PBGC Form 501 Post-Distribution Certification for Standard Termination

PBGC Form 501

Post-Distribution Certification
for Standard Termination
PART I.

IDENTIFYING INFORMATION

Check here if you previously filed a Form 501 for this plan.

1a

Approved OMB 1212-0036
Expires XX/XX/XXX

If checked, provide dates of filing(s):

1b 9-digit employer identification number (EIN)

Plan Name

1c 3-digit plan number (PN)
Attach copy of the most recent complete plan document and any amendments to it.

2 PBGC case number
PART II.
DISTRIBUTION INFORMATION
3a Last distribution date in satisfaction of plan benefits
3b Date of receipt of IRS determination letter
4 Were participants and beneficiaries provided with the name and address of the insurer(s)
no later than 45 days before the date of distribution?

8-digit Case #
(MM/DD/YYYY)
(MM/DD/YYYY)
Yes

No

5

Were you able to locate all participants and beneficiaries? If “No,” see instructions.

Yes

No

6a

Has a copy of the annuity contract, certificate, or written notice been provided to each
participant and beneficiary receiving benefits in the form of an irrevocable commitment?

Yes

No

6b

If “Yes” to 6a, enter the latest date the annuity contract, certificate, or written notice
was provided to each participant and beneficiary receiving benefits:
If “No” or “N/A”, see instructions
Complete name of record of insurer(s) from whom annuity contracts, if any, have been
purchased

7a

7b Annuity Contract Number(s)

Name and address of contact for location of plan records

9

Summary of distribution of plan benefits. Attach distribution documents (see instructions).
(1) # of Participants or Beneficiaries
Type of Benefit
Annuities purchased
(1) For Non-Missing Participants
(2) For Missing Participants
(3) Total

b

Lump sums (including direct transfers)
(1) Consensual
(2) Nonconsensual (i.e., mandatory cash-outs)
(3) Total

c

Benefits transferred to PBGC for Missing Participants
(1) Benefits transferred
(2) Other amounts due PBGC (see instructions)
No Distribution
TOTAL (see instructions)

d
e

PART III.

N/A

(MM/DD/YYYY)

8a

a

N/A

8b Telephone number

(2) Total Cost/Value

0

$

0

$
$
$ 0.00
$
$

0

$ 0.00

PLAN ADMINISTRATOR CERTIFICATION

I, the Plan Administrator, certify that to the best of my knowledge and belief that (1) benefits payable with respect to participants have been
calculated and valued correctly in accordance with applicable provisions of ERISA and the regulations thereunder; (2) all plan benefits (through
priority category 6 under ERISA Section 4044 and 29 CFR Part 4044) under the plan have been satisfied; (3) plan assets in excess of those
needed to satisfy all plan benefits (through priority category 6 under ERISA Section 4044 and 29 CFR Part 4044) have been or will be distributed
in accordance with applicable provisions of ERISA and the regulations thereunder; and (4) the information contained in this filing is true, correct,
and complete. I further certify that I am aware that records supporting the calculation and valuation of benefits and assets must be kept at least six
years after the date this post-distribution certification is filed. In executing this document, I certify that the foregoing is true and correct, and
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 company name and address (Address should include room or suite no.)

Telephone number

E-mail address (optional)

Plan Administrator’s signature

Date

Printed name and title of Plan Administrator

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