500-501 Standard termination forms

Standard Termination Notice
Single-Employer Plan Termination

PBGC Form 500
Approved OMB 1212-0036
Expires 12/31/2013

PART I.
IDENTIFYING INFORMATION
1a
2a

Contributing Sponsor’s name and address
(Address should include room or suite no.)

2e If you used a different EIN or PN for this contributing sponsor/plan in previous filings with
the PBGC, also show the number(s) previously reported.

3a

3d

Plan Administrator’s name and address (if same as 2a, enter “same”)
(Address should include room or suite no.)

Name and address of person to be contacted for more information (if same as 3a, enter
“same”) (Address should include room or suite no.)

PART II. GENERAL PLAN INFORMATION
4a Have you filed, or will you file, with the Internal Revenue Service for a

Yes

determination letter on the termination of this plan?

5a

No

Is this a multiple-employer plan?

Yes
No

6
a

b

Last day of plan year

2b

Sponsor’s telephone number

2c

9-digit employer identification number (EIN)

2d

3-digit plan number (PN)

2f

6-digit business code

3b

Plan Administrator’s telephone number

3c

E-mail address (optional)

3e

Telephone number

3f

E-mail address (optional)

4b

If “Yes” to 4a, enter the filing date:

(MM/DD/YYYY)

5b

If “Yes” to 5a, attach a list of the names
and employer identification numbers of all
contributing sponsors

Reason for plan termination. If more than one reason for the termination (considering (1) - (12) and c.), see instructions.
Plan related
(1) Plan administration too costly or complicated
(2) Plan benefits too costly
(3) Restructuring of retirement program (e.g. adoption of new plan, decision that defined benefit plan no longer meets
employer objectives)
(4) Retirement/illness/death of owner(s)
Business related
(5) Adverse business conditions
(6) Sale of company/subsidiary/division (not involving bankruptcy or similar proceeding)
(7) Company/subsidiary/division closed (not involving bankruptcy or similar proceeding)
(8) Merger of company
(9) Contributing sponsor acquired by another business
(10) Another business acquired by contributing sponsor
(11) Contributing sponsor reorganized (in bankruptcy or similar proceeding)
(12) Contributing sponsor liquidated (in bankruptcy or similar proceeding)

c

1b

Other (specify)

7 Changes in contributing sponsor associated with plan termination (check all that apply).
a No change
b Sale of company/subsidiary/division (not involving bankruptcy or similar proceeding)
c Company/subsidiary/division closed (not involving bankruptcy or similar proceeding)
d Merger of company
e Contributing sponsor acquired by another business
f Another business acquired by contributing sponsor
g Contributing sponsor reorganized (in bankruptcy or similar proceeding)
h Contributing sponsor liquidated (in bankruptcy or similar proceeding)

6a (1)
6a (2)
6a (3)
6a (4)
6b (5)
6b (6)
6b (7)
6b (8)
6b (9)
6b (10)
6b (11)
6b (12)
6c
7a
7b
7c
7d
7e
7f
7g
7h

Standard Termination Notice • Single-Employer Plan Termination
8

PBGC Form 500 • Page 2

Number of plan participants and beneficiaries as of proposed termination date:

a
b
c
d
9

Active participants

8a
8b
8c

Retirees or beneficiaries receiving benefits
Separated vested participants entitled to benefits
Total
Estimated percent of currently employed participants that are covered under the terminated plan that you expect to be
covered under:
No plan

a
b New or existing traditional defined benefit plan
c New or existing hybrid defined benefit plan, other than cash balance plan
d New or existing cash balance plan
e New or existing profit sharing plan
f New or existing 401(k) plan
g New or existing simplified employee plan
h Other new or existing defined contribution plan (specify)
10 If the percent entered for item 9b, 9c or 9d is greater than zero, will the types of benefits under the new or existing

8d
%
%
%
%
%
%
%
%

9a
9b
9c
9d
9e
9f
9g
9h
Yes

defined benefit plan be substantially the same as under the terminating plan for all affected participants (currently employed participants that you expect will be covered under the new or existing defined benefit plan.)

No

(MM/DD/YYYY)

11a

Proposed termination date

11b
12a

Earliest date notices of intent to terminate issued to affected parties

12b

Latest date notices of intent to terminate issued to affected parties

(MM/DD/YYYY)

13

Latest date notices of plan benefits issued to participants or beneficiaries

(MM/DD/YYYY)

14a

Has a formal challenge to the termination been initiated under an existing collective bargaining agreement?

Proposed termination date stated in notice of intent to terminate (if different from 11a)

(MM/DD/YYYY)
(MM/DD/YYYY)

14b

If “Yes” to 14a, attach a copy of the formal challenge and a statement describing the
challenge.

15

Have all PBGC premiums been paid to date?

Yes

No
N/A

Yes

PART III. RESIDUAL PLAN ASSETS
16a Will residual assets be returned to the employer as a result of this termination?

Yes

No
No
N/A

16b If “No” or “N/A” to 16a, do not complete the rest of Part III; go to Part IV.
If “Yes,” enter the estimated amount:

$

17a

Is there a plan provision permitting a reversion of residual assets to the employer?

