Fillable Printable Annual Report Of Self-Insured Voluntary Plan Transactions (De 2568V)
Fillable Printable Annual Report Of Self-Insured Voluntary Plan Transactions (De 2568V)
Annual Report Of Self-Insured Voluntary Plan Transactions (De 2568V)
Amended
-
Itemize 2.D., O t her i ncome
…..
Itemize 3.D., O t her expenses
……
7.x
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
CU
Person completing this form:
Bank Name and Address:
Number of CA employees covered
at the end of the calendar year:
E. Total income (2A through 2D)…………………………………….…………………….…………….….……..……….
3. Expenses during cal endar year:
A. Third Party Adm i ni stration fees….……. . … … . .
Print Name and Title
E-mail Address
THIS REP O RT IS DUE ON FE BRUARY 15 OF EACH YEAR
Area Code and Telephone No., Ext. #
Date
Saving Ac c ount Number
E. Benef i ts paid - Dis abi l ity Insurance… …… … …
Commercial A ccount Number
G. Total expenses (3A through 3F)……………..............................................................................................................
4. Ending VP Fund bal ance as of December 31. (Add 1 and 2E ; subtract 3G)…... …… … …… … …… … . .……... … ..…..
Bank Name and Address:
F. Benef i t s paid - Paid Family Leave…………… . .
6. Bank account and location of VP F unds as of December 31:
A. Employee cont ributions withheld……..…...….
B. Employer contributions.………………….........
(Indicate em ploy er l oan to p l an, wor kers' compensation
reimb ursement, b enefits reimbursed by th e EDD, employ ee
overpayment recovery , funds tr ansferred from other VPs, etc.)
Annual Report of Self-Insured Voluntary Plan (VP) Transactions
As required by Cal ifornia Code of Regulations, title 22, section 3267-2
Report for Calendar Year:
CA Employer Account #:
Voluntary Plan #:
Company Name and Mailing Address
1. Beginning VP Fund Balance as of December 31………………………………………………………………..…..…...….
C. VP A ssess ment paid t o t he EDD……….…….
(Line K on DE 3D) if charged to Plan
B. Employer internal adminis trative expense……
5. Outst andi ng amount of employer loan balanc e t o pl an.…….…
$
D. Other authori zed expenses… …… .………….. .
(Indicate employer loan re-payment, security premiums,
IME, appeals, etc.)
2. Income received during c al endar year:
C. Interest income from VP Fund…………. ..…..
(Bank deposits, investments, interest)
D. Other income………………….…………….….
Other (explain)
Bank Name and Address:
$0.00
$0.00
$0.00
$0.00
$0.00
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.
C.
D.
E. Total income items 2A, B, C, and D. (This is an automatic function of the Excel/DI Server version.)
3. EXPENSES DURING THE CALENDAR YEAR:
A. Enter the total amount of third party administrator fees charged to the plan.
B.
C.
D.
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.)
4.
5.
( )
6. 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.
7. PLEASE CLEARLY PRINT: the name and title, e-mail address, and telephone number of the person completing the form.
Indicate the date completed.
MAIL TO:
DE 2568V Rev. 23 (8-15) (INTERNET) Page 2 of 2
916-653-6209 Fax
Employment Development Department
Voluntary Plan Group, MIC 29VP
PO Box 826880
Sacramento, CA 94280-0001
Outstanding amount of the employer loan balance to plan.
SUBMIT COMPLETED FORM AS FOLLOWS:
E-MAIL or FAX TO:
If you have any questions completing this form, contact the Voluntary Plan Group at 916-653-6839.
THIS REPORT IS DUE ON FEBRUARY 15 OF E ACH YEAR
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.
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.
ENDING VP FUND BALANCE AS OF DECEMBER 31. (Item 1 + Item 2E – Item 3G) (This is an automatic function of the Excel
version.)
INSTRUCTIONS FOR COMPLETING
ANNUAL REPORT OF SELF-INSURED VOLUNTARY PLAN TRANSACTIONS, DE 2568V
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.
Enter all interest, investments, or bank deposit income.
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.
etc.
Enter the total amount of employer’s internal administrative expenses: e.g., phone usage, staff time, postage, equipment use,
