System 2

How To Get Assistance 2

General Instructions 2

Pension and Welfare Plans Required To File
Annual Return/Report 3

Plans Exempt from Filing 3

Who May File 4

What To File 4

When To File 5

Extension of Time To File 5

Delinquent Filer Voluntary Compliance (DFVC)
Program 5

Change in Plan Year 5

Penalties 6

How To File – Electronic Filing Requirement 6

Signature and Date 7

Specific Line-by-Line Instructions 8

Part I – Annual Report Identification
Information 8

Part II – Basic Plan Information 9

Part III – Financial Information 13

Part IV – Plan Characteristics 14

Part V – Compliance Questions 15

Part VI – Pension Funding Compliance 18

Part VII – Plan Terminations and Transfers of Assets 19

Paperwork Reduction Act Notice 21

List of Plan Characteristics Codes 22

Codes for Principal Business Activity 24

ERISA Compliance Quick Checklist 27

Index 28

EFAST2 Processing System

Under the computerized ERISA Filing Acceptance System (EFAST2), you must electronically file your 2023 Form 5500-SF, Short Form Annual Return/Report of Small Employee Benefit Plan. You may file your 2023 Form 5500-SF online using EFAST2’s web-based filing system or you may file through an EFAST2-approved vendor. You cannot file a paper Form 5500-SF by mail or other delivery service. For more information, see the instructions for How To File – Electronic Filing Requirement on page 6 and the EFAST2 website at www.efast.dol.gov.

How To Get Assistance

If you need help completing this form, or have other questions, call the EFAST2 Help Desk at

1-866-GO-EFAST (1-866-463-3278) (toll free) or access the EFAST2 or IRS websites. The EFAST2 Help Desk is available Monday through Friday from 8:00 am to 8:00 pm, Eastern Time.

You can access the EFAST2 website 24 hours a day, 7 days a week at www.efast.dol.gov to:

• File the Form 5500-SF or 5500 and any needed schedules or attachments.

• Check on the status of a filing you submitted.

• View filings posted by EFAST2.

• Register for electronic credentials to sign or submit filings.

• View forms and related instructions.

• Get information regarding EFAST2, including approved software vendors.

• See answers to frequently asked questions about the Form 5500-SF, the Form 5500 and its schedules, and EFAST2.

• Access the main Employee Benefits Security Administration (EBSA) and DOL websites for news, regulations, and publications.

You can access the IRS website 24 hours a day, 7 days a week at www.irs.gov to:

• View forms, instructions, and publications.

• See answers to frequently asked tax questions.

• Search publications online by topic or keyword.

• Send comments or request help by e-mail.

• Sign up to receive local and national tax news by e-mail.

You can order other IRS forms and publications at www.irs.gov/orderforms. You can order EBSA publications by calling 1-866-444-EBSA (3272).

General Instructions

The Form 5500-SF, Short Form Annual Return/Report of Small Employee Benefit Plan, is a simplified annual reporting form for use by certain small pension and welfare benefit plans. To be eligible to use the Form

5500-SF, the plan must:

• Be a small plan (i.e., generally have fewer than 100 participants at the beginning of the plan year),

• Meet the conditions for being exempt from the requirement that the plan’s books and records be audited by an independent qualified public accountant (IQPA),

• Have 100% of its assets invested in certain secure investments with a readily determinable fair value,

• Hold no employer securities,

• Not be a multiemployer plan,

• Not be required to file a Form M-1, Report for Multiple-Employer Welfare Arrangements (MEWAs) and Certain Entities Claiming Exception (ECEs) for the plan year,

• Not be a pooled employer plan (see ERISA section 3(43)), and

• Not be filing as, or part of a defined contribution group reporting arrangement (DCG) (see instructions to the Form 5500).

Plans required to file an annual return/report that are not eligible to file the Form 5500-SF must file a Form 5500, Annual Return/Report of Employee Benefit Plan, with all required schedules and attachments (Form 5500), or Form 5500-EZ, Annual Return of A One-Participant (Owners/Partners and Their Spouses) Retirement Plan or A Foreign Plan.

To reduce the possibility of correspondence and penalties, we remind filers that the Internal Revenue Service (IRS), Department of Labor (DOL), and Pension Benefit Guaranty Corporation (PBGC) have consolidated their annual return/report forms to minimize the filing burden for employee benefit plans. Administrators and sponsors of employee benefit plans generally will satisfy their IRS and DOL annual reporting requirements for the plan under ERISA sections 104 and 4065 and Code sections 6058 and 6059 by filing either the Form 5500, Form 5500-SF, or Form 5500-EZ. Defined contribution and defined benefit pension plans may have to file additional information with the IRS including: Form 8955-SSA, Annual Registration Statement Identifying Separated Participants with Deferred Vested Benefits; Form 5330, Return of Excise Taxes Related to Employee Benefit Plans; Form 5310-A, Notice of Plan Merger or Consolidation, Spinoff, or Transfer of Plan Assets or Liabilities; Notice of Qualified Separate Lines of Business. See www.irs.gov for more information. Defined benefit pension plans covered by the PBGC have special additional requirements, including filing premiums and reporting certain transactions directly with that agency. See the PBGC’s website at www.pbgc.gov/practitioners for information on premium filings and reporting and disclosure requirements.

Note. The Form 5500-EZ generally is used by “one-participant plans” or certain foreign plans that are not subject to the requirements of section 104(a) of ERISA to satisfy certain annual reporting and filing obligations imposed by the Code. A “one-participant plan” or certain foreign plans can file a Form 5500-EZ electronically with EFAST2 rather than filing a Form 5500-EZ on paper with the IRS. However, “one-participant plans” or certain foreign plans must file Form 5500-EZ electronically if the filer is required to file at least 250 returns of any type with the IRS during the calendar year, including information returns (for example, Forms W-2 and Forms 1099), income tax returns, employment tax returns, and excise tax returns. For more information on filing Form 5500-EZ, see the Instructions for Form 5500-EZ or go to www.irs.gov.

The Form 5500-SF must be filed electronically. See How To File – Electronic Filing Requirement instructions on page 6 and the EFAST2 website at www.efast.dol.gov. Your

Form 5500-SF entries will be initially screened electronically. Your entries must satisfy this screening for your filing to be received. Once received, your form may be subject to further detailed review, and your filing may be rejected based upon this further review.

ERISA and the Code provide for the assessment or imposition of penalties for not submitting the required information when due. See Penalties on page 6.

Annual returns/reports filed under Title I of ERISA must be made available by plan administrators to plan participants and beneficiaries and by the DOL to the public pursuant to ERISA sections 104 and 106. Pursuant to Section 504 of the Pension Protection Act of 2006 (PPA), this availability for defined benefit pension plans must include the posting of identification and basic plan information and actuarial information (Form 5500-SF, Schedule SB or MB, and all of the Schedule SB or MB attachments) on any plan sponsor intranet website (or website maintained by the plan administrator on behalf of the plan sponsor) that is used for the purpose of communicating with employees and not the public. Section 504 also requires DOL to display such information on DOL’s website within 90 days after the filing of the plan’s annual return/report. To see 2009 and later Forms 5500-SF, including actuarial information, see www.dol.gov/agencies/ebsa.See https://www.dol.gov/agencies/ebsa/workers-and-families/preparing-for-retirement/pension-plan-actuarial-information-search-instructions for 2008 and short plan year 2009 actuarial information filed under the previous paper-based system.

Pension and Welfare Plans Required To File Annual Return/Report

All pension benefit plans and welfare benefit plans covered by ERISA must file a Form 5500 or Form 5500-SF for a plan year unless they are eligible for a filing exemption. (See Code sections 6058 and 6059 and ERISA sections 104 and 4065). An annual return/report must be filed even if the plan is not “tax qualified,” benefits no longer accrue, contributions were not made during this plan year, or contributions are no longer made. Pension benefit plans required to file include both defined benefit plans and defined contribution plans. Profit-sharing plans, stock bonus plans, money purchase plans, 401(k) plans, Code section 403(b) plans covered by Title I of ERISA, and IRA plans established by an employer are among the pension benefit plans for which an annual return/report must be filed. Welfare benefit plans provide benefits such as medical, dental, life insurance, apprenticeship and training, scholarship funds, severance pay, disability, etc. Plans that cover residents of Puerto Rico, the U.S. Virgin Islands, Guam, Wake Island, or American Samoa also must file unless they are eligible for a filing exemption. This includes a plan that elects to have the provisions of section 1022(i)(2) of ERISA apply.

For more information about annual return/report filings for Code section 403(b) plans covered by Title I of ERISA, see Field Assistance Bulletins 2009-02 and 2010-01, available on the DOL website at www.dol.gov.

Plans Exempt From Filing

Under regulations and applicable guidance, some pension benefit plans and many welfare benefit plans with fewer than 100 participants are exempt from filing an annual return/report. Do not file a Form 5500-SF for an employee benefit plan that is any of the following:

1. An unfunded excess benefit plan. See ERISA section 4(b)(5).

2. A pension benefit plan maintained outside the United States primarily for the benefit of persons substantially all of whom are nonresident aliens. However, certain foreign plans are required to file the Form 5500-EZ with the IRS. See the instructions to the Form 5500-EZ for the filing requirements. For more information, go to www.irs.gov/ep or call 1-877-829-5500.

3. An annuity or custodial account arrangement under Code section 403(b)(1) or (7) not established or maintained by an employer as described in 29 CFR 2510.3-2(f).

4. A simplified employee pension (SEP) described in Code section 408(k) that conforms to the alternative

method of compliance described in 29 CFR 2520.104-48 or 29 CFR 104-49. A SEP is a pension plan that meets certain minimum qualifications regarding eligibility and employer contributions.

5. A Savings Incentive Match Plan for Employees of Small Employers (SIMPLE) that involves SIMPLE IRAs under Code section 408(p).

6. A church pension benefit plan not electing coverage under Code section 410(d).

7. An unfunded dues financed pension benefit plan that meets the alternative method of compliance provided by 29 CFR 2520.104-27.

8. An individual retirement account or annuity not considered a pension plan under 29 CFR 2510.3-2(d).

9. A “one-participant plan.” However, certain one-participant plans are required to file the Form 5500-EZ, Annual Return of A One-Participant (Owners/Partners and Their Spouses) Retirement Plan or A Foreign Plan, on paper with the IRS or electronically with EFAST2.

10. A governmental plan.

11. An unfunded pension benefit plan or an unfunded or insured welfare benefit plan: (a) maintained for a select group of management or highly compensated employees, and (b) which meets the terms of 29 CFR 2520.104-23 (including the requirement that a registration statement be timely filed with DOL) or 29 CFR 2520.104-24.

12. A welfare benefit plan that covers fewer than 100 participants as of the beginning of the plan year and is unfunded, fully insured, or a combination of insured and unfunded. For this purpose:

a. An unfunded welfare benefit plan has its benefits paid as needed directly from the general assets of the employer or the employee organization that sponsors the plan.

Note. Plans that are NOT unfunded include those plans that received employee (or former employee) contributions during the plan year and/or used a trust or separately maintained fund (including a Code section 501(c)(9) trust) to hold plan assets or act as a conduit for the transfer of plan assets during the plan year. A welfare benefit plan with employee contributions that is associated with a cafeteria plan under Code section 125 may be treated for annual reporting purposes as an unfunded welfare benefit plan if it meets the requirements of DOL Technical Release 92-01, 57 Fed. Reg. 23272 (June 2, 1992) and 58 Fed. Reg. 45359 (Aug. 27, 1993). The mere receipt of COBRA contributions or other after-tax participant contributions (e.g., retiree contributions) by a cafeteria plan would not by itself affect the availability of the relief provided for cafeteria plans that otherwise meet the requirements of DOL Technical Release 92-01. See 61 Fed. Reg. 41220, 41222-23 (Aug. 7, 1996).

b. A fully insured welfare benefit plan has its benefits provided exclusively through insurance contracts or policies, the premiums of which must be paid directly to the insurance carrier by the employer or employee organization from its general assets or partly from its general assets and partly from contributions by its employees or members (which the employer or employee organization forwards within 3 months of receipt). The insurance contracts or policies discussed above must be issued by an insurance company or similar organization (such as Blue Cross, Blue Shield or a health maintenance organization) that is qualified to do business in any state.

c. A combination unfunded/insured welfare benefit plan has its benefits provided partially as an unfunded plan and partially as a fully insured plan. An example of such a plan is a welfare benefit plan that provides medical benefits as in “a” above and life insurance benefits as in “b” above. See 29 CFR 2520.104-20.

Note. A voluntary employees’ beneficiary association, as used in Code section 501(c)(9) (VEBA), should not be confused with the employer or employee organization that sponsors the plan. See ERISA section 3(4).

13. Plans maintained only to comply with workers’ compensation, unemployment compensation, or disability insurance laws.

14. A welfare benefit plan maintained outside the United States primarily for persons substantially all of whom are nonresident aliens.

15. A church welfare benefit plan under ERISA section 3(33).

16. An unfunded dues financed welfare benefit plan that meets the alternative method of compliance provided by 29 CFR 2520.104-26.

17. A welfare benefit plan that participates in a group insurance arrangement that files a return/report on its behalf under 29 CFR 2520.104-43. A group insurance arrangement generally is an arrangement that provides benefits to the employees of two or more unaffiliated employers (not in connection with a multiemployer plan or a collectively-bargained multiple-employer plan), fully insures one or more welfare benefit plans of each participating employer, uses a trust (or other entity such as a trade association) as the holder of the insurance contracts, and uses a trust as the conduit for payment of premiums to the insurance company.

18. An apprenticeship or training plan meeting all of the conditions specified in 29 CFR 2520.104-22.

For more information on plans that are exempt from filing an annual return/report, call the EFAST2 Help Desk at 1-866-GO-EFAST (1-866-463-3278). For one-participant plan filers, see the Instructions for Form 5500-EZ or call the IRS Help Desk at 1-877-829-5500.

Who May File Form 5500-SF

If your plan is required to file an annual return/report, you may file the Form 5500-SF instead of the Form 5500 only if you meet all of the eligibility conditions listed below.

1. The plan (a) covered fewer than 100 participants at the beginning of the plan year 2023, or (b) under 29 CFR 2520.103-1(d) was eligible to and filed as a small plan for plan year 2022 and did not cover more than 120 participants at the beginning of plan year 2023 (see instructions for line 5 on counting the number of participants). To determine the number of participants covered by defined benefit pension plans and welfare plans, use the number described on Form 5500-SF, line 5a. Defined contribution pension plans use the number described on the Form 5500-SF, line 5c(1), except use the number described on line 5c(2) for defined contribution pension plans that check the “first return/report" box on Part I, line B;

2. The plan did not hold any employer securities at any time during the plan year;

3. At all times during the plan year, the plan was 100% invested in certain secure, easy to value assets that meet the definition of “eligible plan assets” (see the instructions for line 6a), such as mutual fund shares, investment contracts with insurance companies and banks valued at least annually, publicly traded securities held by a registered broker-dealer, cash and cash equivalents, and plan loans to participants;

4. The plan is eligible for the waiver of the annual examination and report of an independent qualified public accountant (IQPA) under 29 CFR 2520.104-46 (but not by reason of enhanced bonding), which requirement includes, among others, giving certain disclosures and supporting documents to participants and beneficiaries regarding the plan’s investments (see instructions for line 6b);

5. The plan is not a multiemployer plan;

6. The plan is not required to file a Form M-1, Report for Multiple-Employer Welfare Arrangements (MEWAs) and Certain Entities Claiming Exception (ECEs) during the plan year;

7. The plan is not a pooled employer plan (see ERISA section 3(43)); and

8. The plan is not filing as, or part of, a DCG reporting arrangement. (see instructions to Form 5500).

Note. Employee Stock Ownership Plans (ESOPs) and Direct Filing Entities (DFEs) (including DCGs) may not file the Form 5500-SF.

What To File

Plans required to file an annual return/report that meet all of the conditions for filing the Form 5500-SF may complete and file the Form 5500-SF in accordance with its instructions. Single-employer defined benefit pension plans using the Form 5500-SF must also file the Schedule SB (Form 5500), Single-Employer Defined Benefit Plan Actuarial Information, and its required attachments. Money purchase plans amortizing a funding waiver using the Form 5500-SF must also file the Schedule MB (Form 5500), Multiemployer Defined Benefit Plan and Certain Money Purchase Plan Actuarial Information, and its required attachments. Multiple-employer pension plans using the Form 5500-SF must also file the Schedule MEP (Form 5500), Multiple-Employer Retirement Plan Information. For information about Schedule SB, Schedule MB, and Schedule MEP, see the 2023 Instructions for Form 5500, Annual Return/Report of Employee Benefit Plan.

