Form 5310 (Rev. 7-85)

Page 5

20 (i)

i)
(k)
10)
(m)
(n)
(0)

(iii) Other .

Liabilities and Net Assets UM / MI)

Accounts and notes payable—

7/

Wf

(i) Past due benefits .

(ii) Employer .

Accrued expenses

Mortgages payable .

Acquisition indebtedness .

Other liabilities.

Total liabilities (add lines @) through (m).

Net assets available to pay benefits (subtract line (n) from line (hy

Complete This Part If You Checked Reason For Filing C or D and Checked “Yes” on Line 6(a).
If you checked Reason for filing C or D and ‘‘Not determined” on line 6(a), completion of this part is optional. However, if you do not
complete this part, you must file the plan document, any amendments to the plan document, and the IRS determination letter(s) for
the plan as described for lines 22(b), (c) and (g). If PBGC later determines that the termination insurance program covers the plan, you

must file the remainder of the information required by this Part (see Part IV instructions).

21 (a)

Name(s) of labor organization(s) representing plan participants (b) Telephone number

¢

)

Address (number and street) (c) Name of principal officer

City or town, state, and ZIP code (d) Title of principal officer

22 Indicate the applicability of items (a) through (i) by checking the appropriate column. Attach each item
that is applicable (see instructions):

(a)
(b)
(c)
(4)
(e)
(f)
(e)
(h)
(i)

Power of attorney. File 2 copies if you are filing ‘‘one-stop’’ (see General Instruction H)
Copy of executed plan document . . .

Copy of executed amendment(s) to the plan document .

Copy of executed group annuity or group insurance contract(s)

Copy of executed trust agreement(s) .

Copy of executed collective bargaining agreement(s)

Copy of IRS determination letter(s)

Copy of the most recent actuarial report. .
Copy of the most recent financial statement of plan assets |

Applicable

Not
applicable

23 Indicate the sufficiency of plan assets (see instructions):

(a)

(b)

(c)

(da)

(e)

Are any participants entitled to receive benefits assigned to categories 1 through 4 under ERISA
section 4044? .

If Yes," complete (b); if “No," " enter N/Ai in ), ©. , and ©.

Do you estimate that plan assets (excluding any amount described in (d) below) are adequate to provide
all the benefits assigned to categories 1 through 4 on the proposed date of plan termination? .

If "Yes," enter N/A in (c) and complete item (d); if ‘'No,"’ complete (c) and (d).

Indicate the estimated amount by which the value of benefits in categories 1 through 4 exceeds
the value of plan assets on the proposed date of plan termination » $ ______________...--------
Is the employer making a commitment (in the form prescribed in the PBGC regulation on determination
of plan sufficiency) to pay, on or before the date assets are distributed, the amount needed to provide all
benefits in categories 1 through 4? :

If “Yes,” attach a signed copy of the commitment; if "No" complete ©.

Has the plan sponsor paid or does the plan sponsor intend to pay employer liability as prescribed in
the PBGC regulation on employer liability before PBGC’'s request for payment? woe
Note: Interest on employer liability will accrue from the date of plan termination.

Yes

No

WT,

YI

_

Ms

24 = Submit participant data schedules in the format shown in the instructions for the following groups of participants:

(a)
(b)
(c)

Retired participants and beneficiaries receiving benefits from the plan;
Participants separated from service not yet receiving vested benefits from the plan; and
All other participants with vested or non-vested accrued benefits.



