Post-Distribution Certification PBGC Form 501 Approved OMB 1212-0036

Expires 3/31/2026

for Standard Termination

PART I. IDENTIFYING INFORMATION

Check here if you previously filed a Form 501 for this plan. If checked, provide dates of filing(s): 

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

Attach copy of the most recent complete plan document and any amendments to it.

1c 3-digit plan number (PN)

2 PBGC case number 8-digit Case #

PART II. DISTRIBUTION INFORMATION

3a Last distribution date in satisfaction of plan benefits (MM/DD/YYYY)

3b Date of receipt of IRS determination letter (MM/DD/YYYY)

4 Were participants and beneficiaries provided with the name and address of the insurer(s)

no later than 45 days before the date of distribution? Yes No N/A

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

6a 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 No N/A

6b If “Yes” to 6a, enter the latest date the annuity contract, certificate, or written notice

was provided to each participant and beneficiary receiving benefits:

If “No” or “N/A”, see instructions

(MM/DD/YYYY)

7a Complete name of record of insurer(s) from whom annuity contracts, if any, have been

 purchased 

7b Annuity Contract Number(s)

8a Name and address of contact for location of plan records 8b Telephone number

9 Summary of distribution of plan benefits. Attach distribution documents (see instructions).

Type of Benefit (1) # of Participants or Beneficiaries (2) Total Cost/Value

a Annuities purchased

(1) For Non-Missing Participants

(2) For Missing Participants

(3) Total $ 

b Lump sums (including direct transfers)

(1) Consensual

(2) Nonconsensual (i.e., mandatory cash-outs)

(3) Total

$

$ 

$ 

c Benefits transferred to PBGC for Missing Participants

(1) Benefits transferred

(2) Other amounts due PBGC (see instructions)

$

$

d No Distribution

e TOTAL (see instructions) $

PART III. PLAN ADMINISTRATOR CERTIFICATION

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

calculated and valued correctly in accordance with applicable provisions of ERISA and the regulations thereunder; (2) all plan benefits (through 

priority category 6 under ERISA Section 4044 and 29 CFR Part 4044) under the plan have been satisfied; (3) plan assets in excess of those 

needed to satisfy all plan benefits (through priority category 6 under ERISA Section 4044 and 29 CFR Part 4044) have been or will be distributed 

in accordance with applicable provisions of ERISA and the regulations thereunder; and (4) 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 executing this document, I certify that the foregoing is true and correct, and 

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 company name and address (Address should include room or suite no.) Telephone number

E-mail address (optional)

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