5500 Schedule SB XML Generator

Plan Identification

For calendar plan year or fiscal plan year beginning and ending

• Round off amounts to nearest dollar.

A Name of plan:ℹ

B Three-digit plan number (PN):ℹ

C Plan sponsor's name as shown on line 2a of Form 5500 or 5500-SF:ℹ

D Employer Identification Number (EIN):ℹ

E Type of plan:ℹ

[1] Single

Multiple-A

Multiple-B

F Prior year plan size:ℹ

100 or fewer

101-500

More than 500

Part I Basic Information

1 Enter the valuation date:ℹ

2 Assets:

a Market valueℹ 2a

b Actuarial valueℹ 2b

3 Funding target/participant count breakdownℹ

	(1) Number of participants	(2) Vested Funding Target	(3) Total Funding Target
a For retired participants and beneficiaries receiving payment.
b For terminated vested participants.
c For active participants.
d Total.

4 If the plan is in at-risk status, check the box and complete lines (a) and (b)ℹ

At-risk

a Funding target disregarding prescribed at-risk assumptionsℹ 4a

b Funding target reflecting at-risk assumptions, but disregarding transition rule for plans that have been in at-risk status for fewer than five consecutive years and disregarding loading factor.ℹ 4b

5 Effective interest rateℹ 5 %

6 Target normal costℹ

a Present value of current plan year accruals.ℹ 6a

b Expected plan-related expensesℹ 6b

c Target normal costℹ 6c

Statement by Enrolled Actuary

To the best of my knowledge, the information supplied in this schedule and accompanying schedules, statements and attachments, if any, is complete and accurate. Each prescribed assumption was applied in accordance with applicable law and regulations. In my opinion, each other assumption is reasonable (taking into account the experience of the plan and reasonable expectations) and such other assumptions, in combination, offer my best estimate of anticipated experience under the plan.

SIGN HERE

Signature of actuary (Signature to be applied on printed form)

Type or print name of actuary

Firm name

Address of the firm

Date

Most recent enrollment number

Telephone number (including area code)

If the actuary has not fully reflected any regulation or ruling promulgated under the statute in completing this schedule, check the box and see instructions.ℹ

Part II Beginning of Year Carryover and Prefunding Balances

	(a) Carryover balance	(b) Prefunding balance
7 Balance at beginning of prior year after applicable adjustments (line 13 from prior year)ℹ
8 Portion elected for use to offset prior year's funding requirement (line 35 from prior year)ℹ
9 Amount remaining (line 7 minus line 8)ℹ
10 Interest on line 9 using prior year's actual return ofℹ %.
11 Prior year's excess contributions to be added to prefunding balance:
a Present value of excess contributions (line 38a from prior year)ℹ
b(1) Interest on the excess, if any, of line 38a over line 38b from prior year Schedule SB, using prior year's effective interest rate ofℹ %
b(2) Interest on line 38b from prior year Schedule SB, using prior year's actual returnℹ
c Total available at beginning of current plan year to add to prefunding balanceℹ
d Portion of (c) to be added to prefunding balanceℹ
12 Other reductions in balances due to elections or deemed electionsℹ
13 Balance at beginning of current year (line 9 + line 10 + line 11d – line 12)ℹ

Part III Funding Percentages

Part III
14 Funding target attainment percentage.ℹ	14	%
15 Adjusted funding target attainment percentage.ℹ	15	%
16 Prior year's funding percentage for purposes of determining whether carryover/prefunding balances may be used to reduce current year's funding requirement.ℹ	16	%
17 If the current value of the assets of the plan is less than 70 percent of the funding target, enter such percentage.ℹ	17	%

Part IV Contributions and Liquidity Shortfalls

18 Contributions made to the plan for the plan year by employer(s) and employeesℹ

(a) Date (MM-DD-YYYY)	(b) Amount paid by employer(s)	(c) Amount paid by employees





Totals →	18(b)	18(c)

19 Discounted employer contributions – see instructions for small plan with a valuation date after the beginning of the year:ℹ

a Contributions allocated toward unpaid minimum required contributions from prior years.ℹ 19a

b Contributions made to avoid restrictions adjusted to valuation date.ℹ 19b

c Contributions allocated toward minimum required contribution for current year adjusted to valuation date.ℹ 19c

20 Quarterly contributions and liquidity shortfalls:ℹ

a Did the plan have a "funding shortfall" for the prior year?ℹ

Yes

No

b If line 20a is "Yes," were required quarterly installments for the current year made in a timely manner?ℹ

Yes

No

c If line 20a is "Yes," see instructions and complete the following table as applicable:ℹ

Liquidity shortfall as of end of quarter of this plan year

(1) 1st	(2) 2nd	(3) 3rd	(4) 4th

Part V Assumptions Used to Determine Funding Target and Target Normal Cost

21 Discount rate:ℹ

a Segment rates: 1st segment: % 2nd segment: % 3rd segment: %

N/A, full yield curve used

b Applicable month (enter code)ℹ 21b

22 Weighted average retirement ageℹ 22

23 Mortality table(s) (see instructions)ℹ

Prescribed – combined

Prescribed – separate

Substitute

Part VI Miscellaneous Items

24 Has a change been made in the non-prescribed actuarial assumptions for the current plan year? If "Yes," see instructions regarding required attachment.ℹ	Yes No
25 Has a method change been made for the current plan year? If "Yes," see instructions regarding required attachment.ℹ	Yes No
26 Demographic and benefit information
a Is the plan required to provide a Schedule of Active Participants? If "Yes," see instructions regarding required attachment.ℹ	Yes No
b Is the plan required to provide a projection of expected benefit payments? If "Yes," see instructions regarding required attachment.ℹ	Yes No
27 If the plan is subject to alternative funding rules, enter applicable code and see instructions regarding attachment.ℹ	27

Part VII Reconciliation of Unpaid Minimum Required Contributions For Prior Years

28 Unpaid minimum required contributions for all prior years.ℹ		28
29 Discounted employer contributions allocated toward unpaid minimum required contributions from prior years (line 19a).ℹ		29
30 Remaining amount of unpaid minimum required contributions (line 28 minus line 29).ℹ		30

Part VIII Minimum Required Contribution For Current Year

31 Target normal cost and excess assets (see instructions):

31a Target normal cost (line 6c).ℹ

31a

31b Excess assets, if applicable, but not greater than line 31a.ℹ

31b

32 Amortization installments:

32a Net shortfall amortization installmentℹ

Outstanding Balance	Installment

32b Waiver amortization installmentℹ

Outstanding Balance	Installment

33 If a waiver has been approved for this plan year, enter the date of the ruling letter granting the approval and the waived amountℹ

33

34 Total funding requirement before reflecting carryover/prefunding balances (lines 31a - 31b + 32a + 32b - 33).ℹ

34

35 Balances elected for use to offset funding requirement:ℹ

35

Carryover balance	Prefunding balance	Total balance

36 Additional cash requirement (line 34 minus line 35).ℹ

36

37 Contributions allocated toward minimum required contribution for current year adjusted to valuation date (line 19c).ℹ

37

38 Present value of excess contributions for current year (see instructions):

38a Total (excess, if any, of line 37 over line 36).ℹ

38a

38b Portion included in line 38a attributable to use of prefunding and funding standard carryover balances.ℹ

38b

39 Unpaid minimum required contribution for current year (excess, if any, of line 36 over line 37).ℹ

39

40 Unpaid minimum required contributions for all years.ℹ

40

Amortization base election (1-3)

Part IX Pension Funding Relief Under the American Rescue Plan Act of 2021 (See Instructions)

41 If an election was made to use the extended amortization rule for a plan year beginning on or before December 31, 2021, check the box to indicate the first plan year for which the rule applies:ℹ

2019

2020

2021

5500 Schedule SB XML Generation Form

Plan Identification

Statement by Enrolled Actuary