Tax Calendar Details

The H Form 5500 is a key document for any business with employees. This form must be filed annually with the IRS, and it provides detailed information about the company's health and welfare plan. Failing to file this form can lead to penalties and other complications, so it's important to understand what's required and submit your paperwork on time. Here we'll provide an overview of the H Form 5500, including what information is included and when it needs to be filed.

Listed here, you'll find a number of information about h form 5500 PDF. You will have the approximate time it could take you to fill out the form and a few further details.

QuestionAnswer
Form NameH Form 5500
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other names5500 filing deadline, h 5500 form, form h 5500, schedule h form 5500

Form Preview Example

 

SCHEDULE H

 

 

Financial Information

 

 

OMB No. 1210-0110

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Form 5500)

 

 

 

 

 

2018

 

 

 

 

 

Department of the Treasury

 

This schedule is required to be filed under section 104 of the Employee

 

 

 

 

 

 

Department of the Treasury

 

 

 

 

 

 

 

 

Retirement Income Security Act of 1974 (ERISA), and section 6058(a) of the

 

 

 

 

 

 

 

Internal Revenue Service

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Internal Revenue Code (the Code).

 

 

 

 

 

 

 

 

Department of Labor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee Benefits Security Administration

 

 

File as an attachment to Form 5500.

 

This Form is Open to Public

 

 

 

 

 

 

 

 

 

 

 

 

 

Pension Benefit Guaranty Corporation

 

 

 

 

 

Inspection

 

 

 

 

For calendar plan year 2018 or fiscal plan year beginning

and ending

 

 

 

 

 

 

A Name of plan

 

 

 

B Three-digit

 

 

 

 

 

 

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

plan number (PN)

 

001

 

 

 

 

 

 

 

 

 

 

 

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

 

 

 

 

 

 

 

 

ABCDEFGHI ABCDEFGHI

 

 

 

 

 

 

 

 

 

 

 

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

 

D Employer Identification Number (EIN)

 

 

 

 

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

012345678

 

 

 

 

 

 

ABCDEFGHI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part I Asset and Liability Statement

1Current 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 & certificates

1c(1)

 

 

 

 

of deposit)

-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

1c(13)

-123456789012345

 

-123456789012345

 

funds)

 

 

 

 

 

 

(14) Value of funds held in insurance company general account (unallocated

1c(14)

-123456789012345

 

-123456789012345

 

contracts)

 

 

 

 

 

 

(15) Other

1c(15)

-123456789012345

 

-123456789012345

 

 

 

 

For Paperwork Reduction Act Notice, see the Instructions for Form 5500.

Schedule H (Form 5500) 2018

 

v.171027

Schedule H (Form 5500) 2018

Page 2

 

 

1d Employer-related investments:

(1)Employer securities.................................................................................

(2)Employer real property ............................................................................

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

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

Liabilities

1g Benefit claims payable...................................................................................

1h Operating payables .......................................................................................

1i Acquisition indebtedness ...............................................................................

1j Other liabilities...............................................................................................

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

Net Assets

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

 

(a) Beginning of Year

(b) End of Year

 

 

 

1d(1)

-123456789012345

-123456789012345

 

 

 

1d(2)

-123456789012345

-123456789012345

 

 

 

1e

-123456789012345

-123456789012345

 

 

 

1f

-123456789012345

-123456789012345

 

 

 

 

 

 

1g

-123456789012345

-123456789012345

 

 

 

1h

-123456789012345

-123456789012345

 

 

 

1i

-123456789012345

-123456789012345

 

 

 

1j

-123456789012345

-123456789012345

 

 

 

1k

-123456789012345

-123456789012345

 

 

 

 

 

 

1l

-123456789012345

-123456789012345

Part II Income and Expense Statement

2Plan 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

 

 

 

 

 

 

 

 

bEarnings on investments:

(1)

Interest:

 

 

 

 

 

 

 

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

2b(1)(A)

-123456789012345

 

 

 

 

 

 

certificates of deposit)

 

 

 

 

 

 

 

 

 

 

 

 

 

(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

 

(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.

 

 

 

 

 

 

 

2b(5)(C)

 

 

-123456789012345

 

 

 

Add lines 2b(5)(A) and (B)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1) X

Schedule H (Form 5500) 2018

Page 3

 

 

(6)Net investment gain (loss) from common/collective trusts .........................

(7)Net investment gain (loss) from pooled separate accounts .......................

(8)Net investment gain (loss) from master trust investment accounts............

(9) Net investment gain (loss) from 103-12 investment entities ......................

(10)Net investment gain (loss) from registered investment

companies (e.g., mutual funds).................................................................

c Other income..................................................................................................

d Total income. Add all income amounts in column (b) and enter total.....................

Expenses

eBenefit payment and payments to provide benefits:

(1)Directly to participants or beneficiaries, including direct rollovers

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

(3)Other........................................................................................................

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

f Corrective distributions (see instructions) .......................................................

g Certain deemed distributions of participant loans (see instructions) ................

h Interest expense.............................................................................................

iAdministrative expenses: (1) Professional fees..............................................

(2)Contract administrator fees.......................................................................

(3)Investment advisory and management fees..............................................

(4)Other........................................................................................................

(5)Total administrative expenses. Add lines 2i(1) through (4)........................

j Total expenses. Add all expense amounts in column (b) and enter total ........

Net Income and Reconciliation

 

(a) Amount

(b) Total

2b(6)

 

-123456789012345

2b(7)

 

-123456789012345

2b(8)

 

-123456789012345

2b(9)

 

-123456789012345

2b(10)

 

-123456789012345

 

 

 

2c

 

-123456789012345

2d

 

-123456789012345

 

 

 

2e(1)

-123456789012345

 

 

 

 

2e(2)

-123456789012345

 

 

 

 

2e(3)

-123456789012345

 

2e(4)

 

-123456789012345

 

 

 

2f

 

-123456789012345

 

 

 

2g

 

-123456789012345

 

 

 

2h

 

-123456789012345

2i(1)

-123456789012345

 

 

 

 

2i(2)

-123456789012345

 

 

 

 

2i(3)

-123456789012345

 

 

 

 

2i(4)

-123456789012345

 

2i(5)

 

-123456789012345

 

 

 

2j

 

-123456789012345

k Net income (loss). Subtract line 2j from line 2d ...........................................................

lTransfers of assets:

(1)To this plan...............................................................................................

(2)From this plan...........................................................................................

2k

2l(1)

2l(2)

-123456789012345

-123456789012345

-123456789012345

Part III Accountant’s Opinion

3Complete 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.

aThe 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

 

 

dThe opinion of an independent qualified public accountant is not attached because:

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

4CCTs 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:

aWas 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.)....................

bWere 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.) ........................................................................................................................................

 

Yes No

Amount

 

 

 

 

 

 

4a

4b

Schedule H (Form 5500) 2018

Page 4-

 

 

 

Yes

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

-123456789012345

 

f

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

 

 

 

 

 

iDid the plan have assets held for investment? (Attach schedule(s) of assets if “Yes” is checked, and

see instructions for format requirements.)

4i

jWere 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

 

 

 

 

 

 

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 were transferred. (See instructions.)

5b(1) Name of plan(s)

5b(2) EIN(s)

5b(3) PN(s)

 

 

 

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

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

 

 

 

 

 

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

123456789

123

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

 

 

 

 

 

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.)

 

 

 

 

 

 

 

 

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .