SCHEDULE D(Form 5500)
Department of the Treasury Internal Revenue Service
Department of Labor Employee Benefits Security Administration
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DFE/Participating Plan Information
This schedule is required to be filed under section 104 of the Employee Retirement Income Security Act of 1974 (ERISA). File as an attachment to Form 5500.
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OMB No. 1210-0110 This Form is Open to Public Inspection. |
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For calendar plan year 2016 or fiscal plan year beginning and ending |
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A Name of plan ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
B
Three-digit |
001 |
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C Plan or DFE sponsor’s name as shown on line 2a of Form 5500 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
D
Employer Identification Number (EIN) |
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Part I |
Information
on interests in MTIAs, CCTs, PSAs, and 103-12 IEs (to be completed
by plans and DFEs)
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a Name of MTIA, CCT, PSA, or 103-12 IE: |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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b Name of sponsor of entity listed in (a): |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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c EIN-PN |
123456789-123 |
d Entity code |
1 |
e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions) |
-123456789012345 |
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a Name of MTIA, CCT, PSA, or 103-12 IE: |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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b Name of sponsor of entity listed in (a): |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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c EIN-PN |
123456789-123 |
d Entity code |
1 |
e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions) |
-123456789012345 |
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a Name of MTIA, CCT, PSA, or 103-12 IE: |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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b Name of sponsor of entity listed in (a): |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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c EIN-PN |
123456789-123 |
d Entity code |
1 |
e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions) |
-123456789012345 |
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a Name of MTIA, CCT, PSA, or 103-12 IE: |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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b Name of sponsor of entity listed in (a): |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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c EIN-PN |
123456789-123 |
d Entity code |
1 |
e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions) |
-123456789012345 |
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a Name of MTIA, CCT, PSA, or 103-12 IE: |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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b Name of sponsor of entity listed in (a): |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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c EIN-PN |
123456789-123 |
d Entity code |
1 |
e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions) |
-123456789012345 |
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a Name of MTIA, CCT, PSA, or 103-12 IE: |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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b Name of sponsor of entity listed in (a): |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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c EIN-PN |
123456789-123 |
d Entity code |
1 |
e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions) |
-123456789012345 |
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a Name of MTIA, CCT, PSA, or 103-12 IE: |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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b Name of sponsor of entity listed in (a): |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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c EIN-PN |
123456789-123 |
d Entity code |
1 |
e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions) |
-123456789012345 |
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For Paperwork Reduction Act Notice, see the Instructions for Form 5500. |
Schedule D (Form 5500) 2016 v.160205 |
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a Name of MTIA, CCT, PSA, or 103-12 IE: |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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b Name of sponsor of entity listed in (a): |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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c EIN-PN |
123456789-123 |
d Entity code |
1 |
e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions) |
-123456789012345 |
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a Name of MTIA, CCT, PSA, or 103-12 IE: |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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b Name of sponsor of entity listed in (a): |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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c EIN-PN |
123456789-123 |
d Entity code |
1 |
e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions) |
-123456789012345 |
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a Name of MTIA, CCT, PSA, or 103-12 IE: |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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b Name of sponsor of entity listed in (a): |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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c EIN-PN |
123456789-123 |
d Entity code |
1 |
e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions) |
-123456789012345 |
|
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a Name of MTIA, CCT, PSA, or 103-12 IE: |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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b Name of sponsor of entity listed in (a): |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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c EIN-PN |
123456789-123 |
d Entity code |
1 |
e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions) |
-123456789012345 |
|
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a Name of MTIA, CCT, PSA, or 103-12 IE: |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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b Name of sponsor of entity listed in (a): |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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c EIN-PN |
123456789-123 |
d Entity code |
1 |
e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions) |
-123456789012345 |
|
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a Name of MTIA, CCT, PSA, or 103-12 IE: |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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b Name of sponsor of entity listed in (a): |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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c EIN-PN |
123456789-123 |
d Entity code |
1 |
e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions) |
-123456789012345 |
|
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a Name of MTIA, CCT, PSA, or 103-12 IE: |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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b Name of sponsor of entity listed in (a): |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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c EIN-PN |
123456789-123 |
d Entity code |
1 |
e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions) |
-123456789012345 |
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a Name of MTIA, CCT, PSA, or 103-12 IE: |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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b Name of sponsor of entity listed in (a): |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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c EIN-PN |
123456789-123 |
d Entity code |
1 |
e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions) |
-123456789012345 |
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a Name of MTIA, CCT, PSA, or 103-12 IE: |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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b Name of sponsor of entity listed in (a): |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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c EIN-PN |
123456789-123 |
d Entity code |
1 |
e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions) |
-123456789012345 |
|
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a Name of MTIA, CCT, PSA, or 103-12 IE: |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD |
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b Name of sponsor of entity listed in (a): |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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c EIN-PN |
123456789-123 |
d Entity code |
1 |
e Dollar value of interest in MTIA, CCT, PSA, or 103-12 IE at end of year (see instructions) |
-123456789012345 |
6
Part II |
Information
on Participating Plans (to be completed by DFEs) |
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a Plan name |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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b Name
of |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
c EIN-PN |
123456789-123 |
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a Plan name |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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b Name
of |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
c EIN-PN |
123456789-123 |
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a Plan name |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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b Name
of |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
c EIN-PN |
123456789-123 |
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a Plan name |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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b Name
of |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
c EIN-PN |
123456789-123 |
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a Plan name |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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b Name
of |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
c EIN-PN |
123456789-123 |
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a Plan name |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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b Name
of |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
c EIN-PN |
123456789-123 |
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a Plan name |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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b Name
of |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
c EIN-PN |
123456789-123 |
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a Plan name |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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b Name
of |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
c EIN-PN |
123456789-123 |
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a Plan name |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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b Name
of |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
c EIN-PN |
123456789-123 |
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a Plan name |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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b Name
of |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
c EIN-PN |
123456789-123 |
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a Plan name |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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b Name
of |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
c EIN-PN |
123456789-123 |
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a Plan name |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
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b Name
of |
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI |
c EIN-PN |
123456789-123 |
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Form 5500 |
| Author | Bruce Silver |
| File Modified | 0000-00-00 |
| File Created | 2021-01-11 |