Form 10-Advance Advance Notice of Reportable Events

Reportable Events

Form-10-Advance

OMB: 1212-0013

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ADVANCE NOTICE

OF REPORTABLE EVENTS

PBGC Form 10-Advance OMB #1212-0013

Expires xxxx



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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






See instructions for descriptions of these events. Check all boxes that apply.




Change in controlled group

Liquidation

Extraordinary dividend or stock redemption Transfer of benefit liabilities

Application for minimum funding waiver

Loan Default

Insolvency or similar settlement


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


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Shape14 Shape15

Change in Controlled Group

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Shape17 Description of the plan’s old and new controlled group structures, including the name of each controlled group member

Shape18 Name of each plan maintained by any member of the plan’s old and new controlled groups, its contributing sponsor(s) and EIN/PN

Shape19 Actuarial Information (see instructions)

Shape20 Company financial information (see instructions)

Shape21

Liquidation


Shape22 Description of the plan's old and new controlled group structure, including the name of each controlled group member

Shape23 Operational status of each controlled group member (in Chapter 7 proceedings, liquidation outside of bankruptcy, on-going, etc.)

Shape24 Name of each plan maintained by any number of the plan's controlled group, its contributing sponsor(s) and EIN/PN

Shape25 Actuarial Information (see instructions)

Shape26 Company financial information (see instructions)

Shape27 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, 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


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Extraordinary Dividend or Stock Redemption

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Shape30 Name and EIN of person making the distribution

Shape31 Date and amount of cash distribution(s) during fiscal year

Shape32 Description, fair market value, and date or dates of any non-cash distributions

Shape33 Statement whether the recipient was a member of the plan’s controlled group

Shape34 Actuarial Information (see instructions)

Shape35 Company financial information (see instructions)


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Application for Minimum Funding Waiver

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Shape38 Copy of waiver application, with all attachments

Shape39 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

Transfer of Benefit Liabilities

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Shape41 Name, contributing sponsor, EIN/PN, and contact information of transferee plan(s)

Shape42 Description of the transferor and transferee's controlled group structures, including the name of each controlled group member

Shape43 Explanation of the actuarial assumptions used in determining the value of benefit liabilities (and, if appropriate, plan assets) transferred

Shape44 Estimate of the assets, liabilities, and number of participants whose benefits are transferred

Shape45 Actuarial Information (see instructions)


Shape46 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.

Shape47

Loan Default

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Shape49 Copy of the relevant loan documents (e.g., promissory note, security agreement, loan agreement amendments and waivers)

Shape50 Due date and amount of any missed payment

Shape51 Copy of any written notice of default or acceleration from lender, any notice of forbearance, or loan agreement amendment or waiver

Shape52 Description of any cross-defaults or anticipated cross- defaults

Shape53 Description of the plan's controlled group structure, including the name of each controlled group member

Shape54 Company financial Information (see instructions)

Shape55 Actuarial Information (see instructions)



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Insolvency or Similar Settlement

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Shape58 Name, address and phone number of any trustee, receiver or similar person

Shape59 Docket number of court filing and location of the court where any relevant proceeding was or will be filed (if known)

Shape60 Description of the plan’s controlled group structure, including the name of each controlled group member

Shape61 Name of each plan maintained by any member of the plan’s controlled group, its contributing sponsor(s) and EIN/PN

Shape62 Actuarial Information (see instructions)

Shape63 Company financial Information (see instructions)


Shape64 If all the required information has not been submitted with this Form 10-Advance, you must explain below.










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Date of Event Notice Due Date



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

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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 TitleForm 10 Advance
SubjectForm 10 Advance
AuthorPBGC
File Modified0000-00-00
File Created2021-08-02

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