Approved OMB 1212-0036
Part A. Contributing Sponsor or Controlled Group Member
1. Name of Entity:
3. Address of Contact Person:
Part B. Distress Criterion Satisfied by Entity
2. Contact Person and Title:
4. Phone of Contact Person: 5. Email of Contact Person:
1. Distress Criterion 1: Liquidating in a federal or state proceeding
2. Distress Criterion 2: Reorganizing in a federal or state proceeding
3. Distress Criterion 3: Unable to pay debts when due and continue in business
4. Distress Criterion 4: Unreasonably burdensome pension costs solely due to decline in covered employment
If an entity does not meet any distress test because it has no operations, employees, or significant assets, check the box
below indicating it is a de minimis entity.
5. De Minimis Entity:
Part C. Additional Information
The following documents and/or information must be attached to Schedule F, if applicable. Check the box to indicate if the item is
attached. If any of the information listed below was provided with another Schedule F, indicate the name of the contributing sponsor
or controlled group member for which it was provided; the information need not be provided again.
For Distress Criterion 1, a copy of the petition for liquidation filed with the court.
For Distress Criterion 2, a copy of the motion seeking termination, if filed with the court.
For Distress Criteria 2, 3, and 4, attach the following:
1. Tax returns, with all schedules, for the most recent four years available.
2. Audited financial statements (income statement, balance sheet, cash flow statement, and notes) for the most recent four
years; if audited financial statements were not prepared, then provide unaudited financial statements and a statement
explaining why audited statements are not available; See more information on financial statements in the Instructions for
Form 600 - Schedule F.
3. Projected financial statements (income statement, balance sheet, cash flow statement) for the current year and the four
following years as well as the key assumptions underlying those projections and a justification for the reasonableness for each
of those key assumptions; See guidelines for preparing financial projections in the Instructions for Form 600 - Schedule F.
4. Description of events leading to the current financial distress.
Submit a Separate Schedule F for each Contributing Sponsor and all members of
each Contributing Sponsor’s controlled group
5. Description of financial and operational restructuring actions taken to address financial distress, including cost cutting
measures, employee count or compensation reductions, creditor concessions obtained, and any other restructuring efforts
undertaken; also, indicate whether any new profit-sharing or other retirement plan has been or will be established or if
benefits under such existing plan will be increased.
Financial Information and Distress Criteria