Pbgc Form 500 - Schedule Ea-S - Standard Termination Certification Of Sufficiency (Page 2 of 2) in pdf

Pbgc Form 500 - Schedule Ea-S - Standard Termination Certification Of Sufficiency Page 2

z z

EA-S-

Estimated amount of residual assets to be

distributed to participants and beneficiaries

Has the plan ever required employee contributions?

YES

If the amount in item 8 is $1 million or more and if any benefits are to be distributed other than through the

purchase of annuity contracts, attach a statement showing interest rate/structure used to value the benefits.

PART III. ENROLLED ACTUARY CERTIFICATION

I, the Enrolled Actuary, certify that:

- I have reviewed all plan documents and plan and participant data, and applied all relevant provisions of

ERISA, the Code, and the regulations promulgated thereunder;

- to the best of my knowledge and belief, this plan's assets equal or exceed the value of its plan benefits

as of the proposed distribution date; and

- to the best of my knowledge and belief, the information contained in this schedule 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.

Enrolled Actuary's Name

(type or print)

Enrollment Number

Company

Full Address

City

State

Zip Code

Telephone

Area Code

Enrolled actuary's signature

Date

PART IV. PLAN ADMINISTRATOR CERTIFICATION FOR CODE SECTION 412(i) PLANS

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

- this plan complies with section 412(i) of the Code and the regulations promulgated thereunder;

- I have reviewed all plan documents and plan and participant data, and applied all relevant provisions of ERISA,

the Code, and the regulations promulgated thereunder;

- this plan's assets equal or exceed the value of its plan benefits as of the proposed distribution date; and

- the information contained in this schedule 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)

Date

Plan administrator's signature

Pbgc Form 500 - Schedule Ea-S - Standard Termination Certification Of Sufficiency Page 2