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SFA Application Checklist

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File Type	application/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Title	SFA Application Checklist
Author	Stone Sara
Last Modified By	Calc
File Modified	2024-07-02
File Created	2026-09-12
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Application Checklist

v202407XXp

Instructions for Section E, Item 1 of the Instructions for Filing Requirements for Multiemployer Plans Applying for Special Financial Assistance (SFA):

The Application to PBGC for Approval of Special Financial Assistance Checklist ("Application Checklist" or "Checklist") identifies all information required to be filed with an initial
or revised application. For a supplemented application, instead use "Application Checklist - Supplemented." The Application Checklist is not required for a lock-in application.
For a plan required to submit additional information described in Addendum A of the SFA Filing Instructions, also complete Checklist Items #40.a. to #49.b., and if there is a merger
as described in Addendum A, also complete Checklist Items #50 through #63.
Applications (including this Application Checklist), with the exception of lock-in applications, 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: revised and supplemented applications must 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:
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 revised application, the filer may, but is not required to, submit an entire application. For all Application Checklist 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 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, 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 #22 to #29c, 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 #39 on the Application Checklist. If there has been an event as described in § 4262.4(f), complete Checklist Items #40.a. through #49.b., and if there has
been a merger described in Addendum A, also complete Checklist Items #50 through #63. Your application will be considered incomplete if No is entered as a Plan Response for any
of Checklist Items #40.a. through #49.b. if you are required to complete Checklist Items # 40.a. through #49.b. Your application will also be considered incomplete if No is entered
as a Plan Response for any of Checklist Items #50 through #63 if you are required to complete Checklist Items #50 through #63.

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 #f.
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

v202407XXp

07/XX/2024

Update checklist items 11.c, 34.a, and 35 for death audit requirements and to align with instructions

v07272023p

7/27/2023

Updated checklist to include new Template 10 requirement and reflect changes to eligibility and death audit instructions

v20221129p

11/29/2022

Updated checklist item 11. for new death audit requirements

v20220802p

8/2/2022

Fixed some of the shading in the checklist

v20220706p

7/6/2022

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

SFA Amount Requested:
Your application will be considered incomplete if No is entered as a Plan Response for any of Checklist Items #1 through #39. In addition, if required to provide information due to a "certain
event" (see Addendum A of the SFA Filing Instructions), your application will be considered incomplete if No is entered as a Plan Response for any Checklist Items #40.a. through #49.b. If there
is a merger event described in Addendum A, your application will also be considered incomplete if No is entered as a Plan Response for any Checklist Items #50 through #63.

Checklist SFA Filing Instructions
Item #
Reference

Response
Options

Plan Information, Checklist, and Certifications
Is this application a revised application submitted after the denial of a previously filed application
a.
for SFA?

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Plan
Response

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

Name of File(s) Uploaded

Page Number
Reference(s)

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

Yes
No

N/A

Plan Comments

Is this application a revised application submitted after a plan has withdrawn its application for
SFA that was initially submitted under the interim final rule?

Yes
No

N/A

Is this application a revised application submitted after a plan has withdrawn its application for
SFA that was submitted under the final rule?

Yes
No

N/A

Did the plan previously file a lock-in application?

Yes
No

N/A

If a "lock-in" application was filed,
provide the filing date.

N/A

Has this plan been terminated?

Yes
No

N/A

If terminated, provide date of plan
termination.

N/A

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

Yes
No

N/A

Section B, Item (1)a.

Does the application include the most recent plan document or restatement of the plan document
and all amendments adopted since the last restatement (if any)?

Yes
No

N/A

Pension plan documents, all versions
available, and all amendments signed
and dated

N/A

Section B, Item (1)b.

Does the application include the most recent trust agreement or restatement of the trust agreement,
and all amendments adopted since the last restatement (if any)?

Yes
No

N/A

Pension plan documents, all versions
available, and all amendments signed
and dated

N/A

Section B, Item (1)c.

Does the application include the most recent IRS determination letter?

Yes
No
N/A

N/A

Pension plan documents, all versions
available, and all amendments signed
and dated

N/A

Yes
No
N/A

N/A

Most recent actuarial valuation for the
plan

YYYYAVR Plan Name

Yes
No

N/A

Rehabilitation plan (or funding
improvement plan, if applicable)

N/A

Enter N/A if the plan does not have a determination letter.
4.

Section B, Item (2)

Does the application include the actuarial valuation report for the 2018 plan year and each
subsequent actuarial valuation report completed before the filing date of the initial application?
Enter N/A if no actuarial valuation report was prepared because it was not required for any
requested year.

Identify here how many reports are
provided.

Is each report provided as a separate document using the required filename convention?
Does the application include the most recent rehabilitation plan (or funding improvement plan, if
applicable), including all subsequent amendments and updates, and the percentage of total
contributions received under each schedule of the rehabilitation plan or funding improvement plan
for the most recent plan year available?

5.a.

Section B, Item (3)

4 of 27

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference
5.b.

Section B, Item (3)

Response
Options
If the most recent rehabilitation plan does not include historical documentation of rehabilitation
plan changes (if any) that occurred in calendar year 2020 and later, does the application include an
additional document with these details?

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Plan
Response

Name of File(s) Uploaded

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

Page Number
Reference(s)

Plan Comments

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

Yes
No
N/A

N/A

Rehabilitation plan (or funding
improvement plan, if applicable)

N/A

Yes
No

N/A

Latest annual return/report of
employee benefit plan (Form 5500)

YYYYForm5500 Plan Name

Yes
No
N/A

N/A

Zone certification

YYYYZoneYYYYMMDD Plan Name,
where the first "YYYY" is the
applicable plan year, and
"YYYYMMDD" is the date the
certification was prepared.

Enter N/A if the historical document is contained in the rehabilitation plans.
6.

Section B, Item (4)

Does the application include the plan's most recently filed (as of the filing date of the initial
application) Form 5500 (Annual Return/Report of Employee Benefit Plan) and all schedules and
attachments (including the audited financial statement)?
Is the 5500 filing provided as a single document using the required filename convention?
Does the application include the plan actuary's certification of plan status ("zone certification") for
the 2018 plan year and each subsequent annual certification completed before the filing date of the
initial application?

7.a.

Enter N/A if the plan does not have to provide certifications for any requested plan year.

Identify how many zone certifications
are provided.

Is each zone certification (including the additional information identified in Checklist Items #7.b.
and #7.c. below, if applicable) provided as a single document, separately for each plan year, using
the required filename convention?

Does the application include documentation for all zone certifications that clearly identifies all
assumptions used including the interest rate used for funding standard account purposes?

7.b.

Section B, Item (5)

If such information is provided in an addendum, addendums are only required for the most recent
actuarial certification of plan status completed before January 1, 2021 and each subsequent annual
certification.

Yes
No
N/A

N/A - include as part of documents in
Checklist Item #7.a.

N/A

N/A - include as part of documents in N/A - included in a single document
Checklist Item #7.a.
for each plan year - See Checklist Item
#7.a.

Yes
No
N/A

N/A - include as part of documents in
Checklist Item #7.a.

N/A

N/A - include as part of documents in N/A - included in a single document
Checklist Item #7.a.
for each plan year - See Checklist Item
#7.a.

Is this information included in the single document in Checklist Item #7.a. for the applicable plan
year?
Enter N/A if the plan entered N/A for Checklist Item #7a.

7.c.

