Form 3 Application for Financial Assistance - Initial

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Application for Financial Assistance - Initial
*Required fields
*Plan name: MEPD Test Pension Plan
*EIN: 11-1111111

(ex. 33-3333333)

*PN: 002

(ex. 333)

*Notice filer name: Zjfh Xceu Rkgsy
*Role of filer:

Accountant

*Insolvency year for which the notice is being
2019
filed:

(YYYY)

*Total amount requested: $ 123.00
*Amount for benefits: $ 234.00
*Amount for expenses: $ 345.00
Projected income: $ 456.00
Amount of current cash on-hand: $ 567.00
Current cash as of date:

5/30/2019

(MM/DD/YYYY)

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Application for Financial Assistance - Initial
Attached Documents
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Documents 1 - 11 are necessary for this filing. If any of these documents are not available,
provide an explanation in the "Comments" box below.
Documents 12 - 22 should be included when applicable to the current filing.
Comments:

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follow the prompts. For additional assistance, please contact us at
[email protected] or 1-800-736-2444 (ext. 3993 or 6047). Local callers
may directly dial 202-326-4000 (ext. 3993 or 6047).

1. Financial assistance request letter
File 1.docx

Delete

2. Financial assistance spreadsheet (bank reconciliation)
File 2.docx

Delete

3. Plan's most recent financial statement (audited, or unaudited if audited not available)
File 3.docx

Delete

4. List of all cash and investment accounts maintained for the plan
File 4.docx

Delete

5. Bank statements for all cash and investment accounts since last audited financial statement
File 5.docx

Delete

6. Check registers since last audited financial statement
File 6.docx

Delete

7. Benefit payment registers since last audited financial statement
File 7.docx

Delete

8. Benefit calculations and supporting data (i.e. accrued benefit, years of service, and etc.) of the benefit
cutbacks to PBGC guaranteed level

File 8.docx

Delete

9. Pension plan documents, all versions available, and all amendments signed and dated
File 9.docx

Delete

10. Names, addresses, and employer relationships of all Trustees(s)
File 10.docx

Delete

11. Participant database
File 11.docx

Delete

12. Latest annual return/report of employee benefit plan (Form 5500)
13. Most recent actuarial valuation for the plan

14. Projected budget for funding period (estimated income, benefit payments and expenses (include copies
of pending invoices to be paid))
15. Copy of insurance contract/policy in place to cover this plan in accordance with DOL requirements
16. Results/report of the latest death search conducted (also indicate frequency at which searches are
performed)
17. Signed contracts or agreements with service providers of the plan
18. Retainer agreements with any professionals held on retainer
19. Paid invoices or receipts for all expenses paid for by the plan from the date of the last audited financial
statement to the date of the financial assistance request
20. Unpaid or pending invoices for all services or expenses outstanding for the plan
21. Description of calculation methodology for any expenses shared between multiple plans and allocated
22. Other

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Data Summary

Application for Financial Assistance - Initial
MEPD Test Pension Plan - 11-1111111/002

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Plan Filing Information

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Plan name:

MEPD Test Pension Plan

EIN / PN:

11-1111111/002

Notice filer name:

Zjfh Xceu Rkgsy

Role of filer:

Accountant

Insolvency year for which the notice is being filed:

2019

Total amount requested:

$123.00

Amount for benefits:

$234.00

Amount for expenses:

$345.00

Projected income:

$456.00

Amount of current cash on-hand:

$567.00

Current cash as of date:

5/30/2019

Attached Documents

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Financial assistance request letter
Financial assistance spreadsheet (bank reconciliation)
Plan's most recent financial statement (audited, or unaudited if audited not available)
List of all cash and investment accounts maintained for the plan
Bank statements for all cash and investment accounts since last audited financial statement
Check registers since last audited financial statement
Benefit payment registers since last audited financial statement
Benefit calculations and supporting data (i.e. accrued benefit, years of service, and etc.) of the benefit
cutbacks to PBGC guaranteed level
Pension plan documents, all versions available, and all amendments signed and dated
Names, addresses, and employer relationships of all Trustees(s)

Participant database
Latest annual return/report of employee benefit plan (Form 5500)
Most recent actuarial valuation for the plan
Projected budget for funding period (estimated income, benefit payments and expenses (include copies of
pending invoices to be paid))

Copy of insurance contract/policy in place to cover this plan in accordance with DOL requirements
Results/report of the latest death search conducted (also indicate frequency at which searches are performed)
Signed contracts or agreements with service providers of the plan
Retainer agreements with any professionals held on retainer
Paid invoices or receipts for all expenses paid for by the plan from the date of the last audited financial
statement to the date of the financial assistance request
Unpaid or pending invoices for all services or expenses outstanding for the plan
Description of calculation methodology for any expenses shared between multiple plans and allocated
Other
Comments
N/A

CONFIDENTIAL

PBGC
Application for Financial Assistance - Initial
Plan Filing Information
Plan name:

MEPD Test Pension Plan

EIN/PN:

11-1111111/002

Notice filer name:

Zjfh Xceu Rkgsy

Role of filer:

Accountant

Insolvency year for which the
notice is being filed:

2019

Total amount requested:

$123.00

Amount for expenses:

$345.00

Current cash as of date :

30-MAY-2019

Date of request:
Amount for benefits:

$234.00

Projected income:

$456.00

Amount of current cash onhand:

$567.00

Submission status - Filing not yet submitted

CONFIDENTIAL

Attached Documents
Financial assistance request letter

Go To Data Summary

Financial assistance spreadsheet (bank reconciliation)
Plan's most recent financial statement (audited, or unaudited if audited not available)
List of all cash and investment accounts maintained for the plan
Bank statements for all cash and investment accounts since last audited financial statement
Check registers since last audited financial statement
Benefit payment registers since last audited financial statement
Benefit calculations and supporting data (i.e. accrued benefit, years of service, and etc.) of the benefit cutbacks
to PBGC guaranteed level
Pension plan documents, all versions available, and all amendments signed and dated
Names, addresses, and employer relationships of all Trustees(s)
Participant database
Latest annual return/report of employee benefit plan (Form 5500)
Most recent actuarial valuation for the plan
Projected budget for funding period (estimated income, benefit payments and expenses (include copies of
pending invoices to be paid))

Copy of insurance contract/policy in place to cover this plan in accordance with DOL requirements
Results/report of the latest death search conducted (also indicate frequency at which searches are performed)
Signed contracts or agreements with service providers of the plan
Retainer agreements with any professionals held on retainer
Paid invoices or receipts for all expenses paid for by the plan from the date of the last audited financial statement
to the date of the financial assistance request
Unpaid or pending invoices for all services or expenses outstanding for the plan
Description of calculation methodology for any expenses shared between multiple plans and allocated
Other
Missing Information If required information has not been submitted, explain below.

Submission status - Filing not yet submitted
Go To Data Summary