4010 (ppa)

4010 Form — Schedule G (General information)

Appendix 1

Section I - General information
1. Controlled group information
a. Name
c. CUSIP number

b. Business code
2. Contact information
a. Name

b. Title
c. Company
d. Address

e. Phone

(

)

-

ext

f. e-mail
/

3. Date current information year ends

/

4. Filing contact (if different from filing coordinator)

Yes

□

No □

6. Is a 4010 filing required for the current
information year?

Yes

□

No □

7. Does §4010.6(c) for previously submitted
materials apply for this filing?

Yes

5. Was a 4010 filing required for the prior
information year?

Help me determine
□

a

No a

Section II - Comments

January 2009 - updated for PPA

Page 1 of 9

4010 Form — Schedule FG (Filing Gateway)

Appendix 3

Section I - Gateway test
1. §4010.4(a)(1) — 4010 Funding target attainment percentage

a. Did any plan sponsored by a member of the controlled group have a
4010 funding target attainment percentage below 80%?

Yes

D No D

b.

Yes

D No D

If (a) is "yes", does the total amount of 4010 funding shortfall in plans
(including exempt plans) maintained by the members of the

contributing sponsor's controlled group exceed $15 million
(disregarding those plans with no 4010 funding shortfall)?
2. § 4010.4(a)(2) — Failure to make required contributions
Did any member of the controlled group:

•

fail to make a required contribution to a defined benefit plan during
the information year within 10 days of its due date, and

•

as a result of the missed contribution, the conditions for imposition

of a lien under ERISA have been met.

Yes ^ No D

3. § 4010.4(a)(3) — Large waiver granted
Have one or more minimum funding waivers been granted for a plan
maintained by a member of the controlled group:
•

totaling in excess of $1 million, and

•

for which there is an outstanding balance at the end of the plan year
ending within the information year (determined in accordance with

§1.4010.4(e))?

Yes DNoD

Section II - Comments

January 2009 - updated for PPA

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4010 Form — Schedule I (Identifying information)

Appendix 3

Section I — Identifying information for controlled group members
The following infonvation must be reported with respect to each non-exempt member of the controlled group.

1. Basic information
a. Name
b. Relationship

.

c. Street address
d. City

e. State/Province

f. Country

g. Zip Code

h. Telephone

i. EIN

2. Information on members being reported for the first time

a. Was this member a member of the controlled group immediately before the current

information year began?
(I) Yes

□
D

(ii) No, member joined controlled group during information year on

/

/

□

(iii) No, other

Section II — Plan information
The following information must be reported with respect to each plan (including exempt plans) sponsored by any
controlled group member as of the last day of the information year

1. Information for current year
a. Plan name
b. Plan sponsor

c. EIN

-

d. Plan number

2. Is this plan a multiple employer plan

Yes D No D

3. Is the requirement to submit actuarial information waived either because the plan

is an exempt plan (as defined in § 1.4010.8(c)) or because the actuarial
information is being reported by another filer (in accordance with § 1.4010.8(f))?

Yes D No D

4. Information related to plan freezes

a. Is this plan frozen for eligibility or benefit accrual purposes?

Yes D No D

Items 3b and 3c are required only if 3a is answered "yes".

b. Date of freeze

c. Nature of freeze

/

(i)
(ii)

/

Plan closed to new entrants
Both pay and service are frozen

□
Q

(iii) Service is frozen, pay is not

(iv) Other/combination (enter explanation)

E

Note to SRA - If questions 2 and 3 are both answered "yes", the instructions will tell the filer to enter the name of the
designated multiple employer plan filer in the Sch 1 comment box. If it's not too difficult, it would be great if the system
could validate that something is entered. Alternatively, it might suffice to have a reminder appear on the validation report
reminding the filer of this rule.

January 2009 - updated for PPA

Page 3 of 9

4010 Form — Schedule I (Identifying information)

Appendix 3

Section II (continued)
5. Information on changes in EIN/PN
a. Has the EIN or PN reported in item 1 changed since the beginning of the

current plan year?

Yes

□

No
N/A (new plan)

□
□

Item 5b Is required only if item 5a is answered "yes"

b. Prior EIN

__-

c. Prior PN

Item 6 is required only if item 5a is answered "N/A (new plan)".

6. New plan information

a. Date plan was first maintained by controlled group

b. Explanation

/

/

(i) Newly-established plan
(ii) Spun-off or transferred from plan sponsored by member outside
controlled group

□

□
D

(iii) Spun-off from plan sponsored by member within controlled group

(iv) Other (enter explanation)

E

Section III — Former members/plans
1. Former controlled group members

If any entity, other than an exempt entity, ceased
to be a member of the controlled group during the

information year, enter required information with
respect to that entity (see instructions).
2. Former plans

If any plan, other than an exempt plan, ceased to
be maintained by a member of the controlled
group during the information year, enter required
information with respect to that plan (see
instructions).

Section IV — Comments

Section V — Attachments
A list of attached files and the text entered to describe each files will appear here.

January 2009 - updated for PPA

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4010 Form — Schedule F (Financial information)

Appendix 3

Section I — Type of Submission
1. Which of the permissible filing alternatives is being used?

a. §4010.9(a)- separate financial information (financial statements or tax returns) for
each non-exempt controlled group member will be provided

□

b. §4010.9(b) - consolidated financial information that includes combined information for
all non-exempt controlled group members will be provided

g

c. Consolidated financial information that includes combined information for some, but
not all controlled group members will be provided, along with separate financial
information for those non-exempt members whose information is not included in the
consolidated information.