Eligible Combined Plans. The Pension Protection Act of 2006 (PPA) established rules for a new type of pension plan, an “eligible combined plan,” effective for plan years beginning after December 31, 2009. See Code section 414(x) and ERISA section 210(e). An eligible combined plan consists of a defined benefit plan and a defined contribution plan that includes a qualified cash or deferred arrangement under Code section 401(k), with the assets of the two plans held in a single trust, but clearly identified and allocated between the plans. The eligible combined plan design is available only to employers that employed an average of at least two, but not more than 500 employees, on business days during the calendar year preceding the plan year as of which the eligible combined plan is established and that employs at least two employees on the first day of the plan year that the plan is established. Because an eligible combined plan includes both a defined benefit plan and a defined contribution plan, the Form 5500-SF filed for the plan must include all the information, schedules, and attachments that would be required for either a defined benefit plan (such as a Schedule SB) or a defined contribution plan.

When To File

File the 2023 Form 5500-SF for plan years that began in 2023. The form, and any required schedules and attachments, must be filed by the last day of the 7th calendar month after the end of the plan year (not to exceed 12 months in length) that began in 2023.

Short Years. For a plan year of less than 12 months (short plan year), file the form and applicable schedules by the last day of the 7th calendar month after the short plan year ends or by the extended due date, if filing under an authorized extension of time. Fill in the short plan year beginning and ending dates in the space provided and check the appropriate box in Part I, line B, of the

Form 5500-SF. For purposes of this return/report, a short plan year ends on the date of the change in accounting period or upon the complete distribution of assets of the plan. Also see the instructions for Final Return/Report to determine if “the final return/report” box in line B should be checked.

Notes. (1) If the filing due date falls on a Saturday, Sunday, or Federal holiday, the return/report may be filed on the next day that is not a Saturday, Sunday, or Federal holiday. (2) If the 2024 Form 5500-SF is not available before the plan filing is due, use the 2023 Form 5500-SF and enter the 2024 fiscal year beginning and ending dates on the line provided at the top of the form.

Extension of Time To File

Using Form 5558

If filing under an extension of time based on the filing of an IRS Form 5558, Application for Extension of Time To File Certain Employee Plan Returns, check the appropriate box on the Form 5500-SF, Part I, line C. A one-time extension of time to file the Form 5500-SF (up to 2½ months) may be obtained by filing Form 5558 on or before the normal due date (not including any extensions) of the return/report. Beginning January 1, 2024, you can file Form 5558 electronically through EFAST2 or you can file paper Form 5558 with the Department of Treasury, Internal Revenue Service Center, Ogden, UT 84201-0045. Approved copies of the paper Form 5558 will not be returned to the filer. A copy of the completed extension request must be retained with the plan’s records. See How to File – Electronic Filing Requirement for details on EFAST receipt and acknowledgement of filings.

Using Extension of Time To File Federal Income Tax Return

An automatic extension of time to file Form 5500-SF until the due date of the federal income tax return of the employer will be granted if all of the following conditions are met: (1) the plan year and the employer’s tax year are the same; (2) the employer has been granted an extension of time to file its federal income tax return to a date later than the normal due date for filing the

Form 5500-SF; and (3) a copy of the application for extension of time to file the federal income tax return is maintained with the filer’s records. An extension of time granted by using this automatic extension procedure CANNOT be extended further by filing an IRS Form 5558, nor can it be extended beyond a total of 9½ months beyond the close of the plan year.

Note. A tax-exempt organization is not required to file a federal income tax return. However, if the organization uses a Form 8868 to request an extension for its Form 990 series return, the filer is automatically granted an extension of time to file the Form 5500 until the extended due date of filing Form 990 series if all conditions listed above are met. An extension granted by using this automatic extension procedure cannot be extended beyond a total of 9½ months beyond the close of the plan year.

Other Extensions of Time

The IRS, DOL, and PBGC may announce special extensions of time under certain circumstances, such as extensions for Presidentially-declared disasters or for service in, or in support of, the Armed Forces of the United States in a combat zone. See www.irs.gov, www.efast.dol.gov, and www.pbgc.gov/practitioners for announcements regarding such special extensions. If you are relying on one of these announced special extensions, check the appropriate box on the Form 5500-SF, Part I, line C, and enter a description of the announced authority for the extension.

Delinquent Filer Voluntary Compliance (DFVC) Program

The DFVC Program facilitates voluntary compliance by plan administrators who are delinquent in filing annual return/report forms under Title I of ERISA by permitting administrators to pay reduced civil penalties for voluntarily complying with their DOL annual reporting obligations. If the Form 5500-SF is being filed under the DFVC Program, check the appropriate box on Form 5500-SF, Part I, line C to indicate that the Form 5500-SF is being filed under the DFVC Program. See www.efast.dol.gov for additional information.

Plan administrators are reminded that they can use the online calculator available at https://askebsa.dol.gov/dfvcepay/calculator to compute the penalties due under the program. Payments under the DFVC Program also may be submitted electronically. For information on how to pay DFVC Program payments online, go to www.dol.gov/ebsa.

F ilers who wish to participate in the DFVC Program for plan years prior to 2021 must use the 2023 version of Form 5500 or, if applicable, Form 5500-SF. Use the Form 5500 Version Selection Tool available at www.efast.dol.gov for further information.

Change in Plan Year

Generally, only defined benefit pension plans need to get approval for a change in plan year. See Code section 412(d)(1). However, under Revenue Procedure 87-27, 1987-1 C.B. 769, these pension plans may be eligible for automatic approval of a change in plan year.

If a change in plan year for a pension or a welfare benefit plan creates a short plan year, file the form and applicable schedules by the last day of the 7th calendar month after the short plan year ends or by the extended due date, if filing under an authorized extension of time. Fill in the short plan year beginning and ending dates in the space provided in Part I and check the appropriate box in Part I, line B of the Form 5500-SF. For purposes of this return/report, the short plan year ends on the date of the change in accounting period or upon the complete distribution of assets of the plan. Also, see the instructions for Final Return/Report to determine if “final return/report” in line B should be checked.

Penalties

Plan administrators and plan sponsors must provide complete and accurate information and must otherwise comply fully with the filing requirements. ERISA and the Code provide for the DOL and the IRS, respectively, to assess or impose penalties for not giving complete and accurate information and for not filing complete and accurate statements and returns/reports. Certain penalties are administrative (that is, they may be imposed or assessed in an administrative proceeding by one of the governmental agencies delegated to administer the collection of the Form 5500-SF data). Others require a legal conviction.

Administrative Penalties

Listed below are various penalties under ERISA and the Code that may be assessed or imposed for not meeting the annual return/report filing requirements. Generally, whether the penalty is under ERISA or the Code, or both, depends upon the agency for which the information is required to be filed. One or more of the following administrative penalties may be assessed or imposed in the event of incomplete filings or filings received after the due date unless it is determined that your failure to file properly is for reasonable cause.

1. A penalty of up to $2,586 a day for each day a plan administrator fails or refuses to file a complete and accurate report. See ERISA section 502(c)(2), 29 CFR 2560.502c-2, and the Federal Civil Penalties Inflation Adjustment Act of 1990, as amended by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015 (2015 Inflation Adjustment Act). Pub. L. No. 114-74; 129 Stat. 599 and the DOL’s implementing regulation at 88 FR 2210 (Jan. 15, 2023). The 2015 Inflation Adjustment Act requires agencies to adjust the levels of civil monetary penalties with an initial catch-up adjustment, followed by annual adjustments for inflation. Because the Federal Civil Penalties Inflation Adjustment Improvements Act of 2015 (Pub. L. No. 114-74; 129 Stat. 599), requires the penalty amount to be adjusted annually after the Form 5500/5500-SF and its schedules, attachments, and instructions are published for filing, be sure to check DOL’s website for any possible required inflation adjustments of the maximum penalty amount that may have been published in the Federal Register after the instructions have been posted.

2. A penalty of $250 a day (up to $150,000) for not filing the annual return/report for certain plans of deferred compensation, trusts and annuities, and bond purchase plans by the due date(s). See Code section 6652(e).

3. A penalty of $1,000 for not filing an actuarial statement (Schedule MB (Form 5500) or Schedule SB (Form 5500)) required by the applicable instructions. See Code section 6692.

Other Penalties

1. Any individual who willfully violates any provision of Part 1 of Title I of ERISA shall on conviction be fined not more than $100,000 or imprisoned not more than 10 years, or both. See ERISA section 501.

2. A penalty up to $10,000, five (5) years imprisonment, or both, may be imposed for making any false statement or representation of fact, knowing it to be false, or for knowingly concealing or not disclosing any fact required by ERISA. See section 1027, Title 18, U.S. Code, as amended by section 111 of ERISA.

How To File – Electronic Filing Requirement

Under the computerized ERISA Filing Acceptance System (EFAST2), you must file your 2023 Form 5500-SF electronically. You may file your 2023 Form 5500-SF online using EFAST2’s web-based filing system or you may file through an EFAST2-approved vendor. Detailed information on electronic filing is available at www.efast.dol.gov. For telephone assistance, call the EFAST2 Help Desk at 1-866-GO-EFAST (1-866-463-3278). The EFAST2 Help Desk is available Monday through Friday from 8:00 am to 8:00 pm, Eastern Time.

Annual returns/reports filed under Title I of ERISA, i ncluding those filed using the Form 5500-SF, must be made available by the plan administrators to plan participants and beneficiaries and by the DOL to the public pursuant to ERISA sections 104 and 106. Even though the Form 5500-SF must be filed electronically, the plan administrator must keep a copy of the Form 5500-SF, including schedules and attachments, with all required signatures on file as part of the plan’s records, and must make a paper copy available on request to participants, beneficiaries, and the DOL as required by section 104 of ERISA and 29 CFR 2520.103-1. Filers may use electronic media for record maintenance and retention, so long as they meet the applicable requirements. (See 29 CFR 2520.107-1).

Generally, questions on the Form 5500-SF relate to the plan year entered at the top of the first page of the form. Therefore, answer all questions on the 2023

Form 5500-SF with respect to the 2023 plan year unless otherwise explicitly stated in the instructions or on the form itself.

Your entries must be in the proper format in order for the EFAST2 system to process your filing. For example, if a question requires you to enter a dollar amount, you cannot enter a word. Your software will not let you submit your return/report unless all entries are in the proper format. To reduce the possibility of correspondence and penalties:

• Complete all lines on the Form 5500-SF unless otherwise specified. Also complete and electronically attach, as required, any applicable schedules and attachments.

• Do not enter “N/A” or “Not Applicable” on the Form 5500-SF or Schedules SB (Form 5500), MB (Form 5500), and MEP (Form 5500) unless specifically permitted. “Yes” or “No” questions on the form and schedules cannot be left blank, unless specifically permitted. Answer “Yes” or “No,” but not both.

• Use the correct employer identification number (EIN) and plan number (PN) for the plan.

You should check your return/report for errors before signing or submitting it to EFAST2. Your filing software or, if you are using it, the EFAST2 web-based filing system will allow you to check your return/report for errors. If, after reasonable attempts to correct your filing to eliminate any identified problem or problems, you are unable to address them, or you believe that you are receiving the message in error, call the EFAST2 Help Desk at 1-866-GO-EFAST (1-866-463-3278) or contact the service provider you used to help prepare and file your annual return/report.

Once you complete the return/report and finish the electronic signature process, you can electronically submit it to EFAST2. When you electronically submit your return/report, EFAST2 is designed to immediately notify you if your submission was received and whether the return/report is ready to be processed by EFAST2. If EFAST2 does not notify you that your submission was successfully received and is ready to be processed, you will need to take steps to correct the problem or you may be deemed a non-filer subject to penalties from DOL, IRS, and/or PBGC.

Once EFAST2 receives your return/report, the EFAST2 system should be able to provide a filing status within 20 minutes. Check back into the EFAST2 system to determine the filing status of your return/report. The filing status message will include a list of any filing errors or warnings that EFAST2 may have identified in your filing. If EFAST2 did not identify any filing errors or warnings, EFAST2 will show the filing status of your return/report as “Filing Received.” Persons other than the submitter can check whether the filing was received by the system by calling the EFAST2 Help Desk at 1-866-GO-EFAST (1-866-463-3278) and using the automated telephone system.

To reduce the possibility of correspondence and penalties from the DOL, IRS, and/or PBGC, you should do the following: (1) Before submitting your return/report to EFAST2, check it for errors, and (2) after you have submitted it to EFAST2, verify that you have received a filing status of “Filing Received” and attempt to correct and resolve any errors or warnings listed in the status report.

Note. Even after being received by the EFAST2 system, your return/report filing may be subject to further detailed review by DOL, IRS, and/or PBGC, and your filing may be deemed deficient based upon this further review. See Penalties on page 5.

The Form 5500-SF, Schedules SB (Form 5500), MB (Form 5500) and MEP (Form 5500), and any attachments that are filed under ERISA are open to public inspection, and the contents are public information subject to publication on the Internet.

D o not enter social security numbers in response to questions asking for an employer identification number (EIN). Because of privacy concerns, the inclusion of a social security number or any portion thereof on the Form 5500-SF or on a schedule or attachment that is open to public inspection may result in the rejection of the filing. If you discover a filing disclosed on the EFAST2 website that contains a social security number, immediately call the EFAST2 Help Desk at 1-866-GO-EFAST (1-866-463-3278).

Do not attach a copy of the annual registration statement identifying separated participants with deferred vested benefits, or a previous year’s Schedule SSA (Form 5500) to your 2023 Form 5500-SF Annual Return/Report. The annual registration statement must be filed directly with the IRS and cannot be attached to a Form 5500-SF submission with EFAST2.

Employers without an employer identification number (EIN) must apply to the IRS for one as soon as possible. The EBSA does not issue EINs. To apply for an EIN from the IRS:

• Mail or fax Form SS-4, Application for Employer Identification Number, obtained at www.irs.gov/orderforms.

• See www.IRS.gov/Businesses and click on “Employer ID Numbers” for additional information. The EIN is issued immediately once the application information is validated. (The online application process is not yet available for corporations with addresses in foreign countries or Puerto Rico.)

Signature and Date

For purposes of Title I of ERISA, the plan administrator is required to file the Form 5500 or 5500-SF. The plan administrator must electronically sign the Form 5500 or 5500-SF submitted to EFAST2.

A fter submitting your filing, you must check the Filing Status. If the filing status is "Processing Stopped" or “Unprocessable,” it is possible your submission was not sent with a valid electronic signature as required, and depending on the error, may be considered not to have been filed. By looking closer at the Filing Status, you can see specific error messages applicable to the transmitted filing and determine whether it was sent with a valid electronic signature and what other errors may need to be corrected.

Note. If the plan administrator is an entity, the electronic signature must be in the name of a person authorized to sign on behalf of the plan administrator.

If the plan administrator does not sign a filing, the filing status will indicate that there is an error with your filing, and your filing will be subject to further review, correspondence, rejection, and civil penalties.

Authorized Service Provider Signatures. A statement for service providers that use this electronic signature option is in the IFILE application. The statement provides that, by signing the electronic filing, the service provider is attesting: (1) that the service provider has been authorized in writing by the plan administrator or plan sponsor/employer, as applicable, to electronically submit the return/report; (2) that a copy of the specific written authorization will be kept in the service provider’s records; (3) that, in addition to any other required schedules or attachments, the electronic filing includes a true and correct PDF copy of the completed Form 5500-SF (without schedules or attachments) return/report bearing the manual signature of the plan administrator or employer/plan sponsor, as applicable, under penalty of perjury; (4) that the service provider advised the plan administrator or employer/plan sponsor, as applicable, that by selecting this electronic signature option, the image of the plan administrator’s or employer/plan sponsor’s manual signature will be included with the rest of the return/report posted by the Department of Labor on the Internet for public disclosure; and (5) that the service provider will communicate to the plan administrator or employer/plan sponsor, as applicable, any inquiries and information received from EFAST2, DOL, IRS or PBGC regarding the return/report.

Note. A Form 5500-SF that is not electronically signed by the plan administrator will be subject to rejection and civil penalties under Title I of ERISA.

The Form 5500-SF Annual Return/Report must be filed electronically and signed. To obtain an electronic signature, go to www.efast.dol.gov and register in EFAST2 as a signer. You will be provided with a UserID and a PIN. Both the UserID and PIN are needed to sign the Form 5500-SF. The plan administrator must keep a copy of the Form 5500-SF, including schedules and attachments, with all required signatures on file as part of the plan’s records. See 29 CFR 2520.103-1. Electronic signatures on annual returns/reports filed under EFAST2 are governed by the applicable statutory and regulatory requirements.

