Annual Report Of Self-Insured Voluntary Plan Transactions {DE 2568V}

DE 2568V, Annual Report of Self-Insured Voluntary Plan Transactions As Required by California Code of Regulations, Title 22, Section 3267-2, • Check “Amended” if this is a corrected report. • Enter your company name and mailing address into the company Name and Mailing Address box to the left. • Enter your six-digit Voluntary Plan Number in the box. • Enter the calendar year for which you are reporting statistics. • Enter the number of California employees covered at the end of the calendar year. • Enter the previous year’s ending loan balance from the DE 2568V, if applicable. 1. Beginning VP fund balance as of December 31: Enter the previous year’s ending balance from the DE 2568V. 2. Income received during the calendar year: A. Enter the total amount of contributions withheld from all employees covered by the plan. B. Enter the total amount of employer contributions paid by the employer under the terms of the plan. The amount is a contribution, not a loan, and cannot be reclaimed at a future date. It includes contributions an employer makes on behalf of all employees or a class of employees. It also includes an employer's share of benefit payments if such a cost commitment is made in the text of the plan. C. Enter all interest, investments, or bank deposit income. D. Enter the total amount of other income. Use the box to the right to itemize the amount and source: e.g., recovered overpayment amount, amount transferred from other VP accounts, workers’ compensation reimbursement amount, EDD reimbursement, etc. E. Enter the total employer loan to plan amount. F. Entered total income from items 2A through E (this field contains an automated calculation function for summing total income). 3. Expenses during the calendar year: A. Enter the total amount of third party administrator fees charged to the plan. B. Enter the total amount of employer’s internal administrative expenses: e.g., phone usage, staff time, postage, equipment use, etc. C. Enter the amount of assessments paid to the EDD as shown on line I of the Quarterly Contribution Return (DE 3D) if charged to the plan. D. Enter the total amount of approved other costs charged to the fund during the calendar year. Use the box to the right to indicate the item and cost. This is the proper line to show security premiums, Independent Medical Examination costs, appeals, etc. E. Enter the total amount of loan repayment charged to the plan. F. Enter the total amount of Disability Insurance benefits paid during the calendar year. G. Enter the total amount of Paid Family Leave benefits paid during the calendar year. H. Total expense items 3A through G (this field contains an automated calculation function for subtracting total expenses). 4. Ending VP fund balance as of December 31: (Item 1 + Item 2F - Item 3H) (This field contains an automated calculation function for calculating the ending fund balance as of December 31). 5. Outstanding amount of the employer loan balance to plan (this field contains an automated calculations by adding Prior Year Loan Balance and adding 2E: Loan to VP and subtracting 3E: Loan Repayment). 6. Bank name, account number and location of VP funds: Provide the bank account number, and indicate the name and address of the bank(s) where the funds are located. If the funds are held in an investment account, enter this information on the line marked “Other” and indicate the name of the institution and where the funds are held as of December 31. 7. Please clearly print: the name and title, email address, and phone number of the person completing the form. Enter the date completed. THIS REPORT IS DUE ON FEBRUARY 15 OF EACH YEAR If you have any questions completing this form, contact the Voluntary Plan Group at 1-916-653-6839. www.FormsWorkflow.com