Fillable Pbgc Form 10 - Post-Event Notice Of Reportable Events printable pdf download

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

Pbgc Form 10 - Post-Event Notice Of Reportable Events

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