SFA Template 5A

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TEMPLATE 5A

v20220802p

Baseline - for non-MPRA plans using the "basic method", or for MPRA plans for which the requested amount of SFA is determined under the
"increasing assets method"
File name: Template 5A Plan Name, where "Plan Name" is an abbreviated version of the plan name.
Instructions for Section C, Item (5) of the Instructions for Filing Requirements for Multiemployer Plans Applying for Special Financial Assistance:
This Template 5A is not required if all assumptions and methods used to determine the requested SFA amount are identical to those used in the most recent actuarial
certification of plan status completed before 1/1/2021 ("pre-2021 certification of plan status"), except the non-SFA and SFA interest rates, and except any
assumptions that were changed in accordance with Section III, Acceptable Assumption Changes in PBGC's SFA assumptions guidance (other than the acceptable
assumption change for "missing" terminated vested participants described in Section III.E. of PBGC's SFA assumptions guidance).

Provide a separate deterministic projection ("Baseline") using the same calculation methodology used to determine the requested SFA amount, in the same format as
Template 4A (Sheets 4A-2, 4A-3, and either 4A-4 or 4A-5) that shows the amount of SFA that would be determined if all underlying assumptions and methods used
in the projection were the same as those used in the pre-2021 certification of plan status, except the plan's non-SFA interest rate and SFA interest rate, which should
be the same as used in Template 4A (Sheet 4A-1).

For purposes of this Template 5A, any assumption change made in accordance with Section III, Acceptable Assumption Changes, in PBGC's SFA assumptions
guidance should be reflected in this Baseline calculation of the SFA amount and supporting projection information, except that an assumption change for “missing”
terminated vested participants described in Section III.E of PBGC’s SFA assumptions guidance should not be reflected in the Baseline projections. See examples in
the SFA instructions for Section C, Item (5).

Additional instructions for each individual worksheet:
Sheet
5A-1

Baseline - Benefit Payments for the "basic method", or for MPRA plans for which the requested amount of SFA is determined under the
"increasing assets method"

See Template 4A instructions for Sheet 4A-2, except provide the benefit payment projection used to determine the Baseline SFA amount.
5A-2

Baseline - Participant Count and Administrative Expenses for the "basic method", or for MPRA plans for which the requested amount of SFA is
determined under the "increasing assets method"

See Template 4A instructions for Sheet 4A-3, except provide the projected total participant count and administrative expense projection used to determine the
Baseline SFA amount.

5A-3

Baseline - Details for the "basic method" under § 4262.4(a)(1) for non-MPRA plans, or for the "increasing assets method" under § 4262.4(a)(2)(i)
for MPRA plans for which the requested amount of SFA is determined under that method

For non-MPRA plans, see Template 4A instructions for Sheet 4A-4, except provide the projection used to determine the Baseline SFA amount under the "basic
method" described in § 4262.4(a)(1). Unlike Sheet 4A-4, it is not necessary to explicitly identify the projected SFA exhaustion year in Sheet 5A-3.
For MPRA plans for which the requested amount of SFA is determined under the "increasing assets method", see Template 4A instructions for Sheet 4A-5, except
provide the projection used to determine the Baseline SFA amount under the "increasing assets method" described in § 4262.4(a)(2)(i). Unlike Sheet 4A-5, it is not
necessary to identify the projected SFA exhaustion year in Sheet 5A-3.

Version Updates (newest version at top)
Version

Date updated

v20220802p

8/2/2022

v20220701p

7/1/2022

Cosmetic changes to increase the size of some rows

TEMPLATE 5A - Sheet 5A-1

v20220802p

Baseline - Benefit Payments for the "basic method", or for MPRA plans for which the requested amount of SFA is determined under the "increasing assets method"
See Template 4A instructions for Sheet 4A-2, except provide the benefit payment projection used to determine the Baseline SFA amount.
PLAN INFORMATION
Abbreviated
Plan Name:
EIN:
PN:
SFA Measurement Date:
On this Sheet, show all benefit payment amounts as positive amounts.
PROJECTED BENEFIT PAYMENTS for:
SFA Measurement
Date / Plan Year Start
Date

Plan Year End Date

Current Retirees and
Beneficiaries in Pay
Status

Current Terminated
Vested Participants

Current Active
Participants

New Entrants

Total

TEMPLATE 5A - Sheet 5A-2

v20220802p

Baseline - Participant Count and Administrative Expenses for the "basic method", or for MPRA plans for which the requested amount of SFA is determined under the "increasing assets method"
See Template 4A instructions for Sheet 4A-3, except provide the projected total participant count and administrative expense projection
used to determine the Baseline SFA amount.
PLAN INFORMATION
Abbreviated
Plan Name:
EIN:
PN:
SFA Measurement Date:
On this Sheet, show all administrative expense amounts as positive amounts.
PROJECTED ADMINISTRATIVE EXPENSES for:
SFA Measurement
Date / Plan Year Start
Date

Plan Year End Date

Total Participant Count
at Beginning of Plan
Year
N/A

PBGC Premiums

Other

Total

TEMPLATE 5A - Sheet 5A-3

v20220802p

Baseline - Details for the "basic method" under § 4262.4(a)(1) for non-MPRA plans, or for the "increasing assets method" under § 4262.4(a)(2)(i) for MPRA plans for which the requested amount of SFA is determined under that method
See Template 4A instructions for Sheet 4A-4 or Sheet 4A-5, except provide the projection used to determine the Baseline SFA amount.
PLAN INFORMATION
Abbreviated
Plan Name:
EIN:
PN:
MPRA Plan?
If a MPRA Plan, which
method yields the
greatest amount of SFA?
SFA Measurement Date:
Fair Market Value of
Assets as of the SFA
Measurement Date:
SFA Amount as of the
SFA Measurement Date
under the method
calculated in this Sheet:
Non-SFA Interest Rate:
SFA Interest Rate:
On this Sheet, show payments INTO the plan as positive amounts, and payments OUT of the plan as negative amounts.
(1)

SFA Measurement
Date / Plan Year Start
Date

Plan Year End Date

Contributions

(2)

Withdrawal Liability
Payments

(3)

(4)

Other Payments to Plan
Benefit Payments
(excluding financial (should match total from
assistance and SFA)
Sheet 5A-1)

(5)
Make-up Payments
Attributable to
Reinstatement of
Benefits Suspended
through the SFA
Measurement Date

(6)

(7)

(8)

(9)

(10)

(11)

Administrative Expenses Benefit Payments (from
Benefit Payments (from
(excluding amount owed
(4) and (5)) and
Projected SFA Assets at
(4) and (5)) and
PBGC under 4261 of Administrative Expenses SFA Investment Income
End of Plan Year
Administrative Expenses Non-SFA Investment
ERISA; should match
(from (6)) Paid from
Based on SFA Interest
(prior year assets +
(from (6)) Paid from
Income Based on Nontotal from Sheet 5A-2)
SFA Assets
Rate
(7) + (8))
Non-SFA Assets
SFA Interest Rate

(12)
Projected Non-SFA
Assets at End of Plan
Year
(prior year assets +
(1) + (2) + (3) +
(10) + (11))