Appendix C 

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 Bricklayers and Allied Craftworkers Local 

5 New York Retirement Fund Pension Plan 

Response Item Description of item Page number 

number in application 

Yes I. Does the application include an original signature of the plan sponsor or an 2 

authorized representative of the plan sponsor. See section 2.0 I. 

Yes 2. Does the application include a desctiption of the proposed benefit 3 

suspension- calculated as if no other limitations apply- that includes: 

• the suspension's effective date (and its expiration date, if 

applicable), 

• a description of the different categories or groups of individuals 

affected, and 

• how the suspension affects these individuals differently. See 

section 2.02. 

Yes 3. Does the application include a penalties-of-petjury statement signed by an 4 

authorized trustee on behalf of the board of trustees. See Section 2.03. 

Yes 4. Does the application include a statement, signed by an authmized trustee on 5 

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. 

Yes 5. Does the application include the plan actuary's certification of critical and 6-9 

declining status and the supporting illustrations, including: 

• the year-by-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 3.0 I. 

Yes 6. Does the application describe the assumptions used. See section 3.0 I. 7 

Z:\009 5\p\Misc Con\20 16\Suspension\Application\Attachments\Appendix C Checklist 5 15.docx 
Yes 7. Does the application include the plan actuary's certification that the plan is 10 

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

illustrations, including: 

• the year-by-year projections demonstrating projected solvency 

during the relevant pe1iod and 

• separately identifying the available resources (and the market value 

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

See section 3.02. 

Yes 8. Does the application include the plan sponsor's determination of projected 18 

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

procedure. See section 3.03. 

Yes 9. Does the application include a demonstration that the limitations on 22 

individual suspensions are satisfied, including calculations regarding: 

• the guarantee-based limitation, 

• the disability-based limitation, and 

• the age-based limitation. 

See section4.01. 

Yes 10. Does the application include a demonstration that the proposed suspension is 27 

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 ). 

N/A 11. Does the application include the required illustration utilizing stochastic NIA 

projections. (This illustration is not required if the plan is not required to 

appoint a retiree representative under § 432( e)(9)(B)(v)(I) and stochastic 

projections were not used in making the required determination.) See section 

4.02(2). 

Yes 12. Does the application include a demonstration that the proposed suspension is not 35 

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

illustrations regarding the plan's solvency ratio and available resources. See 

section 4.03. 

N/A 13. Does the application include a demonstration that the proposed 36 

suspension is equitably distlibuted, including 

• 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), and 

• how any difference in treatment among categories or groups of 

individuals results from a reasonable application of the relevant 

factors. 

See section 4.04. 

Yes 14. Does the application include a copy of the actual notices (including Appendix A 

redacted sample calculations) that meet the requirements under 

§ 432(e)(9)(F). See section 4.05(1). 

Yes 15. Does the application include a description of the efforts that are being taken 36 

to contact pmiicipants, beneficiaries in pay status, and altemate payees. See 

section 4.05(2). 

2 
Yes 16. Does the application desctibe the steps the plan sponsor has taken to ensure 36 

that notices delivered electronically are reasonably accessible to the recipients. 

See section 4.05(3) 

Yes 17. Does the application include a list of each employer who has an obligation to 36-37 

contribute under the Plan and each employee organization representing 

participants under the Plan. See section 4.05(4). 

Yes 18. Does the application include infonnation on past and current measures taken 38 

to avoid insolvency. See section 5.01. 

Yes 19. Does the application include the plan information required by section 5.02. 38 

Yes 20. Does the application describe how the plan sponsor took into account or did not 38 

take into account - the factors listed in section 5.02 in the determination that all 

reasonable measures were taken to avoid insolvency. See section 5.03. 

Yes 21. Does the application describe how the plan sponsor took into account- or did not 38 

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 contlibution increases under the plan on 

employer attrition and retention levels. 

See section 5.03. 

Yes 22. Does the application include a discussion of any other factors the plan sponsor 38 

took into account including how and why those factors were taken into account. 

See section 5.04. 

Yes 23. Does the application include a copy of the proposed ballot. See section 6.01. 39 

Yes 24. Does the application indicate whether the plan sponsor is requesting approval 39 

from the PBGC of a proposed pm1ition under section 4233 of ERISA. See 

section 6.02. 

Yes 25. If the answer to item 24 is yes, does the application specify the effective date of 39-44 

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

reduction in benefit payments attributable to the partition. See section 6.02. 

Yes 26. Does the application describe the plan's experience with certain critical 45 

assumptions, including a disclosure for each of the I 0 plan years immediately 

preceding the application that separately identifies 

• total contributions, 

• total contribution base units, 

• average contribution rates, 

• withdrawal liability payments, and 

• the rate of return on plan assets . 

See section 6.03. 

3 
Yes 27. Does the application include detenninistic projections of the sensitivity of the 46-50 

plan's solvency ratio throughout the extended period by taking into account 

more conservative assumptions of investment experience and future contribution 

base units than assumed elsewhere in the application. See section 6.04. 

Yes 28. Does the plan include deterministic projections for each year m the 51-57 

extended period of 

• the value of plan assets, 

• the plan's accrued liability, and 

• the plan's funded percentage . 

See section 6.05. 

Yes 29. Does the application include the plan sponsor's representation that, if it 58 

receives the Treasmy Depmtment's final authorization to suspend and then 

chooses to implement the suspension, it will also amend the plan 

• to indicate that the suspension will cease upon the plan sponsor's 

failure to dete1mine that both all reasonable measures continue to be 

taken to avoid insolvency and that the plan is projected to become 

insolvent 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 6.06. 

Yes 30. Does the application indicate whether the plan is a plan described in 59 

§ 432(e)(9)(D)(vii)(III) and, if so, how is that fact reflected in the proposed 

benefit suspension. See section 6.07. 

Yes 31. Does the application include the required plan sponsor infonnation, 60 

including 

• name 

• address 

• telephone number 

• email address 

• fax number 

• employer identification number (EIN) and 

• 3-digit plan number (PN) . 

See section 7.01. 

Yes 32. Does the application include the required plan identification infonnation. See 60 

section 7.02. 

Yes 33. Does the application include the required retiree representative 60 

information (if applicable). See section 7.03. 

Yes 34. Does the application include the required enrolled actumy infonnation. See 60 

section 7.04. 

4 
Yes 35. Does the application include a designation of power of attomey for each 60 and 

authoti zed representative who will represent the plan sponsor in connection Appendix B with the application. See section 7.05 and Appendix B. 

Yes 36. Does the application include 61 

• the required plan documents, 

• any recent amendments, 

• the summary plan description (SPD), 

• the summaty ofmatetial modifications, and 

• the most recent determination letter. 

See section 7.06. 

Yes 37. Does the application include the required excerpts fi·om the relevant collective 61 

bargaining agreements and side agreements. See section 7.07. 

Yes 38 Does the application include the required excerpts fi·om the most recently 61 

filed Fonn 5500. See section 7 .08. 

Yes 39. Does the application include the most recently updated rehabilitation plan. See 61 section 7.09. 

Yes 40. Docs the application include this chcckl ist, completed and placed on top of the Appendix C 

application. See section 7.10. 

Signature: 

Date: 

Title or uthor ty --/ _v_...-1_(Z_ -,L _ _ _ _ _ 

Printed Name: _c_· l_Z-4_ 1__:. 0 __ \Ic_o_e_-._L_/L_r:;-_-!C_ 

5