Form 5310 (Rev. 7-85)

Page 4

17

10)

@

(kK)
10}

(m)
(n)

(v) If this is a defined benefit plan, is it intended or is it a fact that any or all of the participants in the
terminating plan will be covered by a new or existing defined benefit plan of the employer?
(vi) If "Yes,"’ does the new plan give full prior service credit for vesting and entitlement purposes?
(vii) If (i) or (v) is “Yes,” then
(A) Has a Form 5300 been submitted for a determination letter for the other plan(s) involved?
If “Yes,"’ attach plan numbers.
(B) Has the IRS granted approval for a change in funding method in connection with this termina-
tion for the other plan(s) involved? If ‘‘Yes,”’ attach a copy of such approval letter(s) . :
(viii) Has the employer previously received a reversion of assets upon termination of a defined benefit
plan in the past 15 years? If '‘Yes,"’ attach explanation .
(in) \f the plan was ever a contributory plan, were distributions of employee contributions made within
the 12 month period immediately preceding the date of plan termination? :
Is this plan or trust currently under examination or is any issue relating to this plan or trust ‘currently
pending before the Internal Revenue Service, the Department of Labor, the Pension Benefit Guaranty
Corporation or any court? If ‘Yes,"’ attach a statement naming the agency(s) and/or court and briefly
describe the issues . . . wee
Did any plan participant during the ‘current plan year or in the 5 prior plan years receive a lump-st ‘sum
distribution (see instructions) or have an annuity contract purchased by the plan from an insurance
company on his or her behalf? .
If “Yes,” state the largest amount so distributed orapplied to purchase a an annuity ‘contract $
Does the plan have ESOP/TRASOP features? . .
Were plan benefits not required to be provided in annuity form valued a as of the proposed distribution
date in accordance with PBGC Regulation 29 CFR 2619.26(b) and (c)? (Attach an explanation of how
lump sum values were determined.) . . .
Does the plan require appropriate written participant and/or ‘spousal consent(s) for distributions where
the present value of the nonforfeitable accrued benefit exceeds $3,500? (See instructions.)
In the case of a distribution from a defined benefit plan, is the interest rate used to determine the
present value of the accrued benefit and the amount to be distributed not greater than the PBGC
interest rate for valuing immediate annuities?

Yes | No

Not
Applicable

Mh

Mi

18

Defined contribution plans (other than money purchase plans) such as profit: sharing, “stock | Bonus, or other such
plans where forfeitures are credited to individual account balances, enter the information for the current plan year

Current year

id the 5 he followit hedule:
and the 5 prior plan years on the following schedule: 19.19... , 19... 19... , 19. 19,
(a) Employer contributions
(b)  Forfeitures
(c) Attach a statement explaining bases on which forfeitures were allocated.
19 Indicate how distributions will be made on termination (check applicable box(es)):
(a) O Lump-sum distribution (b) O Annuitycontract (c) [1 Periodic payments from trust
(d) (1) Transfer of assets and liabilities to another plan (e) [) Other (specify) >
20 Statement of net assets available to pay benefits as of the proposed date of plan termination. Read specific instruction 20, and if you

chet

(a)
(b)

(c)

(a)

(e)
0)

(g)
(h)

Mi

cked Reason for Filing C or D, read specific instruction 25(c) before completing this item.
Assets
Cash and cash equivalents
Receivables—
(i) Employer contributions
(ii) Other .

Party-in-interest investments —

(i) Loans to employer .

(ii) Employer securities

(iii), Other

Other investments—

(i) Government securities
(ii) Pooled funds/mutual funds .

(iii), Corporate (debt and equity instruments) :

(iv) Realestate and mortgages .
(v) Other . .

Buildings and other depreciable property .

Unallocated insurance contracts

Other assets

Total assets (add lines (a) through (g)) .



Form 5310 (Rev. 7-85) Page 6
25 Indicate the information you are filing with this notice by checking one of the following boxes (see instructions):
(a) © lam filing a complete Form 5310 including required attachments.
(b) 1 lam filinga complete Form 5310 except the information showing plan assets allocated to participants (see note below).
(c) (© lam filing a complete Form 5310 except plan asset information (line 20) and participant data schedules (line 24). | will
file the information required by lines 20 and 24 within 90 days after the date of this filing. (See note below.) By not filing
lines 20 and 24 with the form, | am agreeing to extend the 90-day period prescribed by ERISA section 404 1(a) during
which | will not make any distributions pursuant to the proposed termination of the plan.
(d) (© With this form | am filing a request for an extension of time to file the information required by line(s)
(other than the information required by lines 20 and 24). (See note below.) For more information about extensions see
the instructions.

