Check box to indicate the item is attached. If not attached, explain on next page.
INFORMATION REQUIRED TO BE FILED
Active Participant Reduction
Single cause event - statement explaining the cause of the
reduction (e.g., facility shutdown or sale, discontinued
operations, winding down of the company, or reduction in
force).
Attrition event - statement of factors involved in the attrition
(e.g., frozen plan, aging workforce, improved operational
efficiencies that do not require replacing departing active
participants, or single causes that do not meet the reporting
threshold of a single-cause event)
Number of active participants at the date the event occurs and
at the beginning of the plan year in which the event occurred.
Description of the plan's controlled group structure, including
the name of each controlled group member
Actuarial Information (see instructions)
Company financial information (see instructions)
Failure to Make Required Contributions
Due date and amount of the missed contribution
Due date and amount of the next payment due
Due date and amount of all contributions not timely made and not
reported on the last Schedule SB filed
Date and amount of any contribution(s) made related to the missed
contribution(s)
Reason contribution was not made by due date
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)
Inability to Pay Benefits When Due
Date of any missed benefit payment and amount of benefits due
Next date on which the plan is expected
to be unable to pay
benefits, the amount of the projected shortfall, and the number of
plan participants expected to be affected
Amount of the plan’s liquid assets at the end of the quarter, and
the amount of its disbursements for the quarter
Name, address and phone number of plan trustee (and of any
custodian)
Most recent pension plan document(s)
The Internal Revenue Service Determination Letter indicating the
plan is a covered plan, if applicable
Description of the plan’s controlled group structure, including the
name of each controlled group member
Actuarial Information (see instructions)
Company financial information (see instructions)
Distribution to a Substantial Owner
Name, address and phone number of person receiving the
distribution(s)
Amount, form and date of each distribution
Reason for distribution
Description of the plan’s controlled group structure, including
the name of each controlled group member
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 (liabilities and participants should
be broken down by status - active, term vested, and retirees)
Financial Information for the transferor and transferee's
controlled group (see instructions)
Actuarial Information (see instructions)
Ch ange 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
Financial Information for the old and new controlled group (see
instructions)
Actuarial Information (see instructions)
