Fillable 02-301a - BAL 02-301

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02-301a - BAL 02-301

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Health Benefits Premium Conversion (HB-PC)
INPUT FOR FORM 5500
for Executive Branch Agencies
For the plan year ending on December 31, 2001
***Fax completed form to (202) 606-7944 no later than June 1, 2002***
Agency: Payroll Office Number:
Note: if your payroll functions are cross-serviced, do not complete this report; it will be
completed for you by your cross-servicer.
***In completing this report, it is important that you follow the instructions on the reverse***
1. Number of employees
2. Number of employees eligible to participate in HB-PC
3. Number of employees who participated in HB-PC
4. Total FEHB withholdings and contributions for HB-PC participants $
5. If you cross-service the payroll functions of other Executive Branch agencies, attach a list
of those agencies as an addendum to this report.
Name of preparer: Telephone:
Title of preparer: E-mail:
Signature of preparer: Date signed:
INSTRUCTIONS FOR COMPLETING THE INPUT FOR FORM 5500
Line 1: Number of Employees
Enter the total number of employees you paid on the last pay day in calendar year (CY) 2001.
Include ALL employees -- full-time, part-time, intermittent, etc.
Line 2: Number of Employees Eligible to Participate in HB-PC
Enter the total number of employees enrolled in the FEHB Program on the last pay day in CY
2001. Include in this number those for whom FEHB deductions were made and those for whom
you made no FEHB deductions (e.g., those on LWOP).
Line 3: Number of Employees who Participated in HB-PC
Enter the sum of:
The number of HB-PC participants on the last pay day in CY 2001
Plus: the number of employees with pre-tax FEHB deductions, who subsequently waived
participation in HB-PC during CY 2001
Plus: the number of HB-PC participants who terminated or cancelled their FEHB
coverage during CY 2001.
Line 4: Total FEHB Withholdings and Contributions for HB-PC Participants
Enter the total amount of FEHB withholdings and contributions remitted to OPM for all HB-PC
participants during CY 2001.
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02-301a - BAL 02-301

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Completed 17 February 2020

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