Guide to Your IRS/DOL 5500 Forms - MyKplan€¦ · GUIDE TO YOUR IRS/DOL 5500 FORMS 3 Section 2:...

ADP Retirement Services

Guide to Your IRS/DOL 5500 Forms

ADP, the ADP logo and ADP A more human resource are registered trademarks of ADP, LLC. All other trademarks and service marks are the property of their respective owners. 04-2847-0518 Copyright © 2005-2018 ADP, LLC. ALL RIGHTS RESERVED.

IRS/DOL Filing Deadline:Last day of the 7th month following

the end of the plan year.*

* if this date is on a weekend, the deadline is extended to the next business day.

GUIDE TO YOUR IRS/DOL 5500 FORMS 1

• Section 1 Introduction ............................................................................

• Section 2 Important Information ........................................................... Page 3

• Section 3 Electronic Filing (E-filing) Steps ............................................ Page 4

• Section 4 Which Forms & Schedules Must You File Electronically? ... Page 6

• Section 5 Form 5500-SF (Small Plans Only) .......................................... Page 7

• Section 6 Form 5500............................................................................... Page 16

• Section 7 Schedule A ............................................................................. Page 22

• Section 8 Schedule C and Sample Notice (Large Plans Only) ............ Page 23

• Section 9 Schedule D ............................................................................. Page 27

• Section 10 Schedule H (Large Plans Only) ............................................. Page 28

• Section 11 Schedule I (Small Plans with Employer Stock Only) ............ Page 35

• Section 12 Schedule R ............................................................................. Page 40

• Section 13 Which Other Forms & Schedules May be Needed? .......... Page 41

• Section 14 Are Revisions Required? ....................................................... Page 42

• Section 15 Need to File an Extension? ................................................... Page 43

• Section 16 Form 8955-SSA ...................................................................... Page 45

• Section 17 What if You Converted to ADP This Year? ........................... Page 51

• Section 18 Special Notices ...................................................................... Page 54

• Section 19 Fair Value Measurement and Disclosures ............................ Page 55

Table of Contents


Section 1: Introduction

Since your company maintained a qualified retirement plan during the plan year, your company must file a Form 5500 or Form 5500-SF to satisfy the annual filing requirements of the Internal Revenue Service (IRS) and the Department of Labor (DOL). These forms must be filed by the last day of the 7th calendar month after the end of the plan year. For example, if your plan year ends 12/31, the annual deadline is the following 7/31.*

We have prepared the Forms to report the required information for your company’s plan. The items on these Forms have been completed based upon the information you have provided during the year to ADP Retirement Services and ADP Payroll, as well as the “Required Data Update.” Although great care has been taken in completing this information, it is important that you carefully review every item on the Forms. In addition, it is important that you have your tax advisor review the Forms before they are filed with the IRS/DOL.

This Guide contains explanations describing the Forms that have been prepared, and brief instructions to assist you with any items that you will have to complete. Should you wish to review the complete IRS instructions, refer to the DOL’s Website: www.efast.dol.gov.

For plans that have converted from other service providers to ADP Retirement Services and transferred the plan assets during the plan year, it is important that

you review Section 17 entitled “What if You Converted to ADP This Year?” There may be some questions on the Forms that we cannot complete and will necessitate a response from you.

* NOTE: if this date is on a weekend, the deadline is extended to the next business day.

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Section 2: Important Information

• Filing Deadlines

For plan year’s that end on 12/31, the filing deadlines are 7/31/ and 10/15 (if on extension). If either of these dates fall on the weekend, the deadline is extended to the next business day.

• Form 5558 – Application for Extension of Time to File Certain Employee Plan Returns

Form 5558 is used to file for an extension of time to file Form 5500 or Form 5500-SF as well as Form 8955-SSA. We have prepared Form 5558 as part of the 5500 PDF document on the Plan Sponsor Website. In order to extend the due date to file your Form 5500 or Form 5500-SF (as well as Form 8955-SSA, if applicable), you will need to print Form 5558 and mail it to the IRS. See Section 15 of this guide for more information.

• Plan Sponsor Website (PSW) presentation to simplify your e-filing experience:

— A PDF of your Form 5500, including all schedules and Form 8955-SSA (if applicable) is available for reviewing, printing and saving for your files. Please note that Form 5500 or 5500-SF is required to be electronically filed with the Department of Labor and the Form 8955-SSA (if applicable) is required to be electronically filed with the Internal Revenue Service.

— Option to make certain corrections.

— Ability to check the status of the filing of Form 5500 or Form 5500-SF and the 8955-SSA (if applicable).

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Section 3: Electronic Filing (E-filing) Steps

The Department of Labor (DOL) requires that all Form 5500 or Form 5500-SF filings be submitted electronically using the ERISA Filing Acceptance System (EFAST2) Web site. Your 8955-SSA (if applicable) must be electronically filed with the IRS using the FIRE System. For Form 5500-SF filers, the 8955-SSA will automatically be submitted to the IRS at the same time you electronically file your Form 5500. For Form 5500 filers, an extra step must be taken to file the 8955-SSA after you have electronically submitted your Form 5500.

ADP Retirement Services (ADPRS) will prepare your Forms, and will provide them to you through the Plan Sponsor Website (PSW).

Signing Credentials – Before you can electronically file your Form 5500, the individual signing your Plan’s Form will need to obtain “signing credentials” from the DOL EFAST2 Web site.

If you have not done so already, access the Form 5500 EFAST2 link to obtain your credentials by logging onto the Plan Sponsor Website (PSW) at www.mykplan.com/sponsor.

Although Forms are to be transmitted electronically, a completed signed copy of the return must be maintained in the Plan Sponsor’s files for a minimum of seven years to comply with the ERISA record-retention requirements.

To complete the required filing, follow the steps outlined below:

Step #1 Review your Form 5500 or Form 5500-SF on the Plan Sponsor Website (PSW).

Step #2 All filings should include:

a. Form 5500-SF for small plans, or

b. Form 5500 and appropriate Schedules as checked in line item #10 of Form 5500 (large plans or small plans with investments in company stock).

c. 8955-SSA (if applicable)

If you are a Schedule H filer:

You must have an independent accountant audit your company’s 401(k) plan and prepare a financial audit report. The accountant’s report must be attached electronically to your company’s filing of the Form 5500.

Due to increased ADP Security Regulations, we are no longer mailing a CD or paper copies; the audit package is available on the Plan Sponsor Website (PSW).

If your auditor needs access to the PSW, your plan’s security administrator may establish temporary access for him/her by logging into the Security Administration side of the PSW.


Section 3: Electronic Filing (E-filing) Steps, continued

Step #3 If you determine you will need an extension of time, see Form 5558 and instructions in Section 15.

Step #4 If you have any questions or revisions regarding the 5500 Forms, contact ADP Retirement Services Client Services.

Step #5 Summary Annual Report (SAR) – The SAR is a summary of the information reported on your company’s 5500 Forms. The SAR is not included in your filing to the IRS/DOL. It must be distributed by you no later than 2 months following your filing deadline to all eligible employees, to each beneficiary receiving benefits under your plan, and to those participants who have retired or separated from service but have vested benefits remaining in your plan. If you filed the Application for Extension of Time with the IRS by the due date of the Form 5500, then the deadline for distribution of the SAR is extended to two months following the extended 5500 filing due date. If you need an extension of time, see Form 5558 and instructions in Section 15.

Step #6 Print a signed copy of the entire PDF for your records once all Forms are finalized and successfully submitted.

The following Forms are not electronically filed:

• Form 5558 - (Application for Extension of Time to File Certain Employee Plan Returns), if necessary, will need to be filed directly with the IRS in hard copy. Details to follow in Section 15.

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Section 4: Which Forms & Schedules Must You File Electronically?

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The Form 5500 reporting requirements vary depending on whether you are a “large” plan (if your plan covers 100 or more participants) or a “small” plan (if your plan covers fewer than 100 participants). There is an exception (80-120 Participant Rule). If a Form 5500-SF was filed for the plan in the prior plan year and the plan covered fewer than 121 participants as of the beginning of the current plan year, Form 5500-SF may be completed instead of Form 5500 and the applicable schedules.

• Small Plans

— Form 5500-SF — 8955-SSA (if applicable)

• Large Plans & Small Plans with Employer Stock

— Form 5500.

— Schedule A – If your plan provided benefits funded in part or whole by insurance products (e.g. life insurance, annuity contracts) issued by an insurance company.

— Schedule C – If your plan covered 100 or more participants as of the beginning of the plan year (as identified in line item 5 of the Form 5500) and:

1. A service provider received $5,000 or more in total direct or indirect compensation from the plan.

2. A service provider provided an Eligible Indirect Compensation disclosure.

3. An Accountant or Actuary was terminated.

— Schedule D – If your plan has a Common Collective Trust (CCT) or Pooled Separate Account (PSA) investment arrangement.

— Schedule H – If your plan covers 100 or more participants (in Form 5500 line item 5, number of participants) as of the beginning of the plan year. There is an exception (80-120 Participant Rule). If a Schedule I or Form 5500-SF was filed for the plan in the prior plan year and the plan covered fewer than 121 participants as of the beginning of the current plan year, Schedule I or Form 5500-SF may be completed instead of Schedule H. If this exception applies, a Schedule I or Form 5500-SF has been completed.

— Schedule I – If your plan covers fewer than 100 participants (in Form 5500 line item 5, number of participants) as of the beginning of the plan year and your plan had investments in company stock. Note that Schedule I may also be completed (instead of Schedule H) if Schedule I was filed for the prior plan year and the plan covered fewer than 121 participants as of the beginning of the plan year.

— Schedule R – If distributions have been made to participants or your plan is an active money purchase pension plan or includes an active money purchase plan component.

— 8955-SSA (if applicable)

The following pages walk you through each of these Forms & Schedules.


Section 5: Form 5500-SF (Small Plans Only)

Part I Annual Report Identification Information

A-B Line items A-B have been completed on your behalf based on our records.

In line item A, the box for a single-employer plan has been checked.

Boxes in line item B are checked in accordance with the following:

• The first return/report if the plan was first effective in the plan year

• The final return/report if the plan terminated or merged and all assets were distributed

within the plan year

• A short plan year return/report (less than 12 months) if this is a short plan year for

your plan

C If you have told us that you will be filing a Form 5558 (Application for Extension of Time) or

your Corporate Tax Extension (automatic extension), this line item has been completed. See

Section 15 for additional information.

Line Item

Annual Return/Report of Employee Benefit Plan

Form 5500-SFDepartment of the TreasuryInternal Revenue Service

Department of LaborEmployee Benefits Security Administration

Pension Benefit Guaranty Corporation

Short Form Annual Return/Report of Small Employee Benefit Plan

This form is required to be filed under sections 104 and 4065 of the Employee Retirement Income Security Act of 1974 (ERISA), and sections 6057(b) and 6058(a) of the Internal

Revenue Code (the Code).

Complete all entries in accordance with the instructions to the Form 5500-SF.

OMB Nos. 1210-01101210-0089

This Form is Open to Public Inspection

Part I Annual Report Identification InformationFor calendar plan year 20XX or fiscal plan year beginning and ending

A This return/report is for:a single-employer plan

a one-participant plan

a multiple-employer plan (not multiemployer) (Filers checking this box must attach a list of participating employer information in accordance with the form instructions.)a foreign plan

B This return/report is the first return/report the final return/report

an amended return/report a short plan year return/report (less than 12 months)

C Check box if filing under: Form 5558 automatic extension DFVC program

special extension (enter description)

Part II Basic Plan Information—enter all requested information1a Name of plan 1b Three-digit

plan number (PN)

1c Effective date of plan

2a Plan sponsor’s name (employer, if for a single-employer plan)Mailing address (include room, apt., suite no. and street, or P.O. Box)City or town, state or province, country, and ZIP or foreign postal code (if foreign, see instructions)

2b Employer Identification Number(EIN)

2c Sponsor’s telephone number

2d Business code (see instructions)

3a Plan administrator’s name and address Same as Plan Sponsor.

3b Administrator’s EIN

3c Administrator’s telephone number

4 If the name and/or EIN of the plan sponsor has changed since the last return/report filed for this plan, enter thename, EIN, and the plan number from the last return/report.

a Sponsor’s name

4b EIN

4c PN

5a Total number of participants at the beginning of the plan year ................................................................................ 5a b Total number of participants at the end of the plan year ......................................................................................... 5b c Number of participants with account balances as of the end of the plan year (only defined contribution plans

complete this item) ................................................................................................................................................. 5c

d(1) Total number of active participants at the beginning of the plan year .................................................................. 5d(1)d(2) Total number of active participants at the end of the plan year ........................................................................... 5d(2)e Number of participants that terminated employment during the plan year with accrued benefits that were less

than 100% vested ................................................................................................................................................. 5eCaution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established.Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return/report, including, if applicable, a Schedule SB or Schedule MB completed and signed by an enrolled actuary, as well as the electronic version of this return/report, and to the best of my knowledge and belief, it is true, correct, and complete.

SIGNHERE Signature of plan administrator Date Enter name of individual signing as plan administrator

SIGNHERE Signature of employer/plan sponsor Date Enter name of individual signing as employer or plan sponsorPreparer’s name (including firm name, if applicable) and address (include room or suite number ) Preparer’s telephone number

For Paperwork Reduction Act Notice, see the Instructions for Form 5500-SF. Form 5500-SF (2016)v.160205


Section 5: Form 5500-SF (Small Plans Only), continued

Part II Basic Plan Information

1b A three-digit plan number has been reported based on the three-digit plan number specified

on the first page of the Adoption Agreement for your company’s plan. Verify that the correct

plan number has been recorded. For IRS reporting purposes, all qualified retirement plans

are assigned a three-digit number starting with 001 and continuing with 002, etc. when

they are established. The number assigned to one plan should never be used for another

plan, even if the first plan is terminated and the number is no longer in use. This three-digit

number differs from the 6-digit ADP Recordkeeping Plan Number. If this plan is the first plan

your company has ever maintained, the plan number is 001.

2a Plan sponsor’s name and address. NOTE: The name and address are in specific locations

within the box due to government processing specifications.

2d A business code, to describe the product or service your company provides, has been

entered from the information your company provided on the Required Data Update. See

Section 14, “Are Revisions Required?” to complete this information.

Line Item

Form 5500-SFDepartment of the TreasuryInternal Revenue Service







OMB Nos. 1210-01101210-0089



A This return/report is for:a single-employer plan

a one-participant plan

a multiple-employer plan (not multiemployer) (Filers checking this box must attach a list of participating employer information in accordance with the form instructions.)a foreign plan

B This return/report is the first return/report the final return/report

an amended return/report a short plan year return/report (less than 12 months)

C Check box if filing under: Form 5558 automatic extension DFVC program

special extension (enter description)

Part II Basic Plan Information—enter all requested information1a Name of plan 1b Three-digit

plan number (PN)

1c Effective date of plan


2b Employer Identification Number(EIN)

2c Sponsor’s telephone number

2d Business code (see instructions)

3a Plan administrator’s name and address Same as Plan Sponsor.

3b Administrator’s EIN

3c Administrator’s telephone number

4 If the name and/or EIN of the plan sponsor has changed since the last return/report filed for this plan, enter thename, EIN, and the plan number from the last return/report.

a Sponsor’s name

4b EIN

4c PN

5a Total number of participants at the beginning of the plan year ................................................................................ 5a b Total number of participants at the end of the plan year ......................................................................................... 5b c Number of participants with account balances as of the end of the plan year (only defined contribution plans

complete this item) ................................................................................................................................................. 5c

d(1) Total number of active participants at the beginning of the plan year .................................................................. 5d(1)d(2) Total number of active participants at the end of the plan year ........................................................................... 5d(2)e Number of participants that terminated employment during the plan year with accrued benefits that were less

than 100% vested ................................................................................................................................................. 5eCaution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established.Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return/report, including, if applicable, a Schedule SB or Schedule MB completed and signed by an enrolled actuary, as well as the electronic version of this return/report, and to the best of my knowledge and belief, it is true, correct, and complete.

SIGNHERE Signature of plan administrator Date Enter name of individual signing as plan administrator

SIGNHERE Signature of employer/plan sponsor Date Enter name of individual signing as employer or plan sponsorPreparer’s name (including firm name, if applicable) and address (include room or suite number ) Preparer’s telephone number

For Paperwork Reduction Act Notice, see the Instructions for Form 5500-SF. Form 5500-SF (2016)v.160205



3 Since the Plan Administrator of the plan is the same as the Plan Sponsor, option for Plan

administrator’s name and address is marked with an “X.” 3b and 3c are not applicable and

are left blank.

4 If the company’s name in line item 2a and/or the company’s Employer Identification Number

and/or Plan Name in line item 2b differs from what was reported on the prior year Form, line

item 4 has been completed with the information from last year’s Form.

5a - e The number of participants has been calculated based on ADP recordkeeping records

and your coding in payroll records.

NOTE: In a 401(k) plan, the definition of “participant” includes an eligible employee regardless of whether or not the employee actually makes any deferrals to the 401(k) plan and terminated employees that still have assets in the plan. “Alternate payees” entitled to benefits under a Qualified Domestic Relations Order (QDRO) are not counted as participants for these lines.

