2009 Form 1-ES Estimated Flat-rate Premium Payment

Estimated Flat-rate Premium Payment

PBGC Form 1-ES
Pension Benefit
Guaranty Corporation

2009

(Plans with 500 or more Participants in prior filing year)
For Plan Years Beginning in Calendar Year 2009
Check for Amended Filing

1. Plan Sponsor

Check for Disaster Relief

Check for name/address change

2. Plan Administrator

Approved OMB 1212-0009

476320

PB0963

Only use this form to submit premium data
if an exemption from mandatory electronic
filing was granted for this premium filing.

Check for name/address change
Check if same as sponsor and go to Item 3

Name

Name

Address Line 1

Address Line 1

Address Line 2

Address Line 2

City

3.

State

Zip

City

(b) Enter 3-digit PN

If EIN and PN in item 3 (a) and (b) above are NOT BOTH the same as on most recent premium filing, enter BOTH prior EIN and prior PN.
(a) Prior 9-digit EIN

(b) Prior 3-digit PN

(c) Effective Date of Change
MM

5.

Zip

Employer Identification Number/Plan Number (EIN/PN)
(a) Enter 9-digit EIN

4.

State

DD

YYYY

Plan Information
(a) Plan Name
MM

DD

(b) Plan Year Beginning

6.

YYYY

2009

Estimated premium for this plan

MM

DD

YYYY

(c) Plan Year Ending

Estimated Participant Count

(a) Single-Employer

$33.00

X

=

$

(b) Multiemployer

$ 9.00

X

=

$

7.

Credit balance (including overpayment from prior year and estimated short-year credit)

8.

Amount Due
(a) Enter premium payment due (item 6 minus item 7) and submit payment to PBGC.

$

$

(b) Payment method (Check appropriate box to indicate the method for payment to PBGC.)
Electronic Payment

Check enclosed with this form

I certify under penalty of perjury, to the best of my knowledge and belief, that all the information in this filing (other than the
estimated participant count and estimated premium) is true, correct, and complete and has been determined in accordance with
PBGC's premium regulations and instructions.
MM

Signature of Plan Administrator

Print or type first name of individual who signs

DD

YYYY

Date

Print or type last name of individual who signs

I:\regulatory\RM\Paperwork\1212-0009 Part 4007\2009 forms & instrucxs\2009 est filing form to OMB 09.22.08.doc

Telephone Number (include Area Code)

Business E-mail Address (Optional)