For a certification of critical and declining status, does the application include the required planyear-by-plan-year projection (showing the items identified in Section B, Item (5)a. through (5)f. of
the SFA Instructions) demonstrating the plan year that the plan is projected to become insolvent? If
required, is this information included in the single document in Checklist Item #7.a. for the
applicable plan year? Enter N/A if the plan entered N/A for Checklist Item #7.a. or if the
application does not include a certification of critical and declining status.

5 of 27

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference
8.

Section B, Item (6)

Response
Options
Does the application include the most recent account statements for each of the plan's cash and
investment accounts?
Insolvent plans may enter N/A, and identify in the Plan Comments that this information was
previously submitted to PBGC and the date submitted.

Section B, Item (7)

Does the application include the most recent plan financial statement (audited, or unaudited if
audited is not available)?
Insolvent plans may enter N/A, and identify in the Plan Comments that this information was
previously submitted to PBGC and the date submitted.

10.

Section B, Item (8)

Does the application include all of the plan's written policies and procedures governing the plan’s
determination, assessment, collection, settlement, and payment of withdrawal liability?
Are all such items included as a single document using the required filenaming convention?

Does the application include documentation of a death audit to identify deceased participants that
was completed on the census data used for SFA purposes, including identification of the service
provider conducting the audit, date performed, the participant counts (provided separately for
current retirees and beneficiaries, current terminated vested participants not yet in pay status, and
current active participants) run through the death audit, and a copy of the results of the audit
provided to the plan administrator by the service provider?

11.a.

Section B, Item (9)a.

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Plan
Response

Name of File(s) Uploaded

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

Page Number
Reference(s)

Plan Comments

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

Yes
No
N/A

N/A

Bank/Asset statements for all cash and
investment accounts

N/A

Yes
No
N/A

N/A

Plan's most recent financial statement
(audited, or unaudited if audited not
available)

N/A

Yes
No
N/A

N/A

Pension plan documents, all versions
available, and all amendments signed
and dated

WDL Plan Name

Yes
No

N/A

Pension plan documents, all versions
available, and all amendments signed
and dated

Death Audit Plan Name

N/A

N/A - include as part of documents in
Checklist Item #11.a.

If applicable, has personally identifiable information in this report been redacted prior to
submission to PBGC?
Is this information included as a single document using the required filenaming convention?

11.b.

11.c.

If any known deaths occurred before the date of the census data used for SFA purposes, is a
statement certifying these deaths were reflected for SFA calculation purposes provided?

Section B, Item (9)b. & Does the application include full census data (Social Security Number, name, and participant
Item (9)c.
status) of all participants that were included in the SFA projections? Is this information provided in
Excel, or in an Excel-compatible format?

Yes
No
N/A

N/A - include as part of documents in
Checklist Item #11.a.

Yes
No
N/A

N/A

Or, if this data was submitted in advance of the application, in accordance with Section B, Item
(9)c. of the Instructions, does the application contain a description of how the results of PBGC’s
independent death audit are reflected for SFA calculation purposes?

6 of 27

Submit the data file and the date of the Include as the subject “Submission of
census data through PBGC’s secure
Terminated Vested Census Data for
file transfer system, Leapfile. Go to
(Plan Name),” and as the memo
http://pbgc.leapfile.com, click on
“(Plan Name) terminated vested
“Secure Upload” and then enter
census data dated (date of census
[email protected] as the recipient email data) through Leapfile for independent
address and upload the file(s) for
audit by PBGC.”
secure transmission.

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Response
Options

Plan
Response

Name of File(s) Uploaded

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

Page Number
Reference(s)

Plan Comments

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

12.

Section B, Item (10)

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

13.

Section C, Item (1)

Does the application include the plan's projection of expected benefit payments that should have
been attached to the Form 5500 Schedule MB in response to line 8b(1) on the Form 5500 Schedule
MB for plan years 2018 through the last year the Form 5500 was filed by the filing date of the
initial application?

Yes
No
N/A

N/A

Financial assistance spreadsheet
(template)

Template 1 Plan Name

Yes
No
N/A

N/A

Contributing employers

Template 2 Plan Name

Yes
No

N/A

Historical Plan Financial Information
(CBUs, contribution rates, contribution
amounts, withdrawal liability
payments)

Template 3 Plan Name

Enter N/A if the plan is not required to respond Yes to line 8b(1) on the Form 5500 Schedule MB.
See Template 1.
Does the uploaded file use the required filenaming convention?

14.

Section C, Item (2)

If the plan was required to enter 10,000 or more participants on line 6f of the most recently filed
Form 5500 (by the filing date of the initial application), does the application include a current
listing of the 15 largest contributing employers (the employers with the largest contribution
amounts) and the amount of contributions paid by each employer during the most recently
completed plan year before the filing date of the initial application (without regard to whether a
contribution was made on account of a year other than the most recently completed plan year)? If
this information is required, it is required for the 15 largest contributing employers even if the
employer's contribution is less than 5% of total contributions.
Enter N/A if the plan is not required to provide this information. See Template 2.
Does the uploaded file use the required filenaming convention?

15.

Section C, Item (3)

Does the application include historical plan information for the 2010 plan year through the plan
year immediately preceding the date the plan's initial application was filed that separately
identifies: total contributions, total contribution base units (including identification of the unit
used), average contribution rates, and number of active participants at the beginning of each plan
year? For the same period, does the application show all other sources of non-investment income
such as withdrawal liability payments collected, reciprocity contributions (if applicable), additional
contributions from the rehabilitation plan (if applicable), and other identifiable sources of
contributions? See Template 3.
Does the uploaded file use the required filenaming convention?

7 of 27

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference
16.a.

Response
Options

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

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Plan
Response

Name of File(s) Uploaded

Yes
No

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

Page Number
Reference(s)

Plan Comments

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

N/A

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

Template 4A Plan Name

Does the uploaded file use the required filenaming convention?

16.b.i.

Addendum D
If the plan is a MPRA plan, does the application also include the information used to determine the
Section C, Item (4)a. - amount of SFA for the plan using the increasing assets method described in § 4262.4(a)(2)(i) based
MPRA plan information on a deterministic projection and using the actuarial assumptions as described in § 4262.4(e)?
A.
See Template 4A, 4A-5 SFA Details .4(a)(2)(i) sheet and Addendum D for more details on these
requirements.
Addendum D
Section C, Item (4)e. - Enter N/A if the plan is not a MPRA Plan.
MPRA plan information
A.

Yes
No
N/A

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

N/A

N/A - included in Template 4A Plan
Name

16.b.ii.

Addendum D
If the plan is a MPRA plan for which the requested amount of SFA is determined using the
Section C, Item (4)f. - increasing assets method described in § 4262.4(a)(2)(i), does the application also explicitly identify
MPRA plan information the projected SFA exhaustion year based on the increasing assets method? See Template 4A, 4A-5
A.
SFA Details .4(a)(2)(i) sheet and Addendum D.

Yes
No
N/A

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

N/A

N/A - included in Template 4A Plan
Name

N/A

Template 4B Plan Name

N/A

N/A - included in Template 4A Plan
Name

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.

16.b.iii.

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

Yes
No
N/A

Addendum D
Enter N/A if the plan is not a MPRA Plan or if the requested amount of SFA is determined based
Section C, Item (4)e. on the increasing assets method.
(4)f., and (4)g. - MPRA
plan information B.

16.c.

Section C, Items (4)b. Does the application include identification of the non-SFA interest rate and the SFA interest rate,
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

8 of 27

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Response
Options

Plan
Response

Name of File(s) Uploaded

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

Page Number
Reference(s)

Plan Comments

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

16.d.

