SFA 300 Annual Statement of Compliance

OMB Control Number 1212-0074
Expires XX/XX/202X
Updated XX/XX/2024

MULTIEMPLOYER PROGRAM DIVISION
ANNUAL STATEMENT OF COMPLIANCE FOR MULTIEMPLOYER PLANS THAT
RECEIVE SPECIAL FINANCIAL ASSISTANCE
Multiemployer plans that have received special financial assistance (SFA) under section 4262 of the
Employee Retirement Income Security Act of 1974 (ERISA) and PBGC’s SFA regulation (29 CFR part
4262) are required under § 4262.16(i) to submit a Statement of Compliance for each plan year through
the last day of the last plan year ending in 2051.
This form is due annually, no later than 90 days after the end of each plan year, and addresses compliance
during that plan year. However, if 6 months or fewer remain in the plan year after the month that
includes the date the plan first received payment of SFA, then the first submission is due no later than 90
days after the end of the next plan year, and the form must address compliance from the date the plan
received payment of SFA through the next plan year. For example, if a calendar year plan received
payment of SFA on November 15, 2023, the plan’s first statement of compliance would be due by March
31, 2025, covering the period from November 15, 2023, through December 31, 2024.
This form must be signed and dated by a trustee who is a current member of the plan’s board of trustees
and authorized to sign on behalf of the board of trustees, or by another authorized representative of the
plan sponsor. Also, this form must be filed electronically, in accordance with directions on PBGC’s
website, www.pbgc.gov.
Part I. Plan information (required for all plans)
__________________________________________________________________________________
Plan name
___________________________________________
__________________________________
Role of filer
Name of filer
___________________________________________
Street address of filer

__________________________________
Email address of filer

___________________________________________
City, State, ZIP Code of filer

__________________________________
Telephone number of filer

____________________________
EIN

__________
PN

A. Plan year* to which this Statement of Compliance applies: __________
*Provide two plan years only if this form is the plan’s first submission and six months or fewer
remained in the plan year after the month in which the plan first received payment of SFA.
B. Amount of SFA received by the plan (unless previously reported): _____________
C. Date of the plan’s last actuarial valuation report: ______________
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D. The current value of the plan assets in the SFA segregated account established in accordance with
section 4262(l) of ERISA and § 4262.14(a) of PBGC's SFA regulation (hereinafter “SFA funds”) as
of the plan’s last actuarial valuation report: ______________
E. The plan filed (check only one):
____ An application for SFA or a supplemented application for SFA (under § 4262.4(g)(6) and
using Addendum C) after August 8, 2022, OR
____ An application for SFA and received SFA under the interim final rule in effect before
August 8, 2022, and has not yet filed a supplemented application. If checked, then the plan is an
“IFR-only recipient” for purposes of this form, and it should follow the instructions for IFR-only
recipients when providing responses on investment of SFA funds and the phased recognition of
SFA for calculation of withdrawal liability in Parts II and III.
F. Is the plan a “merged plan” (as defined in 29 CFR 4231.2) following PBGC approval of a merger
under § 4262.16(f)(1) [i.e., a plan that resulted from a merger with any plan that has ever received
SFA]?
____ Yes. If yes, skip Part II and complete Part III.
____ No. If no, complete Part II and skip Part III.
Part II. Compliance with restrictions and conditions (required only for plans that are not merged plans)
(Plans that answered “yes” to part I.F should skip part II.)
A. The plan is required to comply with each of the following restrictions and conditions under section
4262(l) of ERISA and §§ 4262.13 and 14 of PBGC’s SFA regulation.
Use of SFA funds (section 4262(l) of ERISA):
(1) The plan must use the SFA funds only to pay benefits and administrative expenses.
(2) The plan must segregate the SFA funds from other plan assets.
(3) The plan must invest the SFA funds only in permissible investments. For IFR-only
recipients, this condition (#3) refers to permissible investments allowed under
§ 4262.14 as it existed before August 8, 2022.
(4) The plan must meet the allocation restriction on return-seeking assets at each
purchase and at least once in every rolling period of 12 consecutive months. This
condition (#4) does not apply to IFR-only recipients.
During the plan year, has the plan complied with the applicable restrictions on the use of
SFA funds listed in this part II.A?
____ Yes.
____ No. If no, attach an explanation of the plan’s non-compliance and include any
corrective action taken by the plan.
B. Benefit increases. (§ 4262.16(b)) (This term refers to benefit increases as described in section
4022A(b)(1) of ERISA without regard to the length of time the benefit or benefit increase has been
in effect. Also, the condition on benefit increases does not apply to the reinstatement of benefits
that were suspended under sections 305(e)(9) or 4245(a) of ERISA (as provided under § 4262.15) or
the restoration of benefits under 26 CFR 1.432(e)(9)-1(e)(3).)

