PBGC Form 500 Standard Termination Certification of Sufficiency

PBGC Schedule EA-S

Standard Termination
Certification of Sufficiency

(PBGC Form 500)

Approved OMB 1212-0036
Expires XX/XX/XXXX

PART I.
IDENTIFYING INFORMATION
1a Plan Name

1b 9-digit employer identification number (EIN)
1c 3-digit plan number (PN)

PART II.
CODE SECTION 412(e)(3) PLANS
2 Is this plan a Code section 412(e)(3) plan?
No: the Enrolled Actuary must complete Parts III and IV. Item 3 and Part V should not be completed.
Yes: item 3 and Part III must be completed. Depending upon who completes Part III, either Part IV or Part V must be completed and
signed by the Plan Administrator or Enrolled Actuary as appropriate.
3a Enter name (full official name of record) and address of the insurer
3b Telephone Number
(Address should include room or suite no.)

PART III.
PLAN SUFFICIENCY
4 Proposed distribution date

(MM/DD/YYYY)

5a

Is the value of plan assets projected to be sufficient as of the proposed distribution date to
provide all plan benefits? If “No,” the plan cannot terminate in a standard termination.

Yes

No

5b

If 5a is “Yes,” is the value of plan assets projected to be sufficient because of an
alternative treatment of one or more majority owners' benefit(s) pursuant to
29 CFR § 4041.21(b)(2)?

Yes

No

6
7
8
9
10
11

Estimated fair market value of plan assets as of the proposed distribution date
Estimated present value of plan benefits as of the proposed distribution date

Yes

No

12

Estimated total amount of residual assets
Estimated amount of residual assets to be distributed to the employer
Estimated amount of residual assets to be distributed to participants and beneficiaries
Has the plan ever required employee contributions?

$
$
$
$
$

If the amount in item 9 is $1 million or more and if any benefits are to be distributed other
than through the purchase of annuity contracts, attach a statement showing interest
rate/structure used to value the benefits.

PART IV.

ENROLLED ACTUARY CERTIFICATION

I, the Enrolled Actuary, certify that: (1) I have reviewed all plan documents and plan and participant data, and applied all relevant provisions of
ERISA and the Internal Revenue Code and regulations promulgated thereunder; (2) to the best of my knowledge and belief, this plan’s assets
equal or exceed the value of its plan benefits as of the proposed distribution date; and (3) to the best of my knowledge and belief, the
information contained in this schedule is true, correct, and complete. In making this certification, I recognize that knowingly and willfully
making false, fictitious, or fraudulent statements to the PBGC is punishable under 18 U.S.C. §1001.
Enrolled Actuary’s Name (Print or type)
Enrolled Actuary’s company’s name and address
(Address should include room or suite no.)
Enrollment Numberr

Telephone Numberr

E-mail address (optional)
Enrolled Actuary’s signature

PART V.

Date

PLAN ADMINISTRATOR CERTIFICATION FOR CODE SECTION 412(e)(3) PLANS

I, the Plan Administrator, certify that, to the best of my knowledge and belief: (1) this plan complies with section 412(e)(3) of the Internal Revenue
Code and regulations promulgated thereunder; (2) I have reviewed all plan documents and plan and participant data, and applied all relevant
provisions of ERISA and the Code and regulations promulgated thereunder; (3) this plan’s assets equal or exceed the value of its plan benefits as
of the proposed distribution date; and (4) the information contained in this schedule is true, correct and complete. In making this certification, I
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 signature

Date

Printed name and title of Plan Administrator