Section C, Item (4).e.ii. For each year in the SFA coverage period, does the application include the projected benefit
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 - included as part of Template 4A Plan
Name

N/A

N/A - included in Template 4A Plan
Name

16.e.

Section C, Item (4)e.iv. For each year in the SFA coverage period, does the application include a breakdown of the
and (4)e.v.
administrative expenses between PBGC premiums and all other administrative expenses? Does the
application include the projected total number of participants at the beginning of each plan year in
the SFA coverage period? See Template 4A, 4A-3 SFA Pcount and Admin Exp sheet.

Yes
No

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

N/A

N/A - included in Template 4A Plan
Name

For a plan that is not a MPRA plan, does the application include a separate deterministic projection
("Baseline") in the same format as Checklist Items #16.a., #16.d., and #16.e. that shows the amount
of SFA that would be determined using the basic method if the assumptions/methods used are the
same as those used in the most recent actuarial certification of plan status completed before January
1, 2021 ("pre-2021 certification of plan status") excluding the plan's non-SFA interest rate and SFA
interest rate, which should be the same as in Checklist Item #16.a.? See Section C, Item (5) of the
SFA Filing Instructions for other potential exclusions from this requirement.

Yes
No
N/A

N/A

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

Template 5A Plan Name

Yes
No
N/A

N/A

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

Template 5A Plan Name

17.a.

Section C, Item (5)

If (a) the plan is a MPRA plan, or if (b) this item is not required for a plan that is not a MPRA plan,
enter N/A. If entering N/A due to (b), add information in the Plan Comments to explain why this
item is not required.
Does the uploaded file use the required filenaming convention?

17.b.

Addendum D
Section C, Item (5)

For a MPRA plan for which the requested amount of SFA is determined using the increasing assets
method, does the application include a separate deterministic projection ("Baseline") in the same
format as Checklist Items #16.b.i., #16.d., and #16.e. that shows the amount of SFA that would be
determined using the increasing assets method if the assumptions/methods used are the same as
those used in the most recent actuarial certification of plan status completed before January 1, 2021
("pre-2021 certification of plan status") excluding the plan's non-SFA interest rate and SFA interest
rate, which should be the same as used in Checklist Item #16.b.i.? See Section C, Item (5) of the
SFA Filing Instructions for other potential exclusions from this requirement. Also see Addendum
D.
If the plan is (a) not a MPRA plan, (b) a MPRA plan using the present value method, or (c) is
otherwise not required to provide this item, enter N/A. If entering N/A due to (c), add information
in the Plan Comments to explain why this item is not required.
Does the uploaded file use the required filenaming convention?

9 of 27

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference
17.c.

Addendum D
Section C, Item (5)

Response
Options
For a MPRA plan for which the requested amount of SFA is determined using the present value
method, does the application include a separate deterministic projection ("Baseline") in the same
format as Checklist Item #16.b.iii. that shows the amount of SFA that would be determined using
the present value method if the assumptions used/methods are the same as those used in the most
recent actuarial certification of plan status completed before January 1, 2021 ("pre-2021
certification of plan status") excluding the plan's SFA interest rate which should be the same as
used in Checklist Item #16.b.iii. See Section C, Item (5) of the SFA Filing Instructions for other
potential exclusions from this requirement. Also see Addendum D.

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Plan
Response

Name of File(s) Uploaded

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

Page Number
Reference(s)

Plan Comments

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

Yes
No
N/A

N/A

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

Template 5B Plan Name

Yes
No
N/A

N/A

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

Template 6A Plan Name

If the plan is (a) not a MPRA plan, (b) a MPRA plan using the increasing assets method, or (c) is
otherwise not required to provide this item, enter N/A. If entering N/A due to (c), add information
in the Plan Comments to explain why this item is not required.
Has this document been uploaded using the required filenaming convention?

18.a.

Section C, Item (6)

For a plan that is not a MPRA plan, does the application include a reconciliation of the change in
the total amount of requested SFA due to each change in assumption/method from the Baseline to
the requested SFA amount? Does the application include a deterministic projection and other
information for each assumption/method change, in the same format as Checklist Item #16.a? Enter
N/A if the plan is not required to provide Baseline information in Checklist Item #17.a. Enter N/A
if the requested SFA amount in Checklist Item #16.a. is the same as the amount shown in the
Baseline details of Checklist Item #17.a. See Section C, Item (6) of the SFA Filing Instructions for
other potential exclusions from this requirement.
If the plan is a MPRA plan, enter N/A. If the plan is otherwise not required to provide this item,
enter N/A and provide an explanation in the Plan Comments.
Does the uploaded file use the required filenaming convention?

10 of 27

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference
18.b.

Addendum D
Section C, Item (6)

Response
Options
For 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 total amount of requested SFA
using the increasing assets method due to each change in assumption/method from the Baseline to
the requested SFA amount? Does the application include a deterministic projection and other
information for each assumption/method change, in the same format as Checklist Item #16.b.i.?

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Plan
Response

Name of File(s) Uploaded

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

Page Number
Reference(s)

Plan Comments

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

Yes
No
N/A

N/A

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

Template 6A Plan Name

Yes
No
N/A

N/A

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

Template 6B Plan Name

Enter N/A if the plan is not required to provide Baseline information in Checklist Item #17.b. Enter
N/A if the requested SFA amount in Checklist Item #16.b.i. is the same as the amount shown in the
Baseline details of Checklist Item #17.b. See Addendum D. See Section C, Item (6) of the SFA
Filing Instructions for other potential exclusions from this requirement, and enter N/A if this item is
not otherwise required.
If the plan is (a) not a MPRA plan, (b) a MPRA plan using the present value method, or (c) is
otherwise not required to provide this item, enter N/A. If entering N/A due to (c), add information
in the Plan Comments to explain why this item is not required.
Does the uploaded file use the required filenaming convention?

18.c.

Addendum D
Section C, Item (6)

For 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 total amount of requested SFA
using the present value method due to each change in assumption/method from Baseline to the
requested SFA amount? Does the application include a deterministic projection and other
information for each assumption/method change, in the same format as Checklist Item #16.b.iii.?
See Section C, Item (6) of the SFA Filing Instructions for other potential exclusions from this
requirement. Also see Addendum D.
If the plan is (a) not a MPRA plan, (b) a MPRA plan using the increasing assets method, or (c) is
otherwise not required to provide this item, enter N/A. If entering N/A due to (c), add information
in the Plan Comments to explain why this item is not required.
Has this document been uploaded using the required filenaming convention?

11 of 27

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference
19.a.

Section C, Item (7)a.

Response
Options
For plans eligible for SFA under § 4262.3(a)(1) or § 4262.3(a)(3), does the application include a
table identifying which assumptions/methods used in determining the plan's eligibility for SFA
differ from those used in the pre-2021 certification of plan status, and does that table include brief
explanations as to why using those assumptions/methods is no longer reasonable and why the
changed assumptions/methods are reasonable (an abbreviated version of information provided in
Checklist Item #28.a.)?

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Plan
Response

Name of File(s) Uploaded

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

Page Number
Reference(s)

Plan Comments

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

Yes
No
N/A

N/A

Financial assistance spreadsheet
(template)

Template 7 Plan Name.

