Form 501 - Post-Distribution Certification For Standard Termination

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Post-Distribution Certification

Approved OMB 1212-0036

Expires 02/28/2017

Check here if you previously filed a Form 501 for this plan.

If checked, provide dates of filing(s):

Plan Name

9-digit employer identification number (EIN)

3-digit plan number (PN)

PBGC case number

8-digit Case #

Last distribution date in satisfaction of plan benefits (or deemed distribution date for plans

(MM/DD/YYYY)

with designated benefits for Missing Participants that will be paid to PBGC)

Date of receipt of IRS determination letter

(MM/DD/YYYY)

Were participants and beneficiaries provided with the name and address of

Yes

the insurer(s) no later than 45 days before the date of distribution? (See page 22 of

instructions.)

Yes

Were you able to locate all participants and beneficiaries? If “No,” see instructions.

Has a copy of the annuity contract, certificate, or written notice been provided to

each participant and beneficiary receiving benefits in the form of an irrevocable

Yes

N/A

commitment?

If “Yes” to 6a, enter the latest date the annuity contract, certificate, or written notice was

(MM/DD/YYYY)

provided to each participant and beneficiary receiving benefits:

If “No” or “N/A”, see instructions

Complete name of record of insurer(s) from whom annuity contracts, if any, have

Annuity Contract Number(s)

been purchased (Address should include room or suite no.)

Name and address of contact for location of plan records

Telephone number

(Address should include room or suite no.)

Summary of distribution of plan benefits

Type of Benefit

(1) # of Participants or Beneficiaries

(2) Total Value

Annuities

Lump sums (including direct transfers

and distributions to participants and

beneficiaries)

(1) Consensual

(2) Nonconsensual

(1) Designated benefits paid to PBGC

for Missing Participants

(2) Other amounts due to PBGC for

for Missing Participants

No Distribution

TOTAL (see instructions)

I, the Plan Administrator, certify that to the best of my knowledge and belief that (1) benefits payable with respect to participants have been calculated

and valued correctly in accordance with applicable provisions of ERISA and the regulations thereunder; (2) all plan benefits (through priority category

6 under ERISA Section 4044 and 29 CFR Part 4044) under the plan have been satisfied; (3) plan assets in excess of those needed to satisfy all

plan benefits (through priority category 6 under ERISA Section 4044 and 29 CFR Part 4044) have been or will be distributed in accordance with ap-

plicable provisions of ERISA and the regulations thereunder; and (4) the information contained in this filing is true, correct, and complete. I further

certify that I am aware that records supporting the calculation and valuation of benefits and assets must be kept at least six years after the date this

post-distribution certification is filed.

In executing this document, I certify that the foregoing is true and correct, and recognize that knowingly and willfully making false, fictitious,

or fraudulent statements to the PBGC is punishable under 18 U.S.C. §1001.

Telephone number

Plan Administrator’s company name and address (Address should include room or suite no.)

E-mail address (optional)

Plan Administrator’s signature

Printed name and title of Plan Administrator

Date