SFA Template Checklist, Supplemented Application

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Application Checklist - Supplemented

v20220802p

Instructions for Addendum C, Section E, Item 1 of the Instructions for Filing Requirements
for Multiemployer Plans Applying for Special Financial Assistance (SFA):
The Supplemented Application to PBGC for Approval of Special Financial Assistance Checklist ("Application Checklist - Supplemented") identifies all information required to
be filed with a supplemented application if the plan is requesting additional SFA. For a plan not requesting additional SFA, no checklist is required. For other SFA
applications, use the SFA Application Checklist.
For a plan required to submit additional information described in Addendum A of the SFA Filing Instructions, also complete and submit the Additional Information for Certain
Events section of the SFA Application Checklist.
Supplemented applications (including this Application Checklist - Supplemented), must be submitted to PBGC electronically through PBGC’s e-Filing Portal,
(https://efilingportal.pbgc.gov/site/). After logging into the e-Filing Portal, go to the Multiemployer Events section and click “Create New ME Filing.” Under “Select a filing
type,” select “Application for Financial Assistance – Special.” Note: a new supplemented application submitted after the denial or withdrawal of a previously filed
supplemented application must also be submitted by selecting “Create New ME Filing.”

Note: If you go to the e-Filing Portal and do not see “Application for Financial Assistance – Special” under the “Select a Filing Type,” then the e-Filing Portal is temporarily
closed and PBGC is not accepting applications (other than lock-in applications) at the time, unless the plan is eligible to make an emergency filing under § 4262.10(f). PBGC’s
website, www.pbgc.gov, will be updated when the e-Filing Portal reopens for applications. PBGC maintains information on its website at www.pbgc.gov to inform prospective
applicants about the current status of the e-Filing portal, as well as to provide advance notice of when PBGC expects to open or temporarily close the e-Filing Portal.
General instructions for completing the Application Checklist - Supplemented:
Complete all items that are shaded:
If required information was already filed: (1) through PBGC's e-Filing Portal; or (2) through any means for an insolvent plan, a plan that has received a partition, or a
plan that submitted an emergency filing, the filer may either upload the information with the application or include a statement in the Plan Comments section of the
Application Checklist indicating the date on which and the submission with which the information was previously filed. For any such items previously provided,
enter N/A as the Plan Response.
For a new supplemented application submitted after the denial or withdrawal of a previously filed supplemented application, the filer may, but is not required to,
submit an entire application. For all Application Checklist - Supplemented items that were previously filed that are not being changed, the filer may include a
statement in the Plan Comments section of the Application Checklist - Supplemented to indicate that the other information was previously provided as part of the
initial application. For each, enter N/A as the Plan Response.
Instructions for specific columns:
Plan Response: Provide a response to each item on the Application Checklist - Supplemented, using only the Response Options shown for
each Checklist Item.

Name(s) of Files Uploaded: Identify the full name of the file or files uploaded that are responsive to the Checklist Item. The column
Upload as Document Type provides guidance on the "document type" to select when submitting documents on PBGC's e-Filing Portal.
Page Number Reference(s): For Checklist Items #10 to #10b, submit all information in a single document and identify here the relevant
page numbers for each such Checklist Item.
Plan Comments: Use this column to provide explanations for any Plan Response that is N/A, to respond as may be specifically identified
for Checklist Items, and to provide any optional explanatory comments.
Additional guidance is provided in the following columns:
Upload as Document Type: When uploading documents in PBGC's e-Filing Portal, select the appropriate Document Type for each
document that is uploaded. This column provides guidance on the Document Type to select for each Checklist Item. You may upload more
than one document using the same Document Type, and there may be Document Types on the e-Filing Portal for which you have no
documents to upload.
Required Filenaming (if applicable): For certain Checklist Items, a specified format for naming the file is required.
SFA Instructions Reference: Identifies the applicable section and item number in PBGC's Instructions for Filing Requirements for
Multiemployer Plans Applying for Special Financial Assistance.

