Form 1-EZ Form 1-EZ Annual Premium Payment for Single-Employer Plans Exempt

1

~nnuali~rsrnium
Payment for

PBGC Form 1-EZ

~in~l&rn~lo~er
P I m ~ e m h ~ i
f mrn the ~ a r i a t 4 1 Premium
6

Pension Benefit
Guaranty Corposwfion

20w7
Check b r r!aaneiaddresschange

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Check if

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Check if sane as pWn spmior &?dgo to i W n 9

rflfEr ins?ructionsnex-t yyear

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1 2. Plan AdmenisPraPor

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(?onot &*ar!t

P h o t ~ w p i e and
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[ {see insppuctions).
CheB br.rlan?ei3ddresschange

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I '1. Plan Sponsor
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iraiiuclioriq

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Name

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i Adbress :.he t

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Add:ass I-ins 3

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Stria
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3.

Employw Ickntiflcatlon NurnlsadPlan Number [EIWPN),
Elwtronlc FIlIng
ia, Enter 9-dili:. EM

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......

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State

Zip

(01 Entsr 3-digit PW

.........*

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................. ,
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# E1N and PN in item 3 (a) snel {b) above are MOT BDTH the same as on the most recent premium lilir?g,enter b t t s prior EIN and
4.

prior PN.
(a) Prior 9-dig:; EIN

jr.) Effmti.de Date ot Chanr,e

( 5 ) Prior 3-digit PN

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....................................................

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Plan Coverage Status (&er;k one) (a)

6.

Is this Ph* first y*FIrrS premium flllng ffrr this plan'?

Ccvai-ed

{a) Pisrr e f f d v e dale

ns

YYYY
..........

2
3
1
....................................................................

1.......................i

................................................................................................................

5.

?u3

(b)

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Urlcerlaitt ;If ur~csrtain,yoa shor~ldfile. Set?Inslritctions, pags 20.)

iT Yes

($0

if yes, enter tl?efoiloiving dates

tc) Plan coverage date

(b) Plan zdopticn date

YYYY

FA M
9 i?
YYVY
,.......................................................................
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:________
..._.._.._
..._.._...
_..
_
.._
..._.._...........................!.

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Transfern from disappearing plans:
Has a piarr other tharr p u n ceased ii' exis?in cogtrrectiai~
vuitl?any t~.ansiel-sf assets or iiabilities from that plan to this
?do
pian since the most mmnt premium fiiing7 (See instructions, page 2 i
IT yes, gke EiWPN of eadl disppearirlg ?railsferc;r plvn and elkr;ti\ie data r,f transfer, and indlrzjte whether it was a
trcsrger :PA). cot?soiidstion(C), or spinoff (3).
. .
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NI R9
D C3
YYYY
!mfi~fe?
Typ
Transferor's S-dicit EIN
3-bigit
............................................................
............PN
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8.

Business Csds and CUSP number

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p1an:
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9, ...Nante

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10.

Name and Phone Number ol Plan Contact
,................................................................................................
(a) Nanse:

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MM

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(a: This remiurri is fcr

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Check here if the plar! year be~inningdats
has changed since last filins with PBGC

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-- Y...Y....Y...Y........
......................----

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.................0
....0
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YL'YY

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r:orlti??ue
on pags 2

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~ W ~ ~ Form
B G 1-EZ
C

S-digit hi

993606

itam 3 (8) and

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82. :fa~.:~slc+RatePreriiiirrn Exerrtptinr~Cetrsyur).: Ctre(:k a single box.
(a)

:ANr;

Vested P.srticif?znts.

472 (i) Plan.

(bj

(c)

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Page 2

3.-digit PN

E,N,PN frem

Fu;!y fi~ndeaolan wittl lewsr than 5UO Participarlts.

,......NIM
....................0
....0
..............Y....Y....Y...Y
............
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Standard krminatron with z ~ ) r ~ p ~ :te~minatron
isd
date (an or before the snapshot date) af:\....................................................................

