Request for Coverage Determination
Part II. All Plans, Required Information (continued)
4 The plan is
already established or
proposed but not yet established.
A plan that is proposed but not yet established may use this form to request an opinion from PBGC under a
pilot program (see instructions).
5 Check the box to confirm that the required item is attached.
□ The plan document
□ Correspondence with the Internal Revenue Service that is relevant to the plan’s status as a qualified
plan under Internal Revenue Code (Code) section 401(a)
Part III. Substantial Owners Plans, Required Information
1 Does the plan cover an individual who is not a substantial owner?
□ Yes □ No (If yes, the plan is likely not eligible for this exemption.)
2 What is the organizational structure of the plan sponsor?
□ Corporation □ Limited liability company (see question below) □ Partnership □ Sole proprietorship
□ Other (explain in explain in Part VIII, Narrative Information)
3 If the plan sponsor is a limited liability company, how is it treated for federal tax purposes?
□ Corporation □ Partnership □ Disregarded entity (part of its owner’s tax return)
4 Check the box to confirm that the required item is attached.
□ List of the names of all the participants (active, retired, and term vested) in the plan
□ Documents showing the percentage of ownership interest that each participant currently holds or
has held in the plan sponsor during the 60 months before the completion of this form
□ Documents reflecting any stock options for the plan sponsor (if the plan sponsor is a corporation)
□ The partnership agreement or other document (e.g. partnership meeting minutes, state
government filing) naming the partners (if the plan sponsor is a partnership)
□ Documents indicating whether the owner’s spouse is an employee, director, or manager (if (1) the
plan sponsor is a corporation or is taxed as a corporation and (2) the plan covers only the owner and
the owner’s spouse)
□ A description of any family relationships between the owner(s) of the plan sponsor and other
participants of the plan and the names and the dates of birth of the owners’ children (if such family
□ Documents (e.g. a spreadsheet) showing dates and amounts paid to participants (providing their
names) within the past six years
□ Date of termination or planned date of termination (if the plan has or will be terminated)
Check the box to confirm reading Part III of the instructions listing additional required items that
PBGC may request.