APPENDIX D 

CHECKLIST - IS THE SUBMISSION COMPLETE? 

Instructions. The application must include a completed checklist placed on top of the application. This will help ensure that the 

application is complete. Answer each question in the checklist by circling Y for yes, N for no or N/A for not applicable, as 

appropriate, in the blank next to the item. Also insert in the appropriate blank next to each item the page number or numbers 

where the item appears in the application. 

Application for approval of benefit suspension for Local 805 Pension and Retirement Plan

Response

Item 

number Description of item

Page number 

in application

Yes 

 

1. Does the application include an original signature of the plan sponsor or an 

authorized representative of the plan sponsor? See section 2.01 of this revenue 

procedure. 

2 

 

Yes 

 

2. Does the application include a description of the proposed benefit suspension - 

calculated as if no other limitations apply - that includes: 

• the suspension’s effective date (and its expiration date, if applicable), 

• whether the suspension provides for different treatment of participants 

and beneficiaries, 

• a description of the different categories or groups of individuals affected, 

and 

• how the suspension affects these individuals differently? 

See section 2.02 of this revenue procedure. 

3 

 

Yes 

 

3. Does the application include a penalties-of-perjury statement signed by an 

authorized trustee on behalf of the board of trustees? See Section 2.03 of this 

revenue procedure. 

4 

 

Yes 

 

4. Does the application include a statement, signed by an authorized trustee on behalf 

of the board of trustees, acknowledging that the application and the application’s 

supporting material will be publicly disclosed on the Treasury Department’s 

website? See section 2.04 of this revenue procedure. 

5 

 

Yes 

 

5. Does the application include the plan actuary’s certification of critical and declining 

status and the supporting illustrations, including: 

• the plan-year-by-plan-year projections demonstrating projected 

insolvency during the relevant period, and 

• separately identifying the available resources (and the market value of 

assets and changes in cash flow) during each of those years? 

See section 3.01 of this revenue procedure. 

6-7 

 

Yes 

 

6. Does the application include the plan actuary’s certification that, taking into account 

the proposed suspension and, if applicable, a proposed partition, the plan is 

projected to avoid insolvency if the suspension takes effect, and the supporting 

illustrations, including: 

• the plan-year-by-plan-year projections demonstrating projected solvency 

during the relevant period, 

• separately identifying the available resources (and the market value of 

assets and changes in cash flow) during each of those years? 

See section 3.02 of this revenue procedure. 

8-15 

 

Yes 

 

7. Does the application include the plan sponsor’s determination of projected 

insolvency that includes the documentation set forth in section 5 of the revenue 

procedure? See section 3.03 of this revenue procedure. 

16-20 

 
Response

Item 

number Description of item

Page number 

in application

Yes 

 

8 Does the application include a demonstration that the limitations on individual 

suspensions are satisfied, including a description of each benefit based on disability, 

as defined under the plan, that is paid to an individual under the plan (without 

regard to whether the disability benefits are available to newly disabled participants) 

and calculations regarding: 

• the guarantee-based limitation, 

• the disability-based limitation, 

• the age-based limitation, taking into account the guarantee-based limitation, and 

• if applicable, the age-based limitation taking into account both the guaranteebased limitation and the disability-based limitation? 

See section 4.01 of this revenue procedure. 

21-30 

 

Yes 

 

9. Does the application include a demonstration that the proposed suspension is 

reasonably estimated to achieve the level necessary to avoid insolvency for the 

extended period, including illustrations regarding the plan’s solvency ratio and 

available resources? See section 4.02(1) of this revenue procedure. 

31-38 

 

N/A 10. Does the application include an illustration that the proposed suspension is 

reasonably estimated to achieve the level necessary to avoid insolvency for the 

extended period utilizing stochastic projections? (This illustration is optional if the 

plan is not required to appoint a retiree representative under § 432(e)(9)(B)(v)(I).) 

See section 4.02(2) of this revenue procedure. 

N/A 

 

N/A 11. Does the application include a demonstration that the proposed suspension is not 

projected to materially exceed the level necessary to avoid insolvency, including: 

• the plan-year-by-plan-year projections demonstrating projected 

insolvency during the relevant period, and 

• a separate identification of the available resources (and the market value 

of assets and changes in cash flow) during each of those years? 

 

See section 4.03 of this revenue procedure 

39 

 

N/A 12. Does the application include a demonstration that the proposed suspension is 

equitably distributed, including: 

• information on the effect of the suspension on the plan in the aggregate, 

• information on the effect of the suspension for different categories or groups, 

• a list of the factors taken into account, 

• an explanation of why none of the factors listed in § 432(e)(9)(D)(vi) were taken 

into account (if applicable), 

• for each factor taken into account that is not one of the factors listed in § 

432(e)(9)(D)(vi), an explanation why the factor is relevant, and 

• an explanation of how any difference in treatment among categories or groups of 

individuals results from a reasonable application of the relevant factors? 

See section 4.04 of this revenue procedure. 

39 

 

Yes 13. Does the application include a copy of the notices (excluding personally identifiable 

information) that meet the requirements under § 432(e)(9)(F)? See section 4.05(1) 

of this revenue procedure. 

Appendix A 

 

Yes 14. Does the application include a description of the efforts that are being taken to 

contact participants, beneficiaries in pay status, and alternate payees? See section 

4.05(2) of this revenue procedure. 

