| WITHDRAWAL LIABILITY INFORMATION |
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| Contact Information |
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Plan Name: |
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Contact Person Position: |
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EIN/PN: |
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Phone Number: |
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Contact Person: |
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E-mail Address: |
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| Questions |
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| Please answer the following questions and fill out the schedule below for specific information about employers. |
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| What industry does the plan primarily cover? |
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| If any withdrawal liability has not been assessed, explain why. |
Examples: Construction exemption / No UVB allocable / Bankruptcy of employer |
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| How many employers that have withdrawn from the plan in the last ten years were not assessed withdrawal liability? |
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Estimate the total withdrawal liability not assessed for the employers that have withdrawn from the plan in the last ten years that were not assessed withdrawal liability, if known. |
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| Please enter any additional comments you think may be relevant here. |
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| Withdrawal Liability Schedule |
|
Please fill out the following table for all contributing employers that owe withdrawal liability, or owed withdrawal liability in the last 10 years (or for a longer period if records are available).
The first rows contains example data. |
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Settlement Information |
Payment Plan Information |
Payments Received |
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| (1) |
(2) |
(3) |
(4) |
(5) |
(6) |
(7) |
(8) |
(9) |
(10) |
(11) |
(12) |
(13) |
(14) |
(15) |
(16) |
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| Employer Name |
Date of Withdrawal |
Employer EIN |
Original UVB alloc |
Scheduled Years of Payments (max 20) Initial Withdrawal Liability |
Mass Withdrawal Date (if any) |
Additional Mass Withdrawal Liability |
Years of payments after Mass Withdrawal |
Statutory Annual Withdrawal Liability Payment (4219(c)(1)) |
Actual Annual Withdrawal Liability Payment, if different |
Amount Settled in a Lump Sum |
Lump Sum Settlement Date |
On Payment Plan? |
Current on Payments? |
Date of Last Payment |
Total Payments Received |
|
| Company A |
1/1/2006 |
111111111 |
$10,000,000 |
20.00 |
1/1/2008 |
$12,000,000 |
infinite |
$700,000 |
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N/A |
N/A |
Yes |
Yes |
N/A |
N/A |
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| Company B |
1/1/2007 |
222222222 |
$10,000,000 |
15.00 |
1/1/2008 |
$12,000,000 |
30 |
$1,100,000 |
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$5,000,000 |
10/1/2008 |
Yes |
Yes |
N/A |
N/A |
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| Company C |
1/1/2008 |
333333333 |
$10,000,000 |
12.50 |
1/1/2008 |
$12,000,000 |
24 |
$1,225,000 |
$1,000,000 |
N/A |
N/A |
No |
No |
1/1/2010 |
$2,000,000 |
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| Company D |
1/1/2008 |
444444444 |
$10,000,000 |
10.25 |
1/1/2008 |
$12,000,000 |
19 |
$1,395,000 |
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$2,000,000 |
10/1/2008 |
No |
Yes |
N/A |
N/A |
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| Total |
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$40,000,000 |
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$48,000,000 |
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$4,420,000 |
$1,000,000 |
$7,000,000 |
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$2,000,000 |
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