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Comprehensive Premium Single Employer VRP filing with overpayment .................................................... 1
Comprehensive Premium Multiemployer paid using Paper Check ............................................................ 23
Estimated Single employer filing paid via EFT (outside of My PAA) ........................................................... 43
Imported Comp Single Employer Exempt Filing paid online via Electronic Check ..................................... 60
Uploaded Filing paid using Other payment alternative .............................................................................. 74
Comprehensive Premium Single Employer VRP filing with overpayment
1
2
3
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5
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18
2013 PBGC Comprehensive Premium Filing
Amended filing
Disaster Relief (enter code) _ _ - _
_
Part I – General Plan Information
1 Plan sponsor information
a Name ___________________________________________________________________________________________________
b Six-digit business code _ _ _ _ _ _ _
c First six digits of CUSIP number _ _ _ _ _ _
2 Plan administrator information
a Name ___________________________________________________________________________________________________
b Address line 1 _____________________________________________________________________________________________
c Address line 2 _____________________________________________________________________________________________
d City _________________________
e State ______
f Zip _______________
g Country (if not U.S.) ______________
h Contact person
(1) Name (for “attention” line of mailings): ______________________________________________________________
(2) e-mail address ___________________________________________________ (3) Phone number: _ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _
3 Additional plan contact (optional)
(1) Name ___________________________________________________________________________________
(2) e-mail address ___________________________________________________ (3) Phone number: _ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _
4 Plan information
a Plan name
______________________________________________________________________________
b Premium payment year information:
(1) This filing is for the premium payment year commencing _ _ /_ _ / _ _ _ _ and ending _ _ /_ _ / _ _ _ _.
(2) If the plan year commencement date has changed since the most recent PBGC filing as a result of a plan amendment changing the plan year,
enter the date the plan year change was adopted _ _/_ _/_ _ _ _ .
(3)
Check box if plan qualifies to pay a prorated premium for this premium payment year (i.e., if plan has less than a full year of coverage).
c Employer Identification Number and Plan Number information:
(1) EIN and PN: EIN _ _ _ _ _ _ _ _ _ PN _ _ _
(2) If the EIN and PN are not both the same as on the most recent premium filing, enter EIN and PN from most recent premium filing:
_ _ _ _ _ PN _ _ _. Otherwise, skip to item 4c(3).
EIN _ _ _ _
(3) If the EIN and PN are not both the same as on the 2012 Form 5500, enter EIN and PN from 2012 Form 5500 and provide explanation: EIN _ _ _
_ _ _ _ _ _ PN _ _ _. Explanation ____________________________________________________________________
_____________________________________________________________________________________Otherwise, skip to item 4d.
d Plan type:
Multiemployer
Single-employer (including multiple-employer plans)
e Plan size (based on prior year participant count):
Small (fewer than 100)
N/A; first year’s filing
Mid-size (100-499)
Large (500 or more)
f Plan effective date _ _ /_ _ / _ _ _ _.
Part II – Flat-Rate Premium Information
5 Flat-rate premium
a Participant count date: Month ___ Day ___ Year ____
b Flat-rate premium calculation
(1) Applicable rate (Single-employer plans enter $35; Multiemployer plans, enter $9)
______________
(2) Participant count as of participant count date
______________
(3) Flat-rate premium (item 5b(1) x item 5b(2))
______________
19
Part III – Variable-rate Premium Information
Multiemployer plans — Skip to Part IV
Complete item 6 only if the plan is electing, or revoking an election, to use the Alternative Premium Funding Target instead of the Standard Premium Funding
Target; otherwise skip to item 7
6 Alternative Premium Funding Target Election or Revocation
a
Election - Check box to elect to use the Alternative Premium Funding Target instead of the Standard Premium Funding Target. The election will be
effective — and the plan will be required to use the Alternative Premium Funding Target — beginning with this premium payment year and for all
subsequent plan years unless and until the election is subsequently revoked.
b
Revocation - Check box to revoke a prior election to use the Alternative Premium Funding Target. The revocation will be effective — and the plan will be
required to use the Standard Premium Funding Target — beginning with this premium payment year and for all subsequent plan years unless and until a
new election is subsequently made.
Note — Elections or Revocations must remain in place for at least five years.
7 Variable-rate premium (VRP)
a Exemptions – If an exemption applies, check applicable box and skip to item 8.
