A Model Notice of Intent to Terminate Plan

APPENDIX A

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 § 2550.404a-3. 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 § 2550.404a-3. The Department of Labor estimates that it will take an average of approximately seventeen 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 § 2550.404a-3, 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 A to part 2550— Model Notice for Section 404a-3

NOTICE OF PLAN TERMINATION

[DO NOT USE FOR ABANDONED PLANS]

[Date of notice]

[Name and last known address of plan participant or beneficiary]

Re: [Name of plan]

Dear [Name of plan participant or beneficiary]:

This notice is to inform you that [name of the plan] (the Plan) has been terminated.

We have determined that you have an interest in the Plan, either as a plan participant or beneficiary. Your account balance in the Plan on [date] is/was [account balance]. We will be distributing this money as permitted under the terms of the Plan and federal regulations. {If applicable, insert the following sentence: The actual amount of your distribution may be more or less than the amount stated in this notice depending on investment gains or losses and the administrative cost of terminating your plan and distributing your benefits.}

Your distribution options under the Plan are {add a description of the Plan’s distribution options}. It is very important that you elect one of these forms of distribution and inform us of your election. The process for informing us of this election is {enter a description of the Plan’s election process}.

If you do not make an election within 30 days from your receipt of this notice, your account balance will be transferred directly to an individual retirement plan (inherited individual retirement plan in the case of a nonspouse beneficiary). {If the name of the provider of the individual retirement plan is known, include the following sentence: The name of the provider of the individual retirement plan is [name, address and phone number of the individual retirement plan provider].} Pursuant to federal law, your money in the individual retirement plan would then be invested in an investment product designed to preserve principal and provide a reasonable rate of return and liquidity. {If fee information is known, include the following sentence: Should your money be transferred to the individual retirement plan described, above, [name of the financial institution] will charge your account the following fees for its services: {add a statement of fees, if any, that will be paid from the participant or beneficiary’s individual retirement plan}.}

For more information about the termination, your account balance, or distribution options, please contact [name, address, and telephone number of the plan administrator or other appropriate contact person].

Sincerely,

[Name of plan administrator or appropriate designee]

[Name of plan]