Pbgc Form 600 - Distress Termination Notice Of Intent To Terminate (Page 6 of 6) in pdf

Post-Distribution Certification

PBGC Form 602

for Distress Termination

Approved OMB 1212-0036

Expires 09/30/2010

PART I.

IDENTIFYING INFORMATION

Plan Name

9-digit employer identification number (EIN)

3-digit plan number (PN)

PBGC case number (8-digit)

PART II.

DISTRIBUTION INFORMATION

(MM/DD/YYYY)

Last distribution date in satisfaction of guaranteed or plan benefits

Date of receipt of IRS determination letter

(MM/DD/YYYY)

Latest date notices of benefit distribution issued to participants or beneficiaries

(MM/DD/YYYY)

Were participants and beneficiaries provided with the name and address of the

Yes

insurer(s) no later than 45 days before the date of distribution?

(See page 21 of instructions.)

Were you able to locate all participants and beneficiaries? If “No,” see instructions.

Yes

Has a copy of the annuity contract, certificate, or written notice been provided to each

participant and beneficiary receiving benefits in the form of an irrevocable commitment?

Yes, enter latest date the annuity contract, certificate or written notice was provided to

participants and beneficiaries____________________________(MM/DD/YYYY)

No, see instructions

N/A, see instructions

Complete office address(es) of insurer(s), if any, from whom annuity contracts have

Annuity Contract Number(s)

been purchased (address should include room or suite no.)

Name and address of contact for location of plan records (address should include room

Telephone number

or suite no.)

Summary of distribution of plan benefits

Form

# of Participants or Beneficiaries

Total Value

Annuities

Lump sums (including direct transfers and distributions to

participants and beneficiaries)

(1) Consensual

(2) Nonconsensual

Designated benefits paid to PBGC for Missing Participants

No Distribution

TOTAL (See instructions)

PART III.

PLAN ADMINISTRATOR CERTIFICATION

I, the Plan Administrator, certify that to the best of my knowledge and belief (1) benefits payable with respect to participants have been calculated and

guaranteed benefits

valued correctly in accordance with applicable provisions of ERISA and the regulations thereunder; (2) all (check one)

OR benefit liabilities under the plan have been satisfied, and (3) the information contained in this filing is true, correct, and complete. I further

certify that I am aware that records supporting the calculation and valuation of benefits and assets must be kept at least six years after the date this

post-distribution certification is filed.

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.

Telephone number

Plan Administrator’s company name and address

(address should include room or suite no.)

Name of Plan Administrator

Title of Plan Administrator

Date

Plan Administrator’s signature