003 Withdrawal Liability

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Withdrawal Liability Information
*Required fields
*Plan name: Withdrawal
*EIN: 33-3333333

(ex. 33-3333333)

*PN: 123

(ex. 333)

*Notice filer name: Zjfh Xceu Rkgsy
*Role of filer:

Accountant

Plan Sponsor Information
*Plan sponsor name: Test
*Address: Test

*City: Test
*State:

GA

*Zip Code: 12312
*Telephone: 123-123-1232

(ex. 12345-1234)
(ex. 202-111-1111)

E-mail address:

Ext.
(ex. aa@a.com)

Fax:

(ex. 202-111-1111)

Plan Sponsor’s Duly Authorized Representative (if any)
First name:
Last name:
Company:
Title:
Address:

City:
State:
Zip Code:
Telephone:
E-mail address:

- select a state (ex. 12345-1234)
(ex. 202-111-1111)

Ext.
(ex. aa@a.com)

Fax:

(ex. 202-111-1111)

*Filing for plan year beginning: 2019
*Is the plan terminated?

(YYYY)

Yes

No
If yes, date of plan termination: 04/03/2019
(MM/DD/YYYY)

*Is the plan insolvent?

Yes

No
If yes, date of plan insolvency: 04/17/2019
(MM/DD/YYYY)

*Did the plan receive withdrawal
liability payments in the plan
year?

Yes

No

What forms of withdrawal liability payments did the plan receive in the plan year?
*Lump sum settlement
payments:

Yes

No

*Number of employers that have made lump sum 98
settlement payments:
*Total of lump sum settlement payments: $
*Periodic payments:

Yes

98.00

No

*Number of employers making periodic payments: 12
*Total of periodic payments: $ 12.00

*Were any of the periodic
payments due to a settlement of
withdrawal liability?

Yes

No

*Number of employers making periodic payments
attributable to settlements: 65
*Total of periodic payments attributable
65.00
to settlements: $

*Number of employers
withdrawn during the plan year
489
not yet assessed withdrawal
liability:

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Withdrawal Liability Information
Attached Documents
Click here for additional instructions.

For each employer that has withdrawn during the plan year and has not yet been assessed withdrawal
liability, attach document/s described in #1 below.
For each withdrawn employer that has been assessed withdrawal liability, attach document/s described
in #2 below. Only one subcategory (A, B or C) is required for each withdrawn employer.
Provide an explanation in the "Comments" box for any missing documents.
Comments:

File:

Document
Type:

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Maximum file size is 25MB. It may take a minute or two to attach large files. Please click
only once. To send files larger than 25MB, please click on this link: http://PBGC.leapfile.com,
click "Secure Upload", enter the recipient's email address, and follow the prompts. For
additional assistance, please contact us at multiemployerprogram@pbgc.gov or 1-800-7362444 (ext. 3993 or 6047). Local callers may directly dial 202-326-4000 (ext. 3993 or 6047).

1. For each employer that has withdrawn during the plan year and has not yet been assessed
withdrawal liability, attach a schedule with the following information:
i. Name of employer
ii. Date of withdrawal
iii. Amount of withdrawal liability, if already calculated
iv. Contribution owed in plan year before withdrawal
v. Reason employer has not yet been assessed withdrawal liability

The attached template may be used.
File 1.docx

Delete

2. For each employer that has been assessed withdrawal liability, attach one of the three (A, B, and/or C):
(A). Schedule of lump sum and periodic payments received in the plan year and/or expected to be
received in future plan years with the following information:
For lump sum payments:
i. Name of employer
ii. Amount of payment
iii. Date of payment
iv. Is the amount of payment included in the assets as of the last valuation date? Y/N
v. If yes, provide the date of the last valuation

For periodic payments:
i. Name of employer
ii. Amount of payment
iii. Payment starting date
iv. Payment ending date
v. Frequency of payment (monthly, quarterly, annually)
vi. Is the employer currently on making its payments? Y/N
vii. If no, provide the date of the last payment received

The attached templates may be used. The first tab is for lump sum payments and the second tab is for periodic
payments.
File 3.docx

Delete

(B). Documents showing withdrawal liability paid. Attach documents containing the information
required in the payment information listed in 2(A), such as the employer's withdrawal liability
settlement agreement or the employer's withdrawal liability payment schedule established under 29
CFR part 4219.

