B Model Notice of Plan Abandonment and Intent to Serve as

APPENDIX B

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 seventy 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 notification 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 B to Part 2578 ‒ Model Notice of Plan Abandonment and Intent to Serve as Qualified Termination Administrator (For Plans Found Abandoned Pursuant to 29 CFR 2578.1(b))

NOTIFICATION OF PLAN ABANDONMENT AND INTENT TO SERVE AS QUALIFIED TERMINATION ADMINISTRATOR

[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 from]	[Name]
	Plan’s Form 5500	[Address]
	[Plan account number]	[E-mail address]
	[Address]	[Telephone number]
	[Telephone number]	[EIN]

Abandoned Plan Coordinator:

Pursuant to 29 CFR 2578.1(b), we have determined that the subject plan is or may become abandoned by its sponsor. We are eligible to serve as a Qualified Termination Administrator for purposes of terminating and winding up the plan in accordance with 29 CFR 2578.1, and hereby elect to do so.

We find that {check the appropriate box below and provide additional information as necessary}:

• There have been no contributions to, or distributions from, the plan for a period of at least 12 consecutive months immediately preceding the date of this letter. Our records indicate that the date of the last contribution or distribution was {enter appropriate date}.

• The following facts and circumstances suggest that the plan is or may become abandoned by the plan sponsor {add description below}:

We have also determined that the plan sponsor {check appropriate box below}:

• No longer exists

• Cannot be located

• Is unable to maintain the plan

We have taken the following steps to locate or communicate with the known plan sponsor and have received no objection {provide an explanation below}:

____________________________________________________________________________________________________________________________________________________________________________________________________________________

Part I – Plan Information

1. Estimated number of individuals (participants and beneficiaries) with accounts under the plan as of {insert date}: [number]

2. Plan assets held by Qualified Termination Administrator:

   1. Estimated value of assets as of {insert date}: [value]

   2. Months we have held plan assets, if less than 12: [number]

   3. Hard to value assets {select “yes” or “no” to identify any assets with no readily ascertainable fair market value, and include for those identified assets the best known estimate of their value}:

(a) (b)	Partnership/joint venture interests Employer real property	Yes  	No  	[value] [value]
(c)	Real estate (other than (b))			[value]
(d)	Employer securities			[value]
(e)	Participant loans			[value]
(f)	Loans (other than (e))			[value]
(g)	Tangible personal property			[value]

3. Name and last known address and telephone number of plan sponsor:

4. Dollar amount of delinquent employer and employee contributions: {Separately state employee and employer delinquent contributions.} _____________________________________________________

Part II – Known Service Providers of the Plan

Part III – Services and Related Expenses to be Paid

Part IV – Contact Person {enter information only if different from signatory}:

[Name] [Address]

[E-mail address] [Telephone number]

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] [Address, e-mail address, and telephone number]