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Appendix to §2520.104b–10—The Summary Annual Report (SAR) Under ERISA: A Cross-Reference to the Annual Report

RegSenseEmployee BenefitsCFR RegulationsMultiple Employer Welfare Arrangements (MEWA)Associate Benefits & CompensationCFR SectionFocus AreaHuman Resources

SAR item Form 5500 large plan filer line items Form 5500 small plan filer line items Form 5500-SF filer line items
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.

[Change Notice]

Table 1 to §2520.104 -10—The Summary Annual Report (SAR) Under ERISA: A Cross-Reference to the Annual Report
SAR item Form 5500 large plan filer line items Form 5500 small plan filer line items Form 5500-SF filer line items
A. Pension Plan:
1. Funding arrangementForm 5500-9aSameNot 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):
a. End of plan yearSch. H-1l [Col. (b)]Sch. I-1c [Col. (b)]Line 7c [Col. (b)].
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. Participating employer's percentage of the total contributions (employer and employee) made by all employers participating in a MEP Sch. MEP Line 2c Sch. MEP Line 2c Not applicable.
d. Aggregate account balance of the employer participating in a defined contribution MEP (determined as the sum of the account balances of the employees of such employer (including the beneficiaries of such employees) Sch. MEP Line 2d Sch. MEP Line 2d Not applicable.
e. Gains (losses) from sale of assets Sch. H-2b(4)(C) Not applicable Not applicable.
f. Earnings from investments Sch. H—Subtract the sum of 2a(3), 2b(4)(C) and 2c from 2d Sch. I-2c Line 8b.
11. Total insurance premiums Total of all Schs. A-6b Total of all Schs. A-6b Not applicable.
12. Unpaid minimum required contribution (S-E plans) or Funding deficiency (ME plans):
a. S-E Defined benefit plansSch. SB-39SameSame.
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.
13. Individual plan information for plans participating in a DCG reporting arrangement Schedule DCG Not applicable Not applicable.
B. Welfare Plan:
1. Name of insurance carrierAll Schs. A-1(a)SameNot 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):
a. End of plan yearSch. H-1l [Col. (b)]Sch. I-1c [Col. (b)]Line 7c [Col. (b)].
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.

[44 FR 19403, Apr. 3, 1979, as amended at 44 FR 31640, June 1, 1979; 47 FR 31873, July 23, 1982; 54 FR 8629, Mar. 1, 1989; 65 FR 21085, Apr. 19, 2000; 65 FR 35568, June 5, 2000; 68 FR 16400, Apr. 3, 2003; 72 FR 64729, Nov. 16, 2007]

['Employee Benefits']
['Multiple Employer Welfare Arrangements (MEWA)']
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