Yes, go to 17b

No, go to 18a

17b

If “Yes” to 17a, was the provision adopted prior to 12/18/1988?

Yes, go to 18a

No, go to 17c

17c

If “No” to 17b, enter:
(1) Adoption date:

(MM/DD/YYYY)

(2) Effective date of plan:

(MM/DD/YYYY)

18a
18b

Has the plan been involved in a spin-off/termination transaction?

Yes, go to 18b

No, go to Part IV

If “Yes,” to 18a, have the requirements of the Guidelines been satisfied?

Yes, go to 18c

No, go to 18d
N/A, go to 18d

18c If “Yes” to 18b, enter the dates for (1) and (2) and go to Part IV:

(1) latest date a description of the transactions(s) was issued to participants in the ongoing
plan.

(2) latest date notices of plan benefits were issued to participants in the ongoing plan.

18d

(MM/DD/YYYY)
(MM/DD/YYYY)

If you checked “No” or “N/A” in 18b, attach a statement that describes the transaction(s) and explains why the Guidelines were not, or need
not have been, followed.

PART IV.

PLAN ADMINISTRATOR CERTIFICATION

I, the Plan Administrator, certify that, to the best of my knowledge and belief: (1) I am implementing the termination of the plan in accordance with all
applicable laws and regulations; and (2) the information contained in this filing and made available to the Enrolled Actuary is true, correct, and complete. In making this certification, I recognize that knowingly and willfully making false, fictitious, or fraudulent statements to the PBGC is
punishable under 18 U.S.C. §1001.

Plan Administrator’s signature

Date

Printed name and title of Plan Administrator

PBGC Schedule EA-S

Standard Termination
Certification of Sufficiency

(PBGC Form 500)

Approved OMB 1212-0036
Expires 12/31/2013

PART I.
IDENTIFYING INFORMATION
1a Plan Name

1b

9-digit employer identification number (EIN)

1c

3-digit plan number (PN)

PART II. CODE SECTION 412(i) PLANS
2 Is this plan a Code section 412(i) plan?
No: the Enrolled Actuary must complete Parts III and IV. Item 3 and Part V should not be completed.
Yes: item 3 and Part III must be completed. Depending upon who completes Part III, either Part IV or Part V must be completed and
signed by the Plan Administrator or Enrolled Actuary as appropriate.

3a

Enter name (full official name of record) and address of the insurer
(Address should include room or suite no.)

3b

PART III. PLAN SUFFICIENCY
4 Proposed distribution date
5 Is the value of plan assets projected to be sufficient as of the proposed distribution

date to provide all plan benefits? If “No,” the plan cannot terminate in a standard
termination.

6
7
8
9
10
11
12

Estimated fair market value of plan assets as of the proposed distribution date

Telephone Number

(MM/DD/YYYY)
Yes

No

Yes

No

$
$
$
$
$

Estimated present value of plan benefits as of the proposed distribution date
Estimated total amount of residual assets
Estimated amount of residual assets to be distributed to the employer
Estimated amount of residual assets to be distributed to participants and beneficiaries
Has the plan ever required employee contributions?
If the amount in item 9 is $1 million or more and if any benefits are to be distributed
other than through the purchase of annuity contracts, attach a statement showing
interest rate/structure used to value the benefits.

PART IV.

ENROLLED ACTUARY CERTIFICATION

I, the Enrolled Actuary, certify that: (1) I have reviewed all plan documents and plan and participant data, and applied all relevant provisions of ERISA
and the Internal Revenue Code and regulations promulgated thereunder; (2) to the best of my knowledge and belief, this plan’s assets equal or
exceed the value of its plan benefits as of the proposed distribution date; and (3) to the best of my knowledge and belief, the information contained
in this schedule is true, correct, and complete. In making this certification, I recognize that knowingly and willfully making false, fictitious, or
fraudulent statements to the PBGC is punishable under 18 U.S.C. §1001.

Enrolled Actuary’s company’s name and address
(Address should include room or suite no.)

Enrolled Actuary’s Name (Print or type)

Enrollment Number
Telephone Number

Enrolled Actuary’s signature

PART V.

E-mail address (optional)

Date

PLAN ADMINISTRATOR CERTIFICATION FOR CODE SECTION 412(i) PLANS

I, the Plan Administrator, certify that, to the best of my knowledge and belief: (1) this plan complies with section 412(i) of the Internal Revenue Code
and regulations promulgated thereunder; (2) I have reviewed all plan documents and plan and participant data, and applied all relevant provisions of
ERISA and the Code and regulations promulgated thereunder; (3) this plan’s assets equal or exceed the value of its plan benefits as of the proposed
distribution date; and (4) the information contained in this schedule is true, correct and complete. In making this certification, I recognize that
knowingly and willfully making false, fictitious, or fraudulent statements to the PBGC is punishable under 18 U.S.C. §1001.

Plan Administrator’s signature

Date

Printed name and title of Plan Administrator

PBGC Schedule REP-S

Standard Termination
Designation of Representative

(PBGC Form 500)

Approved OMB 1212-0036
Expires 12/31/2013

PART I.
IDENTIFYING INFORMATION
1a Plan Name

2a

Plan Administrator’s name and address
(Address should include room or suite no.)

