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pdfAugust 2012
Draft of Primary My PAA Screens for Plan Year 2013 Premium Filings
The screen mockups are intended to show the expected placement of the 2013 data elements. Please
disregard any data reflected on the screens, e.g., 2012 or inconsistent data.
Contents
Comprehensive Premium Single Employer VRP filing with overpayment .................................................... 1
Comprehensive Premium Multiemployer paid using Paper Check ............................................................ 25
Estimated Single employer filing paid via EFT (outside of My PAA) ........................................................... 45
Imported Comp Single Employer Exempt Filing paid online via Electronic Check ..................................... 62
Uploaded Filing paid using Other payment alternative .............................................................................. 76
Comprehensive Premium Single Employer VRP filing with overpayment
1
2
3
4
5
6
7
8
All plans except multiemployer plans, single-employer plans exempt from the VRP, and singleemployer plans reporting eligibility for the small employer cap.
9
Single-employer plans reporting eligibility for the small employer cap choosing to report the data
in items 7c through 7g.
10
Single-employer plans eligible for the small employer cap choosing not to report the data in
items 7c through 7g must omit items 7c-“Assumptions” through 7g-“Uncapped variable rate
premium”.
11
12
13
14
15
16
17
18
19
20
This form is for illustrative purposes only.
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:
EIN _ _ _ _ _ _ _ _ _ PN _ _ _. Otherwise, skip to item 4c(3).
(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 $42; Multiemployer plans, enter $12)
______________
(2) Participant count as of participant count date
______________
(3) Flat-rate premium (item 5b(1) x item 5b(2))
______________
21
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 small employer cap applicable to certain plans of small employers (those with 25 or fewer
employees), check box . If box is checked, items 7c through 7g 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
st
1 segment ____%
2nd segment ____%
3rd 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 Uncapped variable-rate premium (item 7f x 0.009)
_____________
h Maximum variable-rate premium
_____________
(1) MAP-21 cap ($400 x item 5b(2) )
_____________
(2) Small employer cap, if applicable ($5 x item 5b(2) x item 5b(2)) – Omit this item if plan is not eligible for this cap
_____________
(3) Maximum variable-rate premium — If the plan qualifies for the small employer cap, the lesser of item 7h(1) and 7h(2).
Otherwise, item 7h(1).
_____________
i Variable-rate premium — If the plan qualifies for the small employer cap and item 7g was omitted, item 7h(3). Otherwise, the
lesser of item 7g and item 7h(3).
_____________
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 7i, if applicable)
______________
9 Total premium — If the plan does not qualify for premium proration, item 5b(3) + item 7i, if applicable. If the plan qualifies for
premium proration, item 8b x item 8a ÷ 12.
____________
22
Part V – Payment Information
10 Premium credit
a Payments made previously for this premium payment year
______________
b Outstanding credit from the plan year immediately preceding the premium payment year
______________
c Total (item 10a + item 10b)
______________
11 Amount due (excess, if any, of item 9 over item 10c)
______________
12 Treatment of overpayment
a Excess, if any, of item 10c over item 9
b Treatment of balance (select one):
Credit towards next year’s premium
Refund by check
Refund by electronic funds transfer (EFT). If you select this option, complete item 12c.
c Information for EFT refund:
Type of account
Checking
______________
Savings
Bank routing number _______________________
Account number ___________________
Sub-account number (if any) _________________
Part VI – Miscellaneous Information
13 Final filing – If this is the last filing for this plan, enter the date of event _ _ /_ _ / _ _ _ _ and check box that best describes why filing obligation is
ceasing: Merger/Consolidation
Trusteeship Distribution pursuant to termination
Cessation of covered status
14 New and newly-covered plans – If this filing is for a new plan or a newly-covered plan, report the adoption date _ _ /_ _ / _ _ _ _ and the plan
coverage date _ _ /_ _ / _ _ _ _.
15 Transfers from other plans – If another plan transferred assets or liabilities to this plan since the most recent comprehensive premium filing, provide
the following information with respect to each plan from which assets or liabilities were transferred (if transfer involved a new or newly-covered plan,
see instructions).
