Annual Report of Self-Insured Voluntary Plan (VP) Transactions As required by California Code of Regulations, title 22, section 3267-2 Amended Voluntary Plan #: CA Employer Account #: Report for Calendar Year: Number of CA employees covered at the end of the calendar year: Company Name and Mailing Address - 1. Beginning VP Fund Balance as of December 31......................................................................................... 2. Income received during calendar year: A. Employee contributions withheld.................. B. Employer contributions............................... C. Interest income from VP Fund.................... (Bank deposits, investments, interest) Itemize 2.D., Other income D. Other income.......................................... (Indicate employer loan to plan, workers' compensation reimbursement, benefits reimbursed by the EDD, employee overpayment recovery, funds transferred from other VPs, etc.) $0.00 ..... E. Total income (2A through 2D).......................................................................................................... 3. Expenses during calendar year: A. Third Party Administration fees.................... B. Employer internal administrative expense...... C. VP Assessment paid to the EDD................. (Line K on DE 3D) if charged to Plan $0.00 Itemize 3.D., Other expenses D. Other authorized expenses......................... (Indicate employer loan re-payment, security premiums, IME, appeals, etc.) ...... E. Benefits paid - Disability Insurance............... F. Benefits paid - Paid Family Leave................. G. Total expenses (3A through 3F)............................................................................................................................. 4. Ending VP Fund balance as of December 31. (Add 1 and 2E; subtract 3G)...................................................... 5. Outstanding amount of employer loan balance to plan...........$ 6. Bank account and location of VP Funds as of December 31: Commercial Account Number Saving Account Number Other (explain) Bank Name and Address: Bank Name and Address: Bank Name and Address: $0.00 $0.00 Person completing this form: 7.x Print Name and Title E-mail Address Area Code and Telephone No., Ext. # Date THIS REPORT IS DUE ON FEBRUARY 15 OF EACH YEAR See "Instructions for Completing Annual Report..." (2nd tab on Excel version) for directions on how to submit your completed report. DE 2568V Rev. 23 (8-15) (INTERNET) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com CU INSTRUCTIONS FOR COMPLETING ANNUAL REPORT OF SELF-INSURED VOLUNTARY PLAN TRANSACTIONS, DE 2568V Check "Amended" if this is a corrected report. Enter your company name and mailing address in the box to the left. Enter your six digit Voluntary Plan Number in the box. Enter your CA Employer Account Number. Enter the calendar year for which you are reporting statistics. Enter the number of California employees covered at the end of the calendar year. 1. BEGINNING VP FUND BALANCE AS OF DECEMBER 31: Enter the year ending balance from the previous year's 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., employer loan to plan, recovered overpayment amount, amount transferred from other VP accounts, workers' compensation reimbursement amount, EDD reimbursement, etc. E. Total income items 2A, B, C, and D. (This is an automatic function of the Excel/DI Server version.) 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 K 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 repayment of loans the employer has made to the plan, security premiums, Independent Medical Examination costs, appeals, etc. E. Enter the total amount of Disability Insurance benefits paid during the calendar year. F. Enter the total amount of Paid Family Leave benefits paid during the calendar year. G. Total expense items 3A, B, C, D, E, and F. (This is an automatic function of the Excel version.) ENDING VP FUND BALANCE AS OF DECEMBER 31. (Item 1 + Item 2E ­ Item 3G) (This is an automatic function of the Excel version.) Outstanding amount of the employer loan balance to plan. () BANK 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 explain where the funds are. PLEASE CLEARLY PRINT: the name and title, e-mail address, and telephone number of the person completing the form. Indicate 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 916-653-6839. SUBMIT COMPLETED FORM AS FOLLOWS: E-MAIL or FAX TO: 3. 4. 5. 6. 7. MAIL TO: Employment Development Department Voluntary Plan Group, MIC 29VP PO Box 826880 Sacramento, CA 94280-0001 vp68v@edd.ca.gov 916-653-6209 Fax DE_2568V Rev. 23 (8-15) (INTERNET) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com CU