Forms 600-602 Distress termination forms

PBGC Form 600

Distress Termination
Notice of Intent to Terminate

PART I.
1a

2a

Approved OMB 1212-0036
Expires 12/31/2013

IDENTIFYING INFORMATION

Plan Name

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

2e If you used a different EIN or PN than that in 2c or 2d 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.
4
5
a

b
c
d

1b

Plan effective date (MM/DD/YYYY)

1c

Last day of plan year

2b

Sponsor’s telephone number

2c

9-digit employer identification number (EIN)

2d

3-digit plan number (PN)

2f

Contributing sponsor’s tax year
end (MM/DD/YYYY)

2g

6-digit business code

3b

Plan Administrator’s telephone number

3c

E-mail address (optional)

3e

Telephone number

3f

E-mail address (optional)

GENERAL PLAN INFORMATION

Proposed termination date

(MM/DD/YYYY)

Estimated number of plan participants as of the proposed termination date
Active participants:
(i)

Fully vested

(ii) Partially vested
(iii) Nonvested
(iv) Total active participants [add a(i) through a(iii)]
Retirees or beneficiaries receiving benefits
Separated vested participants entitled to benefits
Total [add 5a(iv) through 5c]

6 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 (bankruptcy or similar proceeding)

5a (i)
5a (ii)
5a (iii)
5a (iv)
5b
5c
5d
6a
6b
6c
6d
6e
6f
6g
6h

Distress Termination • Notice of Intent to Terminate

PBGC Form 600 • Page 2

7 Intention concerning expected pension coverage for currently employed participants covered under the terminated plan
(check all that apply):

a No new plan
b New or existing defined benefit plan
c New or existing profit-sharing plan
d New or existing 401(k) plan
e Other new or existing plan. Specify:

7a
7b
7c
7d
7e

8a Is there more than one contributing sponsor?
b If “Yes,” is this a multiple-employer plan?
9a Is the contributing sponsor(s) a member of a controlled group?
b If you checked “Yes” in 8a or 9a, attach a statement identifying each contributing spon-

Yes

No

Yes

No

Yes

No

sor and each member of the contributing sponsor’s controlled group as of the proposed
termination date.
c For each entity listed on the attachment for item 9b, attach a statement identifying the
distress test that you expect it will meet, and describe in detail why it meets the distress
test that you have identified. Based on the distress test identified for each entity, attach
the required information for that test. See pages __-__ of the instructions for what information is required and when a response to 9c must be submitted.
Has there been a change in the composition of a contributing sponsor’s controlled group with the 5-year period prior to the proposed termination date?

10

Yes

No

If “Yes,” attach a statement that describes the change(s).

11

12

Are all eligible participant/beneficiaries, who are entitled to and have applied for benefits, receiving such monthly benefits from the plan?
Yes
No
If “No,” attach a statement describing (a) the reason for non-payment, (b) the number of all participants/beneficiaries who are not being paid,
(c) the total monthly amount not being paid to all such participants/beneficiaries, (d) the last date on which benefits were paid, and e) the
date on which benefits were last paid.
Are plan assets expected to be sufficient to continue to pay all benefits when due during the next 180 days?
Yes

No

If “No,” attach a statement describing the amount and nature of the plan assets, including their liquidity, the number of participants/beneficiaries owed benefits over that period, and the total monthly amount that is owed over the period.

Yes
13a Are any participants/beneficiaries receiving benefits in excess of estimated Title IV
b If “Yes” to 13a, are benefits scheduled to be reduced to the estimated Title IV as of the proposed termination date?
Yes

No

No

If “No,” attach a statement describing why no reduction is scheduled.