5a This line item has been completed with the total number of participants at the beginning of

the plan year.

5b This line item has been completed with the total number of participants at the end of the

plan year.

5c This line item has been completed with the number of participants with account balances as

of the end of the plan year, as recorded on our recordkeeping systems. This includes both

active and terminated participants.

5d(1) This line item has been completed with the number of active participants at the beginning of

the plan year.

5d(2) This line item has been completed with the number of active participants at the end of the

plan year.

5e This line item has been completed with the number of participants who terminated

employment during the plan year and were less than 100% vested.

Line Item

Form 5500-SFDepartment of the Treasury Internal Revenue Service

Department of Labor Employee Benefits Security Administration






OMB Nos. 1210-0110 1210-0089


Part I Annual Report Identification InformationFor calendar plan year 2017 or fiscal plan year beginning and ending

A This return/report is for:X a single-employer plan

X a one-participant plan

X a multiple-employer plan (not multiemployer) (Filers checking this box must attach a list of participating employer information in accordance with the form instructions.)

X a foreign plan

B This return/report is X the first return/report X the final return/report

X an amended return/report X a short plan year return/report (less than 12 months)

C Check box if filing under: X Form 5558 X automatic extension X DFVC program

X special extension (enter description)

Part II Basic Plan Information—enter all requested information1a Name of plan ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

1b Three-digitplan number (PN) 001

1c Effective date of planYYYY-MM-DD

2a Plan sponsor’s name (employer, if for a single-employer plan) Mailing address (include room, apt., suite no. and street, or P.O. Box) City or town, state or province, country, and ZIP or foreign postal code (if foreign, see instructions)ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGH ABCDEFGHI ABCDEFGHI ABCDEFGHI I

2b Employer Identification Number(EIN) 012345678

2c Sponsor’s telephone number1234567890

2d Business code (see instructions)123456

3a Plan administrator’s name and address X Same as Plan Sponsor.ABCDEFGHI ABCDEFGHI

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIc/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE

CITYEFGHI ABCDEFGHI AB ST 012345678901I A

3b Administrator’s EIN012345678

3c Administrator’s telephone number1234567890

4 If the name and/or EIN of the plan sponsor or the plan name has changed since the last return/report filed forthis plan, enter the plan sponsor’s name, EIN, the plan name and the plan number from the last return/report.

a Sponsor’s namec Plan Name DEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI CDEFGHI

4b EIN012345678

4d PN 012

5a Total number of participants at the beginning of the plan year .................................................................................. 5a 12345678

b Total number of participants at the end of the plan year ............................................................................................ 5b 12345678c Number of participants with account balances as of the end of the plan year (only defined contribution plans

complete this item) ..................................................................................................................................................... 5c

d(1) Total number of active participants at the beginning of the plan year .................................................................... 5d(1) d(2) Total number of active participants at the end of the plan year ............................................................................. 5d(2) e Number of participants who terminated employment during the plan year with accrued benefits that were less

than 100% vested ..................................................................................................................................................... 5e Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established.Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return/report, including, if applicable, a Schedule SB or Schedule MB completed and signed by an enrolled actuary, as well as the electronic version of this return/report, and to the best of my knowledge and belief, it is true, correct, and complete.

SIGN HERE

Signature of plan administrator Date Enter name of individual signing as plan administrator

SIGN HERE Signature of employer/plan sponsor Date Enter name of individual signing as employer or plan sponsor For Paperwork Reduction Act Notice, see the Instructions for Form 5500-SF. Form 5500-SF (2017)

v.170203



6a “YES” has been entered since all assets are eligible.

6b “YES” has been entered because your plan is eligible for a waiver of the annual examination

and report of an independent qualified public accountant. Your plan meets the conditions

needed:

— at least 95% of the plan’s assets are “qualifying plan assets” as of the end of the preceding

plan year.

— in response to any request from a participant or beneficiary, you must, without charge,

make available for examination, or upon request furnish copies of each regulated financial

institution statement.

— Summary Annual Report (SAR) must be distributed by you to all employees eligible to

participate in your plan.

7a-c Financial Information

The financial information for your company’s plan has been completed with the information

that we have on file on the Retirement Services’ recordkeeping system.

NOTE: If your plan has Deemed Distributed Loans (DDLs), the amount of the DDLs is not included in the assets reported in line item 7a-7c. To explain, a DDL occurs when a participant misses a loan payment for any reason other than certain types of leave of absence and fails to make it up by a specified date, or the term for repaying a loan expires without full payment of the outstanding amount by a specified date. At that time, the participant is taxed on the outstanding amount, including applicable interest accrued to date, as if it had been distributed. The IRS requires two ways to account for DDLs. In recordkeeping the plan, the DDLs are treated as on-going active loans. Interest is accrued monthly and added to the amount of the outstanding loan. However, for Form 5500 reporting purposes, DDLs are to be removed from the plan assets. This is done on line item 8e at the time the loan is deemed distributed and as interest continues to accrue. The result is reflected in line item 7.

Line Item

Form 5500-SF 2016 Page 2

6a Were all of the plan’s assets during the plan year invested in eligible assets? (See instructions.) ......................................................... X Yes X Nob Are you claiming a waiver of the annual examination and report of an independent qualified public accountant (IQPA)

under 29 CFR 2520.104-46? (See instructions on waiver eligibility and conditions.).............................................................................. X Yes X NoIf you answered “No” to either line 6a or line 6b, the plan cannot use Form 5500-SF and must instead use Form 5500.

c If the plan is a defined benefit plan, is it covered under the PBGC insurance program (see ERISA section 4021)? ...... X Yes X No X Not determined

Part III Financial Information7 Plan Assets and Liabilities (a) Beginning of Year (b) End of Yeara Total plan assets ....................................................................................7a -123456789012345 -123456789012345b Total plan liabilities .................................................................................7b -123456789012345 123456789012345 c Net plan assets (subtract line 7b from line 7a) ........................................7c -123456789012345 -123456789012345

8 Income, Expenses, and Transfers for this Plan Year (a) Amount (b) Totala Contributions received or receivable from:

(1) Employers .......................................................................................8a(1) -123456789012345(2) Participants......................................................................................8a(2) -123456789012345(3) Others (including rollovers)...............................................................8a(3) -123456789012345

b Other income (loss) ................................................................................8b -123456789012345c Total income (add lines 8a(1), 8a(2), 8a(3), and 8b) ...............................8c -123456789012345d Benefits paid (including direct rollovers and insurance premiums

to provide benefits).................................................................................8d -123456789012345e Certain deemed and/or corrective distributions (see instructions) ...........8e -123456789012345f Administrative service providers (salaries, fees, commissions) ...............8f -123456789012345g Other expenses ......................................................................................8g -123456789012345h Total expenses (add lines 8d, 8e, 8f, and 8g) .........................................8h -123456789012345i Net income (loss) (subtract line 8h from line 8c) .....................................8i -123456789012345j Transfers to (from) the plan (see instructions).........................................8j -123456789012345

Part IV Plan Characteristics9a 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 Questions10 During the plan year: Yes No N/A Amount

a Was there a failure to transmit to the plan any participant contributions within the time perioddescribed in 29 CFR 2510.3-102? (See instructions and DOL’s Voluntary Fiduciary CorrectionProgram) ............................................................................................................................................10a -123456789012345

b Were there any nonexempt transactions with any party-in-interest? (Do not include transactionsreported on line 10a.) ...........................................................................................................................10b -123456789012345

c Was the plan covered by a fidelity bond? ............................................................................................10c -123456789012345d Did the plan have a loss, whether or not reimbursed by the plan’s fidelity bond, that was caused

by fraud or dishonesty?........................................................................................................................10d -123456789012345e 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 the plan? (See instructions.).................................................................................................................10e -123456789012345

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.) ................................10gh If this is an individual account plan, was there a blackout period? (See instructions and 29 CFR

2520.101-3.) ........................................................................................................................................10h -123456789012345i 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



8a-j Line Item 8a(1): Forfeitures generated from non-vested funds of participants receiving

distributions during the plan year are automatically used to reduce employer matching

contributions that are calculated on a per payroll basis. If applicable, they may also be used

to reduce a Non-Elective Contribution or Discretionary Match liability (including a Safe

Harbor Non-Elective Contribution or Safe Harbor Matching Contribution) and/or a QNEC or

QMAT. If forfeitures were applied during the plan year, this line item has been reduced to

reflect this amount.

Line Item 8d: Loans that were previously deemed distributed that are now offset are not

reflected in the benefit payments amount reported in this line item, because they were

removed from the reporting via line item 8e.

Line Item 8e: The amount shown represents a combination of deemed loans and any

corrective distributions which were distributed during the plan year. The deemed loan

amount takes the following into consideration:

— the principal plus an accrued interest

— the accrued interest on previously deemed loans

— Minus a deemed distributed loan including the accrued interest repaid during the

plan year.

Line Item











































9a Line item 9a has been completed with the applicable codes for your specific type of plan from

the following list:

2A Allocations based upon age, service, age and service, or New Comparability

2C Money Purchase Plan

2E Profit Sharing Plan

A 401(k) plan is a profit sharing plan with a 401(k) feature.



2F 404(c)

Participants in defined contribution plans that have investment control of their

accounts are not considered fiduciaries because of that control and no other fiduciary

will be responsible for any losses as a result of a participant’s exercise of that control.

ERISA Section 404(c) can be relied on as a defense in the event of an investment loss if

the plan complies with the requirements of the regulation. This includes giving notice

to plan participants that the plan is designed to comply with ERISA Section 404(c)

and that plan fiduciaries may be relieved of liability for investment losses that are the

direct and necessary result of the participants’ investment instructions. Generally,

participants must be furnished with information on investment alternatives, how to

give investment instructions, who the investment manager is, transaction fees and

expenses, name, address, and phone number of the plan fiduciary responsible for

providing the information, and voting rights information.

2G Participant-Directed Accounts

2J 401(k) Feature

2K 401(m) Matching Provision Feature

2R Self-Directed Brokerage Account

2S Automatic Enrollment

2T Default Investment for Participant-Directed Accounts

3B Plan covering Self-Employed individuals

3D Prototype Plan Document

3F Company had leased employees during the plan year

Note: Generally, if your company has individuals providing services to your company

under an agreement between your company and a leasing organization (or an

agreement between an independent contractor and your company), where the

individuals perform services for your company for a period of at least one year and

the services are performed under the primary direction or control of your company,

“3F” may be required for this line item. You should consult with your tax advisor in

determining whether certain individuals are leased employees.

3H Controlled Group or Affiliated Service Group

You should consult with your company’s tax advisor if you have questions as

to whether your company is a member of a controlled group or an affiliated

service group.

9b Line item 9b is not applicable and is intentionally left blank.

Line Item
























Part V Compliance Questions

SPECIAL NOTE: Under plan asset regulations as defined by 29 CFR 2510.3-102, participant contributions to a pension plan are considered plan assets at the earliest time they can be reasonably segregated from the general funds of the employer, but no later than: • For plans with fewer than 100 participants as of the beginning of the plan

year, 7 business days from the check date they are associated with, or the date they are received by the employer.

• For plans with 100 or more participants as of the beginning of the plan year, 15th business day of the following month.

“NO” means all contributions were transmitted in a timely manner. If this needs to be

changed, contact ADP Retirement Services Client Services for assistance.

“YES” means that some or all contributions were not transmitted in a timely manner. This is

based on your response on the Required Data Update (RDU).

IMPORTANT NOTE: If “YES” has been entered, you must file Form 5330 with the IRS.

Refer to www.irs.gov and consult with your tax advisor regarding the filing of Form 5330.

10b “NO” has been entered because this question refers to situations that, to ADP’s knowledge,

did not occur within your plan. However, you should consult with your legal or tax advisor to

determine whether you need to revise this response.

Line Item






















10a



10c Generally, every plan official of an employee benefit plan who handles funds or other

property of such plan must be covered by a Fidelity Bond. The Department of Labor requires

the Bond to cover at least the greater of 10% of plan assets as of the beginning of the plan

year or $1,000 with a maximum of $500,000. Line 10c has been completed based on the

bond purchased on behalf of the plan by the plan’s Trustee or Plan Sponsor. If the plan

became effective during the year, the bond amount should be a minimum of $1,000.

10d “NO” has been entered because these questions refer to situations that, to ADP’s

knowledge, did not occur within your plan. However, you should consult with your legal or tax

advisor to determine whether you need to revise this response.

10e If any benefits under the plan are provided by an insurance company, insurance service,

or other similar organization, or if the plan has investments with insurance companies

such as guaranteed investment contracts (GICs), report the total of all insurance fees and

commissions paid to agents, brokers and/or other persons directly or indirectly.

10f “NO” has been entered because this question refers to situations that, to ADP’s knowledge,

did not occur within your plan.

10g “YES” has been entered if your plan had any participant loan activity during the plan year.

An amount has been entered if there was an outstanding amount at the end of the plan year.

Otherwise “NO”.

10h “YES” has been entered if your plan converted to the ADP 401(k) plan and transferred plan

assets during the plan year. Otherwise “NO”.

10i “YES” has been entered if 10h is “YES”. Otherwise this line is blank.

11 This line item is not applicable and is intentionally left blank.

Line ItemForm 5500-SF 2016 Page 2




















exceptions to providing the notice applied under 29 CFR 2520.101-3 ..................................................10iForm 5500-SF 2016 Page 3- 1 x

Part VI Pension Funding Compliance 11 Is this a defined benefit plan subject to minimum funding requirements? (If "Yes," see instructions and complete Schedule SB

(Form 5500) and line 11a below) .............................................................................................................................................................X Yes X No

11a Enter the unpaid minimum required contributions for all years from Schedule SB (Form 5500) line 40 ..........................................11a 12 Is this a defined contribution plan subject to the minimum funding requirements of section 412 of the Code or section 302 of

ERISA? ...................................................................................................................................................................................................(If "Yes," complete line 12a or lines 12b, 12c, 12d, and 12e below, as applicable.)

X Yes X No

a If a waiver of the minimum funding standard for a prior year is being amortized in this plan year, see instructions, and enter the date of the letter rulinggranting the waiver. ............................................................................................................................. Month _______ Day _______ Year ________

If you completed line 12a, complete lines 3, 9, and 10 of Schedule MB (Form 5500), and skip to line 13.

b Enter the minimum required contribution for this plan year ............................................................................................. 12b 123456789012345

c Enter the amount contributed by the employer to the plan for this plan year ................................................................... 12c -123456789012345d Subtract the amount in line 12c from the amount in line 12b. Enter the result (enter a minus sign to the left of a

negative amount) ..........................................................................................................................................................12d YYYY-MM-DD

e Will the minimum funding amount reported on line 12d be met by the funding deadline?......................................................X Yes X No X N/A

Part VII Plan Terminations and Transfers of Assets13a Has a resolution to terminate the plan been adopted in any plan year? ......................................................................................................................................X Yes X No

If “Yes,” enter the amount of any plan assets that reverted to the employer this year ..........................................................................................................13a

b Were all the plan assets distributed to participants or beneficiaries, transferred to another plan, or brought under thecontrol of the PBGC? ................................................................................................................................................................. X Yes X No

c If, during this plan year, any assets or liabilities were transferred from this plan to another plan(s), identify the plan(s) towhich assets or liabilities were transferred. (See instructions.)

13c(1) Name of plan(s): 13c(2) EIN(s) 13c(3) PN(s)ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

123456789 012

Part VIII Trust Information 14a Name of trust ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

14b Trust’s EIN

14c Name of trustee or custodian 14d Trustee’s or custodian’stelephone number

Part IX IRS Compliance Questions

15a Is the plan a 401(k) plan? If “No,” skip b.......................................................................................................................................................X Yes X No

15b How did the plan satisfy the nondiscrimination requirements for employee deferrals under section401(k)(3) for the plan year? Check all that apply: .......................................................................................................................................

X Design-based safe harbor X “Prior year” ADP

test

X “Current year” ADP test X N/A

16a What testing method was used to satisfy the coverage requirements under section 410(b) for the planyear? Check all that apply: .........................................................................................................................................................................X

Ratio percentage test

X Average benefit test X N/A

16b Did the plan satisfy the coverage and nondiscrimination requirements of sections 410(b) and 401(a)(4)for the plan year by combining this plan with any other plan under the permissive aggregation rules?............................................

X Yes X No

17a If the plan is a master and prototype plan (M&P) or volume submitter plan that received a favorable IRS opinion letter or advisory letter, enter the date ofthe letter _______/_______/_______ and the serial number ________________.

17b If the plan is an individually-designed plan that received a favorable determination letter from the IRS, enter the date of the most recent determinationletter ______/_______/_______.

18 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? ………………………………………………………………………………………………….....................

X Yes X No

19 Was any plan participant a 5% owner who had attained at least age 70 ½ during the prior plan year? ........................................................X Yes X No



12 “NO” has been entered because this line item is not applicable to 401(k) plans.

13a If your company has notified ADP Retirement Services that it has formally terminated the plan

and ended all contributions (i.e., recorded the termination of the plan in writing by corporate

resolution or otherwise), “YES” has been entered. The amount of ‘0’ has been entered to

indicate that no assets have reverted to the employer. Otherwise, “No” has been entered.

