Form e-410 e-4010 Form

4010 Form — Schedule G (General information) Appendix 1

Section I – General information
1. Controlled group information
a. Name		_________________________________________________________
b. Business code		_ _ _ _ _ _	c. CUSIP number			_ _ _ _ _ _
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) ________________________________________ ________________________________________ ________________________________________
5. Was a 4010 filing required for the prior information year?			Yes  No 
6. Is a 4010 filing required for the current information year?			Yes  No  Help me determine 
7. Does §4010.6(c) for previously submitted materials apply for this filing?			Yes  No 
Section II – Comments

Section I – Gateway test
1. § 4010.4(a)(1) — 4010 Funding target attainment percentage
Did any plan sponsored by a member of the controlled group have a 4010 funding target attainment percentage below 80%?	Yes  No 
b. Applicable waivers - 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)?	Yes  No 
Does the aggregate number of participants in plans maintained by the members of the contributing sponsor's controlled group (including exempt plans) equal or exceed 500?	Yes  No 
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 
If (a) is “yes”, did the plan administrator submit a “Form 200” reporting this failure to PBGC?	Yes  No 
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  No 
If (a) is “yes”, did the plan administrator notify PBGC, as required under ERISA 4043, that an application for such funding waiver(s) was submitted to IRS?	Yes  No 
Section II – Comments

Section I — Identifying information for controlled group members The following information 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? Yes No, member joined controlled group during information year on _ _/_ _/_ _ _ _ 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  No 

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  No 

4. Information related to plan freezes

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

Yes  No 

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

b. Date of freeze

_ _ / _ _ / _ _ _ _

c. Nature of freeze

(i) Plan closed to new entrants (ii) Both pay and service are frozen (iii) Service is frozen, pay is not (iv) Other/combination (enter explanation) ________________________________________________ ________________________________________________

   

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 (iii) Spun-off from plan sponsored by member within controlled group (iv) Other (enter explanation) ________________________________ _____________________________________________________

   

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.

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 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						  
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						_________________

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 attached to this filing?		(i) 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

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 participants

Benefit liabilities 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

_______________

Section III 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 (this item may be left blank)

___________

b. 4010 funding target attainment percentage (as of valuation date)

_______%

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

_______%

d. Discount rate used to determine (a), (b) and (c) above

Segment rates

1st segment ____%

2nd segment ___%

3rd segment ____%

N/A, full yield curve used 

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

Yes  No 

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

f. If (e) is “yes”, enter additional required information ________________________________ _______________________________________________________________________

g. Was the plan in at-risk status (as defined in ERISA 303(i)(4)?

Yes  No 

h. 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  No 

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  No 

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)	

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	____________________	Date	_ _ / _ _ / _ _ _ _

Illustrative form for information years beginning on or after January 1, 2017 Page 2 of 14