Note: If you checked reason for filing C and you are not sending all the information required in Parts |, III, IV, and either completed
Form(s) 6088 or a second copy of the complete participant data schedules described in the line 24 instructions of Form
5310, the 270-day period prescribed by Code section 7476(b)(3) will not commence until you file the remaining required
information.

© USGP.O: 1986 ~491-473/20124


Department of the Treasury

Internal Revenue Service Notice of Intent To Terminate

rom 9010 Application for Determination Upon Termination; | omen. 1545.0202
(Rev. J Notice of Merger, Consolidation or Transfer of Plan | ®s*%%
fev. July 1985) sa httet

Assets or Liabilities; For Agency Use Only

Gustonty Corporation (Under sections 401(a) and 6058(b) of the Internal Revenue Code and

section 4041(a) of the Employee Retirement Income Security Act of 1974)

Complete every applicable part of this form. If an item in an applicable part does not apply, enter N/A.
Multiemployer plans covered by PBGC insurance program, see Purpose on page 1 of the instructions.

Reason for filing (check applicable box(es); see General Instructions):

A
B

0 Notice of plan—(i) Merger, (ii) Consolidation, or (iii) Transfer of plan assets or liabilities to another plan
CO. Application for ONLY an Internal Revenue Service (IRS) determination letter regarding a plan termination. (This is NOT a notice
of intent to terminate for the Pension Benefit Guaranty Corporation.)

Cc CO Defined benefit plan filing “ONE STOP” for:

(i) Notice of intent to terminate under the Pension Benefit Guaranty Corporation (PBGC) termination insurance program AND
(ii) Application for an IRS determination letter upon plan termination.

(One-Stop filing is a voluntary choice in lieu of separate filings under B and D. It is NOT available when the Enrolled Actuary
Certification Program is being used.)

D C Defined benefit plan filing ONLY a notice of intent to terminate under the PBGC termination insurance program. (This is NOT a

E

request for an IRS determination letter.)

O Enrolled Actuary Certification for a defined benefit plan filing ONLY a notice of intent to terminate under the PBGC termination
insurance program

All Filers Complete This Part

1 (a) Name of plan sponsor (see instructions): 1 (b) Employer identification number
Address (number and street) 1c) Sponsor's telephone number
( ) _
City or town, state, and ZIP code 1(d) Employer's tax year ends
Month Day Year 19
2 (a) Name of plan administrator (if same as 1(a), enter “‘same’’) 1 (e) Business code number
Address (number and street) 1(f) Date business incorporated or began
City or town, state, and ZIP code
2 (b) Administrator's employer identification number | 2 (c) Administrator's telephone number
! ( )
2 (d) Name, address, and telephone number of person to be contacted if more information is needed (see instructions):
Name Telephone number ( )
Address _ =
2 (e) Office of the District Director of the key district where sponsor is located (see instructions):
3. If you checked reason for filing B, C, D, or E, has each party who Is required to be notified been properly informed of
this filing (see instructions)? _. : eee wee : we I Yes O Noe
4 Type of plan entity (check only one box; see instructions):
(a) (4) Single-employer plan (d) (©) Multiple-employer plan (other)
(b) ( Plan ofcontrolled group of corporations or trades or businesses under common control (e) [1] Other (specify) _
(c)_ [1 Multiple-employer-collectively-bargained plan (other than a multiemployer plan)
5 (a) Planname (b) Plannumber —_|(c) Plan year ends
6 (a) Is this a defined benefit plan covered under the Pension Benefit Guaranty
Corporation termination insurance program (see Part lV instructions)? . . (i) 1 Yes (ii) 1 No (iii) O Not determined
(b) If you checked “Yes” or ‘Not determined,” have you ever used an employer identification number or plan
number in any prior filing with PBGC other than the ones entered on lines 1(b) or 5(b) above? . Loe . O Yes O No
If “Yes,"’ enter the number(s) previously reported. >
7 Indicate type of plan (see General Instruction E):

(a) C1 Defined benefit (i) C1 Fixedbenefit (i) (1 Unit benefit (iii) O Flat benefit
(b) (J Money purchase (c)] Profit-sharing (d) [J Other (specify) >

Under penalties of perjury, | declare that | have examined this application, including accompanying statements, and to the best of my knowledge and belief it is true, correct

‘and compiete.

