Fill - Free fillable PBGC Form 500 Single-Employer Plan Termination Standard Termination (Pension Benefit Guaranty Corporation) PDF form

PBGC Form 500

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Expires 3/31/2023

Standard Termination Notice

Single-Employer Plan Termination

PART I. IDENTIFYING INFORMATION

Plan Name 1b Last day of plan year

2a Contributing Sponsor’s name and address

(Address should include room or suite no.)

2b Sponsor’s telephone number

2c 9-digit employer identification number (EIN)

3-digit plan number (PN)

If you used a different EIN or PN for this contributing sponsor/plan in previous filings

with the PBGC, also show the number(s) previously reported

6-digit business code

Plan Administrator’s name and address (if same as 2a, enter “same”) (Address should

include room or suite no.)

Plan Administrator’s telephone number

E-mail address (optional)

Name and address of person to be contacted for more information (if same as 3a, enter

“same”) (Address should include room or suite no.)

Telephone number

E-mail address (optional)

PART II. GENERAL PLAN INFORMATION

Have you filed, or will you file, with the Internal Revenue Service

for a determination letter on the termination of this plan?

Yes

4b If “Yes” to 4a, enter the filing date:

(MM/DD/YYYY)

5a Is this a multiple-employer plan?

Yes

5b If “Yes” to 5a, attach a list of the names and

employer identification numbers of all contributing

sponsors

6 Reason for plan termination. If more than one reason for the termination (considering (1) - (12) and c.), see instructions.

a Plan related

(1) Plan administration too costly or complicated

(2) Plan benefits too costly

(3)

Restructuring of retirement program (e.g. adoption of new plan, decision that defined benefit plan no

longer meets employer objectives)

) Retirement/illness/death of owner(s)

b Business related

(5) Adverse business conditions

(6) Sale of c

ompany/subsidiary/division (not involving bankruptcy or similar proceeding)

(7) Company/subsidiary/divisi

on closed

(

not i

nvolving bankruptc

imilar proceeding)

(8) Merger of company

(9) Contributing sponsor acquired by

another business

(10) Another business acquired by contributing sponsor

(11) Contributing sponsor reorganized (in bankruptcy or similar proceeding)

(12) Contributing sponsor liquidated (in bankruptcy or similar proceeding)

c Other (specify)

6a(1)

6a(2)

6a(3)

6a(4)

6b(5)

6b(6)

6b(7)

6b(8)

6b(9)

6b(10)

6b(11)

6b(12)

Changes in contributing sponsor associated with plan termination (check all that apply)

a No change

b Sale of company/subsidiary/division (not involving bankruptcy or similar proceeding)

c Company/subsidiary/division closed (not involving bankruptcy or similar proceeding)

d Merger o

f company

e Contributing sponsor acquired by another business

f Another business acquired by contributing sponsor

g Contributing sponsor reorganized (in bankruptcy or similar proceeding)

h Contributing sponsor liquidated (in bankruptcy

or similar proceeding)

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

e Total

9 Estimated percent of currently employed participants that are covered under the termi

nated plan that you expect to be

covered under:

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.)

Yes

11a Proposed termination date

(MM/DD/YYYY)

11b Proposed termination date stated in notice of intent to terminate (if different from 11a)

Attach copy of notice of intent to terminate.

(MM/DD/YYYY)

12a Earliest date notices of intent to terminate issued to affected parties

(MM/DD/YYYY)

12b Latest date notices of intent to terminate issued to affected parties

(MM/DD/YYYY)

13 Latest date notices of plan benefits issued to participants or beneficiaries Attach copies of

sample notices of plan benefits; see instructions.

(MM/DD/YYYY)

14a Has a formal challenge to the termination been initiated under an existing collective bar -

gaining agreement?

Yes

N/A

14b If “Yes” to 14a, attach a copy of the formal challenge and a statement describing the

challenge.

15 Have all PBGC premiums been paid to date?

Yes

PART III. RESIDUAL PLAN ASSETS

16a

Will residual assets be returned to the employer as a result of this termination?

Yes

N/A

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

Yes

, go to 17b

, go to 18a

17b

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:

(MM/DD/YYYY)

(2) Effective date of plan:

(MM/DD/YYYY)

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

plan.