You must select N/A if a Checklist Item # is not applicable to your application. Your application will be considered incomplete if No is entered as a Plan Response for any of
Checklist Items #1 through #16 on the Application Checklist. If there has been a plan merger as described in § 4262.4(f)(1)(ii), you also must provide the separate Application
Checklist - Certain Events.
If a Checklist Item # asks multiple questions or requests multiple items, the Plan Response should only be Yes if the plan is providing all information requested for that
Checklist Item.
Note, a Yes or No response is also required for Checklist Items #a through #c.
Note, in the case of a plan applying for priority consideration, the plan's application must also be submitted to the Treasury Department. If that requirement applies to an
application, PBGC will transmit the application to the Treasury Department on behalf of the plan. See IRS Notice [NOTICE] for further information.

All information and documentation, unless covered by the Privacy Act, that is included in an SFA application may be posted on PBGC’s website at www.pbgc.gov or
otherwise publicly disclosed, without additional notification. Except to the extent required by the Privacy Act, PBGC provides no assurance of confidentiality in any
information included in an SFA application.

Version Updates (newest version at top)
Version

Date updated

v20220802p

8/2/2022

v20220706p

7/6/2022

Fixed the formatting of the SFA Amount Approved Under Interim Final Rule

Application to PBGC for Approval of Special Financial Assistance (SFA)
APPLICATION CHECKLIST - SUPPLEMENTED
Plan name:
EIN:
PN:

v20220802p

This Application Checklist - Supplemented is only used for a supplemented application. See Application Checklist for all other applications.
Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

---------------------------Filers provide responses here for each Checklist Item:-------------------------------------------

SFA Amount Approved Under
Interim Final Rule:
SFA Amount Requested Under Final
Rule:

Explain all N/A responses. Provide comments
where noted. Also add any other optional
explanatory comments.

Your application will be considered incomplete if No is entered as a Plan Response for any of
Checklist Items #1 through #16.
Checklist
Item #

SFA Filing Instructions
Reference

Response
Options

Plan
Response

Name of File(s) Uploaded

Page Number
Reference(s)

Plan Comments

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

a.

Is this application a new supplemented application, submitted after the denial of a previously filed
supplemented application for SFA?

Yes
No

N/A

N/A

N/A

N/A

b.

Is this application a new supplemented application, submitted after a plan has withdrawn its
previously filed supplemented application for SFA?

Yes
No

N/A

N/A

N/A

N/A

c.

Is this plan a MPRA plan as defined under § 4262.4(a)(3) of PBGC's SFA regulation?

Yes
No

N/A

N/A

N/A

N/A

Does the application include information required to enable the plan to receive electronic transfer
of funds if the SFA application is approved, including (if applicable) a notarized payment form?
See SFA Instructions, Section B, Item (10).

Yes
No

N/A

Other

N/A

Section C,
Does the application include the information used to determine the amount of SFA for the plan
Items (4)a., (4)e.,
using the basic method described in § 4262.4(a)(1) based on a deterministic projection and using
and (4)f.
the actuarial assumptions as described in § 4262.4(e)?
(Also See Addendum C, See Template 4A, 4A-4 SFA Details .4(a)(1) sheet, Section C, Item (4) of the SFA Filing
Section C, Item (4)) Instructions and Addendum C for more details on these requirements.

Yes
No

N/A

Projections for special financial
assistance (estimated income, benefit
payments and expenses)

Template 4A Supp Plan Name

1.

2.

Section B, Item (10)

Does the uploaded file use the required filenaming convention?

3.a.

Addendum C
Section G, Item (1)

If the plan is a MPRA plan, does the application also include the information used to determine the
amount of SFA for the plan using the increasing assets method described in § 4262.4(a)(2)(i) based
on a deterministic projection and using the actuarial assumptions as described in § 4262.4(e)?
See Template 4A, 4A-5 SFA Details .4(a)(2)(i) sheet and Addendum D for more details on these
requirements.

Yes
No
N/A

N/A - included as part of Template 4A Plan
Name

N/A

N/A

Template 4A Supp Plan Name

Yes
No
N/A

N/A - included as part of Template 4A Plan
Name

N/A

N/A

Template 4A Supp Plan Name

Enter N/A if the plan is not a MPRA Plan.

3.b.

Addendum C
Section G, Item (1)

If the plan is a MPRA plan for which the requested amount of SFA is determined using the
increasing assets method described in § 4262.4(a)(2)(i), does the application also explicitly identify
the projected SFA exhaustion year based on the increasing assets method? See Template 4A, 4A-5
SFA Details .4(a)(2)(i) sheet and Addendum D.
Enter N/A if the plan is not a MPRA Plan or if the requested amount of SFA is determined based
on the present value method.

4 of 8

Application to PBGC for Approval of Special Financial Assistance (SFA)
APPLICATION CHECKLIST - SUPPLEMENTED
Plan name:
EIN:
PN:

v20220802p

This Application Checklist - Supplemented is only used for a supplemented application. See Application Checklist for all other applications.
Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

---------------------------Filers provide responses here for each Checklist Item:-------------------------------------------

SFA Amount Approved Under
Interim Final Rule:
SFA Amount Requested Under Final
Rule:

Explain all N/A responses. Provide comments
where noted. Also add any other optional
explanatory comments.

Your application will be considered incomplete if No is entered as a Plan Response for any of
Checklist Items #1 through #16.
Checklist
Item #

SFA Filing Instructions
Reference

4.

Addendum C
Section H, Item (1)

Response
Options
If the plan is a MPRA plan for which the requested amount of SFA is determined using the present
value method described in § 4262.4(a)(2)(ii), does the application also include the information for
such plans as shown in Template 4B, including 4B-1 SFA Ben Pmts sheet, 4B-2 SFA Details 4(a)
(2)(ii) sheet, and 4B-3 SFA Exhaustion sheet? See Addendum D and Template 4B.

Plan
Response

Name of File(s) Uploaded

Yes
No
N/A

Page Number
Reference(s)

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

N/A

N/A

Template 4B Supp Plan Name

Plan Comments

Enter N/A if the plan is not a MPRA Plan or if the requested amount of SFA is determined based
on the increasing assets method.

5.

Section C, Items (4)b. Does the application include identification of the Non-SFA interest rate and the SFA interest,
and (4)c.
including details on how each was determined? See Template 4A, 4A-1 Interest Rates sheet.

Yes
No

N/A - included as part of Template 4A Plan
Name

N/A

N/A

N/A - included in Template 4A Plan
Name

6.

Addendum C
For each year in the SFA coverage period, does the application include the projected benefit
Section C, Item (4)e.ii. payments (excluding make-up payments, if applicable), separately for current retirees and
beneficiaries, current terminated vested participants not yet in pay status, current active
participants, and new entrants? See Template 4A, 4A-2 SFA Ben Pmts sheet.

Yes
No
N/A

N/A - included as part of Template 4A Plan
Name

N/A

N/A

N/A - included in Template 4A Plan
Name

Financial Assistance Application

SFA App Supp Plan Name

Enter N/A if the total projected benefit payments are the same as those used in the application
approved under the interim final rule.

7.

Section D

8.a.

8.b.

Addendum C
Section D, Item (1)

Was the application signed and dated by an authorized trustee who is a current member of the
board of trustees or another authorized representative of the plan sponsor and include the printed
name and title of the signer?

Yes
No

Identify here the name of the single
document that includes all information
requested in Section D of the SFA
Filing Instructions (Checklist Items #7
through #10.b.).

Does the application include a cover letter identifying the date the plan's application was approved
under the interim final rule, as well as the approved SFA amount under the interim final rule as of
the SFA measurement date?

Yes
No

N/A - included as part of SFA App Plan
Name

N/A

N/A - included as part of SFA App
Plan Name

For a plan that is a MPRA plan, does the application include a cover letter? Does the cover letter
identify the calculation method (basic method, increasing assets method, or present value method)
that provides the greatest amount of SFA?

Yes
No
N/A

N/A - included as part of SFA App Plan
Name

N/A

N/A - included as part of SFA App
Plan Name

Yes
No

N/A - included as part of SFA App Plan
Name

N/A

N/A - included as part of SFA App
Plan Name

Enter N/A if the plan is not a MPRA plan.
9.

Section D, Item (2)

Does the application include the name, address, email, and telephone number of the plan sponsor,
the plan sponsor's authorized representative, and any other authorized representatives?

5 of 8

Application to PBGC for Approval of Special Financial Assistance (SFA)
APPLICATION CHECKLIST - SUPPLEMENTED
Plan name:
EIN:
PN:

v20220802p

This Application Checklist - Supplemented is only used for a supplemented application. See Application Checklist for all other applications.
Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

---------------------------Filers provide responses here for each Checklist Item:-------------------------------------------

SFA Amount Approved Under
Interim Final Rule:
SFA Amount Requested Under Final
Rule:

Explain all N/A responses. Provide comments
where noted. Also add any other optional
explanatory comments.

Your application will be considered incomplete if No is entered as a Plan Response for any of
Checklist Items #1 through #16.
Checklist
Item #

SFA Filing Instructions
Reference

10.a.

Addendum C
Section D, Item (5)a.

Response
Options
If the projected employer contributions are different from those assumed in the application
approved under the interim final rule, does the application include a detailed narrative description
of the assumed future contributions (including assumed contribution rates) used to calculate the
requested SFA amount under the final rule?

Plan
Response

Name of File(s) Uploaded

Yes
No
N/A

N/A - included as part of SFA App Plan
Name

Yes
No
N/A

N/A - included as part of SFA App Plan
Name

Page Number
Reference(s)

Plan Comments

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

N/A

N/A - included as part of SFA App
Plan Name

N/A

N/A - included as part of SFA App
Plan Name

Enter N/A if the projected employer contributions are unchanged from those assumed in the
application approved under the interim final rule.

10.b.

Addendum C
Section D, Item (5)b.

If the Plan Response to Checklist Item #10.a. is Yes, does the application include documentation
described in § 4262.4(c)(3) of PBGC's SFA regulation that substantiates that the contributing rate
increases that are excluded were agreed to on or after July 9, 2021?

Briefly describe the documentation
included.

Enter N/A if the response to Checklist Item #10.a. is N/A.

11.a.

Section E, Item (1)

Does the application include a fully completed Application Checklist - Supplemented, including the
required information at the top of the Application Checklist (plan name, employer identification
number (EIN), 3-digit plan number (PN), SFA amount approved under the interim final rule, and
SFA amount requested under the final rule)?

Yes
No

N/A

Special Financial Assistance Checklist

App Checklist Supp Plan Name

11.b.

Section E, Item (1) Addendum A

If the plan is required to provide information required by Addendum A of the SFA Filing
Instructions (for "certain events"), does the application include the fully completed Additional
Information for Certain Events section of the general Application Checklist?

Yes
No
N/A

N/A

Special Financial Assistance Checklist

App Checklist Certain Events Plan
Name

Yes
No

N/A

Financial Assistance Application

SFA Amount Cert Supp Plan Name

Enter N/A if the plan is not required to submit the additional information described in Addendum
A.

12.a.

Does the application include the certification by the plan's enrolled actuary that the requested
amount of SFA is the amount to which the plan is entitled under section 4262(j)(1) of ERISA and §
4262.4 of PBGC's SFA regulation? Does this certification include:
(i) plan actuary's certification that identifies the requested amount of SFA under the final rule
(without any offset for SFA already paid to the plan under the interim final rule) and certifies that
this is the amount to which the plan is entitled?
(ii) confirmation that all assumptions and methods used, sources of participant data and census
data, SFA measurement date, and other relevant information are the same as in the application that
was approved under the interim final rule with the exception of the non-SFA and SFA interest
rates, the application of the new calculation methodology under the final rule and a change to the
plan's employer contribution assumption to exclude contribution rate increases agreed to on or after
July 9, 2021 (if applicable)?
(iii) a statement that the actuary is qualified to render the actuarial opinion?
Is the information in Checklist #12a combined with #12b (if applicable) as a single document, and
uploaded using the required filenaming convention?
Addendum C
Section E, Item (5)

6 of 8

Application to PBGC for Approval of Special Financial Assistance (SFA)
APPLICATION CHECKLIST - SUPPLEMENTED
Plan name:
EIN:
PN:

v20220802p

This Application Checklist - Supplemented is only used for a supplemented application. See Application Checklist for all other applications.
Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

---------------------------Filers provide responses here for each Checklist Item:-------------------------------------------

SFA Amount Approved Under
Interim Final Rule:
SFA Amount Requested Under Final
Rule:

Explain all N/A responses. Provide comments
where noted. Also add any other optional
explanatory comments.

Your application will be considered incomplete if No is entered as a Plan Response for any of
Checklist Items #1 through #16.
Checklist
Item #

SFA Filing
Instructions
Addendum
C
Reference
Section
E, Item (5)

12.b.

Response
Options
If the plan is a MPRA plan, does the certification by the plan's enrolled actuary identify the amount
of SFA determined under the basic method described in § 4262.4(a)(1) and the amount determined
under the increasing assets method in § 4262.4(a)(2)(i)?

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

N/A

N/A - included in SFA Amount Cert
Plan Name

N/A - included in SFA Amount Cert
Plan Name

Yes
No

N/A

Financial Assistance Application

Penalty Plan Name

Yes
No
N/A

N/A

Projections for special financial
assistance (estimated income, benefit
payments and expenses)

Template 9 Plan Name

Yes
No
N/A

N/A

Projections for special financial
assistance (estimated income, benefit
payments and expenses)

Template 9 Plan Name

Yes
No
N/A

Plan
Response

Name of File(s) Uploaded
N/A - included with SFA Amount Cert Plan
Name

Page Number
Reference(s)

Plan Comments

If the amount of SFA determined under the “present value method” described in § 4262.4(a)(2)(ii)
is not the greatest amount of SFA under § 4262.4(a)(2), does the certification state as such?
If the amount of SFA determined under the “present value method” described in § 4262.4(a)(2)(ii)
is the greatest amount of SFA under § 4262.4(a)(2), does the certification identify that amount?
Enter N/A if the plan is not a MPRA plan.

13.

Section E, Item (10)

Does the application include one or more copies of the penalties of perjury statement (see Section
E, Item (10) of the SFA Filing Instructions) that (a) are signed by an authorized trustee who is a
current member of the board of trustees, and (b) includes the trustee's printed name and title.
Is all such information included in a single document and uploaded using the required filenaming
convention?

14.

Addendum C
Section F, Item (1)

If the plan is not a MPRA plan, does the application include a reconciliation of the change in the
total amount of SFA under the final rule from the total amount of SFA approved under the interim
final rule, each as of the SFA measurement date? See Template 9 and its instructions for details on
the reconciliation and information to be provided.
Enter N/A if the plan is a MPRA plan.
Does the uploaded document use the required filenaming convention?

15.

Addendum C
Section G, Item (2)

If the plan is a MPRA plan for which the requested amount of SFA is based on the increasing assets
method, does the application include a reconciliation of the change in the requested amount of SFA
under the final rule from the total amount of SFA approved under the interim final rule, each as of
the SFA measurement date? See Template 9 and its instructions for details on the reconciliation
and information to be provided.
Enter N/A if the plan is a not a MPRA plan or if the plan is a MPRA plan using the present value
method.
Does the uploaded document use the required filenaming convention?

7 of 8

Application to PBGC for Approval of Special Financial Assistance (SFA)
APPLICATION CHECKLIST - SUPPLEMENTED
Plan name:
EIN:
PN:

v20220802p

This Application Checklist - Supplemented is only used for a supplemented application. See Application Checklist for all other applications.
Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

---------------------------Filers provide responses here for each Checklist Item:-------------------------------------------

SFA Amount Approved Under
Interim Final Rule:
SFA Amount Requested Under Final
Rule:

Explain all N/A responses. Provide comments
where noted. Also add any other optional
explanatory comments.

Your application will be considered incomplete if No is entered as a Plan Response for any of
Checklist Items #1 through #16.
Checklist
Item #

SFA Filing Instructions
Reference

16.

Addendum C
Section H, Item (2)

Response
Options
If the plan is a MPRA plan for which the requested amount of SFA is based on the present value
method, does the application include a reconciliation of the change in the requested amount of SFA
under the final rule from the total amount of SFA approved under the interim final rule, each as of
the SFA measurement date? See Template 9 and its instructions for details on the reconciliation
and information to be provided.

Plan
Response

Name of File(s) Uploaded

Yes
No
N/A

Page Number
Reference(s)
N/A

Enter N/A if the plan is a not a MPRA plan or if the plan is a MPRA plan using the increasing
assets method.
Does the uploaded document use the required filenaming convention?

8 of 8

Plan Comments

In the e-Filing Portal, upload as
Document Type
Projections for special financial
assistance (estimated income, benefit
payments and expenses)

Use this Filenaming Convention
Template 9 Plan Name