Yes
No

N/A

Financial assistance spreadsheet
(template)

Template 7 Plan Name

Yes
No

N/A

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

Template 8 Plan Name

Enter N/A if the plan is eligible for SFA under § 4262.3(a)(2) or § 4262.3(a)(4) or if the plan is
eligible based on a certification of plan status completed before 1/1/2021. Also enter N/A if the
plan is eligible based on a certification of plan status completed after 12/31/2020 but that reflects
the same assumptions as those in the pre-2021 certification of plan status. See Template 7, 7a
Assump Changes for Elig sheet.
Does the uploaded file include both Checklist Items #19.a. and #19.b., and does it use the required
filenaming convention?

19.b.

Section C, Item (7)b.

Does the application include a table identifying which assumptions/methods used to determine the
requested SFA differ from those used in the pre-2021 certification of plan status (except the interest
rates used to determine SFA)? Does this item include brief explanations as to why using those
original assumptions/methods is no longer reasonable and why the changed assumptions/methods
are reasonable? If a changed assumption is an extension of the CBU assumption or the
administrative expenses assumption as described in Paragraph A “Adoption of assumptions not
previously factored into pre-2021 certification of plan status” of Section III, Acceptable
Assumption Changes of PBGC’s SFA assumptions guidance, does the application state so? This
should be an abbreviated version of information provided in Checklist Item #28.b. See Template 7,
7b Assump Changes for Amount sheet.
Does the uploaded file include both Checklist Items #19.a. and #19.b., and does it use the required
filenaming convention?

Does the application include details of the projected contributions and withdrawal liability
payments used to calculate the requested SFA amount, including total contributions, contribution
base units (including identification of base unit used), average contribution rate(s), reciprocity
contributions (if applicable), additional contributions from the rehabilitation plan (if applicable),
and any other identifiable contribution streams? See Template 8.

20.a.

Section C, Item (8)

12 of 27

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference
20.b.

Section C, Item (8)

21.

Section C, Item (10)

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Response
Options
Does the application separately show the amounts of projected withdrawal liability payments for
employers that are currently withdrawn as of the date the initial application is filed, and assumed
future withdrawals? Does the application also provide the projected number of active participants at
the beginning of each plan year? See Template 8.

Yes
No

Does the application provide a table identifying and describing all assumptions and methods used
in i) the pre-2021 certification of plan status, ii) the “Baseline” projection in Section C Item (5),
and iii) the determination of the amount of SFA in Section C Item (4)?

Yes
No

Plan
Response

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

Name of File(s) Uploaded

Page Number
Reference(s)

N/A - include as part of Checklist Item #20.a.

N/A

N/A - included in Template 8 Plan
Name

N/A

Financial assistance spreadsheet
(template)

Template 10 Plan Name

Identify here the name of the single
document that includes all information
requested in Section D of the SFA
Filing Instructions (Checklist Items #22
through #29.c.).

Financial Assistance Application

SFA App Plan Name

For each Checklist Item #22 through
#29.c., identify the relevant page
number(s) within the single document.

N/A

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

Plan Comments

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

Does the table state if each changed assumption falls under Section III, Acceptable Assumption
Changes, or Section IV, Generally Accepted Assumption Changes, in PBGC’s SFA assumptions
guidance, or if it should be considered an “Other Change”?
Does the uploaded file use the required filenaming convention?

22.

Section D

23.a.

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

For a plan that is not a MPRA plan, does the application include an optional cover letter?

Yes
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

N/A

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

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 plan is a MPRA plan, or if the plan is not a MPRA plan and did not include an
optional cover letter.
23.b.

Section D, Item (1)

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? For a MPRA plan with a partition, does the cover letter
include a statement that the plan has been partitioned under section 4233 of ERISA?
Enter N/A if the plan is not a MPRA plan.

24.

Section D, Item (2)

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

Yes
No

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

25.

Section D, Item (3)

Does the application identify the eligibility criteria in § 4262.3 that qualifies the plan as eligible to
receive SFA, and include the requested information for each item that is applicable, as described in
Section D, Item (3) of the SFA Filing Instructions?

Yes
No

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

13 of 27

Briefly note here the basis for eligibility
for SFA.

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference

Response
Options
If the plan's application is submitted on or before March 11, 2023, does the application identify the
plan's priority group (see § 4262.10(d)(2))?

26.a.

Enter N/A if the plan's application is submitted after March 11, 2023.
26.b.

Section D, Item (4)

If the plan is submitting an emergency application under § 4262.10(f), is the application identified
as an emergency application with the applicable emergency criteria identified?
Enter N/A if the plan is not submitting an emergency application.

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Plan
Response

Name of File(s) Uploaded

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

Page Number
Reference(s)

Plan Comments

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

Yes
No
N/A

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

Briefly identify here the priority group,
if applicable.

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

Briefly identify the emergency criteria,
if applicable.

N/A

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

27.

Section D, Item (5)

Does the application include a detailed narrative description of the development of the assumed
future contributions and assumed future withdrawal liability payments used in the basic method
(and in the increasing assets method for a MPRA plan)?

Yes
No

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

N/A

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

28.a.

Section D, Item (6)a.

For plans eligible for SFA under § 4262.3(a)(1) or § 4262.3(a)(3), does the application identify
which assumptions/methods (if any) used in showing the plan's eligibility for SFA differ from those
used in the most recent certification of plan status completed before 1/1/2021? If there are any
assumption/method changes, does the application include detailed explanations and supporting
rationale and information as to why using the identified assumptions/methods is no longer
reasonable and why the changed assumptions/methods are reasonable?

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 eligible under § 4262.3(a)(1) or § 4262.3(a)(3). Enter N/A if there are
no such assumption changes.

28.b.

Section D, Item (6)b.

Does the application identify which assumptions/methods (if any) used to determine the requested
SFA amount differ from those used in the most recent certification of plan status completed before
1/1/2021 (excluding the plan's non-SFA and SFA interest rates, which must be the same as the
interest rates required by § 4262.4(e)(1) and (2))? If there are any assumption/method changes,
does the application include detailed explanations and supporting rationale and information as to
why using the identified original assumptions/methods is no longer reasonable and why the
changed assumptions/methods are reasonable? Does the application state if the changed
assumption is an extension of the CBU assumption or the administrative expenses assumption as
described in Paragraph A “Adoption of assumptions not previously factored into pre-2021
certification of plan status” of Section III, Acceptable Assumption Changes of PBGC’s SFA
Assumptions?

14 of 27

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference
28.c.

Section D, Item (6)

Response
Options
If the mortality assumption uses a plan-specific mortality table or a plan-specific adjustment to a
standard mortality table (regardless of if the mortality assumption is changed or unchanged from
that used in the most recent certification of plan status completed before 1/1/2021), is supporting
information provided that documents the methodology used and the rationale for selection of the
methodology used to develop the plan-specific rates, as well as detailed information showing the
determination of plan credibility and plan experience?

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Plan
Response

Name of File(s) Uploaded

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

Page Number
Reference(s)

Plan Comments

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

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

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

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

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

N/A

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

N/A

Special Financial Assistance Checklist

App Checklist Plan Name

N/A

Special Financial Assistance Checklist

N/A

Enter N/A is the mortality assumption does not use a plan-specific mortality table or a plan-specific
adjustment to a standard mortality table for eligibility or for determining the SFA amount.
29.a.

Section D, Item (7)

Does the application include, for an eligible plan that implemented a suspension of benefits under
section 305(e)(9) or section 4245(a) of ERISA, a narrative description of how the plan will
reinstate the benefits that were previously suspended and a proposed schedule of payments (equal
to the amount of benefits previously suspended) to participants and beneficiaries?
Enter N/A for a plan that has not implemented a suspension of benefits.

