Schedule A (Pbgc Form 1) - Single-Employer Plan

Schedule A (Pbgc Form 1) - Single-Employer Plan - 2001

SCHEDULE A

Single-Employer Plan

Approved

OMB 1212-0009

(PBGC Form 1)

Variable Rate Premium

2001

(See Part J for General Instructions and Part K for Line-By-Line Instructions)

PB0144

535814

Photocopies of this form may not be filed.

Downloaded forms may be filed (see instructions).

9-digit EIN

3-digit PN

M M

D D

Y Y Y Y

(a)

Plan Year from

(b)

EIN/PN from Form 1

2 0 0 1

Form 1 line 12(a):

line 3 (a) and (b):

(c)

Plan Name:

SECTION ONE: FILING METHOD.

Check a single box and go to line 2. See Section Four for required certifications.

(a)

General Rule.

(b)

Alternative Calculation Method (ACM).

(1)

Plan with fewer than 500 Participants.

(2)

Plan with 500 or more Participants.

M M

D D

Y Y Y Y

Modified ACM for Plan Terminating in Distress or Involuntary

(c)

Termination with a pre-2001 Plan Year termination date of:

. . . . . . . . . . . . . . . . . . . . . . . .

SECTION TWO: UNFUNDED VESTED BENEFITS.

M M

D D

Y Y Y Y

Present Value of Vested Benefits:

Plan Values are determined as of:

. . . . . . . . . . . . . . . . . . . . . . .

The assumed retirement age is

years. The adjusted values are based on a

Required Interest Rate of

% and an accrual factor of

(a)

Plan Value of Vested Benefits (ACM filers only)

(b) Adjusted Value of Vested Benefits

Value

Interest Rate

(1)

Retirees/beneficiaries

receiving payments

(2)

Participants not

receiving payments

(3)

Total

(Line (1) plus line (2))

M M

D D

Y Y Y Y

Value of Plan Assets:

(a)

Enter value of Plan Assets as of

. . . . . . . . . . . . . .

(b)

Enter contribution receivables included in line 3(a)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(c)

Discounted paid contributions.

(Note: For plans with fewer than 500 participants, this line is optional)

. . . . . . . . . . . . . . . . . . . .

(d)

Enter adjusted value of plan assets (Line 3(a) minus line 3(b) plus line 3(c))

. . . . . . . . . . . . . . . .

Adjusted Unfunded Vested Benefits:

Enter adjusted unfunded vested benefits. (ACM filers see

instructions for this line in Part K, Subpart 2, for interest and significant events adjustments.)

. . . . . .

SECTION THREE: VARIABLE RATE PREMIUM.

Variable Rate Premium:

Enter here and on Form 1, line 15(b), either

. . . . . . . . . . . . . . . . . . . . . . . .

(a)

$0, if line 4 was $0; or

(b)

the amount on line 4 multiplied by 0.009.

Schedule A (Pbgc Form 1) - Single-Employer Plan - 2001

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