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In addition to the restrictions in section 305(f)(1) of ERISA:
(1) The plan must not adopt a retrospective benefit or benefit increase attributable in
whole or in part to service accrued or other events occurring before the adoption date
of the amendment.
(2) The plan must not adopt a prospective benefit or benefit increase, unless both of the
following conditions apply:
i. The plan actuary certified that employer contribution increases projected to
be sufficient to pay for the benefit increase have been adopted or agreed to.
ii. Those increased contributions were not included in the determination of
SFA.
(3) Beginning 10 years after the end of the plan year in which it receives payment of
SFA, a plan may apply for an exception to the condition on retrospective and
prospective benefit increases. See § 4262.16(b)(3).
During the plan year, did the plan adopt a retrospective benefit increase?
____ Yes. If yes, attach (1) a statement that the plan received PBGC’s approval for this
adoption or that a request for approval is pending with PBGC, or (2) an explanation of
the non-compliance and include any corrective action taken by the plan.
____ No.
During the plan year, did the plan adopt a prospective benefit increase?
____ Yes. If yes, attach (1) a statement that the adoption met the required conditions
listed above in B.2, (2) a statement that the plan received PBGC’s approval (described in
B.3) for this adoption or that a request for approval is pending with PBGC, or (3) an
explanation of the non-compliance and include any corrective action taken by the plan.
____ No.
C. Allocation of plan assets (§ 4262.16(c))
The plan’s assets, including SFA funds, must be held in permissible investments that are
investment grade fixed income, as described in § 4262.14(d) of PBGC’s SFA regulation,
sufficient to pay for at least 1 year (or until the date the plan is projected to become insolvent, if
earlier) of projected benefit payments and administrative expenses, taking into account the
limitations on derivatives and leverage in § 4262.14(h).
During the plan year, did the plan comply with the conditions relating to allocation of
plan assets listed in part II.C?
____ Yes.
____ No. If no, attach an explanation of the plan’s non-compliance and include any
corrective action taken by the plan.
D. Contribution decreases (§ 4262.16(d))
The contributions to the plan required for each contribution base unit must be not less than, and
the definition of the contribution base units used must not be different from, those set forth in
collective bargaining agreements or plan documents (including contribution increases to the end
of the collective bargaining agreements) in effect on March 11, 2021.
Exception:
• The plan sponsor determined that the change lessens the risk of loss to plan
participants and beneficiaries; and
• If the contribution reduction affects over $10 million of annual contributions and
over 10 percent of all employer contributions, the plan submitted a request for
PBGC approval.
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During the plan year, did the plan experience a contribution decrease?
____ Yes. If yes, attach (1) an explanation of the plan sponsor’s determination under
the exception described and, if necessary, a statement that the plan received PBGC’s
approval for this contribution decrease, or (2) an explanation of the non-compliance and
include any corrective action taken by the plan.
____ No.
E. Allocating contributions and other practices (§ 4262.16(e))
An allocation of income or expenses must not decrease the proportion of income or increase the
proportion of expenses allocated to the plan pursuant to a written or oral agreement or practice
(other than a written agreement in existence on March 11, 2021, to the extent not subsequently
amended or modified) under which the income or expenses are divided or are to be divided
between the plan and one or more other employee benefit plans.
Exceptions. This prohibition does not apply to a good faith allocation of:
• Contributions pursuant to a reciprocity agreement;
• Costs of securing shared space, goods, or services, where such allocation does
not constitute a prohibited transaction under ERISA or is exempt from such
prohibited transaction provisions pursuant to sections 408(b)(2) or 408(c)(2) of
ERISA, or pursuant to a specific prohibited transaction exemption issued by the
Department of Labor under section 408(a) of ERISA;
• The actual cost of services provided to the plan by an unrelated third party;
• Contributions where the contributions to the plan required for each contribution
base unit are not reduced, unless permitted under II.D above; or
• Reallocations between employee benefit plans described in § 4261.16(e)(2) for
