POST-EVENT NOTICE OF PBGC Form 10 OMB Control No. 1212-0013 REPORTABLE EVENTS 7/31 024/2 Expires This form is used by a plan administrator or contributing sponsor of a single-employer plan when notifying the Pension Benefit Guaranty Corporation that a reportable event has occurred. For questions regarding this form, contact (202) 326-4070 or post- event.report@pbgc.gov IDENTIFYING INFORMATION Planname Name of authorized contact at filer Name of filer Title of contact Street address of filer Email address of contact City, State, Zip Street address of contact EIN ofcontributing sponsor Plannumber City, State, Zip Filer is: Plan administrator Contributing sponsor Telephonenumberofcontact Ext REPORTABLE EVENTS See instructions for descriptions of these events. Check all boxes that apply. Active participantreduction Change in controlled group Failure tomake required contributionsunder $1M Liquidation Inability to pay benefits whendue Extraordinarydividendorstock redemption Distribution to a substantial owner Application for minimumfunding waiver Transfer of benefit liabilities Loan Default Insolvency or similar settlement BRIEF DESCRIPTION Briefly describe the pertinent facts relating to each event. The next page lists additional information that must be submitted with this form, if not included above. |
PBGC Form 10 INFORMATION REQUIRED TO BE FILED Check boxtoindicatetheitemis attached. If not attached, explain in the Missing Information section on next page. Active Participant Reduction The Internal Revenue Service Determination Letter indicating the plan is a covered plan, if applicable Single cause event -statement explaining the cause of the Description of the plan’s controlled group structure, including the reduction (e.g., facility shutdown or sale, discontinued name of each controlled group member operations, winding down of the company, or reduction in Actuarial Information (see instructions) force) Attrition event - statement of factors involved in the attrition Company f inancial nformationi (see instructions) (e.g., frozen plan, aging workforce improved, operational efficiencies that do notrequirereplacing departing active Distribution to a Substantial Owner participants, or single causes that do not meet the reporting threshold of a single-cause event) Name, address and phone numberofperson receivingthe Numberof active participantsatthedate theevent occurs and distribution(s) at the beginning of the plan year in which the event occurred Amount, form and date of each distribution Description of the plan's controlled group structure, including the name of each controlled group member Reason for distribution Actuarial Information (see instructions) Description of the plan’s controlled group structure, including Company financ ial nformationi (see instructions) the name of each controlled group member Actuarial Information (see instructions) Company f inancial nformationi (see instructions) Failure to Make Required Contributions Transfer of Benefit Liabilities Due date and amount of the missed contribution Name, contributing sponsor, EIN/PN, and contact information of Due date and amount of the next payment due transferee plan(s) Due date and amount ofall contributions not timely made and not Description of the transferor and transferee's controlled group reported on the last Schedule SB filed structures, including the name of each controlled group member Date and amount of any contribution(s) made related to the missed contribution(s) Explanation of the actuarial assumptions used in determining the Evidence of any amount paid related to the missed contribution value of benefit liabilities (and, if appropriate, plan assets) (cancelled check, wire transfer, asset statement) transferred Reason contribution was not made by due date Estimate of the assets, liabilities, and number of participants Description of the plan's controlled group structure, including the whose benefits are transferred (liabilities and participants should be broken down by status - active, term vested, and retirees) name of each controlled group member Financial Information for the transferor and transferee's Name of each plan maintained by any member of the plan’s controlled group, its contributing sponsor(s) and EIN/PN controlled group (see instructions) Actuarial Information (see instructions) Actuarial Information (see instructions) Company f inancial nformationi (see instructions) Change ni Controlled Group Inability to Pay Benefits When Due Description of the plan’s old and new controlled group structures, Date of any missed benefit payment and amount of benefits due including the name of each controlled group member Next date on which the plan is expected to be unable to pay Name of each plan maintained by any member of the plan's old benefits, the amount of the projected shortfall, and the number of and new controlled groups, its contributing sponsor(s) and EIN/PN plan participants expected to be affected Financial Information forthe old and new controlledgroup (see Amount of the plan’s liquid assets at the end of the quarter, and instructions) the amount of its disbursements for the quarter Actuarial Information (see instructions) Name, address and phone number of plan trustee (and of any custodian) Most recent pension plan document(s) |
PBGC Form 10 Liquidation Appli cation for Minimum Funding Waiver Description of the plan's controlled group structure before and Copy of waiver application, with all attachments after the liquidation, including the name of each controlled group Minimumfunding projectionsforthenext 5 years(with andwithout member thewaiver) including all details supporting the calculations andall Operational status of each controlled group member (in Chapter 7 assumptions, to the extent not included inthe waiver application proceedings, liquidating outside of bankruptcy, on-going, etc.) Name of each plan maintained by any member of the plan's Loan Default controlled group, its contributing sponsor(s) and EIN/PN Actuarial Information (see instructions) Copy of the relevant loan documents (e.g., promissory note, Company f inancial nformationi (see instructions) security agreement, loan agreement amendments and waivers) If the plan sponsor resolves to cease all revenue-generating Due date and amount of any missed payment business operations, sell substantially all its assets, or otherwise Copy of any written notice of default or any notice of effect or implement its complete liquidation, also provide: acceleration from lender, any notice of forbearance, or loan • Date on which such resolution was made agreement amendment or waiver • Mostrecentpensionplandocument(s) Description of any cross-defaults or anticipated cross-defaults • Address of each controlled group member Description of the plan's controlled group structure, including • TheInternalRevenueServiceDetermination Letter indicating the plan is a covered plan, if applicable the name of each controlled group member Actuarial Information (see instructions) Company fina ncial nformationi (see instructions) Extraordinary Dividend or Stock Redemption Insolvency or Similar Settlement Name and EIN of person making the distribution Date and amount of cash distribution(s) during fiscal year Name, address and phone number of any trustee, receiver or Description, fair market value, and date or dates of any non-cash similar person distributions Docket number of court filing and location of the court where any Statement whether the recipient was a member of the plan's relevant proceeding was or will be filed (if known) controlled group Description of the plan’s controlled group structure, including the Description of the plan's controlled group structure, including name of each controlled group member the name of each controlled group member Name of each plan maintained by any member of the plan’s controlled group, its contributing sponsor(s) and EIN/PN Actuarial Information (see instructions) Company f inancial information (see instructions) Actuarial Information (see instructions) Company f inancial information (see instructions) |
PBGC Form10 MISSING INFORMATION If all the required information has not been submitted with this Form 10, you must explain below. FILING INFORMATION Date of Event Notice Due Date Notice Filing Date (if late, explain below) REASON FOR LATE FILING OR EXTENSION CLAIMED If filing is late or an extension is claimed, explain below. See the instructions for when an extension may be claimed for an Active Participant Reduction event or a Liquidation event. CERTIFICATION I certify that, to the best of my knowledge and belief, the information submitted in this filing is true, correct, and complete. In making this certification, I recognize that knowingly and willfully making false, fictitious, or fraudulent statements to the PBGC is punishable under 18 U.S.C. § 1001. Signature of Individual Submitting Form Name and Title of Individual Submitting Form Telephone Number of Individual Submitting Form Employer of Individual Submitting Form |