No vested participants
412(e)(3) plan
Standard termination with a proposed termination date of _ _ /_ _ /_ _ _ _
b VRP cap qualification – If this plan qualifies for the VRP cap applicable to certain plans of small employers (those with 25 or fewer employees), check box
. If box is checked, items 7c through 7g(1) may, but need not, be omitted.
c Assumptions and methods used to determine premium funding target
(1) Premium funding target method:
(2) Discount rate(s)
Standard
Alternative (If Alternative, enter effective interest rate
st
1 segment ____%
nd
2 segment ____%
rd
3 segment ____%
____%)
N/A, full yield curve used
(3) UVB valuation date: Month ___ Day ___ Year ____
d Premium funding target as of UVB valuation date –
Check box if the reported premium funding target information is an estimate.
(1) Attributable to active participants
_____________
(2) Attributable to terminated vested participants
_____________
(3) Attributable to retirees and beneficiaries receiving payment
_____________
(4) Total premium funding target (item 7d(1) + item 7d(2) + item 7d(3))
_____________
e Market value of assets as of UVB valuation date
_____________
f Unfunded vested benefits (excess, if any, of item 7d(4) over item 7e, rounded up to the next $1,000)
_____________
g Variable-rate premium calculation
If the plan does not qualify for the VRP cap, omit the following two items and skip to item 7g(3).
(1) Variable-rate premium before reflecting the cap (item 7f x 0.009)
______________
(2) Maximum VRP ($5 x item 5b(2) x item 5b(2))
______________
(3) Variable-rate premium — If the plan does not qualify for the VRP cap, item 7f x 0.009. If the plan qualifies for the VRP cap, the
lesser of item 7g(1) and 7g(2) or, if item 7g(1) was omitted, item 7g(2).
_____________
Part IV – Total Premium Information
8 Premium proration (If the plan does not qualify for premium proration, skip to item 9)
a Number of months (complete and partial) in the short plan year
______________
b Total premium before reflecting proration (item 5b(3) + item 7g(3), if applicable)
______________
9 Total premium — If the plan does not qualify for premium proration, item 5b(3) + item 7g(3), if applicable. If the plan qualifies for
premium proration, item 8b x item 8a ÷ 12.
______________
20
21
Part VII – Certifications
20 Certification of Plan Administrator – The plan administrator must sign and complete this item.
I certify under penalty of perjury, to the best of my knowledge and belief, that all the information in the filing is true, correct
and complete and has been determined in accordance with the PBGC's premium regulations and instructions, except that if
the filing reports an estimated premium funding target, the estimate is reasonable, takes into account the most current
information available to the enrolled actuary, and has been determined in accordance with generally accepted actuarial
principles and practices, and that if I received variable-rate premium information certified by an enrolled actuary for this
filing, the variable-rate premium information in the filing is the same as the variable-rate premium information certified by the
enrolled actuary.
Name of person signing: First name _______________ Last name _____________________________
____________________________________________
_ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _ _
E-mail address
Telephone
___________________________________________
_ _ /_ _ /_ _ _ _
Signature
Date
21 Certification of Enrolled Actuary – An enrolled actuary must sign and complete this item unless the plan is a multiemployer
plan, is exempt from the variable-rate premium, or is eligible for and paying the maximum VRP and not reporting the
uncapped VRP.
I certify under penalty of perjury, to the best of my knowledge and belief, that the variable-rate premium information in the
filing is true, correct and complete and has been determined in accordance with PBGC's premium regulations and
instructions; except that if the premium funding target is estimated, the estimate is reasonable, takes into account the most
current information available to me and has been determined in accordance with generally accepted actuarial principles and
practices.
Name of person signing: First name _______________ Last name _____________________________
_____________________________________________
_ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _ _
Firm
Telephone
_____________________________________________
___________
E-mail address
Enrollment number
____________________________________________
_ _ /_ _ /_ _ _ _
Signature
Date
22
Comprehensive Premium Multiemployer paid using Paper Check
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
2013 PBGC Comprehensive Premium Filing
Amended filing
Disaster Relief (enter code) _ _ - _
_
Part I – General Plan Information
1 Plan sponsor information
a Name ___________________________________________________________________________________________________
b Six-digit business code _ _ _ _ _ _ _
c First six digits of CUSIP number _ _ _ _ _ _
2 Plan administrator information
a Name ___________________________________________________________________________________________________
b Address line 1 _____________________________________________________________________________________________
c Address line 2 _____________________________________________________________________________________________
d City _________________________
e State ______
f Zip _______________
g Country (if not U.S.) ______________
h Contact person
(1) Name (for “attention” line of mailings): ______________________________________________________________
(2) e-mail address ___________________________________________________ (3) Phone number: _ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _
3 Additional plan contact (optional)
(1) Name ___________________________________________________________________________________
(2) e-mail address ___________________________________________________ (3) Phone number: _ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _
4 Plan information
a Plan name
______________________________________________________________________________
b Premium payment year information:
(1) This filing is for the premium payment year commencing _ _ /_ _ / _ _ _ _ and ending _ _ /_ _ / _ _ _ _.
