Pbgc Form 500 – Fill Out and Use This PDF

The PBGC Form 500 serves as a Standard Termination Notice for single-employer pension plans deciding to terminate. It encompasses detailed sections including identifying information of the plan and its administrator, reasons for termination, participant data, and certification by the plan administrator to ensure compliance with all applicable laws. It's a critical step for employers to fulfill regulatory requirements and ensure a smooth termination process. To accurately fill out and submit your PBGC Form 500, click the button below for assistance.

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Pbgc Form 500 PDF Details

Navigating the intricacies of plan terminations requires a comprehensive understanding of specific regulatory procedures, one of which includes the PBGC Form 500. This form plays a pivotal role for single-employer plan terminations, offering a structured avenue for employers to notify the Pension Benefit Guaranty Corporation (PBGC) about their intentions. Detailed sections within the form capture essential information ranging from identifying details of the plan and its sponsor to intricate aspects of plan participant demographics and the ultimate distribution of plan assets. Moreover, the form delves into the reasons behind plan terminations, illuminating whether they stem from business restructuring, financial duress, or strategic shifts in employee retirement benefits. Additionally, it addresses the aftermath of termination processes, such as the disposition of residual plan assets and the certification of plan sufficiency by an enrolled actuary, ensuring alignment with legal and regulatory stipulations. With its comprehensive scope, the form embodies the procedural and legal rigor essential for executing plan terminations in a manner consistent with both employer objectives and participant rights under the protective gaze of the PBGC.

Question	Answer
Form Name	Pbgc Form 500
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	segal pbgc claim forms, pbgc 501, what is the termination standard for the ontario employment standards act, pbgc form 500

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		Standard Termination Notice				PBGC Form 500
		Standard Termination Notice				Approved OMB 1212-0036
		Single-Employer Plan Termination				Expires 3/31/2021
		Single-Employer Plan Termination

PART I.			IDENTIFYING INFORMATION
1a	Plan Name				1b Last day of plan year

2a	Contributing Sponsor’s name and address				2b Sponsor’s telephone number
	(Address should include room or suite no.)

					2c 9-digit employer identification number (EIN)

					2d	3-digit plan number (PN)

2e If you used a different EIN or PN for this contributing sponsor/plan in previous filings					2f	6-digit business code
	with the PBGC, also show the number(s) previously reported

3a Plan Administrator’s name and address (if same as 2a, enter “same”) (Address should					3b Plan Administrator’s telephone number
	include room or suite no.)

					3c E-mail address (optional)

3d Name and address of person to be contacted for more information (if same as 3a, enter					3e	Telephone number
	“same”)	(Address should include room or suite no.)

					3f E-mail address (optional)

PART II.			GENERAL PLAN INFORMATION
4a	Have you filed, or will you file, with the Internal Revenue Service			Yes	4b If “Yes” to 4a, enter the filing date:
	for a determination letter on the termination of this plan?			No		(MM/DD/YYYY)

5a	Is this a multiple-employer plan?			Yes	5b If “Yes” to 5a, attach a list of the names and
				No		employer identification numbers of all contributing
				No		sponsors
						sponsors

6Reason for plan termination. If more than one reason for the termination (considering (1) - (12) and c.), see instructions. a Plan related

	(1)	Plan administration too costly or complicated
			6a(1)
	(2)	Plan benefits too costly
			6a(2)
	(3)	Restructuring of retirement program (e.g. adoption of new plan, decision that defined benefit plan no
			6a(3)
		longer meets employer objectives)
	(4)	Retirement/illness/death of owner(s)	6a(4)
b Business related

