Form 10-Advance Advance Notice of Reportable Event

ADVANCE NOTICE
OF REPORTABLE EVENTS

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

This form may be used by a contributing sponsor of a single-employer plan required to notify the Pension Benefit
Guaranty Corporation in advance that a reportable event will occur.
IDENTIFYING INFORMATION

Name of plan

Name of contributing sponsor

Name / title of individual to contact

Street address of contributing sponsor

Street address of contact

City, State, Zip

City, State, Zip

EIN of contributing sponsor

REPORTABLE EVENTS

Plan number

Telephone number of contact

See instructions for descriptions of these events. Check all boxes that apply.

Change in contributing sponsor or controlled group

Application for minimum funding waiver

Liquidation

Loan default

Extraordinary dividend or stock redemption

Bankruptcy or similar settlement

Transfer of benefit liabilities

BRIEF DESCRIPTION

Briefly describe the pertinent facts relating to the event.

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

PBGC Form 10-Advance
ADDITIONAL INFORMATION TO BE FILED

Change in Contributing Sponsor or Controlled Group

Transfer of Benefit Liabilities

Expected effective date of event

Name, contributing sponsor and EIN/PN of transferor plan
and transferee plan(s)

Description of the plan's old and new 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

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

Estimate of the assets, liabilities, and number of participants
whose benefits are transferred

Most recent audited (or, if unavailable, unaudited) financial
statements and interim financial statements of the plan's
contributing sponsor (both old and new in the case of a
change in the contributing sponsor) and any persons that
will cease to be in the plan's controlled group

Note: To the extent this information is filed with the IRS Form
5310A, PBGC will accept a copy of that filing.

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

Liquidation
Expected effective date of event
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
Most recent actuarial valuation report for each plan in
the controlled group

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 from lender
Copy of any written notice of acceleration from lender

Bankruptcy or Similar Settlement
Extraordinary Dividend or Stock Redemption
Name and EIN of person making the distribution
Date and amount of cash distribution(s) during fiscal year
Description, fair market value, and date or dates of any
non-cash distributions
Statement as to whether the recipient was a member of
the plan's controlled group

Copy of all papers filed in the relevant proceeding,
including, but not limited to, petitions and supporting
schedules
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