14 Attach copies of the following documents:
a All plan documents, including all amendments within the last five years;
b Trust documents and/or insurance contracts;
c Most recent financial statement of plan assets;
d Collective bargaining agreements relating to the plan;
e IRS determination letter(s);
f Most recent plan actuarial report;
g Form 5500, Schedules B and SSA (last three years);
h A copy of NOIT sent to affected parties other than PBGC; and
i Information relating to benefit limitations under Code §436.
j All documents required in response to 9c.
15a

15b Telephone number

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

15c Type of Record
PART III.

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 REP-D

Distress Termination
Designation of Representative

(PBGC Form 600)
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)
2a

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

PART II.

2b

Plan Administrator’s telephone number

2c

E-mail address (optional)

DESIGNATION OF REPRESENTATIVE(S)

3

I,
, 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

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

4d

5

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: 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 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

Distress Termination Notice
Single-Employer Plan Termination

PBGC Form 601
Approved OMB 1212-0036
Expires 12/31/2013

PART I.
IDENTIFYING INFORMATION
1a Plan Name

1c

9-digit employer identification number

1b

1d

3-digit plan number (PN)

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

2

PBGC Case Number (8 digit)

PART II.
SPECIFIC PLAN INFORMATION
3a Proposed termination date
3b Proposed termination date stated in notice of intent to terminate (if different from 3a)
4a Earliest date notices of intent to terminate issued to affected parties (other than PBGC)
4b Latest date notices of intent to terminate issued to affected parties (other than PBGC)
5

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

Does each contributing sponsor and each member of a contributing sponsor’s controlled
group meet one of the distress tests described in ERISA § 4041(c)(2)(B)and 29 CFR §
4041.41(c)?

Yes

No

If “Yes,” attach a statement listing the name, address, and employer identification number of each contributing sponsor and each controlled
group member, and identify the distress test met by each. If the distress test for any one of the contributing sponsors or members of their
controlled group differs from that identified in response to item 9c on the Form 600, the information and documents required for the newly
identified distress test must be attached.

6

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

Yes
N/A

No

Yes

No

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

7

For plans that were paying benefits in excess of Title IV benefits, have the benefits of
participants/beneficiaries in pay status been reduced to the estimated Title IV benefits
pursuant to 29 CFR Part 2022, Subpart D?

N/A

If “No” or “N/A,” attach a statement describing why no reduction has occurred or is not applicable.

8

Has the plan ever required employee contributions?

Yes

No

9

Have you filed or will you file with the Internal Revenue Service an application for a
determination letter on the termination of this plan?

Yes

No

If “Yes,” enter the filing date: (MM/DD/YYYY) _________________________

10

Are there outstanding employer contributions owed to the plan that have not been paid
to the plan for which minimum funding waivers have not been granted and for which
waiver requests are not pending.

Yes

No

If “Yes,” attach a schedule showing for each plan year the amount of outstanding employer contributions owed.

PART III.

PLAN ADMINISTRATOR CERTIFICATION

I, the Plan Administrator, certify that, to the best of my knowledge and belief: (1) the information contained in this filing is true, correct, and complete;
and (2) the information provided 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

Name and title of Plan Administrator

PBGC Schedule EA-D

Distress Termination
Enrolled Actuary Certification

(PBGC Form 601)
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.
SUFFICIENCY LEVEL AS OF PROPOSED TERMINATION DATE
2 As of the proposed termination date, is the value of plan assets available to pay for plan benefits, when allocated in accordance with section
4044 of ERISA:

a

less than the value of all benefits guaranteed by the PBGC under section 4022(a)
and (b) of ERISA?

Yes

No

b

equal to or greater than the value of guaranteed benefits, but less than the value of
benefit liabilities?

Yes

No

c

equal to or greater than the value of benefit liabilities?

Yes

No

If you checked “Yes” in 2a, complete the rest of Part II and complete Part IV. Do not complete
Part III. If you checked “No” in 2a, complete the rest of Part II, Part III, and Part IV.