EIN _ _ _ _ _ _ _ _ _ PN _ _ _ Date of transfer _ _ /_ _ / _ _ _ _ Type of transfer:
Merger
Consolidation
Spinoff
Other
EIN _ _ _ _ _ _ _ _ _ PN _ _ _ Date of transfer _ _ /_ _ / _ _ _ _ Type of transfer:
Merger
Consolidation
Spinoff
Other
16 Transfers to other plans – If this plan transferred assets or liabilities to another plan since the most recent comprehensive premium filing, provide the
following information with respect to each plan to which the assets or liabilities were transferred (if transfer involved a new or newly-covered plan, see
instructions).
EIN _ _ _ _ _ _ _ _ _ PN _ _ _ Date of transfer _ _ /_ _ / _ _ _ _ Type of transfer:
Merger
Consolidation
Spinoff
Other
EIN _ _ _ _ _ _ _ _ _ PN _ _ _ Date of transfer _ _ /_ _ / _ _ _ _ Type of transfer:
Merger
Consolidation
Spinoff
Other
17 Participation freeze – If, as of the beginning of the premium payment year, this plan is closed to new entrants, enter the date the plan became closed
to new entrants _ _/_ _/_ _ _ _ .
18 Accrual freeze – If, as of the beginning of the premium payment year, benefit accruals under this plan are partially or totally frozen, enter the date the
freeze became effective_ _/_ _/_ _ _ _ and check box that best describes the nature of the freeze:
For all participants, both pay and service are frozen
For all participants, service is frozen, pay is not
For some participants, both pay and service are frozen
For some participants, service is frozen, pay is not
Other (enter explanation)_________________________________________________________________________________________
19 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 _ _ _.
c If the reason for amending the filing is other than reconciling an estimated Variable-rate Premium and the total premium reported in this amended
filing (item 9) is less than the amount reported in the filing that is being amended, provide an explanation of why an amended filing is necessary:
__________________________________________________________________________________________
23
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 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
24
Comprehensive Premium Multiemployer paid using Paper Check
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
This form is for illustrative purposes only.
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:
EIN _ _ _ _ _ _ _ _ _ PN _ _ _. Otherwise, skip to item 4c(3).
(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 $42; Multiemployer plans, enter $12)
______________
(2) Participant count as of participant count date
______________
(3) Flat-rate premium (item 5b(1) x item 5b(2))
______________
41
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 small employer cap applicable to certain plans of small employers (those with 25 or fewer
employees), check box . If box is checked, items 7c through 7g 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
st
1 segment ____%
2nd segment ____%
3rd 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 Uncapped variable-rate premium (item 7f x 0.009)
_____________
h Maximum variable-rate premium
_____________
(1) MAP-21 cap ($400 x item 5b(2) )
_____________
(2) Small employer cap, if applicable ($5 x item 5b(2) x item 5b(2)) – Omit this item if plan is not eligible for this cap
_____________
(3) Maximum variable-rate premium — If the plan qualifies for the small employer cap, the lesser of item 7h(1) and 7h(2).
Otherwise, item 7h(1).
_____________
i Variable-rate premium — If the plan qualifies for the small employer cap and item 7g was omitted, item 7h(3). Otherwise, the
lesser of item 7g and item 7h(3).
_____________
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 7i, if applicable)
______________
9 Total premium — If the plan does not qualify for premium proration, item 5b(3) + item 7i, if applicable. If the plan qualifies for
premium proration, item 8b x item 8a ÷ 12.
____________
42
Part V – Payment Information
10 Premium credit
a Payments made previously for this premium payment year
______________
b Outstanding credit from the plan year immediately preceding the premium payment year
______________
c Total (item 10a + item 10b)
______________
11 Amount due (excess, if any, of item 9 over item 10c)
______________
12 Treatment of overpayment
a Excess, if any, of item 10c over item 9
b Treatment of balance (select one):
Credit towards next year’s premium
Refund by check
Refund by electronic funds transfer (EFT). If you select this option, complete item 12c.
c Information for EFT refund:
Type of account
Checking
______________
Savings
Bank routing number _______________________
Account number ___________________
Sub-account number (if any) _________________
Part VI – Miscellaneous Information
13 Final filing – If this is the last filing for this plan, enter the date of event _ _ /_ _ / _ _ _ _ and check box that best describes why filing obligation is
ceasing: Merger/Consolidation
Trusteeship Distribution pursuant to termination
Cessation of covered status
14 New and newly-covered plans – If this filing is for a new plan or a newly-covered plan, report the adoption date _ _ /_ _ / _ _ _ _ and the plan
coverage date _ _ /_ _ / _ _ _ _.
15 Transfers from other plans – If another plan transferred assets or liabilities to this plan since the most recent comprehensive premium filing, provide
the following information with respect to each plan from which assets or liabilities were transferred (if transfer involved a new or newly-covered plan,
see instructions).
EIN _ _ _ _ _ _ _ _ _ PN _ _ _ Date of transfer _ _ /_ _ / _ _ _ _ Type of transfer:
Merger
Consolidation
Spinoff
Other
EIN _ _ _ _ _ _ _ _ _ PN _ _ _ Date of transfer _ _ /_ _ / _ _ _ _ Type of transfer:
Merger
Consolidation
Spinoff
Other
16 Transfers to other plans – If this plan transferred assets or liabilities to another plan since the most recent comprehensive premium filing, provide the
following information with respect to each plan to which the assets or liabilities were transferred (if transfer involved a new or newly-covered plan, see
instructions).
EIN _ _ _ _ _ _ _ _ _ PN _ _ _ Date of transfer _ _ /_ _ / _ _ _ _ Type of transfer:
Merger
Consolidation
Spinoff
Other
EIN _ _ _ _ _ _ _ _ _ PN _ _ _ Date of transfer _ _ /_ _ / _ _ _ _ Type of transfer:
Merger
Consolidation
Spinoff
Other
17 Participation freeze – If, as of the beginning of the premium payment year, this plan is closed to new entrants, enter the date the plan became closed
to new entrants _ _/_ _/_ _ _ _ .
18 Accrual freeze – If, as of the beginning of the premium payment year, benefit accruals under this plan are partially or totally frozen, enter the date the
freeze became effective_ _/_ _/_ _ _ _ and check box that best describes the nature of the freeze:
For all participants, both pay and service are frozen
For all participants, service is frozen, pay is not
For some participants, both pay and service are frozen
For some participants, service is frozen, pay is not
Other (enter explanation)_________________________________________________________________________________________
19 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 _ _ _.
c If the reason for amending the filing is other than reconciling an estimated Variable-rate Premium and the total premium reported in this amended
filing (item 9) is less than the amount reported in the filing that is being amended, provide an explanation of why an amended filing is necessary:
__________________________________________________________________________________________
43
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 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
44
Estimated Single employer filing paid via EFT (outside of My PAA)
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
This form is for illustrative purposes only.
2013 PBGC Estimated Flat-rate Premium Filing
Amended filing
Disaster Relief (enter code) _ _ - _ _
Part I – General Plan Information
1 Plan sponsor name _______________________________________________________________________________________________
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:
EIN _ _ _ _ _ _ _ _ _ PN _ _ _. Otherwise, skip to item 4d.
d Plan type:
Multiemployer
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 $42; Multiemployer plans, enter $12.)
______________
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)
______________
______________
60
7 Amount due (excess, if any, of item 5d over item 6
______________
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
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Imported Comp Single Employer Exempt Filing paid online via Electronic
Check
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This form is for illustrative purposes only.
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:
EIN _ _ _ _ _ _ _ _ _ PN _ _ _. Otherwise, skip to item 4c(3).
(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 $42; Multiemployer plans, enter $12)
______________
(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 small employer cap applicable to certain plans of small employers (those with 25 or fewer
employees), check box . If box is checked, items 7c through 7g 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
st
1 segment ____%
2nd segment ____%
3rd 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 Uncapped variable-rate premium (item 7f x 0.009)
_____________
h Maximum variable-rate premium
_____________
(1) MAP-21 cap ($400 x item 5b(2) )
_____________
(2) Small employer cap, if applicable ($5 x item 5b(2) x item 5b(2)) – Omit this item if plan is not eligible for this cap
_____________
(3) Maximum variable-rate premium — If the plan qualifies for the small employer cap, the lesser of item 7h(1) and 7h(2).
Otherwise, item 7h(1).
_____________
i Variable-rate premium — If the plan qualifies for the small employer cap and item 7g was omitted, item 7h(3). Otherwise, the
lesser of item 7g and item 7h(3).
