Form Ustla-8 - Group / Pension Information
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1U.S Depa
rtment of J
Justice
Office of t
the United
States Tru
ustee - Reg
gion VI
1100 Comme
erce Street, Sui
ite 976
1
10 N. College A
Avenue, Suite 3
300
Dallas, TX 7
5242
T
Tyler, TX 75702
2
(214) 767-89
967
(9
903) 590-1461
1
FAX (214) 76
67-8971
F
FAX (903) 590-
-1461
GRO
OUP/PENS
SION INFO
ORMATION
N
Deb
btor:
Bankru
uptcy Case #:
EIN
N:
Is this
a public corpora
ation?
Ye
es
No
o
1.
Does the de
ebtor sponso
r a group hea
alth or dental
l plan?
Yes
No
If No, g
go to #2.
Premiums paid
d through:
em
mployee contribut
tions
employer con
ntributions
Are the premiu
um payments cu
rrent?
Ye
es
No
Benefits paid f
from:
em
mployee contribu
utions
general assets
s of the company
y
Name and add
dress of responsi
ble officer:
Number of pla
an participants:
Amount o
of plan assets:
2.
Does the de
ebtor sponso
r a pension p
plan?
Y
Yes
No
If No
o, go to #3.
401(k) Plan
Profit S
Sharing Plan
Defined Be
enefit Plan*
Money Purchas
se Plan*
Employ
yee Stock Owner
rship Plan
Name and add
dress of responsi
ble officer:
Who is the cus
stodian of the pla
an assets:
Do employees
make contributi
ons to the plan?
Yes
No
Have all emplo
oyee contribution
ns been forwarde
ed to the trust fu
und?
Yes
No
*Are defined b
benefit or money
y purchase plans
fully funded?
Yes
No
Have any trust
tees, officers, ow
wners, or board m
members of the d
debtor received a
any distributions
s from the plan w
within the last yea
ar?
If so,
please provide
e the name(s), ad
ddress(es), and t
title(s):
Has the debto
r received any lo
oans from the pla
an? If so, state
the approximate
e date, amount, a
and purpose of t
the loan:
Number of pla
an participants:
Amount of
f plan assets:
3.
I declare un
nder penalty
of perjury th
hat the answe
ers contained
d in the forego
oing question
n are true and
d correct.
Debtor
Date
A copy of
f this documen
nt may be provi
ided to the Dep
partment of La
abor
USTLA-8
8 (1/03)
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