(MM/DD/YYYY)

(2) latest date notices of plan benefits were issued to participants in the ongoing plan.

(MM/DD/YYYY)

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

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.

Plan Administrator’s signature

Date

Printed name and title of Plan Administrator

PBGC Schedule EA-S

Standard Termination

Certification of Sufficiency

(PBGC Form 500)

Approved OMB 1212-0036

Expires 3/31/2023

PART I. IDENTIFYING INFORMATION

Plan Name 1b 9-digit employer identification number (EIN)

1c 3-digit plan number (PN)

PART II. CODE SECTION 412

(

)(

)

PLANS

Is this plan a Code section 412(e)(3) plan?

No: the Enrolled Actuary must complete Parts III and IV. Item 3 and Part V should not be completed.

Yes: item 3 and Part III must be completed. Depending upon who completes Part III, either Part IV or Part V must be completed and

signed by the Plan Administrator or Enrolled Actuary as appropriate.

3a Enter name (full official name of record) and address of the insurer

(Address should include room or suite no.)

3b Telephone Number

PART III. PLAN SUFFICIENCY

Proposed distribution date

(MM/DD/YYYY)

5 Is the value of plan assets projected to be sufficient as of the proposed distribution date to

provide all plan benefits? If “No,” the plan cannot terminate in a standard termination.

Yes No

6 Estimated fair market value of plan assets as of the proposed distribution date $

Estimated present value of plan benefits as of the proposed distribution date $

Estimated total amount of residual assets $

Estimated amount of residual assets to be distributed to the employer $

10 Estimated amount of residual assets to be distributed to participants and beneficiaries

11 Has the plan ever required employee contributions?

Yes No

12 If the amount in item 9 is $1 million or more and if any benefits are to be distributed other

than through the purchase of annuity contracts, attach a statement showing interest

rate/structure used to value the benefits.

PART IV. ENROLLED ACTUARY CERTIFICATION

I, the Enrolled Actuary, certify that: (1) I have reviewed all plan documents and plan and participant data, and applied all relevant provisions of

ERISA and the Internal Revenue Code and regulations promulgated thereunder; (2) to the best of my knowledge and belief, this plan’s assets

equal or exceed the value of its plan benefits as of the proposed distribution date; and (3) to the best of my knowledge and belief, the

information contained in this schedule 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.

Enrolled Actuary’s company’s name and address

(Address should include room or suite no.)

Enrolled Actuary’s signature Date

Enrolled Actuar

y’s Name (Print or type)

Enrollment Numbe

Telephone Numbe

E-mail address (optional)

PART V. PLAN ADMINISTRATOR CERTIFICATION FOR CODE SECTION 412(e)(3) PLANS

I, the Plan Administrator, certify that, to the best of my knowledge and belief: (1) this plan complies with section 412(e)(3) of the Internal Revenue

Code and regulations promulgated thereunder; (2) I have reviewed all plan documents and plan and participant data, and applied all relevant

provisions of ERISA and the Code and regulations promulgated thereunder; (3) this plan’s assets equal or exceed the value of its plan benefits as

of the proposed distribution date; and (4) the information contained in this schedule 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.

Plan Administrator’s signature

Date

Printed name and title of Plan Administrator

PBGC Schedule REP-S

Standard Termination

pproved OMB 1212-0036

Expires 3/31/2023

Designation of Representative

PART I. IDENTIFYING INFORMATION

1a Plan Name

1b 9-digit employer identification number

(EIN)

1c 3-digit plan number (PN)

2a Plan Administrator’s name and address

(Address should include room or suite no.)

2b Plan Administrator’s telephone number

2c E-mail address (optional)

PART II. DESIGNATION OF REPRESENTATIVE(S)

I, , Plan Administrator of the above-named pension plan, hereby appoint the following

representative(s) to act on my behalf before the Pension Benefit Guaranty Corporation on all matters (other than those specifically excluded

below) relating to the termination of the above-named pension plan:

4a Representative’s name and address

(Address should include room or s

uite no.)

Telephone number

E-mail address (optional)

4d Representative’s name and address

(Address should include room or suite no.)

