Form 500 and 501 500 and 501 Notice Single-Employer Plan Termination (Form 500), Post

PBGC Form 500

Standard Termination Notice
Single-Employer Plan Termination

Approved OMB 1212-0036
Expires 3/31/2023

PART I.
IDENTIFYING INFORMATION
1a Plan Name

1b

Last day of plan year

2a

2b

Sponsor’s telephone number

2c

9-digit employer identification number (EIN)

2d

3-digit plan number (PN)

Contributing Sponsor’s name and address
(Address should include room or suite no.)

2e

If you used a different EIN or PN for this contributing sponsor/plan in previous filings
with the PBGC, also show the number(s) previously reported

2f

6-digit business code

3a

Plan Administrator’s name and address (if same as 2a, enter “same”) (Address should
include room or suite no.)

3b

Plan Administrator’s telephone number

3c

E-mail address (optional)

3e

Telephone number

3f

E-mail address (optional)

3d

Name and address of person to be contacted for more information (if same as 3a, enter
“same”) (Address should include room or suite no.)

PART II.
GENERAL PLAN INFORMATION
4a Have you filed, or will you file, with the Internal Revenue Service

Yes

4b If “Yes” to 4a, enter the filing date:

for a determination letter on the termination of this plan?

No

5a

Is this a multiple-employer plan?

Yes
No

6

employer identification numbers of all contributing
sponsors
Reason for plan termination. If more than one reason for the termination (considering (1) - (12) and c.), see instructions.

a

Plan benefits too costly

(3)

Restructuring of retirement program (e.g. adoption of new plan, decision that defined benefit plan no
longer meets employer objectives)
Retirement/illness/death of owner(s)

6a(1)
6a(2)
6a(3)
6a(4)

Business related
(5)

7

Plan administration too costly or complicated

(2)

(4)

c

5b If “Yes” to 5a, attach a list of the names and

Plan related
(1)

b

(MM/DD/YYYY)

Adverse business conditions

(6)

Sale of company/subsidiary/division (not involving bankruptcy or similar proceeding)

(7)

Company/subsidiary/division closed (not involving bankruptcy or similar proceeding)

(8)

Merger of company

(9)

Contributing sponsor acquired by another business

(10)

Another business acquired by contributing sponsor

(11)

Contributing sponsor reorganized (in bankruptcy or similar proceeding)

(12)

Contributing sponsor liquidated (in bankruptcy or similar proceeding)

Other (specify)

6b(5)
6b(6)
6b(7)
6b(8)
6b(9)
6b(10)
6b(11)
6b(12)
6c

Changes in contributing sponsor associated with plan termination (check all that apply)

a
b
c
d
e
f
g
h

No change
Sale of company/subsidiary/division (not involving bankruptcy or similar proceeding)
Company/subsidiary/division closed (not involving bankruptcy or similar proceeding)
Merger of company
Contributing sponsor acquired by another business
Another business acquired by contributing sponsor
Contributing sponsor reorganized (in bankruptcy or similar proceeding)
Contributing sponsor liquidated (in bankruptcy or similar proceeding)

7a
7b
7c
7d
7e
7f
7g
7h

Standard Termination Notice • Single-Employer Plan Termination
8

PBGC Form 500 • Page 2

Number of plan participants and beneficiaries as of proposed termination date:

a
b
c
d
e

8a
8b
8c
8d
8e

Active participants
Retirees or beneficiaries receiving benefits
Separated vested participants entitled to benefits
Separated non-vested participants
Total

9

Estimated percent of currently employed participants that are covered under the terminated plan that you expect to be
covered under:

a
b
c
d
e
f
g
h
10

No plan

0

9a
9b
9c
9d
9e
9f
9g
9h

New or existing traditional defined benefit plan
New or existing hybrid defined benefit plan, other than cash balance plan
New or existing cash balance plan
New or existing profit sharing plan
New or existing 401(k) plan
New or existing simplified employee plan
Other new or existing defined contribution plan (specify)
If the percent entered for item 9b, 9c or 9d is greater than zero, will the types of benefits under the new or existing
defined benefit plan be substantially the same as under the terminating plan for all affected participants (currently
employed participants that you expect will be covered under the new or existing defined benefit plan.)

11a Proposed termination date
11b Proposed termination date stated in notice of intent to terminate (if different from 11a)
Attach copy of notice of intent to terminate.
Earliest date notices of intent to terminate issued to affected parties

12a
12b Latest date notices of intent to terminate issued to affected parties
13 Latest date notices of plan benefits issued to participants or beneficiaries Attach copies of

%
%
%
%
%
%
%
%
Yes
No

(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)

sample notices of plan benefits; see instructions.

14a

Has a formal challenge to the termination been initiated under an existing collective bar gaining agreement?

Yes

No
N/A

14b If “Yes” to 14a, attach a copy of the formal challenge and a statement describing the
15

challenge.
Have all PBGC premiums been paid to date?

PART III.
RESIDUAL PLAN ASSETS
16a Will residual assets be returned to the employer as a result of this termination?

