STRAP Special Terminal Report for Abandoned Plans

Special Terminal Report for Abandoned Plans

COVER PAGE

PAPERWORK BURDEN DISCLOSURE NOTICE

OMB Control Number 1210-0127; expires xx/xx/2027

Behind this cover page is a model notice that may be used to satisfy the mandatory notification requirements set forth in 29 CFR § 2520.103-13. The model notice is a collection of information instrument subject to the Paperwork Reduction Act. Use of the model notice to meet the notification requirements is optional. You may also develop your own notice, provided it contains all the information required by 29 CFR § 2520.103-13. The Department of Labor estimates that it will take an average of approximately three hours and 15 minutes for plan administrators to complete the model. You may send comments on this collection of information, including suggestions for reducing burden to: US Department of Labor, Office of Research and Analysis, Attention: PRA Officer, 200 Constitution Avenue, NW, Room N-5718, Washington, DC 20210; or send to [email protected]. The notification requirements in 29 CFR § 2520.103-13, referenced above, are also a collection of information under the PRA. The public is not required to respond to a collection of information unless it displays a currently valid OMB control number.

DO NOT INCLUDE THIS PAPERWORK REDUCTION ACT BANNER IN NOTICES

Department of Labor Employee Benefits Security Administration

SPECIAL TERMINAL REPORT FOR ABANDONED PLANS This form is required to be filed under 29 CFR 2520.103-13 and 29 CFR 2578.1. Complete all entries in accordance with the instructions

OMB Control No. 1210-0127 This Form is Open to Public Inspection

Part I	General Information
Name of Plan:
Three-digit plan number (PN):
This report is for (check one): single-employer plan multiemployer plan multiple-employer plan D. Check all that apply (optional): 401(k) 403(a) 403(b) Profit Sharing Plan ESOP Stock Bonus Plan Target Benefit Plan Money Purchase Plan (other than Target Benefit) Other: __________________________
E.1. Plan sponsor’s name and last known address (include street or P.O. Box, city or town, state, and ZIP)					E.2 Plan sponsor’s telephone:
					E.3 Plan sponsor’s EIN:
F.1 Qualified termination administrator’s (QTA) name and address (include street or P.O. Box, city or town, state, and ZIP)					F.2 QTA’s telephone:
					F.3 QTA’s email:
					F.4 QTA’s EIN:
Under penalties of perjury, I declare that I have examined this report, including accompanying schedules, statements and attachments, and to the best of my knowledge and belief, it is true, correct and complete.
Sign Here
		Signature of Qualified Termination Administrator	Date	Print or type name of individual signing as Qualified Termination Administrator
G.1 If the plan sponsor has filed for bankruptcy under Chapter 7 of the U.S. Bankruptcy Code, enter the bankruptcy trustee’s name and mailing address (include street or P.O. Box, city or town, and ZIP code) Same as QTA						H.1 Trustee’s telephone:
						H.2 Trustee’s email:
						H.3 Trustee’s EIN:
I. Total plan assets (as of the date of deemed termination):							$
J. Total termination expenses paid by the QTA from plan assets:							$
K. Total amount of distributions following date of deemed termination:							$
L. Were there distributions to missing participants pursuant to 29 CFR 2578.1(d)(2)(vii)(B)? Yes No
M. Total number of distributions:
N. Total number of distributions to missing participants included in Line M:
O. Did the plan have assets with no readily ascertainable value? Yes No If you answer yes to line O., complete Part III Assets with No Readily Ascertainable Value.

Part II	Itemization of Expenses (If insufficient space, add schedule as described in instructions.)
Service Provider Name		Service Provider EIN	Amount Received			Estimated Amount from NOI		Description of Expense		Relationship to QTA
Service Provider Name		Service Provider EIN	Amount Received			Estimated Amount from NOI		Description of Expense		Relationship to QTA
Part III	Assets with No Readily Ascertainable Value
Asset Class				Yes	No		Value		Method of Valuation
Partnership/joint venture interests
Employer real property
Real estate (other than (b))
Employer securities
Participant loans
Loans (other than (e))
Tangible personal Property
Other Specify:

4