Pbgc Form 601 - Distress Termination Notice Single-Employer Plan Termination (Page 2 of 2) in pdf

Pbgc Form 601 - Distress Termination Notice Single-Employer Plan Termination Page 2

z z

601-

YES

For plans that were paying benefits in excess of Title IV

N/A

benefits, have the benefits of participants/beneficiaries

in pay status been reduced to the estimated Title IV

benefits pursuant to 29 CFR Part 4022, Subpart D?

Has the plan ever required employee contributions?

YES

11a Have you filed or will you file with the Internal Revenue

Service an application for a determination letter on the

termination of this plan?

If "Yes", enter the district and filing date:

District

MM/DD/YYYY

12a Has the Internal Revenue Service granted any

YES

minimum funding waiver(s) for this plan?

If "Yes", attach (1) copies of all waiver ruling letters and

(2) a schedule showing the total amount waived for each

plan year and the remaining unamortized amount of the

waiver.

YES

13a Are there any requests for minimum funding

waiver(s) pending before the IRS?

If "Yes", attach (1) copies of all applications including

cover letters and exhibits and (2) a schedule showing

for each plan year the pending waiver amount.

YES

14a Are there outstanding employer contributions owed to

the plan exclusive of amounts described in 12 and 13?

If "Yes", attach a schedule showing for each plan year

the amount of outstanding employer contributions owed.

PART III. PLAN ADMINISTRATOR CERTIFICATION

I, the Plan Administrator, certify that, to the best of my knowledge and belief:

- the information contained in this filing is true, correct, and complete; and

- the information provided to the enrolled actuary is true, correct, and complete.

In making this certification, I recognize that knowingly and willfully making false, fictitious,

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

Plan administrator's name (type or print)

Plan administrator's signature

Date

Pbgc Form 601 - Distress Termination Notice Single-Employer Plan Termination Page 2