Signature > Title » Date >
Signature > Title > Date >
For Paperwork Reduction Act Notice, see page 1 of the instructions. Form 5310 (Rev. 7-85)



Mf more space is needed for any item, attach additional sheets the same size as this
Form 5310 (Rev. 7-85) form. Identity each sheet with the plan sponsor's name and EIN and identify each item. Page 2

EEG] «Complete This Part If You Checked Reason for Filing A

8 Other plan(s) involved in transaction (see instructions): (b) Name of employer

(a) Planname -

(c) Employer identification number

(f) If the plan listed in 5(a) 1s a defined benefit plan, attach an actuarial statement of valuation evidencing compliance with the
requirements of Code section 401(a)(12) and the Income Tax Regulations under Code section 414(I).

GEE) Complete This Part If You Checked Reason for Filing B, C, D, or E
If you checked reason for filing E, complete only 9, 10(a), (b), 11(a) and 12

9 Effective date of plan

10 (a) Has the plan ever received an IRS determination letter? :
(b) If (a) is ‘'Yes,"’ enter the file folder number and date of the most recent determination letter’ and complete @
through (g). File folder No. _____-_________.------------- eee DatePm ee
(c) If (a) 1s ‘‘No’’ and your reason for filing is B or C, attach a copy of the executed original plan document or
joinder/adoption agreement, all plan amendments, trust agreement, group annuity contracts and custodial
agreements (do not complete (d) through (g)). Uh
(d) If (a) 1s “Yes," has the plan been amended since the last determination letter?
(e) If (d) is ““Yes,"’ and your reason for filing is B or C, attach a copy of the amendment(s) and ‘complete ay and ©.
(f) | Doany of the amendments alter the plan's vesting provisions? .
(g) Do any of the amendments (including the termination) decrease plan benefits? Gee instructions)
11 (a) Proposed date of plan termination » ___
(b) Attach copies of records of all actions taken to terminate the plan (see instructions).
(c) Last contribution to the plan:
(i) Date (ii) Amount (see instructions) $ (iii) For plan year ended

12 Reason for termination (check only one box to indicate primary reason for termination):

7

(a) © Change in ownership by merger
(b) Liquidation or dissolution of employer
(c) (1 Change in ownership by sale or transfer
(d) CO Adverse business conditions (see instructions and attach explanation)
(e) [1 Adoption of new plan (see instructions and attach explanation)
(f) a Other (specify) >
13 Indicate funding arrangement:
(a) © Trust (benefits provided in whole from trust funds)
(b) (1 Trust or other arrangement providing benefits partially through insurance and/or annuity contracts
(c) ( Trust or other arrangement providing benefits exclusively through insurance and/or annuity contracts
(d) ( Custodial account described in Code section 401(f) and not included in (c) above
(e) (1 Other (specify) >
14 (a) Name(s) of trustee(s) or custodian(s) (b) Date trust's accounting period ends

Address (number and street)

City or town, state, and ZIP code

15 Participation (see instructions): Collectively bargained plans and plans filing only a notice of intent to terminate | yes| No | Not
(reason for filing D) do not complete (a) and (c). Certain

(a) (i) \Isthe employer a member of an affiliated service group?

If there is uncertainty whether the employer is a member of an affiliated service se group, check ‘the “Not
Certain” column.

