Schedule I (Form 5500) - Financial Information-Small Plan - 2016 Page 2

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Schedule I (Form 5500) 2016

Page

Part II

Compliance Questions

During the plan year:

Yes

Amount

Was there a failure to transmit to the plan any participant contributions within the time period

described in 29 CFR 2510.3-102? Continue to answer “Yes” for any prior year failures until

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fully corrected. (See instructions and DOL’s Voluntary Fiduciary Correction Program.) .....................

Were any loans by the plan or fixed income obligations due the plan in default as of the

close of plan year or classified during the year as uncollectible? Disregard participant loans

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secured by the participant’s account balance. ....................................................................................

Were any leases to which the plan was a party in default or classified during the year as

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uncollectible? ....................................................................................................................................

Were there any nonexempt transactions with any party-in-interest? (Do not include

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transactions reported on line 4a.) .......................................................................................................

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Was the plan covered by a fidelity bond? ...........................................................................................

Did the plan have a loss, whether or not reimbursed by the plan’s fidelity bond, that was

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caused by fraud or dishonesty? .........................................................................................................

Did the plan hold any assets whose current value was neither readily determinable on an

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established market nor set by an independent third party appraiser? .................................................

Did the plan receive any noncash contributions whose value was neither readily

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determinable on an established market nor set by an independent third party appraiser? .................

Did the plan at any time hold 20% or more of its assets in any single security, debt,

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mortgage, parcel of real estate, or partnership/joint venture interest? ................................................

Were all the plan assets either distributed to participants or beneficiaries, transferred to

another plan, or brought under the control of the PBGC? ..................................................................

Are you claiming a waiver of the annual examination and report of an independent qualified

public accountant (IQPA) under 29 CFR 2520.104-46? If “No,” attach an IQPA’s report or

2520.104-50 statement. (See instructions on waiver eligibility and conditions.) ........................................

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Has the plan failed to provide any benefit when due under the plan? ................................................

If this is an individual account plan, was there a blackout period? (See instructions and 29

CFR 2520.101-3.) .............................................................................................................................

If 4m was answered “Yes,” check the “Yes” box if you either provided the required notice or

one of the exceptions to providing the notice applied under 29 CFR 2520.101-3 ...............................

Defined Benefit Plan or Money Purchase Pension Plan Only:

Were any distributions made during the plan year to an employee who attained age 62 and

had not separated from service? .....................................................................................................................................................

Has a resolution to terminate the plan been adopted during the plan year or any prior plan year?

If “Yes,” enter the amount of any plan assets that reverted to the employer this year...........................

Yes

Amount:

If, during this plan year, any assets or liabilities were transferred from this plan to another plan(s), identify the plan(s) to which assets or liabilities were

transferred. (See instructions.)

5b(1) Name of plan(s)

5b(2) EIN(s)

5b(3) PN(s)

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

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123

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

123456789

123

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

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123

If the plan is a defined benefit plan, is it covered under the PBGC insurance program (See ERISA section 4021.)? ..... …

Yes

Not determined.

If “Yes” is checked, enter the My PAA confirmation number from the PBGC premium filing for this plan year__________________________. (See instructions.)

Part III

Trust Information

Trust’s EIN

Name of trust

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

Trustee’s or custodian telephone number

Name of trustee or custodian

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI