Form 10 Post-Event Notice of Reportable Events

POST-EVENT NOTICE OF
REPORTABLE EVENTS

PBGC Form 10
OMB Control No.
1212-0013 Expires XX/XX/XX

This form is for illustrative purposes only. Form 10 reportable event information should be submitted to PBGC using the e-filing
portal: efilingportal.pbgc.gov. For questions regarding this form, contact (202) 229-4070 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

Plan number

EIN of contributing sponsor
Filer is:

City, State, Zip

Plan administrator
Contributing sponsor

REPORTABLE EVENTS

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

Active participant reduction

Change in controlled group

Failure to make required contributions under $1M

Liquidation

Inability to pay benefits when due

Extraordinary dividend or stock redemption

Distribution to a substantial owner

Application for minimum funding waiver

Transfer of benefit liabilities

Loan Default
Insolvency or similar settlement

BRIEF DESCRIPTION

Briefly describe the pertinent facts relating to each event.

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

Ext

PBGC Form10
INFORMATION REQUIRED TO BE FILED

Check box to indicate the item is attached. If not attached, explain in the Missing
Information section on next page.

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
(e.g., frozen plan, aging workforce, improved operational
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)

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)

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)

Failure to Make Required Contributions
Due date and amount of the missed contribution

Transfer of Benefit Liabilities

Due date and amount of the next payment due

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

Due date and amount of all contributions not timely made and not
reported on the last Schedule SB filed

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

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)

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)

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)

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)

PBGC Form10
Liquidation
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)

Application for Minimum Funding Waiver
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)

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

Due date and amount of any missed payment

• Mostrecent pension plan document(s)

Description of any cross-defaults or anticipated cross-defaults

• Address of each controlled group member
• The Internal RevenueService Determination Letter indicating the
plan is a covered plan, if applicable

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 the plan's controlled group structure, including
the name of each controlled group member
Actuarial Information (see instructions)
Company financial information (see instructions)

Extraordinary Dividend or Stock Redemption
Name and EIN of person making the distribution
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

Insolvency or Similar Settlement
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

Actuarial Information (see instructions)

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

Company financial information (see instructions)

Actuarial Information (see instructions)
Company financial information (see instructions)

PBGC Form10
MISSING INFORMATION

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

FILING INFORMATION

Date of Event

Notice Due Date

Notice Filing Date (if late, explain below)

REASON FOR LATE FILING OR EXTENSION CLAIMED
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.

CERTIFICATION
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