	(5)	Adverse business conditions
			6b(5)
	(6)	Sale of company/subsidiary/division (not involving bankruptcy or similar proceeding)	6b(6)
	(7)	Company/subsidiary/division closed (not involving bankruptcy or similar proceeding)	6b(7)
	(8)	Merger of company	6b(8)
	(9)	Contributing sponsor acquired by another business
			6b(9)
	(10)	Another business acquired by contributing sponsor	6b(10)
	(11)	Contributing sponsor reorganized (in bankruptcy or similar proceeding)	6b(11)
	(12)	Contributing sponsor liquidated (in bankruptcy or similar proceeding)
			6b(12)
c Other (specify)
			6c
7	Changes in contributing sponsor associated with plan termination (check all that apply)
a	No change
			7a
b Sale of company/subsidiary/division (not involving bankruptcy or similar proceeding)
			7b
c Company/subsidiary/division closed (not involving bankruptcy or similar proceeding)
			7c
d Merger of company
			7d
e Contributing sponsor acquired by another business
			7e
f Another business acquired by contributing sponsor
			7f
g Contributing sponsor reorganized (in bankruptcy or similar proceeding)
			7g
h Contributing sponsor liquidated (in bankruptcy or similar proceeding)
			7h

Standard Termination Notice • Single-Employer Plan Termination		PBGC Form 500 • Page 2

8 Number of plan participants and beneficiaries as of proposed termination date:
a	Active participants		8a
b Retirees or beneficiaries receiving benefits
b Retirees or beneficiaries receiving benefits			8b
c Separated vested participants entitled to benefits
c Separated vested participants entitled to benefits			8c
d	Separated non-vested participants
d	Separated non-vested participants		8d
e	Total
e	Total		8e

9Estimated percent of currently employed participants that are covered under the terminated plan that you expect to be covered under:

	a No plan
	a No plan					9a		%
	b New or existing traditional defined benefit plan					9b		%
	c New or existing hybrid defined benefit plan, other than cash balance plan					9c		%
	d New or existing cash balance plan					9d		%
	e New or existing profit sharing plan					9e		%
	f	New or existing 401(k) plan				9f		%
	g New or existing simplified employee plan
	g New or existing simplified employee plan					9g		%
	h Other new or existing defined contribution plan (specify)					9h		%
	10 If the percent entered for item 9b, 9c or 9d is greater than zero, will the types of benefits under the new or existing						Yes
		defined benefit plan be substantially the same as under the terminating plan for all affected participants (currently						No
		employed participants that you expect will be covered under the new or existing defined benefit plan.)
	11a Proposed termination date				(MM/DD/YYYY)
	11b Proposed termination date stated in notice of intent to terminate (if different from 11a)				(MM/DD/YYYY)
		Attach copy of notice of intent to terminate.
	12a Earliest date notices of intent to terminate issued to affected parties				(MM/DD/YYYY)
	12b Latest date notices of intent to terminate issued to affected parties				(MM/DD/YYYY)
	13 Latest date notices of plan benefits issued to participants or beneficiaries Attach copies of				(MM/DD/YYYY)
	sample notices of plan benefits; see instructions.
	14a Has a formal challenge to the termination been initiated under an existing collective bar -				Yes	No
		gaining agreement?				N/A
	14b If “Yes” to 14a, attach a copy of the formal challenge and a statement describing the
		challenge.
	15 Have all PBGC premiums been paid to date?				Yes	No
	PART III.			RESIDUAL PLAN ASSETS
	16a Will residual		assets be returned to the employer as a result of this termination?		Yes	No
						N/A
	16b If “No” or “N/A” to 16a, do not complete the rest of Part III; go to Part IV.
		If “Yes,” enter the estimated amount:			$
	17a Is there a plan provision permitting a reversion of residual assets to the employer				Yes, go to 17b	No, go to 18a
	17b If “Yes” to 17a, was the provision adopted prior to 12/18/1988?				Yes, go to 18a	No, go to 17c
	17c If “No” to 17b, enter:
	(1) Adoption date:				(MM/DD/YYYY)

(2)		Effective date of plan:			(MM/DD/YYYY)