(2) If the plan year commencement date has changed since the most recent PBGC filing as a result of a plan amendment changing the plan year,
enter the date the plan year change was adopted _ _/_ _/_ _ _ _ .
(3)
Check box if plan qualifies to pay a prorated premium for this premium payment year (i.e., if plan has less than a full year of coverage).
c Employer Identification Number and Plan Number information:
(1) EIN and PN: EIN _ _ _ _ _ _ _ _ _ PN _ _ _
(2) If the EIN and PN are not both the same as on the most recent premium filing, enter EIN and PN from most recent premium filing:
_ _ _ _ _ PN _ _ _. Otherwise, skip to item 4c(3).
EIN _ _ _ _
(3) If the EIN and PN are not both the same as on the 2012 Form 5500, enter EIN and PN from 2012 Form 5500 and provide explanation: EIN _ _ _
_ _ _ _ _ _ PN _ _ _. Explanation ____________________________________________________________________
_____________________________________________________________________________________Otherwise, skip to item 4d.
d Plan type:
Multiemployer
Single-employer (including multiple-employer plans)
e Plan size (based on prior year participant count):
Small (fewer than 100)
N/A; first year’s filing
Mid-size (100-499)
Large (500 or more)
f Plan effective date _ _ /_ _ / _ _ _ _.
Part II – Flat-Rate Premium Information
5 Flat-rate premium
a Participant count date: Month ___ Day ___ Year ____
b Flat-rate premium calculation
(1) Applicable rate (Single-employer plans enter $35; Multiemployer plans, enter $9)
______________
(2) Participant count as of participant count date
______________
(3) Flat-rate premium (item 5b(1) x item 5b(2))
______________
39
Part III – Variable-rate Premium Information
Multiemployer plans — Skip to Part IV
Complete item 6 only if the plan is electing, or revoking an election, to use the Alternative Premium Funding Target instead of the Standard Premium Funding
Target; otherwise skip to item 7
6 Alternative Premium Funding Target Election or Revocation
a
Election - Check box to elect to use the Alternative Premium Funding Target instead of the Standard Premium Funding Target. The election will be
effective — and the plan will be required to use the Alternative Premium Funding Target — beginning with this premium payment year and for all
subsequent plan years unless and until the election is subsequently revoked.
b
Revocation - Check box to revoke a prior election to use the Alternative Premium Funding Target. The revocation will be effective — and the plan will be
required to use the Standard Premium Funding Target — beginning with this premium payment year and for all subsequent plan years unless and until a
new election is subsequently made.
Note — Elections or Revocations must remain in place for at least five years.
7 Variable-rate premium (VRP)
a Exemptions – If an exemption applies, check applicable box and skip to item 8.
No vested participants
412(e)(3) plan
Standard termination with a proposed termination date of _ _ /_ _ /_ _ _ _
b VRP cap qualification – If this plan qualifies for the VRP cap applicable to certain plans of small employers (those with 25 or fewer employees), check box
. If box is checked, items 7c through 7g(1) may, but need not, be omitted.
c Assumptions and methods used to determine premium funding target
(1) Premium funding target method::
(2) Discount rate(s)
Standard
Alternative (If Alternative, enter effective interest rate
st
1 segment ____%
nd
2 segment ____%
rd
3 segment ____%
____%)
N/A, full yield curve used
(3) UVB valuation date: Month ___ Day ___ Year ____
d Premium funding target as of UVB valuation date –
Check box if the reported premium funding target information is an estimate.
(1) Attributable to active participants
_____________
(2) Attributable to terminated vested participants
_____________
(3) Attributable to retirees and beneficiaries receiving payment
_____________
(4) Total premium funding target (item 7d(1) + item 7d(2) + item 7d(3))
_____________
e Market value of assets as of UVB valuation date
_____________
f Unfunded vested benefits (excess, if any, of item 7d(4) over item 7e, rounded up to the next $1,000)
_____________
g Variable-rate premium calculation
If the plan does not qualify for the VRP cap, omit the following two items and skip to item 7g(3).