(ii) If (i) is “Yes” or “Not Certain,” did a prior ruling letter rule on what organizations were members of the
employer's affiliated service group or did the employer receive a determination letter o ‘on this plan that
considered the effect of Code section414(m)? . . we

(iii) \f (ii) is “Yes,” have the facts on which that letter was ‘based materially changed? woe ee
(b) Is the employer a member of a controlled group of corporations or a group of trades or businesses under
common control? . eee ee eee



Form 5310 (Rev. 7-85)

Page 3

15 (Continued):

(c)

Complete the following as of the proposed date of plan termination Current year

(current year) and as of the end of the 2 prior plan years: 19 19 ww. 19...

(i) _ Did the plan satisfy the percentage tests of Code section Yes | No | Yes | No | Yes | No
410(b)(1)(A)?

(ii) Total number of employees (if more ‘than 100 enter “100 plus").

(d) Enter the total number of participants employed for the current plan year and each of the 5 prior plan years on the schedule below:

19. 19. 19

(i) | Number at beginning of plan year

Current year

19

(ii) | Number added during the plan year.

(iii) Total (add lines (i) and (ii)

(iv) | Number dropped during the plan year

(v) Number at end of plan year

(subtract (iv) from (iii) a
(vi) Total number of participants in this
plan separated from service during //

S

the plan year without full vesting " o
5 Total ‘Amount of monthly benefits as of
16 Summary of participants or claimants by category: number the mast recent payment date
(a) Retirees and beneficiaries (including disability retirees) receiving benefits
(b) Active participants eligible for normal retirement .
(c) Active participants eligible for early (but not normal) retirement
(d) Active participants vested before termination (other than normal or early retirement)
(e) Allother active participants oe .
(f) Participants separated from service with deterred vested benefits .

(g)_Total (add lines (a) through (f))

UL,

17 Miscellaneous:

(a)
(b)

(c)
(d)

(e)
0)

(e)

(h)

As a result of the termination, are accrued benefits or account balances nonforfeitable as required under
Code section 411(d)(3)? .
For each participant, do the accrued benefits upon termination include the subsidized benefits that the
participant may become entitled to receive subsequent to the termination? (See instructions)
Will the trust continue to operate after termination of the plan? (See instructions) 1.
Were any funds contributed in the form of, or invested in, obligations or property of the employer o or any
group of corporations or group of trades or businesses under common control? .
Will distribution include property other than cash? we
For a defined benefit or money purchase plan, do you estimate there will be a an accumulated funding
deficiency as of the end of the plan year during which the proposed termination date occurs, if no
additional plan contributions are made? . .
If “Yes,” enter the estimated accumulated funding deficiency $ —
(i) If there are unallocated funds which can be reallocated to participants without exceeding the
limitations of Code section 415, have these funds been reallocated? :

(ii) If (iis “Yes,” did the plan originally contain a provision allowing this allocation? .

(iii) \f (ii) is “"No,"' was the plan amended to provide for this allocation? .
Will any funds be, or have any funds been, returned to the employer? (See specific instructions)
If “Yes,"’ enter the estimated amount » $

Complete (i) through (ix) only if 17(h) is “Yes.”

(i) _ Has the terminating plan been involved in a spinoff or other transfer of assets or liabilities, subject
to Code section 414(I), within 60 months preceding the proposed date of termination? If “Yes,”
attach a list and explanation of the transaction(s) involved that have occurred within the 60 month
period preceding the proposed date of termination

(ii) If (i) is “Yes,” answer (A) and (B).

(A) Are the accrued benefits of all participants, in the other plan(s) included in (i), fully vested and
nonforfeitable as of the date of this plan termination? (See instructions) .
(B) Have cash distributions or guaranteed annuity contracts been provided for all accrued benefits, a as of
the date of this termination, of all participants in the other plan(s) included in (i)? (See instructions)
Note: Distributions may not be made to employed participants in non-terminating plans.
(iii) Have cash distributions or guaranteed annuity contracts been provided for all accrued benefits of
all participants inthis plan?. . . oe

(iv) — Attach a statement providing the dates and amounts of these cash distributions or purchase of
annuity contracts.

Not
Yes | No | applicable