Attorney or Party Name, Address, Telephone and FAX Pro Se Debtor OFFICE OF THE UNITED STATES TRUSTEE LOS ANGELES DIVISION SUBMIT TO UNITED STATES TRUSTEE - Do not file with the Court In Re: Case Number: Employee Benefit Questionnaire Debtor-In-Possession A COPY OF THIS DOCUMENT WILL BE PROVIDED TO THE DEPARTMENT OF LABOR 1. Last Four Digits of EIN: _________________________________________________________________ 2. Debtor maintains _____ Group Health Plan _____ Pension Plan 3. If debtor sponsors a group health or dental plan, complete the information below. If debtor mains no group health or dental plan, check here _____. _____ No Employee Benefit Plans a. Premiums are paid through: _____ employee contributions _____ employer contributions (If premiums are paid partly by the employee and partly by the employer, indicate percentages) b. Are the premium payments current? _____ Yes c. 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) d. Name, address and telephone number of responsible officer: ______________________________ _____ No _______________________________________________________________________________ 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 _____ Profit Sharing Plan _____ Money Purchase Plan b. _____ Defined Benefit Plan _____ Employee Stock Ownership Plan Name, address and telephone number of responsible officer: ______________________________ _______________________________________________________________________________ c. Does the employee make contributions to these plans? _____ Yes _____ No d. Have all employee contributions been forwarded to the trust fund? _____ Yes _____ No e. Are all defined benefit or money purchase plans fully funded? _____ No Revised September 1, 2011 _____ Yes USTLA-8 In Re: Case No.: Debtor. f. 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