Form 10 Post-Event Notice of Reportable Events

POST-EVENT NOTICE
OF REPORTABLE EVENTS

PBGC Form 10
Approved OMB #1212-0013
Expires 02/28/09

This form may be used by a plan administrator or contributing sponsor of a single-employer plan when notifying the
Pension Benefit Guaranty Corporation that a reportable event has occurred.
IDENTIFYING INFORMATION

Name of filer

Plan name

Street address of filer

Name / title of individual to contact

City, State, Zip

Street address of contact

EIN of contributing sponsor

Plan number

City, State, Zip

Plan administrator
Filer is:

Contributing sponsor

REPORTABLE EVENTS

Telephone number of contact

See instructions for descriptions of these events. Check all boxes that apply.
Change in contributing sponsor or controlled group

Active participant reduction
Liquidation
Failure to make required contributions
Extraordinary dividend or stock redemption
Inability to pay benefits when due
Application for minimum funding waiver
Distribution to a substantial owner
Loan default
Transfer of benefit liabilities
Bankruptcy or similar settlement
BRIEF DESCRIPTION

Briefly describe the pertinent facts relating to the event.

The reverse side lists additional information that must be submitted with this form, if not
included above.

PBGC Form 10
ADDITIONAL INFORMATION TO BE FILED
Change in Contributing Sponsor or Controlled Group
Active Participant Reduction
Statement explaining the cause of the reduction (e.g.,
facility shutdown or sale)

Description of the plan's old and new controlled group
structures, including the name of each controlled group
member

Number of active participants at the date the event occurs,
at the beginning of the current plan year, and at the
beginning of the prior plan year

Name of each plan maintained by any member of the plan's
old and new controlled groups, its contributing sponsor(s)
and EIN/PN

Failure to Make Required Contributions
Due date and amount of both the missed contribution and
the next payment due
Most recent actuarial valuation report
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

Inability to Pay Benefits When Due

Liquidation
Description of the plan's controlled group structure before
and after the liquidation, 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

Extraordinary Dividend or Stock Redemption
Name and EIN of person making the distribution
Date and amount of cash distribution(s) during fiscal year

Date of any missed benefit payment and amount of benefits
due

Description, fair market value, and date or dates of any
non-cash distributions

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

Statement whether the recipient was a member of the
plan's controlled group

Amount of the plan's liquid assets at the end of the quarter,
and the amount of its disbursements for the quarter

Application for Minimum Funding Waiver
Copy of waiver application, with all attachments

Most recent actuarial valuation report
Name, address and phone number of plan trustee (and of
any custodian)

Distribution to a Substantial Owner
Name, address and phone number of person receiving the
distribution(s)

Loan Default
Copy of the relevant loan documents (e.g., promissory
note, security agreement)
Due date and amount of any missed payment
Copy of any written notice of default or any notice of
acceleration from lender

Amount, form and date of each distribution

Bankruptcy or Similar Settlement
Most recent actuarial valuation report
Copy of bankruptcy petition or similar document

Transfer of Benefit Liabilities
Name, contributing sponsor and EIN/PN of transferee
plan(s)
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
Note: To the extent this information is filed with the IRS Form
5310A, PBGC will accept a copy of that filing.

Docket sheet or other list of documents filed
Last date for filing claims, if known
Name, address and phone number of any trustee, receiver or
similar person
Most recent actuarial valuation report for each plan in the
controlled group
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