Form 4 Application for Financial Assistance - Recurring

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Application for Financial Assistance - Recurring
*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
2018
filed:

(YYYY)

*Date range for funds requested period: From: 04/06/2019

(MM/DD/YYYY)

*To: 04/30/2019

(MM/DD/YYYY)

*Total amount requested: $ 123
*Amount for benefits: $ 123
*Amount for expenses: $ 123
Projected income: $ 123
Amount of current cash on-hand: $ 123
Current cash as of date:

12/04/2018

(MM/DD/YYYY)

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Application for Financial Assistance - Recurring
Attached Documents
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Documents 1 - 8 are necessary for this filing. If any of these documents are not available,
provide an explanation in the "Comments" box below.
Documents 9 - 15 should be included when applicable to the current filing.
Comments:

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may directly dial 202-326-4000 (ext. 3993 or 6047).

1. Financial assistance request letter
2. Financial assistance spreadsheet (bank reconciliation)
3. Bank statements for all cash and/or investment accounts for the period being submitted for reconciliation
4. Check registers since last financial assistance request
5. Benefit payment registers since last financial assistance request
6. Benefit packages
7. Results/report of death searches conducted for the months of the period submitted for reconciliation
8. Paid invoices or receipts for all expenses paid for by the plan for the period being submitted for
reconciliation
9. Projected budget for funding period (estimated income, benefit payments and expenses (include copies of
pending invoices to be paid))
10. Monthly reconciliation of participants/beneficiaries for the period being submitted for reconciliation. This
should include participants placed into pay, removed from pay, or suspended on a monthly basis
11. Any new signed contracts, agreements (including retainer agreements) with service providers and
professionals of the plan entered into since the date of the last financial assistance request
12. Calculation of any expenses shared between multiple plans and allocated to the plan for the period
being submitted for reconciliation

13. Unpaid or pending invoices for all services or expenses outstanding for the plan
14. Retroactive requests
15. Other

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Data Summary

Application for Financial Assistance - Recurring
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:

2018

Date range for funds requested period:

From: 4/6/2019 To: 4/30/2019

Total amount requested:

$123.00

Amount for benefits:

$123.00

Amount for expenses:

$123.00

Projected income:

$123.00

Amount of current cash on-hand:

$123.00

Current cash as of date:

12/4/2018

Attached Documents

Edit

Financial assistance request letter
Financial assistance spreadsheet (bank reconciliation)
Bank statements for all cash and/or investment accounts for the period being submitted for reconciliation
Check registers since last financial assistance request
Benefit payment registers since last financial assistance request
Benefit packages
Results/report of death searches conducted for the months of the period submitted for reconciliation
Paid invoices or receipts for all expenses paid for by the plan for the period being submitted for reconciliation
Projected budget for funding period (estimated income, benefit payments and expenses (include copies of
pending invoices to be paid))

Monthly reconciliation of participants/beneficiaries for the period being submitted for reconciliation. This
should include participants placed into pay, removed from pay, or suspended on a monthly basis
Any new signed contracts, agreements (including retainer agreements) with service providers and
professionals of the plan entered into since the date of the last financial assistance request
Calculation of any expenses shared between multiple plans and allocated to the plan for the period being
submitted for reconciliation
Unpaid or pending invoices for all services or expenses outstanding for the plan
Retroactive requests
Other

Comments
N/A

CONFIDENTIAL

PBGC
Application for Financial Assistance - Recurring
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:

2018

Date of funds request from:

06-APR-2019

Date of funds request to:

30-APR-2019

Total amount requested:

$123.00

Amount for expenses:

$123.00

Current cash as of date :

04-DEC-2018

Date of request:
Amount for benefits:

$123.00

Projected income:

$123.00

Amount of current cash onhand:

$123.00

Submission status - Filing not yet submitted

CONFIDENTIAL

Attached Documents
Financial assistance request letter
Financial assistance spreadsheet (bank reconciliation)
Bank statements for all cash and/or investment accounts for the period being submitted for reconciliation
Check registers since last financial assistance request
Benefit payment registers since last financial assistance request
Benefit packages
Results/report of death searches conducted for the months of the period submitted for reconciliation
Paid invoices or receipts for all expenses paid for by the plan for the period being submitted for reconciliation
Projected budget for funding period (estimated income, benefit payments and expenses (include copies of
pending invoices to be paid))

Monthly reconciliation of participants/beneficiaries for the period being submitted for reconciliation. This should
include participants placed into pay, removed from pay, or suspended on a monthly basis
Any new signed contracts, agreements (including retainer agreements) with service providers and professionals
of the plan entered into since the date of the last financial assistance request
Calculation of any expenses shared between multiple plans and allocated to the plan for the period being
submitted for reconciliation
Unpaid or pending invoices for all services or expenses outstanding for the plan
Retroactive requests
Other

Missing Information If required information has not been submitted, explain below.

Submission status - Filing not yet submitted
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