PSCA’s 55th Annual Survey Worksheet

6. How many employees were eligible to participate in this plan as of December 31, 2011? ______

7. How many employed participants had an account balance as of December 31, 2011? ______

8. How many non-employed participants (i.e. terminated vested employees, etc.) had an account balance as of December 31, 2011? ______

10. What was the total market value of plan assets as of December 31, 2011 (including outstanding plan loans)? ______

11. What was the total (gross) annual payroll of the eligible employees reported in question 6, before any employee salary deferrals? ______

21. What was the total company contribution (non-matching and/or matching contributions) for 2011 for the eligible employees reported in question 6? ______

24. If your plan permits participant contributions, how many participants(employed as of December 31, 2011) contributed to the plan in 2011? ______

25. Please list the number of participants (employed as of December 31, 2011) that made each of the following types of contributions in 2011 and the total dollar value of contributions for the year by those participants. (The total should equal or exceed the answer to question 24 above.)

Number of Participants / Gross 2011 Contribution
Pre-tax contributions:
Roth after-tax contributions:
401(m) after-tax contributions:

26. For non-safe harbor plans, what was the average percentage of deferred (ADP/ACP results) for the following types of contributions?

Pre-tax / Roth after-tax / 401(m) after-tax
By the highly compensated:
By the non-highly compensated:

32. How many investment funds are available to participants for each type of contribution (count lifestyle and target-date series as one fund each)?

Company contributions:______

Participant contributions: ______

52. Who is the primary recordkeeper for the plan?

□ Bank□ Consulting Firm□ Internal Staff□ Mutual Fund□ Third Party Administrator

□ Insurance Company□ Investment Advisor□ Brokerage Firm□ Other: ______

54. If this plan allows 401(k) contributions, how was the ADP (non-discrimination) test passed for 2011? Check all that apply.

□ Passed because of Safe Harbor plan design.

□ Non-safe harbor, passed without adjustments to elections or return of excess contributions for HCEs.

□ Elections of HCEs limited when contributions reached the maximum allowed by the test.

□ Elections of HCEs limited by plan design.

□ Excess contributions returned to participants after the plan year ended.

□ Excess 401(k) amounts deposited into a non-qualified arrangement.

□ Other (describe):______

55. Is this plan top heavy (refer to form 5500)?

□ Yes □ No, because of Safe Harbor Plan Design □ No, more than 40 percent of assets held by non-key employees.

68 a. Does this plan allow participants to take loans?

□ Yes□ No, but loans are being considered. □ No, and loans are not being considered.

b. What was the interest rate on plan loans as of December 31, 2011?

□ Prime□ Prime +1%□ Prime +2%□ Prime +3%□ Other:______

c. What is the minimum loan amount?

□ No minimum□ $500 or less□ $501-$1,000□ Other:______

d. Does this plan allow participants to have more than one loan outstanding?

□ No□ Yes. How many?______

e. Check all loan fees that are charged to borrowers and indicate the fee amounts.

□ Loan origination fee$______

□ Annual fee$______

□ Other:______

□ No fee charged.

f. How many participants had loans outstanding at the end of the plan year? ______

69c. How many participants took a hardship withdrawal in 2011 (when allowed)? ______

34 & 35. Please indicate the types of investment funds available in your plan and the year-end fund balance in each, as well as the investment type and structure. Alternatively, you may fax or e-mail a list of investment funds in your plan and the year-end balance of each, and PSCA will classify them for you.

Fund Type

/ Year-end Fund Balance / Investment Fund Type and Structure
Mutual Fund / Collective Trust / Insurance Account / ETF / Separately Managed
Account
a. Balanced fund
b. Bond-actively managed, domestic
c. Bond-indexed, domestic
d. Bond, International
e. Cash equivalents (CD/money market)
f. Company stock
g. Equity-actively managed, domestic
h. Equity-actively managed, international
i. Equity-indexed, domestic
j. Equity-indexed, international
k. Other sector fund(s)
l. Real estate fund
m. Self-directed (brokerage window)
n. Self-directed (mutual fund window)
o. Stable value fund
p. Target-Date/Life Cycle funds
q. Target-Risk/Lifestyle funds
r. Participant loans
s. Other funds (describe):
______