which the plan has applied for and obtained PBGC’s prior approval no earlier
than 5 years after the end of the plan year in which it receives payment of SFA.
During the plan year, did the plan experience a reallocation of expenses?
____ Yes. If yes, attach (1) an explanation of why this reallocation did not violate the
condition regarding reallocation of expenses, or (2) an explanation of the non-compliance
and include any corrective action taken by the plan.
____ No.
During the plan year, did the plan experience a reallocation of contributions?
____ Yes. If yes, attach (1) an explanation of why this reallocation did not violate the
condition regarding reallocation of contributions, including, if applicable, a statement
that the plan received PBGC’s approval, or (2) an explanation of the non-compliance and
include any corrective action taken by the plan.
____ No.
F. Transfer or merger (§ 4262.16(f))
The plan must not engage in a transfer of assets or liabilities (including a spinoff) or merger
except with PBGC’s approval.
During the plan year, did the plan engage in a transfer of assets or liabilities (including a
spinoff) or merger?
____ Yes.
____ No. If no, skip to Part II.G.
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If yes, did the plan request PBGC’s approval of the transfer or merger?
____ Yes.
____ No. If no, attach an explanation of the non-compliance and include
any corrective action taken by the plan.
G. Withdrawal liability (UVB determination) (§ 4262.16(g)(1) and § 4262.16(g)(2))
In accordance with § 4262.16(g)(1) of PBGC’s SFA regulation, the plan must use the interest
assumptions in Appendix B to part 4044 of PBGC’s regulations to determine unfunded vested
benefits (UVBs) of the plan under section 4213(c) of ERISA (for the purpose of determining
withdrawal liability) beginning with the first plan year in which the plan receives payment of
SFA and until the later of: (i) the 10th plan year after the first plan year in which the plan receives
payment of SFA, or (ii) the last day of the plan year in which, according to the plan’s projection,
the plan will exhaust any SFA assets (extended by the number of years, if any, that the first plan
year of payment is after the plan year that includes the plan’s SFA measurement date). A similar
period applies for an IFR-only recipient, except that the duration of (ii) is determined under the
terms of the interim final rule.
In accordance with § 4262.16(g)(2) of PBGC’s SFA regulation, the plan must determine the
amount of SFA that is phased in for withdrawal liability purposes each year over the projected
life of the SFA assets. The applicable phase-in period is from the first plan year in which the
plan receives payment of SFA through the end of the plan year in which, according to the plan’s
projections, it will exhaust any SFA assets (extended by the number of years, if any, that the first
plan year of payment is after the plan year that includes the plan’s SFA measurement date). For a
plan that received payment of SFA under the terms of the interim final rule and files a
supplemented application, the first plan year of payment is the year in which it received SFA
under the terms of the interim final rule. To calculate the amount of SFA assets excluded for
each plan year during the phase-in period, the plan must take the total amount of SFA paid to the
plan and multiply that by a fraction, the numerator of which is the number of years remaining in
the phase-in period as of the date that the UVBs are being determined, and the denominator is the
total number of years in the phase-in period. For a plan that receives payment of SFA under the
interim final rule and receives a supplemented payment under the final rule, the total amount
(payment under the interim final rule and supplemental payment) will be included in the phased
recognition of SFA assets in determining UVBs for withdrawals going forward.
During the plan year, did the plan determine UVBs for the purpose of determining
withdrawal liability for one or more employers that withdrew from the plan after the plan
year in which the plan received payment of SFA?
____ Yes. If yes, attach the withdrawal liability calculation(s).
____ No. If no, skip to Part II.H.
If yes, did the plan comply with the condition in § 4262.16(g)(1) requiring use of the
prescribed interest assumptions?
____ Yes.
____ No, and the condition has not yet expired for the plan. If checked, attach an
explanation of the non-compliance and include any corrective action taken by the plan.
____ No, and the condition has expired for the plan.
If yes, did the plan comply with the condition in § 4262.16(g)(2) regarding recognizing
the amount of SFA over time? This condition does not apply to IFR-only recipients, and
IFR-only recipients should leave this question blank.
5

