Form 10 Advance

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ADVANCE NOTICE
OF REPORTABLE EVENTS
PBGC Form 10-Advance OMB #1212-0013
Expires xxxxxxxxxxx







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.


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