A Model Notice of Intent to Terminate Abandoned 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 § 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 fifteen 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 A to Part 2578—Model Notice of Intent to Terminate Abandoned Plan

NOTICE OF INTENT TO TERMINATE PLAN

[Date of notice]

[Name of plan sponsor]

[Last known address of plan sponsor]

Re: [Name of plan and account number or other identifying information]

Dear [Name of plan sponsor]:

This letter is a notice of intent to terminate the above referenced plan and distribute benefits in accordance with the U.S. Department of Labor’s Abandoned Plan Program. We will initiate the termination process under the Abandoned Plan Program unless you contact us within 30 days of your receipt of this notice. See 29 CFR 2578.1.

Our basis for taking this action is that our records reflect that there have been no contributions to, or distributions from, the plan within the past 12 months. {If the basis for sending this notice is under 29 CFR 2578.1(b)(1)(i)(B), complete and include the sentence below rather than the sentence above.} Our basis for taking this action is {provide a description of the facts and circumstances indicating plan abandonment}.

We are sending this notice to you because our records show that you are the sponsor of the subject plan. The U.S. Department of Labor requires that you be informed that, as a fiduciary or plan administrator or both, you may be personally liable for all costs, civil penalties, excise taxes, etc. as a result of your acts or omissions with respect to this plan. The termination of this plan by us will not relieve you of your liability for any such costs, penalties, taxes, etc. Federal law also requires us to notify the U.S. Department of Labor, Employee Benefits Security Administration, of the termination. For information about the federal law governing the termination of abandoned plans, you may contact the U.S. Department of Labor at 1.866.444.EBSA (3272) or https://www.dol.gov/agencies/ebsa/about-ebsa/ask-a-question/ask-ebsa.

Please contact [name, address, and telephone number of the person, office, or department that the sponsor must contact regarding the plan] within 30 days in order to prevent this action.

Sincerely,

[Name and address of qualified termination administrator or appropriate designee]