Schedule A Single-Employer Plan

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3 . 2 ~tEz,e, iq:r$fisgf.ir;i.la

.......-.-.

SCHEDULE A
(PWX Farm 1)

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k.f? tq .......d... .,J
.......... :......... ......

5~ /i,+;.ji

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Single-Employer Pian

t

Variab!e R a t e krernium

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Approved

OM9 1212-0009
-? 2.5
237q
%xG%36
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a si,>gie b ~ yat53
. go to item 2. See Section Five for required ceriific~tiocs.

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A

Geileral R u ~ . jbj

Altsrna:we G~lci~lation
Illsthod [AChl).

MU

....... PAodiRed ACM br Plan Terminating in Wstress or ii~voluntary

1

(c) ...-.
j Rrrnination with proposed teriniI?atiorrdate (on or before t6e snapshL,t date) of:

-

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

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

2,

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f ~ m s

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{a)

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zoqf 7

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

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..................
........................... .-----.
SECTION TWO: LBPIBUMOED VEST
................................... ...........ED
......BENEFITS.
......

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

Present Value of V ~ 9 1 % dBenefits: Plan Vaiues arc determined as of: . . . . . . . . . . . . . . . . . . . . . . . i
..............
'fhs assi~rrrsdt.etita~noritage is

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-.......................A-

A

.............. years. The IUlj~stedval~esare baseG on a

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

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Rsqirired interest Rake of

(bj Ae%JusPed
Value of Vested BemfRa
................ ............-

(a) PIan Value of V~tes.4Benetits (ACM filers only)

rsL:eiviriy payrrieots
(2) P~rticipantsnot

receiving payments

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Value
............................
...........................

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............................ ' : " i o

-......-...,

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

(3) Total
(ite;njl) pius item (2))

3,

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

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

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

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.................... I

........M.....M
................ D D
Value of Wan Assets:
(a) Enter vzlije ot Plan Assets as of ,......................>.....

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

Y Y Y Y

(b) Enter contt.ibljt.ion receivables included in item 3(aL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i

jcj Discounted paid contributions.

1.

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

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

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...............,

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S.E.(2)

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S.E.(3)

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S.E.{4j

(bj Total ammnt of adjust~r~en:
due tc sig:iificant events
(It tM:s amount is t>e,ative, pieaae check this b x : )

5.

........................-di

jd) Ente:. adjusied value of plan aaarts (item 3(a) minas iterr! 3&) pius item 31~)).. . . . . . . . . . . . . .
Significant Events (AC;?4or Modilisj ,GM filers with 500 or more pe::icipants vrllyj:
(a) Check each signiticant event (S.E.) that occurred between \he detercqinailon data entered iri item 2 of this
S:hed;tla A and the prert!iutn snapshot date {see Part A.7 of ir~rtruction:; (pp. 4.6) for d~firritior:sj:

j.....j S.E.{ I )

S.E. {5)

S.E (6)

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.--.

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

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

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-- -----j . . . . . . . . . . . . . . . . 1

(Note: For plans with kwer than S M participants, this itern is ~ p l i ~ , ! .l ~
. .!.). . . . . . . . . . . . . . . . . .

4

___

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S.E.(7)

,

3. . . . . . . . . . . . . . . . . . . . . . . . . .

Adjusted Unfunded Vested Bertefits: Enter adjusted ~;nh!ndedvestud berrefiis. (ACP.4 fiiers see
irlslrgctivns, pp. 41.42, b r interest and significant wents arijusrments.) . . . . . . . . . . . . . . . . . . . . . .

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No Significxnt Ev@nts

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23'1986

SECTION
...............THREE:
...............VARML31-E-RATE
...
.........PREMIUM.
...................

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

VariableRate Premium: Enier here and on Form 1, itern 14(?7),eithnr

71.
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. . . . . . . . . . . . . . . . . . . . . . . '1.......

..............................
.................................
--SECnON
................. FOUR: PARTICIPANT
-. .....NOTICE.
...................

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

Z F.

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ElWPN l a m rilrm 1 ilen 3 (3);mCl!:

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Page 2

2 0 4 SCHEDLlLE W {PBGC Form 1)

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

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........

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

Participant Notice Reylslreamnt
6
For the 2W$ plar) p a r , a Participant Notice under EE!$A saction 401 1 arid 29 CFR Part 40'1 1:
j?!
Was not required to be issuad; or (2) ]----J Waqisausd on iirne an3 in accordance with al! cthrr
appllcaMe rctqurrerrlerlts;or
13)/.:--!..., An exnlenatiorr is attached.
...............................
..............................
.....--.....................
FIVE: CEW?IFIGATIONS.
.................................
.........................SECTION
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$

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22.

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Certification o l Plan Admirlistrator. The plan administrator mus? sign and cr,mple?e illis item. Se
i cetlify under per~altycf pe?juryhg'to the best of riyy kno&lodga and b s l i e f , ~ ~ e m ~ ~ in
; ~this
~~~tion
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is true, corrsct, and c o t r ~ p l s l e ? ~
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S i g n a t i : ~of S i i r g l ~ ~ E m p l ~Plan
y e r Adniitlistrator
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Print or tjipe first irame cf irrdividoal who s i ~ n s PrJr~tor type last nzms rrf individual who signs

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........... [a) if Soh 6 i a ) i!; che~:kcd, tire amourr; In item 5 ;nultiplied by ij 964; or
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jb: it'box 6(b) rs cl~cckal.rile lesser of

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:Lj $5 rnulripltrd by the sqttnls;.oi'lhc participartt ci)llnl. tn jtcrr~13; F.nrrll 1 . i
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6 . Vart*ble..ra!i: preilnclrrr cap ..chcck one (see i;l:;tmctiollsj

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1s: E 7kc plsn is nclt cl:rir;~ingqualificlst~oninr the cap cn tht: variable-rate prentium fcjr ccrtain platln c!t'small
cmplcycrs (tiioi;e with 25 or k w e r enrp1oye.:-s).
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pk+fi quaiifif%f ~ ihz
l cap on the rnrirbb-nfe pian!laii for ivHain p!acs of s;lla]l emp{cyt;yr (thr.=
~ W P ern[iji.wrcs:.
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