____ Yes.
____ No, and the condition has not yet expired for the plan. If checked, attach an
explanation of the non-compliance and include any corrective action taken by the plan.
____ No, and the condition has expired for the plan.
H. Withdrawal liability settlement (§ 4262.16((h))
The plan must not, before receiving PBGC approval, make any settlement of withdrawal liability
where the amount of the liability settled was more than $50 million, calculated as the lesser of: (i)
the allocation of unfunded vested benefits to the employer under section 4211 of ERISA; or (ii)
the present value of withdrawal liability payments assessed for the employer discounted using the
interest assumptions under § 4281.13(a) of PBGC’s regulation on Duties of Plan Sponsor
Following Mass Withdrawal.
During the plan year, did the plan make any settlement of withdrawal liability of any
amount?
____ Yes. If yes, attach a copy of the withdrawal liability settlement agreement (unless
previously submitted).
____ No. If no, skip to Part II.I.
During the plan year, did the plan make any settlement of withdrawal liability of more
than $50 million?
____ Yes.
____ No. If no, skip to Part II.I.
If yes, did the plan comply with this condition?
____ Yes.
____ No. If no, attach an explanation of the non-compliance and include any corrective
action taken by the plan.
I.

Has there been any violation of any Federal criminal law involving fraud, bribery, or gratuity
violations potentially affecting the SFA funds?
____ Yes. If yes, attach an explanation of the violation or violations.
____ No.

Part III. Compliance with restrictions and conditions required for all merged plans (as defined in 29
CFR 4231.2) following PBGC approval of a merger under § 4262.16(f)(1) of PBGC’s SFA regulation
(Plans that answered “no” to part I.F should skip part III.)
A. Identify any conditions waived under § 4262.16(f)(4) as part of PBGC approval of a merger.
____ Retrospective benefit increase. If checked, skip Part III.C.
____ Contribution decreases. If checked, skip part III.D.
____ Allocating contributions and other income. If checked, skip Part III.E.
____ None
B. The plan is required to comply with each of the following restrictions and conditions under
section 4262(l) of ERISA and §§ 4262.13 and 4262.14 of PBGC’s SFA regulation.

