Form 10-A Advance Notice of Reportable Events

[LOGO] ADVANCE NOTICE PBGC Form 10-Advance

OF REPORTABLE EVENTS Approved OMB #1212-0013 Expires 03/31/2015

This form may be used by a contributing sponsor of a single-employer plan required to notify the Pension Benefit Guaranty Corporation in advance that a reportable event will occur.

IDENTIFYING INFORMATION

_____________________________________ _____________________________________

Plan Name Name / title of individual to contact at Filer

____________________________________ ____________________________________

Name of contributing sponsor Email address of contact

____________________________________ ____________________________________

Street address of contributing sponsor Street address of contact

____________________________________ ____________________________________

City, State, Zip City, State, Zip

____________________________________ ____________________________________

EIN of contributing sponsor Plan number Telephone number of contact Ext.

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

☐Change in contributing sponsor or controlled group

☐Liquidation

☐Extraordinary dividend or stock redemption

☐Transfer of benefit liabilities

☐Application for minimum funding waiver

☐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-Advance

ADDITIONAL INFORMATION TO BE FILED Check box to indicate the item is attached. If not attached, explain on next page.

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

☐Actuarial Information (see Form 10-A instructions)

☐Most recent audited (or, if unavailable, unaudited) financial statements and interim financial statements of the plan’s contributing sponsor (both old and new in the case of a change in the contributing sponsor) and any persons that will cease to be in the plan’s controlled group

Liquidation *

☐Description of the plan’s controlled group structure before and after the liquidation, including the name of each controlled group member

☐ Operational status of each controlled group member (in Chapter 7 proceedings, liquidating outside of bankruptcy, on-going, etc.)

☐Name of each plan maintained by any member of the plan’s controlled group, its contributing sponsor(s) and EIN/PN

☐ Actuarial information (see Form 10-A instructions)

☐ If the plan sponsor is expected to cease or has ceased substantially all operations also provide:

• Date on which substantially all operations are expected to cease or have ceased

• Most recent pension plan document(s)

• Address of each controlled group member

• The Internal Revenue Service Determination Letter indicating the plan is a covered plan, if applicable

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

☐Actuarial Information (see Form 10-A instructions)

Application for Minimum Funding Waiver *

☐Copy of waiver application, with all attachments

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

☐Actuarial Information (see Form 10-A instructions)

Note: To the extent this information is filed with the IRS Form 5310A, PBGC will accept a copy of that filing.

Loan Default *

☐Copy of the relevant loan documents (e.g., promissory

note, security agreement, loan agreement amendments and waivers)

☐Due date and amount of any missed payment

☐Copy of any written notice of default or any notice of

acceleration from lender, any notice of forbearance, or loan agreement amendment or waiver

☐ Description of any cross-defaults or anticipated cross-defaults

☐Actuarial Information (see Form 10-A instructions)

Bankruptcy or Similar Settlement

☐Name, address and phone number of any trustee, receiver or similar person

☐ Docket number of court filing and location of the court where any relevant proceeding was or will be filed (if known)

☐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

☐Actuarial Information (see Form 10-A instructions)

*Note: Under 29 CFR § 4043.3(d), PBGC may request additional information that, in the case of Advance Reporting, must be submitted by a filer within 7 days of PBGC’s request. PBGC’s recent experience is that it almost always needs to request additional information from Form 10-A filers.

PBGC Form 10-Advance

For Liquidation, Extraordinary Dividend or Stock Redemption, Transfer of Benefit Liabilities, and Loan Default events, PBGC typically requests the financial information described above in the last item under the Change in Contributing Sponsor or Controlled Group event.

For Application for Minimum Funding Waiver events, PBGC typically requests minimum funding projections for the next five years (with and without the waiver), including all details supporting the calculations and all assumptions, to the extent such information is not included in the waiver application.

Filers should expect the request for additional information promptly after filing a Form 10-A. Filers may choose to include the additional information with the Form 10-A filing.

Missing Information If required information has not been submitted with this Form 10-A, explain below.

Filing Information and Certification

______________________________________

Date of Event

______________________________________

Notice Filing Date (if late, explain below)

___________________________________

Notice Due Date

___________________________________

Filing Extension Claimed, if any (explain below)

Extension Claimed or Reason for Late Filing

I certify that, to the best of my knowledge and belief, the information submitted in this filing is true, correct, and complete. In making this certification, I recognize that knowingly and willfully making false, fictitious, or fraudulent statements to the PBGC is punishable under 18 U.S.C. § 1001.

___________________________________ ___________________________________

Signature of Individual Submitting Form Name and title of Individual Submitting Form

___________________________________ ___________________________________

Telephone number of Individual Submitting Form Employer of Individual Submitting Form