PBGC Form 10-Advan Advance Notice of Reportable Events

ADVANCE NOTICE

IDENTIFYING INFORMATION

OF REPORTABLE EVENTS

PBGC Form 10-Advance OMB #1212-0013

Expires xxxxxxxxxxx

This form is used by a contributing sponsor of a single-employer plan required to notify the Pension Benefit Guaranty Corporation in advance that a reportable event will occur. For questions regarding this form, contact (202) 326-4070 or advancere[email protected].

Plan Name Name/ title of individual to contact at Filer

Name of contributing sponsor Email address of contact

Street address of contributing sponsor Street address of contact

^{City, state, Zip} City, State, Zip

EIN of contributing sponsor Plan number Telephone number of contact Ext

Change in contributing sponsor or controlled group Liquidation

Extraordinary dividend or stock redemption Transfer of benefit liabilities

Application for minimum funding waiver Loan Default

Insolvency or similar settlement

The next page lists additional information that must be submitted with this form, if not included above.

INFORMATION REQUIRED TO BE FILED

Check box to indicate the item is attached. If not attached, explain on the next page.

Change in Contributing Sponsor or Controlled Group

Description of the plan’s old and new controlled group structures, including the name of each controlled group member

Name of each plan maintained by any member of the plan’s old and new controlled groups, its contributing sponsor(s) and EIN/PN

Actuarial Information (see instructions) Financial Information (see instructions)

Liquidation

Description of the plan's old and new controlled group structure, including the name of each controlled group member

Operational status of each controlled group member (in Chapter 7 proceedings, liquidation outside of bankruptcy, on-going, etc.)

Name of each plan maintained by any number of the plan's controlled group, its contributing sponsor(s) and EIN/PN

Actuarial Information (see instructions) Financial Information (see instructions)

If the plan sponsor resolves to cease all revenue-generating business operations, sell substantially all its assets, or otherwise effect or implement its complete liquidation, also provide:

• Date on which such resolution was made

• Most recent pension plan document(s)

• Address of each controlled group member

• The Internal Revenue Service Determination Letter indicating the plan is a covered plan, if applicable

Extraordinary Dividend or Stock Redemption

Name and EIN of person making the distribution

Date and amount of cash distribution(s) during fiscal year

Description, fair market value, and date or dates of any non-cash distributions

Statement whether the recipient was a member of the plan’s controlled group

Actuarial Information (see instructions) Financial Information (see instructions)

Application for Minimum Funding Waiver

Copy of waiver application, with all attachments

Transfer of Benefit Liabilities

Name, contributing sponsor, EIN/PN, and contact information of transferee plan(s)

Description of the transferor and transferee's controlled group structures, including the name of each controlled group member

Explanation of the actuarial assumptions used in determining the value of benefit liabilities (and, if appropriate, plan assets) transferred

Estimate of the assets, liabilities, and number of participants whose benefits are transferred

Actuarial Information (see instructions)

Financial Information for the transferor and transferee's controlled group (see instructions)

Note: To the extent this information is filed with the IRS Form 5310A, PBGC will accept a copy of that filing.

Loan Default

Copy of the relevant loan documents (e.g., promissory note, security agreement, loan agreement amendments and waivers)

Due date and amount of any missed payment

Copy of any written notice of default or acceleration from lender, any notice of forbearance, or loan agreement amendment or waiver

Description of any cross-defaults or anticipated cross- defaults

Description of the plan's controlled group structure, including the name of each controlled group member

Financial Information (see instructions)

Actuarial Information (see instructions)

Insolvency or Similar Settlement

Name, address and phone number of any trustee, receiver or similar person

Docket number of court filing and location of the court where any relevant proceeding was or will be filed (if known)

Description of the plan’s controlled group structure, including the name of each controlled group member

Name of each plan maintained by any member of the plan’s controlled group, its contributing sponsor(s) and EIN/PN

Actuarial Information (see instructions) Financial Information (see instructions)

Minimum funding projections for the next 5 years (with and without the waiver) including all details supporting the calculations and all assumptions, to the extent not included in the waiver application

Date of Event Notice Due Date

Notice Filing Date (if late, explain below) Filing Extension Claimed (if any, explain below)

^{REASON FOR LATE FILING OR EXTENSION} If filing late or extension is claimed, explain below.

I certify that, to the best of my knowledge and belief, the information submitted in this filing is true, correct, and complete. In making this certification, I recognize that knowingly and willfully making false, fictitious, or fraudulent statements to the PBGC is punishable under 18

U.S.C. § 1001.

Signature of Individual Submitting Form Name and Title of Individual Submitting Form

Telephone Number of Individual Submitting Form Employer of Individual Submitting Form