Telephone number

E-mail address (optional)

Matters excluded from authority of representative(s). List any specific acts with respect to the plan termination that you are excluding from

the acts otherwise authorized in this designation:

PART III. RETENTION / REVOCATION OF PRIOR DESIGNATION

(

)

Have you filed any prior designation(s) of representative(s) for this termination?

Yes No

6b If “Yes,” do you want any such prior designation(s) of representative(s) to remain in effect?

(Attach a copy of all prior designations that are to remain in effect.)

Yes No

PART IV. SIGNATURE OF PLAN ADMINISTRATOR

NOTE: The PBGC will NOT accept unsigned designations.

If the Plan Administrator is a board (or similar group) composed of employer

and employee representatives, at least one employer representative and one employee representative must sign this form. If the plan does not

designate a plan administrator or it designates the plan sponsor or the contributing sponsor as the plan administrator, this form must be signed by

an officer of the plan sponsor or contributing sponsor who has the authority to sign on behalf of that entity.

In executing this document, I certify that the foregoing is true and correct, and 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

Date

Printed name and title

PBGC Form 501

Post-Distribution Certification

Approved OMB 1212-0036

Expires 3/31/2023

for Standard Termination

PART I.

IDENTIFYING INFORMATION

Check here if you previously filed a Form 501 for this plan. If checked, provide dates of filing(s):

1a Plan Name 1b 9-digit employer identification number (EIN)

Attach copy of the most recent complete plan document and any amendments to it.

1c 3-digit plan number (PN)

2 PBGC case number

8-digit Case #

PART II. DISTRIBUTION INFORMATION

3a Last distribution date in satisfaction of plan benefits

(MM/DD/YYYY)

3b Date of receipt of IRS determination letter

(MM/DD/YYYY)

4 Were participants and beneficiaries provided with the name and address of the insurer(s)

later than 45 days before the date of distribution?

Yes No

N/A

5 Were you able to locate all participants and beneficiaries? If “No,” see instructions.

Yes No

6a Has a copy of the annuity contract, certificate, or written notice been provided to each

participant and b

eneficiary receiving benefits in the form of an irrevocable commitment?

Yes No N/A

6b If “Yes” to 6a, enter the latest date the annuity contract, certificate, or written notice

as provided to each participant and beneficiary receiving benefits:

If “No” or “N/A”, see instructions

(MM/DD/YYYY)

7a Complete name of record of insurer(s) from whom annuity contracts, if any, have been

purchased

7b Annuity Contract Number(s)

Name and address of contact for location of plan records

8b Telephone number

Summary of distribution of plan benefits. Attach distribution documents (see instructions).

Type of Benefit

(1) # of Participants or Beneficiaries

(2) Total Cost/Value

a Annuities purchased

(1) For Non-Missing Participants

(2) For Missing Participants

(3) Total

b Lump sums (including direct transfers)

(1) Consensual

(2) Nonconsensual (i.e., mandatory cash-outs)

(3) Total

c Benefits transferred to PBGC for Missing Participants

(1) Benefits transferred

(2) Other amounts due PBGC (see instructions)

d No Distribution

e TOTAL (see instructions)

PART III.

PLAN ADMINISTRATOR CERTIFICATION

I, the Plan Administrator, certify that to the best of my knowledge and belief that (1) benefits payable with respect to participants have been

calculated and valued correctly in accordance with applicable provisions of ERISA and the regulations thereunder; (2) all plan benefits (through

priority category 6 under ERISA Section 4044 and 29 CFR Part 4044) under the plan have been satisfied; (3) plan assets in excess of those

needed to satisfy all plan benefits (through priority category 6 under ERISA Section 4044 and 29 CFR Part 4044) have been or will be distributed

in accordance with applicable provisions of ERISA and the regulations thereunder; and (4) the information contained in this filing is true, correct,

and complete. I further certify that I am aware that records supporting the calculation and valuation of benefits and assets must be kept at least six

years after the date this post-distribution certification is filed. In executing this document, I certify that the foregoing is true and correct, and

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 company name and address (Address should include room or s

uite no.)

Telephone numbe

E-

mail address (optional)

Plan Administrator’s signature

Date

Printed name and title of Plan Administrator

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PBGC Form 500 Single-Employer Plan Termination Standard Termination (Pension Benefit Guaranty Corporation)

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