Download:
pdf |
pdf4010 Form — Schedule G (General information)
Appendix 1
Section I – General information
1. Controlled group information
a. Full name of ultimate parent company _________________________________________
_______________________________________________________________________
b. Is the ultimate parent a foreign entity?
Yes No
2. Filing coordinator (This information does not get entered on a screen. It is populated on the computergenerated form based on information the filing coordinator provides when signing up for an e-filing portal account)
a. Name
_________________________________________________________
b. Company
_________________________________________________________
c. Title
d. Address
e. City
h. Country
_________________________________________________________
_________________________________________________________
_______________
f. State ____
g. Zip
____________
______________
i. Phone
(_ _ _) _ _ _ - _ _ _ _ ext _ _ _ _ _
j. e-mail
3. Date current information year ends
________________________
_ _ / _ _ / ___ _
4. Name, phone number and email address of person to contact with questions about this filing
(leave blank if that person is the filing coordinator) __________________________________
__________________________________________________________________________
__________________________________________________________________________
5. Was a 4010 filing required for the prior information year?
6. Is a 4010 filing required for the current information year?
7. Does §4010.6(c) for previously submitted materials apply
for this filing?
Section II – Comments
Page 1 of 9
Yes
No
Yes
No
Help me determine
Yes
No
4010 Form — Schedule FG (Filing Gateway)
Appendix 1
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 No
b. Applicable waivers - If (a) is “yes”:
(i) 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)?
(ii) 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
Yes No
2. § 4010.4(a)(2) — Failure to make required contributions
a. 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.
b. If (a) is “yes”, did the plan administrator submit a “Form 200”
reporting this failure to PBGC?
Yes No
Yes No
3. § 4010.4(a)(3) — Large waiver granted
a. 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
b. 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
Page 2 of 9
4010 Form — Schedule I (Identifying information)
Appendix 1
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, including
foreign members.
1. Basic information
a. Name
____________________________________________________________
b. Street address
____________________________________________________________
c. City
_________________________
d. State/Province
________________
e. Country
_________________________
f. Zip Code
________________
g. Telephone
________________________
h. EIN, if U.S. entity
________________
i. If controlled group contains more than 10 non-exempt members, check box and see
instructions re: required attachment. Otherwise, enter the relationship of this member to the
rest of the controlled group ____________________________________________________
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 4b and 4c are required only if 4a is answered “yes”.
b. Date of freeze
c. Nature of freeze
__/__/____
Plan closed to new entrants
Both pay and service are frozen
Service is frozen, pay is not
Other/combination (enter explanation) ______________________
________________________________________________________
Page 3 of 9
4010 Form — Schedule I (Identifying information)
Appendix 1
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
Newly-established plan
___/__/ ____
Spun-off or transferred from plan sponsored by member outside
controlled group
Spun-off from plan sponsored by member within controlled group
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.
Page 4 of 9
4010 Form — Schedule F (Financial information)
Appendix 1
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.
Item 2 is required only if item 1b of Schedule G, section 1 is answered “Yes” (i.e., ultimate parent is foreign) and item 1
of this section is answered (b) or (c).
2.
Is financial information for any U.S. non-exempt members consolidated with the financial
information of the ultimate foreign parent?
Yes No
Section II is required only if item 1b or 1c is selected above (Schedule F, Section I).
Section II — Consolidated financial information
1. With respect to consolidated financial information solely for U.S. entities:
a. What type of financial information is being
reported (check applicable box)?
Audited financial statements
Unaudited financial statements audited financials are not yet available
Unaudited financial statements audited financials are not prepared
Federal tax returns
b. Is this consolidated financial information
attached to this filing?
Yes
No, because it is publicly available
Items 2c and 2d are required only if item 2b of this section is answered “no”
c. Exact URL of webpage where publicly available information can be found
___________________________________________________________
d. When was information made available to the public? _ _ / _ _ / _ _ _ _
Item 2 is required only if item 2 of Schedule F, Section I) is answered “yes”
2. With respect to consolidated financial information for the foreign ultimate parent:
a. What type of financial information is being
reported (check applicable box)?
Audited financial statements
b. Is this consolidated financial information
attached to this filing?
Yes
No, because it is publicly available
Unaudited financial statements audited financials are not yet available
Unaudited financial statements audited financials are not prepared
Items 2c and 2d are required only if item 2b of this section is answered “no”
c. Exact URL of webpage where publicly available information can be found
___________________________________________________________
d. When was information made available to the public?
__/__/____
Page 5 of 9
4010 Form — Schedule F (Financial information)
Appendix 1
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. With respect to the individual member reported in item 1 of this section:
a. What type of financial information is being
reported? (check applicable box)
Audited financial statements
b. Is financial information for this member
attached to this filing?
Yes
No, because it is publicly available
Unaudited financial statements audited financials are not yet available
Unaudited financial statements audited financials are not prepared
Federal tax returns
Items 3c and 3d are required only if item 2b of this section is answered “no”.
c. Exact URL of webpage where publicly available information can be found
___________________________________________________________
d. When was information made available to the public?
__/__/____
Section IV – Comments
Page 6 of 9
4010 Form — Schedule P (Plan actuarial information)
Appendix 1
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
(_ _ _) _ _ _ - _ _ _ _
d. Email
_______________________________________________
c. EA Number
__-____
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 _ _ / _ _ / _ _ _ _
Yes No
c. Is the plan year a short plan year?
Section II — Funded status information (§4044 basis)
Number of
participants
1. Participant count and benefit liabilities
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
Page 7 of 9
_______________
4010 Form — Schedule P (Plan actuarial information)
Appendix 1
Section III — Other information
1. Information related to the [dates entered in section I, items 3a and 3b of this section] plan year
Item 1a may be left blank. Items 1b–1d and 1f are required. Item 1e is required only if item 1d is “yes”.
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. 4010 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 No
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 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)
Page 8 of 9
4010 Form — Schedule P (Plan actuarial information)
Appendix 1
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
____________________
Page 9 of 9
Date
__/__/____
File Type | application/pdf |
Author | PC0014220 |
File Modified | 2020-01-28 |
File Created | 2020-01-28 |