Termination of Abandoned Individual Account Plans

FINAL NOTICE

[Date of notice]

Abandoned Plan Coordinator, Office of Enforcement

Employee Benefits Security Administration

U.S. Department of Labor

200 Constitution Ave., NW, Suite 600

Washington, DC, 20210

Re: Plan Identification Qualified Termination Administrator

[Plan name and plan number] [Name]

[Plan account number] [Address and e-mail address]

[EIN] [Telephone number]

[EIN]

{If applicable, complete and include the following pursuant to 29 CFR 2578.1(j)(3)(iv) unless the same as Qualified Termination Administrator information above }:

Bankruptcy Trustee

[Name]

[Address]

[E-mail address]

[Telephone number]

Abandoned Plan Coordinator:

General Information

The termination and winding-up process of the subject plan has been completed pursuant to 29 CFR 2578.1. Benefits were distributed to participants and beneficiaries on the basis of the best available information pursuant to 29 CFR 2578.1(d)(2)(i). Plan expenses were paid out of plan assets pursuant to 29 CFR 2578.1(d)(2)(v) or 29 CFR 2578.1(j)(3)(vi).

{Include and complete the next section, entitled “Contact Person,” only if the contact person is different from the signatory of this notice.}

Contact Person

[Name]

[Address and e-mail address]

[Telephone number]

{Include and complete the next section, entitled “Expenses Paid” only if fees and expenses paid by the plan exceeded by 20 percent or more the estimate required by 29 CFR 2578.1(c)(3)(v)(B) or 29 CFR 2578.1(j)(2)(v)(B).}

Expenses Paid

The actual fees and/or expenses paid in connection with winding up the Plan exceeded by {insert either: [20 percent or more] or [enter the actual percentage]} the estimate required by 29 CFR 2578.1(c)(3)(v)(B) or 29 CFR 2578.1(j)(2)(v)(B). The reason or reasons for such additional costs are {provide an explanation of the additional costs}.

Other

Under penalties of perjury, I declare that I have examined this notice and to the best of my knowledge and belief, it is true, correct and complete.

[Signature]

[Title of person signing on behalf the Qualified Termination Administrator]

[Address, e-mail address, and telephone number]

Attachment

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 20 minutes per response, including time for gathering the data needed, and completing and reviewing the collection of information. Please send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Policy and Research, Attention: PRA Official, 200 Constitution Avenue, N.W., Room N-5711, Washington, DC 20210 and reference OMB Control Number 1210-0127. Note: Please do not return the completed notice to this address.

OMB Control Number 1210-0127: Expiration Date: XX/ XX/2013