13b “YES” has been entered if the plan has terminated or merged into another plan and all

distributions have been made. Otherwise, “NO” has been entered.

13c If assets were transferred to another plan and your company provided the name, Employer

Identification Number, and plan number of the other plan, then this line item has been

completed. If assets were transferred and we were not provided with the information, you

must contact ADP Retirement Services Client Services to complete this line item.

Line Item

Form 5500-SF 2017 Page 3- 1 x


(Form 5500) and line 11a below) ...............................................................................................................................................................X Yes X No

11a Enter the unpaid minimum required contributions for all years from Schedule SB (Form 5500) line 40 ........................ 11a12 Is this a defined contribution plan subject to the minimum funding requirements of section 412 of the Code or section 302 of

ERISA? ...................................................................................................................................................................................................... (If "Yes," complete line 12a or lines 12b, 12c, 12d, and 12e below, as applicable.)

X Yes X No

a If a waiver of the minimum funding standard for a prior year is being amortized in this plan year, see instructions, and enter the date of the letter rulinggranting the waiver. ................................................................................................................................. Month _______ Day _______ Year ________



c Enter the amount contributed by the employer to the plan for this plan year .................................................................. 12c -123456789012345

d Subtract the amount in line 12c from the amount in line 12b. Enter the result (enter a minus sign to the left of anegative amount) ...........................................................................................................................................................

12d YYYY-MM-DD

e Will the minimum funding amount reported on line 12d be met by the funding deadline? .............................................. X Yes X No X N/A

Part VII Plan Terminations and Transfers of Assets 13a Has a resolution to terminate the plan been adopted in any plan year? ............................................................................... X Yes X No

If “Yes,” enter the amount of any plan assets that reverted to the employer this year ................................................... 13a

b Were all the plan assets distributed to participants or beneficiaries, transferred to another plan, or brought under thecontrol of the PBGC? ...................................................................................................................................................................

X Yes X No



123456789 012

Form 5500-SF 2017 Page 3- 1 x


(Form 5500) and line 11a below) ...............................................................................................................................................................X Yes X No

11a Enter the unpaid minimum required contributions for all years from Schedule SB (Form 5500) line 40 ........................ 11a12 Is this a defined contribution plan subject to the minimum funding requirements of section 412 of the Code or section 302 of

ERISA? ...................................................................................................................................................................................................... (If "Yes," complete line 12a or lines 12b, 12c, 12d, and 12e below, as applicable.)

X Yes X No

a If a waiver of the minimum funding standard for a prior year is being amortized in this plan year, see instructions, and enter the date of the letter rulinggranting the waiver. ................................................................................................................................. Month _______ Day _______ Year ________



c Enter the amount contributed by the employer to the plan for this plan year .................................................................. 12c -123456789012345

d Subtract the amount in line 12c from the amount in line 12b. Enter the result (enter a minus sign to the left of anegative amount) ...........................................................................................................................................................

12d YYYY-MM-DD

e Will the minimum funding amount reported on line 12d be met by the funding deadline? .............................................. X Yes X No X N/A

Part VII Plan Terminations and Transfers of Assets 13a Has a resolution to terminate the plan been adopted in any plan year? ............................................................................... X Yes X No

If “Yes,” enter the amount of any plan assets that reverted to the employer this year ................................................... 13a

b Were all the plan assets distributed to participants or beneficiaries, transferred to another plan, or brought under thecontrol of the PBGC? ...................................................................................................................................................................

X Yes X No



123456789 012

Return to Contents


Section 6: Form 5500

Part I Annual Report Identification Information

A-C Line items A-C have been completed on your behalf based on our records.

In line item A, the box for a single-employer plan has been checked.

Boxes in line item B are checked in accordance with the following:

• The first return/report if the plan was first effective in the plan year

• The final return/report if the plan terminated or merged and all assets were distributed

in the plan year.

• A short plan year return/report (less than 12 months) if this is a short plan year for

your plan

Line item C has been checked if you responded on the Required Data Update that your plan

is a collectively bargained plan.

D If you told us that you will be filing a Form 5558 (Application for Extension of Time) or your

Corporate Tax Extension (automatic extension), this line item has been completed. See

Section 15 for additional information.

Line Item

Annual Return/Report of Employee Benefit Plan

Form 5500

Department of the TreasuryInternal Revenue Service

Department of LaborEmployee Benefits Security

Administration


Annual Return/Report of Employee Benefit PlanThis form is required to be filed for employee benefit plans under sections 104

and 4065 of the Employee Retirement Income Security Act of 1974 (ERISA) and sections 6057(b) and 6058(a) of the Internal Revenue Code (the Code).

Complete all entries in accordance with the instructions to the Form 5500.

OMB Nos. 1210-01101210-0089



A This return/report is for: X a multiemployer plan X a multiple-employer plan (Filers checking this box must attach a list of participating employer information in accordance with the form instructions.)

X a single-employer plan X a DFE (specify) _C_

B This return/report is: X the first return/report X the final return/report


C If the plan is a collectively-bargained plan, check here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X

D Check box if filing under: X Form 5558 X automatic extension X the DFVC program

X special extension (enter description) ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Part II Basic Plan Information—enter all requested information1a Name of planABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

1b Three-digit plannumber (PN) 001



2b Employer IdentificationNumber (EIN)012345678

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI D/B/A ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITYEFGHI ABCDEFGHI AB, ST 012345678901 UK

2c Plan Sponsor’s telephonenumber0123456789

2d Business code (seeinstructions)012345

Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established.Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return/report, including accompanying schedules, statements and attachments, as well as the electronic version of this return/report, and to the best of my knowledge and belief, it is true, correct, and complete.

SIGNHERE

YYYY-MM-DD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE Signature of plan administrator Date Enter name of individual signing as plan administrator

SIGNHERE

YYYY-MM-DD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE Signature of employer/plan sponsor Date Enter name of individual signing as employer or plan sponsor

SIGNHERE

YYYY-MM-DD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE Signature of DFE Date Enter name of individual signing as DFE

Preparer’s name (including firm name, if applicable) and address (include room or suite number) ABCDEFGHI Preparer’s telephone number

For Paperwork Reduction Act Notice, see the Instructions for Form 5500. Form 5500 (2016)v. 160205


Section 6: Form 5500, continued



on the first page of the Adoption Agreement for your company’s plan. Verify that the correct

plan number has been recorded. For IRS reporting purposes, all qualified retirement plans

are assigned a three-digit number starting with 001 and continuing with 002, etc. when

they are established. The number assigned to one plan should never be used for another

plan, even if the first plan is terminated and the number is no longer in use. This three-digit

number differs from the 6-digit ADP Recordkeeping Plan Number. If this plan is the first plan

your company has ever maintained, the plan number is 001.

2a Plan sponsor’s name and address. NOTE: The name and address are in specific locations

within the box due to government processing specifications.

2d A business code, to describe the product or service your company provides, has been

entered from the information your company provided on the Required Data Update. See

Section 14, “Are Revisions Required,” to complete this information

Line Item

Form 5500


Department of LaborEmployee Benefits Security

Administration


Annual Return/Report of Employee Benefit PlanThis form is required to be filed for employee benefit plans under sections 104

and 4065 of the Employee Retirement Income Security Act of 1974 (ERISA) and sections 6057(b) and 6058(a) of the Internal Revenue Code (the Code).

Complete all entries in accordance with the instructions to the Form 5500.

OMB Nos. 1210-01101210-0089



A This return/report is for: X a multiemployer plan X a multiple-employer plan (Filers checking this box must attach a list of participating employer information in accordance with the form instructions.)

X a single-employer plan X a DFE (specify) _C_

B This return/report is: X the first return/report X the final return/report


C If the plan is a collectively-bargained plan, check here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X

D Check box if filing under: X Form 5558 X automatic extension X the DFVC program

X special extension (enter description) ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Part II Basic Plan Information—enter all requested information1a Name of planABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

1b Three-digit plannumber (PN) 001



2b Employer IdentificationNumber (EIN)012345678

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI D/B/A ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITYEFGHI ABCDEFGHI AB, ST 012345678901 UK

2c Plan Sponsor’s telephonenumber0123456789

2d Business code (seeinstructions)012345

Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established.Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return/report, including accompanying schedules, statements and attachments, as well as the electronic version of this return/report, and to the best of my knowledge and belief, it is true, correct, and complete.

SIGNHERE

YYYY-MM-DD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE Signature of plan administrator Date Enter name of individual signing as plan administrator

SIGNHERE

YYYY-MM-DD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE Signature of employer/plan sponsor Date Enter name of individual signing as employer or plan sponsor

SIGNHERE

YYYY-MM-DD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE Signature of DFE Date Enter name of individual signing as DFE

Preparer’s name (including firm name, if applicable) and address (include room or suite number) ABCDEFGHI Preparer’s telephone number

For Paperwork Reduction Act Notice, see the Instructions for Form 5500. Form 5500 (2016)v. 160205



3 Since the Plan Administrator of the plan is the same as the Plan Sponsor, option for Plan

administrator’s name and address is marked with an “X.” 3b and 3c are not applicable and

are left blank.

4 If the company’s name in line item 2a and/or the company’s Employer Identification Number

and/or Plan Name in line item 2b differs from what was reported on last year’s Form, line item

4 has been completed with the information from last year’s form.

5-6h NOTE: In a 401(k) plan, the definition of “participant” includes an eligible employee regardless of whether or not the employee actually makes any deferrals to the 401(k) plan and terminated employees that still have assets

in the plan. “Alternate payees” entitled to benefits under a Qualified Domestic Relations Order (QDRO) are not counted as participants for these lines.

5 This line item has been completed with the number of participants at the beginning of the

plan year.

Line Item

Form 5500 (2017) Page 23a Plan administrator’s name and address X Same as Plan Sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIc/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITYEFGHI ABCDEFGHI AB, ST 012345678901 UK


3c Administrator’s telephonenumber 0123456789

4 If the name and/or EIN of the plan sponsor or the plan name has changed since the last return/report filed for this plan,enter the plan sponsor’s name, EIN, the plan name and the plan number from the last return/report:

4b EIN012345678

a Sponsor’s namec Plan Name

4d PN012

5 Total number of participants at the beginning of the plan year 5 1234567890126 Number of participants as of the end of the plan year unless otherwise stated (welfare plans complete only lines 6a(1), 6a(2), 6b, 6c, and 6d).

a(1) Total number of active participants at the beginning of the plan year .................................................................................. 6a(1)

a(2) Total number of active participants at the end of the plan year .......................................................................................... 6a(2)

b Retired or separated participants receiving benefits ................................................................................................................. 6b 123456789012

c Other retired or separated participants entitled to future benefits ............................................................................................. 6c 123456789012

d Subtotal. Add lines 6a(2), 6b, and 6c. ....................................................................................................................................... 6d 123456789012

e Deceased participants whose beneficiaries are receiving or are entitled to receive benefits. .................................................. 6e 123456789012

f Total. Add lines 6d and 6e. ...................................................................................................................................................... 6f 123456789012

g Number of participants with account balances as of the end of the plan year (only defined contribution planscomplete this item) .................................................................................................................................................................. 6g 123456789012

h Number of participants who terminated employment during the plan year with accrued benefits that wereless than 100% vested .............................................................................................................................................................. 6h 123456789012

7 Enter the total number of employers obligated to contribute to the plan (only multiemployer plans complete this item) .......... 78a If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristics Codes in the instructions:

b If the plan provides welfare benefits, enter the applicable welfare feature codes from the List of Plan Characteristics Codes in the instructions:

9a Plan funding arrangement (check all that apply) 9b Plan benefit arrangement (check all that apply)(1) X Insurance (1) X Insurance(2) X Code section 412(e)(3) insurance contracts (2) X Code section 412(e)(3) insurance contracts (3) X Trust (3) X Trust (4) X General assets of the sponsor (4) X General assets of the sponsor

10 Check all applicable boxes in 10a and 10b to indicate which schedules are attached, and, where indicated, enter the number attached. (See instructions)

a Pension Schedules b General Schedules(1) X R (Retirement Plan Information) (1) X H (Financial Information)

(2) X MB (Multiemployer Defined Benefit Plan and Certain Money Purchase Plan Actuarial Information) - signed by the plan actuary

(2) X I (Financial Information – Small Plan)

(3) X ___ A (Insurance Information)

(4) X C (Service Provider Information)

(3) X SB (Single-Employer Defined Benefit Plan Actuarial Information) - signed by the plan actuary

(5) X D (DFE/Participating Plan Information)

(6) X G (Financial Transaction Schedules)



6a(1) - h The number of participants has been calculated based on ADP recordkeeping records

and your coding in payroll records.

6a(1) This line item has been completed with the number of active participants as of the beginning

of the plan year.

6a(2) This line item has been completed with the number of active participants as of the end of the

plan year.

6b This line item has been completed with the number of retired or separated participants who

were receiving benefits paid from the plan as of the end of the plan year.

6c This line item has been completed with the number of retired or separated participants (not

included in line item 6b) who are entitled to future benefits from the plan.

6e This line item has been completed with the number of deceased participants whose

beneficiaries are receiving or are entitled to receive benefits as of the end of the plan year.

6g This line item has been completed with the number of participants with account balances as

of the end of the plan year. This includes both active and terminated participants.

6h This line item has been completed with the number of participants who terminated

employment during the plan year and were less than 100% vested.

7 Line item 7 is not applicable and is intentionally left blank.

Line Item

Form 5500 (2016) Page 2

3a Plan administrator’s name and address X Same as Plan Sponsor

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITYEFGHI ABCDEFGHI AB, ST 012345678901 UK



4 If the name and/or EIN of the plan sponsor has changed since the last return/report filed for this plan, enter the name, EIN and the plan number from the last return/report:

4b EIN012345678

a Sponsor’s nameABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

4c PN012

5 Total number of participants at the beginning of the plan year 5 123456789012 6 Number of participants as of the end of the plan year unless otherwise stated (welfare plans complete only lines 6a(1),

6a(2), 6b, 6c, and 6d).

a(1) Total number of active participants at the beginning of the plan year................................................................................ 6a(1)

a(2) Total number of active participants at the end of the plan year ....................................................................................... 6a(2)

b Retired or separated participants receiving benefits............................................................................................................. 6b 123456789012

c Other retired or separated participants entitled to future benefits ......................................................................................... 6c 123456789012

d Subtotal. Add lines 6a(2), 6b, and 6c................................................................................................................................... 6d 123456789012

e Deceased participants whose beneficiaries are receiving or are entitled to receive benefits. ............................................... 6e 123456789012

f Total. Add lines 6d and 6e. ................................................................................................................................................. 6f 123456789012

g Number of participants with account balances as of the end of the plan year (only defined contribution plans complete this item) .............................................................................................................................................................. 6g 123456789012

h Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested ........................................................................................................................................................ 6h 123456789012

7 Enter the total number of employers obligated to contribute to the plan (only multiemployer plans complete this item) ........ 78a If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristics Codes in the instructions:


9a Plan funding arrangement (check all that apply) 9b Plan benefit arrangement (check all that apply)(1) X Insurance (1) X Insurance(2) X Code section 412(e)(3) insurance contracts (2) X Code section 412(e)(3) insurance contracts(3) X Trust (3) X Trust(4) X General assets of the sponsor (4) X General assets of the sponsor





(3) X ___ A (Insurance Information)(4) X C (Service Provider Information)


(5) X D (DFE/Participating Plan Information)(6) X G (Financial Transaction Schedules)



8a Line item 8a has been completed with the applicable codes for your specific type of plan

from the following list:

2A Allocations based upon age, service, age and service, or New Comparability

2C Money Purchase Plan

2E Profit Sharing Plan

A 401(k) plan is a profit sharing plan with a 401(k) feature.

2F 404(c)

Participants in defined contribution plans that have investment control of their

accounts are not considered fiduciaries because of that control and no other fiduciary

will be responsible for any losses as a result of a participant’s exercise of that control.

ERISA Section 404(c) can be relied on as a defense in the event of an investment loss

if the plan complies with the requirements of the regulation. This includes giving

notice to plan participants that the plan is designed to comply with ERISA Section

404(c) and that plan fiduciaries may be relieved of liability for investment losses

that are the direct and necessary result of the participants’ investment instructions.

Generally, participants must be furnished with information on investment alternatives,

how to give investment instructions, who the investment manager is, transaction fees

and expenses, name, address, and phone number of the plan fiduciary responsible

for providing the information, and voting rights information.

2G Participant-Directed Accounts

2J 401(k) Feature

2K 401(m) Matching Provision Feature

2R Self-Directed Brokerage Account

2S Automatic Enrollment

2T Default Investment for Participant-Directed Accounts

3B Plan covering Self-Employed individuals

3D Prototype Plan Document

Line Item

Form 5500 (2016) Page 2






4b EIN012345678


4c PN012


6a(2), 6b, 6c, and 6d).






















