PBGC Form 10
ADDITIONAL INFORMATION TO BE FILED
Change in Contributing Sponsor or Controlled Group
Description of the plan’s old and new controlled group
Active Participant Reduction
structures, including the name of each controlled group
member
Statement explaining the cause of the reduction (e.g.,
facility shutdown or sale)
Name of each plan maintained by any member of the plan’s
old and new controlled groups, its contributing sponsor(s)
Number of active participants at the date the event occurs,
and EIN/PN
at the beginning of the current plan year, and at the
beginning of the prior plan year
Liquidation
Failure to Make Required Contributions
Description of the plan’s controlled group structure before
and after the liquidation, including the name of each
controlled group member
Due date and amount of both the missed contribution and
the next payment due
Name of each plan maintained by any member of the plan’s
controlled group, its contributing sponsor(s) and EIN/PN
Most recent actuarial valuation report
Description of the plan’s controlled group structure,
Extraordinary Dividend or Stock Redemption
including the name of each controlled group member
Name of each plan maintained by any member of the plan’s
Name and EIN of person making the distribution
controlled group, its contributing sponsor(s) and EIN/PN
Date and amount of cash distribution(s) during fiscal year
Inability to Pay Benefits When Due
Description, fair market value, and date or dates of any
non-cash distributions
Date of any missed benefit payment and amount of benefits
Statement whether the recipient was a member of the
due
plan’s controlled group
Next date on which the plan is expected to be unable to pay
benefits, the amount of the projected shortfall, and the
number of plan participants expected to be affected
Application for Minimum Funding Waiver
Amount of the plan’s liquid assets at the end of the quarter,
Copy of waiver application, with all attachments
and the amount of its disbursements for the quarter
Most recent actuarial valuation report
Loan Default
Name, address and phone number of plan trustee (and of
Copy of the relevant loan documents (e.g., promissory
any custodian)
note, security agreement)
Due date and amount of any missed payment
Distribution to a Substantial Owner
Copy of any written notice of default or any notice of
Name, address and phone number of person receiving the
acceleration from lender
distribution(s)
Amount, form and date of each distribution
Bankruptcy or Similar Settlement
Most recent actuarial valuation report
Copy of bankruptcy petition or similar document
Docket sheet or other list of documents filed
Transfer of Benefit Liabilities
Last date for filing claims, if known
Name, contributing sponsor and EIN/PN of transferee
Name, address and phone number of any trustee, receiver or
plan(s)
similar person
Explanation of the actuarial assumptions used in
Most recent actuarial valuation report for each plan in the
determining the value of benefit liabilities (and, if
controlled group
appropriate, plan assets) transferred
Description of the plan’s controlled group structure, including
Estimate of the assets, liabilities, and number of participants
the name of each controlled group member
whose benefits are transferred
Note: To the extent this information is filed with the IRS
Name of each plan maintained by any member of the plan’s
Form 5310A, PBGC will accept a copy of that filing.
controlled group, its contributing sponsor(s) and EIN/PN