IDENTIFYING INFORMATION

REPORTABLE EVENTS See instructions for descriptions of these events. Check all boxes that apply.

POST-EVENT NOTICEOF

REPORTABLE EVENTS

PBGC Form 10

OMB Control No. 

1212-0013 Expires XX/XX/XX

Planname Name of authorized contact at filer

Name of filer Title of contact

Street address of filer Email address of contact

City, State, Zip Street address of contact

EIN of contributing sponsor Plannumber City, State, Zip

Fileris: Plan administrator

Contributing sponsor Telephone numberofcontact Ext

Activeparticipantreduction

Failuretomake requiredcontributionsunder $1M 

Inability to pay benefitswhen due

Distribution to a substantial owner

Transfer of benefit liabilities

Change in controlled group

Liquidation

Extraordinarydividendorstockredemption

Application for minimum funding waiver

Loan Default

Insolvency or similar settlement

Briefly describe the pertinent facts relating to each event.

The next page lists additional information that must be submitted with this form, if not included above.

This form is for illustrative purposes only. Form 10 reportable event information should be submitted to PBGC using the e-filing 

portal: efilingportal.pbgc.gov. For questions regarding this form, contact (202) 229-4070 or post- event.report@pbgc.gov.

BRIEF DESCRIPTION
PBGC Form10

Active Participant Reduction

Single cause event - statement explaining the cause of the

reduction (e.g., facility shutdown or sale, discontinued

operations, winding down of the company, or reduction in

force)

Attrition event - statement of factors involved in the attrition

The Internal Revenue Service Determination Letter indicating the

plan is a covered plan, if applicable

Description of the plan’s controlled group structure, including the

name of each controlled group member

Actuarial Information (see instructions)

Company financial information (see instructions)

(e.g., frozen plan, aging workforce, improved operational

efficiencies that do not require replacing departing active

participants, or single causes that do not meet the reporting

threshold of a single-cause event)

Number of active participants at the date the event occurs and

at the beginning of the plan year in which the event occurred

Description of the plan's controlled group structure, including

the name of each controlled group member

Actuarial Information (see instructions)

Company financial information (see instructions)

Failure to Make Required Contributions

Due date and amount of the missed contribution

Due date and amount of the next payment due

Due date and amount of all contributions nottimely made and not

reported on the last Schedule SB filed

Date and amount of any contribution(s) made related to the

missed contribution(s)

Evidence of any amount paid related to the missed contribution

(cancelled check, wire transfer, asset statement)

Reason contribution was not made by due date

Description of the plan's controlled group structure, including the

name of each controlled group member

Name of each plan maintained by any member of the plan’s

controlled group, its contributing sponsor(s) and EIN/PN

Actuarial Information (see instructions)

Company financial information (see instructions)

Inability to Pay Benefits When Due

Date of any missed benefit payment and amount of benefits due

Next date on which the plan is expected to be unable to pay

benefits,the amount of the projected shortfall, and the number of

plan participants expected to be affected

Amount of the plan’s liquid assets at the end of the quarter, and

the amount of its disbursementsforthe quarter

Name, address and phone number of plan trustee (and of any

custodian)

Most recent pension plan document(s)

Distribution to a Substantial Owner

Name, address and phone numberof person receiving the

distribution(s)

Amount, form and date of each distribution

Reason for distribution

Description of the plan’s controlled group structure, including

the name of each controlled group member

Actuarial Information (see instructions)

Company financial information (see instructions)

Transfer of Benefit Liabilities

Name, contributing sponsor, EIN/PN, and contact information of

transferee plan(s)

Description of the transferor and transferee's controlled group

structures, including the name of each controlled group member

Explanation of the actuarial assumptions used in determining the

value of benefit liabilities (and, if appropriate, plan assets)

transferred

Estimate of the assets, liabilities, and number of participants

whose benefits are transferred (liabilities and participantsshould

be broken down by status - active, term vested, and retirees)

Financial Information for the transferor and transferee's

controlled group (see instructions)

Actuarial Information (see instructions)

Change in Controlled Group

Description of the plan’s old and new controlled group structures,

including the name of each controlled group member

Name of each plan maintained by any member of the plan's old

and new controlled groups, its contributing sponsor(s) and EIN/PN

Financial Information forthe old and new controlled group (see

instructions)

Actuarial Information (see instructions)

Check box to indicate the item is attached. If not attached, explain in the Missing

Information section on next page.

INFORMATION REQUIRED TO BE FILED
PBGC Form10

Liquidation Application for Minimum Funding Waiver

Description of the plan's controlled group structure before and

after the liquidation, including the name of each controlled group

member

Operational status of each controlled group member (in Chapter 7

proceedings, liquidating outside of bankruptcy, on-going, etc.)

Name of each plan maintained by any member of the plan's

controlled group, its contributing sponsor(s) and EIN/PN

Actuarial Information (see instructions)

Company financial information (see instructions)

If the plan sponsor resolves to cease all revenue-generating

business operations, sell substantially all its assets, or otherwise

effect or implement its complete liquidation, also provide:

• Date on which such resolution was made

• Mostrecentpensionplandocument(s)

• Address of each controlled group member

• TheInternalRevenueServiceDetermination Letter indicating the

plan is a covered plan, if applicable

Extraordinary Dividend or Stock Redemption

Copy of waiver application, with all attachments

Minimumfunding projectionsforthenext 5 years(with andwithout

the waiver) including all details supporting the calculations and all

assumptions, to the extent not included inthe waiver application

Loan Default

Copy of the relevant loan documents (e.g., promissory note,

security agreement, loan agreement amendments and waivers)

Due date and amount of any missed payment

Copy of any written notice of default or any notice of

acceleration from lender, any notice of forbearance, or loan

agreement amendment or waiver

Description of any cross-defaults or anticipated cross-defaults

Description of the plan's controlled group structure, including

the name of each controlled group member

Actuarial Information (see instructions)

Company financial information (see instructions)

Insolvency or Similar Settlement

Date and amount of cash distribution(s) during fiscal year

Description, fair market value, and date or dates of any non-cash

distributions

Statement whether the recipient was a member of the plan's

controlled group

Description of the plan's controlled group structure, including

the name of each controlled group member

Actuarial Information (see instructions)

Company financial information (see instructions)

Name, address and phone number of any trustee, receiver or

similar person

Docket number of court filing and location of the court where any

relevant proceeding was or will be filed (if known)

Description of the plan’s controlled group structure, including the

name of each controlled group member

Name of each plan maintained by any member of the plan’s

controlled group, its contributing sponsor(s) and EIN/PN

Actuarial Information (see instructions)

Company financial information (see instructions)

Name and EIN of person making the distribution
PBGC Form10

FILING INFORMATION

REASON FOR LATE FILING OR EXTENSION CLAIMED

CERTIFICATION

If all the required information has not been submitted with this Form 10, you must explain below.

Date of Event Notice Due Date

Notice Filing Date (if late, explain below)

If filing is late or an extension is claimed, explain below. See the instructions for when an extension may be claimed for an Active Participant Reduction

event or a Liquidation event.

I certify that, to the best of my knowledge and belief, the information submitted in this filing 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.

Signature of Individual Submitting Form Name and Title of Individual Submitting Form

Telephone Number of Individual Submitting Form Employer of Individual Submitting Form

MISSING INFORMATION