Form 5500 - Annual Return/report Of Employee Benefit Plan - 2016 Page 3

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Form 5500 (2016)

Page

Part III

Form M-1 Compliance Information (to be completed by welfare benefit plans)

11a

If the plan provides welfare benefits, was the plan subject to the Form M-1 filing requirements during the plan year? (See instructions and 29 CFR

2520.101-2.) ........................………..….

Yes

If “Yes” is checked, complete lines 11b and 11c.

11b

Is the plan currently in compliance with the Form M-1 filing requirements? (See instructions and 29 CFR 2520.101-2.) …….....

Yes

11c

Enter the Receipt Confirmation Code for the 2016 Form M-1 annual report. If the plan was not required to file the 2016 Form M-1 annual report, enter the

Receipt Confirmation Code for the most recent Form M-1 that was required to be filed under the Form M-1 filing requirements. (Failure to enter a valid

Receipt Confirmation Code will subject the Form 5500 filing to rejection as incomplete.)

Receipt Confirmation Code______________________