6

Use of SFA funds (section 4262(l) of ERISA):
(1) The plan must use the SFA funds only to pay benefits and administrative expenses.
(2) The plan must segregate the SFA funds from other plan assets.
(3) The plan must invest the SFA funds only in permissible investments. For IFR-only
recipients, this condition refers to permissible investments allowed under § 4262.14 as it
existed before August 8, 2022.
(4) The plan must meet the allocation restriction on return-seeking assets at each purchase
and at least once in every rolling period of 12 consecutive months. This condition does
not apply to IFR-only recipients.
During the plan year, has the plan complied with the applicable restrictions on the use of
SFA funds listed in this Part III.B?
____ Yes.
____ No. If no, attach an explanation of the plan’s non-compliance and include any
corrective action taken by the plan.
C. Retrospective benefit increases. 2 (§ 4262.16(b)(1)) In addition to the restrictions in section
305(f)(1) of ERISA:
(1) The plan must not adopt a retrospective benefit or benefit increase attributable in whole or in
part to service accrued or other events occurring before the adoption date of the amendment.
Absent a waiver, this condition continues to apply to participants in the SFA plan
immediately before the merger.
(2) Beginning 10 years after the end of the plan year in which the SFA plan receives payment of
SFA, a plan may apply for an exception to the condition on retrospective benefit increases.
See § 4262.16(b)(3). Absent a waiver, this condition continues to apply to participants in the
SFA plan immediately before the merger.
During the plan year, did the plan adopt a retrospective benefit increase for the
participants in the SFA plan?
____ Yes. If yes, attach (1) a statement that the plan received PBGC’s approval for this
adoption or that a request for approval is pending with PBGC, or (2) an explanation of
the non-compliance and including any corrective action taken by the plan.
____ No.
D. Contribution decreases (§ 4262.16(d))
The contributions to the plan required for each contribution base unit must be not less than, and
the definition of the contribution base units used must not be different from, those set forth in
collective bargaining agreements or plan documents (including contribution increases to the end
of the collective bargaining agreements) in effect on March 11, 2021. Absent a waiver, this
condition continues to apply to employers who had an obligation to contribute to the SFA plan.
Exceptions:
• The plan sponsor determined that the change lessens the risk of loss to plan
participants and beneficiaries; and
• If the contribution reduction affects over $10 million of annual contributions and
over 10 percent of all employer contributions, the plan submitted a request for
PBGC approval.
This term refers to benefit increases as described in section 4022A(b)(1) of ERISA without regard to the length of
time the benefit or benefit increase has been in effect. Also, the condition on benefit increases does not apply to the
reinstatement of benefits that were suspended under sections 305(e)(9) or 4245(a) of ERISA (as provided under §
4262.15) or the restoration of benefits under 26 CFR 1.432(e)(9)-1(e)(3).
7

2

During the plan year, did the plan experience a contribution decrease?
____ Yes. If yes, attach (1) an explanation of the plan sponsor’s determination under the
exception described and, if necessary, a statement that the plan received PBGC’s
approval for this contribution decrease, or (2) an explanation of the non-compliance and
include any corrective action taken by the plan.
____ No.
E. Allocating contributions and other income (§ 4262.16(e))
An allocation of contributions or other income must not decrease the proportion of income or
increase the proportion of expenses allocated to the plan pursuant to a written or oral agreement
or practice (other than a written agreement in existence on March 11, 2021, to the extent not
subsequently amended or modified) under which the income or expenses are divided or to be
divided between the plan and one or more other employee benefit plans. Absent a waiver, this
condition continues to apply to contributions or income relative to the SFA plan before the date
of merger.
Exceptions. This prohibition does not apply to a good faith allocation of:
• Contributions pursuant to a reciprocity agreement;
• Contributions where the contributions to the plan required for each contribution
base unit are not reduced, unless permitted under Part III.D above; or
• Reallocations between employee benefit plans described in § 4261.16(e)(2) for
which the plan has applied for and obtained PBGC’s prior approval no earlier
than 5 years after the end of the plan year in which it receives payment of SFA.
During the plan year, did the plan experience a reallocation of contributions?
____ Yes. If yes, attach (1) an explanation of why this reallocation did not violate the
condition regarding reallocation of contributions, or (2) an explanation of the noncompliance and include any corrective action taken by the plan.
____ No.
F. Transfer or merger (§ 4262.16(f))
The plan must not engage in a transfer of assets or liabilities (including a spinoff) or merger
except with PBGC’s approval.
During the plan year, did the plan engage in a transfer of assets or liabilities (including a
spinoff) or merger?
____ Yes.
____ No. If no, skip to Part III.G.
If yes, did the plan request PBGC’s approval of the transfer or merger?
____ Yes. If yes, attach a statement that the plan received PBGC’s approval for the
transfer or merger.
____ No. If no, attach an explanation of the non-compliance and include any corrective
action taken by the plan.
G. Withdrawal liability (UVB determination) (§ 4262.16(g)(1) and § 4262.16(g)(2))
In accordance with § 4262.16(g)(1) of PBGC’s SFA regulation, the plan must use the interest
assumptions in Appendix B to part 4044 of PBGC’s regulations to determine unfunded vested
benefits (UVBs) that arose under the SFA plan before the date of the merger for purposes of
allocating UVBs beginning with the first plan year in which the plan receives payment of SFA
8

