Form 1-ES Estimated Premium Payment

PBGC Form I -ES

Estimated Premium Payment

Pensian Benefit
Guaranty Carp~nstion

(Plarls with 5% cr more Palticipar~tsin prior filing yea:')
Fr;r P h , Y~arsBeginning in Calendar Ysa?2NJ6E7

200g 7
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9. Pian Sponsor

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Address l.ii?e 3

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State

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Address iirre 1

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(3) E~lterBdigit PN 1..........

(If more thar! 7 , attact! a separate sheet tt!~!l i s ! ~the additiol?~!
EINiF'Ns, dn?ec-,ar.d trar>s!ar lypes.:
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(r.) tias a plan other tl?anyours ceased to exisl in cnrrnectio!?with any transfer of assets or, .......
iiabaitias Iwm that plan to this plan since the rnost recsn?r~rnn?ii:m
filirrg?
!f yes, give EINiPN of each rjisappeariiic transfern?plat? and effective date of tra~sie!;
wtiather ii was a merger (M), cof~suiideticntC), o: spiric>ll! S ) . @ m + e ~ & &
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3-digil
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Emptoyer Idenlifjcation NumbedPlan Number (EIWPN),
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i Address i.inn 2

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Chscl: i f same ss t;ponsor anrJ gi. to Item 3

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Photocopies and
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Clleck for Disaster Relief ....... j (me inslriictior~s) D, f j j (ses
CherA b r Amended Fliinp
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Clv.xk for narnaiaddrsss change
F
n Administrata
C b s d f ~ nilm~/aSdr~ss
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ctunge
Ct!eck if you c!o not ~ ~ ~
p a f t r instrijcti0r.s :iext p a r

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npp:ovt?d OMS 12T2.009

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frorr: reqiiirsd elwtrrri~izfili?)%;
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4, If EIN and PI4 i n itern 3 ja) and (bj aboue are MOT BOTH the same as or, must recent premium filing, enter both prior E1N and priar PN.
(5) Prior 3-digit PN

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(b) F.la.r, .Yea: Begrrliling

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6. Estitnaied premium far this plan
$31.00

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{c> piat?Year Ending

Estiinated Participant Cnc~nt
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C?~eckenciosed with this li?rfi,

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method [Choclc app:opri&te box tc?indicate the :,?etttc~d
fo: pymer!t to F3RGC.)

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(Il?cli:rJing esli~natecjshorl-par credjfj [See ir~structians,pages 9-30,)
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8. Amount D r ~ s
(a) Er~terpramiun; pzjtment rl?te(item G minus itern 7) arid subrnii payment to PBGC.

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Eledroiliz P&ymont (see instrtictirr~.:;:

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J e s t i v c > a t g ~ - ' 4 f i < t i c i P a \ l ~ {ou,:t/ I certify under penairy of perjtii.g,?&&to
the best of niy krioirvledp?anrl belief, ;tr,,sl ~4 ) I
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Si~natured Plat: Adrrrinistmto:

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P:ir!! ar typ2 first name ~ jindividual
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Teiephane liliirnher. iirlciude Aran Code)

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Print or type last name of indi*~idual
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E-inail Addws:; (Optiortai)

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