Specific Line-by-Line Instructions Form 5500-SF

Part I – Annual Report Identification Information

File the 2023 Form 5500-SF Annual Report for a plan year that began in 2023. Enter the beginning and ending dates in Part I. The 2023 Form 5500-SF Annual Report must be filed electronically.

Check only one of the line A box choices.

Line A – Box for Single-Employer Plan. Check this box if the Form 5500-SF is filed for a single-employer plan. A single-employer plan for purposes of the Form 5500-SF is an employee benefit plan maintained by one employer or one employee organization.

Note. A “controlled group” is generally considered one employer for Form 5500 and Form 5500-SF reporting purposes. A “controlled group” is a controlled group of corporations under Code section 414(b), a group of trades or businesses under common control under Code section 414(c), or an affiliated service group under Code section 414(m). A separate annual return/report with line A (single-employer plan) checked must be filed by each employer participating in a plan or program of benefits in which the funds attributable to each employer are available to pay benefits only for that employer’s employees, even if the plan is maintained by a controlled group.

Line A – Box for Multiple-Employer Plan. Check this box if the Form 5500-SF is being filed for a multiple-employer plan. A multiple-employer plan is a plan that is maintained by more than one employer and is not a single-employer plan or a multiemployer plan. A multiple-employer plan can be collectively bargained and collectively funded, but if covered by PBGC termination insurance, must have properly elected before September 27, 1981, not to be treated as a multiemployer plan under Code section 414(f)(5) or ERISA sections 3(37)(E) and 4001(a)(3), and have not revoked that election or made an election to be treated as a multiemployer plan under Code section 414(f)(6) or ERISA section 3(37)(G). A single Form 5500-SF Annual Return/Report is filed for the multiple-employer plan; participating employers do not file individually for this type of plan.

Note. Do not check this box if all of the employers maintaining the plan are members of the same controlled group or affiliated service group under Code sections 414(b), (c), or (m).

Multiple-Employer Retirement Plan Information. Schedule MEP (Form 5500), Multiple-Employer Retirement Plan Information, must be attached to a Form 5500-SF filed for a pension plan that checks this box, to provide information specific to such plan, including a list of participating employers and related information. See Form 5500 instructions for Schedule MEP for more information.

M ultiemployer plans, pooled employer plans and DCG reporting arrangements cannot use the Form 5500-SF to satisfy their annual reporting obligations. They must file the Form 5500. For these purposes, a plan is a pooled employer plan if it is a multiple-employer pension plan that meets the definition under ERISA section 3(43), and a plan is a multiemployer plan if: (a) more than one employer is required to contribute; (b) the plan is maintained pursuant to one or more collective-bargaining agreements between one or more employee organizations and more than one employer; (c) an election under Code section 414(f)(5) and ERISA section 3(37)(E) has not been made; and (d) the plan meets any other applicable conditions of 29 CFR 2510.3-37. A plan that made a proper election under ERISA section 3(37)(G) and Code section 414(f)(6) on or before Aug. 17, 2007, is also a multiemployer plan. A DCG reporting arrangement is an alternative reporting method used by groups of employee benefits plans meeting certain commonality of plan features and other applicable conditions found in 29 CFR 2520.104-51 and 29 CFR 2520.103-14.

Line B – Box for First Return/Report. Check this box if an annual return/report has not been previously filed for this plan. For the purpose of completing this box, the Form 5500-EZ is not considered an annual return/report.

Line B – Box for Amended Return/Report. Check this box if you have already filed for the 2023 plan year and are now filing an amended return/report to correct errors and/or omissions on the previously filed return/report.

C heck the line B box for an “amended return/report” if you filed a previous 2023 annual return/report that was given a “Filing_Received,” “Filing_Error,” or “Filing_Stopped” status by EFAST2. Do not check the line B box for an “amended return/report” if your previous submission attempts were not successfully received by EFAST2 because of problems with the transmission of your return/report. For more information, go to the EFAST2 website at www.efast.dol.gov or call the EFAST2 Help Desk at 1-866-GO-EFAST (1-866-463-3278).

If you need to file an amended return/report to correct errors and/or omissions in a previously filed annual return/report for the 2023 plan year AND you are eligible to file the Form 5500-SF, you may use the Form 5500-SF even if the original filing was a Form 5500. If you filed a Form 5500-SF, but determine that you were not eligible to file the Form 5500-SF, you must use the Form 5500 or Form 5500-EZ to amend your return/report.

Note. An amended filing should be submitted as a complete replacement of the previously submitted filing. You will need to resubmit the entire form, with all required schedules and attachments, through EFAST2. You cannot submit just the parts of the filing that are being amended. See EFAST2 FAQs available on the EFAST website at www.efast.dol.gov.

Line B – Box for Final Return/Report. Check this box if this is the final report for the plan. Only check this box if all assets under the plan (including insurance/annuity contracts) have been distributed to the participants and beneficiaries or legally transferred to the control of another plan, and when all liabilities for which benefits may be paid under a welfare benefit plan have been satisfied. Do not mark the final return/report box if you are reporting participants and/or assets at the end of the plan year. If a trustee is appointed for a terminated defined benefit pension plan pursuant to ERISA section 4042, the last plan year for which a return/report must be filed is the year in which the trustee is appointed. If you are in this situation, you may contact PBGCTrusteedPlan@dol.gov for further information.

Examples:

Mergers/Consolidations. A final return/report should be filed for the plan year (12 months or less) that ends when all plan assets were legally transferred to the control of another plan.

Pension and Welfare Plans That Terminated Without Distributing All Assets. If the plan was terminated but all plan assets were not distributed, a return/report must be filed for each year the plan has assets. The return/report must be filed by the plan administrator, if designated, or by the person or persons who actually control the plan’s assets/ property.

Welfare Plans Still Liable To Pay Benefits. A welfare plan cannot file a final return/report if the plan is still liable to pay benefits for claims that were incurred prior to the termination date, but not yet paid. See 29 CFR 2520.104b-2(g)(2)(ii).

Line B – Box for Short Plan Year Return/Report. Check this box if this Form 5500-SF is being filed for a plan year period of less than 12 months. Provide the dates in Part I, Plan Year Beginning and Ending.

Line C – Box for Extension and DFVC Program. Check the appropriate box here if:

• You filed for an extension of time to file this form with the IRS using Form 5558, Application for Extension of Time To File Certain Employee Plan Returns, and maintain a copy of the Form 5558 with the filer’s records.

• You are filing using the automatic extension of time to file the Form 5500-SF return/report until the due date of the federal income tax return of the employer and maintain a copy of the employer’s extension of time to file the income tax return with the plan’s records.

• You are filing under the DFVC Program.

• You are filing using a special extension of time to file the Form 5500-SF Annual Return/Report that has been announced by the IRS, DOL, or PBGC. If you checked that you are using a special extension of time, enter a description of the extension of time in the space provided.

C hecking this box does not enter you in the program. You can enter the program at this site:

www.dol.gov/agencies/ebsa/employers-and-advisers/plan-administration-and-compliance/correction-programs/dfvcp

See additional information on the DFVC Program at www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/dfvcp.pdf including filing by mail.

Applying and paying electronically to the DFVC Program is strongly recommended.

Line D – Box for a Collectively-Bargained, Single-Employer Plan. Check this box when the contributions to the plan and/or the benefits paid by the plan are subject to the collective bargaining process. The contributions and/or benefits do not have to be identical for all employees under the plan.

Line E – Box for a retroactively adopted plan as permitted by SECURE Act section 201. Check this box if the plan sponsor adopted the plan during the 2023 plan year (i.e., by the due date, including extension, for filing the plan sponsor’s tax return for the 2022 taxable year) and elected to treat the plan as having been adopted before the 2023 plan year began (i.e., at the close as of the last day of the sponsor’s taxable year) as permitted by section 201 of the Setting Every Community Up for Retirement Enhancement Act of 2019 (SECURE Act). Plans in this situation are not required to file a 2022 Form 5500. However, if the plan is a defined benefit pension plan, the 2022 Schedule SB (Form 5500) must be included as an attachment to the 2023 Schedule SB (Form 5500) as part of the 2023 Form 5500. Please see Instructions for Schedule SB for more information.

Part II – Basic Plan Information

Line 1a. Enter the formal name of the plan or enough information to identify the plan. Abbreviate if necessary. If an annual return/report has previously been filed on behalf of the plan, regardless of the type of Form that was filed (Form 5500, Form 5500-EZ, or

Form 5500-SF), use the same name or abbreviation as was used on the prior filings. Once you use an abbreviation, continue to use it for that plan on all future annual return/report filings with the IRS, DOL, and PBGC. Do not use the same name or abbreviation for any other plan, even if the first plan is terminated. If the plan has changed its name from the prior year filing(s), complete line 4 to indicate that the plan was previously identified by a different name.

Line 1b. Enter the three-digit plan or entity number (PN) that the employer or plan administrator assigned to the plan. This three-digit number, in conjunction with the employer identification number (EIN) entered on line 2b, is used by the IRS, DOL, and PBGC as a unique 12-digit number to identify the plan.

Start at 001 for plans providing pension benefits. Start at 501 for welfare plans. Do not use 888 or 999.

Once you use a plan number, continue to use it for that plan on all future filings with the IRS, DOL, and PBGC. Do not use it for any other plan, even if the first plan is terminated.



For each Form 5500-SF with the same EIN

(line 2b), when	Assign PN 
Codes are entered in line 9a	001 to the first plan. Consecutively number others as 002, 003 . . .
Codes are entered in line 9b, and not in line 9a	501 to the first plan. Consecutively number others as 502, 503 . . .

Exception. If 333 (or a higher number in a sequence beginning with 333) was previously assigned to the plan, that number may be entered on line 1b.

Line 1c. Enter the date the plan first became effective.

Line 2a. Limit your response to the information required in each row as specified below:

1. Enter the plan sponsor’s name. If the plan covers only the employees of one employer, enter the employer’s name.

The term “plan sponsor” means:

• The employer, for an employee benefit plan that a single employer established or maintains;

• The employee organization, in the case of a plan of an employee organization;

• The association, committee, joint board of trustees, or other similar group of representatives of the parties who establish or maintain the plan, if the plan is established or maintained jointly by one or more employers and one or more employee organizations, or by two or more employers; or

• The professional employer organization (PEO), in the case of a PEO multiple-employer plan that meets the conditions under 29 CFR 2510.3-55(c).

2. Enter any ‘‘in care of’’ (C/O) name.

3. Enter the street address. A post office box number may be entered if the Post Office does not deliver mail to the sponsor’s street address.

4. Enter the name of the city.

5. Enter the two-character abbreviation of the U.S. state or possession and zip code.

6. Enter the foreign routing code, if applicable. Leave U.S. state and zip code blank if entering a foreign routing code and country name.

7. Enter the foreign country, if applicable.

8. Enter the D/B/A (the doing business as) or trade name of the sponsor if different from the plan sponsor’s name.

9. Enter any second address. Use only a street address here, not a P.O. Box.

Notes. (1) In the case of a multiple-employer plan, file only one annual return/report for the plan. If an association or other entity is not the sponsor, enter the name of a participating employer as sponsor. For a plan of a controlled group of corporations, the name of one of the sponsoring members should be entered. In either case, the same name must be used in all subsequent filings of the Form 5500 return/report or Form 5500-SF for the multiple-employer plan or controlled group (see instructions for line 4 concerning a change in sponsorship). (2) Use the IRS Form 8822-B to notify the IRS if the address provided here is a change in your business mailing address or your business location.

Line 2b. Enter the employer’s nine-digit employer identification number (EIN). Do not use a social security number (SSN). A Form 5500-SF that is filed under ERISA is open to public inspection and the contents are public information and are subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on this line may result in the rejection of the filing.

Employers without an EIN number must apply to the IRS for one as soon as possible. The EBSA does not issue EINs. To apply for an EIN from the IRS:

• Mail or fax Form SS-4, Application for Employer Identification Number, obtained at www.irs.gov/orderforms.

• See www.IRS.gov/Businesses and click on ”Employer ID Numbers” for additional information. The EIN is issued immediately once the application information is validated. (The online application process is not yet available for corporations with addresses in foreign countries or Puerto Rico.)

A multiple-employer plan or plan of a controlled group of corporations should use the EIN number of the sponsor identified on line 2a. The EIN must be used in all subsequent filings of the Form 5500-SF (or any subsequent Form 5500 or Form 5500-EZ in a year where the plan is not eligible to file the Form 5500-SF) for these plans. (See instructions to line 4 concerning change in EIN).

Note. EINs for funds (trusts or custodial accounts) associated with plans are generally not required to be furnished on the Form 5500-SF. The IRS, however, will issue EINs for such funds for other reporting purposes.

EINs may be obtained as explained above. Plan sponsors should use the trust EIN when opening a bank account or conducting other transactions for a trust.

Line 2c. Enter the telephone number for the plan sponsor. Use numbers only, including area code, and do not include any special characters.

Line 2d. Enter the six-digit business code from the list of business codes on pages 23-26 that:

• In the case of a single-employer plan, best describes the primary nature of the plan sponsor’s business, and

• In the case of a multiemployer plan, best describes the predominant industry in which the active participants are employed (e.g., 484120 - General Freight Trucking, Long-distance, 236110 - Residential Building Construction).

Do not enter code 525100 (Insurance & Employee Benefit Funds) or 813930 (Labor Unions and Similar Labor Organizations) unless the predominant industry in which the active participants are employed is the industry of insurance and employee benefit funds, or labor unions and similar labor organizations.

Line 3a. Limit your response to the information required in each row as specified below:

1. Enter the name of the plan administrator unless the administrator is the sponsor identified on line 2. If both the plan administrator name and address are the same as the plan sponsor name and address, check the “Same as Plan Sponsor” box and disregard items 2 through 6 below.

2. Enter any “in care of” (C/O) name.

3. Enter the current street address. A post office box number may be entered if the Post Office does not deliver mail to the administrator’s street address.

4. Enter the name of the city.

5. Enter the two-character abbreviation of the U.S. state or possession and zip code.

6. Enter the foreign routing code and foreign country, if applicable. Leave U.S. state and zip code blank if entering foreign routing code and country information.

Plan administrator for this purpose means:

• The person or group of persons specified as the administrator by the instrument under which the plan is operated;

• The plan sponsor/employer if an administrator is not so designated;

• The professional employer organization (PEO), in the case of a PEO multiple-employer plan that meets conditions under 29 CFR 2510.3-55(c); or

• Any other person prescribed by applicable regulations if an administrator is not designated and a plan sponsor cannot be identified.

Line 3b. Enter the plan administrator’s nine-digit EIN. A plan administrator must have an EIN for Form 5500-SF reporting. If the plan administrator does not have an EIN, it must apply to the IRS for one as explained in the instructions for line 2b. One EIN should be entered for a group of individuals who are, collectively, the plan administrator.

Note. Employees of the plan sponsor who perform administrative functions for the plan are generally not the plan administrator unless specifically designated in the plan document. If an employee of the plan sponsor is designated as the plan administrator, that employee must obtain an EIN.

Line 3c. Enter the telephone number for the plan administrator. Use numbers only, including area code, and do not include any special characters.

Line 4. If the plan sponsor’s name and/or EIN have changed or the plan name has changed since the last return/report was filed for this plan, enter the plan sponsor’s name, EIN, the plan name, and the plan number as it appeared on the last return/report filed.

T he failure to indicate on line 4 that a plan sponsor was previously identified by a different name or a different employer identification number (EIN) or that the plan name has been changed could result in correspondence from the DOL and/or the IRS.

Line 5. Enter in element (a) the total number of participants at the beginning of the plan year. Enter in element (b) the total number of participants at the end of the plan year. Enter in element (c)(1) the total number of participants included in element (a) (total participants at the beginning of the plan year) who have account balances as of the beginning of the plan year. Enter in element (c)(2) the total number of participants included in element (b) (total participants at the end of the plan year) who have account balances at the end of the plan year. Welfare benefit plans and defined benefit plans do not complete element (c). Enter in element (d)(1) the total number of active participants at the beginning of the plan year. Enter in element (d)(2) the total number of active participants at the end of the plan year.

The description of “participant” in the following instructions is only for purposes of these lines.

