Schedule R (Form 5500) - Retirement Plan Information - 2012

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OMB No. 1210-0110
SCHEDULE R
Retirement Plan Information
(Form 5500)
2012
This schedule is required to be filed under section 104 and 4065 of the
Department of the Treasury
Employee Retirement Income Security Act of 1974 (ERISA) and section
Internal Revenue Service
6058(a) of the Internal Revenue Code (the Code).
Department of Labor
This Form is Open to Public
Employee Benefits Security Administration
File as an attachment to Form 5500.
Inspection.
Pension Benefit Guaranty Corporation
For calendar plan year 2012 or fiscal plan year beginning
and ending
A
B
Name of plan
Three-digit
plan number
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
001
(PN)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI
C
D
Plan sponsor’s name as shown on line 2a of Form 5500
Employer Identification Number (EIN)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
012345678
ABCDEFGHI
Part I
Distributions
All references to distributions relate only to payments of benefits during the plan year.
1
Total value of distributions paid in property other than in cash or the forms of property specified in the
instructions ..............................................................................................................................................................
-123456789012345
1
2
Enter the EIN(s) of payor(s) who paid benefits on behalf of the plan to participants or beneficiaries during the year (if more than two, enter EINs of the two
payors who paid the greatest dollar amounts of benefits):
EIN(s):
_______________________________
_______________________________
Profit-sharing plans, ESOPs, and stock bonus plans, skip line 3.
3
Number of participants (living or deceased) whose benefits were distributed in a single sum, during the plan
12345678
year. ..........................................................................................................................................................................
3
Part II
Funding Information
(If the plan is not subject to the minimum funding requirements of section of 412 of the Internal Revenue Code or
ERISA section 302, skip this Part)
4
X
X
X
Yes
No
N/A
Is the plan administrator making an election under Code section 412(d)(2) or ERISA section 302(d)(2)? .........................
If the plan is a defined benefit plan, go to line 8.
5
If a waiver of the minimum funding standard for a prior year is being amortized in this
plan year, see instructions and enter the date of the ruling letter granting the waiver.
Date:
Month _________
Day _________
Year _________
If you completed line 5, complete lines 3, 9, and 10 of Schedule MB and do not complete the remainder of this schedule.
6
a
Enter the minimum required contribution for this plan year (include any prior year accumulated funding
-123456789012345
6a
)
deficiency not waived
.......................................................................................................................................
b
-123456789012345
6b
Enter the amount contributed by the employer to the plan for this plan year .....................................................
c
Subtract the amount in line 6b from the amount in line 6a. Enter the result
-123456789012345
(enter a minus sign to the left of a negative amount)..........................................................................................
6c
If you completed line 6c, skip lines 8 and 9.
7
Will the minimum funding amount reported on line 6c be met by the funding deadline? ......................................
X
X
X
Yes
No
N/A
8
If a change in actuarial cost method was made for this plan year pursuant to a revenue procedure or other
authority providing automatic approval for the change or a class ruling letter, does the plan sponsor or plan
X
X
X
Yes
No
N/A
administrator agree with the change? ....................................................................................................................
Part III
Amendments
9
If this is a defined benefit pension plan, were any amendments adopted during this plan
year that increased or decreased the value of benefits? If yes, check the appropriate
X
X
X
X
Increase
Decrease
Both
No
box. If no, check the “No” box. ...........................................................................................
Part IV
ESOPs
(see instructions). If this is not a plan described under Section 409(a) or 4975(e)(7) of the Internal Revenue Code,
skip this Part.
X
X
10
Yes
No
Were unallocated employer securities or proceeds from the sale of unallocated securities used to repay any exempt loan? ..............
X
X
11 a
Yes
No
Does the ESOP hold any preferred stock? ....................................................................................................................................
b
If the ESOP has an outstanding exempt loan with the employer as lender, is such loan part of a “back-to-back” loan?
X
X
Yes
No
(See instructions for definition of “back-to-back” loan.) ..................................................................................................................
12
X
Yes
X
No
Does the ESOP hold any stock that is not readily tradable on an established securities market? ........................................................
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500.
Schedule R (Form 5500) 2012
v. 120126

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