Form PBGC Form 501 PBGC Form 501 Post-Distribution Certification for Standard Termination

PBGC Form 501

Post-Distribution Certification
for Standard Termination
PART I.

Approved OMB 1212-0036
Expires 11/30/2017

IDENTIFYING INFORMATION

Check here if you previously filed a Form 501 for this plan.

If checked, provide dates of filing(s):

1a Plan Name

1b 9-digit employer identification number (EIN)
1c 3-digit plan number (PN)

Attach copy of the most recent complete plan document and any amendments to it.

2

PBGC case number

8-digit Case #

PART II.
DISTRIBUTION INFORMATION
3a Last distribution date in satisfaction of plan benefits
3b Date of receipt of IRS determination letter
4 Were participants and beneficiaries provided with the name and address of

(MM/DD/YYYY)
(MM/DD/YYYY)

the insurer(s) no later than 45 days before the date of distribution?

5

Were any participants missing (as defined in the applicable regulation, see instructions)?

6a Has a copy of the annuity contract, certificate, or written notice been provided to

Yes

No

Yes

No

Yes

each participant and beneficiary receiving benefits in the form of an irrevocable
commitment?

6b If “Yes” to 6a, enter the latest date the annuity contract, certificate, or written notice was

No

N/A

(MM/DD/YYYY)

provided to each participant and beneficiary receiving benefits:
If “No” or “N/A”, see instructions

7a Complete name of record of insurer(s) from whom annuity contracts, if any, have

7b Annuity Contract Number(s)

been purchased (Address should include room or suite no.)

8a Name and address of contact for location of plan records
(Address should include room or suite no.)

9

8b Telephone number

Summary of distribution of plan benefits. Attach distribution documents (see instructions).

Type of Benefit

(1) # of Participants or Beneficiaries

(2) Total Value

a Annuities Purchased
(1) For Non-Missing Participants
(2) For Missing Participants
(3) Total

b Lump sums (including direct transfers)
(1) Consensual
(2) Nonconsensual (i.e., mandatory cashouts)
(3) Total

c Benefits transferred to PBGC for Missing
Participants
(1) Benefits transferred
(2) Other amounts due PBGC (see
instructions)

$

$

d No Distribution
e Total
PART III.

$
PLAN ADMINISTRATOR CERTIFICATION

I, the Plan Administrator, certify that to the best of my knowledge and belief that (1) benefits payable with respect to participants have been calculated
and valued correctly in accordance with applicable provisions of ERISA and the regulations thereunder; (2) all plan benefits (through priority category
6 under ERISA Section 4044 and 29 CFR Part 4044) under the plan have been satisfied; (3) plan assets in excess of those needed to satisfy all
plan benefits (through priority category 6 under ERISA Section 4044 and 29 CFR Part 4044) have been or will be distributed in accordance with
applicable provisions of ERISA and the regulations thereunder; and (4) the information contained in this filing is true, correct, and complete. I further
certify that I am aware that records supporting the calculation and valuation of benefits and assets must be kept at least six years after the date this
post-distribution certification is filed.
In executing this document, I certify that the foregoing is true and correct, and recognize that knowingly and willfully making false, fictitious,
or fraudulent statements to the PBGC is punishable under 18 U.S.C. §1001.
Telephone number
Plan Administrator’s company name and address (Address should include room or suite no.)

E-mail address (optional)

Plan Administrator’s signature

Date

Printed name and title of Plan Administrator