(1) Variable-rate premium before reflecting the cap (item 7f x 0.009)
______________
(2) Maximum VRP ($5 x item 5b(2) x item 5b(2))
______________
(3) Variable-rate premium — If the plan does not qualify for the VRP cap, item 7f x 0.009. If the plan qualifies for the VRP cap, the
lesser of item 7g(1) and 7g(2) or, if item 7g(1) was omitted, item 7g(2).
_____________
Part IV – Total Premium Information
8 Premium proration (If the plan does not qualify for premium proration, skip to item 9)
a Number of months (complete and partial) in the short plan year
______________
b Total premium before reflecting proration (item 5b(3) + item 7g(3), if applicable)
______________
9 Total premium — If the plan does not qualify for premium proration, item 5b(3) + item 7g(3), if applicable. If the plan qualifies for
premium proration, item 8b x item 8a ÷ 12.
______________
40
41
Part VII – Certifications
20 Certification of Plan Administrator – The plan administrator must sign and complete this item.
I certify under penalty of perjury, to the best of my knowledge and belief, that all the information in the filing is true, correct
and complete and has been determined in accordance with the PBGC's premium regulations and instructions, except that if
the filing reports an estimated premium funding target, the estimate is reasonable, takes into account the most current
information available to the enrolled actuary, and has been determined in accordance with generally accepted actuarial
principles and practices, and that if I received variable-rate premium information certified by an enrolled actuary for this
filing, the variable-rate premium information in the filing is the same as the variable-rate premium information certified by the
enrolled actuary.
Name of person signing: First name _______________ Last name _____________________________
____________________________________________
_ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _ _
E-mail address
Telephone
___________________________________________
_ _ /_ _ /_ _ _ _
Signature
Date
21 Certification of Enrolled Actuary – An enrolled actuary must sign and complete this item unless the plan is a multiemployer
plan, is exempt from the variable-rate premium, or is eligible for and paying the maximum VRP and not reporting the
uncapped VRP.
I certify under penalty of perjury, to the best of my knowledge and belief, that the variable-rate premium information in the
filing is true, correct and complete and has been determined in accordance with PBGC's premium regulations and
instructions; except that if the premium funding target is estimated, the estimate is reasonable, takes into account the most
current information available to me and has been determined in accordance with generally accepted actuarial principles and
practices.
Name of person signing: First name _______________ Last name _____________________________
_____________________________________________
_ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _ _
Firm
Telephone
_____________________________________________
___________
E-mail address
Enrollment number
____________________________________________
_ _ /_ _ /_ _ _ _
Signature
Date
42
Estimated Single employer filing paid via EFT (outside of My PAA)
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
2013 PBGC Estimated Flat-rate Premium Filing
Amended filing
Disaster Relief (enter code) _ _ - _ _
Part I – General Plan Information
1 Plan sponsor information
a Name ___________________________________________________________________________________________________
b Six-digit business code _ _ _ _ _ _ _
c First six digits of CUSIP number _ _ _ _ _ _
2 Plan administrator information
a Name ___________________________________________________________________________________________________
b Address line 1 _____________________________________________________________________________________________
c Address line 2 _____________________________________________________________________________________________
d City _________________________
e State ______
f Zip _______________
g Country (if not U.S.) ______________
h Contact person
(1) Name (for “attention” line of mailings): ______________________________________________________________
(2) e-mail address ___________________________________________________ (3) Phone number: _ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _
3 Additional plan contact (optional)
(1) Name ___________________________________________________________________________________
(2) e-mail address ___________________________________________________ (3) Phone number: _ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _
4 Plan information
a Plan name
_____________________________________________________________________
b Premium payment year information:
(1) This filing is for the premium payment year commencing _ _ /_ _ / _ _ _ _ and ending _ _ /_ _ / _ _ _ _.
(2)
Check box if plan qualifies to pay a prorated premium for this premium payment year (i.e., if plan has less than a full year of coverage).
c Employer Identification Number and Plan Number information:
(1) EIN and PN: EIN _ _ _ _ _ _ _ _ _ PN _ _ _
(2) If the EIN and PN are not both the same as on the most recent premium filing, enter EIN and PN from most recent premium filing:
_ _ _ _ _ PN _ _ _. Otherwise, skip to item 4d.
d Plan type:
Multiemployer
EIN _ _ _ _
Single-employer (including multiple-employer plans)
e Plan effective date _ _ /_ _ / _ _ _ _.
