Pbgc Schedule Rep-S (Pbgc Form 500) - Standard Termination Designation Of Representative
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1Standard Termination
PBGC Schedule REP-S
Designation of Representative
(PBGC Form 500)
Approved OMB 1212-0036
Expires 09/30/2010
PART I.
IDENTIFYING INFORMATION
1b
1a
9-digit employer identification number (EIN)
Plan Name
1c
3-digit plan number (PN)
2a
Plan Administrator’s name and address
2b
Plan Administrator’s telephone number
(Address should include room or suite no.)
2c
E-mail address (optional)
PART II.
DESIGNATION OF REPRESENTATIVE(S)
3
I,
, Plan Administrator of the above-named pension plan, hereby appoint the following
representative(s) to act on my behalf before the Pension Benefit Guaranty Corporation on all matters (other than those specifically
excluded below) relating to the termination of the above-named pension plan:
4b
4a
Telephone number
Representative’s name and address
(Address should include room or suite no.)
4c
E-mail address (optional)
4e
4d
Telephone number
Representative’s name and address
(Address should include room or suite no.)
4f
E-mail address (optional)
5
Matters excluded from authority of representative(s). List any specific acts with respect to the plan termination that you are excluding from the
acts otherwise authorized in this designation:
PART III.
RETENTION / REVOCATION OF PRIOR DESIGNATION(S)
6a
Have you filed any prior designation(s) of representative(s) for this termination?
Yes
No
6b
If “Yes,” do you want any such prior designation(s) of representative(s) to remain in
Yes
No
effect? (Attach a copy of all prior designations that are to remain in effect.)
PART IV.
SIGNATURE OF PLAN ADMINISTRATOR
NOTE: The PBGC will NOT accept unsigned designations. If the Plan Administrator is a board (or similar group) composed of employer and
employee representatives, at least one employer representative and one employee representative must sign this form. If the plan does not designate
a plan administrator or it designates the plan sponsor or the contributing sponsor as the plan administrator, this form must be signed by an officer of
the plan sponsor or contributing sponsor who has the authority to sign on behalf of that entity.
In executing this document, I certify that the foregoing is true and correct, and recognize that knowingly and willfully making false, fictitious,
§
or fraudulent statements to the PBGC is punishable under 18 U.S.C.
1001.
Date
Printed name and title
Signature
Date
Printed name and title
Signature
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