Schedule Mb (Form 5500) - Multiemployer Defined Benefit Plan And Certain Money Purchase Plan Actuarial Information - 2016 Page 2

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Schedule MB (Form 5500) 2016

Page

Operational information as of beginning of this plan year:

-123456789012345

Current value of assets (see instructions)

“RPA ‘94” current liability/participant count breakdown:

(1) Number of participants

(2) Current liability

12345678

-123456789012345

(1) For retired participants and beneficiaries receiving payment ...................................

12345678

-123456789012345

(2) For terminated vested participants ..........................................................................

(3) For active participants:

(a) Non-vested benefits .........................................................................................

-123456789012345

(b) Vested benefits ................................................................................................

-123456789012345

12345678

-123456789012345

(4) Total .......................................................................................................................

If the percentage resulting from dividing line 2a by line 2b(4), column (2), is less than 70%, enter such

123.12

percentage ..........................................................................................................................................................

Contributions made to the plan for the plan year by employer(s) and employees:

(a) Date

(b) Amount paid by

(a) Date

(b) Amount paid by

c) Amount paid by

(MM-DD-YYYY)

employer(s)

employees

(MM-DD-YYYY)

employer(s)

employees

Totals ►

3(b)

3(c)

Information on plan status:

Funded percentage for monitoring plan’s status (line 1b(2) divided by line 1c(3)) ..............................................

Enter code to indicate plan’s status (see instructions for attachment of supporting evidence of plan’s status). If

code is “N,” go to line 5 ………………………………………………………………………………………………..

Is the plan making the scheduled progress under any applicable funding improvement or rehabilitation plan?..............................................................

Yes

If the plan is in critical status or critical and declining status, were any benefits reduced (see instructions)? .................................................

Yes

If line d is “Yes,” enter the reduction in liability resulting from the reduction in benefits (see instructions),

-123456789012345

measured as of the valuation date ....................................................................................................................

If the rehabilitation plan projects emergence from critical status or critical and declining status, enter the plan

year in which it is projected to emerge.

If the rehabilitation plan is based on forestalling possible insolvency, enter the plan year in which insolvency is

expected and check here …………………………….......................................................................................

Actuarial cost method used as the basis for this plan year’s funding standard account computations (check all that apply):

Attained age normal

Entry age normal

Accrued benefit (unit credit)

Aggregate

Frozen initial liability

Individual level premium

Individual aggregate

Shortfall

________________________________________________________________________________

Other (specify):

________________________________________________________________________________

YYYY-MM-DD

If box h is checked, enter period of use of shortfall method ...............................................................................

Has a change been made in funding method for this plan year? ...................................................................................................................

Yes

If line k is “Yes,” was the change made pursuant to Revenue Procedure 2000-40 or other automatic approval? ..........................................

Yes

If line k is “Yes,” and line l is “No,” enter the date (MM-DD-YYYY) of the ruling letter (individual or class)

YYYY-MM-DD

approving the change in funding method ...........................................................................................................