C Model Notice of Intent to Serve as QTA

APPENDIX C

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 C to Part 2578— Model Notice of Intent to Serve as Qualified Termination Administrator (For Plans Deemed Abandoned Pursuant to 29 CFR 2578.1(j)(2))

NOTIFICATION OF 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 and plan number]	[Name]
	[EIN]	[Address]
	[Plan account number]	[E-mail address]
	[Address]	[Telephone number]
	[Telephone number]	[EIN]

{If applicable, include and complete 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]

{Include below the plan sponsor’s chapter 7 case number and bankruptcy court jurisdiction from the notice/order entered in the case reflecting the trustee’s appointment. This information serves to link the plan with any fiduciary breach information reported by the bankruptcy trustee after the plan has been terminated and wound up.}

Case Number:_____________

Bankruptcy Court Jurisdiction:_______________________

Abandoned Plan Coordinator:

Pursuant to 29 CFR 2578.1(j)(2), the subject plan is considered abandoned because the sponsor of the plan is in liquidation pursuant to a chapter 7 bankruptcy proceeding.

{Insert as applicable: [I have been appointed to administer the plan sponsor’s case under chapter 7 of the U.S. Bankruptcy Code, and attached is a copy of the notice or order entered in the case reflecting my appointment. As the bankruptcy trustee administering this case, I am eligible to serve as 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.]

or

[A bankruptcy trustee has been appointed to administer the plan sponsor’s case under chapter 7 of the U.S. Bankruptcy Code, and attached is a copy of the notice or order entered in the case reflecting the trustee’s appointment. {[I]or[We]} have been designated by the bankruptcy trustee and {[am]or[are]} eligible to serve as 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.]}

Part I – Plan Information

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

2. Name, EIN, address and email address of the entity holding plan assets (if the entity is not the QTA):

__________________________________________________________________________________________________________________________________________________________________________________________________________________

1. Estimated value of plan assets as of the date of the entry of an order for relief under chapter 7 of the U.S. Bankruptcy Code: [value]

2. Months entity has 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.}

{Following section is not required if the Qualified Termination Administrator is described in 29 CFR 2578.1(j)(4)(i).}

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

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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]