Form 001 Notice of Insolvency Benefit Level

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Notice of Insolvency Benefit Level
*Required fields
*Plan name: MEPD Test Pension Plan
*EIN: 11-1111111

(ex. 33-3333333)

*PN: 002

(ex. 333)

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

Accountant

Plan Sponsor Information
*Plan sponsor name: UIVR Vftd Wjpko mf Poxmacxw
*Address: 1531 T Wm Sy

*City: Washington
*State:

DC

*Zip Code: 20005
*Telephone: 972-576-5841

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

E-mail address: mask@pbgc.gov

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:

*The Plan is/will be
insolvent under:

(ex. 202-111-1111)

Mass Withdrawal (Sec. 4281)
Ongoing/Critical Status (Sec. 4245)

*Insolvency year for which
2019
the notice is being filed:

(YYYY)

*The estimated amount of annual benefit payments under the plan (determined without regard to the
insolvency) for the insolvency year:
$ 989
*The estimated amount of the plan’s available resources for the insolvency year:
$ 65
*The estimated amount of the annual benefits guaranteed by PBGC for the insolvency year:
$ 123
The amount of financial assistance, if any, requested from PBGC:
$ 456

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Notice of Insolvency Benefit Level
Attached Documents
Click here for additional instructions.
Documents 1 - 3 are required for all filings.
Document 4 is only required if it has not previously been submitted to PBGC.
Provide an explanation in the "Comments" box for any missing documents.
Comments:

File:
Document
Type:

no 4 or 5

Choose File No file chosen
- Select a document type Attach
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 1-800-736-2444 (ext. 3993 or 6047). Local callers
may directly dial 202-326-4000 (ext. 3993 or 6047).

*Required documents
1. *Most recent actuarial valuation for the plan
File 1.docx

Delete

2. *Certification, signed by the plan sponsor (or duly authorized representative), that the notices of
insolvency have been given to all interested parties (defined in 29 CFR 4245.2) for critical status
plans or to participants and beneficiaries for plans terminated by mass withdrawal
File 2.docx

Delete

3. *Sample notice of insolvency benefit level given to all interested parties or to participants and
beneficiaries
File 3.docx

Delete

4. Plan document (Including any amendments/restatements)
5. Other

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Data Summary

Notice of Insolvency Benefit Level
MEPD Test Pension Plan - 11-1111111/002

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Submit Filing

Plan Filing Information

Edit

Plan name:

MEPD Test Pension Plan

EIN / PN:

11-1111111/002

Notice filer name:

Zjfh Xceu Rkgsy

Role of filer:

Accountant

Return to Home Page

Plan Sponsor Information
Name:

UIVR Vftd Wjpko mf Poxmacxw

Address:

1531 T Wm Sy Washington, DC 20005

Phone:

972-576-5841

Email:

mask@pbgc.gov

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

The Plan is/will be insolvent under:

Ongoing/Critical Status (Sec. 4245)

Insolvency year for which the notice is being filed:

2019

The estimated amount of annual benefit payments under
the plan (determined without regard to the insolvency) for $989.00
the insolvency year:
The estimated amount of the plan’s available resources
for the insolvency year:

$65.00

The estimated amount of the annual benefits guaranteed

$123.00

by PBGC for the insolvency year:
The amount of financial assistance, if any, requested from
$456.00
PBGC:

Attached Documents

Edit

Most recent actuarial valuation for the plan
Certification, signed by the plan sponsor (or duly authorized representative), that the notices of insolvency
have been given to all interested parties (defined in 29 CFR 4245.2) for critical status plans or to participants
and beneficiaries for plans terminated by mass withdrawal

Sample notice of insolvency benefit level given to all interested parties or to participants and beneficiaries
Plan document (Including any amendments/restatements)
Other
Comments
no 4 or 5

CONFIDENTIAL

PBGC
Notice of Insolvency Benefit Level
Plan Filing Information
Plan name:

MEPD Test Pension Plan

EIN/PN:

11-1111111/002

Notice filer name:

Zjfh Xceu Rkgsy

Role of filer:

Accountant

Plan Sponsor Information
Plan sponsor name:

UIVR Vftd Wjpko mf Poxmacxw

Address:

1531 T Wm Sy

City:

Washington

State:

DC

Zip:

20005

Telephone:

(972) 576-5841 Ext:

E-mail:

mask@pbgc.gov

Fax:

Plan Sponsor's Authorized Representative Information
First name:

Last name:

Company:

Title:

Address:

City:

State:

Zip:
Ext:

Telephone:

E-mail:

Fax:

Mass Withdrawal (Sec. 4281)
Ongoing/Critical Status (Sec. 4245)

The Plan is/will be insolvent
under:

2019

Estimated amount of annual
benefit payments under the plan
for the insolvency year:

$989.00

Estimated amount of the plan's
available resources for the
insolvency year:

$65.00

Estimated amount of annual
benefits guaranteed by PBGC
for the insolvency year:

$123.00

Amount of financial assistance,
if any, requested from PBGC:

$456.00

Insolvency year for which the
notice is being filed:

Submission status - Filing not yet submitted

CONFIDENTIAL

Attached Documents
Most recent actuarial valuation for the plan
Certification, signed by the plan sponsor (or duly authorized representative), that the notices of insolvency have
been given to all interested parties (defined in 29 CFR 4245.2) for critical status plans or to participants and
beneficiaries for plans terminated by mass withdrawal

Sample notice of insolvency benefit level given to all interested parties or to participants and beneficiaries
Plan document (Including any amendments/restatements)
Other
Missing Information If required information has not been submitted, explain below.
no 4 or 5

Submission status - Filing not yet submitted
Go To Data Summary