_____________
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 7i, if applicable)
______________
9 Total premium — If the plan does not qualify for premium proration, item 5b(3) + item 7i, if applicable. If the plan qualifies for
premium proration, item 8b x item 8a ÷ 12.
____________
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Part V – Payment Information
10 Premium credit
a Payments made previously for this premium payment year
______________
b Outstanding credit from the plan year immediately preceding the premium payment year
______________
c Total (item 10a + item 10b)
______________
11 Amount due (excess, if any, of item 9 over item 10c)
______________
12 Treatment of overpayment
a Excess, if any, of item 10c over item 9
b Treatment of balance (select one):
Credit towards next year’s premium
Refund by check
Refund by electronic funds transfer (EFT). If you select this option, complete item 12c.
c Information for EFT refund:
Type of account
Checking
______________
Savings
Bank routing number _______________________
Account number ___________________
Sub-account number (if any) _________________
Part VI – Miscellaneous Information
13 Final filing – If this is the last filing for this plan, enter the date of event _ _ /_ _ / _ _ _ _ and check box that best describes why filing obligation is
ceasing: Merger/Consolidation
Trusteeship Distribution pursuant to termination
Cessation of covered status
14 New and newly-covered plans – If this filing is for a new plan or a newly-covered plan, report the adoption date _ _ /_ _ / _ _ _ _ and the plan
coverage date _ _ /_ _ / _ _ _ _.
15 Transfers from other plans – If another plan transferred assets or liabilities to this plan since the most recent comprehensive premium filing, provide
the following information with respect to each plan from which assets or liabilities were transferred (if transfer involved a new or newly-covered plan,
see instructions).
EIN _ _ _ _ _ _ _ _ _ PN _ _ _ Date of transfer _ _ /_ _ / _ _ _ _ Type of transfer:
Merger
Consolidation
Spinoff
Other
EIN _ _ _ _ _ _ _ _ _ PN _ _ _ Date of transfer _ _ /_ _ / _ _ _ _ Type of transfer:
Merger
Consolidation
Spinoff
Other
16 Transfers to other plans – If this plan transferred assets or liabilities to another plan since the most recent comprehensive premium filing, provide the
following information with respect to each plan to which the assets or liabilities were transferred (if transfer involved a new or newly-covered plan, see
instructions).
EIN _ _ _ _ _ _ _ _ _ PN _ _ _ Date of transfer _ _ /_ _ / _ _ _ _ Type of transfer:
Merger
Consolidation
Spinoff
Other
EIN _ _ _ _ _ _ _ _ _ PN _ _ _ Date of transfer _ _ /_ _ / _ _ _ _ Type of transfer:
Merger
Consolidation
Spinoff
Other
17 Participation freeze – If, as of the beginning of the premium payment year, this plan is closed to new entrants, enter the date the plan became closed
to new entrants _ _/_ _/_ _ _ _ .
18 Accrual freeze – If, as of the beginning of the premium payment year, benefit accruals under this plan are partially or totally frozen, enter the date the
freeze became effective_ _/_ _/_ _ _ _ and check box that best describes the nature of the freeze:
For all participants, both pay and service are frozen
For all participants, service is frozen, pay is not
For some participants, both pay and service are frozen
For some participants, service is frozen, pay is not
Other (enter explanation)_________________________________________________________________________________________
19 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 _ _ _.
c If the reason for amending the filing is other than reconciling an estimated Variable-rate Premium and the total premium reported in this amended
filing (item 9) is less than the amount reported in the filing that is being amended, provide an explanation of why an amended filing is necessary:
__________________________________________________________________________________________
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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 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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Uploaded Filing paid using Other payment alternative
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This form is for illustrative purposes only.
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:
EIN _ _ _ _ _ _ _ _ _ PN _ _ _. Otherwise, skip to item 4c(3).
(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 $42; Multiemployer plans, enter $12)
______________
(2) Participant count as of participant count date
______________
(3) Flat-rate premium (item 5b(1) x item 5b(2))
______________
84
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 small employer cap applicable to certain plans of small employers (those with 25 or fewer
employees), check box . If box is checked, items 7c through 7g 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
st
1 segment ____%
2nd segment ____%
3rd 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 Uncapped variable-rate premium (item 7f x 0.009)
_____________
h Maximum variable-rate premium
_____________
(1) MAP-21 cap ($400 x item 5b(2) )
_____________
(2) Small employer cap, if applicable ($5 x item 5b(2) x item 5b(2)) – Omit this item if plan is not eligible for this cap
_____________
(3) Maximum variable-rate premium — If the plan qualifies for the small employer cap, the lesser of item 7h(1) and 7h(2).