and until the later of: (i) 10th plan year after the first plan year in which the plan receives payment
of SFA, or (ii) the last day of the plan year in which, according to the plan’s projection, the plan
will exhaust any SFA assets (extended by the number of years, if any, that the first plan year of
payment is after the plan year that includes the plan’s SFA measurement date). A similar period
applies for an IFR-only recipient, except that the duration of (ii) is determined under the terms of
the interim final rule.
This condition applies for determining withdrawal liability for employers that participated in the
SFA plan immediately before the merger.
In accordance with § 4262.16(g)(2) of PBGC’s SFA regulation, to determine unfunded vested
benefits UVBs that arose under the SFA plan before the date of the merger the plan must
determine the amount of SFA that is phased in for withdrawal liability purposes each year over
the projected life of the SFA assets. The applicable phase-in period is from the first plan year in
which the plan receives payment of SFA through the end of the plan year in which, according to
the plan’s projections, it will exhaust any SFA assets (extended by the number of years, if any,
that the first plan year of payment is after the plan year that includes the plan’s SFA measurement
date). For a plan that received payment of SFA under the terms of the interim final rule and files
a supplemented application, the first plan year of payment is the year in which it received SFA
under the terms of the interim final rule. To calculate the amount of SFA assets excluded for
each plan year during the phase-in period, the plan must take the total amount of SFA paid to the
plan and multiply that by a fraction, the numerator of which is the number of years remaining in
the phase-in period as of the date that the UVBs are being determined, and the denominator is the
total number of years in the phase-in period. For a plan that receives payment of SFA under the
interim final rule and receives a supplemented payment under the final rule, the total amount
(payment under the interim final rule and supplemental payment) will be included in the phased
recognition of SFA assets in determining UVBs for withdrawals going forward.
This condition applies for determining withdrawal liability for employers that participated in the
SFA plan.
During the plan year, did the plan determine UVBs for the purpose of determining
withdrawal liability for one or more employers that participated in the SFA plan and that
withdrew from the SFA plan after the plan year in which the SFA plan received payment
of SFA?
____ Yes. If yes, attach the withdrawal liability calculation(s).
____ No. If no, skip to Part III.H.
If yes, did the plan comply with the condition in § 4262.16(g)(1) requiring use of the
prescribed interest assumptions for employers that participated in the SFA plan?
____ Yes.
____ No, and the condition has not yet expired for the plan. If checked, attach an
explanation of the non-compliance and include any corrective action taken by the plan.
____ No, and the condition has expired for the plan.
If yes, did the plan comply with the condition in § 4262.16(g)(2) regarding recognizing
the amount of SFA over time for employers that participated in the SFA plan? This
condition does not apply to IFR-only recipients, and IFR-only recipients should leave
this question blank.
____ Yes.
9

____ No, and the condition has not yet expired for the plan. If checked, attach an
explanation of the non-compliance and include any corrective action taken by the plan.
____ No, and the condition has expired for the plan.
H. Withdrawal liability settlement (§ 4262.16((h))
The plan must not, before receiving PBGC approval, make any settlement of withdrawal liability
where the amount of the liability settled was more than $50 million, calculated as the lesser of: (i)
the allocation of unfunded vested benefits to the employer under section 4211 of ERISA; or (ii)
the present value of withdrawal liability payments assessed for the employer discounted using the
interest assumptions under § 4281.13(a) of PBGC’s regulation on Duties of Plan Sponsor
Following Mass Withdrawal.
During the plan year, did the plan make any settlement of withdrawal liability of any
amount)?
____ Yes. If yes, attach a copy of the withdrawal liability settlement agreement (unless
previously submitted).
____ No. If no, skip to part III.I.
During the plan year, did the plan make any settlement of withdrawal liability of more
than $50 million?
____ Yes.
____ No. If no, skip to part III.I.
If yes, did the plan comply with this condition?
____ Yes.
____ No. If no, attach an explanation of the non-compliance and include any corrective
action taken by the plan.
I.