An individual becomes a participant covered under an employee welfare benefit plan on the earliest of:

• The date designated by the plan as the date on which the individual begins participation in the plan;

• The date on which the individual becomes eligible under the plan for a benefit subject only to occurrence of the contingency for which the benefit is provided; or

• The date on which the individual makes a contribution to the plan, whether voluntary or mandatory.

See 29 CFR 2510.3-3(d)(1). This includes former employees who are receiving group health continuation coverage benefits pursuant to Part 6 of ERISA and who are covered by the employee welfare benefit plan. Covered dependents are not counted as participants. A child who is an “alternate recipient” entitled to health benefits under a qualified medical child support order (QMCSO) should not be counted as a participant for line 5. An individual is not a participant covered under an employee welfare plan on the earliest date on which the individual (a) is ineligible to receive any benefit under the plan even if the contingency for which such benefit is provided should occur, and (b) is not designated by the plan as a participant. See 29 CFR 2510.3-3(d)(2).

B efore counting the number of participants, especially in a welfare benefit plan, it is important to determine whether the plan sponsor has established one or more plans for Form 5500/Form 5500-SF reporting purposes. As a matter of plan design, plan sponsors can offer benefits through various structures or combinations. For example, a plan sponsor could create (i) one plan providing major medical benefits, dental benefits, and vision benefits, (ii) two plans with one providing major medical benefits and the other providing self-insured dental and vision benefits; or (iii) three separate plans. You must review the governing documents and actual operations to determine whether welfare benefits are being provided under a single plan or separate plans.

The fact that you have separate insurance policies for each different welfare benefit does not necessarily mean that you have separate plans. Some plan sponsors use a “wrap” document to incorporate various benefits and insurance policies into one comprehensive plan. In addition, whether a benefit arrangement is deemed to be a single plan may be different for purposes other than Form 5500/Form 5500-SF reporting. For example, special rules may apply for purposes of HIPAA, COBRA, and Internal Revenue Code compliance. If you need help determining whether you have a single welfare benefit plan for Form 5500/Form 5500-SF reporting purposes, you should consult a qualified benefits consultant or legal counsel.

For pension benefit plans, “alternate payees” entitled to benefits under a qualified domestic relations order (QDRO) are not to be counted as participants for this line.

For pension benefit plans, “participant” for this line means any individual who is included in one of the categories below.

1. Active participants (i.e., any individuals who are currently in employment covered by the plan and who are earning or retaining credited service under the plan). This includes any individuals who are eligible to elect to have the employer make payments under a Code section 401(k) qualified cash or deferred arrangement. Active participants also include any nonvested individuals who are earning or retaining credited service under the plan. This does not include (a) nonvested former employees who have incurred the break in service period specified in the plan or (b) former employees who have received a “cash-out” distribution or deemed distribution of their entire nonforfeitable accrued benefit.

2. Retired or separated participants receiving benefits (i.e., individuals who are retired or separated from employment covered by the plan and who are receiving benefits under the plan). This does not include any individual to whom an insurance company has made an irrevocable commitment to pay all the benefits to which the individual is entitled under the plan.

3. Other retired or separated participants entitled to future benefits (i.e., any individuals who are retired or separated from employment covered by the plan and who are entitled to begin receiving benefits under the plan in the future). This does not include any individual to whom an insurance company has made an irrevocable commitment to pay all the benefits to which the individual is entitled under the plan.

4. Deceased individuals who had one or more beneficiaries who are receiving or are entitled to receive benefits under the plan. This does not include any individual to whom an insurance company has made an irrevocable commitment to pay all the benefits to which the beneficiaries of that individual are entitled under the plan.

Line 5e. Include any individual who terminated employment during this plan year, whether or not they (a) incurred a break in service, (b) received an irrevocable commitment from an insurance company to pay all the benefits to which they are entitled under the plan, and/or (c) received a cash distribution or deemed cash distribution of their nonforfeitable accrued benefit.

Line 6. If your plan is required to file an annual return/ report, you may file the Form 5500-SF instead of the Form 5500 only if you meet all of the eligibility conditions listed below.

1. The plan (a) covered fewer than 100 participants at the beginning of the plan year 2023, or (b) under 29 CFR 2520.103-1(d) was eligible to and filed as a small plan for plan year 2022 and did not cover more than 120 participants at the beginning of plan year 2023 (see instructions for Who May File Form 5500-SF on counting the number of participants to determine whether a plan is eligible);

2. The plan did not hold any employer securities at any time during the plan year;

3. At all times during the plan year, the plan was 100% invested in certain secure, easy to value assets such as mutual fund shares, investment contracts with insurance companies and banks valued at least annually, publicly traded securities held by a registered broker-dealer, cash and cash equivalents, and plan loans to participants that meet the definition of “eligible plan assets” (see the instructions for line 6a);

4. The plan is eligible for the waiver of the annual examination and report of an independent qualified public accountant (IQPA) under 29 CFR 2520.104-46 (but not by reason of enhanced bonding), whose requirements include, among others, giving certain disclosures and supporting documents to participants and beneficiaries regarding the plan’s investments (see instructions for line 6b);

5. The plan is not a multiemployer plan;

6. The plan is not required to file a Form M-1, Report for Multiple-Employer Welfare Arrangements (MEWAs) and Certain Entities Claiming Exception (ECEs) during the plan year; and

7. The plan is not a pooled employer plan. See ERISA section 3(43).

Line 6a – Eligible Plan Assets. To be eligible to file the Form 5500-SF, all of the plan’s assets must be “eligible plan assets.” Answer line 6a “Yes” or “No.” Do not leave this question blank. If the answer to line 6a is “No” you CANNOT file the Form 5500-SF and must file the Form 5500. See discussion under Who May File Form 5500-SF.

For the purposes of this line, “eligible plan assets” are assets that have a readily determinable fair market value for purposes of this annual reporting requirement as described in 29 CFR 2520.103-1(c)(2)(ii)(C), are not employer securities, and are held or issued by one of the following regulated financial institutions: a bank or similar financial institution as defined in 29 CFR 2550.408b-4(c) (for example, banks, trust companies, savings and loan associations, domestic building and loan associations, and credit unions); an insurance company qualified to do business under the laws of a state; organizations registered as broker-dealers under the Securities Exchange Act of 1934; investment companies registered under the Investment Company Act of 1940; or any other organization authorized to act as a trustee for individual retirement accounts under Code section 408. Examples of assets that would qualify as eligible plan assets for this annual reporting purpose are mutual fund shares, investment contracts with insurance companies or banks that provide the plan with valuation information at least annually, publicly traded stock held by a registered broker-dealer, cash and cash equivalents held by a bank. Participant loans meeting the requirements of ERISA section 408(b)(1) are also “eligible plan assets” for this purpose whether or not they have been deemed distributed.

Line 6b. In addition to all of the plan’s assets being eligible plan assets as defined in line 6a, to be eligible to file the Form 5500-SF the plan also must be exempt from the requirement to be audited annually by an independent qualified public accountant (IQPA).

Welfare plans that cover fewer than 100 participants at the beginning of the plan year are exempt from the annual audit requirement.

A pension plan is exempt from the annual audit requirement if it covered fewer than 100 participants at the beginning of the plan year or under 29 CFR 2520.103-1(d) was eligible to and filed as a small plan for plan year 2022 and did not cover more than 120 participants at the beginning of plan year 2023 and meets the following three requirements for the audit waiver under 29 CFR 2520.104-46: (1) as the last day of the preceding plan year, at least 95% of a small pension plan’s assets were “qualifying plan assets;” (2) the plan includes the required audit waiver disclosure in the Summary Annual Report (SAR) furnished to participants and beneficiaries, in accordance with 29 CFR 2520.104b-10. For defined benefit pension plans that are required pursuant to section 101(f) of ERISA to furnish an Annual Funding Notice (AFN), the administrator must instead either provide the information to participants and beneficiaries with the AFN or as a stand-alone notification at the time an SAR would have been due and in accordance with the rules for furnishing an SAR, although such plans do not have to furnish an SAR; and (3) in response to a request from any participant or beneficiary, the plan administrator must furnish without charge copies of statements from the regulated financial institutions holding or issuing the plan’s “qualifying plan assets.”

I n order to be eligible to file the Form 5500-SF, a small pension plan must meet the audit waiver conditions by virtue of having 95% or more of its assets as “qualifying plan assets” in accordance with 29 CFR 2520.104-46(b)(1)(i)(A)(1). If the small plan satisfies the conditions of the audit waiver by virtue of having an enhanced fidelity bond under 29 CFR 2520.104-46(b)(1)(i)(A)(2), the plan does not satisfy the conditions for filing the Form 5500-SF and must file the Form 5500, along with the appropriate schedules and attachments. Also, although many “qualifying plan assets” for audit waiver purposes will also be “eligible plan assets” as described in the instructions for line 6a, the definitions are not the same. If, as of the last day of the preceding plan year, the plan was 100% invested in “eligible plan assets,” the plan would satisfy the “qualifying plan asset” prong of the audit waiver conditions. Holding all the plan’s investments in “qualifying plan assets,” however, would not necessarily satisfy the conditions for filing the

Form 5500-SF. For example, real estate held by a bank as trustee for a plan could be a qualifying plan asset for purposes of the small pension plan audit waiver conditions but it would not be an “eligible plan asset” for purposes of the plan being eligible to file the Form 5500-SF because real estate would not have a readily determinable fair market value as described in 29 CFR 2520.103-1(c)(2)(ii)(C).

Line 6c. If you are uncertain whether the plan is covered under the PBGC termination insurance program, check the box “Not determined” and contact the PBGC either by phone at 1-800-736-2444, or by E-mail at coverage@pbgc.gov. If you checked the box “Yes,” enter the My PAA generated confirmation number for the premium filing for this plan year (see filing receipt). If you amended your premium filing for this plan year, enter the confirmation number for that filing and not for the previous filing(s). Defined contribution plans and welfare plans do not need to complete this item.

Part III – Financial Information

Note. The cash, modified cash, or accrual basis may be used for recognition of transactions in Part III, as long as you use one method consistently. Round off all amounts reported on the Form 5500-SF to the nearest dollar. Any other amounts are subject to rejection. Check all subtotals and totals carefully.

Current value means fair market value where available. Otherwise, it means the fair value as determined in good faith under the terms of the plan by a trustee or named fiduciary, assuming an orderly liquidation at the time of the determination. See ERISA section 3(26).

Line 7 – Plan Assets and Liabilities. Amounts reported on lines 7a, 7b, and 7c of the Form 5500-SF for the beginning of the plan year must be the same as reported for the end of the plan year for the corresponding lines on the return/report for the preceding plan year. However, if the Form 5500 was filed the previous year, the amounts reported on the Form 5500-SF, lines 7a, column (a), 7b, column (a), and 7c, column (a), should correspond to the amounts entered in lines 1a, column (b), 1b, column (b), and 1c, column (b), of the 2022 Schedule I (Form 5500) or the amounts entered in lines 1f, column (b), 1k, column (b), and 1l, column (b), of Schedule H (Form 5500), whichever schedule was filed.

Line 7a. Enter the total amount of plan assets at the beginning of the plan year in column (a). Do not include contributions designated for the 2023 plan year in column (a).

Enter the total amount of plan assets at the end of the plan year in column (b). Do not include in column (b) a participant loan that has been deemed distributed during the plan year under the provisions of Code section 72(p) and Treasury Regulations section 1.72(p)-1 if both the following circumstances apply: (1) Under the plan, the participant loan is treated as a directed investment solely of the participant’s individual account; and (2) As of the end of the plan year, the participant is not continuing repayment under the loan.

If the deemed distributed participant loan is included in column (a) and both of these circumstances apply, include the value of the loan as a deemed distribution on line 8e. However, if either of these two circumstances does not apply, the current value of the participant loan (including interest accruing thereon after the deemed distribution) should be included in column (b) without regard to the occurrence of a deemed distribution.

After a participant loan that has been deemed distributed is included in the amount reported on line 8e, it is no longer to be reported as an asset on line 7a unless, in a later year, the participant resumes repayment under the loan. However, such a loan (including interest accruing thereon after the deemed distribution) that has not been repaid is still considered outstanding for purposes of applying Code section 72(p)(2)(A) to determine the maximum amount of subsequent loans. Also, the deemed distribution is not treated as an actual distribution for other purposes, such as the qualification requirements of Code section 401, including, for example, the determination of top-heavy status under Code section 416 and the vesting requirements of Treasury Regulations section 1.411(a)-7(d)(5). See Q&As 12 and 19 of Treasury Regulations section 1.72(p)-1.

The entry on line 7a, column (b) (plan assets at end of year) must include the current value of any participant loan included as a deemed distribution in the amount reported for any earlier year if, during the plan year, the participant resumes repayment under the loan. In addition, the amount to be entered on line 8e must be reduced by the amount of the participant loan reported as a deemed distribution for the earlier year.

Line 7b. Enter the total liabilities at the beginning and end of the plan year. Liabilities to be entered here do not include the value of future pension payments to participants. The amount to be entered in line 7b for accrual basis filers includes, among other things:

1. Benefit claims that have been processed and approved for payment by the plan but have not been paid (including all incurred but not reported (IBNR) welfare benefit claims);

2. Accounts payable obligations owed by the plan that were incurred in the normal operations of the plan but have not been paid; and

3. Other liabilities such as acquisition indebtedness and any other amount owed by the plan.

Line 7c. Enter the net assets as of the beginning and end of the plan year. (Subtract line 7b from 7a). Line 7c, column (b), must equal the sum of line 7c, column (a), plus lines 8i (net income (loss)) and 8j (transfers to (from) the plan).

Line 8 – Income, Expenses, and Transfers for this Plan Year.

Line 8a. Include the total cash contributions received and/or (for accrual basis plans) due to be received.

Line 8a(1). Plans using the accrual basis of accounting must not include contributions designated for years before the 2023 plan year on line 8a(1).

Line 8a(2). For welfare plans, report all employee contributions, including all elective contributions under a cafeteria plan (Code section 125). For pension plans, participant contributions, for purposes of this line item, also include elective contributions under a qualified cash or deferred arrangement (Code section 401(k)).

Line 8a(3). Enter the current value, at date contributed, of all other contributions, including rollovers from other plans.

Line 8b. Enter all other plan income for the plan year. Do not include transfers from other plans that are reported on line 8j. Examples of other income received and/or receivable include:

1. Interest on investments (including money market accounts, sweep accounts, etc.)

2. Dividends. (Accrual basis plans should include dividends declared for all stock held by the plan even if the dividends have not been received as of the end of the plan year.)

3. Net gain or loss from the sale of assets.

4. Other income such as unrealized appreciation (depreciation) in plan assets.

To compute this amount, subtract the current value of all assets at the beginning of the year plus the cost of any assets acquired during the plan year from the current value of all assets at the end of the year minus assets disposed of during the plan year.

Line 8c. Enter the total of all cash contributions (line 8a(1) through line 8a(3)) and other plan income (line 8b) during the plan year. If entering a negative number, enter a minus sign (“–”) to the left of the number.

Line 8d. Include (1) payments made (and for accrual basis filers payments due) to or on behalf of participants or beneficiaries in cash, securities, or other property (including rollovers of an individual’s accrued benefit or account balance). Include all eligible rollover distributions as defined in Code section 401(a)(31)(D) paid at the participant’s election to an eligible retirement plan (including an IRA within the meaning of Code section 401(a)(31)(E)); (2) payments to insurance companies and similar organizations, such as Blue Cross, Blue Shield, and health maintenance organizations for the provision of plan benefits (e.g., paid-up annuities, accident insurance, health insurance, vision care, dental coverage, etc.); and (3) payments made to other organizations or individuals providing benefits. Generally, these payments discussed in (3) are made to individual providers of welfare benefits such as legal services, day care services, and training and apprenticeship services. If securities or other property are distributed to plan participants or beneficiaries, include the current value as of the date of distribution.

Line 8e. Include on this line all distributions paid during the plan year of excess deferrals under Code section 402(g)(2)(A)(ii), excess contributions under Code section 401(k)(8), and excess aggregate contributions under Code section 401(m)(6). Include allocable income distributed. Also include on this line any elective deferrals and employee contributions distributed or returned to employees during the plan year as well as any attributable income that was also distributed.

For line 8e, also include in the total amount a participant loan included in line 7a, column (a) that has been deemed distributed during the plan year under the provisions of Code section 72(p) and Treasury Regulations section 1.72(p)-1 only if both of the following circumstances apply:

1. Under the plan, the participant loan is treated as a directed investment solely of the participant’s individual account; and

2. As of the end of the plan year, the participant is not continuing repayment under the loan.

If either of these circumstances does not apply, a deemed distribution of a participant loan should not be included in the total on line 8e. Instead, the current value of the participant loan (including interest accruing thereon after the deemed distribution) should be included on lines 7a, column (b) (plan assets – end of year), and 10g (participant loans – end of year), without regard to the occurrence of a deemed distribution.