3F Company had leased employees during the plan year

Note: Generally, if your company has individuals providing services to your company

under an agreement between your company and a leasing organization (or an

agreement between an independent contractor and your company), where the

individuals perform services for your company for a period of at least one year and

the services are performed under the primary direction or control of your company,

“3F” may be required for this line item. You should consult with your tax advisor in

determining whether certain individuals are leased employees.

3H Controlled Group or Affiliated Service Group

You should consult with your company’s tax advisor if you have questions as

to whether your company is a member of a controlled group or an affiliated

service group.

8b Line item 8b is not applicable and is intentionally left blank.

9a-9b Plan funding and benefit arrangements.

10 The Schedules attached (and in some cases the quantity of the Schedules) are indicated.

Line Item

Form 5500 (2016) Page 2






4b EIN012345678


4c PN012


6a(2), 6b, 6c, and 6d).




















Return to Contents


Section 7: Schedule A (if applicable)

Insurance InformationSchedule A must be included with the Form 5500 filing for plans that provide benefits funded in part or whole by insurance products (e.g. life insurance, annuity contracts) issued by an insurance company.

If your plan contained this type of funding arrangement (product), the insurance company is required to provide the information needed to complete this form. If the insurance company has provided this information, a Schedule A has been prepared and is included in your package.

Part IV

11 “NO” has been entered.

12 Has been intentionally left blank.

SCHEDULE A (Form 5500)

Department of the Treasury Internal Revenue Service



Insurance Information

This schedule is required to be filed under section 104 of theEmployee Retirement Income Security Act of 1974 (ERISA).

File as an attachment to Form 5500.

Insurance companies are required to provide the information pursuant to ERISA section 103(a)(2).

OMB No. 1210-0110


For calendar plan year 2017 or fiscal plan year beginning and endingA Name of planABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE FGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI

B Three-digitplan number (PN) 001

C Plan sponsor’s name as shown on line 2a of Form 5500ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE FGHI ABCDEFGHI

D Employer Identification Number (EIN)012345678

Part I Information Concerning Insurance Contract Coverage, Fees, and Commissions Provide information for each contracton a separate Schedule A. Individual contracts grouped as a unit in Parts II and III can be reported on a single Schedule A.

1 Coverage Information:

(a) Name of insurance carrierABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

(b) EIN (c) NAICcode

(d) Contract or identification number

(e) Approximate number ofpersons covered at end of

policy or contract year

Policy or contract year

(f) From (g) To

012345678 ABCDE ABCDE0123456789 1234567 YYYY-MM-DD YYYY-MM-DD

2 Insurance fee and commission information. Enter the total fees and total commissions paid. List in line 3 the agents, brokers, and other persons indescending order of the amount paid.

(a) Total amount of commissions paid (b) Total amount of fees paid

123456789012345 123456789012345

3 Persons receiving commissions and fees. (Complete as many entries as needed to report all persons).(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901

(b) Amount of sales and basecommissions paid

Fees and other commissions paid (e) Organization code(c) Amount (d) Purpose

-123456789012345 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

1

(a) Name and address of the agent, broker, or other person to whom commissions or fees were paidABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901

(b) Amount of sales and basecommissions paid

Fees and other commissions paid (e) Organization code(c) Amount (d) Purpose

-123456789012345 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

1

For Paperwork Reduction Act Notice, see the Instructions for Form 5500. Schedule A (Form 5500) 20XXv. 170203

20XX

Schedule A (Form 5500) 2016 Page 4

Part III Welfare Benefit Contract InformationIf more than one contract covers the same group of employees of the same employer(s) or members of the same employee organizations(s), the information may be combined for reporting purposes if such contracts are experience-rated as a unit. Where contracts cover individual employees, the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report.

8 Benefit and contract type (check all applicable boxes)

a X Health (other than dental or vision) b X Dental c X Vision d X Life insurance

e X Temporary disability (accident and sickness) f X Long-term disability g X Supplemental unemployment h X Prescription drug

i X Stop loss (large deductible) j X HMO contract k X PPO contract l X Indemnity contract

m X Other (specify) ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCKEFGHI ABCDEFGHI ABCDEFGHI ABCDE

9 Experience-rated contracts: a Premiums: (1) Amount received ................................................................ 9a(1) -123456789012345

(2) Increase (decrease) in amount due but unpaid ................................... 9a(2) -123456789012345(3) Increase (decrease) in unearned premium reserve ............................. 9a(3) -123456789012345(4) Earned ((1) + (2) - (3)) ...............................................................................................................................................9a(4) 123456789012345

b Benefit charges (1) Claims paid............................................................... 9b(1) -123456789012345(2) Increase (decrease) in claim reserves................................................. 9b(2) -123456789012345(3) Incurred claims (add (1) and (2))................................................................................................................ 9b(3) 123456789012345 (4) Claims charged.......................................................................................................................................... 9b(4) 123456789012345

c Remainder of premium: (1) Retention charges (on an accrual basis) -- -123456789012345(A) Commissions ............................................................................... 9c(1)(A) -123456789012345(B) Administrative service or other fees ............................................. 9c(1)(B) -123456789012345(C) Other specific acquisition costs.................................................... 9c(1)(C) -123456789012345(D) Other expenses ........................................................................... 9c(1)(D) -123456789012345(E) Taxes........................................................................................... 9c(1)(E) -123456789012345(F) Charges for risks or other contingencies ...................................... 9c(1)(F) -123456789012345(G) Other retention charges............................................................... 9c(1)(G) -123456789012345(H) Total retention..................................................................................................................................... 9c(1)(H) 123456789012345

(2) Dividends or retroactive rate refunds. (These amounts were X paid in cash, or X credited.).................. 9c(2) 123456789012345 d Status of policyholder reserves at end of year: (1) Amount held to provide benefits after retirement ............... 9d(1) 123456789012345

(2) Claim reserves .......................................................................................................................................... 9d(2) 123456789012345 (3) Other reserves .......................................................................................................................................... 9d(3) 123456789012345

e Dividends or retroactive rate refunds due. (Do not include amount entered in line 9c(2).).............................. 9e 123456789012345 10 Nonexperience-rated contracts:

a Total premiums or subscription charges paid to carrier................................................................................... 10a 123456789012345 b If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or

retention of the contract or policy, other than reported in Part I, line 2 above, report amount. ......................... 10b-

123456789012345 Specify nature of costs.

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

Part IV Provision of Information 11 Did the insurance company fail to provide any information necessary to complete Schedule A? ............. X Yes X No

12 If the answer to line 11 is “Yes,” specify the information not provided. ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Line Item

Return to Contents


Section 8: Schedule C and Sample Notice (Large Plans Only)

1. Service providers who received only “eligible indirect compensation”.

1a. “Yes” or “No” has been selected based on whether you are excluding a service provider from the remainder of Part 1 because the service provider received only “eligible indirect compensation” (“EIC”) for which you received the required disclosures. Your plan’s EIC disclosures are available on the Plan Sponsor Website (PSW) using the left navigation bar under Reports – Standard Reports – Audit Package Reports

1b. Name, Employer Identification Number and/or address of each person who provided EIC disclosures relevant to your plan for a service provider who received only EIC.

Line Item

Service Provider InformationSchedule C is filed for plans that are required to file Schedule H and one or both of the following conditions existed in the plan year:

• A service provider received $5,000 or more in total direct or indirect compensation from the plan.

• An Accountant or Actuary was terminated.

Where does compensation information on Schedule C come from?

• Information from our records

• Information provided directly to us by certain service providers and investment funds

• Information you provided in response to our request for Schedule C information

ADP has prepared Schedule C based on information in our records that is accurate and complete to the best of our knowledge and based on information provided by third parties that ADP did not review for accuracy or completeness. While ADP prepares your Schedule C, you as your plan’s administrator sign and file Form 5500 and are ultimately responsible for its accuracy and completeness.

Part I: Service Provider Information

Schedule C (Form 5500) 2011 Page 1SCHEDULE C

(Form 5500)Department of the TreasuryInternal Revenue Service



Service Provider Information

This schedule is required to be filed under section 104 of the Employee Retirement Income Security Act of 1974 (ERISA).


OMB No. 1210-0110

2016

This Form is Open to Public Inspection.

For calendar plan year 2016 or fiscal plan year beginning and endingA Name of planABCDEFGHI


C Plan sponsor’s name as shown on line 2a of Form 5500ABCDEFGHI


Part I Service Provider Information (see instructions)

You must complete this Part, in accordance with the instructions, to report the information required for each person who received, directly or indirectly, $5,000 or more in total compensation (i.e., money or anything else of monetary value) in connection with services rendered to the plan or the person's position with the plan during the plan year. If a person received only eligible indirect compensation for which the plan received the required disclosures, you are required to answer line 1 but are not required to include that person when completing the remainder of this Part.

1 Information on Persons Receiving Only Eligible Indirect Compensationa Check "Yes" or "No" to indicate whether you are excluding a person from the remainder of this Part because they received only eligible

indirect compensation for which the plan received the required disclosures (see instructions for definitions and conditions).. . . . . . . . . . . . . . . X Yes X No

b If you answered line 1a “Yes,” enter the name and EIN or address of each person providing the required disclosures for the service providers whoreceived only eligible indirect compensation. Complete as many entries as needed (see instructions).

(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation




For Paperwork Reduction Act Notice, see the Instructions for Form 5500. Schedule C (Form 5500) 2016v.160205


Section 8: Schedule C and Sample Notice, continued

2. Information regarding service provider(s) (other than those covered by Line 1) receiving direct or indirect compensation totaling $5,000 or more in connection with your plan. If compensation is reported as a formula, the service provider’s total compensation is assumed to be at least $5,000.

3. Detailed information regarding indirect compensation received by “key” service providers listed on Line 2 who received $1,000 or more in indirect compensation from a single source. If indirect compensation is reported as a formula, it is assumed to be at least $1,000.

Line Item

Schedule C (Form 5500) 2016 Page 3 - 1 x

2. Information on Other Service Providers Receiving Direct or Indirect Compensation. Except for those persons for whom youanswered “Yes” to line 1a above, complete as many entries as needed to list each person receiving, directly or indirectly, $5,000 or more in total compensation(i.e., money or anything else of value) in connection with services rendered to the plan or their position with the plan during the plan year. (See instructions).

(a) Enter name and EIN or address (see instructions)

(b)Service Code(s)

(c)Relationship to

employer, employee organization, or

person known to be a party-in-interest

(d)Enter direct

compensation paid by the plan. If none,

enter -0-.

(e)Did service provider

receive indirect compensation? (sources other than plan or plan

sponsor)

(f)Did indirect compensation

include eligible indirect compensation, for which the plan received the required

disclosures?

(g)Enter total indirect

compensation received by service provider excluding

eligible indirect compensation for which you answered “Yes” to element

(f). If none, enter -0-.

(h)Did the service

provider give you a formula instead of

an amount or estimated amount?

ABCDEFGHI ABCDEFGHI ABCD

123456789012345 Yes X No X Yes X No X

123456789012345 Yes X No X


(b)ServiceCode(s)

(c)Relationship to



(d)Enter direct


enter -0-.



sponsor)



disclosures?





(h)Did the service




123456789012345 Yes X No X Yes X No X

123456789012345 Yes X No X


(b)Service Code(s)

(c)Relationship to



(d)Enter direct


enter -0-.



sponsor)



disclosures?





(h)Did the service




123456789012345 Yes X No X Yes X No X Yes X No X


Part I Service Provider Information (continued)3. If you reported on line 2 receipt of indirect compensation, other than eligible indirect compensation, by a service provider, and the service provider is a fiduciary

or provides contract administrator, consulting, custodial, investment advisory, investment management, broker, or recordkeeping services, answer the followingquestions for (a) each source from whom the service provider received $1,000 or more in indirect compensation and (b) each source for whom the serviceprovider gave you a formula used to determine the indirect compensation instead of an amount or estimated amount of the indirect compensation. Complete asmany entries as needed to report the required information for each source.

(a) Enter service provider name as it appears on line 2 (b) Service Codes(see instructions)

(c) Enter amount of indirectcompensation

(d) Enter name and EIN (address) of source of indirect compensation (e) Describe the indirect compensation, including anyformula used to determine the service provider’s eligibility

for or the amount of the indirect compensation.











Part II: Service Provider(s) who fail or refuse to provide information

Unless you otherwise instructed ADP, this section has been left blank. For further information,

refer to the “Guide to ADP’s Preparation of Your Form 5500 Schedule C.”

Line Item


Part II Service Providers Who Fail or Refuse to Provide Information4 Provide, to the extent possible, the following information for each service provider who failed or refused to provide the information necessary to complete

this Schedule.(a) Enter name and EIN or address of service provider (see

instructions)(b) Nature of

ServiceCode(s)

(c) Describe the information that the service provider failed or refused toprovide

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 10 11 12 13

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 1234567890

(a) Enter name and EIN or address of service provider (seeinstructions)

(b) Nature ofServiceCode(s)


























ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 1234567890



a Name: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD b EIN: 123456789 c Position: ABCDEFGHI ABCDEFGHI ABCD d Address: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

e Telephone: 1234567890

Explanation: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

















Part III Termination Information on Accountants and Enrolled Actuaries (see instructions)(complete as many entries as needed)

NOTE: Review the following for additional critical information about Parts I and II:

• Review the booklet entitled “Guide to ADP’s Preparation of your Form 5500 Schedule C,”

available at the time ADP Retirement Services provides your 2017 Form 5500.

• Review your Plan’s Schedule C EIC Disclosures.

Part III Termination Information on Accountants and Enrolled Actuaries.

Line items a and b have been completed based on information you provided on the Required

Data Update (if applicable). Contact ADP Retirement Services Client Services to provide the

terminated accountant’s address, phone number and reason for termination so we can complete

this information.

You must also provide the terminated accountant with a copy of the explanation for the

termination that is entered on the Schedule C, along with a completed copy of a “Notice To

Terminated Accountant,” Sample on next page.



Sample Notice

Notice To Terminated Accountant

I, as plan administrator, verify that the explanation that is produced below or attached to this notice is the explanation concerning your termination reported on the Schedule C (Form 5500) attached to the 2017 Annual Return/Report Form 5500 for the __________________________ (enter name of plan). This Form 5500 is identified in line 2b by the nine-digit EIN _____-__________ (enter sponsor’s EIN), and in line 1b by the three-digit PN _____ (enter plan number).

You have the opportunity to comment to the Department of Labor concerning any aspect of this explanation. Comments should include the name, EIN, and PN of the plan and be submitted to: Office of Enforcement, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210.

Signed _____________________________________________

Dated _____________________________________________

Return to Contents


Section 9: Schedule D

DFE/Participating Plan InformationSchedule D must be included with the Form 5500 filing for plans with a Common Collective Trust (CCT) or Pooled Separate Account (PSA) investment arrangement. If your plan contains either investment arrangement, a Schedule D has been prepared and is included in your package.

Part I Information on interests in MTIAs, CCTs, PSAs and 103-12 IEs (to be completed by plans

and DFEs)

(a) Name of the Common Collective Trust (CCT) or Name of the Pooled Separate Account (PSA).

(b) Name of the sponsor of the CCT or PSA.

(c) Employer Identification Number and IRS plan number of the CCT or PSA.

(d) ‘C’ indicates Common Collective Trust

‘P’ indicates Pooled Separate Account

(e) Dollar value held in the CCT or PSA at the end of the year.

SCHEDULE I FILERS: The dollar value consists only of the funds in the CCT or PSA

investment arrangement. If there are additional investments in the Plan, such as mutual funds

etc., then the dollar value of the CCTs or PSAs will not add up to the end of the year assets

on Schedule I.

For all plans, please note that each fund is reported separately under Part I (each fund is

considered to be a separate CCT or PSA).

NOTE: “DFE” stands for Direct Filing Entity. This refers to the CCT or PSA sponsor who is responsible for filing their own Form 5500 showing the assets, income, and expenses for the funds in the CCT or PSA. If the sponsor files a “DFE filing,” and if the plan files Schedule H, then the CCT or PSA assets and income can be reported on one specific line item and there is no need to provide information on the underlying assets.

However, the sponsor of the CCT or PSA may, but is not required to, file a “DFE filing” for the CCTs or PSAs. If the sponsor of the CCT or PSA does not submit the DFE filing, then the “PN” (plan number) in Schedule D, Part I line (c) will be “000”. In that case, if the plan files Schedule H, the assets at the beginning and end of the year are not to be reported as CCT or PSA assets, but instead they are to be reported as whatever the underlying assets are; for example, Interest Bearing Cash or Registered Investment Companies.

Line Item

SCHEDULE D (Form 5500)



DFE/Participating Plan Information

This schedule is required to be filed under section 104 of the Employee Retirement Income Security Act of 1974 (ERISA).


