Looking for a Form 5500 Templates? Download it for free!

SCHEDULE MB

Multiemployer Defined Benefit Plan and Certain

OMB No. 1210-0110

Money Purchase Plan 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

Retirement Income Security Act of 1974 (ERISA) and section 6059 of the

Department of Labor

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.

Name of plan

Three-digit

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

001

plan number (PN)

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

ABCDEFGHI ABCDEFGHI

Plan sponsor’s name as shown on line 2a of Form 5500 or 5500-SF

Employer Identification Number (EIN)

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

012345678

ABCDEFGHI

(1)

(2)

Type of plan:

Multiemployer Defined Benefit

Money Purchase (see instructions)

Enter the valuation date:

Month _________

Day _________

Year _________

Assets

(1) Current value of assets ........................................................................................................................

1b(1)

(2) Actuarial value of assets for funding standard account ........................................................................

1b(2)

1c(1)

(1) Accrued liability for plan using immediate gain methods .....................................................................

(2) Information for plans using spread gain methods:

1c(2)(a)

(a) Unfunded liability for methods with bases ............................................................................................

-123456789012345

1c(2)(b)

(b) Accrued liability under entry age normal method .................................................................................

-123456789012345

1c(2)(c)

(c) Normal cost under entry age normal method .......................................................................................

-123456789012345

1c(3)

(3) Accrued liability under unit credit cost method ...........................................................................................

-123456789012345

Information on current liabilities of the plan:

(1) Amount excluded from current liability attributable to pre-participation service (see instructions) .............

1d(1)

-123456789012345

(2) “RPA ‘94” information:

(a) Current liability .....................................................................................................................................

1d(2)(a)

-123456789012345

(b) Expected increase in current liability due to benefits accruing during the plan year ...........................

1d(2)(b)

-123456789012345

(c) Expected release from “RPA ‘94” current liability for the plan year .....................................................

1d(2)(c)

-123456789012345

(3) Expected plan disbursements for the plan year .........................................................................................

1d(3)

-123456789012345

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

Type or print name of actuary

Most recent enrollment number

Firm name

Telephone number (including area code)

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

instructions