Yes

No

Yes

No
N/A

16b If “No” or “N/A” to 16a, do not complete the rest of Part III; go to Part IV.
If “Yes,” enter the estimated amount:

$

17a Is there a plan provision permitting a reversion of residual assets to the employer
17b If “Yes” to 17a, was the provision adopted prior to 12/18/1988?
17c If “No” to 17b, enter:

Yes, go to 17b

No , go to 18a

Yes, go to 18a

No, go to 17c

(1) Adoption date:

(MM/DD/YYYY)

(2) Effective date of plan:

(MM/DD/YYYY)

18a Has the plan been involved in a spin-off/termination transaction?
18b If “Yes” to 18a, have the requirements of the Guidelines been satisfied?

Yes, go to 18b

No, go to Part IV

Yes, go to 18c

No, go to 18d
N/A, go to 18d

18c

If “Yes” to 18b, enter the dates for (1) and (2) and go to Part IV:

(1) latest date a description of the transactions(s) was issued to participants in the ongoing
plan.
(2) latest date notices of plan benefits were issued to participants in the ongoing plan.

(MM/DD/YYYY)
(MM/DD/YYYY)

18d If you checked “No” or “N/A” in 18b, attach a statement that describes the transaction(s) and explains why the Guidelines were not, or need
not have been, followed.

PART IV.

PLAN ADMINISTRATOR CERTIFICATION

I, the Plan Administrator, certify that, to the best of my knowledge and belief: (1) I am implementing the termination of the plan in accordance with
all applicable laws and regulations; and (2) the information contained in this filing and made available to the Enrolled Actuary 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.
Plan Administrator’s signature

Date

Printed name and title of Plan Administrator

PBGC Schedule EA-S

Standard Termination
Certification of Sufficiency

(PBGC Form 500)

Approved OMB 1212-0036
Expires 3/31/2023

PART I.
IDENTIFYING INFORMATION
1a Plan Name

1b 9-digit employer identification number (EIN)
1c 3-digit plan number (PN)

PART II.
CODE SECTION 412(e)(3) PLANS
2 Is this plan a Code section 412(e)(3) plan?
No: the Enrolled Actuary must complete Parts III and IV. Item 3 and Part V should not be completed.
Yes: item 3 and Part III must be completed. Depending upon who completes Part III, either Part IV or Part V must be completed and
signed by the Plan Administrator or Enrolled Actuary as appropriate.
3a Enter name (full official name of record) and address of the insurer
3b Telephone Number
(Address should include room or suite no.)

PART III.
PLAN SUFFICIENCY
4 Proposed distribution date
5 Is the value of plan assets projected to be sufficient as of the proposed distribution date to
6
7
8
9
10
11
12

provide all plan benefits? If “No,” the plan cannot terminate in a standard termination.
Estimated fair market value of plan assets as of the proposed distribution date
Estimated present value of plan benefits as of the proposed distribution date
Estimated total amount of residual assets
Estimated amount of residual assets to be distributed to the employer
Estimated amount of residual assets to be distributed to participants and beneficiaries
Has the plan ever required employee contributions?

(MM/DD/YYYY)
Yes

No

Yes

No

$
$
$
$
$

If the amount in item 9 is $1 million or more and if any benefits are to be distributed other
than through the purchase of annuity contracts, attach a statement showing interest
rate/structure used to value the benefits.

PART IV.

ENROLLED ACTUARY CERTIFICATION

I, the Enrolled Actuary, certify that: (1) I have reviewed all plan documents and plan and participant data, and applied all relevant provisions of
ERISA and the Internal Revenue Code and regulations promulgated thereunder; (2) to the best of my knowledge and belief, this plan’s assets
equal or exceed the value of its plan benefits as of the proposed distribution date; and (3) to the best of my knowledge and belief, the
information contained in this schedule 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.
Enrolled Actuary’s Name (Print or type)
Enrolled Actuary’s company’s name and address
(Address should include room or suite no.)
Enrollment Number

Telephone Number

E-mail address (optional)
Enrolled Actuary’s signature

PART V.

Date

PLAN ADMINISTRATOR CERTIFICATION FOR CODE SECTION 412(e)(3) PLANS

I, the Plan Administrator, certify that, to the best of my knowledge and belief: (1) this plan complies with section 412(e)(3) of the Internal Revenue
Code and regulations promulgated thereunder; (2) I have reviewed all plan documents and plan and participant data, and applied all relevant
provisions of ERISA and the Code and regulations promulgated thereunder; (3) this plan’s assets equal or exceed the value of its plan benefits as
of the proposed distribution date; and (4) the information contained in this schedule 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.

Plan Administrator’s signature

Date

Printed name and title of Plan Administrator

PBGC Schedule REP-S

Standard Termination
Designation of Representative

Approved OMB 1212-0036
Expires 3/31/2023

PART I.
IDENTIFYING INFORMATION
1a Plan Name

1b 9-digit employer identification number
(EIN)

2a Plan Administrator’s name and address
(Address should include room or suite no.)