39 

 

Yes 15. Does the application describe the steps the plan sponsor has taken to ensure that 

notices delivered electronically are reasonably accessible to the recipients? See 

section 4.05(3) of this revenue procedure. 

39 

 
Response

Item 

number Description of item

Page number 

in application

Yes 16. Does the application include a list of each employer who has an obligation to 

contribute under the plan and each employee organization representing participants 

under the plan? See section 4.05(4) of this revenue procedure. 

39-40 

 

Yes 17. Does the application include information on past and current measures taken to 

avoid insolvency? See section 5.01 of this revenue procedure. 

41 

 

Yes 18. Does the application include information regarding the plan factors described in § 

432(e)(9)(C)(ii), for the past 10 plan years immediately preceding the plan year in 

which the application is submitted? See section 5.02 of this revenue procedure. 

41 

 

Yes 19. Does the application describe how the plan sponsor took into account – or did not 

take into account – the factors listed in section 5.02 of this revenue procedure in the 

determination that all reasonable measures were taken to avoid insolvency? See 

section 5.03 of this revenue procedure. 

41 

 

Yes 20. Does the application describe how the plan sponsor took into account - or did not 

take into account - in the determination that all reasonable measures have been 

taken to avoid insolvency, the impact of: 

• benefit and contribution levels on retaining active participants and bargaining 

groups under the plan, and 

• past and anticipated contribution increases under the plan on employer attrition 

and retention levels? 

See section 5.03 of this revenue procedure. 

41 

 

Yes 21. Does the application include a discussion of any other factors the plan sponsor took 

into account including how and why those factors were taken into account? See 

section 5.04 of this revenue procedure. 

41 

 

Yes 22. Does the application include a copy of the proposed ballot, excluding the 

information regarding the statement in opposition, the individualized estimate, and 

the voting procedures? See section 6.01 of this revenue procedure. 

42 

 

Yes 23. Does the application indicate whether the plan sponsor is requesting approval from 

PBGC of a proposed partition under section 4233 of ERISA? See section 6.02 of 

this revenue procedure. 

42 

 

Yes 24. If the answer to item 23 is yes, does the application specify the effective date of the 

proposed partition and include a plan-year-by-plan-year projection of the amount of 

the reduction in benefit payments attributable to the partition? See section 6.02 of 

this revenue procedure. 

42-46 

 

Yes 

 

25. Does the application include: 

• a description of each of the assumptions used in the projections required 

under sections 3.01, 3.02, 4.02(1), 4.02(2), and 4.03 of this revenue 

procedure, 

• supporting evidence for the selection of those assumptions, and 

• an explanation of any differences among the assumptions used for various 

purposes? 

See section 6.03 and Appendix B of this revenue procedure. 

Appendix B 

 

Yes 26. Does the application describe the plan’s experience with certain critical 

assumptions, including a disclosure for each of the 10 plan years immediately 

preceding the application that separately identifies: 

• the total contributions, 

• the total contribution base units, 

• the average contribution rates, 

• the withdrawal liability payments, and 

48 
Response

Item 

number Description of item

Page number 

in application

• the rate of return on plan assets? 

See section 6.04 of this revenue procedure. 

 

Yes 27. Does the application include deterministic projections of the sensitivity of the plan’s 

solvency ratio throughout the extended period by taking into account the more 

conservative assumptions of investment experience and future contribution base 

units than assumed elsewhere in the application? See section 6.05 of this revenue 

procedure. 

49-53 

 

Yes 28. Does the plan include deterministic projections for each year in the extended period 

of: 

• the value of plan assets, 

• the plan’s accrued liability, and 

• the plan’s funded percentage? 

See section 6.06 of this revenue procedure. 

54-61 

 

Yes 29. Does the application include the plan sponsor’s representation that, if it receives the 

Treasury Department’s final authorization to suspend and then chooses to 

implement the suspension, it will also amend the plan: 

• to provide that the suspension will cease upon the plan sponsor’s failure 

to maintain a written record of its annual determination that (i) all 

reasonable measures continue to be taken to avoid insolvency and (ii) the 

plan would not be projected to avoid insolvency without a suspension, 

• to require that any future benefit improvements must satisfy 

§432(e)(9)(E), and 

• to specify that the plan sponsor will not modify these amendments, 

notwithstanding any other provision of the plan document? 

See section 6.07 of this revenue procedure. 

62 

 

Yes 30. Does the application indicate whether the plan is a plan described in 

§432(e)(9)(D)(vii) and, if it is, how that is reflected in the proposed benefit 

suspension? See section 6.08. 

63 

 

Yes 31 Does the application include a narrative statement of the reasons the plan is in 

critical and declining status? 

See section 6.09. 

63 

 

Yes 32. Does the application include the required plan sponsor identification and contact 

information? See section 7.01 of this revenue procedure. 

64 

 

Yes 33. Does the application include the required plan identification information? See 

section 7.02 of this revenue procedure. 

64 

 

Yes 34. Does the application include the required retiree representative information (if 

applicable)? See section 7.03 of this revenue procedure. 

64 

 

Yes 35. Does the application include the required enrolled actuary information? See section 

7.04 of this revenue procedure. 

64 

 

Yes 36. Does the application include a designation of power of attorney for each authorized 

representative who will represent the plan sponsor in connection with the 

application? See section 7.05 and Appendix C of this revenue procedure. 

64 and 

Appendix C