This is a summary of the annual report for [name of plan] for [period covered by this report].
The annual report has been filed with the Internal Revenue Service, as required under the Employee Retirement Income Security Act of 1974 (ERISA).
Benefits under the plan are provided by [indicate funding arrangements]. Plan expenses were $ _______. These expenses included $ _______ in administrative expenses and $ ________ in benefits paid to participants and beneficiaries, and $ ________ in other expenses. A total of [enter amount] persons were participants in or beneficiaries of the plan at the end of the plan year, although not all of these persons had yet earned the right to receive benefits.
If the plan is funded other than solely by allocated insurance contracts:
The value of plan assets, after subtracting liabilities of the plan, was $ _________ as of [the end of the plan year], compared to $ ________ as of the [beginning of the plan year]. During the plan year, the plan experienced a[n] increase decrease in its net assets of $ ________. This increase decrease includes unrealized appreciation or depreciation in the value of plan assets; that is, the difference between the value of the plan's assets at the end of the year and the value of the assets at the beginning of the year or the cost of assets acquired during the year. The plan had total income of $ _______, including employer contributions of $ _______, employee contributions of $ ______ gains losses of $ _________ from the sale of assets, and earnings from investments of $ _______.
If any funds are used to purchase allocated insurance contracts:
The plan has (a) contract(s) with [name of insurance carrier(s)] which allocate(s) funds toward [state whether individual policies, group deferred annuities, or other]. The total premiums paid for the plan year ending [date] were $ ________.
If the plan is a defined benefit plan:
An actuary's statement shows that enough money was contributed to keep it funded in accordance with the minimum funding standards of ERISA not enough money was contributed to the plan to keep it funded in accordance with the minimum funding standards of ERISA. The amount of the deficit was $ ________.
If the plan is a defined contribution plan covered by funding requirements:
Enough money was contributed to the plan to keep it funded in accordance with the minimum funding standards of ERISA
Not enough money was contributed to the plan to keep it funded in accordance with the minimum funding standards of ERISA. The amount of the deficit was $ _______.
You have the right to receive a copy of the full annual report, or any part thereof on request. The items listed below are included in that report: [Note--list only those items which are actually included in the latest annual report]
To obtain a copy of the full annual report, or any part thereof write or call the office of [name], who is [state title: e.g., the plan administrator], [business address and telephone number]. The charge to cover copying costs will be $ _________, for the full annual report, or $ _________ per page for any part thereof.
You also have the right to receive from the plan administrator, on request and at no charge, a statement of the assets and liabilities of the plan and accompanying notes, or a statement of income and expenses of the plan and accompanying notes, or both. If you request a copy of the full annual report from the plan administrator, these two statements and accompanying notes will be included as part of that report. The charge to cover copying costs given above does not include a charge for the copying of these portions of the report because these portions are furnished without charge. You also have the legally protected right to examine the annual report at the main office of the plan [address] at any location where the report is available for examination, and at the U.S. Department of Labor in Washington, D.C., or to obtain a copy from the U.S. Department of Labor upon payment of copying costs.
Requests to the Department should be addressed to: Public Disclosure Room, N4677, Pension and Welfare Benefits Programs, Department of Labor, 200 Constitution Avenue, NW, Washington, DC 20216.