PART II.
3 I,

1c

3-digit plan number (PN)

2b

Plan Administrator’s telephone number

2c

E-mail address (optional)

DESIGNATION OF REPRESENTATIVE(S)

, Plan Administrator of the above-named pension plan, hereby appoint the following
representative(s) to act on my behalf before the Pension Benefit Guaranty Corporation on all matters (other than those specifically excluded
below) relating to the termination of the above-named pension plan:

4a Representative’s name and address

4b

Telephone number

4c

E-mail address (optional)

4e

Telephone number

4f

E-mail address (optional)

(Address should include room or suite no.)

4d Representative’s name and address
(Address should include room or suite no.)

5

Matters excluded from authority of representative(s). List any specific acts with respect to the plan termination that you are excluding from
the acts otherwise authorized in this designation:

PART III.
RETENTION / REVOCATION OF PRIOR DESIGNATION(S)
6a Have you filed any prior designation(s) of representative(s) for this termination?

Yes

No

6b If “Yes,” do you want any such prior designation(s) of representative(s) to remain in effect?

Yes

No

(Attach a copy of all prior designations that are to remain in effect.)

PART IV.

SIGNATURE OF PLAN ADMINISTRATOR

NOTE: The PBGC will NOT accept unsigned designations. If the Plan Administrator is a board (or similar group) composed of employer
and employee representatives, at least one employer representative and one employee representative must sign this form. If the plan does not
designate a plan administrator or it designates the plan sponsor or the contributing sponsor as the plan administrator, this form must be signed by
an officer of the plan sponsor or contributing sponsor who has the authority to sign on behalf of that entity.
In executing this document, I certify that the foregoing is true and correct, and recognize that knowingly and willfully making
false, fictitious, or fraudulent statements to the PBGC is punishable under 18 U.S.C. § 1001.

Plan Administrator’s signature

Date

Printed name and title

PBGC Form 501

Post-Distribution Certification
for Standard Termination
PART I.

IDENTIFYING INFORMATION

Check here if you previously filed a Form 501 for this plan.

1a

Approved OMB 1212-0036
Expires 3/31/2023

If checked, provide dates of filing(s):

1b 9-digit employer identification number (EIN)

Plan Name

1c 3-digit plan number (PN)
Attach copy of the most recent complete plan document and any amendments to it.

2 PBGC case number
PART II.
DISTRIBUTION INFORMATION
3a Last distribution date in satisfaction of plan benefits
3b Date of receipt of IRS determination letter
4 Were participants and beneficiaries provided with the name and address of the insurer(s)
no later than 45 days before the date of distribution?

8-digit Case #
(MM/DD/YYYY)
(MM/DD/YYYY)
Yes

No

5

Were you able to locate all participants and beneficiaries? If “No,” see instructions.

Yes

No

6a

Has a copy of the annuity contract, certificate, or written notice been provided to each
participant and beneficiary receiving benefits in the form of an irrevocable commitment?

Yes

No

6b

If “Yes” to 6a, enter the latest date the annuity contract, certificate, or written notice
was provided to each participant and beneficiary receiving benefits:
If “No” or “N/A”, see instructions
Complete name of record of insurer(s) from whom annuity contracts, if any, have been
purchased

7a

7b Annuity Contract Number(s)

Name and address of contact for location of plan records

9

Summary of distribution of plan benefits. Attach distribution documents (see instructions).
(1) # of Participants or Beneficiaries
Type of Benefit
Annuities purchased
(1) For Non-Missing Participants
(2) For Missing Participants
(3) Total

b

Lump sums (including direct transfers)
(1) Consensual
(2) Nonconsensual (i.e., mandatory cash-outs)
(3) Total

c

Benefits transferred to PBGC for Missing Participants
(1) Benefits transferred
(2) Other amounts due PBGC (see instructions)
No Distribution
TOTAL (see instructions)

d
e

PART III.

N/A

(MM/DD/YYYY)

8a

a

N/A

8b Telephone number

(2) Total Cost/Value

0

$

0

$
$
$ 0.00
$
$

0

$ 0.00

PLAN ADMINISTRATOR CERTIFICATION

I, the Plan Administrator, certify that to the best of my knowledge and belief that (1) benefits payable with respect to participants have been
calculated and valued correctly in accordance with applicable provisions of ERISA and the regulations thereunder; (2) all plan benefits (through
priority category 6 under ERISA Section 4044 and 29 CFR Part 4044) under the plan have been satisfied; (3) plan assets in excess of those
needed to satisfy all plan benefits (through priority category 6 under ERISA Section 4044 and 29 CFR Part 4044) have been or will be distributed
in accordance with applicable provisions of ERISA and the regulations thereunder; and (4) the information contained in this filing is true, correct,
and complete. I further certify that I am aware that records supporting the calculation and valuation of benefits and assets must be kept at least six
years after the date this post-distribution certification is filed. In executing this document, I certify that the foregoing is true and correct, and
recognize that knowingly and willfully making false, fictitious, or fraudulent statements to the PBGC is punishable under 18 U.S.C.
§1001.
Plan Administrator’s company name and address (Address should include room or suite no.)

Telephone number

E-mail address (optional)

Plan Administrator’s signature

Date

Printed name and title of Plan Administrator

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