29.b.

Section D, Item (7)

If Yes was entered for Checklist Item #29.a., does the proposed schedule show the yearly aggregate
amount and timing of such payments, and is it prepared assuming the effective date for
reinstatement is the day after the SFA measurement date?
Enter N/A for a plan that entered N/A for Checklist Item #29.a.

29.c.

Section D, Item (7)

If the plan restored benefits under 26 CFR 1.432(e)(9)-1(e)(3) before the SFA measurement date,
does the proposed schedule reflect the amount and timing of payments of restored benefits and the
effect of the restoration on the benefits remaining to be reinstated?
Enter N/A for a plan that did not restore benefits under 26 CFR 1.432(e)(9)-1(e)(3) before the SFA
measurement date. Also enter N/A for a plan that entered N/A for Checklist Items #29.a. and
#29.b.

30.a.

Section E, Item (1)

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

Yes
No

30.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"), are the additional Checklist Items #40.a. through #49.b.
completed?

Yes
No
N/A

N/A

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

15 of 27

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference
31.

Section E, Item (2)

Response
Options
If the plan claims SFA eligibility under § 4262.3(a)(1) of PBGC's SFA regulation based on a
certification by the plan's enrolled actuary of plan status for SFA eligibility purposes completed on
or after January 1, 2021, does the application include:
(i) plan actuary's certification of plan status for SFA eligibility purposes for the specified year (and,
if applicable, for each plan year after the plan year for which the pre-2021 zone certification was
prepared and for the plan year immediately prior to the specified year)?
(ii) for each certification in (i) above, does the application include all details and additional
information described in Section B, Item (5) of the SFA Filing Instructions, including clear
documentation of all assumptions, methods and census data used?
(iii) for each certification in (i) above, does the application identify all assumptions and methods
that are different from those used in the pre-2021 zone certification?

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Plan
Response

Name of File(s) Uploaded

Yes
No
N/A

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

Page Number
Reference(s)

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

N/A

Financial Assistance Application

SFA Elig Cert CD Plan Name

N/A

Financial Assistance Application

SFA Elig Cert C Plan Name

Plan Comments

Does the certification by the plan's enrolled actuary include clear indication of all assumptions and
methods used including source of and date of participant data, measurement date, and a statement
that the actuary is qualified to render the actuarial opinion?
If the plan does not claim SFA eligibility under § 4262.3(a)(1) or claims SFA eligibility under
§ 4262.3(a)(1) using a zone certification completed before January 1, 2021, enter N/A.
Is the information for this Checklist Item #31 contained in a single document and uploaded using
the required filenaming convention?

32.a.

Section E, Item (3)

If the plan claims SFA eligibility under § 4262.3(a)(3) of PBGC's SFA regulation based on a
certification by the plan's enrolled actuary of plan status for SFA eligibility purposes completed on
or after January 1, 2021, does the application include:
(i) plan actuary's certification of plan status for SFA eligibility purposes for the specified year (and,
if applicable, for each plan year after the plan year for which the pre-2021 zone certification was
prepared and for the plan year immediately prior to the specified year)?
(ii) for each certification in (i) above, does the application include all details and additional
information described in Section B, Item (5) of the SFA Filing Instructions, including clear
documentation of all assumptions, methods and census data used?
(iii) for each certification in (i) above, does the application identify all assumptions and methods
that are different from those used in the pre-2021 zone certification?
Does the certification by the plan's enrolled actuary include clear indication of all assumptions and
methods used including source of and date of participant data, measurement date, and a statement
that the actuary is qualified to render the actuarial opinion?
If the plan does not claim SFA eligibility under § 4262.3(a)(3) or claims SFA eligibility under
§ 4262.3(a)(3) using a zone certification completed before January 1, 2021, enter N/A.
Is the information for Checklist Items #32.a. and #32.b. contained in a single document and
uploaded using the required filenaming convention?

16 of 27

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference
32.b.

Section E, Item (3)

Response
Options
If the plan claims SFA eligibility under § 4262.3(a)(3) of PBGC's SFA regulation, does the
application include a certification from the plan's enrolled actuary that the plan qualifies for SFA
based on the applicable certification of plan status for SFA eligibility purposes for the specified
year, and by meeting the other requirements of § 4262.3(c) of PBGC's SFA regulation. Does the
provided certification include:
(i) identification of the specified year for each component of eligibility (certification of plan status
for SFA eligibility purposes, modified funding percentage, and participant ratio)
(ii) derivation of the modified funded percentage
(iii) derivation of the participant ratio

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Yes
No
N/A

Plan
Response

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

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

Page Number
Reference(s)

Plan Comments

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

N/A

Financial Assistance Application

N/A - included in SFA Elig Cert C
Plan Name

N/A

Financial Assistance Application

PG Cert Plan Name

Does the certification identify what test(s) under section 305(b)(2) of ERISA is met for the
specified year listed above?
Does the certification identify all assumptions and methods (including supporting rationale, and
where applicable, reliance on the plan sponsor) used to develop the withdrawal liability receivable
that is utilized in the calculation of the modified funded percentage?
Enter N/A if the plan does not claim SFA eligibility under §4262.3(a)(3).

33.

Section E, Item (4)

Is the information for Checklist Items #32.a. and #32.b. contained in a single document and
uploaded using the required filenaming convention?
If the plan's application is submitted on or prior to March 11, 2023, does the application include a
certification from the plan's enrolled actuary that the plan is eligible for priority status, with specific
identification of the applicable priority group?

Yes
No
N/A

This item is not required (enter N/A) if the plan is insolvent, has implemented a MPRA suspension
as of 3/11/2021, is in critical and declining status and had 350,000+ participants, or is listed on
PBGC's website at www.pbgc.gov as being in priority group 6. See § 4262.10(d).
Does the certification by the plan's enrolled actuary include clear indication of all assumptions and
methods used including source of and date of participant data, measurement date, and a statement
that the actuary is qualified to render the actuarial opinion?
Is the filename uploaded using the required filenaming convention?

17 of 27

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference

Response
Options
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 and certifies that this is
the amount to which the plan is entitled?
(ii) clear indication of all assumptions and methods used including source of and date of participant
data, measurement date, and a statement that the actuary is qualified to render the actuarial opinion?
(iii) the count of participants (provided separately, after reflection of the death audit results in
Section B(9), for current retirees and beneficiaries, current terminated vested participants not yet in
pay status, and current active participants) as of the participant census date?

34.a.

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Plan
Response

Name of File(s) Uploaded

Yes
No

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

Page Number
Reference(s)

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

N/A

Financial Assistance Application

SFA Amount Cert Plan Name

N/A

N/A - included in SFA Amount Cert
Plan Name

Plan Comments

Is the information in Checklist #34.a. combined with #34.b. (if applicable) as a single document,
and uploaded using the required filenaming convention?

Section E, Item (5)
34.b.

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)?

Yes
No
N/A

N/A - included with SFA Amount Cert Plan
Name

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.

18 of 27

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference
35.