Has there been any violation of any Federal criminal law involving fraud, bribery, or gratuity
violations potentially affecting the SFA funds?
____ Yes. If yes, attach an explanation of the violation or violations.
____ No.

Part IV. Compliance with the requirement to reinstate benefits and pay any make-up payments under
section 4262(k) of ERISA and § 4262.15 of PBGC’s SFA regulation required for plans with benefits that
were suspended under sections 305(e)(9) or 4245(a) of ERISA before receipt of SFA (plans without
suspended benefits should skip part IV).
A. NOTE: The following question is applicable only if the plan received SFA during the plan
year. If inapplicable, skip Part IV.A.
The plan must reinstate suspended benefits (under sections 305(e)(9) or 4245(a) of ERISA)
effective as of the first month in which the SFA was paid to the plan in accordance with IRS
Notice 2021-38.
Did the plan timely reinstate benefits of participants and beneficiaries in pay status at the time
when the plan received SFA?
____ Yes.
____ No. If no, attach an explanation of the non-compliance and include any corrective
action taken by the plan.
B. NOTE: The following question is applicable only if the plan had participants or
beneficiaries who entered pay status during the plan year. If inapplicable, skip Part IV.B.
10

As stated in IRS Notice 2021-38, any future payments by the plan of benefits to participants or
beneficiaries must be made as if the amendment suspending benefits had never been adopted.
Were the benefits of participants and beneficiaries who entered pay status during the plan year
based on their reinstated benefits?
____ Yes.
____ No. If no, attach an explanation of the non-compliance and include any corrective
action taken by the plan.
C. NOTE: The following question is applicable only if the plan was obligated to pay make-up
payments during the plan year. If inapplicable, skip Part IV.C. The plan must pay make-up
payments in the amount of previously suspended benefits (under section 305(e)(9) or section
4245(a) of ERISA) to any participants and beneficiaries who are in pay status as of the date that
SFA is paid to the plan, in accordance with IRS Notice 2021-38. The make-up payments must be
paid either in the form of a lump sum or in the form of equal monthly installments over a period
of 5 years. Make-up payments must be paid or commence within 3 months of the date that SFA
is paid.
Did the plan timely pay make-up payments in the form of a lump sum or equal monthly
installments? Both “yes” answers may be checked for a plan that has used both forms of
payment.
____ Yes, the plan timely paid make-up payments in the form of a lump sum.
____ Yes, the plan is timely paying make-up payments in the form of equal monthly
installments over a period of 5 years.
____ No. If no, attach an explanation of the non-compliance and include any corrective
action taken by the plan.
D. NOTE: The following question is applicable only if the plan was obligated to send notices of
reinstatement during the plan year. If inapplicable, skip Part IV.D. The plan must send
notices of reinstatement to every participant and beneficiary as required by § 4262.15(c) and
Addendum B – Instructions for Notice of Reinstatement.
Did the plan send timely notices of reinstatement to every participant and beneficiary as required
by § 4262.15(c) and Addendum B – Instructions for Notice of Reinstatement?
____ Yes.
____ No. If no, attach an explanation of the non-compliance and include any corrective
action taken by the plan.
Part V. Required documents (required for all plans)
In addition to any documentation required under Part II, III, or IV, attach the following documents to this
form:
• Most recent audited financial statements of the plan;
• Most recent actuarial valuation report;
• Restatement of the plan document (if applicable) and all plan amendments adopted within the past
plan year (if any);
• Account statements covering entire plan year in review (demonstrating segregation of SFA funds
from other assets);
o If transfers are made from SFA segregated account(s) to other account(s), the account
statements of the transferred account(s) and/or support documentation tying out
transferred amount are required.
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•