Part II – Flat-rate Premium Information
5 Estimated flat-rate premium
a Applicable rate (Single-employer plans enter $35; Multiemployer plans, enter $9.)
______________
b Estimated participant count
______________
c Premium proration (If the plan does not qualify for premium proration, skip to item 5d)
(1) Number of months (complete and partial) in the short plan year
______________
(2) Estimated flat-rate premium before reflecting proration (item 5a x item 5b)
______________
d Estimated flat-rate premium
If the plan does not qualify for premium proration, item 5a x item 5b
If the plan qualifies for premium proration, item 5c(2) x item 5c(1) ÷ 12.
______________
6 Premium credit (including any payments already made for this premium payment year and any overpayment from
prior plan year unless refund was requested)
______________
7 Amount due (excess, if any, of item 5d over item 6)
______________
58
8 Amended filing — Complete this item only if this is an amended filing
a If either the first or last day of the premium payment year reported in this amended filing (item 4b(1)) differs from what was reported in the filing that is
being amended, provide the dates that were reported in the original filing:
Date premium payment year commenced _ _ /_ _ /_ _ _ _ Date premium payment year ended _ _ /_ _ /_ _ _ _.
b If the EIN and PN reported in this amended filing (item 4c(1)) are not both the same as what was reported in the filing that is being amended, enter the
EIN and PN from the original filing: EIN _ _ _ _ _ _ _ _ _ PN _ _ _.
Part III – Certification
9 Certification of Plan Administrator – The plan administrator must sign and complete this item.
I certify under penalty of perjury, to the best of my knowledge and belief, that all the information in this filing (other than the estimated participant count
and estimated premium) is true, correct and complete and has been determined in accordance with PBGC's premium regulations and instructions.
Name of person signing: First name _______________ Last name _____________________________
____________________________________________
_ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _ _
E-mail address
Telephone
___________________________________________
_ _ /_ _ /_ _ _ _
Signature
Date
59
Imported Comp Single Employer Exempt Filing paid online via Electronic
Check
60
61
62
63
64
65
66
67
68
69
2013 PBGC Comprehensive Premium Filing
Amended filing
Disaster Relief (enter code) _ _ - _
_
Part I – General Plan Information
1 Plan sponsor information
a Name ___________________________________________________________________________________________________
b Six-digit business code _ _ _ _ _ _ _
c First six digits of CUSIP number _ _ _ _ _ _
2 Plan administrator information
a Name ___________________________________________________________________________________________________
b Address line 1 _____________________________________________________________________________________________
c Address line 2 _____________________________________________________________________________________________
d City _________________________
e State ______
f Zip _______________
g Country (if not U.S.) ______________
h Contact person
(1) Name (for “attention” line of mailings): ______________________________________________________________
(2) e-mail address ___________________________________________________ (3) Phone number: _ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _
3 Additional plan contact (optional)
(1) Name ___________________________________________________________________________________
(2) e-mail address ___________________________________________________ (3) Phone number: _ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _
4 Plan information
a Plan name
______________________________________________________________________________
b Premium payment year information:
(1) This filing is for the premium payment year commencing _ _ /_ _ / _ _ _ _ and ending _ _ /_ _ / _ _ _ _.
(2) If the plan year commencement date has changed since the most recent PBGC filing as a result of a plan amendment changing the plan year,
enter the date the plan year change was adopted _ _/_ _/_ _ _ _ .
(3)
Check box if plan qualifies to pay a prorated premium for this premium payment year (i.e., if plan has less than a full year of coverage).
c Employer Identification Number and Plan Number information:
(1) EIN and PN: EIN _ _ _ _ _ _ _ _ _ PN _ _ _
(2) If the EIN and PN are not both the same as on the most recent premium filing, enter EIN and PN from most recent premium filing:
_ _ _ _ _ PN _ _ _. Otherwise, skip to item 4c(3).
EIN _ _ _ _
(3) If the EIN and PN are not both the same as on the 2012 Form 5500, enter EIN and PN from 2012 Form 5500 and provide explanation: EIN _ _ _
_ _ _ _ _ _ PN _ _ _. Explanation ____________________________________________________________________
_____________________________________________________________________________________Otherwise, skip to item 4d.
d Plan type:
Multiemployer
Single-employer (including multiple-employer plans)
e Plan size (based on prior year participant count):
Small (fewer than 100)
N/A; first year’s filing
Mid-size (100-499)
Large (500 or more)
f Plan effective date _ _ /_ _ / _ _ _ _.
