Standard Termination Notice • Single-Employer Plan Termination PBGC Form 500 • Page 2
Number of plan participants and beneficiaries as of proposed termination date:
a Active participants
b Retirees or beneficiaries receiving benefits
c Separated vested participants entitled to benefits
d Separated non-vested participants
9 Estimated percent of currently employed participants that are covered under the termi
nated plan that you expect to be
a No plan
b New or existing traditional defined benefit plan
c New or existing hybrid defined benefit plan, other than cash balance plan
d New or existing cash balance plan
e New or existing profit sharing plan
f New or existing 401(k) plan
g New or existing simplified employee plan
h Other new or existing defined contribution plan (specify)
If the percent entered for item 9b, 9c or 9d is greater than zero, will the types of benefits under the new or existing
defined benefit plan be substantially the same as under the terminating plan for all affected participants (currently
employed participants that you expect will be covered under the new or existing defined benefit plan.)
11a Proposed termination date
11b Proposed termination date stated in notice of intent to terminate (if different from 11a)
Attach copy of notice of intent to terminate.
12a Earliest date notices of intent to terminate issued to affected parties
12b Latest date notices of intent to terminate issued to affected parties
13 Latest date notices of plan benefits issued to participants or beneficiaries Attach copies of
sample notices of plan benefits; see instructions.
14a Has a formal challenge to the termination been initiated under an existing collective bar -
14b If “Yes” to 14a, attach a copy of the formal challenge and a statement describing the
15 Have all PBGC premiums been paid to date?
PART III. RESIDUAL PLAN ASSETS
Will residual assets be returned to the employer as a result of this termination?
16b If “No” or “N/A” to 16a, do not complete the rest of Part III; go to Part IV.
If “Yes,” enter the estimated amount:
17a Is there a plan provision permitting a reversion of residual assets to the employer
, go to 17b
, go to 18a
If “Yes” to 17a, was the provision adopted prior to 12/18/1988?
Yes, go to 18a
No, go to 17c
17c If “No” to 17b, enter:
(1) Adoption date:
(2) Effective date of plan:
18a Has the plan been involved in a spin-off/termination transaction?
Yes, go to 18b
No, go to Part IV
18b If “Yes” to 18a, have the requirements of the Guidelines been satisfied?
Yes, go to 18c
No, go to 18d
N/A, go to 18d
18c If “Yes” to 18b, enter the dates for (1) and (2) and go to Part IV:
(1) latest date a description of the transactions(s) was issued to participants in the ongoing
(2) latest date notices of plan benefits were issued to participants in the ongoing plan.
18d If you checked “No” or “N/A” in 18b, attach a statement that describes the transaction(s) and explains why the Guidelines were not, or need
not have been, followed.
PART IV. PLAN ADMINISTRATOR CERTIFICATION
I, the Plan Administrator, certify that, to the best of my knowledge and belief: (1) I am implementing the termination of the plan in accordance with
all applicable laws and regulations; and (2) the information contained in this filing and made available to the Enrolled Actuary is true, correct, and
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.
Plan Administrator’s signature
Printed name and title of Plan Administrator