OMB No. 1210-0110


For calendar plan year 2017 or fiscal plan year beginning and endingA Name of planABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI


C Plan or DFE sponsor’s name as shown on line 2a of Form 5500ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI


Part I Information on interests in MTIAs, CCTs, PSAs, and 103-12 IEs (to be completed by plans and DFEs) (Complete as many entries as needed to report all interests in DFEs)

a Name of MTIA, CCT, PSA, or 103-12 IE: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD

b Name of sponsor of entity listed in (a):ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

c EIN-PN 123456789-123d Entity

code 1e Dollar value of interest in MTIA, CCT, PSA, or

103-12 IE at end of year (see instructions) -123456789012345






























103-12 IE at end of year (see instructions) -123456789012345For Paperwork Reduction Act Notice, see the Instructions for Form 5500. Schedule D (Form 5500) 2017

v.170203

Return to Contents


Section 10: Schedule H (Large Plans Only)

Financial InformationSchedule H “Financial Information” must be included with a Form 5500 filing for a plan with 100 or more participants (in Form 5500 line item 5, number of participants) as of the beginning of the plan year.

Parts I & II Asset and Liability Statement and Income and Expense Statement



NOTE: If there are Deemed Distribution Loans (DDLs) in the plan, then extra steps are needed in reporting the assets on the 5500 Forms. To explain, a DDL occurs when a participant misses a loan payment for any reason other than certain types of leave of absence and fails to make it up by a specified date, or the term for repaying a loan expires without full payment of the outstanding amount by a specified date. At that time, the participant is taxed on the outstanding amount, including applicable interest accrued to date, as if it had been distributed. The IRS requires two ways to account for DDLs. In recordkeeping for the plan, the DDLs are treated as on-going active loans. Interest is accrued monthly and added to the amount of the outstanding loan. However, for 5500 reporting purposes, DDLs are to be removed from the plan assets. This is done on line item 2g at the time the loan is deemed distributed and as interest continues to accrue. The result is reflected in line item 1c(8), participant loans.

Line Item


Section 10: Schedule H (Large Plans Only), continued

Part I Asset and Liability Statement

1c(8) & 1(f) If your plan has Deemed Distributed Loans (DDLs), the amount of the DDLs is not included in

the participant loan assets reported in these line items.

Part II Income and Expense Statement

2a(1)(A) Forfeitures generated from non-vested funds of participants receiving distributions during

the plan year are automatically used to reduce employer matching contributions that

are calculated on a per payroll basis. If applicable, they may also be used to reduce a

Non-Elective Contribution or Discretionary Match liability and/or a QNEC or QMAT. If

forfeitures were applied during the plan year, this line item has been reduced to reflect this

amount.

2b(2)(c) All dividends that were generated for registered investment company funds are reported

here as a separate line item.

Line Item

SCHEDULE H (Form 5500)

Department of the Treasury Department of the Treasury Internal Revenue Service



Financial Information

This schedule is required to be filed under section 104 of the Employee Retirement Income Security Act of 1974 (ERISA), and section 6058(a) of the

Internal Revenue Code (the Code).


OMB No. 1210-0110




C Plan sponsor’s name as shown on line 2a of Form 5500ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI


Part I Asset and Liability Statement 1 Current value of plan assets and liabilities at the beginning and end of the plan year. Combine the value of plan assets held in more than one trust. Report

the value of the plan’s interest in a commingled fund containing the assets of more than one plan on a line-by-line basis unless the value is reportable on lines 1c(9) through 1c(14). Do not enter the value of that portion of an insurance contract which guarantees, during this plan year, to pay a specific dollar benefit at a future date. Round off amounts to the nearest dollar. MTIAs, CCTs, PSAs, and 103-12 IEs do not complete lines 1b(1), 1b(2), 1c(8), 1g, 1h, and 1i. CCTs, PSAs, and 103-12 IEs also do not complete lines 1d and 1e. See instructions.

Assets (a) Beginning of Year (b) End of Year

a Total noninterest-bearing cash ....................................................................... 1a -123456789012345 -123456789012345

b Receivables (less allowance for doubtful accounts):

(1) Employer contributions ........................................................................... 1b(1) -123456789012345 -123456789012345

(2) Participant contributions ......................................................................... 1b(2) -123456789012345 -123456789012345

(3) Other ....................................................................................................... 1b(3) -123456789012345 -123456789012345 c General investments:

(1) Interest-bearing cash (include money market accounts & certificatesof deposit) ............................................................................................. 1c(1) -123456789012345 -123456789012345

(2) U.S. Government securities .................................................................... 1c(2) -123456789012345 -123456789012345

(3) Corporate debt instruments (other than employer securities):

(A) Preferred .......................................................................................... 1c(3)(A) -123456789012345 -123456789012345

(B) All other ............................................................................................ 1c(3)(B) -123456789012345 -123456789012345

(4) Corporate stocks (other than employer securities):

(A) Preferred .......................................................................................... 1c(4)(A) -123456789012345 -123456789012345

(B) Common .......................................................................................... 1c(4)(B) -123456789012345 -123456789012345

(5) Partnership/joint venture interests .......................................................... 1c(5) -123456789012345 -123456789012345

(6) Real estate (other than employer real property) ..................................... 1c(6) -123456789012345 -123456789012345

(7) Loans (other than to participants) ........................................................... 1c(7) -123456789012345 -123456789012345

(8) Participant loans ..................................................................................... 1c(8) -123456789012345 -123456789012345

(9) Value of interest in common/collective trusts .......................................... 1c(9) -123456789012345 -123456789012345

(10) Value of interest in pooled separate accounts ........................................ 1c(10) -123456789012345 -123456789012345

(11) Value of interest in master trust investment accounts ............................ 1c(11) -123456789012345 -123456789012345

(12) Value of interest in 103-12 investment entities ....................................... 1c(12) -123456789012345 -123456789012345(13) Value of interest in registered investment companies (e.g., mutual funds) ...................................................................................... 1c(13) -123456789012345 -123456789012345

(14) Value of funds held in insurance company general account (unallocatedcontracts) ................................................................................................ 1c(14) -123456789012345 -123456789012345

(15) Other ....................................................................................................... 1c(15) -123456789012345 -123456789012345

For Paperwork Reduction Act Notice, see the Instructions for Form 5500. Schedule H (Form 5500) 20XXv.170203

20XX

Schedule H (Form 5500) 2017 Page 2

(5) Unrealized appreciation (depreciation) of assets: (A) Real estate ....................... 2b(5)(A) -123456789012345

(B) Other ................................................................................................. 2b(5)(B) -123456789012345(C) Total unrealized appreciation of assets.

Add lines 2b(5)(A) and (B) ................................................................ 2b(5)(C) -123456789012345

1d Employer-related investments: (a) Beginning of Year (b) End of Year

(1) Employer securities .................................................................................. 1d(1) -123456789012345 -123456789012345

(2) Employer real property ............................................................................. 1d(2) -123456789012345 -123456789012345

1e Buildings and other property used in plan operation ....................................... 1e -123456789012345 -123456789012345

1f Total assets (add all amounts in lines 1a through 1e) ..................................... 1f -123456789012345 -123456789012345

Liabilities1g Benefit claims payable .................................................................................... 1g -123456789012345 -123456789012345

1h Operating payables ......................................................................................... 1h -123456789012345 -123456789012345

1i Acquisition indebtedness ................................................................................ 1i -123456789012345 -123456789012345

1j Other liabilities ................................................................................................. 1j -123456789012345 -123456789012345

1k Total liabilities (add all amounts in lines 1g through1j) .................................... 1k -123456789012345 -123456789012345

Net Assets 1l Net assets (subtract line 1k from line 1f) ......................................................... 1l -123456789012345 -123456789012345

Part II Income and Expense Statement 2 Plan income, expenses, and changes in net assets for the year. Include all income and expenses of the plan, including any trust(s) or separately maintained

fund(s) and any payments/receipts to/from insurance carriers. Round off amounts to the nearest dollar. MTIAs, CCTs, PSAs, and 103-12 IEs do not complete lines 2a, 2b(1)(E), 2e, 2f, and 2g.

Income (a) Amount (b) Total

a Contributions:

(1) Received or receivable in cash from: (A) Employers ................................ 2a(1)(A) -123456789012345

(B) Participants ....................................................................................... 2a(1)(B) -123456789012345

(C) Others (including rollovers) ............................................................... 2a(1)(C) -123456789012345

(2) Noncash contributions .............................................................................. 2a(2) -123456789012345

(3) Total contributions. Add lines 2a(1)(A), (B), (C), and line 2a(2) ............... 2a(3) -123456789012345

b Earnings on investments:

(1) Interest:(A) Interest-bearing cash (including money market accounts and

certificates of deposit) ....................................................................... 2b(1)(A) -123456789012345

(B) U.S. Government securities .............................................................. 2b(1)(B) -123456789012345

(C) Corporate debt instruments ............................................................... 2b(1)(C) -123456789012345

(D) Loans (other than to participants) ..................................................... 2b(1)(D) -123456789012345

(E) Participant loans ................................................................................ 2b(1)(E) -123456789012345

(F) Other ................................................................................................. 2b(1)(F) -123456789012345

(G) Total interest. Add lines 2b(1)(A) through (F) ................................... 2b(1)(G) -123456789012345

(2) Dividends: (A) Preferred stock .................................................................. 2b(2)(A) -123456789012345

(B) Common stock .................................................................................. 2b(2)(B) -123456789012345

(C) Registered investment company shares (e.g. mutual funds) ............ 2b(2)(C)

(D) Total dividends. Add lines 2b(2)(A), (B), and (C) 2b(2)(D) -123456789012345

(3) Rents ......................................................................................................... 2b(3) -123456789012345

(4) Net gain (loss) on sale of assets: (A) Aggregate proceeds ..................... 2b(4)(A) -123456789012345

(B) Aggregate carrying amount (see instructions) .................................. 2b(4)(B) -123456789012345

(C) Subtract line 2b(4)(B) from line 2b(4)(A) and enter result ................ 2b(4)(C) -123456789012345



Part II, continued

2e(1) Loans that were previously deemed distributed that are now offset are not reflected in the

benefit payments amount reported in this line item, because they were removed from the

reporting via line item 2g.

2g The amount shown represents the participant loans that have been deemed distributed

during the plan year. The total consists of:

— The principal of the deemed distributed loans (DDL)

— Plus deemed distributed loan accumulated interest

— Minus deemed distributed loan principal and interest of any loan that was repaid.

Line Item


(a) Amount (b) Total

(6) Net investment gain (loss) from common/collective trusts ......................... 2b(6) -123456789012345

(7) Net investment gain (loss) from pooled separate accounts ....................... 2b(7) -123456789012345

(8) Net investment gain (loss) from master trust investment accounts ........... 2b(8) -123456789012345

(9) Net investment gain (loss) from 103-12 investment entities ...................... 2b(9) -123456789012345(10) Net investment gain (loss) from registered investment

companies (e.g., mutual funds) .................................................................. 2b(10) -123456789012345

c Other income .................................................................................................... 2c -123456789012345 d Total income. Add all income amounts in column (b) and enter total ..................... 2d -123456789012345

Expenses e Benefit payment and payments to provide benefits:

(1) Directly to participants or beneficiaries, including direct rollovers .............. 2e(1) -123456789012345

(2) To insurance carriers for the provision of benefits ..................................... 2e(2) -123456789012345

(3) Other .......................................................................................................... 2e(3) -123456789012345

(4) Total benefit payments. Add lines 2e(1) through (3) .................................. 2e(4) -123456789012345

f Corrective distributions (see instructions) ........................................................ 2f -123456789012345 g Certain deemed distributions of participant loans (see instructions) ................ 2g -123456789012345

h Interest expense ............................................................................................... 2h -123456789012345

i Administrative expenses: (1) Professional fees .............................................. 2i(1) -123456789012345

(2) Contract administrator fees ........................................................................ 2i(2) -123456789012345

(3) Investment advisory and management fees .............................................. 2i(3) -123456789012345

(4) Other .......................................................................................................... 2i(4) -123456789012345

(5) Total administrative expenses. Add lines 2i(1) through (4) ......................... 2i(5) -123456789012345j Total expenses. Add all expense amounts in column (b) and enter total........ 2j -123456789012345

Net Income and Reconciliation k Net income (loss). Subtract line 2j from line 2d ............................................................. 2k -123456789012345 l Transfers of assets:

(1) To this plan ................................................................................................. 2l(1) -123456789012345

(2) From this plan ............................................................................................ 2l(2) -123456789012345

Part III Accountant’s Opinion 3 Complete lines 3a through 3c if the opinion of an independent qualified public accountant is attached to this Form 5500. Complete line 3d if an opinion is not

attached.a The attached opinion of an independent qualified public accountant for this plan is (see instructions):

(1) X Unqualified (2) X Qualified (3) X Disclaimer (4) X Adverse

b Did the accountant perform a limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)? X Yes X No

c Enter the name and EIN of the accountant (or accounting firm) below:(1) Name: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD (2) EIN: 123456789

d The opinion of an independent qualified public accountant is not attached because: (1) X This form is filed for a CCT, PSA, or MTIA. (2) X It will be attached to the next Form 5500 pursuant to 29 CFR 2520.104-50.

Part IV Compliance Questions 4 CCTs and PSAs do not complete Part IV. MTIAs, 103-12 IEs, and GIAs do not complete lines 4a, 4e, 4f, 4g, 4h, 4k, 4m, 4n, or 5.

103-12 IEs also do not complete lines 4j and 4l. MTIAs also do not complete line 4l.

During the plan year: Yes No Amount

a Was there a failure to transmit to the plan any participant contributions within the timeperiod described in 29 CFR 2510.3-102? Continue to answer “Yes” for any prior year failures until fully corrected. (See instructions and DOL’s Voluntary Fiduciary Correction Program.) ..................... 4a

b Were any loans by the plan or fixed income obligations due the plan in default as of the close of the plan year or classified during the year as uncollectible? Disregard participant loans secured by participant’s account balance. (Attach Schedule G (Form 5500) Part I if “Yes” is checked.) ............................................................................................................................................ 4b



Part III Accountant’s Opinion

An independent accountant must audit the plan and prepare a financial audit report.

This audit report must be attached to the Form 5500 filing. Please note that filing the

Form 5500 without the required accountant’s report will subject your company’s filing

to rejection, and penalties may be imposed. This requirement is clearly stated in your

Administration Manual.

3a-3b Our legal staff has reviewed the Department of Labor regulations governing limited scope

audits and has concluded on the basis of those regulations that a plan is eligible for a limited

scope audit to the extent that a bank, insurance company, or similar entity regulated by and

subject to periodic examination by a state or federal regulatory agency provides and certifies

to the required information set forth in the regulations. The plan’s Trustee will provide the

required certification to the plan’s assets.

However, because ADP cannot provide you with legal or tax advice, the final decision of how

extensive an audit should be on any qualified plan resides with the accountant performing

the independent audit. If your Accountant does not agree with our conclusion that your

plan is eligible for a Limited Scope Audit, contact ADP Retirement Services Client Services to

revise these line items.

3c Name and Employer Identification Number of accountant. If this line item is blank, your

company did not provide the information on the Required Data Update. See Section 14,

“Are Revisions Required?” to complete this information.

3d Line item 3d is not applicable and is intentionally left blank.

Line Item



(6) Net investment gain (loss) from common/collective trusts ......................... 2b(6) -123456789012345(7) Net investment gain (loss) from pooled separate accounts ....................... 2b(7) -123456789012345(8) Net investment gain (loss) from master trust investment accounts............ 2b(8) -123456789012345(9) Net investment gain (loss) from 103-12 investment entities ...................... 2b(9) -123456789012345

(10) Net investment gain (loss) from registered investmentcompanies (e.g., mutual funds)................................................................. 2b(10) -123456789012345

c Other income.................................................................................................. 2c -123456789012345d Total income. Add all income amounts in column (b) and enter total..................... 2d -123456789012345

Expensese Benefit payment and payments to provide benefits:

(1) Directly to participants or beneficiaries, including direct rollovers .............. 2e(1) -123456789012345(2) To insurance carriers for the provision of benefits..................................... 2e(2) -123456789012345(3) Other ........................................................................................................ 2e(3) -123456789012345

(4) Total benefit payments. Add lines 2e(1) through (3).................................. 2e(4) -123456789012345

f Corrective distributions (see instructions) ....................................................... 2f -123456789012345g Certain deemed distributions of participant loans (see instructions) ................ 2g -123456789012345h Interest expense............................................................................................. 2h -123456789012345i Administrative expenses: (1) Professional fees.............................................. 2i(1) -123456789012345

(2) Contract administrator fees....................................................................... 2i(2) -123456789012345(3) Investment advisory and management fees.............................................. 2i(3) -123456789012345(4) Other ........................................................................................................ 2i(4) -123456789012345(5) Total administrative expenses. Add lines 2i(1) through (4)........................ 2i(5) -123456789012345

j Total expenses. Add all expense amounts in column (b) and enter total ........ 2j -123456789012345Net Income and Reconciliation

k Net income (loss). Subtract line 2j from line 2d ........................................................... 2k -123456789012345l Transfers of assets:

(1) To this plan............................................................................................... 2l(1) -123456789012345(2) From this plan........................................................................................... 2l(2) -123456789012345

Part III Accountant’s Opinion3 Complete lines 3a through 3c if the opinion of an independent qualified public accountant is attached to this Form 5500. Complete line 3d if an opinion is not




c Enter the name and EIN of the accountant (or accounting firm) below: (1) Name: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD (2) EIN: 123456789

d The opinion of an independent qualified public accountant is not attached because:(1) X This form is filed for a CCT, PSA, or MTIA. (2) X It will be attached to the next Form 5500 pursuant to 29 CFR 2520.104-50.

