Model Certificatio Model Certification

CERTIFICATION THAT PLAN AMENDMENT
TO REINSTATE SUSPENDED BENEFITS WILL BE TIMELY ADOPTED
As required by 29 C.F.R. § 4262.7(e)(2) for the application for special financial assistance for
the [NAME OF PLAN] (the “Application” for the “Plan”), we, the members of the Board of
Trustees of the Plan hereby certify that the proposed amendment to the [NAME AND DATE OF
CURRENT PLAN DOCUMENT] to reinstate benefits under the Plan that have been suspended
under [CHOOSE EITHER: ‘section 305(e)(9) of ERISA’ OR ‘section 4245(a) of ERISA due to
plan insolvency’], which proposed amendment is submitted herewith as part of the Application,
will be timely adopted upon approval by the Pension Benefit Guaranty Corporation of the
Application.
[INCLUDE ONLY IF LESS THAN THE ENTIRE BOARD OF TRUSTEES IS SIGNING:] Section
[REFERENCE TO APPROPRIATE PROVISION] of the [NAME AND DATE OF PLAN’S
CURRENT TRUST DOCUMENT], as amended, authorizes [DESCRIBE HOW TRUST
DOCUMENT AUTHORIZES THE SIGNERS TO SIGN ON BEHALF OF ENTIRE BOARD].
[INSERT ONE SIGNATURE BLOCK FOR EACH TRUSTEE, EACH WITH A PRINTED NAME
AND TITLE:]
___________________________
[PRINTED NAME]
[TITLE]

___________________________
[PRINTED NAME]
[TITLE]

___________________________
[PRINTED NAME]
[TITLE]

___________________________
[PRINTED NAME]
[TITLE]

Date: [DATE OF EXECUTION]

- Certification of Benefit Reinstatement, Page 1 of 1 -