Appendix B To § 2578.1

**Notification of Plan Abandonment and Intent to Serve as Qualified
Termination Administrator**

\[*Date of notice*\]

Abandoned Plan Coordinator, Office of Enforcement

Employee Benefits Security Administration

U.S. Department of Labor

200 Constitution Ave., NW, Suite 600

Washington, DC, 20210

Re: Plan Identification Qualified Termination Administrator

\[*Plan name and plan number*\] \[N*ame*\]

\[*EIN*\] \[*Address*\]

\[*Plan account number*\] \[*E-mail address*\]

\[*Address*\] \[*Telephone number*\]

\[*Telephone number*\] \[*EIN*\]

Abandoned Plan Coordinator:

Pursuant to 29 CFR 2578.1(b), we have determined that the subject plan
is or may become abandoned by its sponsor. We are eligible to serve as a
Qualified Termination Administrator for purposes of terminating and
winding up the plan in accordance with 29 CFR 2578.1, and hereby elect
to do so.

We find that the {*check the appropriate box below and provide
additional information as necessary*}:

⁯There have been no contributions to, or distributions from, the plan for
a period of at least 12 consecutive months immediately preceding the
date of this letter. Our records indicate that the date of the last
contribution or distribution was {*enter appropriate date*}.

⁯The following facts and circumstances suggest that the plan is or may
become abandoned by the plan sponsor {*add description below*}:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

We have also determined that the plan sponsor {*check appropriate box
below*}:

⁯No longer exists

⁯Cannot be located

⁯Is unable to maintain the plan

We have taken the following steps to locate or communicate with the
known plan sponsor and have received no objection {*provide an
explanation below*}:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Part I -- Plan Information

1.  Estimated number of individuals (participants and beneficiaries)
    with accounts\
    under the plan: \[*number*\]

2.  Plan assets held by Qualified Termination Administrator:

> A. Estimated value of assets: \[*value*\]
>
> B. Months we have held plan assets, if less than 12: \[*number*\]
>
> C. Hard to value assets {*select "yes" or "no" to identify any assets
> with no*
>
> *readily ascertainable fair market value, and include for those
> identified*
>
> *assets the best known estimate of their value*}*:\
> * Yes No
>
> \(a\) Partnership/joint venture interests ⁯ ⁯ \[*value*\]
>
> \(b\) Employer real property ⁯ ⁯ \[*value*\]
>
> \(c\) Real estate (other than (b)) ⁯ ⁯ \[*value*\]
>
> \(d\) Employer securities ⁯ ⁯ \[*value*\]
>
> \(e\) Participant loans ⁯ ⁯ \[*value*\]
>
> \(f\) Loans (other than (e)) ⁯ ⁯ \[*value*\]
>
> \(g\) Tangible personal property ⁯ ⁯ \[*value*\]

3.  Name and last known address and telephone number of plan sponsor:
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> 4\. Other:
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Part II -- Known Service Providers of the Plan

> Name Address Telephone
>
> 1\.
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> 2\.
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> 3\.
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Part III -- Services and Related Expenses to be Paid

> Services Service Provider Estimated Cost
>
> 1\.
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> 2\.
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> 3\.
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Part IV -- Investigation

> In the past 24 months {*check one box*}:
>
> ⁯ Neither we nor our affiliates are or have been the subject of an
> investigation, examination, or enforcement action by the Department,
> Internal Revenue Service, or Securities and Exchange Commission
> concerning such entity's conduct as a fiduciary or party in interest
> with respect to any plan covered by the Act.
>
> ⁯ We or our affiliates are or have been the subject of an
> investigation, examination, or enforcement action by the Department,
> Internal Revenue Service, or Securities and Exchange Commission
> concerning such entity's conduct as a fiduciary or party in interest
> with respect to any plan covered by the Act.

Part V -- Contact Person {*enter information only if different from
signatory*}:

> \[*Name*\]
>
> \[*Address*\]
>
> \[*E-mail address*\]
>
> \[*Telephone number*\]

Under penalties of perjury, I declare that I have examined this notice
and to the best of my knowledge and belief, it is true, correct and
complete.

\[*Signature*\]

\[*Title of person signing on behalf the Qualified Termination
Administrator*\]

\[*Address, e-mail address, and telephone number*\]