Schedule H (Form 5500) - Financial Information - 2016
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OMB No. 1210-0110
SCHEDULE H
Financial Information
(Form 5500)
2016
This schedule is required to be filed under section 104 of the Employee
Internal Revenue Service
Retirement Income Security Act of 1974 (ERISA), and section 6058(a) of the
Department of Labor
Internal Revenue Code (the Code).
Employee Benefits Security Administration
This Form is Open to Public
File as an attachment to Form 5500.
Pension Benefit Guaranty Corporation
Inspection
For calendar plan year 2016 or fiscal plan year beginning
and ending
A
Name of plan
B
Three-digit
plan number (PN)
Plan sponsor’s name as shown on line 2a of Form 5500
C
D
Employer Identification Number (EIN)
Part I
Asset and Liability Statement
1
Current value of plan assets and liabilities at the beginning and end of the plan year. Combine the value of plan assets held in more than one trust. Report
the value of the plan’s interest in a commingled fund containing the assets of more than one plan on a line-by-line basis unless the value is reportable on
lines 1c(9) through 1c(14). Do not enter the value of that portion of an insurance contract which guarantees, during this plan year, to pay a specific dollar
benefit at a future date. Round off amounts to the nearest dollar. MTIAs, CCTs, PSAs, and 103-12 IEs do not complete lines 1b(1), 1b(2), 1c(8), 1g, 1h,
and 1i. CCTs, PSAs, and 103-12 IEs also do not complete lines 1d and 1e. See instructions.
Assets
(a) Beginning of Year
(b) End of Year
a
Total noninterest-bearing cash ......................................................................
1a
b
Receivables (less allowance for doubtful accounts):
1b(1)
(1) Employer contributions ..........................................................................
1b(2)
(2) Participant contributions ........................................................................
1b(3)
(3) Other .....................................................................................................
c
General investments:
(1) Interest-bearing cash (include money market accounts & certificates
1c(1)
of deposit) ............................................................................................
1c(2)
(2) U.S. Government securities ..................................................................
(3) Corporate debt instruments (other than employer securities):
1c(3)(A)
(A) Preferred ........................................................................................
1c(3)(B)
(B) All other ..........................................................................................
(4) Corporate stocks (other than employer securities):
1c(4)(A)
(A) Preferred ........................................................................................
1c(4)(B)
(B) Common .........................................................................................
1c(5)
(5) Partnership/joint venture interests .........................................................
1c(6)
(6) Real estate (other than employer real property) .....................................
1c(7)
(7) Loans (other than to participants) ..........................................................
1c(8)
(8) Participant loans ....................................................................................
1c(9)
(9) Value of interest in common/collective trusts .........................................
1c(10)
(10) Value of interest in pooled separate accounts .......................................
1c(11)
(11) Value of interest in master trust investment accounts ............................
1c(12)
(12) Value of interest in 103-12 investment entities .......................................
(13) Value of interest in registered investment companies (e.g., mutual
1c(13)
funds) ....................................................................................
(14) Value of funds held in insurance company general account (unallocated
1c(14)
contracts) ..............................................................................................
1c(15)
(15) Other .....................................................................................................
For Paperwork Reduction Act Notice, see the Instructions for Form 5500.
Schedule H (Form 5500) 2016
v.160205
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