Form 5 Combined Notice of Insolvency and Notice of Insolvency B

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Combined Notice of Insolvency and Notice of Insolvency Benefit Level
*Required fields
*Plan name: Example Plan
*EIN: 00-0000001

(ex. 33-3333333)

*PN: 001

(ex. 333)

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

Accountant

Plan Sponsor Information
*Plan sponsor name: Plan Sponsor
*Address: Pbgc Way

*City: Washington
*State:

DC

*Zip Code: 20005
*Telephone: 215-987-9878

(ex. 12345-1234)
(ex. 202-111-1111)

E-mail address:

Ext.
(ex. [email protected])

Fax:

(ex. 202-111-1111)

Plan Sponsor’s Duly Authorized Representative (if any)
First name:
Last name:
Company:
Title:
Address:

City:
State:
Zip Code:
Telephone:
E-mail address:

- select a state (ex. 12345-1234)
(ex. 202-111-1111)

Ext.
(ex. [email protected])

Fax:

*The Plan is/will be
insolvent under:

(ex. 202-111-1111)

Mass Withdrawal (Sec. 4281)
Ongoing/Critical Status (Sec. 4245)

*Insolvency year for which
2018
the notice is being filed:

(YYYY)

*The estimated amount of annual benefit payments under the plan (determined without regard to the
insolvency) for the insolvency year:
$ 98.00
*The estimated amount of the plan’s available resources for the insolvency year:
$ 65.00
*The estimated amount of the annual benefits guaranteed by PBGC for the insolvency year:
$ 32.00
*Estimated month of
12
insolvency:

(MM)

The amount of financial assistance, if any, requested from PBGC:
$ 12,345.00

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Combined Notice of Insolvency and Notice of Insolvency Benefit Level
Attached Documents
Click here for additional instructions.
Documents 1 - 3 listed below are required for all filings.
Documents 4 and 5 are only required if they have not previously been submitted to PBGC.
Provide an explanation in the “Comments” box for any missing documents.
Comments: No 4 or 5 needed

File:
Document
Type:

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Maximum file size is 25MB. It may take a minute or two to attach large files. Please click
only once. To send files larger than 25MB, please click on this link:
http://PBGC.leapfile.com, click "Secure Upload", enter the recipient's email address, and
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).

*Required documents
1. *Most recent actuarial valuation for the plan
File 1.docx

Delete

2. *Certification, signed by the plan sponsor (or duly authorized representative), that the combined
notices of insolvency and notices of insolvency benefit level have been given to all interested parties
(defined in 29 CFR 4245.2) for critical status plans or to participants and beneficiaries for plans
terminated by mass withdrawal
File 2.docx

Delete

3. *Sample copy of the combined notice provided to interested parties or to participants and
beneficiaries
File 3.docx

Delete

4. Plan document (Including any amendments/restatements)
5. Most recent copy of the Schedule MB for the plan (if available, and only if the Schedule MB contains more
recent information than the most recent actuarial valuation)
6. Other

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Data Summary

Combined Notice of Insolvency and Notice of Insolvency Benefit Level
Example Plan - 00-0000001/001

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Submit Filing

Plan Filing Information

Edit

Plan name:

Example Plan

EIN / PN:

00-0000001/001

Notice filer name:

Zjfh Xceu Rkgsy

Role of filer:

Accountant

Return to Home Page

Plan Sponsor Information
Name:

Plan Sponsor

Address:

Pbgc Way Washington, DC 20005

Phone:

215-987-9878

Email:

N/A

Fax:

N/A

Plan Sponsor’s Duly Authorized Representative
Name:
Company:

N/A

Title:

N/A

Address:
Phone:

N/A

Email:

N/A

Fax:

N/A

The Plan is/will be insolvent under:

Ongoing/Critical Status (Sec. 4245)

Insolvency year for which the notice is being filed:

2018

The estimated amount of annual benefit payments under
the plan (determined without regard to the insolvency) for $98.00
the insolvency year:
The estimated amount of the plan’s available resources
for the insolvency year:

$65.00

The estimated amount of the annual benefits guaranteed

$32.00

by PBGC for the insolvency year:
Estimated month of insolvency:

12

The amount of financial assistance, if any, requested from
$12,345.00
PBGC:

Attached Documents

Edit

Most recent actuarial valuation for the plan
Certification, signed by the plan sponsor (or duly authorized representative), that the combined notices of
insolvency and notices of insolvency benefit level have been given to all interested parties (defined in 29 CFR
4245.2) for critical status plans or to participants and beneficiaries for plans terminated by mass withdrawal

Sample copy of the combined notice provided to interested parties or to participants and beneficiaries
Plan document (Including any amendments/restatements)
Most recent copy of the Schedule MB for the plan (if available, and only if the Schedule MB contains more
recent information than the most recent actuarial valuation)
Other
Comments
No 4 or 5 needed

CONFIDENTIAL

PBGC
Combined Notice of Insolvency and Notice of Insolvency Benefit Level
Plan Filing Information
Plan name:

Example Plan

EIN/PN:

000000001/001

Notice filer name:

Zjfh Xceu Rkgsy

Role of filer:

Accountant

Plan Sponsor Information
Plan sponsor name:

Plan Sponsor

Address:

Pbgc Way

City:

Washington

State:

DC

Zip:

20005

Telephone:

(215) 987-9878 Ext:

E-mail:

Fax:

Plan Sponsor's Authorized Representative Information
First name:

Last name:

Company:

Title:

Address:

City:

State:

Zip:

Telephone:

Ext:

E-mail:

Fax:

Mass Withdrawal (Sec. 4281)
Ongoing/Critical Status (Sec. 4245)

The Plan is/will be insolvent
under:

2018

Estimated amount of annual
benefit payments under the plan
for the insolvency year:

Estimated amount of the plan's
available resources for the
insolvency year:

$65.00

Estimated amount of annual
benefits guaranteed by PBGC for
the insolvency year:
$32.00

Estimated month of insolvency:

12

Amount of financial assistance, if
any, requested from PBGC:

Insolvency year for which the
notice is being filed:

Submission status - Filing not yet submitted

$98.00

$12,345.00

CONFIDENTIAL

Attached Documents
Most recent actuarial valuation for the plan
Certification, signed by the plan sponsor (or duly authorized representative), that the combined notices of
insolvency and notices of insolvency benefit level have been given to all interested parties (defined in 29 CFR
4245.2) for critical status plans or to participants and beneficiaries for plans terminated by mass withdrawal

Sample copy of the combined notice provided to interested parties or to participants and beneficiaries
Plan document (Including any amendments/restatements)
Most recent copy of the Schedule MB for the plan (if available, and only if the Schedule MB contains more recent
information than the most recent actuarial valuation)
Other
Missing Information If required information has not been submitted, explain below.
No 4 or 5 needed

Submission status - Filing not yet submitted
Go To Data Summary