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pdfAPPENDIX 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
Yes No
N/A
Item
number
1.
Description of item
Does the application include an original signature of the plan sponsor or an
authorized representative of the plan sponsor? See section 2.01.
Page number
in application
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),
• whether the suspension provides for different treatment of participants and
beneficiaries,
• 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 plan-year-by-plan-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, including the new entrant profile, the total contribution base units, and the average contribution
rates? 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 plan-year-by-plan-year projections demonstrating projected solvency during the
relevant period,
• a description of the assumptions used, including the new entrant
profile, the total contribution base units, and the average contribution rates, 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.
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Response
Yes No
N/A
Item
number
8.
Description of item
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:
• information on the effect of the suspension on the plan in the aggregate,
• information on the effect of the suspension for different categories or groups,
• 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),
• for each factor taken into account that is not one of the factors listed in
§ 432(e)(9)(D)(vi), an explanation why the factor is relevant, 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 notices (excluding personally
identifiable information) 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)
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Page number
in application
May 9, 2016
Response
Yes No
N/A
Item
number
17.
Description of item
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, excluding the
information regarding the statement in opposition, the individualized estimate, and the voting procedures? See section 6.01.
Yes No
N/A
24.
Does the application indicate whether the plan sponsor is requesting approval from 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 plan-year-by-plan-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.
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Page number
in application
Bulletin No. 2016 –19
Response
Yes No
N/A
Item
number
27.
Description of item
Does the application include deterministic projections of the sensitivity of
the plan’s solvency ratio throughout the extended period by taking into
account the more conservative assumptions of investment experience and
future contribution base units than assumed elsewhere in the application?
See section 6.04.
Page number
in application
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 would not be projected to avoid insolvency
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) 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.
Yes No
N/A
35.
Does the application include a designation of power of attorney for each
authorized representative who will represent the plan sponsor in connection
with the application? See section 7.05 and Appendix B.
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Response
Yes No
N/A
Item
number
36.
Page number
in application
Description of item
Does the application include:
• the required plan documents,
• any recent amendments,
• the summary plan description (SPD),
• the summary of material modifications, and
• the most recent determination letter?
See section 7.06.
Yes No
N/A
37.
Does the application include the required excerpts from the relevant collective bargaining agreements and side agreements? See section 7.07.
Yes No
N/A
38.
Does the application include the required excerpts from the most recently
filed Form 5500? See section 7.08.
Yes No
N/A
39.
Does the application include the most recently updated rehabilitation plan?
See section 7.09.
Yes No
N/A
40.
Does the application include this checklist, completed and placed on top of
the application? See section 7.10.
Yes No
N/A
41.
If the application is being submitted for resubmission review, does the application include:
• a statement that the application is being submitted for resubmission
review, and
• the date on which the Treasury Department gave approval to submit an
application for resubmission review?
See section 8.
Signature
Date
Title or Authority
Typed or printed name of person signing checklist
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| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |