U.S. Department of Justice United States Trustees Central District of California 411 W. Fourth St Suite 7160 Santa Ana, CA 92701 (714) 338-3400 FAX (714) 338-3421 915 Wilshire Blvd. Suite 1850 Los Angeles, CA 90017 (213) 894-6811 FAX (213) 894-2603 3801 University Ave.. Suite 720 Riverside, CA 92501 (909) 276-6990 FAX (909) 276-6973 Debtor: Bankruptcy Case # EIN: Employer maintains a group health pension plan Is this a public corporation? Yes No 1. If the debtor sponsors a group health or dental plan, complete the information below. Yes . If No, go to #2. Premiums paid through employee contributions employer contributions Are the premium payments current? Yes No Benefits paid from employee contributions general assets of the company Name, address and telephone number of responsible officer: 2. If the debtor sponsors a pension plan, complete the information below. Yes . If No, go to #3. 401(k) Plan Profit Sharing Plan Defined Benefit Plan Money Purchase Plan Employee Stock Ownership Plan Name, address and telephone number of responsible officer: Does the employee make contributions to the Plan? Yes No Have all employee contributions been forwarded to the trust fund? Yes No If the debtor maintains a defined benefit or money purchase plan, are they fully funded? Have any trustees, officers, owners or board members of the debtor received any distributions form the plan within the last year? If so, please provide the name, address and title for each individual: Have any trustees, officers, owners or board members received any loans from the plan that are not participant loans? If so, please provide the name, address and title for each individual: Has the debtor company received any loans from the plan? If so, please state the approximate date, amount and purpose of the loan. 3. I declare under penalty of perjury that the answers contained in the foregoing question are true and correct to the best of my knowledge. Dated By: A copy of this document will be provided to the Department of Labor Revised August 2018 USTLA-8 American LegalNet, Inc. www.FormsWorkFlow.com