E Model Abandoned Plans Final Notice

APPENDIX E

COVER PAGE

PAPERWORK BURDEN DISCLOSURE NOTICE

OMB Control Number 1210-0127; expires xx/xx/2027

Behind this cover page is a model notice that may be used to satisfy the mandatory notification requirements set forth in 29 CFR § 2578.1. The model notice is a collection of information instrument subject to the Paperwork Reduction Act. Use of the model notice to meet the notification requirements is optional. You may also develop your own notice, provided it contains all the information required by 29 CFR § 2578.1. The Department of Labor estimates that it will take an average of approximately ten minutes for plan administrators to complete the model. You may send comments on this collection of information, including suggestions for reducing burden to: US Department of Labor, Office of Research and Analysis, Attention: PRA Officer, 200 Constitution Avenue, NW, Room N-5718, Washington, DC 20210; or send to ebsa.opr@dol.gov. The disclosure requirements in 29 CFR § 2578.1, referenced above, are also a collection of information under the PRA. The public is not required to respond to a collection of information unless it displays a currently valid OMB control number.

DO NOT INCLUDE THIS PAPERWORK REDUCTION ACT BANNER IN NOTICES

Appendix E to Part 2578 ‒ Model Abandoned Plans Final Notice

FINAL NOTICE

[Date of notice]

Abandoned Plan Coordinator, Office of Enforcement

Employee Benefits Security Administration

U.S. Department of Labor

200 Constitution Ave., NW, Suite 600

Washington, DC, 20210

Re:	Plan Identification	Qualified Termination Administrator
	[Plan name, EIN and plan number	[Name]
	from the plan’s Form 5500]	[Address and e-mail address]
	[Plan account number]	[Telephone number]
		[EIN]

{If applicable, complete and include the following pursuant to 29 CFR 2578.1(j)(6)(i) unless the same as Qualified Termination Administrator information above }:

Bankruptcy Trustee

[Name]

[Address]

[E-mail address]

[Telephone number]

Abandoned Plan Coordinator:

General Information

The termination and winding-up process of the subject plan has been completed pursuant to 29 CFR 2578.1. Benefits were distributed to participants and beneficiaries on the basis of the best available information pursuant to 29 CFR 2578.1(d)(2)(i). Plan expenses were paid out of plan assets pursuant to 29 CFR 2578.1(d)(2)(v) and 29 CFR 2578.1(j)(7)(iv).

{Include and complete the next section, entitled “Contact Person,” only if the contact person is different from the signatory of this notice.}

Contact Person

[Name]

[Address and e-mail address] [Telephone number]

{Include and complete the next section, entitled “Expenses Paid” only if fees and expenses paid by the plan exceeded by 20 percent or more the estimate required by 29 CFR 2578.1(c)(3)(v)(B) or 29 CFR 2578.1(j)(6)(vi)(B).}

Expenses Paid

The actual fees and/or expenses paid in connection with winding up the Plan exceeded by

{insert either: [20 percent or more] or [enter the actual percentage]} the estimate required by 29 CFR 2578.1(c)(3)(v)(B) or 29 CFR 2578.1(j)(6)(vi)(B). The reason or reasons for such additional costs are {provide an explanation of the additional costs}

{Include and complete next section, entitled “Delinquent Contributions,” unless 100% of delinquent contributions were previously reported in the notification required by 29 CFR 2578.1 (c) or 2578.1(j)(6.)}

Delinquent Contributions

Dollar amount of employee and employer contributions:______________________________

____________________________________________________________________________

{Separately state employee and employer delinquent contributions.}

{Include and complete the next section, entitled “other fiduciary breaches,” if Qualified Termination Administrator, is a bankruptcy or an eligible designee, defined in 29 CFR 2578.1(j)(4)(ii), unless previously reported in the notification required by 29 CFR 2578.1(j)(6.)}

Other Fiduciary Breaches

Activities evidencing breaches of fiduciary duty described in 29 CFR 2578.1(j)(7)(ii) are described, below.

{Include and complete the next section, entitled “Distributions on Behalf of Deceased Participants and Beneficiaries,” if distributions were made in accordance with 29 CFR 404a-3(d)(v).}

Distributions on Behalf of Deceased Participants and Beneficiaries

We have made distributions permitted by 29 CFR404a-3(d)(v) and have reasonably and in good faith made the findings required by {Insert whichever is applicable: “29 CFR 404a-3(d)(v)(A) for distributions were made to a person other than the estate of the participant” or “29 CFR 404a-(3)(d)(v)(B) if distributions were made to the estate of the participant.”} The summary of the findings required by 29 CFR 404a-3(d)(v)(C), including the basis for the findings and an attestation that we have the full name and last known address of the deceased participant, is attached.

Under penalties of perjury, I declare that I have examined this notice and to the best of my knowledge and belief, it is true, correct and complete.

[Signature]

[Title of person signing on behalf the Qualified Termination Administrator]