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(s) [...... Plarl at Full Fuilding Liinit.
13. 51te: P4RTlClg!4NT COUMT for ths plan p a r sper;lfied i r l itern ?I.
(Se??instrt~c?:ons,page 24.)
.@3%
14. PREMILIM: FJl!~ltiplytho participant count in ilt'rn 13 by m.. . . . . . . . . . . . . . . . . . . . . .
15. Premium credits (See ii~t;lructior~i;,paga 24.)
ia) Amtaunt gsid wit11 2008estir:>ateciiilirig

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( b j I-%he: credit jinclgidinc; any credit c!aimed in the 2 ~ g e s t i m a t e dfiling and any
short-yea: crodit). (Sac instruetior!$, oagr 24.). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(c) Total credit: Add items ?$(a: and .15jh). Enter amor~nt

16. Ari>cuntdue.

17'.

t i the atnourlt it) iter;~14 is LARGER lhari the a:nouri:. ii>ilerri 15ic).
slihtract item 15:~)from Item i S and enter the zmount due tn item 35. . . . . . . . . . . . . . . . . . 16
Ses paDe 25 of irlstrucliorls lor payntsrlt rr~ettiods.ir~dicatshr.>w yr.ru ace paying ii>earlwur~tdue:
,----7
by electronic pajwent
1- 1-jy check enciused wi;h this form. orOverpavment. It tho amount in item '14 is SMAI.1.ER thar? the amount in item '15jc).
s ~ ; b t , ~itcw?
~ . t 14 1rc;r:l iterr! 35ic) and enter the rxw:payrriei>tirr ile!n 17 . . . . . . . . . . . . . . . . . . . . . . 17
An amount st overpzyment may $he refunded or ~:edit& ~gains:the ~!an'snext prfirnitim tiling.
,-----.,
if
want to take a cr-edit, check here: . . . . .......
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i i ycu wart! a refund, snech her??:.. . . .

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or savings amot:i-rt
.iab-accn\:ot

For a :ef!ind by electronic t,inds transfnr, indicate whether transfer is tr, a checkjog account
.......................................,
....................................................
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i ai?daccoul~tnumhsr
mler the tmnk
rm~tingnrlmber i ...................................... j for the relurld
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? 8. Partieipac~tNotice Raquirec!tenl
For the 20?:&pIzn yaal: 3 Participant Notice t!nde: Fr'RiSA section 401 1 and 2 C CFR Par: 401!:

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--I bVas not- ~.equiredto bs issued: or
0'

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byas isi;ned oil tirr~eand in ar?cnrdancewith ail other
RpplicaMe requirements; or

~htwc?lg,+;

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Ar. explznstion is attacherf.

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Put ElNlPN (its;:> Sja) anrj jb)) ar~ddate prsrl>ii:m
payrnerll year contrrierlced (PYC) or) each sheet.

19, if you have attadimertts, check here: . .

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20. Crrtitkaiion of Plan Admioistr~tor.I cer!h,!;ncier pei?aiy oi perjunl#&?o.ti*.

best of my ke2+4
in nrcor.&,,g
wirh PBQC's
p*"ixrn t?p.,iq!;~~l
hl Nl
90
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t o<,:,j ; w ~ i c t ; + c r . 8
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Signature af Sirigig-Einpioyer Plsrl Administrator
i3ate
......................., a.........................................

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Prir~tor type first name 131 individual vrho signs

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F':ir~t or type fast name of individtiai wt~osigns

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3usines:; E-mail
Address iC3Dtin:ial)

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21. Ce!?illcatiorl of Enroiled Aciuary. An Enrruiled Actuary ............aigrt
..._ .and
...- cumplete
, . _ !he certification belay-..---.........-...
if hox 5 $+ -y,~:,ii
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?wi k 1, fir .,+t5 a k,!
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C,(T..~SV!

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En:c?llrr~antNurme:

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Date

Sig~?z?rire
of Enroiiwd tZctuary

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Print or type !irst name of individi~alwho signs Prirl; or type last :lanke uf individual who signs
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Street Addrnss

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Telephone Ni~rnbercr E-n?ali';Optior.a:) i
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Stat5*. ..--..Zip
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