PART II.
3 I,

1b

9-digit employer identification number (EIN)

1c

3-digit plan number (PN)

2b

Plan Administrator’s telephone number

2c

E-mail address (optional)

DESIGNATION OF REPRESENTATIVE(S)

, Plan Administrator of the above-named pension plan, hereby appoint the following
representative(s) to act on my behalf before the Pension Benefit Guaranty Corporation on all matters (other than those specifically
excluded below) relating to the termination of the above-named pension plan:

4a

4d

5

Representative’s name and address
(Address should include room or suite no.)

Representative’s name and address
(Address should include room or suite no.)

4b

Telephone number

4c

E-mail address (optional)

4e

Telephone number

4f

E-mail address (optional)

Matters excluded from authority of representative(s). List any specific acts with respect to the plan termination that you are excluding from the
acts otherwise authorized in this designation:

PART III.
RETENTION / REVOCATION OF PRIOR DESIGNATION(S)
6a Have you filed any prior designation(s) of representative(s) for this termination?

Yes

No

6b

Yes

No

If “Yes,” do you want any such prior designation(s) of representative(s) to remain in
effect? (Attach a copy of all prior designations that are to remain in effect.)

PART IV.

SIGNATURE OF PLAN ADMINISTRATOR

NOTE: The PBGC will NOT accept unsigned designations. If the Plan Administrator is a board (or similar group) composed of employer and
employee representatives, at least one employer representative and one employee representative must sign this form. If the plan does not designate
a plan administrator or it designates the plan sponsor or the contributing sponsor as the plan administrator, this form must be signed by an officer of
the plan sponsor or contributing sponsor who has the authority to sign on behalf of that entity.
In executing this document, I certify that the foregoing is true and correct, and recognize that knowingly and willfully making false, fictitious,
or fraudulent statements to the PBGC is punishable under 18 U.S.C. §1001.

Signature

Date

Printed name and title

Signature

Date

Printed name and title

Post-Distribution Certification
for Standard Termination
PART I.

PBGC Form 501
Approved OMB 1212-0036
Expires 12/31/2013

IDENTIFYING INFORMATION

Check here if you previously filed a Form 501 for this plan.

1a

2

Plan Name

PBGC case number

1b

9-digit employer identification number (EIN)

1c

3-digit plan number (PN)

8-digit Case #

PART II.
DISTRIBUTION INFORMATION
3a Last distribution date in satisfaction of plan benefits
3b Date of receipt of IRS determination letter
4 Were participants and beneficiaries provided with the name and address of

(MM/DD/YYYY)

(MM/DD/YYYY)

the insurer(s) no later than 45 days before the date of distribution? (See page 22 of
instructions.)

5
6a

Were you able to locate all participants and beneficiaries? If “No,” see instructions.
Has a copy of the annuity contract, certificate, or written notice been provided to
each participant and beneficiary receiving benefits in the form of an irrevocable
commitment?

Yes

No

Yes

No

Yes

No

6b If “Yes” to 6a, enter the latest date the annuity contract, certificate, or written notice was
provided to each participant and beneficiary receiving benefits:
If “No” or “N/A”, see instructions

(MM/DD/YYYY)

7a

Complete name of record of insurer(s) from whom annuity contracts, if any, have
been purchased (Address should include room or suite no.)

7b

Annuity Contract Number(s)

8a

Name and address of contact for location of plan records
(Address should include room or suite no.)

8b

Telephone number

9

Summary of distribution of plan benefits

Type of Benefit

a
b

c

(1) # of Participants or Beneficiaries

N/A

(2) Total Value

Annuities

$

Lump sums (including direct transfers
and distributions to participants and
beneficiaries)
(1) Consensual

$
$

(2) Nonconsensual
Designated benefits paid to PBGC for
Missing Participants

$

d No Distribution
e TOTAL (see instructions)
PART III.
PLAN ADMINISTRATOR CERTIFICATION

$

I, the Plan Administrator, certify that to the best of my knowledge and belief that (1) benefits payable with respect to participants have been calculated
and valued correctly in accordance with applicable provisions of ERISA and the regulations thereunder; (2) all plan benefits (through priority category
6 under ERISA Section 4044 and 29 CFR Part 4044) under the plan have been satisfied; (3) plan assets in excess of those needed to satisfy all
plan benefits (through priority category 6 under ERISA Section 4044 and 29 CFR Part 4044) have been or will be distributed in accordance with applicable provisions of ERISA and the regulations thereunder; and (4) the information contained in this filing is true, correct, and complete. I further
certify that I am aware that records supporting the calculation and valuation of benefits and assets must be kept at least six years after the date this
post-distribution certification is filed.
In executing this document, I certify that the foregoing is true and correct, and recognize that knowingly and willfully making false, fictitious,
or fraudulent statements to the PBGC is punishable under 18 U.S.C. §1001.
Telephone number

Plan Administrator’s company name and address (Address should include room or suite no.)

Plan Administrator’s signature

Date

E-mail address (optional)

Printed name and title of Plan Administrator