Form 10-Advance Advance Notice of Reportable Events

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

ADVANCE NOTICE
OF REPORTABLE EVENTS

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This form is for illustrative purposes only. Form 200 information should be submitted to PBGC using the e-filing portal:
efilingportal.pbgc.gov. For questions regarding this form, contact (202) 229-4070 or [email protected].

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IDENTIFYING INFORMATION

Name / title of individual to contact at Filer

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Plan Name

Name of contributing sponsor

Email address of contact

Street address of contributing sponsor

Street address of contact

City, state, Zip

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City, State, Zip

EIN of contributing sponsor

Telephone number of contact

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Plan number

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See instructions for descriptions of these events. Check all boxes that apply.
Change in controlled group

Application for minimum funding waiver

Liquidation

Loan Default

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Extraordinary dividend or stock redemption

Insolvency or similar settlement

Briefly describe the pertinent facts relating to each event.

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Transfer of benefit liabilities

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

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PBGC Form 10-Advance
INFORMATION REQUIRED TO BE FILED

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

Transfer of Benefit Liabilities

Change in Controlled Group

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

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

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Description of the transferor and transferee's controlled
group structures, including the name of each
controlled group member
Explanation of the actuarial assumptions used in
determining the value of benefit liabilities (and, if
appropriate, plan assets) transferred

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

Estimate of the assets, liabilities, and number of participants
whose benefits are transferred
Actuarial Information (see instructions)

Liquidation
Description of the plan's old and new controlled group
structure, including the name of each controlled group
member
Operational status of each controlled group member (in
Chapter 7 proceedings, liquidation outside of bankruptcy,
on-going, etc.)

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

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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:

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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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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.

Loan Default

Copy of the relevant loan documents (e.g., promissory
note, security agreement, loan agreement amendments
and waivers)
Due date and amount of any missed payment

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

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Company financial information (see instructions)

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

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

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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
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

Copy of any written notice of default or acceleration from
lender, any notice of forbearance, or loan agreement
amendment or waiver
Description of any cross-defaults or anticipated crossdefaults
Description of the plan's controlled group structure,
including the name of each controlled group member
Company financial Information (see instructions)
Actuarial Information (see instructions)

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
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)

PBGC Form 10-Advance

Date of Event

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

Notice Due Date

Notice Filing Date (if late, explain below)

Filing Extension Claimed (if any, explain below)

If filing late or extension is claimed, explain below.

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REASON FOR LATE FILING OR EXTENSION CLAIMED

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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.

Name and Title of Individual Submitting Form

Telephone Number of Individual Submitting Form

Employer of Individual Submitting Form

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Signature of Individual Submitting Form