Fillable ADVANCE NOTICE OF REPO RTABLE EVENTS PBGC Form (Pension Benefit Guaranty Corporation)

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ADVANCE NOTICE OF REPO RTABLE EVENTS PBGC Form (Pension Benefit Guaranty Corporation)

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PBGC Form 10-Advance
OMB #1212-0013
Expires 3/31/2023
ADVANCE NOTICE
OF REPO
RTABLE EVENTS
IDENTIFYING INFORMATION
Plan Name Name / title of individual to contact at Filer
Name of contributing sponsor Email address of contact
Street address of contributing sponsor Street address of contact
City, state, Zip
City, State, Zip
EIN of contributing sponsor
Plan number Telephone number of contact Ext
See instructions for descriptions of these events. Check all boxes that apply.
Application for minimum funding waiver
Loan Default
Insolvency or similar settlement
Change in controlled group
Liquidation
Extraordinary dividend or stock redemption
Transfer of benefit liabilities
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.
This form is used by a contributing sponsor of a single-employer plan required to notify the Pension Benefit Guaranty
Corporation in advance that a reportable event will occur. For questions regarding this form, contact (202) 326-4070 or
advancereport@pbgc.gov.
PBGC Form 10-Advance
Check box to indicate the item is attached. If not attached, explain on next page.
Change in Controlled Group
Description of the plan’s old and new controlled group
structures, including the name of each controlled
group member
Name of each plan maintained by any member of the
plan’s old and new controlled groups, its contributing
sponsor(s) and EIN/PN
Actuarial Information (see instructions)
Company financial information (see instructions)
Liquidation
Description of the plan's old and new controlled group
structure, including the name of each controlled group
member
Operational status of each controlled group member (in
Chapter 7 proceedings, liquidation outside of bankruptcy,
on-going, etc.)
Name of each plan maintained by any number of the
plan's controlled group, its contributing sponsor(s) and
EIN/PN
Actuarial Information (see instructions)
Company financial information (see instructions)
If the plan sponsor resolves to cease all revenue-generating
business operations, sell substantially all its assets, or
otherwise effect or implement its complete liquidation,
provide:
•
Date on which such resolution was made
•
Most recent pension plan document(s)
•
Address of each controlled group member
•
The Internal Revenue Service Determination Letter
indicating the plan is a covered plan, if applicable
Extraordinary Dividend or Stock Redemption
Application for Minimum Funding Waiver
Name and EIN of person making the distribution
Date and amount of cash distribution(s) during fiscal year
Description, fair market value, and date or dates of any
non-cash distributions
Statement whether the recipient was a member of the
plan’s controlled group
Actuarial Information (see instructions)
Company financial information (see instructions)
Transfer of Benefit Liabilities
Name, contributing sponsor, EIN/PN, and contact
information of transferee plan(s)
Description of the transferor and transferee's controlled
group structures, including the name of each
controlled group member
Explanation of the actuarial assumptions used in
determining the value of benefit liabilities (and, if
appropriate, plan assets) transferred
Estimate of the assets, liabilities, and number of participants
whose benefits are transferred
Actuarial Information (see instructions)
Financial Information for the transferor and transferee's
controlled group (see instructions)
Note: To the extent this information is filed with the IRS Form
5310A, PBGC will accept a copy of that filing.
Loan Default
Copy of the relevant loan documents (e.g., promissory
note, security agreement, loan agreement amendments
and waivers)
Due date and amount of any missed payment
Copy of any written notice of default or acceleration from
l
ender, any notice of forbearance, or loan agreement
amendment or waiver
Description of any cross-defaults or anticipated cross-
defaults
Description of the plan's controlled group structure,
including the name of each controlled group member
Company financial Information (see instructions)
Actuarial Information (see instructions)
Insolvency or Similar Settlement
Name, address and phone number of any trustee, receiver
or similar person
Docket number of court filing and location of the court
where any relevant proceeding was or will be filed (if
known)
Description of the plan’s controlled group structure,
including 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 financial Information (see instructions)
Copy of waiver application, with all attachments
Minimum funding projections for the next 5 years (with and without
the waiver) including all details supporting the calculations and all
assumptions, to the extent not included in the waiver application
INFORMATION REQUIRED TO BE FILED
PBGC Form 10-Advance
Date of Event Notice Due Date
Notice Filing Date (if late, explain below) Filing Extension Claimed (if any, explain below)
REASON FOR LATE FILING OR EXTENSION CLAIMED
If filing late or extension is claimed, explain below.
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
If all the required information has not been submitted with this Form 10-Advance, you must explain
below.
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ADVANCE NOTICE OF REPO RTABLE EVENTS PBGC Form (Pension Benefit Guaranty Corporation)

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Completed 11 August 2020

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