Code of Federal Regulations Title 29. Labor § 29.2520.104b–10—The Summary Annual Report (SAR) Under ERISA:  A Cross-Reference to the Annual Report

A.

PENSION PLAN:

1.

Funding arrangement․․․․․․

Form 5500-9a․․․․․․․․․

Same․․․․․․․․․․․․․․․․․

Not applicable.

2.

Total plan expenses․․․․․․

Sch. H-2j․․․․․․․․․․․․

Sch. I-2j․․․․․․․․․․․․

Line 8h.

3.

Administrative expenses․․

Sch. H-2i(5)․․․․․․․․․

Sch. I-2h․․․․․․․․․․․․

Line 8f.

4.

Benefits paid․․․․․․․․․․․․

Sch. H-2e(4)․․․․․․․․․

Sch. I-2e․․․․․․․․․․․․

Line 8d.

5.

Other expenses․․․․․․․․․․․

Sch. H-Subtract the sum of 2e(4) & 2i(5) from 2j

Sch. I-2i․․․․․․․․․․․․

Line 8g.

6.

Total participants․․․․․․․

Form 5500-6f․․․․․․․․․

Same․․․․․․․․․․․․․․․․․

Line 5b.

7.

Value of plan assets (net):

Sch. H-1l [Col. (b)]․

Sch. I-1c [Col. (b)]․

Line 7c [Col. (b)].

a.

End of plan year

b.

Beginning of plan year

Sch. H-1l [Col. (a)]․

Sch. I-1c [Col. (a)]․

Line 7c [Col. (a)].

8.

Change in net assets․․․․․

Sch. H-Subtract 1l [Col. (a)] from 1l [Col. (b)]

Sch. I-Subtract 1c [Col. (a) from Col. (b)]

Line 7c-Subtract Col. (a) from Col. (b).

9.

Total income․․․․․․․․․․․․․

Sch. H-2d․․․․․․․․․․․․

Sch. I-2d․․․․․․․․․․․․

Line 8c.

a.

Employer contributions

Sch. H-2a(1)(A) & 2a(2) if applicable

Sch. I-2a(1) & 2b if applicable

Line 8a(1) if applicable.

b.

Employee contributions

Sch. H-2a(1)(B) & 2a(2) if applicable

Sch. I-2a(2) & 2b if applicable

Line 8a(2) & 8a(3) if applicable.

c.

Gains (losses) from sale of assets

Sch. H-2b(4)(C)․․․․․․

Not applicable․․․․․․․

Not applicable.

d.

Earnings from investments

Sch. H-Subtract the sum of 2a(3), 2b(4)(C) and 2c from 2d

Sch. I-2c․․․․․․․․․․․․

Line 8b.

10.

Total insurance premiums․

Total of all Schs. A-6b

Total of all Schs. A-6b

Not applicable.

11.

Unpaid minimum required contribution (S-E plans) or Funding deficiency (ME plans):

Sch. SB-39․․․․․․․․․․․

Same․․․․․․․․․․․․․․․․․

Same.

a.

S-E Defined benefit plans

b.

ME Defined benefit plans

Sch. MB-10․․․․․․․․․․․

Same․․․․․․․․․․․․․․․․․

Not applicable.

c.

Defined contribution plans

Sch. R-6c, if more than zero

Same․․․․․․․․․․․․․․․․․

Line 12d.

B.

WELFARE PLAN

1.

Name of insurance carrier

All Schs. A-1(a)․․․․․

Same․․․․․․․․․․․․․․․․․

Not applicable.

2.

Total (experience rated and non-experienced rated) insurance premiums

All Schs. A-Sum of 9a(1) and 10a

Same․․․․․․․․․․․․․․․․․

Not applicable.

3.

Experience rated premiums

All Schs. A-9a(1)․․․․

Same․․․․․․․․․․․․․․․․․

Not applicable.

4.

Experience rated claims․․

All Schs. A-9b(4)․․․․

Same․․․․․․․․․․․․․․․․․

Not applicable.

5.

Value of plan assets (net):

Sch. H-1l [Col. (b)]․

Sch. I-1c [Col. (b)]․

Line 7c [Col. (b)].

a.

End of plan year

b.

Beginning of plan year

Sch. H-1l [Col. (a)]․

Sch. I-1c [Col. (a)]․

Line 7c [Col. (a)].

6.

Change in net assets․․․․․

Sch. H-Subtract 1l [Col. (a)] from 1l [Col. (b)]

Sch. I-Subtract 1c [Col. (a)] from 1c [Col. (b)]

Line 7c-Subtract [Col. (a)] from 7c [Col. (b)].

7.

Total income․․․․․․․․․․․․․

Sch. H-2d․․․․․․․․․․․․

Sch. I-2d․․․․․․․․․․․․

Line 8c

a.

Employer contributions

Sch. H-2a(1)(A) & 2a(2) if applicable

Sch. I-2a(1) & 2b if applicable

Line 8a(1) if applicable.

b.

Employee contributions

Sch. H-2a(1)(B) & 2a(2) if applicable

Sch. I-2a(2) & 2b if applicable

Line 8a(2) if applicable.

c.

Gains (losses) from sale of assets

Sch. H-2b(4)(C)․․․․․․

Not applicable․․․․․․․

Not applicable.

d.

Earnings from investments

Sch. H-Subtract the sum of 2a(3), 2b(4)(C) and 2c from 2d

Sch. I-2c․․․․․․․․․․․․

Line 8b.

8.

Total plan expenses․․․․․․

Sch. H-2j․․․․․․․․․․․․

Sch. I-2j․․․․․․․․․․․․

Line 8h.

9.

Administrative expenses․․

Sch. H-2i(5)․․․․․․․․․

Sch. I-2h․․․․․․․․․․․․

Line 8f.

10.

Benefits paid․․․․․․․․․․․․

Sch. H-2e(4)․․․․․․․․․

Sch. I-2e․․․․․․․․․․․․

Line 8d.

11.

Other expenses․․․․․․․․․․․

Sch. H-Subtract the sum of 2e(4) & 2i(5) from 2j

Sch. I-2i․․․․․․․․․․․․

Line 8g.