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Standard Termination PBGC Schedule EA-S

Certification of Sufficiency (PBGC Form 500)

Approved OMB 1212-0036 

Expires 3/31/2026

PART I. IDENTIFYING INFORMATION

1a Plan Name 1b 9-digit employer identification number (EIN)

1c 3-digit plan number (PN)

PART II. CODE SECTION 412(e)(3) PLANS

Is this plan a Code section 412(e)(3) plan?

No: the Enrolled Actuary must complete Parts III and IV. Item 3 and Part V should not be completed.

Yes: item 3 and Part III must be completed. Depending upon who completes Part III, either Part IV or Part V must be completed and 

signed by the Plan Administrator or Enrolled Actuary as appropriate.

3a Enter name (full official name of record) and address of the insurer

(Address should include room or suite no.)

3b Telephone Number

PART III. PLAN SUFFICIENCY

4 Proposed distribution date (MM/DD/YYYY)

5 Is the value of plan assets projected to be sufficient as of the proposed distribution date to 

provide all plan benefits? If “No,” the plan cannot terminate in a standard termination.

Yes No

6 Estimated fair market value of plan assets as of the proposed distribution date $

7 Estimated present value of plan benefits as of the proposed distribution date $

8 Estimated total amount of residual assets $

9 Estimated amount of residual assets to be distributed to the employer $

10 Estimated amount of residual assets to be distributed to participants and beneficiaries $

11 Has the plan ever required employee contributions? Yes No

12 If the amount in item 9 is $1 million or more and if any benefits are to be distributed other

than through the purchase of annuity contracts, attach a statement showing interest 

rate/structure used to value the benefits.

PART IV. ENROLLED ACTUARY CERTIFICATION

I, the Enrolled Actuary, certify that: (1) I have reviewed all plan documents and plan and participant data, and applied all relevant provisions of 

ERISA and the Internal Revenue Code and regulations promulgated thereunder; (2) to the best of my knowledge and belief, this plan’s assets 

equal or exceed the value of its plan benefits as of the proposed distribution date; and (3) to the best of my knowledge and belief, the 

information contained in this schedule 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.

Enrolled Actuary’s company’s name and address 

(Address should include room or suite no.)

Enrolled Actuary’s signature Date

Enrolled Actuary’s Name (Print or type)

Enrollment Number

Telephone Number

E-mail address (optional)

PART V. PLAN ADMINISTRATOR CERTIFICATION FOR CODE SECTION 412(e)(3) PLANS

I, the Plan Administrator, certify that, to the best of my knowledge and belief: (1) this plan complies with section 412(e)(3) of the Internal Revenue 

Code and regulations promulgated thereunder; (2) I have reviewed all plan documents and plan and participant data, and applied all relevant 

provisions of ERISA and the Code and regulations promulgated thereunder; (3) this plan’s assets equal or exceed the value of its plan benefits as 

of the proposed distribution date; and (4) the information contained in this schedule 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.

Plan Administrator’s signature Date Printed name and title of Plan Administrator