Otherwise, item 7h(1).
_____________
i Variable-rate premium — If the plan qualifies for the small employer cap and item 7g was omitted, item 7h(3). Otherwise, the
lesser of item 7g and item 7h(3).
_____________
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 7i, if applicable)
______________
9 Total premium — If the plan does not qualify for premium proration, item 5b(3) + item 7i, if applicable. If the plan qualifies for
premium proration, item 8b x item 8a ÷ 12.
____________
85
Part V – Payment Information
10 Premium credit
a Payments made previously for this premium payment year
______________
b Outstanding credit from the plan year immediately preceding the premium payment year
______________
c Total (item 10a + item 10b)
______________
11 Amount due (excess, if any, of item 9 over item 10c)
______________
12 Treatment of overpayment
a Excess, if any, of item 10c over item 9
b Treatment of balance (select one):
Credit towards next year’s premium
Refund by check
Refund by electronic funds transfer (EFT). If you select this option, complete item 12c.
c Information for EFT refund:
Type of account
Checking
______________
Savings
Bank routing number _______________________
Account number ___________________
Sub-account number (if any) _________________
Part VI – Miscellaneous Information
13 Final filing – If this is the last filing for this plan, enter the date of event _ _ /_ _ / _ _ _ _ and check box that best describes why filing obligation is
ceasing: Merger/Consolidation
Trusteeship Distribution pursuant to termination
Cessation of covered status
14 New and newly-covered plans – If this filing is for a new plan or a newly-covered plan, report the adoption date _ _ /_ _ / _ _ _ _ and the plan
coverage date _ _ /_ _ / _ _ _ _.
15 Transfers from other plans – If another plan transferred assets or liabilities to this plan since the most recent comprehensive premium filing, provide
the following information with respect to each plan from which assets or liabilities were transferred (if transfer involved a new or newly-covered plan,
see instructions).
EIN _ _ _ _ _ _ _ _ _ PN _ _ _ Date of transfer _ _ /_ _ / _ _ _ _ Type of transfer:
Merger
Consolidation
Spinoff
Other
EIN _ _ _ _ _ _ _ _ _ PN _ _ _ Date of transfer _ _ /_ _ / _ _ _ _ Type of transfer:
Merger
Consolidation
Spinoff
Other
16 Transfers to other plans – If this plan transferred assets or liabilities to another plan since the most recent comprehensive premium filing, provide the
following information with respect to each plan to which the assets or liabilities were transferred (if transfer involved a new or newly-covered plan, see
instructions).
EIN _ _ _ _ _ _ _ _ _ PN _ _ _ Date of transfer _ _ /_ _ / _ _ _ _ Type of transfer:
Merger
Consolidation
Spinoff
Other
EIN _ _ _ _ _ _ _ _ _ PN _ _ _ Date of transfer _ _ /_ _ / _ _ _ _ Type of transfer:
Merger
Consolidation
Spinoff
Other
17 Participation freeze – If, as of the beginning of the premium payment year, this plan is closed to new entrants, enter the date the plan became closed
to new entrants _ _/_ _/_ _ _ _ .
18 Accrual freeze – If, as of the beginning of the premium payment year, benefit accruals under this plan are partially or totally frozen, enter the date the
freeze became effective_ _/_ _/_ _ _ _ and check box that best describes the nature of the freeze:
For all participants, both pay and service are frozen
For all participants, service is frozen, pay is not
For some participants, both pay and service are frozen
For some participants, service is frozen, pay is not
Other (enter explanation)_________________________________________________________________________________________
19 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 _ _ _.
c If the reason for amending the filing is other than reconciling an estimated Variable-rate Premium and the total premium reported in this amended
filing (item 9) is less than the amount reported in the filing that is being amended, provide an explanation of why an amended filing is necessary:
__________________________________________________________________________________________
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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 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 | 2012-09-11 |
| File Created | 2012-09-11 |