	18a Has the plan been involved in a spin-off/termination transaction?				Yes, go to 18b	No, go to Part IV
	18b If “Yes” to 18a, have the requirements of the Guidelines been satisfied?				Yes, go to 18c	No, go to 18d
						N/A, go to 18d
	18c If “Yes” to 18b, enter the dates for (1) and (2) and go to Part IV:
	(1) latest date a description of the transactions(s) was issued to participants in the ongoing				(MM/DD/YYYY)
		plan.
	(2) latest date notices of plan benefits were issued to participants in the ongoing plan.				(MM/DD/YYYY)

	18d If you checked “No” or “N/A” in 18b, attach a statement that describes the transaction(s) and				explains why the Guidelines were not, or need
		not have been, followed.
	PART IV.			PLAN ADMINISTRATOR CERTIFICATION

I, the Plan Administrator, certify that, to the best of my knowledge and belief: (1) I am implementing the termination of the plan in accordance with all applicable laws and regulations; and (2) the information contained in this filing and made available to the Enrolled Actuary 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

	Standard Termination		PBGC Schedule EA-S
	Certification of Sufficiency		(PBGC Form 500)
	Certification of Sufficiency		Expires 3/21/2021
			Approved OMB 1212-0036

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

2Is 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)
5	Is the value of plan assets projected to be sufficient as of the proposed distribution date to		Yes	No
	provide all plan benefits? If “No,” the plan cannot terminate in a standard termination.
6	Estimated fair market value of plan assets as of the proposed distribution date		$
7	Estimated present value of plan benefits as of the proposed distribution date		$
8	Estimated total amount of residual assets		$
9	Estimated amount of residual assets to be distributed to the employer		$
10 Estimated amount of residual assets to be distributed to participants and beneficiaries			$
11 Has the plan ever required employee contributions?			Yes	No

12If 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 company’s name and addressEnrolled Actuary’s Name (Print or type) (Address should include room or suite no.)

				Enrollment Number

				Telephone Number

				E-mail address (optional)

	Enrolled Actuary’s signature		Date

PART V.		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

	Standard Termination			PBGC Schedule REP-S
	Designation of Representative			Approved OMB 1212-0036
	Designation of Representative			Expires 3/21/2021
				Expires 3/21/2021

PART I.		IDENTIFYING INFORMATION
1a Plan Name				1b 9-digit employer identification number
				(EIN)

				1c 3-digit plan number (PN)

2a Plan Administrator’s name and address				2b Plan Administrator’s telephone number
(Address should include room or suite no.)

				2c E-mail address (optional)

PART II.		DESIGNATION OF REPRESENTATIVE(S)
3 I,			, Plan Administrator of the above-named pension plan, hereby appoint the following

representative(s) to act on my behalf before the Pension Benefit Guaranty Corporation on all matters (other than those specifically excluded below) relating to the termination of the above-named pensionplan:

4a Representative’s name and address	4b	Telephone number
(Address should include room or suite no.)

	4c	E-mail address (optional)

4d Representative’s name and address	4e	Telephone number
(Address should include room or suite no.)

	4f	E-mail address (optional)

5Matters excluded from authority of representative(s). List any specific acts with respect to the plan termination that you are excluding from the acts otherwise authorized in this designation:

PART III.	RETENTION / REVOCATION OF PRIOR DESIGNATION(S)
6a Have you filed any prior designation(s) of representative(s) for this termination?		Yes	No

6b If “Yes,” do you want any such prior designation(s) of representative(s) to remain in effect?		Yes	No
(Attach a copy of all prior designations that are to remain in effect.)
PART IV.	SIGNATURE OF PLAN ADMINISTRATOR

NOTE: The PBGC will NOT accept unsigned designations. If the Plan Administrator is a board (or similar group) composed of employer and employee representatives, at least one employer representative and one employee representative must sign this form. If the plan does not designate a plan administrator or it designates the plan sponsor or the contributing sponsor as the plan administrator, this form must be signed by

an officer of the plan sponsor or contributing sponsor who has the authority to sign on behalf of that entity.