Part IV Compliance Questions4 CCTs and PSAs do not complete Part IV. MTIAs, 103-12 IEs, and GIAs do not complete lines 4a, 4e, 4f, 4g, 4h, 4k, 4m, 4n, or 5.



a 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 fully corrected. (See instructions and DOL’s Voluntary Fiduciary Correction Program.).................... 4a

b Were any loans by the plan or fixed income obligations due the plan in default as of the close of the plan year or classified during the year as uncollectible? Disregard participant loans secured by participant’s account balance. (Attach Schedule G (Form 5500) Part I if “Yes” is checked.) ........................................................................................................................................ 4b



Part IV Compliance Questions

4a Special Note: Under plan asset regulations set forth in 29 CFR 2510.3-102, participant

contributions to a pension plan are considered plan assets at the earliest time they can be

reasonably segregated from the general funds of the employer, but no later than the 15th

business day of the month following withholding or receipt by the employer.

“NO” means all contributions were transmitted in a timely manner. If this needs to be

changed, contact ADP Retirement Services Client Services for assistance.



IMPORTANT NOTE: If “YES” has been entered, you must file Form 5330 with the

IRS. Refer to www.irs.gov and consult with your tax advisor regarding the filing of

Form 5330.

4b-4c “NO” has been entered because these questions refer to plan loans (other than participant

loans) and leases, which are not part of the investment portfolio of your plan.

Line Item



(6) Net investment gain (loss) from common/collective trusts ......................... 2b(6) -123456789012345(7) Net investment gain (loss) from pooled separate accounts ....................... 2b(7) -123456789012345(8) Net investment gain (loss) from master trust investment accounts............ 2b(8) -123456789012345(9) Net investment gain (loss) from 103-12 investment entities ...................... 2b(9) -123456789012345

(10) Net investment gain (loss) from registered investmentcompanies (e.g., mutual funds)................................................................. 2b(10) -123456789012345

c Other income.................................................................................................. 2c -123456789012345d Total income. Add all income amounts in column (b) and enter total..................... 2d -123456789012345

Expensese Benefit payment and payments to provide benefits:

(1) Directly to participants or beneficiaries, including direct rollovers .............. 2e(1) -123456789012345(2) To insurance carriers for the provision of benefits..................................... 2e(2) -123456789012345(3) Other ........................................................................................................ 2e(3) -123456789012345

(4) Total benefit payments. Add lines 2e(1) through (3).................................. 2e(4) -123456789012345

f Corrective distributions (see instructions) ....................................................... 2f -123456789012345g Certain deemed distributions of participant loans (see instructions) ................ 2g -123456789012345h Interest expense............................................................................................. 2h -123456789012345i Administrative expenses: (1) Professional fees.............................................. 2i(1) -123456789012345

(2) Contract administrator fees....................................................................... 2i(2) -123456789012345(3) Investment advisory and management fees.............................................. 2i(3) -123456789012345(4) Other ........................................................................................................ 2i(4) -123456789012345(5) Total administrative expenses. Add lines 2i(1) through (4)........................ 2i(5) -123456789012345

j Total expenses. Add all expense amounts in column (b) and enter total ........ 2j -123456789012345Net Income and Reconciliation

k Net income (loss). Subtract line 2j from line 2d ........................................................... 2k -123456789012345l Transfers of assets:

(1) To this plan............................................................................................... 2l(1) -123456789012345(2) From this plan........................................................................................... 2l(2) -123456789012345

Part III Accountant’s Opinion3 Complete lines 3a through 3c if the opinion of an independent qualified public accountant is attached to this Form 5500. Complete line 3d if an opinion is not




c Enter the name and EIN of the accountant (or accounting firm) below: (1) Name: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD (2) EIN: 123456789

d The opinion of an independent qualified public accountant is not attached because:(1) X This form is filed for a CCT, PSA, or MTIA. (2) X It will be attached to the next Form 5500 pursuant to 29 CFR 2520.104-50.

Part IV Compliance Questions4 CCTs and PSAs do not complete Part IV. MTIAs, 103-12 IEs, and GIAs do not complete lines 4a, 4e, 4f, 4g, 4h, 4k, 4m, 4n, or 5.



a 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 fully corrected. (See instructions and DOL’s Voluntary Fiduciary Correction Program.).................... 4a

b Were any loans by the plan or fixed income obligations due the plan in default as of the close of the plan year or classified during the year as uncollectible? Disregard participant loans secured by participant’s account balance. (Attach Schedule G (Form 5500) Part I if “Yes” is checked.) ........................................................................................................................................ 4b



4d “NO” has been entered because this question refers to situations that, to ADP’s knowledge,



4e Generally, every plan official of an employee benefit plan who handles funds or other

property of such plan must be covered by a Fidelity Bond. The Department of Labor requires

the Bond to cover at least the greater of 10% of plan assets as of the beginning of the plan

year or $1,000 with a maximum of $500,000. Line 4e has been completed based on the bond

purchased on behalf of the plan by the plan’s Trustee or Plan Sponsor. If the plan became

effective in the plan year, the bond amount should be a minimum of $1,000.

4f-4h “NO” has been entered because these questions refer to situations that, to ADP’s

knowledge, did not occur within your plan. However, you should consult with your legal or tax

advisor to determine whether you need to revise this response.

4i “YES” has been entered to indicate that the plan has assets held for investment and the

‘Schedule H, Line 4i – Schedule of Assets (Held at End of Year)’ is attached.

If the plan has no assets, or has terminated or merged and all assets have been distributed as

of the end of the plan year, then “NO” has been entered.

4j “NO” has been entered because this question refers to a situation that did not occur within

your plan. Note that transactions under a participant-directed account plan do not have to

be reported.

4k If the plan has terminated or merged into another plan and all distributions have been made,

“YES” has been entered. If the plan is ongoing, “NO” has been entered.

Line Item

Schedule H (Form 5500) 2016 Page 4- 1 xYes No Amount

c Were any leases to which the plan was a party in default or classified during the year as uncollectible? (Attach Schedule G (Form 5500) Part II if “Yes” is checked.) ........................................ 4c -123456789012345

d Were there any nonexempt transactions with any party-in-interest? (Do not include transactions reported on line 4a. Attach Schedule G (Form 5500) Part III if “Yes” is checked.)................................................................................................................................................... 4d -123456789012345

e Was this plan covered by a fidelity bond?................................................................................................ 4e -123456789012345f Did the plan have a loss, whether or not reimbursed by the plan’s fidelity bond, that was caused by

fraud or dishonesty? ................................................................................................................................ 4f -123456789012345

g Did the plan hold any assets whose current value was neither readily determinable on an established market nor set by an independent third party appraiser?.................................................... 4g -123456789012345

h Did the plan receive any noncash contributions whose value was neither readily determinable on an established market nor set by an independent third party appraiser? ................... 4h -123456789012345

i Did the plan have assets held for investment? (Attach schedule(s) of assets if “Yes” is checked, and see instructions for format requirements.) ............................................................................................... 4i

j Were any plan transactions or series of transactions in excess of 5% of the current value of plan assets? (Attach schedule of transactions if “Yes” is checked, and see instructions for format requirements.) ............................................................................................... 4j

k Were all the plan assets either distributed to participants or beneficiaries, transferred to another plan, or brought under the control of the PBGC? .................................................................................... 4k

l Has the plan failed to provide any benefit when due under the plan?.................................................... 4l -123456789012345

m If this is an individual account plan, was there a blackout period? (See instructions and 29 CFR 2520.101-3.).............................................................................................................................................. 4m

n 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............................................. 4n

o 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? …………………………………………………………………............................. 4o

5a 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........................... X Yes X No Amount:-

5b 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 weretransferred. (See instructions.)5b(1) Name of plan(s) 5b(2) EIN(s) 5b(3) PN(s)ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

123456789 123

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

123456789 123


123456789 123


123456789 123

5c If the plan is a defined benefit plan, is it covered under the PBGC insurance program (See ERISA section 4021.)? ...... X Yes X No X Not determinedIf “Yes” is checked, enter the My PAA confirmation number from the PBGC premium filing for this plan year________________. (See instructions.)

Part V Trust Information 6a Name of trustABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

6b Trust’s EIN

6c Name of trustee or custodianABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

6d Trustee’s or custodian’s telephone number+12345678901234567890123456



Return to Contents

4l “NO” has been entered because this question refers to situations that, to ADP’s knowledge,

did not occur within your plan.

4m “YES” has been entered if your company’s plan converted to the ADP 401(k) plan and

transferred its plan assets during the plan year. Otherwise “NO.”

4n “YES” has been entered if 4m is “YES”. Otherwise this line is blank.





5b If assets were transferred to another plan and your company provided the name, Employer


completed. If assets were transferred and we were not provided with the information, you

must contact ADP Retirement Services Client Services to complete this line item.

Line Item

Schedule H (Form 5500) 2017 Page 4- 1 xYes No Amount

c Were any leases to which the plan was a party in default or classified during the year as uncollectible? (Attach Schedule G (Form 5500) Part II if “Yes” is checked.) ....................................... 4c -123456789012345

d Were there any nonexempt transactions with any party-in-interest? (Do not include transactions reported on line 4a. Attach Schedule G (Form 5500) Part III if “Yes” is checked.) ............................................................................................................................................... 4d -123456789012345

e Was this plan covered by a fidelity bond? ............................................................................................. 4e -123456789012345f Did the plan have a loss, whether or not reimbursed by the plan’s fidelity bond, that was caused by

fraud or dishonesty? ............................................................................................................................. 4f -123456789012345

g Did the plan hold any assets whose current value was neither readily determinable on an established market nor set by an independent third party appraiser? .................................................. 4g -123456789012345

h Did the plan receive any noncash contributions whose value was neither readily determinable on an established market nor set by an independent third party appraiser? ................... 4h -123456789012345

i Did the plan have assets held for investment? (Attach schedule(s) of assets if “Yes” is checked, and see instructions for format requirements.) ............................................................................................. 4i

j Were any plan transactions or series of transactions in excess of 5% of the current value of plan assets? (Attach schedule of transactions if “Yes” is checked, andsee instructions for format requirements.) ............................................................................................. 4j

k Were all the plan assets either distributed to participants or beneficiaries, transferred to another plan, or brought under the control of the PBGC? .................................................................................. 4k

l Has the plan failed to provide any benefit when due under the plan? .................................................. 4l -123456789012345

m If this is an individual account plan, was there a blackout period? (See instructions and 29 CFR 2520.101-3.) .......................................................................................................................................... 4m

n 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. .......................................... 4n

5a Has a resolution to terminate the plan been adopted during the plan year or any prior plan year?........ X Yes X No If “Yes,” enter the amount of any plan assets that reverted to the employer this year ____________________________________.

5b 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 weretransferred. (See instructions.)

5b(1) Name of plan(s) 5b(2) EIN(s) 5b(3) PN(s)ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

123456789 123

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

123456789 123


123456789 123


123456789 123

5c If the plan is a defined benefit plan, is it covered under the PBGC insurance program (See ERISA section 4021.)? ...... X Yes X No X Not determined If “Yes” is checked, enter the My PAA confirmation number from the PBGC premium filing for this plan year________________________. (See instructions.)


Section 11: Schedule I (Small Plans with Employer Stock Only)

Financial InformationSchedule I “Financial Information” must be included with a Form 5500 filing for a plan with fewer than 100 participants (in Form 5500 line item 5, number of participants) as of the beginning of the plan year.

Part I Small Plan Financial Information



NOTE: If there are Deemed Distributed Loans (DDLs) in the plan, then extra steps are needed in reporting the assets on the 5500 Forms. To explain, a DDL occurs when a participant misses a loan payment for any reason other than certain types of leave of absence and fails to make it up by a specified date, or the term for repaying a loan expires without full payment of the outstanding amount by a specified date. At that time, the participant is taxed on the outstanding amount, including applicable interest accrued to date, as if it had been distributed. The IRS requires two ways to account for DDLs. In recordkeeping for the plan, the DDLs are treated as on-going active loans. Interest is accrued monthly and added to the amount of the outstanding loan. However, for 5500 reporting purposes, DDLs are to be removed from the plan assets. This is done on line item 2g at the time the loan is deemed distributed and as interest continues to accrue. The result is reflected in line items 1a and 3e, participant loans.

1a and 3 e If your plan has Deemed Distributed Loans (DDLs), the amount of the DDLs is not included in

the participant loan assets reported in these line items.

Line Item

SCHEDULE I(Form 5500)




Financial Information—Small Plan




OMB No. 1210-0110

2016This Form is Open to Public

Inspection

For calendar plan year 2016 or fiscal plan year beginning and endingA Name of plan

B Three-digitplan number (PN)

C Plan sponsor’s name as shown on line 2a of Form 5500 D Employer Identification Number (EIN)

Complete Schedule I if the plan covered fewer than 100 participants as of the beginning of the plan year. You may also complete Schedule I if you are filing as a small plan under the 80-120 participant rule (see instructions). Complete Schedule H if reporting as a large plan or DFE.

Part I Small Plan Financial InformationReport below the current value of assets and liabilities, income, expenses, transfers and changes in net assets during the plan year. Combine the value of plan assets held in more than one trust. Do not enter the value of the portion of an insurance contract that guarantees during this plan year to pay a specific dollar benefit at a future date. Include all income and expenses of the plan including any trust(s) or separately maintained fund(s) and any payments/receipts to/from insurance carriers. Round off amounts to the nearest dollar.1 Plan Assets and Liabilities: (a) Beginning of Year (b) End of Yeara Total plan assets .........................................................................................1a b Total plan liabilities ......................................................................................1b c Net plan assets (subtract line 1b from line 1a) ................................ 1c

2 Income, Expenses, and Transfers for this Plan Year: (a) Amount (b) Totala Contributions received or receivable:

(1) Employers............................................................................................2a(1)(2) Participants..........................................................................................2a(2)(3) Others (including rollovers) ................................................................2a(3)

b Noncash contributions .................................................................................2bc Other income...............................................................................................2cd Total income (add lines 2a(1), 2a(2), 2a(3), 2b, and 2c) ..............................2de Benefits paid (including direct rollovers) ......................................................2ef Corrective distributions (see instructions) ....................................................2fg Certain deemed distributions of participant loans

(see instructions).........................................................................................2gh Administrative service providers (salaries, fees, and

commissions) ..............................................................................................2hi Other expenses...........................................................................................2i

j Total expenses (add lines 2e, 2f, 2g, 2h, and 2i)................................ 2j

k Net income (loss) (subtract line 2j from line 2d) ................................ 2kl Transfers to (from) the plan (see instructions) ................................ 2l

3 Specific Assets: If the plan held assets at any time during the plan year in any of the following categories, check “Yes” and enter the current value of any assets remaining in the plan as of the end of the plan year. Allocate the value of the plan’s interest in a commingled trust containing the assets of more than one plan on a line-by-line basis unless the trust meets one of the specific exceptions described in the instructions.

Yes No Amounta Partnership/joint venture interests ................................................................................................3a

b Employer real property ...................................................................................................................3b

c Real estate (other than employer real property)..............................................................................3c

d Employer securities ........................................................................................................................3de Participant loans ............................................................................................................................3ef Loans (other than to participants) ................................................................................................3fg Tangible personal property................................................................................................ 3gFor Paperwork Reduction Act Notice, see the Instructions for Form 5500. Schedule I (Form 5500) 2016

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Section 11: Schedule I, continued

2a(1) Forfeitures generated from non-vested funds of participants receiving distributions during

the plan year are automatically used to reduce employer matching contributions that

are calculated on a per payroll basis. If applicable, they may also be used to reduce a

Non-Elective Contribution or Discretionary Match liability and/or a QNEC or QMAT. If

forfeitures were applied during the plan year, this line item has been reduced to reflect this

amount.

2e Loans that were previously deemed distributed that are now offset are not reflected in the

benefit payments amount reported in this line item, because they were removed from the

reporting via line item 2g.

2g The amount shown represents the participant loans that have been deemed distributed

during the plan year. The total consists of:

— The principal of the deemed distributed loans (DDL)

— Plus deemed distributed loan accumulated interest

— Minus deemed distributed loan principal and interest of any loan that was repaid.

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Part II Compliance Questions

SPECIAL NOTE: Under plan asset regulations as defined by 29 CFR 2510.3-102, participant contributions to a pension plan are considered plan assets at the earliest time they can be reasonably segregated from the general funds of the employer, but no later than: • For plans with fewer than 100 participants as of the beginning of the plan

year, 7 business days from the check date they are associated with, or the date they are received by the employer.

• For plans with 100 or more participants as of the beginning of the plan year, 15th business day of the following month.

“NO” means all contributions were transmitted in a timely manner.



IMPORTANT NOTE: If “YES” has been entered, you must file Form 5330 with the IRS.

Refer to www.irs.gov and consult with your tax advisor regarding the filing of Form 5330.

4b-4c “NO” has been entered because these questions refer to plan loans (other than participant

loans) and leases, which are not part of the investment portfolio of your plan.

