Schedule Sb (Form 5500) - Single-Employer Defined Benefit Plan Actuarial Information - 2013

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SCHEDULE SB
Single-Employer Defined Benefit Plan
OMB No. 1210-0110
Actuarial Information
(Form 5500)
2013
Department of the Treasury
Internal Revenue Service
This schedule is required to be filed under section 104 of the Employee
Department of Labor
Retirement Income Security Act of 1974 (ERISA) and section 6059 of the
This Form is Open to Public
Employee Benefits Security Administration
Internal Revenue Code (the Code).
Inspection
Pension Benefit Guaranty Corporation
File as an attachment to Form 5500 or 5500-SF.
For calendar plan year 2013 or fiscal plan year beginning
and ending
Round off amounts to nearest dollar.
Caution: A penalty of $1,000 will be assessed for late filing of this report unless reasonable cause is established.
A
B
Name of plan
Three-digit
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
001
plan number (PN)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
C
D
Plan sponsor’s name as shown on line 2a of Form 5500 or 5500-SF
Employer Identification Number (EIN)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
012345678
ABCDEFGHI ABCDEFGHI
E
F
Type of plan:
X
Single
X
Multiple-A
X
Multiple-B
Prior year plan size:
X
100 or fewer
X
101-500
X
More than 500
Part I
Basic Information
1
Enter the valuation date:
Month _________
Day _________
Year _________
2
Assets:
a
2a
-123456789012345
Market value ........................................................................................................................................................
b
2b
-123456789012345
Actuarial value .....................................................................................................................................................
3
(1) Number of participants
(2) Funding Target
Funding target/participant count breakdown:
a
3a
12345678
-123456789012345
For retired participants and beneficiaries receiving payment .................
b
3b
-123456789012345
12345678
For terminated vested participants .........................................................
c
For active participants:
3c(1)
(1) Non-vested benefits ...................................................................
-123456789012345
3c(2)
-123456789012345
(2) Vested benefits ..........................................................................
3c(3)
(3) Total active ................................................................................
-123456789012345
d
3d
12345678
-123456789012345
Total .......................................................................................................
4
If the plan is in at-risk status, check the box and complete lines (a) and (b) ..............................
X
a
4a
-123456789012345
Funding target disregarding prescribed at-risk assumptions ..............................................................................
b
Funding target reflecting at-risk assumptions, but disregarding transition rule for plans that have been in
4b
-123456789012345
at-risk status for fewer than five consecutive years and disregarding loading factor .....................................
5
5
123.12
%
Effective interest rate ..............................................................................................................................................
6
6
-123456789012345
Target normal cost ..................................................................................................................................................
Statement by Enrolled Actuary
To the best of my knowledge, the information supplied in this schedule and accompanying schedules, statements and attachments, if any, is complete and accurate. Each prescribed assumption was applied in
accordance with applicable law and regulations. In my opinion, each other assumption is reasonable (taking into account the experience of the plan and reasonable expectations) and such other assumptions, in
combination, offer my best estimate of anticipated experience under the plan.
SIGN
HERE
Signature of actuary
Date
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
YYYY-MM-DD
Type or print name of actuary
Most recent enrollment number
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
1234567
Firm name
Telephone number (including area code)
123456789 ABCDEFGHI ABCDEFGHI ABCDE
1234567890
123456789 ABCDEFGHI ABCDEFGHI ABCDE
UK
Address of the firm
If the actuary has not fully reflected any regulation or ruling promulgated under the statute in completing this schedule, check the box and see
X
instructions
For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500 or 5500-SF.
Schedule SB (Form 5500) 2013
v. 130118

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