Form 1 Annual Premium Payment

I

P%GC

Pension Benefit
Guaranty
Co oration

/

For Plan Years Beginning in Calenear Ye&r 20@? 7
Filing

TOW?

7
.......
1Cine& h r Disastlr Rejie1

;

App:wed C ? P V ~ ~1~ R2 1 2 . ~ ~ 9 ,

PBW46

B15N

Photucoples end

(see
..............fur
.... the ir!ssucfaos .for
.......Form
...........1...

-.

....................

+

Annual Premium Payment

i\

Farm 1

........

1. man Sponsor
pa f

ChesH if yma do not vdac~t
instil,ctlons nea year

U

CRc;& if same as plan ~p~>~?so:
and go to Item 3

[:2)
I

1

-

.........

.

i

3.

............-

i

..........-..

i.....City
.........

................
---

-. ........................

Address Line 1

....

I

..........

.....................

................
......................

...................-...-..-.
Employer Wentllleartion NurnberCPlan Number (EIPBIPM). Elecbonic Filing

r
.....

(a) Enter Ydtyit

7
;

.......

(b) Eninr 3-dig2 PIJ

......................

(r) Does EIN!?H match entry on 201:1$~oini

55W?

1
3hs

No

[--.FFe

n

0

ZQOj3 Form 55W not regl:irsd.

4.

It ElM and PM in item 3 (a) and fb) above are N 5 T BOW tho same as on fhe Inorst wcent premium filBn$>enter both prlor ElN and
prior PN.
(5) Prior >digit PM
(c) Efbctiw Date of Ct~acgr
bA M
YYYY
...........

5.

plan C w e m g e ~ t a f u (check
s
one)

8.

Is this the nrst year's prrmilam filing for this plan?
No
[-.. Y e
Ia) Plan ef%lise date
jb) ?Ian adoption date

7.

Transfers fvom disaslppcarlng ptanfi:
Has s plan other than ymtt~ceased to exrst rn mnnacttan wfih any transfer d assets or liabrltties from that plan to this
plan smce the most recent prerr~iumfrting'? {See instrcjCt~o:?s,
p g e 29.)
.?lo
If yes, give EIWPN of e a c h disappearing transbmr plan and el'hdive date of tr,msMr. and hflica:~whether it \*as 3
or :;pinoff JS).
merger (M!, consoldation (C).
Transhr T y p
Ill M
DD
y ~ y y
Transforor's !;-digit flPJ
3-digi; PN

(3)

!x

Csver&

(b:

0 I.lncsrtairl [If ur?Certaln,yolk should file. See inStrllCtion~,wye 28.)

[-I

If yes, enter the ?~llcw!ng
dates.
(c) Plar! coverage date

c

........................

................

-------7-.----*

,

;

j

2

.........................
:
' i........................
.....

p~nore
th3n 2. attach a-sgpfim"fe?hset that iists the ~ f i ~ ~ ~ . i ~ ~ ! g dates.
! . ~ ! -anag!!?f?.:jy~s,
~~~$s.
and check

(a) Enter 6-rdiqt
i
Dusinnss C,de:

0.

I

,

:

i
.---..........---..

Name at Plan:

..........................

1 --

...............................................
................

[-I-j %s

;icG@.kxin iten 18:j

..lllllll

(b) fntar first 6 digits

......................

.........................

.-----........--.
.....-..
........................

.............
.............

............

-

contcouo on page 2

9-digit Elf4

EIWPM from
3 (11 and

~~~

9911506

1 8 . Name and Phonls
........ --. of Plan
-- .....Number
........onk
. kc^

ia!

12.

[

..........-----.

..........I

I

i

rA

Mu;crnrnployer plan

jb)
k4 M

(a) n i i s prsminm is for
the plan year hecinnir1g:

jcj

13.

..............

_71

i .............

............
..........-..........+.,
arid .-::
PtMm@Nun?bef
L.............-........-..............-......-................-.......-...
.......

DD

Y .Y....
Y...Y
.

.........-. O D ........ .--YY
-. Y v......

jb) This pre~imiumis for

/.

..................

Adoption date of

..
[--.I

GIreck hare if the plan year beginrrirrg date
has changed sirice last frlinc with PBGC

I

PJ M

.....0
...-0
....

i

YYYY

1

Enter F?4RTIC:IPANT CCILIFJT for the pian yeat. specified in itetn 12.
(See instrl~dions,paat? 39.). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.........

r--"'

i.......

