Document No. 40.1 

APPENDIXC 

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 AUTOMOTIVE INDUSTRIES PENSION PLAN 

Response Item Description of item Page number 

number in application 

1. Does the application include an original signature of the plan sponsor 1.0; 

Yes or an authorized representative of the plan sponsor? See section 2.01 . 1.1.1 

Yes 2. Does the application include a description of the proposed benefit 2.0; 

suspension - calculated as if no other limitations apply - that includes: 2.1 .1-2.1.4 

• 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. 

Yes 3. Does the application include a penalties-of-perjury statement signed by an 3.0; 

authorized trustee on behalf of the board of trustees? See Section 2.03. 3.1.1 

Yes 4. Does the application include a statement, signed by an authorized trustee 4.0; 

on behalf of the board of trustees, acknowledging that the application and 4.1.1 

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 5.0 

and declining status and the supporting illustrations, including: 5.1.1-5.1 .15; 

• the plan-year-by-plan-year projections demonstrating 5.2.1 - 5.2.5 

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 . 

Yes 6. Does the application describe the assumptions used, including the 6.0; 

new entrant profile, the total contribution base units, and the average 6.1 .1-6.1.66 

contribution rates? See section 3.01 . 

Page 40.1 .1 
Yes 7. Does the application include the plan actuary's certification that the plan 7.0; 

is projected to avoid insolvency if the suspension takes effect and the 7.1.1-7.1.28; 

supporting illustrations, including: 7.2.1-7.2.68 

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

projected solvency during the relevant period, 

• a description of the assumptions used, including the new 

entrant profile, the total contribution base units, and the 

average contribution rates, 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 8.0; 

projected insolvency that includes the documentation set forth in section 5 8.1.1 

of the revenue procedure? See section 3.03. 

Yes 9. Does the application include a demonstration that the limitations on 9.0 

individual suspensions are satisfied, including calculations regarding: 9.1.1-9.1.2 

• the guarantee-based limitation, 9.2.1 - 9.2.43 

• the disability-based limitation, and 

• the age-based limitation? 

See section 4.01. 

Yes 10. Does the application include a demonstration that the proposed 10.0 

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 ). 

Yes 11 . Does the application include the required illustration utilizing stochastic 11.0 

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

appoint a retiree representative under§ 432(e)(9)(B)(v)(l) 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 12.0 

suspension is not 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. 

Yes 13. Does the application include a demonstration that the 13.0; 

proposed suspension is equitably distributed, including: 13.1.1 -13.1.4; 

• information on the effect of the suspension on the plan in the 13.2.1 

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 

• how any difference in treatment among categories or groups of 

individuals results from a reasonable application of the 

relevant factors? 

See section 4.04. 

Page 40.1.2 
Yes 14. Does the application include a copy of the notices (excluding personally 14.0 

identifiable information) that meet the requirements under§ 14.1.1-14.1.6 

432(e)(9)(F)? See section 4.05(1 ). 14.2.1-14.2.43 

Yes 15. Does the application include a description of the efforts that are being 15.0; 

taken to contact participants, beneficiaries in pay status, and 15.1.1-15.1.2 

alternate payees? See section 4.05(2). 

16. Does the application describe the steps the plan sponsor has taken to 16.0 

Yes ensure 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 17.0; 

obligation to contribute under the Plan and each employee organization 17.1.1-17.1.4; 

representing participants under the Plan? See section 4.05(4). 17.2.1 

Yes 18. Does the application include information on past and current 18.0; 

measures taken to avoid insolvency? See section 5.01 . 18.1.1 - 18.1.2 

Yes 19. Does the application include the plan information required by 19.0; 

section 5.02? 19.1.1-19.1.5; 

19.2.1 -19.2.3 

Yes j2o. Does the application describe how the plan sponsor took into account - 20.0; 

or did not take into account- the factors listed in section 5.02 in the 20.1 .1-20.1.3 

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- 21.0; 

or did not take into account- in the determination that all reasonable 21.1 .1 

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. 

Yes 122. Does the application include a discussion of any other factors the plan 22.0 

sponsor 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, excluding the 23.0; 

information regarding the statement in opposition, the individualized 23.1.1 - 23.1.6 

estimate, and the voting procedures? See section 6.01. 

Yes 24. Does the application indicate whether the plan sponsor is requesting 24.0 

approval from PBGC of a proposed partition under section 4233 of 

ERISA? See section 6.02. 

25. If the answer to item 24 is yes, does the application specify the effective 25.0 

N/A 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. 

Page 40.1.3 
Yes 26. Does the application describe the plan's experience with certain critical 26.0; 

assumptions, including a disclosure for each of the 10 plan years 26.1.1 - 26.1 .23 

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. 

Yes 27. Does the application include deterministic projections of the sensitivity of 27.0 

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 

appjication? See section 6.04. 

Yes 128. Does the plan include deterministic projections for each year in 28.0 

the 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 29.0; 

receives the Treasury Department's final authorization to suspend and 29.1.1 

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 determine that both all reasonable measures 

continue to be taken to avoid insolvency and that 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 6.06. 

Yes 30. Does the application indicate whether the plan is a plan described in 30.0 

§ 432(e)(9)(D)(vii) 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 31.0 

information, 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 32.0 

information? See section 7.02. 

Page 40 .1.4 
Yes 33. Does the application include the required retiree representative 

information (if applicable)? See section 7.03. 

Yes 34. Does the application include the required enrolled actuary 

information? See section 7.04. 

Yes 35. 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 B. 

Yes 36. Does the application include: 

• the required plan documents, 

• any recent amendments, 

• the summary plan description (SPD), 

• the summary of material modifications, and 

• the most recent determination letter? 

See section 7.06. 

Yes 37. Does the application include the required excerpts from the relevant 

collective bargaining agreements and side agreements? See section 

7.07. 

Yes 38. Does the application include the required excerpts from the most 

recently filed Form 5500? See section 7.08. 

Yes 39. Does the application include the most recently updated 

rehabilitation plan? See section 7.09. 

Yes f40. Does the application include this checklist, completed and placed on 

top of the application? See section 7.10. 

f41. If the application is being submitted for resubmission review, does 

N/A the application include: 

• a statement that the application is being submitted for 

resubmission review, and 

• the date on which the Treasury Department gave approval to 

submit an application for resubmission review? 

See section 8. 

Title or Authority 

Date 9/27/16 

Chairman, Authorized Trustee on behalf of the 

Board of Trustees of the Automotive 

Industries Pension Plan 

Typed or printed name of person signing checklist 

James H. Beno 

Page 40.1.5 

33.0 

34.0 

34.1.1 

35.0; 

35.1.1 -35.1.2 

36.0; 

36.1.1 - 36.1.60; 

36.2.1 - 36.2.55; 

36.3.1 - 36.3.3 

37.0; 

37.1.1-

37.1 .1006 

38.0; 

38.1.1 - 38.1.2 

39.0; 

39.1 .1 - 39.1.6; 

39.2.1 - 39.2.6 

40.0 

40.1.1-40.1.5 

41.0 

Redacted by the U.S. Department of the Treasury