3

a

Estimated value of plan assets available to pay for plan benefits, determined as of the
proposed termination date:
Estimated fair market value of plan assets (excluding value of contributions owed to the
plan)

b

Estimated total contributions owed to the plan

c
d

Estimated collectible value of 3b

4
5

Estimated value of total plan assets (sum of a and c)
Estimated value of Title IV benefits as of the proposed termination date
Estimated present value of all benefit liabilities as of the proposed termination date

$
$
$
$
$
$

PART III. SUFFICIENCY LEVEL AS OF PROPOSED DISTRIBUTION DATE
6 Proposed distribution date
7 As of the proposed distribution date, do you project that the plan will have sufficient

(MM/DD/YYYY)

assets available to pay for plan benefits, when allocated in accordance with section
4044 of ERISA, to provide:

a

all benefits guaranteed by the PBGC under section 4022(a) and (b) of ERISA, but not
all benefit liabilities?

Yes

No

b

all benefit liabilities?

Yes

No

PART IV.

ENROLLED ACTUARY CERTIFICATION

I, the Enrolled Actuary, certify that: (1) I have reviewed all relevant plan documents, plan and participant data, and the method used to value the
plan assets; (2) I have applied all relevant provisions of ERISA and the Internal Revenue Code and regulations promulgated thereunder; (3) to the
best of my knowledge and belief, the information contained in this schedule is true, correct, and complete; and (4) to the best of my knowledge and
belief, the plan’s assets and benefits have been valued in accordance with Title IV and PBGC regulations; and the value of the plan’s assets, when
allocated in accordance with the PBGC’s regulation on allocation of assets (29 CFR Part 4044), is sufficient (as of the proposed termination date)
to provide plan benefits as indicated (check one):
Insufficient for guaranteed benefits

Sufficient for guaranteed benefits but not for benefit liabilities

Sufficient for benefit liabilities

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 signature

Date

Enrolled Actuary’s Name (Print or type)

Enrollment Number

Telephone Number

E-mail address (optional)

Post-Distribution Certification
for Distress Termination

PBGC Form 602
Approved OMB 1212-0036
Expires 12/31/2013

PART I.
IDENTIFYING INFORMATION
1a Plan Name

2

9-digit employer identification number (EIN)

1c

3-digit plan number (PN)

PBGC case number (8-digit)

PART II.
3a
3b
4
5

1b

DISTRIBUTION INFORMATION

Last distribution date in satisfaction of guaranteed or plan benefits

(MM/DD/YYYY)

Date of receipt of IRS determination letter

(MM/DD/YYYY)

Latest date notices of benefit distribution issued to participants or beneficiaries

(MM/DD/YYYY)

Were participants and beneficiaries provided with the name and address of the
insurer(s) no later than 45 days before the date of distribution?
(See page 21 of instructions.)

6

Were you able to locate all participants and beneficiaries? If “No,” see instructions.

Yes

No

Yes

No

7

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, enter latest date the annuity contract, certificate or written notice was provided to
participants and beneficiaries____________________________(MM/DD/YYYY)
No, see instructions
N/A, see instructions

8a

Complete office address(es) of insurer(s), if any, from whom annuity contracts have
been purchased (address should include room or suite no.)

8b Annuity Contract Number(s)

9a

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

9b Telephone number

10

Summary of distribution of plan benefits

Form

a
b

# of Participants or Beneficiaries

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

c

Designated benefits paid to PBGC for Missing Participants

d

No Distribution

e

TOTAL (See instructions)

PART III.

Total Value

$

$
$
$
$

PLAN ADMINISTRATOR CERTIFICATION

I, the Plan Administrator, certify that to the best of my knowledge and belief (1) benefits payable with respect to participants have been calculated and
guaranteed benefits
valued correctly in accordance with applicable provisions of ERISA and the regulations thereunder; (2) all (check one)
OR benefit liabilities under the plan have been satisfied, and (3) 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 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 company name and address
(address should include room or suite no.)

Plan Administrator’s signature

Date

Telephone number

Name of Plan Administrator

Title of Plan Administrator