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 signature

Date

Printed name and title

	Post-Distribution Certification				PBGC Form 501
	Post-Distribution Certification				Approved OMB 1212-0036
	for Standard Termination				Expires 3/21/2021
					Expires 3/21/2021

PART I.		IDENTIFYING INFORMATION
Check here if you previously filed a Form 501 for this plan.			If checked, provide dates of filing(s):

1a Plan Name				1b 9-digit employer identification number (EIN)

				1c 3-digit plan number (PN)

Attach copy of the most recent complete plan document and any amendments to it.


2	PBGC case number		8-digit Case #
PART II.		DISTRIBUTION INFORMATION
3a	Last distribution date in satisfaction of plan benefits		(MM/DD/YYYY)
3b Date of receipt of IRS determination letter			(MM/DD/YYYY)
4 Were participants and beneficiaries provided with the name and address of the insurer(s)			Yes	No	N/A
	no later than 45 days before the date of distribution?		Yes	No	N/A
	no later than 45 days before the date of distribution?
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		Yes	No	N/A
	participant and beneficiary receiving benefits in the form of an irrevocable commitment?		Yes	No	N/A

6b If “Yes” to 6a, enter the latest date the annuity contract, certificate, or written notice			(MM/DD/YYYY)
	was provided to each participant and beneficiary receiving benefits:
	If “No” or “N/A”, see instructions
7a	Complete name of record of insurer(s) from whom annuity contracts,		7b Annuity Contract Number(s)
	if any, have been purchased (Address should include room or suite no.)

8a	Name and address of contact for location of plan records		8b Telephone number
	(Address should include room or suite no.)

9Summary of distribution of plan benefits. Attach distribution documents (see instructions).


	Type of Benefit				(1) # of Participants or Beneficiaries	(2) Total Cost/Value
a	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)				$
d	No Distribution
e	TOTAL (see instructions)					$
PART III.				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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1. It's vital to fill out the pbgc form 500 properly, hence pay close attention while filling in the areas that contain these specific fields:

Filling in segment 1 in segal pbgc claim forms

2. Once your current task is complete, take the next step – fill out all of these fields - Plan administration too costly or, Restructuring of retirement, longer meets employer objectives, b Business related, Adverse business conditions Sale, Merger of company Contributing, c Other specify, Changes in contributing sponsor, a No change b Sale of, a a a a, b b b b b b b b c, and a b c d e f g h with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Part number 2 for filling in segal pbgc claim forms

3. This subsequent segment is normally rather straightforward, a No change b Sale of, and a b c d e f g h - each one of these empty fields is required to be filled in here.

Many people generally make mistakes when completing a No change b Sale of in this section. You should definitely read twice everything you type in here.

4. It is time to fill in this fourth portion! In this case you will get all these Estimated percent of currently, Standard Termination Notice, Number of plan participants and, a Active participants b Retirees, covered under a No plan b New or, If the percent entered for item b, a Proposed termination date b, MMDDYYYY MMDDYYYY, PBGC Form Page, a b c d e, a b c d e f g h, and Yes No empty form fields to complete.

Filling out part 4 in segal pbgc claim forms

5. The very last section to complete this document is essential. Ensure to fill out the mandatory blanks, and this includes a Proposed termination date b, MMDDYYYY MMDDYYYY, Attach copy of notice of intent to, a Earliest date notices of intent, sample notices of plan benefits, a Has a formal challenge to the, gaining agreement, challenge, b If Yes to a attach a copy of the, Have all PBGC premiums been paid, b If No or NA to a do not complete, If Yes enter the estimated amount, a Is there a plan provision, Adoption date Effective date of, and a Has the plan been involved in a, before using the pdf. Neglecting to do it could end up in a flawed and possibly unacceptable form!

segal pbgc claim forms writing process detailed (portion 5)

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