Suspension of Benefits Under the Multiemployer Pension Reform Act of 2014

APPENDIX C

CHECKLIST - IS THE SUBMISSION COMPLETE?

Instructions The application must include a completed checklist placed on top of the application.  This will help ensure that the application is complete.  Answer each question in the checklist by circling Y for yes, N for no or N/A for not applicable, as appropriate, in the blank next to the item.  Also insert in the appropriate blank next to each item the page number or numbers where the item appears in the application.

APPLICATION FOR APPROVAL OF BENEFIT SUSPENSION FOR [INSERT NAME OF PLAN]

Response	Item number	Description of item	Page number in application
Yes No N/A	1.	Does the application include an original signature of the plan sponsor or an authorized representative of the plan sponsor. See section 2.01.
Yes No N/A	2.	Does the application include a description of the proposed benefit suspension - calculated as if no other limitations apply - that includes: the suspension’s effective date (and its expiration date, if applicable), a description of the different categories or groups of individuals affected, and how the suspension affects these individuals differently. See section 2.02.
Yes No N/A	3.	Does the application include a penalties-of-perjury statement signed by an authorized trustee on behalf of the board of trustees. See Section 2.03.
Yes No N/A	4.	Does the application include a statement, signed by an authorized trustee on behalf of the board of trustees, acknowledging that the application and the application’s supporting material will be publicly disclosed on the Treasury Department’s website. See section 2.04.
Yes No N/A	5.	Does the application include the plan actuary’s certification of critical and declining status and the supporting illustrations, including: the year-by-year projections demonstrating projected insolvency during the relevant period and separately identifying the available resources (and the market value of assets and changes in cash flow) during each of those years. See section 3.01.
Yes No N/A	6.	Does the application describe the assumptions used. See section 3.01.
Yes No N/A	7.	Does the application include the plan actuary’s certification that the plan is projected to avoid insolvency if the suspension takes effect and the supporting illustrations, including: the year-by-year projections demonstrating projected solvency during the relevant period and separately identifying the available resources (and the market value of assets and changes in cash flow)during each of those years. See section 3.02.
Yes No N/A	8.	Does the application include the plan sponsor’s determination of projected insolvency that includes the documentation set forth in section 5 of the revenue procedure. See section 3.03.
Yes No N/A	9.	Does the application include a demonstration that the limitations on individual suspensions are satisfied, including calculations regarding: the guarantee-based limitation, the disability-based limitation, and the age-based limitation. See section 4.01.
Yes No N/A	10.	Does the application include a demonstration that the proposed suspension is reasonably estimated to achieve the level necessary to avoid insolvency for the extended period, including illustrations regarding the plan’s solvency ratio and available resources. See section 4.02(1).
Yes No N/A	11.	Does the application include the required illustration utilizing stochastic projections. (This illustration is not required if the plan is not required to appoint a retiree representative under § 432(e)(9)(B)(v)(I) and stochastic projections were not used in making the required determination.) See section 4.02(2).
Yes No N/A	12.	Does the application include a demonstration that the proposed suspension is not projected to materially exceed the level necessary to avoid insolvency, including illustrations regarding the plan’s solvency ratio and available resources. See section 4.03.
Yes No N/A	13.	Does the application include a demonstration that the proposed suspension is equitably distributed, including a list of the factors taken into account, an explanation of why none of the factors listed in § 432(e)(9)(D)(vi) were taken into account (if applicable), and how any difference in treatment among categories or groups of individuals results from a reasonable application of the relevant factors. See section 4.04.
Yes No N/A	14.	Does the application include a copy of the actual notices (including redacted sample calculations) that meet the requirements under § 432(e)(9)(F). See section 4.05(1).
Yes No N/A	15.	Does the application include a description of the efforts that are being taken to contact participants, beneficiaries in pay status, and alternate payees. See section 4.05(2).
Yes No N/A	16.	Does the application describe the steps the plan sponsor has taken to ensure that notices delivered electronically are reasonably accessible to the recipients. See section 4.05(3)
Yes No N/A	17.	Does the application include a list of each employer who has an obligation to contribute under the Plan and each employee organization representing participants under the Plan. See section 4.05(4).
Yes No N/A	18.	Does the application include information on past and current measures taken to avoid insolvency. See section 5.01.
Yes No N/A	19.	Does the application include the plan information required by section 5.02.
Yes No N/A	20.	Does the application describe how the plan sponsor took into account – or did not take into account – the factors listed in section 5.02 in the determination that all reasonable measures were taken to avoid insolvency. See section 5.03.
Yes No N/A	21.	Does the application describe how the plan sponsor took into account - or did not take into account - in the determination that all reasonable measures have been taken to avoid insolvency the impact of benefit and contribution levels on retaining active participants and bargaining groups under the plan, and past and anticipated contribution increases under the plan on employer attrition and retention levels. See section 5.03.
Yes No N/A	22.	Does the application include a discussion of any other factors the plan sponsor took into account including how and why those factors were taken into account. See section 5.04.
Yes No N/A	23.	Does the application include a copy of the proposed ballot. See section 6.01.
Yes No N/A	24.	Does the application indicate whether the plan sponsor is requesting approval from the PBGC of a proposed partition under section 4233 of ERISA. See section 6.02.
Yes No N/A	25.	If the answer to item 24 is yes, does the application specify the effective date of the proposed partition and include a year-by-year projection of the amount of the reduction in benefit payments attributable to the partition. See section 6.02.
Yes No N/A	26.	Does the application describe the plan’s experience with certain critical assumptions, including a disclosure for each of the 10 plan years immediately preceding the application that separately identifies total contributions, total contribution base units, average contribution rates, withdrawal liability payments, and the rate of return on plan assets. See section 6.03.
Yes No N/A	27.	Does the application include deterministic projections of the sensitivity of the plan’s solvency ratio throughout the extended period by taking into account more conservative assumptions of investment experience and future contribution base units than assumed elsewhere in the application. See section 6.04.
Yes No N/A	28.	Does the plan include deterministic projections for each year in the extended period of the value of plan assets, the plan’s accrued liability, and the plan’s funded percentage. See section 6.05.
Yes No N/A	29.	Does the application include the plan sponsor’s representation that, if it receives the Treasury Department’s final authorization to suspend and then chooses to implement the suspension, it will also amend the plan to indicate that the suspension will cease upon the plan sponsor’s failure to determine that both all reasonable measures continue to be taken to avoid insolvency and that the plan is projected to become insolvent without a suspension, to require that any future benefit improvements must satisfy § 432(e)(9)(E), and to specify that the plan sponsor will not modify these amendments, notwithstanding any other provision of the plan document. See section 6.06.
Yes No N/A	30.	Does the application indicate whether the plan is a plan described in § 432(e)(9)(D)(vii)(III) and, if so, how is that fact reflected in the proposed benefit suspension. See section 6.07.
Yes No N/A	31.	Does the application include the required plan sponsor information, including name address telephone number email address fax number employer identification number (EIN) and 3-digit plan number (PN). See section 7.01.
Yes No N/A	32.	Does the application include the required plan identification information. See section 7.02.
Yes No N/A	33.	Does the application include the required retiree representative information (if applicable). See section 7.03.
Yes No N/A	34.	Does the application include the required enrolled actuary information. See section 7.04.