Pbgc Form 1-Ez - Annual Premium Payment For Single-Employer Plans Exempt From The Variable-Rate Premium - 2007
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1
2Annual Premium Payment for
Approved OMB 1212-0009
PBGC Form 1-EZ
PB0724
234695
Single-Employer Plans Exempt
Pension Benefit
from the Variable-Rate Premium
Guaranty Corporation
For Plan Years Beginning in Calendar Year 2007
Photocopies and
downloaded forms
2007
Check for Amended Filing
Check for Disaster Relief
(see instructions)
may be filed
See the 2007 Instructions for Final Premiums for the instructions for Form 1-EZ
(see instructions).
2.
1.
Plan Administrator
Plan Sponsor
Check for name/address change
Check for name/address change
Check if you do not want
Check if same as plan sponsor and go to Item 3
paper instructions next year
Name
Name
Address Line 1
Address Line 1
Address Line 2
Address Line 2
City
State
City
State
Zip
Zip
3.
Employer Identification Number/Plan Number (EIN/PN),
Electronic Filing
(a) Enter 9-digit EIN
(b) Enter 3-digit PN
No
(c) Does EIN/PN match entry on 2006 Form 5500?
Yes
2006 Form 5500 not required.
If no, attach explanation, check box in item 19, and
9-digit EIN
3-digit PN
enter EIN/PN from 2006 Form 5500:
(d) Did PBGC grant the plan an exemption from required electronic filing for
this premium filing?
Yes
No, attach explanation and check box in item 19.
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.
(c) Effective Date of Change
(a) Prior 9-digit EIN
(b) Prior 3-digit PN
M M
D D
Y Y Y Y
5.
Uncertain (If uncertain, you should file. See instructions, page 20.)
Plan Coverage Status (check one) (a)
Covered
(b)
6.
Is this the first year’s premium filing for this plan?
Yes
If yes, enter the following dates.
No
(a) Plan effective date
(b) Plan adoption date
(c) Plan coverage date
D D
D D
D D
M M
M M
M M
Y Y Y Y
Y Y Y Y
Y Y Y Y
7.
Transfers from disappearing plans:
Yes
Has a plan other than yours ceased to exist in connection with any transfer of assets or liabilities from that plan to this
No
plan since the most recent premium filing? (See instructions, page 20.)
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
D D
M M
Transferor’s 9-digit EIN
3-digit PN
Y Y Y Y
S
M
C
(If more than 1, attach a separate sheet that lists the additional EIN/PNs, dates, and transfer types, and check the box in item 19.)
8.
Business Code and CUSIP number
(a) Enter 6-digit
(b) Enter first 6 digits of
Business Code:
CUSIP number:
9.
Name of Plan:
10.
Name and Phone Number of Plan Contact
(a) Name:
(b) Area Code and
Phone Number
D D
D D
M M
M M
Y Y Y Y
Y Y Y Y
11.
(a) This premium is for
(b) This premium is for
2 0 0 7
the plan year ending:
the plan year beginning:
D D
M M
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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