NOTE: ONLY FIELDS HIGHLIGHTED IN YELLOW SHALL BE ENTERED BY THE USER.																						
1	Provider/Plan Name:																					
2	Is this an ERISA Covered Plan?																					
																						
		Year 1	Year 2	Year 3	Year 4	Year 5	(1) Schedule B Reference	(2) Schedule SB Reference														
																						
SECTION A: REQUIRED INFORMATION (FROM ACTUARIAL VALUATION REPORT OR SCHEDULE B OF FORM 5500)																						
3	Plan Year Beginning																					
4	Valuation Date						 1a 	1														
5	Valuation Interest Rate						 6e Pre-ret 	5														
6	Normal Cost (PRM-Part I-Section 2142.5 (B))						 9b 	6														
7	Actuarial Accrued Liability (PRM-Part I-Section 2142.5 (A))						 1c(1) 	"3d, column (2)"														
8	Actuarial Value of Assets (PRM-Part I-Section 2142.5 (A))						 1b(2) 	2b														
9	Unfunded Actuarial Liability (Spread Gain Methods Only)						 1c(2)(a) 	N/A														
																						
SECTION B: ERISA AMORTIZATION INFORMATION FROM SCHEDULE B OR SCHEDULE SB (ERISA COVERED PLANS ONLY)																						
10	Funding Standard Account Credit Balance						 9h 	N/A														
ERISA Amortization Amounts 		  																				
11	Amortization Charges						 9c(1) + 9c(2) 	32a + 32b														
12	    Amortization Charges Outstanding Balance						 9c(1) + 9c(2) 	32a + 32b														
13	Amortization Credits						 9j 	N/A														
14	    Amortization Credits Outstanding Balance						 9j 	N/A														
	 	0	0	0	0	0																
SECTION C: REQUIRED INFORMATION (BASED ON PRIOR COST REPORTS)																						
15	Pension Cost Reported for Period																					
16	Accumulated Prepayments Credits From Prior Periods		 (PRM-Part I-Section 2142.6 (C)) 																			
17	Cost Adjustment Carryover from Prior Periods  (3)		 FI / MAC Use ONLY 																			
END OF INPUT WORKSHEET																						
																						
	ERISA Amortization ERROR Code - Possible Explanations:				ERROR-Not an ERISA Covered Plan - Possible explanations																	
																						
	Both charges and credits must be entered as positive values				Line 2 incorrectly indicates plan is not ERISA covered.																	
	"If you enter an amortization charge/credit, you must also enter the corresponding outstanding balance"				Data entered anywhere on Lines 10 through 14.																	
	The amortization balance can never be less than the amortization amount																					
																						
Footnotes																						
																						
(1)	"For plans that are not ERISA covered plans, the entries for lines 2 through 8 shall conform to the data that would be reported on Schedule B of IRS Form 5500, determined without regard to the Pension Protection Act amendments."																					
																						
(2)	"Special Note for ERISA Covered Plans ONLY:  For Plan Years Beginning after December 31, 2007, ERISA Covered Plans shall use data from the referenced lines of the IRS Form 5500 Schedule SB, which replaced the Schedule B effective in 2008."																					
																						
(3)	Cost Adjustment Carryover Charges for Reported Pension Cost in excess of the Allowable Pension Cost are shown as a positive value.  Cost Adjustment Carryover Credits for Allowable Pension Cost in excess of the Reported Pension Cost are shown as a negative positive value.																					
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
																						