Note. The amount to be reported on line 8e must be reduced if, during the plan year, a participant resumes repayment under a participant loan reported as a deemed distribution on line 2g of Schedule H or Schedule I of a prior Form 5500 or line 8e of a prior Form 5500-SF for any earlier year. The amount of the required reduction is the amount of the participant loan that was reported as a deemed distribution on such line for any earlier year. If entering a negative number, enter a minus sign (“–”) to the left of the number. The current value of the participant loan must then be included on line 7a, column (b) (plan assets – end of year).

Although certain participant loans deemed distributed are to be reported on line 8e, and are not to be reported on the Form 5500-SF or on the Schedule H or Schedule I of the Form 5500 as an asset thereafter (unless the participant resumes repayment under the loan in a later year), they are still considered outstanding loans and are not treated as actual distributions for certain purposes. See Q&As 12 and 19 of Treasury Regulations section 1.72(p)-1.

Line 8f. The amount to be reported for expenses involving administrative service providers (salaries, fees, and commissions) includes the total fees paid (or in the case of accrual basis plans, costs incurred during the plan year but not paid as of the end of the plan year) by the plan for, among others:

1. Salaries to employees of the plan;

2. Fees and expenses for accounting, actuarial, legal, investment management, investment advice, and securities brokerage services;

3. Contract administrator fees; and

4. Fees and expenses for individual plan trustees, including reimbursement for travel, seminars, and meeting expenses.

Line 8g. Other expenses (paid and/or payable) include other administrative and miscellaneous expenses paid by or charged to the plan, including among others, office supplies and equipment, telephone, and postage.

Line 8h. Enter the total of all benefits paid or due reported on lines 8d and 8e and all other plan expenses reported on lines 8f and 8g during the year.

Line 8i. Subtract line 8h from line 8c.

Line 8j. Enter the net value of all assets transferred to and from the plan during the plan year, including those resulting from mergers and spinoffs. A transfer of assets or liabilities occurs when there is a reduction of assets or liabilities with respect to one plan and the receipt of these assets or the assumption of these liabilities by another plan. Transfers out at the end of the year should be reported as occurring during the plan year.

Note. A distribution of all or part of an individual participant’s account balance that is reportable on Form 1099-R, Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc., should not be included on line 8j but must be included in benefit payments reported on line 8d. Do not submit IRS Form 1099-R with the

Form 5500-SF.

Part IV – Plan Characteristics

Line 9 - Benefits Provided Under the Plan. Do not leave blank. In the boxes for line 9a and 9b, as appropriate, enter all applicable two-character plan characteristics codes from the List of Plan Characteristics Codes on pages 22 and 23 that describe the characteristics of the plan being reported.

Note. In the case of an eligible combined plan under Code section 414(x) and ERISA section 210(e), the codes entered in line 9a must include any codes applicable for either the defined benefit pension features or the defined contribution pension features of the plan.

F or plan sponsors of Puerto Rico plans, enter characteristic code 3C only if:

1. Only Puerto Rico residents participate,

2. The trust is exempt from income tax under the laws of Puerto Rico, and

3. The plan administrator has not made the election under section 1022(i)(2), and, therefore, the plan is not intended to qualify under section 401(a) of the Internal Revenue Code (U.S.).

Part V – Compliance Questions

Line 10. Answer all lines either “Yes” or “No.” Do not leave any answer blank unless otherwise directed. For lines 10a, b, c, d, e, f, g, and j, if the answer is “Yes,” an amount must be entered.

Line 10a. Amounts paid by a participant or beneficiary to an employer and/or withheld by an employer for contribution to the plan are participant contributions that become plan assets as of the earliest date on which such contributions can reasonably be segregated from the employer’s general assets. See 29 CFR 2510.3-102. In the case of a plan with fewer than 100 participants at the beginning of the plan year, any amount deposited with such plan not later than the 7^th business day following the day on which such amount is received by the employer (in the case of amounts that a participant or beneficiary pays to an employer), or the 7^th business day following the day on which such amount would otherwise have been payable to the participant in cash (in the case of amounts withheld by an employer from a participant’s wages), shall be deemed to be contributed or repaid to such plan on the earliest date on which such contributions or participant loan repayments can reasonably be segregated from the employer’s general assets. See 29 CFR 2510.3-102(a)(2). Plans that check “Yes,” must enter the aggregate amount of all late contributions for the year. The total amount of the delinquent contributions must be included on line 10a for the year in which the contributions were delinquent and must be carried over and reported again on line 10a for each subsequent year (or on line 4a of Schedule H or I of the Form 5500 if not eligible to file the Form 5500-SF in the subsequent year) until the year after the violation has been fully corrected by payment of the late contributions and reimbursement of the plan for lost earnings or profits. If no participant contributions were received or withheld by the employer during the plan year, answer “No.”

An employer holding participant contributions commingled with its general assets after the earliest date on which such contributions can reasonably be segregated from the employer’s general assets will have engaged in a prohibited use of plan assets (see ERISA section 406). If such a nonexempt prohibited transaction occurred with respect to a disqualified person (see Code section 4975(e)(2)), file IRS Form 5330, Return of Excise Taxes Related to Employee Benefit Plans, with the IRS to pay any applicable excise tax on the transaction.

Participant loan repayments paid to and/or withheld by an employer for purposes of transmittal to the plan that were not transmitted to the plan in a timely fashion must be reported either on line 10a in accordance with the reporting requirements that apply to delinquent participant contributions or on line 10b. See Advisory Opinion 2002-02A, available at www.dol.gov/agencies/ebsa.

Applicants that satisfy both the DOL Voluntary Fiduciary Correction Program (VFCP) and the conditions of Prohibited Transaction Exemption (PTE) 2002-51 are eligible for immediate relief from payment of certain prohibited transaction excise taxes for certain corrected transactions, and are also relieved from the requirement to file the IRS Form 5330 with the IRS. For more information on how to apply under the VFCP, the specific transactions covered (which transactions include delinquent participant contributions to pension and welfare plans), and acceptable methods for correcting violations, see 71 Fed. Reg. 20261 (Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19, 2006). All delinquent participant contributions must be reported on line 10a at least for the year in which they were delinquent even if violations have been fully corrected by the close of the plan year. Information about the VFCP is also available on the Internet at www.dol.gov/agencies/ebsa.

Line 10b. Plans that check “Yes” must enter the amount. Check “Yes” if any nonexempt transaction with a party-in-interest occurred. Do not check “Yes” with respect to transactions that are: (1) statutorily exempt under Part 4 of Title I of ERISA; (2) administratively exempt under ERISA section 408(a); (3) exempt under Code sections 4975(c) or 4975(d); (4) the holding of participant contributions in the employer’s general assets for a welfare plan that meets the conditions of ERISA Technical Release 92-01; or (5) delinquent participant contributions or delinquent loan repayments reported on line 10a. You may indicate that an application for an administrative exemption is pending. If you are unsure whether a transaction is exempt or not, you should consult either with a qualified public accountant, legal counsel, or both. If the plan is a qualified pension plan and a nonexempt prohibited transaction occurred with respect to a disqualified person, an IRS Form 5330 is required to be filed with the IRS to pay the excise tax on the transaction.

Nonexempt transactions. Nonexempt transactions with a party-in-interest include any direct or indirect:

A. Sale or exchange, or lease, of any property between the plan and a party-in-interest.

B. Lending of money or other extension of credit between the plan and a party-in-interest.

C. Furnishing of goods, services, or facilities between the plan and a party-in-interest.

D. Transfer to, or use by or for the benefit of, a party-in-interest, of any income or assets of the plan.

E. Acquisition, on behalf of the plan, of any employer security or employer real property in violation of ERISA section 407(a).

F. Dealing with the assets of the plan for a fiduciary’s own interest or own account.

G. Acting in a fiduciary’s individual or any other capacity in any transaction involving the plan on behalf of a party (or represent a party) whose interests are adverse to the interests of the plan or the interests of its participants or beneficiaries.

H. Receipt of any consideration for his or her own personal account by a party-in-interest who is a fiduciary from any party dealing with the plan in connection with a transaction involving the income or assets of the plan.

Party-in-Interest. For purposes of this form, party-in-interest is deemed to include a disqualified person. See Code section 4975(e)(2). The term “party-in-interest” means, as to an employee benefit plan:

A. Any fiduciary (including, but not limited to, any administrator, officer, trustee, or custodian), counsel, or employee of the plan;

B. A person providing services to the plan;

C. An employer, any of whose employees are covered by the plan;

D. An employee organization, any of whose members are covered by the plan;

E. An owner, direct or indirect, of 50% or more of:

1. the combined voting power of all classes of stock entitled to vote or the total value of shares of all classes of stock of a corporation;

2. the capital interest or the profits interest of a partnership; or

3. the beneficial interest of a trust or unincorporated enterprise which is an employer or an employee organization described in C or D;

F. A relative of any individual described in A, B, C, or E;

G. A corporation, partnership, or trust or estate of which (or in which) 50% or more of:

1. the combined voting power of all classes of stock entitled to vote or the total value of shares of all classes of stock of such corporation,

2. the capital interest or profits interest of such partnership, or

3. the beneficial interest of such trust or estate, is owned directly or indirectly, or held by persons described in A, B, C, D, or E;

H. An employee, officer, director (or an individual having powers or responsibilities similar to those of officers or directors), or a 10% or more shareholder directly or indirectly, of a person described in B, C, D, E, or G, or of the employee benefit plan; or

I. A 10% or more (directly or indirectly in capital or profits) partner or joint venture of a person described in B, C, D, E, or G.

A pplicants that satisfy the VFCP requirements and the conditions of PTE 2002-51 (see the instructions for line 10a) are eligible for immediate relief from payment of certain prohibited transaction excise taxes for certain corrected transactions and the requirement to file the Form 5330 with the IRS. For more information, see 71 Fed. Reg. 20261 (Apr. 19, 2006) and 71 Fed. Reg. 20135 (Apr. 19, 2006). When the conditions of PTE 2002-51 have been satisfied, the corrected transactions should be treated as exempt under Code section 4975(c) for the purposes of answering line 10b.

Line 10c. Plans that check “Yes” must enter the aggregate amount of fidelity bond coverage for all claims. Check “Yes” only if the plan itself (as opposed to the plan sponsor or administrator) is a named insured under a fidelity bond that is from an approved surety covering plan officials and that protects the plan from losses due to fraud or dishonesty as described in 29 CFR Part 2580. Generally, every plan official of an employee benefit plan who “handles” funds or other property of such plan must be bonded. Generally, a person shall be deemed to be “handling” funds or other property of a plan, so as to require bonding, whenever their duties or activities with respect to given funds are such that there is a risk that such funds could be lost in the event of fraud or dishonesty on the part of such person, acting either alone or in collusion with others. Section 412 of ERISA and 29 CFR Part 2580 describe the bonding requirements, including the definition of “handling” (29 CFR 2580.412-6), the permissible forms of bonds (29 CFR 2580.412-10), the amount of the bond (29 CFR Part 2580, Subpart C), and certain exemptions such as the exemption for unfunded plans, certain banks and insurance companies (ERISA section 412), and the exemption allowing plan officials to purchase bonds from surety companies authorized by the Secretary of the Treasury as acceptable reinsurers on federal bonds (29 CFR 2580.412-23). Information concerning the list of approved sureties and reinsurers is available on the Internet at www.fms.treas.gov/c570. For more information on the fidelity bonding requirements, see Field Assistance Bulletin 2008-04, available at www.dol.gov/agencies/ebsa.

Note. Plans are permitted under certain conditions to purchase fiduciary liability insurance. These fiduciary liability insurance policies are not written specifically to protect the plan from losses due to dishonest acts and cannot be reported as fidelity bonds on line 10c.

Line 10d. Check “Yes” if the plan had suffered or discovered any loss as a result of any dishonest or fraudulent act(s) even if the loss was reimbursed by the plan’s fidelity bond or from any other source. If “Yes” is checked, enter the full amount of the loss. If the full amount of the loss has not yet been determined, provide an estimate as determined in good faith by a plan fiduciary. You must keep, in accordance with ERISA section 107, records showing how the estimate was determined.

W illful failure to report is a criminal offense. See ERISA section 501.

Line 10e. If any benefits under the plan are provided by an insurance company, insurance service, or other similar organization (such as Blue Cross Blue Shield or a health maintenance organization) or if the plan has investments with insurance companies such as guaranteed investment contracts (GICs), report the total of all insurance fees and commissions paid to agents, brokers and/or other persons directly or indirectly attributable to the contract(s) placed with or retained by the plan.

For purposes of line 10e, commissions and fees include sales or base commissions and all other monetary and non-monetary forms of compensation where the broker’s, agent’s, or other person’s eligibility for the payment or the amount of the payment is based, in whole or in part, on the value (e.g., policy amounts, premiums) of contracts or policies (or classes thereof) placed with or retained by an ERISA plan, including, for example, persistency and profitability bonuses. The amount (or pro rata share of the total) of such commissions or fees attributable to the contract or policy placed with or retained by the plan must be reported. Insurers must provide plan administrators with a proportionate allocation of commissions and fees attributable to each contract. Any reasonable method of allocating commissions and fees to policies or contracts is acceptable, provided the method is disclosed to the plan administrator. A reasonable allocation method could allocate fees and commissions based on a calendar year calculation even if the plan year or policy year was not a calendar year. For additional information on these reporting requirements, see ERISA Advisory opinion 2005-02A, available on the Internet at www.dol.gov/agencies/ebsa.

Where benefits under a plan are purchased from and guaranteed by an insurance company, insurance service, or other similar organization, and the total fees and commissions are reported on the Form 5500-SF, payments of reasonable monetary compensation by the insurer out of its general assets to affiliates or third parties for performing administrative activities necessary for the insurer to fulfill its contractual obligation to provide benefits, where there is no direct or indirect charge to the plan for administrative services other than the insurance premium, then the payments for administrative services by the insurer to the affiliates or third parties do not need to be reported on line 10e. This would include compensation for services such as recordkeeping and claims processing services provided by a third party pursuant to a contract with the insurer to provide those services but would not include compensation provided by the insurer incidental to the sale or renewal of a policy, such as finders’ fees, insurance brokerage commissions and fees, or similar fees.

Reporting also is not required for compensation paid by the insurer to a “general agent” or “manager” for that general agent’s or manager’s management of an agency or performance of administrative functions for the insurer. For this purpose, (1) a “general agent” or “manager” does not include brokers representing insureds, and (2) payments would not be treated as paid for managing an agency or performance of administrative functions where the recipient’s eligibility for the payment or the amount of the payment is dependent or based on the value (e.g., policy amounts, premiums) of contracts or policies (or classes thereof) placed with or retained by ERISA plan(s).

Reporting is not required for occasional gifts or meals of insubstantial value which are tax deductible for federal income tax purposes by the person providing the gift or meal and would not be taxable income to the recipient. For this exemption to be available, the gift or gratuity must be both occasional and insubstantial. For this exemption to apply, the gift must be valued at less than $50, the aggregate value of gifts from one source in a calendar year must be less than $100, but gifts with a value of less than $10 do not need to be counted toward the $100 annual limit. If the $100 aggregate value limit is exceeded, then the aggregate value of all the gifts will be reportable. For this purpose, non-monetary gifts of less than $10 also do not need to be included in calculating the aggregate value of all gifts required to be reported if the $100 limit is exceeded.

Gifts from multiple employees of one service provider should be treated as originating from a single source when calculating whether the $100 threshold applies. On the other hand, in applying the threshold to an occasional gift received from one source by multiple employees of a single service provider, the amount received by each employee should be separately determined in applying the $50 and $100 thresholds. For example, if six employees of a broker attend a business conference put on by an insurer designed to educate and explain the insurer’s products for employee benefit plans, and the insurer provides, at no cost to the attendees, refreshments valued at $20 per individual, the gratuities would not be reportable on this line even though the total cost of the refreshments for all the employees would be $120.

These thresholds are for purposes of line 10e reporting. Filers are cautioned that the payment or receipt of gifts and gratuities of any amount by plan fiduciaries may violate ERISA and give rise to civil liabilities and criminal penalties.

Important Reminder. The insurance company, insurance service, or other similar organization is required under ERISA section 103(a)(2) to provide the plan administrator with the information needed to complete this return/report. Your insurance company must provide you with the information you need to answer this question. If your insurance company, insurance service, or other similar organization does not automatically send you this information, you should make a written request for the information. If you have difficulty getting the information from your insurance company, contact the nearest office of the DOL’s Employee Benefits Security Administration.

Line 10f. You must check “Yes” if any benefits due under the plan were not timely paid or not paid in full. This would include required minimum distributions to 5% owners who have attained the applicable ages as described in Code section 401(a)(9)(C)(v) whether or not retired and/or non-5% owners who have attained the applicable ages as described in Code section 401(a)(9)(C)(v) and have retired or separated from service; see Code section 401(a)(9). Include in this amount the total of any outstanding amounts that were not paid when due in previous years that have continued to remain unpaid.

Note: In the absence of other guidance, filers do not need to report on this line unpaid required minimum distribution (RMD) amounts for participants who have retired or separated from service, or their beneficiaries, who cannot be located after reasonable efforts or where the plan is in the process of engaging in such reasonable efforts at the end of the plan year reporting period. Plan administrators and employers should review their plan documents for written procedures on locating missing participants. Although the Department of Labor’s Field Assistance Bulletin 2014-01 is specifically applicable to terminated defined contribution plans, employers and plan administrators of ongoing plans may want to consider periodically using one or more of the search methods described in the Field Assistance Bulletin in connection with making reasonable efforts to locate RMD-eligible missing participants.

Line 10g. You must check “Yes” if the plan had any participant loans outstanding at any time during the plan year and enter the amount outstanding as of the end of the plan year. If no participant loans are outstanding as of the end of the plan year, enter “0”.

Line 10h. Code section 401(k) and other individual account pension plans must complete line 10h. Other filers should leave line 10h blank. Check “Yes” if there was a “blackout period.” A blackout period is a temporary suspension of more than three consecutive business days during which participants or beneficiaries of a 401(k) or other individual account pension plan were unable, or were limited or restricted in their ability, to direct or diversify assets credited to their accounts, obtain loans from the plan, or obtain distributions from the plan. A “blackout period” generally does not include a temporary suspension of the right of participants and beneficiaries to direct or diversify assets credited to their accounts, obtain loans from the plan, or obtain distributions from the plan if the temporary suspension is: (1) part of the regularly scheduled operations of the plan that has been disclosed to participants and beneficiaries; (2) due to a qualified domestic relations order (QDRO) or because of a pending determination as to whether a domestic relations order is a QDRO; (3) due to an action or a failure to take action by an individual participant or because of an action or claim by someone other than the plan regarding a participant’s individual account; or (4) by application of federal securities laws. For more information, see the DOL’s regulation at 29 CFR 2520.101-3 (available at www.dol.gov/agencies/ebsa).

Line 10i. Code section 401(k) and other individual account pension plans who answered “Yes” to line 10h must complete line 10i. Other filers should leave line 10i blank. If there was a blackout period, did you provide the required notice not less than 30 days nor more than 60 days in advance of restricting the rights of participants and beneficiaries to change their plan investments, obtain loans from the plan, or obtain distributions from the plan? If so, check “Yes.” See 29 CFR 2520.101-3 for specific notice requirements and for exceptions from the notice requirement. Also, answer “Yes” if one of the exceptions to the notice requirement under 29 CFR 2520.101-3 applies.

Part VI – Pension Funding Compliance

Complete Part VI only if the plan is subject to the minimum funding requirements of Code section 412 or ERISA section 302.

All qualified defined benefit and defined contribution plans are subject to the minimum funding requirements of Code section 412 unless they are described in the exceptions listed under Code section 412(e)(2). These exceptions include profit-sharing or stock bonus plans, insurance contract plans described in Code section 412(e)(3), and certain plans to which no employer contributions are made.

Nonqualified employee pension benefit plans are subject to the minimum funding requirements of ERISA section 302 unless specifically exempted under ERISA sections 4(a) or 301(a).

The employer or plan administrator of a single-employer or multiple-employer defined benefit plan that is subject to the minimum funding requirements must file the Schedule SB (Form 5500) as an attachment to the

Form 5500-SF. The employer or plan administrator of a money purchase plan that is currently amortizing a waiver of the minimum funding requirements must complete lines 3, 9, and 10 of the Schedule MB (Form 5500) and file it as an attachment to the Form 5500-SF.

Line 11. If “Yes” is checked, attach a completed and signed Schedule SB (Form 5500), and complete lines 11a and 11b. See the instructions for the Schedule SB in the Instructions for Form 5500.

Note. If this is a defined contribution pension plan, leave line 11 blank and complete line 12.

Line 11a. Enter the amount from line 40 of Schedule SB (Form 5500).

Line 11b. Do not complete this item unless the plan is covered by PBGC and the amount reported in line 11a is greater than $0.

In general, a PBGC-insured single-employer plan must notify PBGC if a required contribution is not made by its due date. With the exception of situations where the accumulated value of missed contributions exceeds $1 million, PBGC waives reporting if contributions equal to or exceeding the missed amount are made by the 30^th day after the due date. For more information, see 29 CFR 4043.25 and 4043.81 and the filing instructions for PBGC Forms 10 and 200.

If PBGC has been notified of the missed contribution, check the “Yes” box. Otherwise, check the box that best explains why PBGC wasn’t notified. If the “No. Other. Provide explanation.” box is checked, provide an explanation as to why the PBGC wasn’t notified (e.g., “The due date for filing Form 10 has not yet passed; the plan administrator intends to file Form 10 with PBGC shortly” or “Reporting was waived under 29 CFR 4043.25(c)(3) because the unpaid contribution resulted solely from an administrative error related to an election to use a pre-funding balance”).

Line 12. Check the “Yes” box if the plan is a defined contribution plan subject to the minimum funding requirements of Code section 412 and ERISA section 302. Those money purchase plans (including target benefit plans) that are amortizing a waiver of the minimum funding standard for a prior year should fill out line 12a and then skip to line 13. Those defined contribution plans answering “Yes” to the line 12 question that do not fill out line 12a should fill out lines 12b-12e. Other defined contribution pension plans that are not subject to the minimum funding requirements check “no” in Line 12 and skip to Line 13. Defined benefit pension plans complete Line 11; if you are filing on behalf of a defined benefit pension plan, leave line 12 blank.

Line 12a. If a money purchase defined contribution plan (including a target benefit plan) has received a waiver of the minimum funding standard, and the waiver is currently being amortized, complete lines 3, 9, and 10 of Schedule MB (Form 5500). See instructions for Schedule MB in the Instructions for Form 5500. The Schedule MB for a money purchase defined contribution plan does not need to be signed by an enrolled actuary.

Line 12b. The minimum required contribution for a money purchase defined contribution plan (including a target benefit plan) for a plan year is the amount required to be contributed for the year under the formula set forth in the plan document. If there is an accumulated funding deficiency for a prior year that has not been waived, that amount should also be included as part of the contribution required for the current year.

Line 12c. Include all contributions for the plan year made not later than 8 ½ months after the end of the plan year. Show only contributions actually made to the plan by the date the form is filed. For example, do not include receivable contributions for this purpose.

Line 12d. If the minimum required contribution exceeds the contributions for the plan year made not later than 8 ½ months after the end of the plan year, the excess is an accumulated funding deficiency for the plan year. File IRS Form 5330, Return of Excise Taxes Related to Employee Benefit Plans, with the IRS to pay the excise tax on the deficiency. There is a penalty for not filing Form 5330 on time.

Line 12e. Check “Yes” if the minimum required contribution remaining in line 12d will be made not later than 8 ½ months after the end of the plan year. If “Yes,”

and contributions are actually made by this date, then there will be no reportable deficiency and IRS Form 5330 will not need to be filed.

Part VII – Plan Terminations and Transfers of Assets

Line 13a. Check “Yes” if a resolution to terminate the plan was adopted during this or any prior plan year, unless the termination was revoked and no assets reverted to the employer. If “Yes” is checked, enter the amount of plan assets that reverted to the employer during the plan year in connection with the implementation of such termination. Enter “0” if no reversion occurred during the current plan year.

A Form 5500 or a Form 5500-SF must be filed for each year the plan has assets, and, for a welfare benefit plan, if the plan is still liable to pay benefits for claims incurred before the termination date, but not yet paid. See 29 CFR 2520.104b-2(g)(2)(ii).

Line 13b. Check “Yes” if all of the plan assets (including insurance/annuity contracts) were distributed to the participants and beneficiaries, legally transferred to the control of another plan, or brought under the control of the PBGC.

Check “No” for a welfare benefit plan that is still liable to pay benefits for claims that were incurred before the termination date, but not yet paid. See 29 CFR 2520.104b-2(g)(2)(ii).

Line 13c. Enter information concerning assets and/or liabilities transferred from this plan to another plan(s) (including spinoffs) during the plan year. A transfer of assets or liabilities occurs when there is a reduction of assets or liabilities with respect to one plan and the receipt of these assets or the assumption of these liabilities by another plan. Enter the name, plan sponsor EIN, and PN of the transferee plan(s) involved on lines 13c(1), c(2), and c(3).

Do not use a social security number in place of an EIN or include an attachment that contains visible social security numbers. The Form 5500-SF is open to public inspection, and the contents are public information and are subject to publication on the Internet. Because of privacy concerns, the inclusion of a social security number or any portion thereof on this Form 5500-SF may result in the rejection of the filing.

Note. A distribution of all or part of an individual participant’s account balance that is reportable on Form 1099-R should not be included on line 13c. Do not submit Form 1099-R with the Form 5500-SF.

IRS Form 5310-A, Notice of Plan Merger or Consolidation, Spinoff, or Transfer of Plan Assets or Liabilities; Notice of Qualified Separate Lines of Business, must be filed at least 30 days before any plan merger or consolidation or any transfer of plan assets or liabilities to another plan. There is a penalty for not filing

IRS Form 5310-A on time. In addition, a transfer of benefit liabilities involving a plan covered by PBGC insurance may be reportable to the PBGC. See PBGC Form 10, Post-Event Notice of Reportable Event, and PBGC Form 10-Advance, Advance Notice of Reportable Event (see the “Reportable Events and Large Unpaid Contributions” section of the Practitioners page on PBGC’s website, which is available at www.pbgc.gov/practitioners).

Part VIII – IRS Compliance Questions

Line 14a. A multiple-employer plan should skip this question. Check "Yes" if this plan was permissively aggregated with another plan to satisfy the requirements of Code sections 410(b) and 401(a)(4). Generally, each single plan must separately satisfy the coverage and nondiscrimination requirements. However, an employer generally may designate two or more separate plans as a single plan for purposes of applying the ratio percentage test of Treasury Regulations section 1.410(b)-2(b)(2) or the nondiscriminatory classification test of Treasury Regulations section 1.410(b)-4. Two or more plans that are permissively aggregated and treated as a single plan for purposes of the minimum coverage test of Code section 410(b) must also be treated as a single plan for purposes of the nondiscrimination test under Code section 401(a)(4). See Treasury Regulations sections 1.410(b)-7(d) and 1.401(a)(4)-(9)(a) for more information.

Line 14b. A multiple-employer plan should skip this question. Check the applicable method used to satisfy the nondiscrimination requirements of Code section 401(k). A safe harbor 401(k) plan is similar to a traditional 401(k) plan, but it must provide for employer contributions. These contributions may be employer matching contributions limited to employees who defer, or employer contributions made on behalf of all eligible employees, regardless of whether they make elective deferrals. A safe harbor 401(k) plan is not subject to the complex annual nondiscrimination tests that apply to traditional 401(k) plans.

Check "Design-based safe harbor method" if this is a safe harbor 401(k) plan, that is, a SIMPLE 401(k) plan under Code section 401(k)(11), a safe harbor 401(k) plan under Code section 401(k)(12), or a qualified automatic contribution arrangement under Code section 401(k)(13). If the plan, by its terms, does not satisfy the safe harbor method, it generally must satisfy the regular nondiscrimination test, known as the actual deferral percentage (ADP) test.

Check the appropriate box to indicate if the plan uses the "current year" ADP test or the "prior year" ADP test.

Check "current year" ADP test if the plan uses the current year testing method under which the ADP test is performed by comparing the current plan year's ADP for highly compensated employees (HCEs) with the current plan year's (rather than the prior plan year's) ADP for nonhighly compensated employees (NHCEs).

Check all boxes that apply for a plan that tests different groups of employees on a disaggregated basis, or uses different testing methods for different portions of the plan. For example, a plan that allows for immediate eligibility for elective deferrals and statutory eligibility for safe harbor contributions would be a safe harbor plan for statutory employees. However, the plan would be subject to ADP testing for non-statutory employees.

Check "N/A" if the plan is not required to test for nondiscrimination under Code section 401(k)(3), such as a plan in which no HCE is benefiting.

Line 15. If a plan sponsor or an employer adopted a Pre-approved Plan that had received a favorable Opinion Letter, enter the date of the most recent favorable Opinion Letter issued by the IRS and the Opinion Letter serial number listed on the letter. A “Pre-approved Plan” is a plan approved by the IRS with a favorable opinion letter that is made available by a Provider for adoption by employers, including a standardized plan or a nonstandardized plan. A Pre-approved Plan may utilize either of two forms: a basic plan document with an adoption agreement or a single plan document. The employer is permitted to make minor modifications to the plan. An “Adopting Employer” is an employer that adopts a Pre-approved Plan offered by a Provider, including a plan that is word-for-word identical to, or a minor modification of, a plan of a Mass Submitter. If a plan was modified in such a way that negates the Opinion Letter, then the plan sponsor is now no longer an Adopting Employer of a Pre-approved Plan, and the plan is treated as an individually designed plan. An “Opinion Letter” is a written statement issued by the IRS to a Provider or Mass Submitter as an opinion on the qualification in form of a plan under Code section 401(a), Code section 403(a), or both Code sections 401(a) or 403(a) and 4975(e)(7). See Revenue Procedure 2017-41 for more information. The opinion letter serial number is a unique combination of a capital letter and a series of six numbers assigned to each opinion letter.

OMB Control Numbers

Agency OMB Number

Employee Benefits Security Administration 1210–0110

1210–0089

Internal Revenue Service 1545–1610

Pension Benefit Guaranty Corporation 1212–0057

Paperwork Reduction Act Notice

We ask for the information on this form to carry out the law as specified in ERISA and in Code sections 6058(a) and 6059(a). You are required to give us the information. We need it to determine whether the plan is operating according to the law.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books and records relating to a form or its instructions must be retained as long as their contents may become material in the administration of the Internal Revenue Code or are required to be maintained pursuant to Title I or IV of ERISA. The Form 5500-SF return/reports are open to public inspection and are subject to publication on the Internet.

The time needed to complete and file the Form 5500-SF and the Schedules SB (Form 5500) and MB (Form 5500) shown in the list below reflects the combined requirements of the Internal Revenue Service, Department of Labor, and Pension Benefit Guaranty Corporation. These times will vary depending on individual circumstances. The estimated average times are:

Form	Pension Plans	Welfare Plans
Form 5500-SF Schedule MB (Form 5500) Schedule SB (Form 5500) Schedule MEP (Form 5500)	2 hr., 35 min. 8 hr., 40 min. 6 hr., 49 min. 10 mins.	2 hr., 35 min. N/A N/A N/A

If you have comments concerning the accuracy of these time estimates or suggestions for making these forms simpler, we would be happy to hear from you. You can write to the Internal Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, IR-6526, Washington, DC 20224. Do not send this form or these schedules to this address. The form and schedules must be filed electronically. See How To File – Electronic Filing Requirement.