Line Item

Schedule I (Form 5500) 2016 Page 2- 1 x

5a 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........................... X Yes X No Amount: -

5c If the plan is a defined benefit plan, is it covered under the PBGC insurance program (See ERISA section 4021.)? ..... …X Yes X No X Not determined.If “Yes” is checked, enter the My PAA confirmation number from the PBGC premium filing for this plan year__________________________. (See instructions.)

6a Name of trustABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

6b Trust’s EIN


6d Trustee’s or custodian telephone number

Part II Compliance Questions4 During the plan year: Yes No Amounta 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 untilfully corrected. (See instructions and DOL’s Voluntary Fiduciary Correction Program.) .....................4a -123456789012345

b Were any loans by the plan or fixed income obligations due the plan in default as of theclose of plan year or classified during the year as uncollectible? Disregard participant loans secured by the participant’s account balance. ....................................................................................4b -123456789012345

c Were any leases to which the plan was a party in default or classified during the year asuncollectible? ....................................................................................................................................4c -123456789012345

d Were there any nonexempt transactions with any party-in-interest? (Do not includetransactions reported on line 4a.) .......................................................................................................4d -123456789012345

e Was the plan covered by a fidelity bond? ...........................................................................................4e -123456789012345

f Did the plan have a loss, whether or not reimbursed by the plan’s fidelity bond, that wascaused by fraud or dishonesty? .........................................................................................................4f -123456789012345

g Did the plan hold any assets whose current value was neither readily determinable on anestablished market nor set by an independent third party appraiser? .................................................4g -123456789012345

h Did the plan receive any noncash contributions whose value was neither readilydeterminable on an established market nor set by an independent third party appraiser? .................4h -123456789012345

i Did the plan at any time hold 20% or more of its assets in any single security, debt,mortgage, parcel of real estate, or partnership/joint venture interest?................................................4i -123456789012345

j Were all the plan assets either distributed to participants or beneficiaries, transferred toanother plan, or brought under the control of the PBGC? ..................................................................4j

k Are you claiming a waiver of the annual examination and report of an independent qualifiedpublic 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.) ........................................4k

l Has the plan failed to provide any benefit when due under the plan? ................................................4l -123456789012345

m If this is an individual account plan, was there a blackout period? (See instructions and 29CFR 2520.101-3.) .............................................................................................................................4m

n If 4m was answered “Yes,” check the “Yes” box if you either provided the required notice orone of the exceptions to providing the notice applied under 29 CFR 2520.101-3...............................4n

o Defined Benefit Plan or Money Purchase Pension Plan Only:Were any distributions made during the plan year to an employee who attained age 62 andhad not separated from service? .....................................................................................................................................................4o


5b(1) Name of plan(s) 5b(2) EIN(s) 5b(3) PN(s)ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 123456789 123 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 123456789 123 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 123456789 123

Part III Trust Information

4a






4e Generally, every plan official of an employee benefit plan who handles funds or other property

of such plan must be covered by a Fidelity Bond. The Department of Labor requires the Bond to

cover at least the greater of 10% of plan assets as of the beginning of the plan year or $1,000 with

a maximum of $500,000. Line 4e has been completed based the bond purchased on behalf of

the plan by the plan’s Trustee or Plan Sponsor. If the plan became effective during the plan year,

the bond amount should be a minimum of $1,000.

4f-4h “NO” has been entered because these questions refer to situations that, to ADP’s knowledge,



4i “NO” has been entered because IRS/DOL instructions state that “YES” should not be checked

for securities held as a result of participant-directed transactions.

4j If the plan has terminated or merged into another plan and all distributions have been made,

“YES” has been entered. If the plan is ongoing, “NO” has been entered.

4k “YES” has been entered because your plan is eligible for a waiver of the annual examination and

report of an independent qualified public accountant. Your plan meets the conditions needed:

— at least 95% of the plan’s assets are “qualifying plan assets” as of the end of the preceding

plan year.

— in response to any request from a participant or beneficiary, you must, without charge,

make available for examination, or upon request furnish copies of each regulated financial

institution statement.

Line Item


5a 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........................... X Yes X No Amount: -

5c If the plan is a defined benefit plan, is it covered under the PBGC insurance program (See ERISA section 4021.)? ..... …X Yes X No X Not determined.If “Yes” is checked, enter the My PAA confirmation number from the PBGC premium filing for this plan year__________________________. (See instructions.)

6a Name of trustABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

6b Trust’s EIN


6d Trustee’s or custodian telephone number

Part II Compliance Questions4 During the plan year: Yes No Amounta 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 untilfully corrected. (See instructions and DOL’s Voluntary Fiduciary Correction Program.) .....................4a -123456789012345

b Were any loans by the plan or fixed income obligations due the plan in default as of theclose of plan year or classified during the year as uncollectible? Disregard participant loans secured by the participant’s account balance. ....................................................................................4b -123456789012345

c Were any leases to which the plan was a party in default or classified during the year asuncollectible? ....................................................................................................................................4c -123456789012345

d Were there any nonexempt transactions with any party-in-interest? (Do not includetransactions reported on line 4a.) .......................................................................................................4d -123456789012345

e Was the plan covered by a fidelity bond? ...........................................................................................4e -123456789012345

f Did the plan have a loss, whether or not reimbursed by the plan’s fidelity bond, that wascaused by fraud or dishonesty? .........................................................................................................4f -123456789012345

g Did the plan hold any assets whose current value was neither readily determinable on anestablished market nor set by an independent third party appraiser? .................................................4g -123456789012345

h Did the plan receive any noncash contributions whose value was neither readilydeterminable on an established market nor set by an independent third party appraiser? .................4h -123456789012345

i Did the plan at any time hold 20% or more of its assets in any single security, debt,mortgage, parcel of real estate, or partnership/joint venture interest?................................................4i -123456789012345

j Were all the plan assets either distributed to participants or beneficiaries, transferred toanother plan, or brought under the control of the PBGC? ..................................................................4j

k Are you claiming a waiver of the annual examination and report of an independent qualifiedpublic 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.) ........................................4k

l Has the plan failed to provide any benefit when due under the plan? ................................................4l -123456789012345

m If this is an individual account plan, was there a blackout period? (See instructions and 29CFR 2520.101-3.) .............................................................................................................................4m

n If 4m was answered “Yes,” check the “Yes” box if you either provided the required notice orone of the exceptions to providing the notice applied under 29 CFR 2520.101-3...............................4n

o Defined Benefit Plan or Money Purchase Pension Plan Only:Were any distributions made during the plan year to an employee who attained age 62 andhad not separated from service? .....................................................................................................................................................4o


5b(1) Name of plan(s) 5b(2) EIN(s) 5b(3) PN(s)ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 123456789 123 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 123456789 123 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 123456789 123

Part III Trust Information



Return to Contents

— the provided Summary Annual Report (SAR) must be distributed by you to all employees

eligible to participate in your plan.

4l “NO” has been entered because this question refers to situations that, to ADP’s knowledge, did

not occur within your plan.

4m “YES” has been entered if your plan if your company’s plan converted to the ADP 401(k) plan and

transferred its plan assets during the plan year. Otherwise “NO.”

4n “YES” has been entered if 4m is “YES”. Otherwise this line is blank.

4o Not applicable.





5b If assets were transferred to another plan and your company provided the name, Employer


completed. If assets were transferred and we were not provided with the information, you must

contact ADP Retirement Services Client Services to complete this line item.

Line Item


5a Has a resolution to terminate the plan been adopted during the plan year or any prior plan year?........ X Yes X No-If “Yes,” enter the amount of any plan assets that reverted to the employer this year ____________________________________.

5c If the plan is a defined benefit plan, is it covered under the PBGC insurance program (See ERISA section 4021.)? ..... …X Yes X No X Not determined. If “Yes” is checked, enter the My PAA confirmation number from the PBGC premium filing for this plan year__________________________. (See instructions.)

Part II Compliance Questions 4 During the plan year: Yes No 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? Continue to answer “Yes” for any prior year failures until fully corrected. (See instructions and DOL’s Voluntary Fiduciary Correction Program.) ........... 4a -123456789012345

b Were any loans by the plan or fixed income obligations due the plan in default as of theclose of plan year or classified during the year as uncollectible? Disregard participant loans secured by the participant’s account balance. ............................................................................ 4b -123456789012345

c Were any leases to which the plan was a party in default or classified during the year asuncollectible? ............................................................................................................................. 4c -123456789012345

d Were there any nonexempt transactions with any party-in-interest? (Do not includetransactions reported on line 4a.) ............................................................................................... 4d -123456789012345

e Was the plan covered by a fidelity bond? ................................................................................... 4e -123456789012345

f Did the plan have a loss, whether or not reimbursed by the plan’s fidelity bond, that wascaused by fraud or dishonesty? ................................................................................................. 4f -123456789012345

g Did the plan hold any assets whose current value was neither readily determinable on anestablished market nor set by an independent third party appraiser? ........................................ 4g -123456789012345

h Did the plan receive any noncash contributions whose value was neither readilydeterminable on an established market nor set by an independent third party appraiser? ........ 4h -123456789012345

i Did the plan at any time hold 20% or more of its assets in any single security, debt,mortgage, parcel of real estate, or partnership/joint venture interest? ........................................ 4i -123456789012345

j Were all the plan assets either distributed to participants or beneficiaries, transferred toanother plan, or brought under the control of the PBGC? .......................................................... 4j

k 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.) ................................ 4k

l Has the plan failed to provide any benefit when due under the plan? ........................................ 4l -123456789012345

m If this is an individual account plan, was there a blackout period? (See instructions and 29CFR 2520.101-3.) ....................................................................................................................... 4m

n If 4m was answered “Yes,” check the “Yes” box if you either provided the required notice orone of the exceptions to providing the notice applied under 29 CFR 2520.101-3 ...................... 4n


5b(1) Name of plan(s) 5b(2) EIN(s) 5b(3) PN(s)ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 123456789 123ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 123456789 123ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 123456789 123


Section 12: Schedule R

Return to Contents

Retirement Plan InformationSchedule R must be included with your Form 5500 filing if:

• distributions have been made to participants or

• your plan is an active money purchase pension plan or includes an active money purchase plan component.

For a profit sharing /401(k) plan, only Part I (line items 1 and 2) must be completed.

A. Part I (Distributions), line items 1 and 2. The amount paid in property other than in cash or annuity contracts, and the Employer Identification Number of the Payor who paid benefits on behalf of the plan must be reported.

SCHEDULE R (Form 5500)




Retirement Plan Information

This schedule is required to be filed under sections 104 and 4065 of the Employee Retirement Income Security Act of 1974 (ERISA) and section

6058(a) of the Internal Revenue Code (the Code).


OMB No. 1210-0110




C Plan sponsor’s name as shown on line 2a of Form 5500ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI


Part I Distributions

1 Total value of distributions paid in property other than in cash or the forms of property specified in theinstructions ...............................................................................................................................................................

1-123456789012345

Part II Funding Information (If the plan is not subject to the minimum funding requirements of section 412 of the Internal Revenue Code orERISA section 302, skip this Part.)

If you completed line 5, complete lines 3, 9, and 10 of Schedule MB and do not complete the remainder of this schedule.

If you completed line 6c, skip lines 8 and 9.

7 Will the minimum funding amount reported on line 6c be met by the funding deadline? ............................................ X Yes X No X N/A

8 If a change in actuarial cost method was made for this plan year pursuant to a revenue procedure or otherauthority providing automatic approval for the change or a class ruling letter, does the plan sponsor or plan administrator agree with the change? ....................................................................................................................... X Yes X No X N/A

Part III Amendments 9 If this is a defined benefit pension plan, were any amendments adopted during this plan

year that increased or decreased the value of benefits? If yes, check the appropriate box. If no, check the “No” box. .............................................................................................. X Increase X Decrease X Both X No

Part IV ESOPs (see instructions). If this is not a plan described under section 409(a) or 4975(e)(7) of the Internal Revenue Code, skip this Part.

10 Were unallocated employer securities or proceeds from the sale of unallocated securities used to repay any exempt loan?................. X Yes X No

11 a Does the ESOP hold any preferred stock? .................................................................................................................................... X Yes X No

b If the ESOP has an outstanding exempt loan with the employer as lender, is such loan part of a “back-to-back” loan?(See instructions for definition of “back-to-back” loan.) ..................................................................................................................

X Yes X No

12 Does the ESOP hold any stock that is not readily tradable on an established securities market? ........................................................ X Yes X No

For Paperwork Reduction Act Notice, see the Instructions for Form 5500. Schedule R (Form 5500) 20XXv. 170203

All references to distributions relate only to payments of benefits during the plan year.

2 Enter the EIN(s) of payor(s) who paid benefits on behalf of the plan to participants or beneficiaries during the year (if more than two, enter EINs of the twopayors who paid the greatest dollar amounts of benefits):

EIN(s): _______________________________ _______________________________

Profit-sharing plans, ESOPs, and stock bonus plans, skip line 3.

3 Number of participants (living or deceased) whose benefits were distributed in a single sum, during the planyear ...........................................................................................................................................................................

312345678

4 Is the plan administrator making an election under Code section 412(d)(2) or ERISA section 302(d)(2)? .......................... X Yes X No X N/A

If the plan is a defined benefit plan, go to line 8.

5 If a waiver of the minimum funding standard for a prior year is being amortized in thisplan year, see instructions and enter the date of the ruling letter granting the waiver. Date: Month _________ Day _________ Year _________

6 a Enter the minimum required contribution for this plan year (include any prior year accumulated fundingdeficiency not waived) .......................................................................................................................................

6a -123456789012345

b Enter the amount contributed by the employer to the plan for this plan year ..................................................... 6b -123456789012345

c Subtract the amount in line 6b from the amount in line 6a. Enter the result (enter a minus sign to the left of a negative amount) ......................................................................................... 6c -123456789012345

20XX


Section 13: Which Other Forms & Schedules May be Needed?

Return to Contents

• Form 5558 (Application for Extension of Time to File Certain Employee Plan Returns).

Details are in Section 15.

• Form 8955-SSA (Annual Registration Statement Identifying Separated Participants with

Deferred Vested Benefits). Details are in Section 16.


Section 14: Are Revisions Required?

Return to Contents

• On the Plan Sponsor Website, you have the ability to:

— Request that the Form be updated to indicate that an extension of time (Form 5558) or corporate extension will be filed - See Section 15 for more information.

— Update your Business Code.

— Supply details surrounding Late Contributions (if applicable).

— Update Accountant Information (Large plans). When you request an update to any information, ADP Retirement Services will revise your Form and a new one will be available within 5 days for you to file.

• If other revisions are required, contact ADP Retirement Services Client Services for assistance.


Section 15: Need to File an Extension?

Return to Contents

If your company requires additional time to review the 5500 information before filing and you have not filed a corporate tax extension, a hard copy of the Form 5558 (Application for Extension of Time) must be filed with the IRS to request that the filing due date be extended to 2½ months after your normal due date. The Form 5558 should be postmarked by the original due date of the filing (7 months after the end of the plan year) which is July 31 for calendar year plans. For example, if your company’s filing due date is July 31 and a Form 5558 is filed, your company’s filing deadline is extended to October 15th.

ADP has pre-filled part of the form and included a partially completed Form 5558 with the PDF of your Form 5500 or Form 5500-SF on the PSW.

If you notified ADP via the Required Data Update (RDU) that you were planning to go on extension, the Form 5558 box has been checked off on your Form 5500 or Form 5500-SF. You are responsible for mailing Form 5558 to the IRS. See below for further instructions on filing for the extension.

You should print the entire PDF for your records once all Forms are finalized and successfully submitted.

If you determine at this time that a request for an extension (Form 5558) is necessary, you can:1. Select ‘Yes’ (Do you want to file an extension for your Form 5500?) under step 2 of the E-filing

checklist on the PSW. ADP will check off the Form 5558 box on the Form 5500 or Form 5500-SF.

NOTE: ADP must be notified prior to 7 days before your filing deadline if you will be filing an extension.

2. If you are filing for an extension of time for the Form 8955-SSA, ensure Part II Line 3 is completed with the same due date as shown for Part II Line 2.

3. File the Form 5558 by mailing to:

Department of the Treasury Internal Revenue Service Center Ogden, UT 84201-0045

4. You should print the entire PDF for your records once all Forms are finalized and successfully submitted.

If your company has already filed a Form 5558, or can benefit from an automatic corporate extension, under step 2 of the E-filing checklist on the PSW, indicate which extension of time your plan is using then select submit. ADP will check off the appropriate box on the Form 5500 or Form 5500-SF.

A sample of the Form 5558 is on the following page.

ABC Company

One ABC Way

Anytown, AB 1234

12-3456789

ABC Company 401(k) Plan 0 0 1 12 31 20XX

X

10 15 20XX

10 15 20XX


Section 16: Form 8955-SSA

Introduction

If applicable, ADP Retirement Services (ADP RS) has prepared the Form 8955-SSA to report the required information for your company’s plan (i.e. participants who have separated from service during the plan year, and are entitled to a deferred vested benefit which has not been paid out). The items on the Form have been completed based on the information you have provided to ADP RS. Although great care has been taken in completing this information, it is important that you carefully review each item on the Form. In addition, it is important that you have your tax advisor review the Form prior to electonically filing it with the IRS.

