Termination of Abandoned Individual Account Plans

NOTIFICATION OF PLAN ABANDONMENT AND INTENT TO SERVE AS QUALIFIED TERMINATION ADMINISTRATOR

[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]

[EIN] [Address]

[Plan account number] [E-mail address]

[Address] [Telephone number]

[Telephone number] [EIN]

Abandoned Plan Coordinator:

Pursuant to 29 CFR 2578.1(b), we have determined that the subject plan is or may become abandoned by its sponsor. We are eligible to serve as a Qualified Termination Administrator for purposes of terminating and winding up the plan in accordance with 29 CFR 2578.1, and hereby elect to do so.

We find that {check the appropriate box below and provide additional information as necessary}:

 There have been no contributions to, or distributions from, the plan for a period of at least 12 consecutive months immediately preceding the date of this letter. Our records indicate that the date of the last contribution or distribution was {enter appropriate date}.

 The following facts and circumstances suggest that the plan is or may become abandoned by the plan sponsor {add description below}:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

We have also determined that the plan sponsor {check appropriate box below}:

 No longer exists

 Cannot be located

 Is unable to maintain the plan

We have taken the following steps to locate or communicate with the known plan sponsor and have received no objection {provide an explanation below}:

________________________________________________________________________________________________________________________________________________________________________________________________________________________

Part I – Plan Information

1. Estimated number of individuals (participants and beneficiaries) with accounts
   under the plan: [number]

2. Plan assets held by Qualified Termination Administrator:

A. Estimated value of assets: [value]

B. Months we have held plan assets, if less than 12: [number]

C. Hard to value assets {select “yes” or “no” to identify any assets with no

readily ascertainable fair market value, and include for those identified

assets the best known estimate of their value}:
Yes No

(a) Partnership/joint venture interests   [value]

(b) Employer real property   [value]

(c) Real estate (other than (b))   [value]

(d) Employer securities   [value]

(e) Participant loans   [value]

(f) Loans (other than (e))   [value]

(g) Tangible personal property   [value]

3. Name and last known address and telephone number of plan sponsor: _______________________________________________________________________________________________________________________________________________________________________________________________________________

4. Other:

_______________________________________________________________________________________________________________________________________________________________________________________________________________

Part II – Known Service Providers of the Plan

Name Address Telephone

1.___________________________________________________________________

2.___________________________________________________________________

3.___________________________________________________________________

Part III – Services and Related Expenses to be Paid

Services Service Provider Estimated Cost

1.___________________________________________________________________

2.___________________________________________________________________

3.___________________________________________________________________

Part IV – Contact Person {enter information only if different from signatory}:

[Name]

[Address]

[E-mail address]

[Telephone number]

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]

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 one hour per response, including time for preparing, reviewing, and distributing the notices. The obligation to respond to this collection is required to obtain or retain benefit. 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 application to this address.

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