Part II – Flat-Rate Premium Information
5 Flat-rate premium
a Participant count date: Month ___ Day ___ Year ____
b Flat-rate premium calculation
(1) Applicable rate (Single-employer plans enter $35; Multiemployer plans, enter $9)
______________
(2) Participant count as of participant count date
______________
(3) Flat-rate premium (item 5b(1) x item 5b(2))
______________
70
Part III – Variable-rate Premium Information
Multiemployer plans — Skip to Part IV
Complete item 6 only if the plan is electing, or revoking an election, to use the Alternative Premium Funding Target instead of the Standard Premium Funding
Target; otherwise skip to item 7
6 Alternative Premium Funding Target Election or Revocation
a
Election - Check box to elect to use the Alternative Premium Funding Target instead of the Standard Premium Funding Target. The election will be
effective — and the plan will be required to use the Alternative Premium Funding Target — beginning with this premium payment year and for all
subsequent plan years unless and until the election is subsequently revoked.
b
Revocation - Check box to revoke a prior election to use the Alternative Premium Funding Target. The revocation will be effective — and the plan will be
required to use the Standard Premium Funding Target — beginning with this premium payment year and for all subsequent plan years unless and until a
new election is subsequently made.
Note — Elections or Revocations must remain in place for at least five years.
7 Variable-rate premium (VRP)
a Exemptions – If an exemption applies, check applicable box and skip to item 8.
No vested participants
412(e)(3) plan
Standard termination with a proposed termination date of _ _ /_ _ /_ _ _ _
b VRP cap qualification – If this plan qualifies for the VRP cap applicable to certain plans of small employers (those with 25 or fewer employees), check box
. If box is checked, items 7c through 7g(1) may, but need not, be omitted.
c Assumptions and methods used to determine premium funding target
(1) Premium funding target method::
(2) Discount rate(s)
Standard
Alternative (If Alternative, enter effective interest rate
st
1 segment ____%
nd
2 segment ____%
rd
3 segment ____%
____%)
N/A, full yield curve used
(3) UVB valuation date: Month ___ Day ___ Year ____
d Premium funding target as of UVB valuation date –
Check box if the reported premium funding target information is an estimate.
(1) Attributable to active participants
_____________
(2) Attributable to terminated vested participants
_____________
(3) Attributable to retirees and beneficiaries receiving payment
_____________
(4) Total premium funding target (item 7d(1) + item 7d(2) + item 7d(3))
_____________
e Market value of assets as of UVB valuation date
_____________
f Unfunded vested benefits (excess, if any, of item 7d(4) over item 7e, rounded up to the next $1,000)
_____________
g Variable-rate premium calculation
If the plan does not qualify for the VRP cap, omit the following two items and skip to item 7g(3).
(1) Variable-rate premium before reflecting the cap (item 7f x 0.009)
______________
(2) Maximum VRP ($5 x item 5b(2) x item 5b(2))
______________
(3) Variable-rate premium — If the plan does not qualify for the VRP cap, item 7f x 0.009. If the plan qualifies for the VRP cap, the
lesser of item 7g(1) and 7g(2) or, if item 7g(1) was omitted, item 7g(2).
_____________
Part IV – Total Premium Information
8 Premium proration (If the plan does not qualify for premium proration, skip to item 9)
a Number of months (complete and partial) in the short plan year
______________
b Total premium before reflecting proration (item 5b(3) + item 7g(3), if applicable)
______________
9 Total premium — If the plan does not qualify for premium proration, item 5b(3) + item 7g(3), if applicable. If the plan qualifies for
premium proration, item 8b x item 8a ÷ 12.
______________
71
72
Part VII – Certifications
20 Certification of Plan Administrator – The plan administrator must sign and complete this item.
I certify under penalty of perjury, to the best of my knowledge and belief, that all the information in the filing is true, correct
and complete and has been determined in accordance with the PBGC's premium regulations and instructions, except that if
the filing reports an estimated premium funding target, the estimate is reasonable, takes into account the most current
information available to the enrolled actuary, and has been determined in accordance with generally accepted actuarial
principles and practices, and that if I received variable-rate premium information certified by an enrolled actuary for this
filing, the variable-rate premium information in the filing is the same as the variable-rate premium information certified by the
enrolled actuary.