Section E, Item (6)

Response
Options
Does the application include the plan sponsor's identification of the amount of fair market value of
assets at the SFA measurement date and certification that this amount is accurate? Does the
application also include:
(i) information that substantiates the asset value and how it was developed (e.g., trust or account
statements, specific details of any adjustments)?
(ii) a reconciliation of the fair market value of assets from the date of the most recent audited plan
financial statements to the SFA measurement date (showing beginning and ending fair market
value of assets for this period as well as the following items for the period: contributions,
withdrawal liability payments, benefits paid, administrative expenses, and investment income)?
(iii) if the SFA measurement date is the end of a plan year for which the audited plan financial
statements have been issued, does the application include a reconciliation schedule showing
adjustments, if any, made to the audited fair market value of assets used to determine the SFA
amount?

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Plan
Response

Name of File(s) Uploaded

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

Page Number
Reference(s)

Plan Comments

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

Yes
No

N/A

Financial Assistance Application

FMV Cert Plan Name

With the exception of account statements and financial statements already provided as Checklist
Items #8 and #9, is all information contained in a single document that is uploaded using the
required filenaming convention?

36.

Section E, Item (7)

Does the application include a copy of the executed plan amendment required by § 4262.6(e)(1) of
PBGC's SFA regulation which (i) is signed by authorized trustee(s) of the plan and (ii) includes the
plan compliance language in Section E, Item (7) of the SFA Filing Instructions?

Yes
No

N/A

Pension plan documents, all versions
available, and all amendments signed
and dated

Compliance Amend Plan Name

37.

Section E, Item (8)

In the case of a plan that suspended benefits under section 305(e)(9) or section 4245 of ERISA,
does the application include:
(i) a copy of the proposed plan amendment(s) required by § 4262.6(e)(2) to reinstate suspended
benefits and pay make-up payments?
(ii) a certification by the plan sponsor that the proposed plan amendment(s) will be timely adopted?
Is the certification signed by either all members of the plan's board of trustees or by one or more
trustees duly authorized to sign the certification on behalf of the entire board (including, if
applicable, documentation that substantiates the authorization of the signing trustees)?

Yes
No
N/A

N/A

Pension plan documents, all versions
available, and all amendments signed
and dated

Reinstatement Amend Plan Name

Enter N/A if the plan has not suspended benefits.
Is all information included in a single document that is uploaded using the required filenaming
convention?

19 of 27

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference
38.

Section E, Item (9)

Response
Options
In the case of a plan that was partitioned under section 4233 of ERISA, does the application include
a copy of the executed plan amendment required by § 4262.9(c)(2)?
Enter N/A if the plan was not partitioned.

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Plan
Response

Name of File(s) Uploaded

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

Page Number
Reference(s)

Plan Comments

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

Yes
No
N/A

N/A

Pension plan documents, all versions
available, and all amendments signed
and dated

Partition Amend Plan Name

Yes
No

N/A

Financial Assistance Application

Penalty Plan Name

Is the document uploaded using the required filenaming convention?

39.

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?

Additional Information for Certain Events under § 4262.4(f) - Applicable to Any Events in § 4262.4(f)(2) through (f)(4) and Any Mergers in § 4262.4(f)(1)(ii)
NOTE: If the plan is not required to provided information described in Addendum A of the SFA Filing Instructions, the Plan Response should be left blank for the remaining Checklist Items.
Addendum A for Certain Does the application include an additional version of Checklist Item #16.a. (also including
Yes
40.a.
Events
Checklist Items #16.c., #16.d., and #16.e.), that shows the determination of the SFA amount using
No
Section C, Item (4) the basic method described in § 4262.4(a)(1) as if any events had not occurred? See Template 4A.

40.b.i.

Addendum A for Certain If the plan is a MPRA plan for which the requested amount of SFA is based on the increasing assets
Events
method described in § 4262.4(a)(2)(i), does the application also include an additional version of
Section C, Item (4) Checklist Item #16.b.i. that shows the determination of the SFA amount using the increasing assets
method as if any events had not occurred? See Template 4A, sheet 4A-5 SFA Details .5(a)(2)(i).

Yes
No
N/A

N/A - included as part of file in Checklist
Item #40.a.

Enter N/A if the plan is not a MPRA Plan or if the plan is a MPRA plan for which the requested
amount of SFA is based on the present value method.

20 of 27

N/A

Projections for special financial
For additional submission due to any
assistance (estimated income, benefit event: Template 4A Plan Name CE.
payments and expenses)
For an additional submission due to a
merger, Template 4A Plan Name
Merged, where "Plan Name Merged"
is an abbreviated version of the plan
name for the separate plan involved in
the merger.

N/A

N/A - included as part of file in
Checklist Item #40.a.

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference
40.b.ii.

Response
Options

Addendum A for Certain If the plan is a MPRA plan for which the requested amount of SFA is based on the increasing assets
Events
method described in § 4262.4(a)(2)(i), does the application also include an additional version of
Section C, Item (4) Checklist Item #16.b.ii. that explicitly identifies 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.

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Plan
Response

Name of File(s) Uploaded

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

Page Number
Reference(s)

Plan Comments

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

Yes
No
N/A

N/A

Yes
No
N/A

N/A

Projections for special financial
For additional submission due to any
assistance (estimated income, benefit event: Template 4B Plan Name CE.
payments and expenses)
For an additional submission due to a
merger, Template 4B Plan Name
Merged, where "Plan Name Merged"
is an abbreviated version of the plan
name for the separate plan involved in
the merger.

Yes
No
N/A

N/A

Projections for special financial
For an additional submission due to a
assistance (estimated income, benefit merger, Template 4A (or Template 4B)
payments and expenses)
Plan Name Merged, where "Plan
Name Merged" is an abbreviated
version of the plan name for the
separate plan involved in the merger.

N/A

N/A - included as part of file in
Checklist Item #40.a.

Enter N/A if the plan is not a MPRA Plan or if the plan is a MPRA plan for which the requested
amount of SFA is based on the present value method.

40.b.iii.

Addendum A for Certain If the plan is a MPRA plan for which the requested amount of SFA is based on the present value
Events
method described in § 4262.4(a)(2)(ii), does the application also include an additional version of
Section C, Item (4) Checklist Item #16.b.iii. that shows the determination of the SFA amount using the present value
method as if any events had not occurred? See Template 4B, sheet 4B-1 SFA Ben Pmts, sheet 4B-2
SFA Details .4(a)(2)(ii), and sheet 4B-3 SFA Exhaustion.
Enter N/A if the plan is not a MPRA Plan or if the plan is a MPRA plan for which the requested
amount of SFA is based on the increasing assets method.

41.

Addendum A for Certain For any merger, does the application show the SFA determination for this plan and for each plan
Events
merged into this plan (each of these determined as if they were still separate plans)? See Template
Section C, Item (4) 4A for a non-MPRA plan using the basic method, and for a MPRA plan using the increasing assets
method. See Template 4B for a MPRA Plan using the present value method.
Enter N/A if the plan has not experienced a merger.

42.a.

Addendum A for Certain Does the application include a narrative description of any event and any merger, including relevant
Events
supporting documents which may include plan amendments, collective bargaining agreements,
Section D
actuarial certifications related to a transfer or merger, or other relevant materials?

Yes
No

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

42.b.

Addendum A for Certain For a transfer or merger event, does the application include identifying information for all plans
Events
involved including plan name, EIN and plan number, and the date of the transfer or merger?
Section D

Yes
No

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

21 of 27

For each Checklist Item #42.a. through
#45.b., identify the relevant page
number(s) within the single document.

Financial Assistance Application

SFA App Plan Name

Financial Assistance Application

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

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Response
Options

Plan
Response

Name of File(s) Uploaded

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

Page Number
Reference(s)

Plan Comments

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

43.a.

