Form 10 Post-Event Notice of Reportable Events
Reportable Events
Form-10_Revised_Clean
OMB: 1212-0013
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]
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 |
EIN of contributing sponsor Plan number City, State, Zip
Filer
is: Plan administrator
Contributing sponsor Telephone number of contact Ext
Active
participant reduction
Failure
to make
required contributions
under $1M
Inability to
pay benefits
when due
Distribution
to a substantial owner Transfer of benefit liabilities
Change in controlled group Liquidation
Extraordinary
dividend or
stock redemption
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.
Active Participant Reduction
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
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)
efficiencies that do not require replacing departing active participants, or single causes that do not meet the reporting threshold of a single-cause event)
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)
Failure to Make Required Contributions
Distribution to a Substantial Owner
Name,
address and
phone number
of person
receiving the
distribution(s)
Amount,
form and date of each distribution Reason for distribution
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)
Transfer of Benefit Liabilities
Due
date and amount of the missed contribution Due date and amount of
the next payment due
Due
date and
amount of
all contributions
not timely
made and
not reported on the last Schedule SB
filed
Date
and amount of any contribution(s) made related to the missed
contribution(s)
Evidence
of any amount paid related to the missed contribution (cancelled
check, wire transfer, asset statement)
Reason
contribution was not made by due date
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)
Company
financial information (see instructions)
Inability to Pay Benefits When Due
Date
of any missed benefit payment and amount of benefits due
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
Amount
of the plan’s liquid assets at the end of the quarter, and the
amount of its disbursements for the quarter
Name,
address and phone number of plan trustee (and of any custodian)
Most
recent pension plan document(s)
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 (liabilities and participants should be
broken down by status - active, term vested, and retirees)
Financial
Information for the transferor and transferee's controlled group
(see instructions)
Actuarial
Information (see instructions)
Change in 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
Financial
Information for
the old
and new
controlled group
(see instructions)
Actuarial
Information (see instructions)
Description
of the plan's controlled group structure before and after the
liquidation, including the name of each controlled group member
Operational
status of each controlled group member (in Chapter 7 proceedings,
liquidating outside of bankruptcy, on-going, etc.)
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)
Company
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
Copy of waiver application, with all attachments
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
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 any notice of 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
Actuarial Information (see instructions)
Company
financial information (see instructions)
Insolvency or Similar Settlement
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
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)
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)
Company
financial information (see instructions)
Date of Event Notice Due Date
Notice Filing Date (if late, explain below)
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.
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 Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | PBGC Form 10 |
| Subject | Form 10 |
| Author | PBGC |
| File Modified | 0000-00-00 |
| File Created | 2021-08-02 |
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