PBGC Form 10-Advance OMB

Control No. 1212-0013 Expires 

XX/XX/XX

ADVANCE NOTICE 

OF REPORTABLE EVENTS 

IDENTIFYING INFORMATION 

Plan Name Name / title of individual to contact at Filer 

Name of contributing sponsor Email address of contact 

Street address of contributing sponsor Street address of contact 

City, state, Zip City, State, Zip 

EIN of contributing sponsor Plan number Telephone number of contact Ext 

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

Application for minimum funding waiver 

Loan Default 

Insolvency or similar settlement

Change in controlled group 

Liquidation 

Extraordinary dividend or stock redemption 

Transfer of benefit liabilities 

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 200 information should be submitted to PBGC using the e-filing portal: 

efilingportal.pbgc.gov. For questions regarding this form, contact (202) 229-4070 or form200@pbgc.gov.

For Illustrative Purposes Only
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PBGC Form 10-Advance 

Check box to indicate the item is attached. If not attached, explain on next page. 

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 

Actuarial Information (see instructions) 

Company financial information (see instructions) 

Liquidation 

Description of the plan's old and new controlled group 

structure, including the name of each controlled group 

member 

Operational status of each controlled group member (in 

Chapter 7 proceedings, liquidation outside of bankruptcy,

on-going, etc.) 

Name of each plan maintained by any number 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, 

provide:

• Date on which such resolution was made

• Most recent pension plan document(s)

• Address of each controlled group member

• The Internal Revenue Service Determination Letter 

indicating the plan is a covered plan, if applicable

Extraordinary Dividend or Stock Redemption 

Application for Minimum Funding Waiver 

Name and EIN of person making the distribution 

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 

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 

Actuarial Information (see instructions) 

Financial Information for the transferor and transferee's 

controlled group (see instructions) 

Note: To the extent this information is filed with the IRS Form 

5310A, PBGC will accept a copy of that filing. 

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 acceleration from 

lender, any notice of forbearance, or loan agreement 

amendment or waiver 

Description of any cross-defaults or anticipated crossdefaults 

Description of the plan's controlled group structure, 

including the name of each controlled group member 

Company financial Information (see instructions)

Actuarial Information (see instructions) 

Insolvency or Similar Settlement 

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) 

Copy of waiver application, with all attachments

Minimum funding projections for the next 5 years (with and without 

the waiver) including all details supporting the calculations and all 

assumptions,to the extent not included in the waiver application 

INFORMATION REQUIRED TO BE FILED

For Illustrative Purposes Only
 

 

 

 

 

 

PBGC Form 10-Advance 

Date of Event Notice Due Date 

Notice Filing Date (if late, explain below) Filing Extension Claimed (if any, explain below) 

REASON FOR LATE FILING OR EXTENSION CLAIMED If filing late or extension is claimed, explain below.

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 

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

below.

For Illustrative Purposes Only