Name of person signing: First name _______________ Last name _____________________________
____________________________________________
_ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _ _
E-mail address
Telephone
___________________________________________
_ _ /_ _ /_ _ _ _
Signature
Date
21 Certification of Enrolled Actuary – An enrolled actuary must sign and complete this item unless the plan is a multiemployer
plan, is exempt from the variable-rate premium, or is eligible for and paying the maximum VRP and not reporting the
uncapped VRP.
I certify under penalty of perjury, to the best of my knowledge and belief, that the variable-rate premium information in the
filing is true, correct and complete and has been determined in accordance with PBGC's premium regulations and
instructions; except that if the premium funding target is estimated, the estimate is reasonable, takes into account the most
current information available to me and has been determined in accordance with generally accepted actuarial principles and
practices.
Name of person signing: First name _______________ Last name _____________________________
_____________________________________________
_ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _ _
Firm
Telephone
_____________________________________________
___________
E-mail address
Enrollment number
____________________________________________
_ _ /_ _ /_ _ _ _
Signature
Date
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2013 PBGC Comprehensive Premium Filing
Amended filing
Disaster Relief (enter code) _ _ - _
_
Part I – General Plan Information
1 Plan sponsor information
a Name ___________________________________________________________________________________________________
b Six-digit business code _ _ _ _ _ _ _
c First six digits of CUSIP number _ _ _ _ _ _
2 Plan administrator information
a Name ___________________________________________________________________________________________________
b Address line 1 _____________________________________________________________________________________________
c Address line 2 _____________________________________________________________________________________________
d City _________________________
e State ______
f Zip _______________
g Country (if not U.S.) ______________
h Contact person
(1) Name (for “attention” line of mailings): ______________________________________________________________
(2) e-mail address ___________________________________________________ (3) Phone number: _ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _
3 Additional plan contact (optional)
(1) Name ___________________________________________________________________________________
(2) e-mail address ___________________________________________________ (3) Phone number: _ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _
4 Plan information
a Plan name
______________________________________________________________________________
b Premium payment year information:
(1) This filing is for the premium payment year commencing _ _ /_ _ / _ _ _ _ and ending _ _ /_ _ / _ _ _ _.
(2) If the plan year commencement date has changed since the most recent PBGC filing as a result of a plan amendment changing the plan year,
enter the date the plan year change was adopted _ _/_ _/_ _ _ _ .
(3)
Check box if plan qualifies to pay a prorated premium for this premium payment year (i.e., if plan has less than a full year of coverage).
c Employer Identification Number and Plan Number information:
(1) EIN and PN: EIN _ _ _ _ _ _ _ _ _ PN _ _ _
(2) If the EIN and PN are not both the same as on the most recent premium filing, enter EIN and PN from most recent premium filing:
_ _ _ _ _ PN _ _ _. Otherwise, skip to item 4c(3).
EIN _ _ _ _
(3) If the EIN and PN are not both the same as on the 2012 Form 5500, enter EIN and PN from 2012 Form 5500 and provide explanation: EIN _ _ _
_ _ _ _ _ _ PN _ _ _. Explanation ____________________________________________________________________
_____________________________________________________________________________________Otherwise, skip to item 4d.
d Plan type:
Multiemployer
Single-employer (including multiple-employer plans)
e Plan size (based on prior year participant count):
Small (fewer than 100)
N/A; first year’s filing
Mid-size (100-499)
Large (500 or more)
f Plan effective date _ _ /_ _ / _ _ _ _.
Part II – Flat-Rate Premium Information
5 Flat-rate premium
a Participant count date: Month ___ Day ___ Year ____
b Flat-rate premium calculation
(1) Applicable rate (Single-employer plans enter $35; Multiemployer plans, enter $9)
______________
(2) Participant count as of participant count date
______________
(3) Flat-rate premium (item 5b(1) x item 5b(2))
______________
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Part III – Variable-rate Premium Information
Multiemployer plans — Skip to Part IV
Complete item 6 only if the plan is electing, or revoking an election, to use the Alternative Premium Funding Target instead of the Standard Premium Funding
Target; otherwise skip to item 7
6 Alternative Premium Funding Target Election or Revocation
a
Election - Check box to elect to use the Alternative Premium Funding Target instead of the Standard Premium Funding Target. The election will be
effective — and the plan will be required to use the Alternative Premium Funding Target — beginning with this premium payment year and for all
subsequent plan years unless and until the election is subsequently revoked.
b
Revocation - Check box to revoke a prior election to use the Alternative Premium Funding Target. The revocation will be effective — and the plan will be
required to use the Standard Premium Funding Target — beginning with this premium payment year and for all subsequent plan years unless and until a
new election is subsequently made.