Section II is required only if item 1b or 1c is selected above (Schedule F, Section I).

Section II — Consolidated financial information
1. Reporting method

a. What type of information is being reported?

(i) Audited financial statements
(ii) Unaudited financial statements
(iii) Federal tax returns

□
□
O

b. Is consolidated financial information attached
to this filing?

(i) Yes
(ii) No, because it is publicly available

□
□

Items 1c and 1d are required only if item 1b of this section is answered "no"

c. Where can the publicly available information
be obtained?

(i) SEC
(ii) Elsewhere (enter explanation)

d. Date information was made available to the public

□
□

/__/

2. Additional required financial information for each non-exempt member of the controlled group
included in the consolidated financial information

a. Name

b. EIN

__-

c. Revenues for the current information year
d. Operating income for the current information year
e. Net assets at the end of the current information year

January 2009 - updated for PPA

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401Q Form — Schedule F (Financial information)

Appendix 3

Section III is required only if item 1a or 1c is selected in Schedule F, Section I

Section III — Individual member financial information
The following information must be reported with respect to each non-exempt member of the controlled group whose
financial information is not included in a consolidated statement.

1. Basic information

a. Name

b. EIN

_-_

2. Reporting method

a. What type of information is being reported?

(i) Audited financial statements
(ii) Unaudited financial statements
(iii) Federal tax returns

□
□
□

b. Is financial information for this member

(i)

□

attached to this filing?

Yes
(ii) No, because it is publicly available

□

Items 2c and 2d are required only if item 1b of this section is answered "no".

c. Where can the publicly available information

be obtained?

(i) SEC
{ii) Elsewhere (enter explanation)

d. Date information was made available to the public

_/

/

Section IV - Comments

January 2009 - updated for PPA

Page 6 of 9

□

□

4010 Form — Schedule P (Plan actuarial information)

Appendix 3

Section I — Basic information
1. Plan identifying information
a. Plan name

b. Plan sponsor

c. EIN

-

d. Plan number

2. Enrolled actuary information
a. Name

b. Telephone

(

)

-

c. EA Number

d. Email (optional)
3. Enter the following information with respect to the plan year ending within the information year
a. Date plan year begins

/

/

b. Date plan year ends

c. Is the plan year a short plan year?

/

/

Yes □ No □

Section II — Funded status information (§4044 basis)
1. Participant count and benefit liabilities

Number of

Benefit liabilities

participants

at plan year-end
Before reflecting expense load

a. Active
b. Terminated vested
c. Receiving benefits

d. Total
2.Benefit Liabilities after reflecting expense load

a. Expense load per § 4044.52(e)
b. Total benefit liabilities*
* Determined using retirement age, interest, mortality, expense load provided in § 4044.51-57 and other assumptions
as provided in § 4010.8(d)(2).

3. Census data used

to determine
benefit liabilities

a. Projection from a date within the plan year ending within the

information year

□

b. As of the end of the plan year ending within the information

year or the beginning of the subsequent year

□

4. Interest rate used to determine benefit liabilities
a. Period 1

% for first

years

b. Period 2

% for all years thereafter

5. Fair market value of assets (excluding receivables) at plan year-end

January 2009 - updated for PPA

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4010 Form — Schedule P (Plan actuarial information)

Appendix 3

Section HI not required if the plan year began (i.e., the date entered in section II, item 3a) is before 2008

Section III — Other information
1. Information related to the [dates entered in section I, items 3a and 3b of this section] plan year
a. Funding target (as of the valuation date) determined as if the plan has
been in at-risk status for a consecutive period of at least 5 plan years
b. Funding target attainment percentage (as of valuation date)

%

c. Adjusted funding target attainment percentage (as of valuation date)

%

d. Did any benefit limitations apply under ERISA 206(g) at any time during
the plan year?

Yes D No D

Item 1e is required only if item 1d of this section is answered "yes"

e. If (d) is "yes", enter additional required information

f. Has one or more minimum funding waivers been granted for the plan
totaling in excess of $1 million for which there is an outstanding balance at
the end of the plan year

Yes

D No D

2. Information related to the information year ending [date entered in Schedule G, item 1 ]
a. Has a statutory lien arisen during the information year as the result of
missed contributions in excess of $1 million (that were not made within 10
days of the due date)?

Yes

D No D

Section IV — Additional actuarial information
Which of the following five statements best describes the method under which the additional
information required under §4010.8(a)(3) will be provided?

1. All of the information is included in one actuarial valuation report. It is my understanding
that the report will be submitted:
a. As an attachment to this filing

□

b. Electronically within 15 days of the Form 5500 filing deadline for the plan year ending
within the information year
2. The actuarial valuation report does not contain all of the additional required information.
Therefore, supplemental information will also be provided. It is my understanding that the
report and the supplemental information will be submitted:
a. As an attachment to this filing

b. Electronically within 15 days of the Form 5500 filing deadline for the plan year ending
within the information year
c. A combination of (a) and (b)

January 2009 - updated for PPA

Page 8 of 9

4010 Form — Schedule P (Plan actuarial information)

Appendix 3

Section v - Comments

Section VI - Certification

I am the actuary reported in Section I, item 2. To the best of my knowledge and belief, the
actuarial information submitted above is true, correct, and complete and conforms to all

applicable laws and regulations. If this certification is qualified, as permitted under 26 CFR
§301.6059-1 (d), I have included an explanation below:
Qualification

Signature

January 2009 - updated for PPA

Date

Page 9 of 9