10 Post-Event Notice of Reportable Events

POST-EVENT NOTICE
OF REPORTABLE EVENTS

PBGC Form 10

Approved OMB #1212-0013
Expires 03/31/2012

This form may be used by a plan administrator or contributing sponsor of a single-employer plan when notifying the
Pension Benefit Guaranty Corporation that a reportable event has occurred.

IDENTIFYING INFORMATION
Name of filer

Plan name

Street address of filer

Name / title of individual to contact

City, State, Zip

Street address of contact

EIN of contributing sponsor
Filer is:

Plan number

City, State, Zip

Plan administrator
Telephone number of contact

Contributing sponsor

REPORTABLE EVENTS

Ext.

See instructions for descriptions of these events. Check all boxes that apply.

Active participant reduction

Change in contributing sponsor or controlled group

Failure to make required contributions

Liquidation

Inability to pay benefits when due

Extraordinary dividend or stock redemption

Distribution to a substantial owner

Application for minimum funding waiver

Transfer of benefit liabilities

Loan default
Bankruptcy or similar settlement

BRIEF DESCRIPTION

Briefly describe the pertinent facts relating to the event.

The next page lists additional information that must be submitted with this form, if not included above.

PBGC Form 10
ADDITIONAL INFORMATION TO BE FILED
Active Participant Reduction
Statement explaining the cause of the reduction (e.g.,
facility shutdown or sale)
Number of active participants at the date the event occurs,
at the beginning of the current plan year, and at the
beginning of the prior plan year
Failure to Make Required Contributions
Due date and amount of both the missed contribution and
the next payment due
Most recent actuarial valuation report
Description of the plan’s controlled group structure,
including the name of each controlled group member
Name of each plan maintained by any member of the plan’s
controlled group, its contributing sponsor(s) and EIN/PN
Inability to Pay Benefits When Due
Date of any missed benefit payment and amount of benefits
due
Next date on which the plan is expected to be unable to pay
benefits, the amount of the projected shortfall, and the
number of plan participants expected to be affected
Amount of the plan’s liquid assets at the end of the quarter,
and the amount of its disbursements for the quarter
Most recent actuarial valuation report
Name, address and phone number of plan trustee (and of
any custodian)
Distribution to a Substantial Owner
Name, address and phone number of person receiving the
distribution(s)
Amount, form and date of each distribution
Most recent actuarial valuation report
Transfer of Benefit Liabilities
Name, contributing sponsor and EIN/PN of transferee
plan(s)
Explanation of the actuarial assumptions used in
determining the value of benefit liabilities (and, if
appropriate, plan assets) transferred
Estimate of the assets, liabilities, and number of participants
whose benefits are transferred
Note: To the extent this information is filed with the IRS
Form 5310A, PBGC will accept a copy of that filing.

Change in Contributing Sponsor or Controlled Group
Description of the plan’s old and new controlled group
structures, including the name of each controlled group
member
Name of each plan maintained by any member of the plan’s
old and new controlled groups, its contributing sponsor(s)
and EIN/PN
Liquidation
Description of the plan’s controlled group structure before
and after the liquidation, including the name of each
controlled group member
Name of each plan maintained by any member of the plan’s
controlled group, its contributing sponsor(s) and EIN/PN
Extraordinary Dividend or Stock Redemption
Name and EIN of person making the distribution
Date and amount of cash distribution(s) during fiscal year
Description, fair market value, and date or dates of any
non-cash distributions
Statement whether the recipient was a member of the
plan’s controlled group
Application for Minimum Funding Waiver
Copy of waiver application, with all attachments
Loan Default
Copy of the relevant loan documents (e.g., promissory
note, security agreement)
Due date and amount of any missed payment
Copy of any written notice of default or any notice of
acceleration from lender
Bankruptcy or Similar Settlement
Copy of bankruptcy petition or similar document
Docket sheet or other list of documents filed
Last date for filing claims, if known
Name, address and phone number of any trustee, receiver or
similar person
Most recent actuarial valuation report for each plan in the
controlled group
Description of the plan’s controlled group structure, including
the name of each controlled group member
Name of each plan maintained by any member of the plan’s
controlled group, its contributing sponsor(s) and EIN/PN