File 4.docx

Delete

(C). For any plan year in which the information required to be filed does not change from the
information filed for a previous year, a statement that there is no change in the employer's
withdrawal liability payment.

File 5.docx

Delete

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Data Summary
Withdrawal Liability Information
Withdrawal - 33-3333333/123

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Submit Filing

Plan Filing Information

Edit

Plan name:

Withdrawal

EIN / PN:

33-3333333/123

Notice filer name:

Zjfh Xceu Rkgsy

Role of filer:

Accountant

Plan Sponsor Information
Name:

Test

Address:

Test Test, GA 12312

Phone:

123-123-1232

Email:

N/A

Fax:

N/A

Plan Sponsor’s Duly Authorized Representative
Name:
Company:

N/A

Title:

N/A

Address:
Phone:

N/A

Email:

N/A

Fax:

N/A

Filing for plan year beginning:

2019

Is the plan terminated?

Yes

If yes, date of plan termination:
Is the plan insolvent?
If yes, date of insolvency:
Did the plan receive withdrawal liability payments in the
plan year?

4/3/2019
Yes
4/17/2019
Yes

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Lump sum settlement payments:

Yes

Number of employers that have made lump sum

98

settlement payments:
Total of lump sum settlement payments:

$98.00

Periodic payments:

Yes

Number of employers making periodic payments:

12

Total of periodic payments:

$12.00

Were any of the periodic payments due to a settlement of
withdrawal liability?
Number of employers making periodic payments

65

attributable to settlements:
Total of periodic payments attributable to settlements:
Number of employers withdrawn during the plan year and
not yet assessed withdrawal liability:

Attached Documents

Yes

$65.00
489

Edit

Schedule for employer that has not yet been assessed withdrawal liability

Schedule of lump sum and periodic payments for employer that has been assessed withdrawal liability
Documents showing withdrawal liability paid
A statement that there is no change in employer's withdrawal liability payment
Comments
N/A

PBGC
Withdrawal Liability Information

CONFIDENTIAL

Plan Filing Information
Plan name:

Withdrawal

EIN/PN:

333333333/123

Notice filer name:

Zjfh Xceu Rkgsy

Role of filer:

Accountant

Plan Sponsor Information
Plan sponsor name:

Test

Address:

Test

City:

Test

State:

GA

Zip:

12312

Telephone:

(123) 123-1232 Ext:

E-mail:

Fax:
Plan Sponsor's Authorized Representative Information
First name:

Last name:

Company:

Title:

Address:

City:

State:

Zip:

Telephone:

Ext:

E-mail:

Fax:

Filing for plan year beginning:

2019

Is the plan terminated?

Yes

No

Date of plan termination:

03-APR-2019

Is the plan insolvent?

Yes

No

Date of insolvency:

17-APR-2019

Did the plan receive withdrawal liability payments in the plan year?

Yes

No

Yes

No

What forms of withdrawal liability payments did the plan receive in the plan year?
Lump sum settlement payments:
Number of employers that have made lump sum settlement
payments:

98

Total of lump sum settlement payments:

$98.00

Periodic payments:

Yes
Number of employers making periodic payments:

12

Total of periodic payments:

$12.00

Were any of the periodic payments due to a settlement of
withdrawal liability?

Yes

Number of employers making
periodic payments attributable to

No

No

settlements:

65

Total of periodic payments
attributable to settlements:

$65.00

Number of employers withdrawn and not yet assessed withdrawal liability:

489

Submission status - Filing not yet submitted
CONFIDENTIAL

Attached Documents
Schedule for employer that has not yet been assessed withdrawal liability
Schedule of lump sum and periodic payments for employer that has been assessed withdrawal liability
Documents showing withdrawal liability paid
A statement that there is no change in employer's withdrawal liability payment

Missing Information If required information has not been submitted, explain below.

Submission status - Filing not yet submitted
Go To Data Summary