LIST OF PLAN CHARACTERISTICS CODES FOR LINES 9a AND 9b

CODE	Defined Benefit Pension Features
1A	Benefits are primarily pay related.
1B	Benefits are primarily flat dollar (includes dollars per year of service).
1C	Cash balance or similar plan – Plan has a “cash balance” formula. For this purpose, a “cash balance” formula is a benefit formula in a defined benefit plan by whatever name (for example, personal account plan, pension equity plan, life cycle plan, cash account plan, etc.) that rather than, or in addition to, expressing the accrued benefit as a life annuity commencing at normal retirement age, defines benefits for each employee in terms more common to a defined contribution plan such as a single sum distribution amount (for example, 10% of final average pay times years of service, or the amount of the employee’s hypothetical account balance).
1D	Floor-offset plan – Plan benefits are subject to offset for retirement benefits provided by an employer-sponsored defined contribution plan.
1E	Code section 401(h) arrangement – Plan contains separate accounts under Code section 401(h) to provide employee health benefits.
1F	Code section 414(k) arrangement – Benefits are based partly on the balance of the separate account of the participant (also include appropriate defined contribution pension feature codes).
1H	Plan covered by PBGC that was terminated and closed out for PBGC purposes – Before the end of the plan year (or a prior plan year), (1) the plan terminated in a standard (or distress) termination and completed the distribution of plan assets in satisfaction of all benefit liabilities (or all ERISA Title IV benefits for distress termination); or (2) a trustee was appointed for a terminated plan pursuant to ERISA section 4042.
1I	Frozen plan – As of the last day of the plan year, the plan provides that no participant will get any new benefit accrual (whether because of service or compensation).
CODE	Defined Contribution Pension Features
2A	Use this code if employer contributions in the return year were based on one of the following allocation types: Age/service weighted or new comparability or similar plan – Age/service weighted plan: Allocations are based on age, service, or age and service. New comparability or similar plan: Allocations are based on participant classifications and a classification(s) consists entirely or predominantly of highly compensated employees; or the plan provides an additional allocation rate on compensation above a specified threshold, and the threshold or additional rate exceeds the maximum threshold or rate allowed under the permitted disparity rules of Code section 401(l).
2B	Target benefit plan.
2C	Money purchase (other than target benefit) plan.
2D	Offset plan – Plan benefits are subject to offset for retirement benefits provided in another plan or arrangement of the employer.
2E	Profit Sharing plan.
2F	ERISA section 404(c) plan – This plan, or any part of it, is intended to meet the conditions of 29 CFR 2550.404c-1.
2G	Total participant-directed account plan – Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
2H	Partial participant-directed account plan – Participants have the opportunity to direct the investment of a portion of the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
2J	Code section 401(k) feature – A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
2K	Code section 401(m) arrangement – Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contributions to the plan. Not applicable if plan is a Code section 401(k) plan with only QNECs and/or QMACs. Also not applicable if plan is a Code section 403(b)(1), 403(b)(7), or 408 arrangement/ accounts annuities.
2L	An annuity contract purchased by Code section 501(c)(3) organization or public school as described in Code section 403(b)(1) arrangement.
2M	Custodial accounts for regulated investment company stock as described in Code section 403(b)(7).
2N	Code section 408 accounts and annuities.
2R	Participant-directed brokerage accounts provided as an investment option under the plan.
2S	401(k) plan or 403(b) plan that provides for automatic enrollment in plan that has elective contributions deducted from payroll.
2T	Total or partial participant-directed account plan – plan uses default investment account for participants who fail to direct assets in their account.
2U	Multiple-employer pension plan sponsored by a bona fide group or association of employers that is an Association Retirement Plan that meets all the conditions under 29 CFR 2510.3-55(b).
2V	Multiple-employer pension plan that is a Professional Employer Organization Plan (PEO Plan) that meets all the conditions under 29 CFR 2510.3-55(c).
2X	Multiple-employer defined contribution pension plan that does not fall under characteristics codes 2U or 2V and is not a pooled employer plan as defined in ERISA section 3(43).
CODE	Other Pension Benefit Features
3B	Use this code if the plan covered self-employed individuals in the return year.
3C	Plan not intended to be qualified – A plan not intended to be qualified under Code sections 401, 403, or 408.
3D	Pre-approved pension plan – A pre-approved plan under sections 401, 403(a), 403(b), and 4975(e)(7) of the Code that is subject to a favorable opinion letter from the IRS.

LIST OF PLAN CHARACTERISTICS CODES FOR LINES 9a AND 9b (Continued)

3F	Plan sponsor(s) received services of leased employees, as defined in Code section 414(n), during the plan year.
3H	Plan sponsor(s) is (are) a member(s) of a controlled group under Code section 414(b) or (c) or of an affiliated service group under section 414(m).
3J	U.S.-based plan that covers residents of Puerto Rico and is qualified under both Code section 401 and section 1165 of the Internal Revenue Code of Puerto Rico.
CODE	Welfare Benefit Features
4A	Health (other than vision or dental).
4B	Life insurance.
4C	Supplemental unemployment.
4D	Dental.
4E	Vision.
4F	Temporary disability (accident and sickness).
4G	Prepaid legal.
4H	Long-term disability.
4I	Severance pay.
4J	Apprenticeship and training.

4K	Scholarship (funded).
4L	Death benefits (include travel accident but not life insurance).
4P	Taft-Hartley Financial Assistance for Employee Housing Expenses.
4Q	Other.
4R	Unfunded, fully insured, or combination unfunded/fully insured welfare plan that will not file an annual report for next plan year pursuant to 29 CFR 2520.104-20.
4S	Unfunded, fully insured, or combination unfunded/fully insured welfare plan that stopped filing annual reports in an earlier plan year pursuant to 29 CFR 2520.104-20.
4T	10 or more employer plan under Code section 419A(f)(6).