The due date to file the Form is the last day of the seventh month following the end of your plan year.

Please note that for Form 5500-SF filers, the 8955-SSA will be transmitted automatically to the IRS at the same time your Form 5500-SF is filed with the DOL. For Form 5500 filers, an extra step must be taken to electronically submit this form to the IRS after you have submitted your Form 5500 to the DOL.

This section describes the Form and provides brief instructions to assist you with any items that you need to complete. If you would like to review the complete IRS instructions, refer to the Internal Revenue Web site at www.irs.gov.


Section 16: Form 8955-SSA, continued

Steps to Follow to File Form 8955-SSA To complete the required filing of Form 8955-SSA with the IRS, please follow these steps:

• Step #1 – Review

Review the explanations provided for each line item and verify that the data reported is accurate.

• Step #2 – Electronically File

Form 5500-SF Filers: The 8955-SSA will be automatically submitted to the IRS at the same time you file your Form 5500. You will receive a separate status back from the IRS indicating the electronic filing of the 8955-SSA was submitted.

Form 5500 Filers: After you have filed your Form 5500, an extra step must be taken to complete the electronic filing of the 8955-SSA. You will receive a separate status back from the IRS indicating the electronic filing of the 8955-SSA was submitted.

Note: If you need to file the Form 5558 to extend the filing due date of your Form 8955-SSA, please see Section 15.

If you have any questions regarding the enclosed Form, please contact your ADP Retirement Services Client Services team using the toll free telephone number listed in your Plan Administration Manual.



Part I Annual Statement Identification Information

A Line item A is applicable only for government and church plans and is intentionally left blank.

B Line item B refers to an amended Form 8955-SSA and is intentionally left blank.

C Line item C has been checked if ADP RS was notified that an extension has been filed.

Otherwise, this line item is blank.

If you have filed an extension but did not notify ADP RS yet, please contact ADP RS to have the

form updated. (see below)

Line Item

Form 8955-SSA (2009)For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions. Cat. No. 52729U

Form 8955-SSA Department of the Treasury Internal Revenue Service

Annual Registration Statement Identifying Separated Participants With Deferred Vested Benefits

Under Section 6057 of the Internal Revenue Code

OMB No. 1545-2187

This Form is NOT Open to Public Inspection

PART I Annual Statement Identification InformationFor the plan year beginning , and ending A Check here if plan is a government, church, or other plan that elects to voluntarily file Form 8955-SSA. (See instructions.)B Check here if this is an amended registration statement.C Check the appropriate box if filing under: Form 5558 Automatic extension

Special extension (enter description)PART II Basic Plan Information - enter all requested information

1a Name of plan 1b Three-digit Plan Number (PN)

Plan Sponsor Information2a Plan sponsor’s name 2b Employer Identification Number (EIN)

2c Trade name (if different from plan sponsor name) 2d Plan sponsor's phone number

2e In care of name

2f Mailing address (room, apt., suite no. and street, or P.O. Box) 2g City 2h State

2i ZIP code

2j Foreign province (or state) 2k Foreign country

2l Foreign postal code

Plan Administrator Information3a Plan administrator’s name (if other than plan sponsor) 3b Employer Identification Number (EIN)

3c In care of name 3d Plan administrator’s phone number

3e Mailing address (room, apt., suite no. and street, or P.O. Box) 3f City 3g State

3h ZIP code

3i Foreign province (or state) 3j Foreign country

3k Foreign postal code

4 If the name or EIN of the plan administrator has changed since the last return filed for this plan, enter the name and EIN from the last filed return:Plan administrator’s name EIN

5 If the name or EIN of the plan sponsor has changed since the last return filed for this plan, enter the name, EIN, and plan number from that return:Plan sponsor’s name EIN Plan Number (PN)

6 a. Participants who separated with a deferred vested benefit required to be reported on this Form 8955-SSA . . . . . . . . . . 6a b. Participants who separated with a deferred vested benefit voluntarily reported on this Form 8955-SSA in the same year as the separation occurred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6b

7 Total number of participants reported on lines 6a and 6b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 8 Did the plan administrator provide an individual statement to each participant required to receive a statement? . . . . . . . . .

Under penalties of perjury, I declare that I have examined this statement, and to the best of my knowledge and belief, it is true, correct, and complete.

Signature of plan sponsor Date signed Signature of plan administrator Date signedSign Here

Yes No




1a Name of plan – self-explanatory.


on the first page of the Adoption Agreement for your company’s plan. Please verify that the

correct plan number has been recorded. For IRS reporting purposes, all qualified retirement plans

are assigned a three-digit number starting with 001 and continuing with 002, etc. when they are

established. The number assigned by you to one plan should never be used for another plan, even

if the first plan is terminated and the number is no longer in use. This three-digit number differs

from the six-digit ADP Recordkeeping Plan Number. If this is the first plan your company has ever

maintained, the plan number is 001.

2a-b Plan sponsor’s name and Employer Identification Number – self-explanatory.

2c Trade name – intentionally left blank.

2d Plan sponsor’s phone number – self-explanatory.

2e In care of name – intentionally left blank.

2f-l Plan sponsor’s address – self-explanatory.

Line Item





OMB No. 1545-2187







2e In care of name


2i ZIP code






3h ZIP code









Yes No



3 Since the plan administrator of the plan is the plan sponsor, the response for 3a is ‘Same’ and 3b

through 3k are not applicable and, therefore, left blank.

4 If the name and/or EIN of the plan administrator has changed since the most recent

Form 8955-SSA or Form 5500 Schedule SSA has been filed, the name and EIN of the plan

administrator from the most recent filing has been entered here.

5 If the name and/or EIN of the plan sponsor has changed since the most recent Form 8955-SSA or

Form 5500 Schedule SSA has been filed, the name, EIN and three-digit plan number of the plan

sponsor from the most recent filing has been entered here.

6a Zero. This is the number of participants who terminated in the prior year and who were not

reported on your prior year Form 8955-SSA, if applicable.

6b Total number of participants reported on line item 9.

7 Sum of line items 6a and 6b.

8 Line 8 of Form 8955-SSA requires the Plan Administrator to confirm that it has provided an

individual statement containing the information on the Form to each affected participant. In

addition to the quarterly statement provided to your Plan participants, you will need to send a

termination package containing the plan’s distribution options to every participant who separates

from service during a plan year prior to your filing of Form 8955-SSA to ensure the individual

statement requirements are met.

Line Item





OMB No. 1545-2187







2e In care of name


2i ZIP code






3h ZIP code









Yes No



Return to Contents

Part III Participant Information

9 Line items (a) through (i) are completed separately for each particpant reported on

Form 8955-SSA

9a Entry code A means the particpant has not been previously reported. Entry code D means the

particpant has been previously reported under this plan and the deferred vested benefits have

now been distributed.

9b Social Security Number – self-explanatory.

9c Name of Particpant – self-explanatory. On the form that we provided, the middle initial is

included with the first name.

9d Annuity code A means Single Sum; Annuity code G means Joint and Last Survivor Life Annuity

9e Payment Frequency Code A means Lump Sum; Payment Frequency Code E means Monthly.

9f Line item 9f is not applicable and is intentionally left blank.

9g The participant’s vested account balance as of his/her date of termination.

9h-i Line items 9h and 9i are not applicable and are intentionally left blank

Line Item

Page 2.1 Page 2 of 2

Form 8955-SSA (2009)

Form 8955-SSA (2009) Name of plan Plan Number EIN

PART III Participant Information - enter all requested information9 Enter one of the following Entry Codes in column (a) for each separated participant with deferred vested benefits who:

Code A — has not previously been reported. Code B — has previously been reported under the above plan number, but whose previously reported information requires revisions. Code C — has previously been reported under another plan, but who will be receiving benefits from the plan listed above instead. Code D — has previously been reported under the above plan number, but whose benefits have been paid out or who is no longer entitled to those deferred vested benefits.

Use with entry code "A", "B", "C", or "D"

(a) Entry Code

(b) Social Security

Number (or Foreign)

(c) Name of Participant (See instructions.)

First name M.I. Last name

Use with entry code "A" or "B"

Enter code for nature and form of benefit

(d) Type of annuity

(e) Payment frequency

Amount of vested benefit

(f) Defined benefit plan —

periodic payment

(g) Defined contribution plan — total value

of account

Use with entry code "C" only

(h) Previous sponsor’s

EIN

(i) Previous

plan number


Section 17: What if You Converted to ADP This Year?

Form 5500-SF

4 You must review this line item.

If the plan sponsor’s name, and/or EIN have changed since the last return/report was filed for this

plan, contact ADP Retirement Services Client Services to complete this information.

7a - c IMPORTANT NOTE: If your financial information was left blank, this would indicate that your company did not provide the information required to complete this section. You must contact ADP Retirement Services Client Service to provide the financial information from the prior recordkeeper.

10b ‘NO’ has been entered because this question refers to situations that, to ADP’s knowledge, did

not occur within your plan. However, you may need to confirm with your prior recordkeeper

for details of any nonexempt transactions prior to your plan’s conversion to ADP. Contact ADP

Retirement Services Client Services to update this information.

10d ‘NO’ has been entered because this question refers to situations that, to ADP’s knowledge, did

not occur within your plan. However, you may need to confirm with your prior recordkeeper



Form 5500

4 You must review this line item.

If the plan sponsor’s name, and/or EIN and/or Plan Name have changed since the last return/

report was filed for this plan, contact ADP Retirement Services Client Services to complete this

line item.

Line Item

NOTE: If your company’s plan converted to the ADP 401(k) plan and transferred its plan assets during the plan year, additional information, outside of ADP records, is required in order to complete the 5500 Forms. Your particular attention is required for the line items indicated in this supplement.

If all of the requested information was not provided, including the prior year’s 5500 Form and asset reconciliation information, we were unable to complete several items of this year’s 5500 Forms, including the financial section of the forms. It is your responsibility to ensure that this information is completed in its entirety prior to filing the Form with the Department of Labor.


Section 17: What if You Converted to ADP This Year? continued

6h If there were participants who terminated employment during the plan year prior to the plan’s

conversion to ADP and they were less than 100% vested, contact ADP Retirement Services Client

Services to complete this line item.

Schedule A

11 ‘NO’ has been entered based on the information from the ADP recordkeeping system. However,

if your plan contained this type of funding arrangement (product) prior to transferring to ADP,

‘YES’ has been entered.

12 If Line item 11 has been entered as ‘YES’ and the necessary information was not provided, ‘No

info on comm/fees or financials’ has been entered.

Schedule D – DFE/Participating Plan Information

If the prior year Form 5500 was provided and a Schedule D was filed last year, a Schedule D has

been completed.

If your company did not provide the prior year Form 5500, and your plan invested in a Common

Collective Trust (CCT), Pooled Separate Account (PSA), Master Trust Investment (MTIA), or

103-12 Investment Entity (103-12 IE) at any time during the plan year prior to conversion to ADP,

you must complete Schedule D with the name and sponsor of each investment arrangement,

the Employer Identification Number of the investment arrangement sponsor, the plan number

of the investment arrangement, and the value of the investment arrangement in your plan at

the end of the year. Should you need to complete this form, contact ADP Retirement Services

Client Services.

Schedule H & I – Financial Information

IMPORTANT NOTE: If your financial information was left blank, this would indicate that your company did not provide the information required to complete the form. You must contact ADP Retirement Services Client Services to provide the financial information from the prior recordkeeper.

4b “NO” has been entered based on the information from the ADP recordkeeping system. If

any loans (other than participant loans) were classified as uncollectible during the year prior to

your plan’s conversion to ADP, contact ADP Retirement Services Client Services to update this

information.

4c “NO” has been entered based on the information from the ADP recordkeeping system.

If there were any leases to which the plan was a party in default of otherwise classified as not

collectible prior to your plan’s conversion to ADP, contact ADP Retirement Service Client Services

to update this information.

Line Item


Section 17: What if You Converted to ADP This Year? continued

Return to Contents


did not occur within your plan. However you may need to confirm with your prior recordkeeper



4f “NO” has been entered because this question refers to situations that, to ADP’s knowledge,



4g “NO” has been entered because this question refers to situations that, to ADP’s knowledge, did


If the plan had any noncash assets that were not readily valued (fair market value) prior to

your plan’s conversion to ADP (e.g. – real estate, nonpublic traded securities, shares in limited

partnership or collectibles), contact ADP Retirement Service Client Services to update this

information.

4h “NO” has been entered because this question refers to situations that, to ADP’s knowledge, did


If the plan received noncash contributions (e.g. nonpublic traded securities) that were not

appraised in writing by an independent third party appraiser prior to purchase or receipt, before

your plan’s conversion to ADP, contact ADP Retirement Service Client Services to update this

information.

Line Item


Section 18: Special Notices

Return to Contents

For Plan Transfers, Plan Terminations and for Plans that Stopped ContributionsNOTICE – Plan Contributions Stopped on or before the end of the plan year.

If your plan stopped depositing contributions through ADP prior to the end of the plan year and assets remained in the trust, the financial information as well as other information contained in the Form 5500-SF or Form 5500 and Schedules would only show the amounts recorded in our recordkeeping system. If you deposited contributions to another service provider, this information is incomplete and can only be used as a worksheet to assist your new service provider in preparing the Form 5500-SF or Form 5500. As the Plan Administrator and Fiduciary to this plan, you are responsible for ensuring the plan is operating under all applicable laws governing qualified plans.

NOTICE - Plan Terminated on or before the end of the plan year.

If your company’s plan is terminated, a FINAL Form 5500 or Final Form 5500-SF cannot be prepared if you still have plan assets (forfeitures or participant accounts). If you need assistance in allocating forfeitures and distributing plan assets in accordance with the plan provisions you can contact ADP Retirement Services Client Services.

If either of the above applies to your plan, we strongly encourage you to review the Form 5500-SF or Form 5500 and Schedules with your tax advisor.


Section 19: Fair Value Measurement and Disclosures (ASC Topic 820) (Formerly FASB Statement 157)

How does this apply to you?I. PLANS WITH 100 OR MORE PARTICIPANTS (Schedule H Filers)

The Financial Accounting Standards Board (FASB) issues accounting standards that apply to all reporting entities required or permitted to measure or disclose the fair value of an asset, a liability or an instrument classified in a reporting entity’s shareholders’ equity in the financial statement. FASB previously issued Statement 157 regarding such fair value measurement and disclosure standards. On July 1, 2009, FASB Statement 157 was codified into Topic 820 of the Accounting Standards Codification (ASC).

ASC Topic 820 is important to all plans required to prepare financial statements in accordance with generally accepted accounting principles, regardless of whether a plan sponsor engages its auditor to perform a full scope or a limited scope audit. The plan sponsor will need to have appropriate valuation processes in place and sufficient data to determine the fair value of the plan’s investment using the framework provided in ASC Topic 820 and have the financial statement present the disclosures as discussed in ASC Topic 820.

ASC Topic 820 sets forth a fair value measurement hierarchy for different investments. Most, if not all (in some cases), of the investments choices offered through our various products will qualify as “Level 1” investments where the fair market valuation of assets will be based on quoted market prices in active markets. These values will be received from investment providers (or parties acting on their behalf, such as clearing houses) who are responsible for providing ADP Retirement Services with daily valuation information. ADP Retirement Services may also receive valuation information for shares or units of “Level 2” and “Level 3” investments from investment providers, such as investment managers or trustees of common and collective trusts selected by plan fiduciaries, or insurance companies that maintain guaranteed investment contracts. These investment vehicles may hold private equity and other investments that are not publicly traded.

This is to advise you that ADP Retirement Services is not an accounting or valuation firm. Therefore, ADP does not independently verify the valuations of these shares or units (and any underlying assets on which such valuation is based) that the investment provider (or another third party) may make. While ADP Retirement Services receives information from these investment providers (or third parties), who may be plan fiduciaries, and relies on this information to report the value of units or shares on the draft Form 5500 that we prepare for our clients, it is the client’s accounting firm’s responsibility for preparing certified financial statements for each employer’s plan which will meet the requirements of ASC Topic 820. The accounting firm will be responsible for reconciling differences, if any, between their financial statements and the draft Form 5500 ADP Retirement Services prepares before the signature ready Form 5500 is signature-ready.


Section 19: Fair Value Measurement and Disclosures (ASC Topic 820) (Formerly FASB Statement 157), continued

Return to Contents

II. PLANS WITH FEWER THAN 100 PARTICIPANTS (Form 5500-SF or Schedule I Filers)

For most, if not all, of the investments choices offered through our various products, the fair market valuation of assets will be based on quoted market prices in active markets (for example mutual funds), the values of which will be received from investment providers (or third parties acting on their behalf, such as clearing houses) who are responsible for providing ADP Retirement Services with daily valuation information. For other investments that do not have a publicly available quoted fair value, that may include investments that are not publicly traded (for example, common or collective trusts maintained by a bank), ADP will rely on share or unit values provided from the institution responsible for valuing such shares or units (often the manager of the investment), and does not value the assets underlying them.

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