Form 5500-Sf Draft - Short Form Annual Return/report Of Small Employee Benefit Plan - 2017 Page 2
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Form 5500-SF 2017
Page
X
X
6a
Yes
No
Were all of the plan’s assets during the plan year invested in eligible assets? (See instructions.) .........................................................
b
Are you claiming a waiver of the annual examination and report of an independent qualified public accountant (IQPA)
X
X
Yes
No
under 29 CFR 2520.104-46? (See instructions on waiver eligibility and conditions.) ...............................................................................
If you answered “No” to either line 6a or line 6b, the plan cannot use Form 5500-SF and must instead use Form 5500.
c
X
X
X
If the plan is a defined benefit plan, is it covered under the PBGC insurance program (see ERISA section 4021)? ......
Yes
No
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
Financial Information
7
Plan Assets and Liabilities
(a) Beginning of Year
(b) End of Year
a
-123456789012345
-123456789012345
Total plan assets ...............................................................................
7a
b
-123456789012345
123456789012345
Total plan liabilities ............................................................................
7b
c
-123456789012345
-123456789012345
Net plan assets (subtract line 7b from line 7a) ..................................
7c
8
Income, Expenses, and Transfers for this Plan Year
(a) Amount
(b) Total
a
Contributions received or receivable from:
-123456789012345
(1) Employers .................................................................................. 8a(1)
-123456789012345
(2) Participants................................................................................. 8a(2)
-123456789012345
(3) Others (including rollovers) ......................................................... 8a(3)
b
-123456789012345
Other income (loss) ...........................................................................
8b
c
-123456789012345
Total income (add lines 8a(1), 8a(2), 8a(3), and 8b) .........................
8c
d
Benefits paid (including direct rollovers and insurance premiums
-123456789012345
to provide benefits) ............................................................................
8d
e
-123456789012345
Certain deemed and/or corrective distributions (see instructions) ....
8e
f
-123456789012345
Administrative service providers (salaries, fees, commissions) ........
8f
g
-123456789012345
Other expenses .................................................................................
8g
h
-123456789012345
Total expenses (add lines 8d, 8e, 8f, and 8g) ...................................
8h
i
-123456789012345
Net income (loss) (subtract line 8h from line 8c) ...............................
8i
j
Transfers to (from) the plan (see instructions) ..................................
-123456789012345
8j
Part IV Plan Characteristics
9a
If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristic Codes in the instructions:
b
If the plan provides welfare benefits, enter the applicable welfare feature codes from the List of Plan Characteristic Codes in the instructions:
Part V
Compliance Questions
10
Yes
No
During the plan year:
Amount
a
Was there a failure to transmit to the plan any participant contributions within the time period
described in 29 CFR 2510.3-102? (See instructions and DOL’s Voluntary Fiduciary Correction
-123456789012345
Program) .......................................................................................................................................... 10a
b
Were there any nonexempt transactions with any party-in-interest? (Do not include transactions
-123456789012345
reported on line 10a.) ......................................................................................................................... 10b
c
Was the plan covered by a fidelity bond? ......................................................................................... 10c
-123456789012345
d
Did the plan have a loss, whether or not reimbursed by the plan’s fidelity bond, that was caused
-123456789012345
by fraud or dishonesty? ..................................................................................................................... 10d
e
Were any fees or commissions paid to any brokers, agents, or other persons by an insurance
carrier, insurance service, or other organization that provides some or all of the benefits under
-123456789012345
the plan? (See instructions.) .............................................................................................................. 10e
f
Has the plan failed to provide any benefit when due under the plan? .............................................. 10f
-123456789012345
g
Did the plan have any participant loans? (If “Yes,” enter amount as of year-end.) ........................... 10g
h
If this is an individual account plan, was there a blackout period? (See instructions and 29 CFR
-123456789012345
2520.101-3.) ...................................................................................................................................... 10h
i
If 10h was answered “Yes,” check the box if you either provided the required notice or one of the
exceptions to providing the notice applied under 29 CFR 2520.101-3 .............................................. 10i
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