Forms 5500, 5500-SF, and 5500-EZ Codes for Principal Business Activity		This list of principal business activities and their associated codes is designed to classify an enterprise by the type of activity in which it is engaged.		These principal activity codes are based on the North American Industry Classification System.
Code	Code		Code		Code
Agriculture, Forestry, Fishing	Specialty Trade Contractors		Printing and Related Support		Computer and Electronic Product
and Hunting	238100 Foundation, Structure, &		Activities		Manufacturing
Crop Production	Building Exterior Contractors		323100 Printing & Related Support		334110 Computer & Peripheral
111100 Oilseed & Grain Farming	(including framing carpentry,		Activities		Equipment Mfg
111210 Vegetable & Melon Farming	masonry, glass, roofing, &		Petroleum and Coal Products		334200 Communications Equipment
(including potatoes & yams)	siding)		Manufacturing		Mfg
111300 Fruit & Tree Nut Farming	238210 Electrical Contractors		324110 Petroleum Refineries		334310 Audio & Video Equipment Mfg
111400 Greenhouse, Nursery, &	238220 Plumbing, Heating, &		(including integrated)		334410 Semiconductor & Other
Floriculture Production	Air-Conditioning Contractors		324120 Asphalt Paving, Roofing, &		Electronic Component Mfg
111900 Other Crop Farming	238290 Other Building Equipment		Saturated Materials Mfg		334500 Navigational, Measuring,
(including tobacco, cotton,	Contractors		324190 Other Petroleum & Coal		Electromedical, & Control
sugarcane, hay, peanut,	238300 Building Finishing		Products Mfg		Instruments Mfg
sugar beet, & all other crop	Contractors (including		Chemical Manufacturing		334610 Manufacturing & Reproducing
farming)	drywall, insulation, painting,		325100 Basic Chemical Mfg		Magnetic & Optical Media
Animal Production	wallcovering, flooring, tile, &		325200 Resin, Synthetic Rubber, &		Electrical Equipment, Appliance, and
112111 Beef Cattle Ranching &	finish carpentry)		Artificial & Synthetic Fibers &		Component Manufacturing
Farming	238900 Other Specialty Trade		Filaments Mfg		335100 Electric Lighting Equipment
112112 Cattle Feedlots	Contractors (including site		325300 Pesticide, Fertilizer, & Other		Mfg
112120 Dairy Cattle & Milk	preparation)		Agricultural Chemical Mfg		335200 Major Household Appliance Mfg
Production	Manufacturing		325410 Pharmaceutical & Medicine Mfg		335310 Electrical Equipment Mfg
112210 Hog & Pig Farming	Food Manufacturing		325500 Paint, Coating, & Adhesive Mfg		335900 Other Electrical Equipment &
112300 Poultry & Egg Production	311110 Animal Food Mfg		325600 Soap, Cleaning Compound, &		Component Mfg
112400 Sheep & Goat Farming	311200 Grain & Oilseed Milling		Toilet Preparation Mfg		Transportation Equipment
112510 Aquaculture (including	311300 Sugar & Confectionary		325900 Other Chemical Product &		Manufacturing
shellfish & finfish farms &	Product Mfg		Preparation Mfg		336100 Motor Vehicle Mfg
hatcheries)	311400 Fruit & Vegetable Preserving		Plastics and Rubber Products		336210 Motor Vehicle Body & Trailer
112900 Other Animal Production	& Specialty Food Mfg		Manufacturing		Mfg
Forestry and Logging	311500 Dairy Product Mfg		326100 Plastics Product Mfg		336300 Motor Vehicle Parts Mfg
113110 Timber Tract Operations	311610 Animal Slaughtering and		326200 Rubber Product Mfg		336410 Aerospace Product & Parts
113210 Forest Nurseries & Gathering	Processing		Nonmetallic Mineral Product		Mfg
of Forest Products	311710 Seafood Product Preparation		Manufacturing		336510 Railroad Rolling Stock Mfg
113310 Logging	& Packaging		327100 Clay Product & Refractory Mfg		336610 Ship & Boat Building
Fishing, Hunting and Trapping	311800 Bakeries, Tortilla & Dry Pasta		327210 Glass & Glass Product Mfg		336990 Other Transportation
114110 Fishing	Mfg		327300 Cement & Concrete Product Mfg		Equipment Mfg
114210 Hunting & Trapping	311900 Other Food Mfg (including		327400 Lime & Gypsum Product Mfg		Furniture and Related Product
Support Activities for Agriculture	coffee, tea, flavorings &		327900 Other Nonmetallic Mineral		Manufacturing
and Forestry	seasonings)		Product Mfg		337000 Furniture & Related Product
115110 Support Activities for Crop	Beverage and Tobacco Product		Primary Metal Manufacturing		Manufacturing
Production (including cotton	Manufacturing		331110 Iron & Steel Mills & Ferroalloy		Miscellaneous Manufacturing
ginning, soil preparation,	312110 Soft Drink & Ice Mfg		Mfg		339110 Medical Equipment &
planting, & cultivating)	312120 Breweries		331200 Steel Product Mfg from		Supplies Mfg
115210 Support Activities for Animal	312130 Wineries		Purchased Steel		339900 Other Miscellaneous Mfg
Production	312140 Distilleries		331310 Alumina & Aluminum		Wholesale Trade
115310 Support Activities for	312200 Tobacco Manufacturing		Production & Processing		Merchant Wholesalers, Durable
Forestry	Textile Mills and Textile Product		331400 Nonferrous Metal (except		Goods
Mining	Mills		Aluminum) Production &		423100 Motor Vehicle, & Motor
211120 Crude Petroleum Extraction	313000 Textile Mills		Processing		Vehicle Parts & Supplies
211130 Natural Gas Extraction	314000 Textile Product Mills		331500 Foundries		423200 Furniture & Home Furnishings
212110 Coal Mining	Apparel Manufacturing		Fabricated Metal Product		423300 Lumber & Other Construction
212200 Metal Ore Mining	315100 Apparel Knitting Mills		Manufacturing		Materials
212310 Stone Mining & Quarrying	315210 Cut & Sew Apparel		332110 Forging & Stamping		423400 Professional & Commercial
212320 Sand, Gravel, Clay, &	Contractors		332210 Cutlery & Handtool Mfg		Equipment & Supplies
Ceramic & Refractory	315220 Men’s & Boys’ Cut & Sew		332300 Architectural & Structural		423500 Metal & Mineral (except
Minerals Mining, & Quarrying	Apparel Mfg.		Metals Mfg		petroleum)
212390 Other Nonmetallic Mineral	315240 Women’s, Girls’ and Infants’		332400 Boiler, Tank, & Shipping		423600 Household Appliances and
Mining & Quarrying	Cut & Sew Apparel Mfg.		Container Mfg		Electrical & Electronic Goods
213110 Support Activities for Mining	315280 Other Cut & Sew Apparel Mfg		332510 Hardware Mfg		423700 Hardware, Plumbing, &
Utilities	315990 Apparel Accessories & Other		332610 Spring & Wire Product Mfg		Heating Equipment &
221100 Electric Power Generation,	Apparel Mfg		332700 Machine Shops; Turned		Supplies
Transmission & Distribution	Leather and Allied Product		Product; & Screw, Nut, & Bolt		423800 Machinery, Equipment, &
221210 Natural Gas Distribution	Manufacturing		Mfg		Supplies
221300 Water, Sewage & Other	316110 Leather & Hide Tanning, &		332810 Coating, Engraving, Heat		423910 Sporting & Recreational
Systems	Finishing		Treating, & Allied Activities		Goods & Supplies
221500 Combination Gas & Electric	316210 Footwear Mfg (including		332900 Other Fabricated Metal		423920 Toy, & Hobby Goods, &
Construction	rubber & plastics)		Product Mfg		Supplies
Construction of Buildings	316990 Other Leather & Allied		Machinery Manufacturing		423930 Recyclable Materials
236110 Residential Building	Product Mfg		333100 Agriculture, Construction, &		423940 Jewelry, Watch, Precious
Construction	Wood Product Manufacturing		Mining Machinery Mfg		Stone, & Precious Metals
236200 Nonresidential Building	321110 Sawmills & Wood		333200 Industrial Machinery Mfg		423990 Other Miscellaneous Durable
Construction	Preservation		333310 Commercial & Service		Goods
Heavy and Civil Engineering	321210 Veneer, Plywood, &		Industry Machinery Mfg		Merchant Wholesalers, Nondurable
Construction	Engineered Wood Product		333410 Ventilation, Heating,		Goods
237100 Utility System Construction	Mfg		Air-Conditioning, &		424100 Paper & Paper Products
237210 Land Subdivision	321900 Other Wood Product Mfg		Commercial Refrigeration		424210 Drugs & Druggists’ Sundries
237310 Highway, Street, & Bridge	Paper Manufacturing		Equipment Mfg		424300 Apparel, Piece Goods, &
Construction	322100 Pulp, Paper, & Paperboard		333510 Metalworking Machinery Mfg		Notions
237990 Other Heavy & Civil	Mills		333610 Engine, Turbine & Power		424400 Grocery & Related Products
Engineering Construction	322200 Converted Paper Product Mfg		Transmission Equipment Mfg		424500 Farm Product Raw Materials
			333900 Other General Purpose		424600 Chemical & Allied Products
			Machinery Mfg
Forms 5500, 5500-SF, and 5500-EZ Codes for Principal Business Activity (continued)
Code	Code		Code		Code
424700 Petroleum & Petroleum	448140 Family Clothing Stores		Support Activities for Transportation		Securities, Commodity Contracts,
Products	448150 Clothing Accessories Stores		488100 Support Activities for Air		and Other Financial Investments and
424800 Beer, Wine, & Distilled	448190 Other Clothing Stores		Transportation		Related Activities
Alcoholic Beverages	448210 Shoe Stores		488210 Support Activities for Rail		523110 Investment Banking &
424910 Farm Supplies	448310 Jewelry Stores		Transportation		Securities Dealing
424920 Book, Periodical, &	448320 Luggage & Leather Goods		488300 Support Activities for Water		523120 Securities Brokerage
Newspapers	Stores		Transportation		523130 Commodity Contracts Dealing
424930 Flower, Nursery Stock, &	Sporting Goods, Hobby, Book, and		488410 Motor Vehicle Towing		523140 Commodity Contracts
Florists’ Supplies	Music Stores		488490 Other Support Activities for		Brokerage
424940 Tobacco & Tobacco Products	451110 Sporting Goods Stores		Road Transportation		523210 Securities & Commodity
424950 Paint, Varnish, & Supplies	451120 Hobby, Toy, & Game Stores		488510 Freight Transportation		Exchanges
424990 Other Miscellaneous	451130 Sewing, Needlework, & Piece		Arrangement		523900 Other Financial Investment
Nondurable Goods	Goods Stores		488990 Other Support Activities for		Activities (including portfolio
Wholesale Electronic Markets and	451140 Musical Instrument &		Transportation		management & investment
Agents and Brokers	Supplies Stores		Couriers and Messengers		advice)
425110 Business to Business	451211 Book Stores		492110 Couriers		Insurance Carriers and Related
Electronic Markets	451212 News Dealers & Newsstands		492210 Local Messengers & Local		Activities
425120 Wholesale Trade Agents &	General Merchandise Stores		Delivery		524130 Reinsurance Carriers
Brokers	452200 Department Stores		Warehousing and Storage		524140 Direct Life, Health, & Medical
Retail Trade	452300 General Merchandise		493100 Warehousing & Storage		Insurance Carriers
Motor Vehicle and Parts Dealers	Stores incl. Warehouse Clubs &		(except lessors of		524150 Direct Insurance (except Life,
	Supercenters		miniwarehouses & self-storage		Health & Medical) Carriers
441110 New Car Dealers			units)		524210 Insurance Agencies &
441120 Used Car Dealers	Miscellaneous Store Retailers				Brokerages
441210 Recreational Vehicle Dealers	453110 Florists		Information		524290 Other Insurance Related
441222 Boat Dealers	453210 Office Supplies & Stationery		Publishing Industries (except Internet)		Activities (including third-
441228 Motorcycle, ATV, and All	Stores		511110 Newspaper Publishers		party administration of
Other Motor Vehicle Dealers	453220 Gift, Novelty, & Souvenir		511120 Periodical Publishers		Insurance and pension funds)
441300 Automotive Parts,	Stores		511130 Book Publishers		Funds, Trusts, and Other Financial
Accessories, & Tire Stores	453310 Used Merchandise Stores		511140 Directory & Mailing List		Vehicles
Furniture and Home Furnishings	453910 Pet & Pet Supplies Stores		Publishers		525100 Insurance & Employee
Stores	453920 Art Dealers		511190 Other Publishers		Benefit Funds
442110 Furniture Stores	453930 Manufactured (Mobile) Home		511210 Software Publishers		525910 Open-End Investment Funds
442210 Floor Covering Stores	Dealers		Motion Picture and Sound Recording		(Form 1120-RIC)
442291 Window Treatment Stores	453990 All Other Miscellaneous Store		Industries		525920 Trusts, Estates, & Agency
442299 All Other Home Furnishings	Retailers (including tobacco,		512100 Motion Picture & Video		Accounts
Stores	candle, & trophy shops)		Industries (except video rental)		525990 Other Financial Vehicles
Electronics and Appliance Stores	Nonstore Retailers		512200 Sound Recording Industries		(including mortgage REITs &
443141 Household Appliance Stores	454110 Electronic Shopping &		Broadcasting (except Internet)		closed-end investment funds)
443142 Electronics Stores (including	Mail-Order Houses		515100 Radio & Television		“Offices of Bank Holding Companies”
Audio, Video, Computer, and	454210 Vending Machine Operators		Broadcasting		and “Offices of Other Holding Companies”
Camera Stores)	454310 Fuel Dealers (including Heating		515210 Cable & Other Subscription		are located under Management
Building Material and Garden	Oil and Liquefied Petroleum)		Programming		of Companies (Holding Companies).
Equipment and Supplies Dealers	454390 Other Direct Selling		Telecommunications		Real Estate and Rental and
444110 Home Centers	Establishments (including		517000 Telecommunications		Leasing
444120 Paint & Wallpaper Stores	door-to-door retailing, frozen		(including paging, cellular,		Real Estate
	food plan providers, party		satellite, cable & other program		531110 Lessors of Residential
444130 Hardware Stores	plan merchandisers, &		distribution, resellers, other		Buildings & Dwellings
444190 Other Building Material	coffee-break service providers)		telecommunications, &		(including equity REITs)
Dealers	Transportation and		internet service providers)		531120 Lessors of Nonresidential
444200 Lawn & Garden Equipment &	Warehousing		Data Processing Services		Buildings (except
Supplies Stores	Air, Rail, and Water Transportation		518210 Data Processing, Hosting, &		Miniwarehouses) (including
Food and Beverage Stores	481000 Air Transportation		Related Services		equity REITs)
445110 Supermarkets and Other	482110 Rail Transportation		Other Information Services		531130 Lessors of Miniwarehouses &
Grocery (except	483000 Water Transportation		519100 Other Information Services		Self-Storage Units (including
Convenience) Stores	Truck Transportation		(including news syndicates,		equity REITs)
445120 Convenience Stores	484110 General Freight Trucking,		libraries, internet publishing &		531190 Lessors of Other Real Estate
445210 Meat Markets	Local		broadcasting)		Property (including equity
445220 Fish & Seafood Markets	484120 General Freight Trucking,		Finance and Insurance		REITs)
445230 Fruit & Vegetable Markets	Long-distance		Depository Credit Intermediation		531210 Offices of Real Estate Agents
445291 Baked Goods Stores	484200 Specialized Freight Trucking		522110 Commercial Banking		& Brokers
445292 Confectionery & Nut Stores	Transit and Ground Passenger		522120 Savings Institutions		531310 Real Estate Property
445299 All Other Specialty Food	Transportation		522130 Credit Unions		Managers
Stores	485110 Urban Transit Systems		522190 Other Depository Credit		531320 Offices of Real Estate
445310 Beer, Wine, & Liquor Stores	485210 Interurban & Rural Bus		Intermediation		Appraisers
Health and Personal Care Stores	Transportation		Nondepository Credit Intermediation		531390 Other Activities Related to
446110 Pharmacies & Drug Stores	485310 Taxi Service		522210 Credit Card Issuing		Real Estate
446120 Cosmetics, Beauty Supplies,	485320 Limousine Service		522220 Sales Financing		Rental and Leasing Services
& Perfume Stores	485410 School & Employee Bus		522291 Consumer Lending		532100 Automotive Equipment Rental &
446130 Optical Goods Stores	Transportation		522292 Real Estate Credit		Leasing
446190 Other Health & Personal	485510 Charter Bus Industry		(including mortgage bankers &		532210 Consumer Electronics &
Care Stores	485990 Other Transit & Ground		originators)		Appliances Rental
Gasoline Stations	Passenger Transportation		522293 International Trade Financing		532281 Formal Wear & Costume Rental
447100 Gasoline Stations (including	Pipeline Transportation		522294 Secondary Market Financing		532282 Video Tape & Disc Rental
convenience stores with gas)	486000 Pipeline Transportation		522298 All Other Nondepository
Clothing and Clothing Accessories	Scenic & Sightseeing Transportation		Credit Intermediation
Stores	487000 Scenic & Sightseeing		Activities Related to Credit
448110 Men’s Clothing Stores	Transportation		Intermediation
448120 Women’s Clothing Stores			522300 Activities Related to Credit
448130 Children’s & Infants’ Clothing			Intermediation (including loan
Stores			brokers, check clearing, &
			money transmitting)
Forms 5500, 5500-SF, and 5500-EZ Codes for Principal Business Activity (continued)
Code	Code		Code		Code
532283 Home Health Equipment	Administrative and Support and		Medical and Diagnostic Laboratories		Other Services
Rental	Waste Management and		621510 Medical & Diagnostic		Repair and Maintenance
532284 Recreational Goods Rental	Remediation Services		Laboratories		811110 Automotive Mechanical, &
532289 All Other Consumer Goods	Administration and Support Services		Home Health Care Services		Electrical Repair &
Rental	561110 Office Administrative Services		621610 Home Health Care Services		Maintenance
532310 General Rental Centers	561210 Facilities Support Services		Other Ambulatory Health Care Services		811120 Automotive Body, Paint,
532400 Commercial & Industrial	561300 Employment Services		621900 Other Ambulatory Health Care		Interior, & Glass Repair
Machinery & Equipment	561410 Document Preparation Services		Services (including ambulance		811190 Other Automotive Repair &
Rental & Leasing	561420 Telephone Call Centers		services & blood & organ banks)		Maintenance (including oil
Lessors of Nonfinancial Intangible	561430 Business Service Centers		Hospitals		change & lubrication shops &
Assets (except copyrighted works)	(including private mail centers		622000 Hospitals		car washes)
533110 Lessors of Nonfinancial	& copy shops)		Nursing and Residential Care		811210 Electronic & Precision
Intangible Assets (except	561440 Collection Agencies		Facilities		Equipment Repair &
copyrighted works)	561450 Credit Bureaus		623000 Nursing & Residential Care		Maintenance
Professional, Scientific, and	561490 Other Business Support		Facilities		811310 Commercial & Industrial
Technical Services	Services (including		Social Assistance		Machinery & Equipment
Legal Services	repossession services, court		624100 Individual & Family Services		(except Automotive &
541110 Offices of Lawyers	reporting, & stenotype		624200 Community Food & Housing, &		Electronic) Repair &
541190 Other Legal Services	services)		Emergency & Other Relief		Maintenance
Accounting, Tax Preparation,	561500 Travel Arrangement &		Services		811410 Home & Garden Equipment &
Bookkeeping, and Payroll Services	Reservation Services		624310 Vocational Rehabilitation		Appliance Repair &
541211 Offices of Certified Public	561600 Investigation & Security		Services		Maintenance
Accountants	Services		624410 Child Day Care Services		811420 Reupholstery & Furniture
541213 Tax Preparation Services	561710 Exterminating & Pest Control		Arts, Entertainment, and		Repair
541214 Payroll Services	Services		Recreation		811430 Footwear & Leather Goods
541219 Other Accounting Services	561720 Janitorial Services		Performing Arts, Spectator Sports,		Repair
Architectural, Engineering, and	561730 Landscaping Services		and Related Industries		811490 Other Personal & Household
Related Services	561740 Carpet & Upholstery Cleaning		711100 Performing Arts Companies		Goods Repair & Maintenance
541310 Architectural Services	Services		711210 Spectator Sports (including		Personal and Laundry Services
541320 Landscape Architecture	561790 Other Services to Buildings &		sports clubs & racetracks)		812111 Barber Shops
Services	Dwellings		711300 Promoters of Performing Arts,		812112 Beauty Salons
541330 Engineering Services	561900 Other Support Services		Sports, & Similar Events		812113 Nail Salons
541340 Drafting Services	(including packaging &		711410 Agents & Managers for		812190 Other Personal Care
541350 Building Inspection Services	labeling services, & convention		Artists, Athletes, Entertainers, &		Services (including diet &
541360 Geophysical Surveying &	& trade show organizers)		Other Public Figures		weight reducing centers)
Mapping Services	Waste Management and		711510 Independent Artists, Writers, &		812210 Funeral Homes & Funeral
541370 Surveying & Mapping (except	Remediation Services		Performers		Services
Geophysical) Services	562000 Waste Management and		Museums, Historical Sites, and Similar		812220 Cemeteries & Crematories
541380 Testing Laboratories	Remediation Services		Institutions		812310 Coin-Operated Laundries &
Specialized Design Services	Educational Services		712100 Museums, Historical Sites, &		Drycleaners
541400 Specialized Design Services	611000 Educational Services		Similar Institutions		812320 Drycleaning & Laundry
(including interior, industrial,	(including schools, colleges,		Amusements, Gambling, and		Services (except
graphic, & fashion design)	& universities)		Recreation Industries		Coin-Operated)
Computer Systems Design and	Health Care and Social Assistance		713100 Amusement Parks & Arcades		812330 Linen & Uniform Supply
Related Services	Offices of Physicians and Dentists		713200 Gambling Industries		812910 Pet Care (except Veterinary)
541511 Custom Computer	621111 Offices of Physicians (except		713900 Other Amusement &		Services
Programming Services	mental health specialists)		Recreation Industries		812920 Photofinishing
541512 Computer Systems Design	621112 Offices of Physicians, Mental		(including golf courses, skiing		812930 Parking Lots & Garages
Services	Health Specialists		facilities, marinas, fitness		812990 All Other Personal Services
541513 Computer Facilities	621210 Offices of Dentists		centers, & bowling centers)		Religious, Grantmaking, Civic,
Management Services	Offices of Other Health Practitioners		Accommodation and Food Services		Professional, and Similar
541519 Other Computer Related	621310 Offices of Chiropractors		Accommodation		Organizations
Services	621320 Offices of Optometrists		721110 Hotels (except Casino Hotels) &		813000 Religious, Grantmaking,
Other Professional, Scientific, and	621330 Offices of Mental Health		Motels		Civic, Professional, & Similar
Technical Services	Practitioners (except		721120 Casino Hotels		Organizations (including
541600 Management, Scientific, &	Physicians)		721191 Bed & Breakfast Inns		condominium and
Technical Consulting Services	621340 Offices of Physical,		721199 All other Traveler		homeowners associations)
541700 Scientific Research &	Occupational & Speech		Accommodation		813930 Labor Unions and Similar
Development Services	Therapists, & Audiologists		721210 RV (Recreational Vehicle)		Labor Organizations
541800 Advertising & Related	621391 Offices of Podiatrists		Parks & Recreational Camps		921000 Governmental Instrumentality
Services	621399 Offices of all Other		721310 Rooming and Boarding Houses,		or Agency
541910 Marketing Research & Public	Miscellaneous Health		Dormitories, and Workers’
Opinion Polling	Practitioners		Camps
541920 Photographic Services	Outpatient Care Centers		Food Services and Drinking Places
541930 Translation & Interpretation	621410 Family Planning Centers		722300 Special Food Services
Services	621420 Outpatient Mental Health &		(including food service
541940 Veterinary Services	Substance Abuse Centers		contractors & caterers)
541990 All Other Professional,	621491 HMO Medical Centers		722410 Drinking Places (Alcoholic
Scientific, & Technical	621492 Kidney Dialysis Centers		Beverages)
Services	621493 Freestanding Ambulatory		722511 Full-Service Restaurants
Management of Companies	Surgical & Emergency Centers		722513 Limited-Service Restaurants
(Holding Companies)	621498 All Other Outpatient Care		722514 Cafeterias and Buffets
551111 Offices of Bank Holding	Centers		722515 Snack and Non-alcoholic
Companies			Beverage Bars
551112 Offices of Other Holding
Companies

ERISA COMPLIANCE QUICK CHECKLIST

Compliance with the Employee Retirement Income Security Act (ERISA) begins with knowing the rules. Plan administrators and other plan officials can use this checklist as a quick diagnostic tool for assessing a plan’s compliance with certain important ERISA rules; it is not a complete description of all ERISA’s rules and it is not a substitute for a comprehensive compliance review. Use of this checklist is voluntary, and it is not to be filed with your Form 5500-SF.

If you answer “No” to any of the questions below, you should review your plan’s operations because you may not be in full compliance with ERISA’s requirements.

1. Have you provided plan participants with a summary plan description, summaries of any material modifications of the plan, and annual summary financial reports or annual pension funding reports?

2. Do you maintain copies of plan documents at the principal office of the plan administrator for examination by participants and beneficiaries?

3. Do you respond to written participant inquires for copies of plan documents and information within 30 days?

4. Does your plan include written procedures for making benefit claims and appealing denied claims, and are you complying with those procedures?

5. Is your plan covered by fidelity bonds protecting the plan against losses due to fraud or dishonesty by persons who handle plan funds or other property?

6. Are the plan’s investments diversified so as to minimize the risk of large losses?

7. If the plan permits participants to select the investments in their plan accounts, has the plan provided them with enough information to make informed decisions?

8. Has a plan official determined that the investments are prudent and solely in the interest of the plan’s participants and beneficiaries, and evaluated the risks associated with plan investments before making the investments?

9. Did the employer or other plan sponsor send participant contributions to the plan on a timely basis?

10. Did the plan pay participant benefits on time and in the correct amounts?

11. Did the plan give participants and beneficiaries 30 days advance notice before imposing a “blackout period” of at least three consecutive business days during which participants or beneficiaries of a 401(k) or other individual account pension plan were unable to change their plan investments, obtain loans from the plan, or obtain distributions from the plan?

If you answer “Yes” to any of the questions below, you should review your plan’s operations because you may not be in full compliance with ERISA’s requirements.

1. Has the plan engaged in any financial transactions with persons related to the plan or any plan official? (For example, has the plan made a loan to or participated in an investment with the employer?)

2. Has a plan official used the assets of the plan for his/her own interest?

3. Have plan assets been used to pay expenses that were not authorized in the plan document, were not necessary for the proper administration of the plan, or were more than reasonable in amount?

If you need help answering these questions or want additional guidance about ERISA requirements, a plan official should contact the U.S. Department of Labor Employee Benefits Security Administration office in your region or consult with the plan’s legal counsel or professional employee benefit advisor.

Index

A

Annual Report Identification

Information 8

B

Basic Plan Information 9

C

Change in Plan Year 5

Codes for Principal Business

Activity 24

Compliance Questions 15

D

Delinquent Filer Voluntary Compliance (DFVC)

Program 5

E

EFAST2 Processing System 2

ERISA Compliance Quick

Checklist 27

Extension of Time To File 5

F

Financial Information 13

H

How To File – Electronic Filing Requirement 6

How To Get Assistance 2

N

Nonexempt Transactions 15

P

Paperwork Reduction Act

Notice 21

Party-In-Interest 15

Penalties:

Administrative 6

Other 6

Pension and Welfare Plans Required To File Annual Return/Report 3

Pension Funding

Compliance 18

Plan Assets and Liabilities 13

Plan Characteristics Codes 22

Plan Terminations 19

Plans Exempt From Filing 3

S

Signature and Date 7

Specific Line-by-Line Instructions (Form 5500-SF) 8

T

Transfers of Assets 19

W

What To File 4

When To File 5

Who May File 4