Appendix 1 Appendix 1 - 4010 Illustrative form

4010 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

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

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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

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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) ______________________
________________________________________________________

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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

_______________

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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

__/__/____