Addendum A for Certain Does the narrative description in the application identify the amount of SFA reflecting any event,
Events
the amount of SFA determined as if the event had not occurred, and confirmation that the requested
Section D
SFA is no greater than the amount that would have been determined if the event had not occurred,
unless the event is a contribution rate reduction and such event lessens the risk of loss to plan
participants and beneficiaries?

Yes
No

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

Financial Assistance Application

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

43.b.

Addendum A for Certain For a merger, is the determination of SFA as if the event had not occurred equal to the sum of the
Events
amount that would be determined for this plan and each plan merged into this plan (each as if they
Section D
were still separate plans)?

Yes
No
N/A

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

Financial Assistance Application

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

Enter N/A if the event described in Checklist Item #42.a. was not a merger.

44.a.

Addendum A for Certain Does the application include an additional version of Checklist Item #25 that shows the
Events
determination of SFA eligibility as if any events had not occurred?
Section D

Yes
No

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

Financial Assistance Application

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

44.b.

Addendum A for Certain For any merger, does this item include demonstrations of SFA eligibility for this plan and for each
Events
plan merged into this plan (each of these determined as if they were still separate plans)?
Section D
Enter N/A if the event described in Checklist Item #42.a. was not a merger.

Yes
No
N/A

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

Financial Assistance Application

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

45.a.

Addendum A for Certain If the event is a contribution rate reduction and the amount of requested SFA is not limited to the
Events
amount of SFA determined as if the event had not occurred, does the application include a detailed
Section D
demonstration that shows that the event lessens the risk of loss to plan participants and
beneficiaries?

Yes
No
N/A

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

Financial Assistance Application

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

Yes
No
N/A

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

Financial Assistance Application

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

Enter N/A if the event is not a contribution rate reduction, or if the event is a contribution rate
reduction but the requested SFA is limited to the amount of SFA determined as if the event had not
occurred.

45.b.

Addendum A for Certain Does the demonstration in Checklist Item #45.a. also identify all assumptions used, supporting
Events
rationale for the assumptions and other relevant information?
Section D
Enter N/A if the plan entered N/A for Checklist Item #45.a.

22 of 27

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference
46.a.

Response
Options

Addendum A for Certain Does the application include an additional certification from the plan's enrolled actuary with respect
Events
to the plan's SFA eligibility but with eligibility determined as if any events had not occurred? This
Section E, Items (2) and should be in the format of Checklist Item #31 if the SFA eligibility is based on the plan status of
(3)
critical and declining using a zone certification completed on or after January 1, 2021. This should
be in the format of Checklist Items #32.a. and #32.b. if the SFA eligibility is based on the plan
status of critical using a zone certification completed on or after January 1, 2021.

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Plan
Response

Name of File(s) Uploaded

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

Page Number
Reference(s)

Plan Comments

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

Yes
No
N/A

N/A

Financial Assistance Application

SFA Elig Cert Plan Name CE

Yes
No
N/A

N/A

Financial Assistance Application

SFA Elig Cert Plan Name Merged CE

Yes
No

N/A

If the above SFA eligibility is not based on § 4262.3(a)(1) or § 4262.3(a)(3) or is based on a zone
certification completed prior to January 1, 2021, enter N/A.
Is all relevant information contained in a single document and uploaded using the required
filenaming convention?

46.b.

Addendum A for Certain For any merger, does the application include additional certifications of the SFA eligibility for this
Events
plan and for each plan merged into this plan (each of these determined as if they were still separate
Section E, Items (2) and plans)?
(3)
If the above SFA eligibility is not based on § 4262.3(a)(1) or § 4262.3(a)(3) or is based on a zone
certification completed prior to January 1, 2021, enter N/A.

"Plan Name Merged" is an abbreviated
version of the plan name for the
separate plan involved in the merger.

Enter N/A if the event described in Checklist Item #42.a. was not a merger.

47.a.

Addendum A for Certain Does the application include an additional certification from the plan's enrolled actuary with respect
Events
to the plan's SFA amount (in the format of Checklist Item #34.a.), but with the SFA amount
Section E, Item (5) determined as if any events had not occurred?

23 of 27

Financial Assistance Application

SFA Amount Cert Plan Name CE

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference
47.b.

Response
Options

Addendum A for Certain If the plan is a MPRA plan, does the certification in Checklist Item #46.a. identify the amount of
Events
SFA determined under the basic method described in § 4262.4(a)(1) and the amount determined
Section E, Item (5) under the increasing assets method in § 4262.4(a)(2)(i)?

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Plan
Response

Name of File(s) Uploaded

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

Page Number
Reference(s)

Plan Comments

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

Yes
No
N/A

N/A - included in SFA Amount Cert Plan
Name CE

N/A

N/A - included in SFA Amount Cert
Plan Name

N/A - included in SFA Amount Cert
Plan Name CE

N/A - included in SFA Amount Cert Plan
Name CE

N/A

N/A - included in SFA Amount Cert
Plan Name

N/A - included in SFA Amount Cert
Plan Name CE

N/A

Financial Assistance Application

SFA Amount Cert Plan Name Merged
CE

47.c.

Addendum A for Certain Does the certification in Checklist Items #47.a. and #47.b. (if applicable) clearly identify all
Events
assumptions and methods used, sources of participant data and census data, and other relevant
Section E, Item (5) information?

Yes
No

48.a.

Addendum A for Certain For any merger, does the application include additional certifications of the SFA amount
Events
determined for this plan and for each plan merged into this plan (each of these determined as if they
Section E, Item (5) were still separate plans)?

Yes
No
N/A

"Plan Name Merged" is an abbreviated
version of the plan name for the
separate plan involved in the merger.

Enter N/A if the event described in Checklist Item #42.a. was not a merger.

48.b.

Addendum A for Certain For any merger, do the certifications clearly identify all assumptions and methods used, sources of
Events
participant data and census data, and other relevant information?
Section E, Item (5)
Enter N/A if the event described in Checklist Item #42.a. was not a merger.

Yes
No
N/A

49.a.

Addendum A for Certain If the event is a contribution rate reduction and the amount of requested SFA is not limited to the
Events
amount of SFA determined as if the event had not occurred, does the application include a
Section E
certification from the plan's enrolled actuary (or, if appropriate, from the plan sponsor) with respect
to the demonstration to support a finding that the event lessens the risk of loss to plan participants
and beneficiaries?

Yes
No
N/A

N/A - included in SFA Amount Cert Plan
Name CE

24 of 27

N/A

N/A - included in SFA Amount Cert
Plan Name CE

N/A

Financial Assistance Application

Cont Rate Cert Plan Name CE

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference
49.b.

Response
Options

Addendum A for Certain Does the demonstration in Checklist Item #48.a. also identify all assumptions used, supporting
Events
rationale for the assumptions and other relevant information?
Section E
Enter N/A if the event is not a contribution rate reduction, or if the event is a contribution rate
reduction but the requested SFA is limited to the amount of SFA determined as if the event had not
occurred.

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Yes
No
N/A

Plan
Response

Name of File(s) Uploaded
N/A - included in Cont Rate Cert Plan Name
CE

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

Page Number
Reference(s)

Plan Comments

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

N/A

N/A - included in Cont Rate Cert Plan N/A - included in Cont Rate Cert Plan
Name CE
Name CE

Additional Information for Certain Events under § 4262.4(f) - Applicable Only to Any Mergers in § 4262.4(f)(1)(ii)
Plans that have experienced mergers identified in § 4262.4(f)(1)(ii) must complete Checklist
Items #50 through #63. If you are required to complete Checklist Items #50 through #63,
your application will be considered incomplete if No is entered as a Plan Response for any of
Checklist Items #50 through #63. All other plans should not provide any responses for
Checklist Items #50 through #63.
50.