•

•
•

Most recent plan year-end investment/custodian account statement(s) (hardcopy and Microsoft Excel
compatible worksheet) that shows an allocation to return-seeking assets that is less than or equal to
33%of all remaining SFA assets;
o Additionally, for any period during which return-seeking assets are purchased, the associated
investment/custodian account statement(s) (hardcopy and Microsoft Excel compatible
worksheet), that shows an allocation to return-seeking assets that is less than or equal to 33% of
all remaining SFA assets, are required;
Microsoft Excel compatible worksheet that shows the allocation of the plan’s SFA investments to each
of the following categories at the end of the most recent plan year:
o Permissible fund vehicles invested predominantly in:
 Investment grade fixed income securities, as further described in 29 CFR
4262.14(d)(2)
 Publicly traded equity securities, as further described in 29 CFR 4262.14(c)(2)
o Investment-grade debt (144A securities)
o Cash or cash equivalents
o Common stock that is denominated in U.S. dollars and registered under section 12(b) of
the Securities Exchange Act of 1934
o High-yield debt (which was investment-grade at time of purchase)
o Other (Assets in this “other” category are not permissible investments of SFA funds and
must be reported. All permissible investments of SFA funds are covered in the preceding
categories.);
Most recent zone certification(s) of the plan-year under review; and
Using Template 4A from the PBGC website, please provide an Updated Cash Flow Projections
Microsoft Excel Compatible Worksheet through the earlier of a) SFA projection period or b)
insolvency, with a summary of or reference to the actuarial assumptions and methods used in the
projections attached. These projections should include the following:
o Contributions
o Withdrawal Liability Payments
o Benefit Payments (both reinstated and recurring)
o Administrative Expenses
o Other Payments to Plan
o SFA Investment Income
o Non-SFA Investment Income

PBGC may request additional documents and information as needed for the plan to demonstrate
compliance with the restrictions and conditions.

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Part VI. Certification (required for all plans)
The Annual Statement of Compliance must be signed and dated by a trustee who is a current member of
the plan’s board of trustees and authorized to sign on behalf of the board of trustees, or by another
authorized representative of the plan sponsor.
Under penalty of perjury under the laws of the United States of America, I declare that I have examined
this Annual Statement of Compliance, including accompanying documents, and, to the best of my
knowledge and belief, the form contains all the relevant facts relating to the form; all statements of fact
contained in the form are true, correct, and not misleading because of omission of any material fact; and
all accompanying documents are what they purport to be.
______________________________________________________________________________
Signed
Date
____________________________________________ __________________________________
Printed name of signatory
Title

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PAPERWORK REDUCTION ACT NOTICE
This section provides information on the time and cost estimates for preparing and filing the Annual
Statement of Compliance and required information. If you have any comments concerning the accuracy
of these estimates or suggestions for making it simpler to submit the information, please send your
comments to the Pension Benefit Guaranty Corporation, Office of the General Counsel, 445 12th Street
SW, Washington, DC 20024-2101.
Information filed with PBGC under these requirements is confidential to the extent provided in the
Freedom of Information Act and the Privacy Act. If PBGC receives a request for confidential
information, it will notify the submitter of the records, and afford them a reasonable period of time to
object to the disclosure, pursuant to PBGC procedures and as required under Executive Order 12600. If
PBGC decides not to sustain a submitter’s objection in any request, it will provide the submitter with a
written statement explaining why it has determined to disclose within a reasonable number of days before
a specified disclosure date. PBGC will share the Annual Statement of Compliance, including any
supporting documents and information, with the U.S. Department of Labor and the Treasury Department
(collectively the Agencies) to enable the Agencies to fulfill their responsibilities under ERISA.
This information collection is necessary for PBGC to properly administer the SFA program. PBGC uses
the information it receives in a plan’s Annual Statement of Compliance to ensure that the plan is
compliant with the restrictions and conditions imposed on the plan under section 4262 of ERISA and 29
CFR part 4262.
PBGC estimates an average per plan hour burden of 2 hours of fund office time and an average cost
burden of $2,400 in contractor costs for work done by attorneys. These are estimates and the actual time
and cost per plan will vary depending on the circumstances of a given filing and the size of the plan.
This collection of information has been approved by the Office of Management and Budget (OMB)
under control number 1212-0074 (expires 05/31/2024). Under the Paperwork Reduction Act, an agency
may not conduct or sponsor, and a person is not required to respond to, a collection of information unless
it displays a currently valid OMB control number.

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