Form 10-Advance Advance Notice of Reportable Event

I:\regulatory\RM\Paperwork\1212-0013 Part 4043\FORM 10-ADVANCE_Proposed Rule_to OMB 11_09.doc

ADVANCE NOTICE OF REPORTABLE EVENTS
PBGC Form 10-Advance
Approved OMB #1212-0013
Expires xx/xx/xx
This form must 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 contributing sponsor
Street address of contributing sponsor
City, State, Zip
Telephone number of contributing sponsor
EIN of contributing sponsor __________ PN of plan ___
Plan name
Name / title of individual to contact
Street address of contact
City, State, Zip
Telephone number of contact
REPORTABLE EVENTS - See instructions for descriptions of these events. Check all boxes
that apply.
Change in contributing sponsor or controlled group (29 CFR §4043.62)
Liquidation (29 CFR §4043.63)
Extraordinary dividend or stock redemption (29 CFR §4043.64)
Transfer of benefit liabilities (29 CFR §4043.65)
Application for minimum funding waiver (29 CFR §4043.66)
Loan default (29 CFR §4043.67)
Bankruptcy or similar settlement (29 CFR §4043.68)
Adjusted funding target attainment percentage under 60% (29 CFR §4043.69)

BRIEF DESCRIPTION - Briefly describe the pertinent facts relating to the event.

The following pages list additional information that must be submitted with this form, if not
included above.

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ADDITIONAL INFORMATION TO BE FILED
Information Required For All Reportable Events:
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A copy of the plan document in effect - the last restatement of the plan and all
amendments thereto
A copy of the most recent actuarial valuation report that includes, or is supplemented
by, all items described in 29 CFR §4010.8(a)(11)); see list of items required in General
Information of Part III of the Form-10 Advance instructions
A copy of the most recent Adjusted Funding Target Attainment Percentage (AFTAP)
certification
A statement of any material change in the assets or liabilities of the plan occurring after
the date of the most recent actuarial valuation and certification
The most recent month-end market-value statement of plan assets

Additional Information Required for Each Event:
Change in Contributing Sponsor or Controlled Group
• Expected effective date of event
• Description of the plan’s old and new controlled group structures, including the name and
address of each controlled group member
• Name of each plan maintained by any member of the plan’s old and new controlled groups,
its contributing sponsor(s) and EIN/PN
• For a change in the controlled group sponsoring the pension plan, financial statements of (i)
the plan’s controlled group before the change, and (ii) the plan’s controlled group after the
change, unless publicly available
If a filer is unable with reasonable diligence to obtain any of the following information about
a controlled group other than the filer’s controlled group—(1) a description of the controlled
group structure, (2) information about plans maintained, or (3) a financial statement of a
controlled group—the filer may instead file a statement to that effect.
Liquidation
• Expected effective date of event
• Description of the plan’s controlled group structure before and after the liquidation, including
the name and address 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
• Description, fair market value, and date(s) of any non-cash distribution(s)
• Statement whether the recipient was a member of the plan’s controlled group
• Financial statements for all controlled group members unless publicly available

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Transfer of Benefit Liabilities
• Name, contributing sponsor and EIN/PN of transferor plan and each transferee plan
• 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
• Financial statements of (i) the transferor’s controlled group and (ii) the transferee’s
controlled group
If a filer is unable with reasonable diligence to obtain any of the following information about
a controlled group other than the filer’s controlled group—(1) a description of the controlled
group structure, (2) information about plans maintained, or (3) a financial statement of a
controlled group—the filer may instead file a statement to that effect.
Application for Minimum Funding Waiver
• Copy of waiver application, with all attachments
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
• Financial statements for all controlled group members unless publicly available
Bankruptcy or Similar Settlement
• Name, address and phone number of any trustee, receiver or similar person
• Description of the plan’s controlled group structure, including the name and address 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
• Docket number of bankruptcy filing and bankruptcy Court district where the bankruptcy was
filed
Adjusted Funding Target Attainment Percentage (AFTAP) Under 60%
• If an enrolled actuary has certified that the AFTAP is less than 60%, a copy of the enrolled
actuary’s certification
• If the AFTAP is presumed to be less than 60%, a description of the basis for the presumption,
which may be included in the “Brief Description” section, above

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