Addendum A for Certain In addition to the information provided with Checklist Item #1, does the application also include
Events
similar plan documents and amendments for each plan that merged into this plan due to a merger
Section B, Item (1)a. described in § 4262.4(f)(1)(ii)?

Yes
No

N/A

Pension plan documents, all versions
available, and all amendments signed
and dated

N/A

51.

Addendum A for Certain In addition to the information provided with Checklist Item #2, does the application also include
Events
similar trust agreements and amendments for each plan that merged into this plan due to a merger
Section B, Item (1)b. described in § 4262.4(f)(1)(ii)?

Yes
No

N/A

Pension plan documents, all versions
available, and all amendments signed
and dated

N/A

52.

Addendum A for Certain In addition to the information provided with Checklist Item #3, does the application also include
Events
the most recent IRS determination for each plan that merged into this plan due to a merger
Section B, Item (1)c. described in § 4262.4(f)(1)(ii)?

Yes
No
N/A

N/A

Pension plan documents, all versions
available, and all amendments signed
and dated

N/A

Enter N/A if the plan does not have a determination letter.
53.

Addendum A for Certain In addition to the information provided with Checklist Item #4, for each plan that merged into this
Events
plan due to a merger described in § 4262.4(f)(1)(ii), does the application include the actuarial
Section B, Item (2) valuation report for the 2018 plan year and each subsequent actuarial valuation report completed
before the application filing date?

Yes
No

N/A

54.

Addendum A for Certain In addition to the information provided with Checklist Items #5.a. and #5.b., does the application
Events
include similar rehabilitation plan information for each plan that merged into this plan due to a
Section B, Item (3) merger described in § 4262.4(f)(1)(ii)?

Yes
No

N/A

Rehabilitation plan (or funding
improvement plan, if applicable)

N/A

55.

Addendum A for Certain In addition to the information provided with Checklist Item #6, does the application include similar
Events
Form 5500 information for each plan that merged into this plan due to a merger described in §
Section B, Item (4) 4262.4(f)(1)(ii)?

Yes
No

N/A

Latest annual return/report of
employee benefit plan (Form 5500)

YYYYForm5500 Plan Name Merged,
"Plan Name Merged" is abbreviated
version of the plan name for the plan
merged into this plan.

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Identify here how many reports are
provided.

Most recent actuarial valuation for the YYYYAVR Plan Name Merged, where
plan
"Plan Name Merged" is abbreviated
version of the plan name for the plan
merged into this plan.

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Response
Options

Plan
Response

Name of File(s) Uploaded

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

Page Number
Reference(s)

56.

Addendum A for Certain In addition to the information provided with Checklist Items #7.a., #7.b., and #7.c., does the
Events
application include similar certifications of plan status for each plan that merged into this plan due
Section B, Item (5) to a merger described in § 4262.4(f)(1)(ii)?

Yes
No

N/A

57.

Addendum A for Certain In addition to the information provided with Checklist Item #8, does the application include the
Events
most recent cash and investment account statements for each plan that merged into this plan due to
Section B, Item (6) a merger described in § 4262.4(f)(1)(ii)?

Yes
No

58.

Addendum A for Certain In addition to the information provided with Checklist Item #9, does the application include the
Events
most recent plan financial statement (audited, or unaudited if audited is not available) for each plan
Section B, Item (7) that merged into this plan due to a merger described in § 4262.4(f)(1)(ii)?

59.

Addendum A for Certain In addition to the information provided with Checklist Item #10, does the application include all of
Events
the written policies and procedures governing the plan’s determination, assessment, collection,
Section B, Item (8) settlement, and payment of withdrawal liability for each plan that merged into this plan due to a
merger described in § 4262.4(f)(1)(ii)?

Plan Comments
Identify how many zone certifications
are provided.

In the e-Filing Portal, upload as
Document Type

Use this Filenaming Convention

Zone certification

YYYYZoneYYYYMMDD Plan Name
Merged, where the first "YYYY" is
the applicable plan year, and
"YYYYMMDD" is the date the
certification was prepared. "Plan Name
Merged" is an abbreviated version of
the plan name for the plan merged into
this plan.

N/A

Bank/Asset statements for all cash and
investment accounts

N/A

Yes
No

N/A

Plan's most recent financial statement
(audited, or unaudited if audited not
available)

N/A

Yes
No

N/A

Pension plan documents, all versions
WDL Plan Name Merged,
available, and all amendments signed
where "Plan Name Merged" is an
and dated
abbreviated version of the plan name
for the plan merged into this plan.

Are all such items included in a single document using the required filenaming convention?

60.

Addendum A for Certain In addition to the information provided with Checklist Item #11, does the application include
Events
documentation of a death audit (with the information described in Checklist Item #11) for each plan
Section B, Item (9) that merged into this plan due to a merger described in § 4262.4(f)(1)(ii)?

Yes
No

61.

Addendum A for Certain In addition to the information provided with Checklist Item #13, does the application include the
Events
same information in the format of Template 1 for each plan that merged into this plan due to a
Section C, Item (1) merger described in § 4262.4(f)(1)(ii)?

Yes
No
N/A

Pension plan documents, all versions
Death Audit Plan Name Merged,
available, and all amendments signed
where "Plan Name Merged" is an
and dated
abbreviated version of the plan name
for the plan merged into this plan.

Financial assistance spreadsheet
(template)

Enter N/A if each plan that fully merged into this plan is not required to respond Yes to line 8b(1)
on the most recently filed Form 5500 Schedule MB.

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Template 1 Plan Name Merged, where
"Plan Name Merged" is an abbreviated
version of the plan name for the plan
merged into this plan.

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

v202407XXp

Do NOT use this Application Checklist for a supplemented application. Instead use Application Checklist - Supplemented.

Checklist SFA Filing Instructions
Item #
Reference
62.

Response
Options

Addendum A for Certain In addition to the information provided with Checklist Item #14, does the application include the
Events
same information in the format of Template 2 (if required based on the participant threshold) for
Section C, Item (2) each plan that merged into this plan due to a merger described in § 4262.4(f)(1)(ii)?

Plan
Response

Name of File(s) Uploaded

Yes
No
N/A

Addendum A for Certain In addition to the information provided with Checklist Item #15, does the application include
Events
similar information in the format of Template 3 for each plan that merged into this plan due to a
Section C, Item (3) merger described in § 4262.4(f)(1)?

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

Page Number
Reference(s)

Plan Comments

In the e-Filing Portal, upload as
Document Type
Contributing employers

Enter N/A if each plan that merged into this plan has less than 10,000 participants on line 6f of the
most recently filed Form 5500.

63.

Unless otherwise specified:
YYYY = plan year
Plan Name = abbreviated plan name

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

Yes
No

Use this Filenaming Convention
Template 2 Plan Name Merged, where
"Plan Name Merged" is an abbreviated
version of the plan name fore the plan
merged into this plan.

Historical Plan Financial Information Template 3 Plan Name Merged, where
(CBUs, contribution rates, contribution "Plan Name Merged" is an abbreviated
amounts, withdrawal liability
version of the plan name for the plan
payments)
merged into this plan.

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