Form 10 Form 10 Post-Event Notice of Reportable Events

Reportable Events

Form-10_Revised_Clean

Reportable Events

OMB: 1212-0013

Document [docx]
Download: docx | pdf

Shape1


POST-EVENT NOTICE OF REPORTABLE EVENTS

PBGC Form 10

OMB #1212-0013

Shape2 Expires xxxxxxxx



This form is used by a plan administrator or contributing sponsor of a single-employer plan when notifying the Pension Benefit Guaranty Corporation that a reportable event has occurred. For questions regarding this form, contact (202) 326-4070 or post- [email protected]

Shape3

Shape4

IDENTIFYING INFORMATION





Plan name


Name of authorized contact at filer

Name of filer


Title of contact

Street address of filer


Email address of contact

City, State, Zip


Street address of contact

Shape5
Shape6












EIN of contributing sponsor Plan number City, State, Zip


Shape11 Shape10 Filer is: Plan administrator

Contributing sponsor Telephone number of contact Ext

Shape12


Shape13 Active participant reduction

Shape14 Shape15 Shape16 Failure to make required contributions under $1M Inability to pay benefits when due

Shape17 Distribution to a substantial owner Transfer of benefit liabilities

Change in controlled group Liquidation

Shape18 Shape19 Shape20 Shape21 Shape22 Shape23 Extraordinary dividend or stock redemption Application for minimum funding waiver Loan Default

Insolvency or similar settlement


Shape24













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


Shape25


Shape26

Active Participant Reduction


Shape28


Shape29 Shape30 Single cause event - statement explaining the cause of the reduction (e.g., facility shutdown or sale, discontinued operations, winding down of the company, or reduction in force).

Attrition event - statement of factors involved in the attrition


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

Shape31 Shape32 Description of the plan’s controlled group structure, including the name of each controlled group member

Shape33 Actuarial Information (see instructions)

Shape34 Company financial information (see instructions)

(e.g., frozen plan, aging workforce, improved operational

efficiencies that do not require replacing departing active participants, or single causes that do not meet the reporting threshold of a single-cause event)

Shape35 Shape36 Shape37 Number of active participants at the date the event occurs and at the beginning of the plan year in which the event occurred. Description of the plan's controlled group structure, including the name of each controlled group member

Actuarial Information (see instructions)

Company financial information (see instructions)




Shape38

Failure to Make Required Contributions


Shape39

Distribution to a Substantial Owner


Shape40


Shape41 Name, address and phone number of person receiving the distribution(s)

Shape42 Shape43 Shape44 Amount, form and date of each distribution Reason for distribution

Description of the plan’s controlled group structure, including

Shape45 Shape46 the name of each controlled group member Actuarial Information (see instructions) Company financial information (see instructions)

Shape47

Transfer of Benefit Liabilities


Shape48


Shape49 Shape50 Due date and amount of the missed contribution Due date and amount of the next payment due

Shape51 Due date and amount of all contributions not timely made and not reported on the last Schedule SB filed

Shape52 Date and amount of any contribution(s) made related to the missed contribution(s)

Shape53 Evidence of any amount paid related to the missed contribution (cancelled check, wire transfer, asset statement)

Shape54 Reason contribution was not made by due date

Shape55 Description of the plan's controlled group structure, including the name of each controlled group member


Shape56 Name of each plan maintained by any member of the plan’s controlled group, its contributing sponsor(s) and EIN/PN

Shape57 Actuarial Information (see instructions)

Shape58 Company financial information (see instructions)

Shape59

Inability to Pay Benefits When Due


Shape60

Shape61 Date of any missed benefit payment and amount of benefits due


Shape62 Next date on which the plan is expected to be unable to pay benefits, the amount of the projected shortfall, and the number of plan participants expected to be affected

Shape63 Amount of the plan’s liquid assets at the end of the quarter, and the amount of its disbursements for the quarter

Shape64 Name, address and phone number of plan trustee (and of any custodian)


Shape65 Most recent pension plan document(s)

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

Shape66 Shape67 Description of the transferor and transferee's controlled group structures, including the name of each controlled group member

Shape68 Explanation of the actuarial assumptions used in determining the value of benefit liabilities (and, if appropriate, plan assets) transferred

Shape69 Estimate of the assets, liabilities, and number of participants whose benefits are transferred (liabilities and participants should be broken down by status - active, term vested, and retirees)

Shape70 Financial Information for the transferor and transferee's controlled group (see instructions)

Shape71 Actuarial Information (see instructions)


Shape72

Change in Controlled Group


Shape73

Shape74 Description of the plan’s old and new controlled group structures, including the name of each controlled group member

Shape75 Name of each plan maintained by any member of the plan's old and new controlled groups, its contributing sponsor(s) and EIN/PN

Shape76 Financial Information for the old and new controlled group (see instructions)

Shape77 Actuarial Information (see instructions)


Shape78


Shape79 Shape80

Liquidation

Application for Minimum Funding Waiver


Shape81 Shape82


Shape83 Description of the plan's controlled group structure before and after the liquidation, including the name of each controlled group member

Shape84 Operational status of each controlled group member (in Chapter 7 proceedings, liquidating outside of bankruptcy, on-going, etc.)

Shape85 Name of each plan maintained by any member of the plan's controlled group, its contributing sponsor(s) and EIN/PN

Shape86 Actuarial Information (see instructions)

Shape87 Company financial information (see instructions)

Shape88 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



Shape89

Shape90 Extraordinary Dividend or Stock Redemption

Copy of waiver application, with all attachments

Shape91 Shape92 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

Shape93

Loan Default


Shape94


Shape95 Copy of the relevant loan documents (e.g., promissory note, security agreement, loan agreement amendments and waivers)

Shape96 Due date and amount of any missed payment

Shape97 Copy of any written notice of default or any notice of acceleration from lender, any notice of forbearance, or loan agreement amendment or waiver

Shape98 Shape99 Shape100 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

Actuarial Information (see instructions)

Shape101 Company financial information (see instructions)

Shape102

Insolvency or Similar Settlement


Shape103


Shape104 Date and amount of cash distribution(s) during fiscal year

Shape105 Description, fair market value, and date or dates of any non-cash distributions

Shape106 Statement whether the recipient was a member of the plan's controlled group

Shape107 Description of the plan's controlled group structure, including the name of each controlled group member

Shape108 Actuarial Information (see instructions)

Shape109 Company financial information (see instructions)

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

Shape110 Shape111 Docket number of court filing and location of the court where any relevant proceeding was or will be filed (if known)

Shape112 Description of the plan’s controlled group structure, including the name of each controlled group member

Shape113 Name of each plan maintained by any member of the plan’s controlled group, its contributing sponsor(s) and EIN/PN

Shape114 Actuarial Information (see instructions)

Shape115 Company financial information (see instructions)




Shape116















Shape117



Date of Event Notice Due Date



Notice Filing Date (if late, explain below)

Shape121

If filing is late or an extension is claimed, explain below. See the instructions for when an extension may be claimed for an Active Participant Reduction event or a Liquidation event.













Shape122

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

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitlePBGC Form 10
SubjectForm 10
AuthorPBGC
File Modified0000-00-00
File Created2021-06-15

© 2024 OMB.report | Privacy Policy