. . . . . . . . . . . . . . . . . . . . . . . . . . 14jaj

( 9 ) SINGI.E.EMP1.OYER nai.raee premiuin:
$31
Mu:iliply The participant cuurrl in item 1 3 by=.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I:f(tJ>
jc) S1NC;I.E-EMP!.WER
:fariahie-.qte prerriium:
Frrziii Sc!i&ule A, itsn?6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1,tjc)
jri) SING1.E-.EMPI.CYER totat prsninm:
Add itsii~s14(C) anr! la{cj. Eriter arno,cnt.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14(d)

Y

...........................
......
.........
r-..............---.

!

...........
....-...

Y

Y

Y

..........--.

...........

I

Y

.

Y

Y

~

..

!

.......... ...-

...................... j

L-

.-.......

,..........

Prerr~iurncredits (See instacticns, page 31.j
(a) Arr~ouiitpaid with 2~01~estinated
filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..15(a)
jljj Othar credit (inciudirrg any credit claimed in tho 2O~~&stlrnacerj
ii!ir!y and any
siwrl-par credit). (See il:st:uctir7ns, page 33 .) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.........--.

..........

2

.........-

'-?

jc) Trctal crsdii: Add ite~ns1Sja) and 1.5jbj. Enter arnou!nt.

17.

1

_____

war c?yal\ge: .____..

Multiply item1 13 by tho $6 pierrriur?irate and erlter arno1:nt

f

_I

.........

Single-Employer plan (lridudes Mujltipie Errrplryer plan)

114. ;a! MULTIEMPL.CY~ER
prsrniun:

15.

t

Page 2

%digit PN
r.-.
.............
,

(bi
, , Area

..................-.
..................--.---.
.................. .......---.
.........
..
................-......
.............
Plan Type (Check appraprjate box to Indicate type of ~ I a n
and ? ~ P C
of flllng.)

.............(a)
......Narna:
. .--.

11.

......... .--.

i

..........-.....

-..........-......

--

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15(c,i

............

:
i.--.....-.

......

.........

I

;

........................
........
krircunt due. If the airiount in ttsm 14ja) 3r 14j:j) is LARGER than :he ariiount in ilsni 15(c),
suI~raC:item 1S(rj from iten? l4(a) or 13(d) and a b r the amoi,n? did@in item 16 . . . . . . . . ? R
............
See .......
page 34 oi instruc;bns for paymerit inethod:?. Indicate how yo11are paviric; the anlourit duo:
by eledrfitiic caymen?.
[----j by check snciosd with this form, or
..--.....--.
.........---. ..........
Overpayment. If 'the amount in iterri 14ja) or .i4jd! is SMALLER tliari Eiie amount in itern 15(c).
aibliac! hem I?(nj or 14!6) from item 15ic) a d enter tb~swarpaymen! ic %ern17 . . . . . i7
j
An amount ol ave:naynen? may be refunded or credited against the slan's next premium filin~.
;-If you want to take a credit. check here:. . . .
If you want a refund. check here: .....
.....,
For a refurid by eledrcmic furrds tran.ift?r, indicate whather trarislar is to a d~ecitingaccount
or sa.vings account
ar>d
sub-account ].....---'..........---ai,d accollnt nlttr,ber
I
.
.
e!i@r tho bank
... ..............-.....
?
i
roucng nltmber
......................... ..
rlumbar ;it afiyj
i_..........___....

-7

[

7

a

5

I

I

f 8. If ?oil have atlac!~rner)!sother tlia:, Schedule A. check hew:

19. h4i~ltienpl~ver
Fla:i

1
,-

(7

____;

.I

Put EINIPN {item >(a) and {b)) and date prerrriurrr
naymei?tysar commenced (PYC) on each sheet.

DeclaraSon (NME: S1NGL.E-EMPLWER Plari Adrninistntow must aicn the cerliiimtinn in iterr, 8 of Sd~eduisA,)

i cur ti^{ urtder psnaltv d pt?rjury:M<
toi'the bmt d ~rrykrrowledge ai?d..*h*?.,t..c!\,
bexef,$he infotrriation in this filing
is true, wrrec*. and sociinleternnd h n 5 bpFile Typeapplication/pdfFile Modified2006-11-02File Created2006-11-02