OMB control number
Request for Coverage Determination
OMB 1212-0072 ยท PBGC.
OMB 1212-0072
This form is used by a plan administrator or plan sponsor of a plan to request that the Pension Benefit Guaranty Corporation determine whether a plan is covered under title IV of the Employee Retirement Income Security Act of 1974.
The latest form for Request for Coverage Determination expires 2028-06-30 and is listed under ICR 202511-1212-002.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form Form 1 Request for Coverage Determination | Form |
| Proposed Edits to Request for Coverage Determination Form.pdf | Justification for No Material/Nonsubstantive Change |
| Proposed Edits to Request for Coverage Determination Instructions.pdf | Justification for No Material/Nonsubstantive Change |
 Justification for No Material or Nonsubstantive Change to Currently Approved Collection 1212-0072.03.docx | Justification for No Material/Nonsubstantive Change |
| Justification of Nonmaterial Change Request_1212-0072 e-Filing Portal.02.docx | Justification for No Material/Nonsubstantive Change |
| 1212-0072 Supporting Statement 2025.05.docx | Supporting Statement A |
 Request for Coverage Determination |
Form |
| Request for Coverage Determination |
Instruction |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202607-1212-004 | No material or nonsubstantive change to a currently approved collection | 2026-07-29 | ||
| 202511-1212-002 | No material or nonsubstantive change to a currently approved collection | 2025-11-21 | Approved without change | |
| 202505-1212-001 | Revision of a currently approved collection | 2025-05-19 | ||
| 202205-1212-001 | Revision of a currently approved collection | 2022-05-09 | Approved without change | |
| 201905-1212-004 | New collection (Request for a new OMB Control Number) | 2019-05-08 | Approved with change |