Form 1-Ez - Annual Premium Payment For 2 0 0 1 From The Variable Rate Premium Single-Employer Plans Exempt
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1
2Annual Premium Payment for
Approved OMB 1212-0009
PBGC Form 1-EZ
Single-Employer Plans Exempt
PB0155
536924
from the Variable Rate Premium
Pension Benefit
Photocopies of this
Guaranty Corporation
For Plan Years Beginning in Calendar Year 2001
form may not be filed.
Downloaded forms
2001
Check for Amended Filing
Check for Disaster Relief
(see instructions)
may be filed
See the 2001 Premium Payment Package for the instructions for Form 1-EZ
(see instructions).
1.
2.
Plan Sponsor
Check for address change
Plan Administrator
Check for address change
Check if you do not want forms
and instructions next year
Check if same as plan sponsor and go to Item 3
Name
Name
Address
Address
City
State
Zip
City
State
Zip
3.
Employer Identification Number/
Plan Number (EIN/PN)
(a)
Enter 9-digit EIN
(b)
Enter 3-digit PN
(c)
Does EIN/PN match entry on 2000 Form 5500?
Yes
No
2000 Form 5500 not required.
If no, attach explanation, check box in item 18, and
enter EIN/PN from 2000 Form 5500:
9-digit EIN
3-digit PN
4.
If EIN and PN in Item 3 (a) and (b) above are NOT BOTH the same as on the most recent premium filing, enter both prior EIN and
prior PN.
(a)
Prior 9-digit EIN
(b)
Prior 3-digit PN
(c)
Effective Date of Change
M M
D D
Y Y Y Y
5.
Plan Coverage Status
(check one)
(a)
Covered
(b)
Uncertain (If uncertain, you should file. See instructions, page 14.)
6.
Is this the first premium filing for this plan?
No
Yes
If yes, enter the following dates.
(a)
Plan effective date
(b)
Plan adoption date
(c)
Plan coverage date
M M
D D
Y Y Y Y
M M
D D
Y Y Y Y
M M
D D
Y Y Y Y
7.
Transfers from disappearing plans:
No
Yes
Has a plan other than yours ceased to exist in connection with any transfer of assets or liabilities from that plan to this
plan since the most recent premium filing? (See instructions, page 15.)
If yes, give EIN/PN of each disappearing transferor plan and effective date of transfer, and indicate whether it was a
merger (M), consolidation (C), or spinoff (S).
Transfer Type
Transferor's 9-digit EIN
3-digit PN
M M
D D
Y Y Y Y
M
C
S
(If more than 1, attach a separate sheet that lists the additional EIN/PNs, dates, and transfer types, and check the box in item 18.)
8.
Enter 6-Digit
Industry Code:
9.
Name of Plan:
10.
Name and Phone Number of Plan Contact
(a)
Name:
(b)
Area Code and
Phone Number
M M
D D
Y Y Y Y
M M
D D
Y Y Y Y
11.
(a)
This premium is for
(b)
This premium is for
2 0 0 1
the plan year beginning:
the plan year ending:
M M
D D
Y Y Y Y
Check here if the plan year beginning date
(d)
Adoption date of
(c)
has changed since last filing with PBGC
plan year change:
continue on page 2
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