Form 10-Advance Advance Notice of Reportable Events
Reportable Events
Form-10-Advance
OMB: 1212-0013
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
See
instructions for
descriptions of
these events.
Check all
boxes that
apply.
-
Change in controlled group
Liquidation
Extraordinary dividend or stock redemption Transfer of benefit liabilities
Application for minimum funding waiver
Loan
Default
Insolvency
or
similar
settlement
The next page lists additional information that must be submitted with this form, if not included above.
Change in 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
instructions)
Company
financial information
(see instructions)
Description
of the
plan's old
and new
controlled group
structure, including
the name
of each
controlled group
member
Operational
status of each controlled group member (in
Chapter 7 proceedings, liquidation outside of bankruptcy,
on-going, etc.)
Name
of each
plan maintained
by any
number of
the plan's
controlled group,
its contributing
sponsor(s) and
EIN/PN
Actuarial
Information (see
instructions)
Company
financial information
(see instructions)
If
the plan sponsor resolves to
cease all
revenue-generating
business operations, sell substantially all its assets, or
otherwise effect or implement its complete liquidation,
provide:
Date on which such resolution was made
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
instructions)
Company
financial information
(see instructions)
Application for Minimum Funding Waiver
Copy
of waiver
application, with
all attachments
Minimum
funding
projections
for the
next 5
years (with
and without
the waiver)
including all
details supporting
the calculations
and all assumptions,
to the
extent not
included in
the waiver
application
Transfer of Benefit Liabilities
Name,
contributing sponsor,
EIN/PN, and
contact information
of transferee plan(s)
Description
of the
transferor and
transferee's controlled
group structures,
including the
name of
each controlled
group member
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
instructions)
Financial
Information for
the transferor
and transferee's
controlled group (see
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 acceleration from
lender, any notice of forbearance, or loan agreement
amendment or
waiver
Description
of any
cross-defaults or
anticipated cross-
defaults
Description
of the plan's controlled group structure,
including
the name
of each
controlled group
member
Company
financial Information
(see instructions)
Actuarial
Information (see
instructions)
Insolvency 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
instructions)
Company
financial Information
(see instructions)
If
all
the
required
information
has
not
been
submitted
with
this
Form
10-Advance,
you
must
explain
below.
Date of Event Notice Due Date
Notice Filing Date (if late, explain below) Filing Extension Claimed (if any, explain below)
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
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Form 10 Advance |
| Subject | Form 10 Advance |
| Author | PBGC |
| File Modified | 0000-00-00 |
| File Created | 2021-08-02 |
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