California > Federal > USBC Central > US Trustee
Employee Benefit Questionnaire (Los Angeles Division) USTLA-8 - California
| Employee Benefit Questionnaire (Los Angeles Division) Form. This is a California form and can be used in US Trustee USBC Central Federal . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Attorney or Party Name, Address, Telephone and FAX Pro Se Debtor OFFICE OF THE UNITED STATES TRUSTEE LOS ANGELES DIVISION In Re: SUBMIT TO UNITED STATES TRUSTEE - Do not file with the Court Case Number: Employee Benefit Questionnaire Debtor-In-Possession A COPY OF THIS DOCUMENT WILL BE PROVIDED TO THE DEPARTMENT OF LABOR 1. 2. 3. Last Four Digits of EIN: _________________________________________________________________ Debtor maintains _____ Group Health Plan _____ Pension Plan _____ No Employee Benefit Plans If debtor sponsors a group health or dental plan, complete the information below. If debtor mains no group health or dental plan, check here _____. a. b. c. d. Premiums are paid through: _____ employee contributions _____ employer contributions (If premiums are paid partly by the employee and partly by the employer, indicate percentages) Are the premium payments current? _____ Yes _____ No Benefits are paid from: _____ employee contributions _____ general assets of the company (If benefits are paid partly by the employee and partly by the employer, indicate percentages) Name, address and telephone number of responsible officer: ______________________________ _______________________________________________________________________________ 4. If the debtor sponsors a pension plan, complete the following information. If debtor does not sponsor a pension plan, check here _____. a. Debtor sponsors the following pension plans (check all that apply): _____ 40l(k) Plan b. c. d. e. _____ Profit Sharing Plan _____ Defined Benefit Plan _____ Employee Stock Ownership Plan _____ Money Purchase Plan Name, address and telephone number of responsible officer: ______________________________ _______________________________________________________________________________ Does the employee make contributions to these plans? Are all defined benefit or money purchase plans fully funded? _____ Yes _____ Yes _____ No _____ No _____ No Have all employee contributions been forwarded to the trust fund? _____ Yes Revised September 1, 2011 USTLA-8 In Re: Debtor. f. Case No.: Have any trustees, officers, owners or board members of the debtor received any distributions from the plan within the last year? _____ Yes _____ No. If yes, please provide the name, address and title for each individual: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ g. Has the debtor received any loans from the plan? _____ Yes _____ No. If yes, state the approximate date, amount and purpose of the loan: ______________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ I declare under penalty of perjury that the answers set forth above are true and correct to the best of my knowledge. Dated: Signature of Debtor APPROVED: Dated: Law Firm Name By: Attorney for Debtor or Debtor In Pro Per (Image of Original Signatures Required) Revised September 1, 2011 USTLA-8
|
|||||||