Note — Elections or Revocations must remain in place for at least five years.
7 Variable-rate premium (VRP)
a Exemptions – If an exemption applies, check applicable box and skip to item 8.
No vested participants
412(e)(3) plan
Standard termination with a proposed termination date of _ _ /_ _ /_ _ _ _
b VRP cap qualification – If this plan qualifies for the VRP cap applicable to certain plans of small employers (those with 25 or fewer employees), check box
. If box is checked, items 7c through 7g(1) may, but need not, be omitted.
c Assumptions and methods used to determine premium funding target
(1) Premium funding target method::
(2) Discount rate(s)
Standard
Alternative (If Alternative, enter effective interest rate
st
1 segment ____%
nd
2 segment ____%
rd
3 segment ____%
____%)
N/A, full yield curve used
(3) UVB valuation date: Month ___ Day ___ Year ____
d Premium funding target as of UVB valuation date –
Check box if the reported premium funding target information is an estimate.
(1) Attributable to active participants
_____________
(2) Attributable to terminated vested participants
_____________
(3) Attributable to retirees and beneficiaries receiving payment
_____________
(4) Total premium funding target (item 7d(1) + item 7d(2) + item 7d(3))
_____________
e Market value of assets as of UVB valuation date
_____________
f Unfunded vested benefits (excess, if any, of item 7d(4) over item 7e, rounded up to the next $1,000)
_____________
g Variable-rate premium calculation
If the plan does not qualify for the VRP cap, omit the following two items and skip to item 7g(3).
(1) Variable-rate premium before reflecting the cap (item 7f x 0.009)
______________
(2) Maximum VRP ($5 x item 5b(2) x item 5b(2))
______________
(3) Variable-rate premium — If the plan does not qualify for the VRP cap, item 7f x 0.009. If the plan qualifies for the VRP cap, the
lesser of item 7g(1) and 7g(2) or, if item 7g(1) was omitted, item 7g(2).
_____________
Part IV – Total Premium Information
8 Premium proration (If the plan does not qualify for premium proration, skip to item 9)
a Number of months (complete and partial) in the short plan year
______________
b Total premium before reflecting proration (item 5b(3) + item 7g(3), if applicable)
______________
9 Total premium — If the plan does not qualify for premium proration, item 5b(3) + item 7g(3), if applicable. If the plan qualifies for
premium proration, item 8b x item 8a ÷ 12.
______________
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Part VII – Certifications
20 Certification of Plan Administrator – The plan administrator must sign and complete this item.
I certify under penalty of perjury, to the best of my knowledge and belief, that all the information in the filing is true, correct
and complete and has been determined in accordance with the PBGC's premium regulations and instructions, except that if
the filing reports an estimated premium funding target, the estimate is reasonable, takes into account the most current
information available to the enrolled actuary, and has been determined in accordance with generally accepted actuarial
principles and practices, and that if I received variable-rate premium information certified by an enrolled actuary for this
filing, the variable-rate premium information in the filing is the same as the variable-rate premium information certified by the
enrolled actuary.
Name of person signing: First name _______________ Last name _____________________________
____________________________________________
_ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _ _
E-mail address
Telephone
___________________________________________
_ _ /_ _ /_ _ _ _
Signature
Date
21 Certification of Enrolled Actuary – An enrolled actuary must sign and complete this item unless the plan is a multiemployer
plan, is exempt from the variable-rate premium, or is eligible for and paying the maximum VRP and not reporting the
uncapped VRP.
I certify under penalty of perjury, to the best of my knowledge and belief, that the variable-rate premium information in the
filing is true, correct and complete and has been determined in accordance with PBGC's premium regulations and
instructions; except that if the premium funding target is estimated, the estimate is reasonable, takes into account the most
current information available to me and has been determined in accordance with generally accepted actuarial principles and
practices.
Name of person signing: First name _______________ Last name _____________________________
_____________________________________________
_ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _ _
Firm
Telephone
_____________________________________________
___________
E-mail address
Enrollment number
____________________________________________
_ _ /_ _ /_ _ _ _
Signature
Date
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| File Type | application/pdf |
| Author | dpcixa31 |
| File Modified | 2012-05-08 |
| File Created | 2012-05-08 |