Form MP 200 and Sc Missing Participants Program Plan Information for Define

Missing Participants Program
Plan Information for Defined Contribution Plans
□ Amended Filing

Form MP-200

Approved OMB 1212-####
Expires xx/xx/xxxx

Pending OMB approval

Part I — General Information

1 Plan information
a Plan name___________________________________________________________________________
b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _ c 8-digit PBGC Case # _ _ _ _ _ _ _ _
d Plan contact
(1) Name __________________________
(2) Company ___________________________________
(3) Street address ___________________________________________________________________________
(4) City_____________________________
(5) State _____
(6) Zip __________
(7) Telephone _ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _ _

(8) email ___________________________________

e Is plan electing to be a transferring plan or a notifying plan? (check applicable box) □ Transferring □ Notifying
(1)
(2)
(3)
2 Number of Missing Distributees
Account $250 or less
Account more than $250
Total
(Notifying plans may omit breakdown)
________
________
________
3 Amended filings only - Did the original filing contain information on anyone who is no longer considered
missing (i.e., has anyone been removed from the applicable Schedule B)? (attachment required if “Yes”)

□ Yes
□ No

Part II — Additional Information for Transferring Plans
4 Benefit transfer date

_ _ /_ _/_ _ _ _

5 Amounts owed to PBGC for missing distributees reported in this filing
a Aggregate account balances [sum of item 5 from all Schedules B]

_____________

b Administrative fee [$35 x number reported in column (2) of item 2]

_____________

c Total [item 5a + item 5b]

_____________

6 Reconciliation (amended filings only)
a Amounts previously paid in conjunction with prior Forms MP-200 for this plan

_____________

b Underpayment/(overpayment) [item 5c – item 6a]

_____________

7 Payment method

□ Pay.gov

□ Other electronic funds transfer

□ Paper check

8 Default beneficiary provision — Does the plan have a default beneficiary designation provision?

□ Yes □ No

Part III — Certification
9 Certification – The plan administrator or qualified termination administrator must sign and complete this item.
I certify that to the best of my knowledge and belief that all the information in this filing is true, correct and complete and
has been determined in accordance with PBGC's Missing Participants regulations and instructions, including the diligent
search requirements of 29 CFR § 4050.204.

Name of person signing:

First name _______________ Last name _____________________________

_________________________________
email
___________________________________________
Signature

_ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _ _
Telephone
______________
Date

Schedule A
(Form MP-200)

Individual Information - Notifying Plans

Approved OMB 1212-####
Expires xx/xx/xxxx

This Schedule A is # _______ of __________ (insert total # of Schedules A included in this filing)

Part I — Plan/Financial Institution Information
1 Plan information
a Plan name_________________________________________________________________________________
b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _
c 8-digit PBGC Case # _ _ _ _ _ _ _ _
2 Financial institution information
a Financial institution name ___________________________________________
b Financial institution contact information
(1) Name ____________________
(2) Telephone _ _ _ -_ _ _ - _ _ _ _
(3) email __________________
c Financial institution address
(1) Street address _________________________________________________________________
(2) City_______________________________
(3) State ____
(4) Zip _________
Part II — Individual Information

Complete items 3-4 for each missing individual whose DC account was transferred to a financial institution that you are reporting
to PBGC. Use additional schedules as needed.

3 Missing distributee information
a Identifying information
(1) Name (last, first, middle) _______________________________

(2) Date of birth _ _ /_ _/_ _ _ _

(3) Social security number _ _ _-_ _-_ _ _ _
b Last-known address
(1) Street address__________________________________________________________________________
(2) City_____________________________

(3) State _____

(4) Zip _________

c Account information
(1) Account number _____________________

(2) Account balance transferred ________________

4 Amended filing code — If this is an amended filing, enter the applicable code to indicate whether
information for this missing distributee has changed or is being reported for the first time (see instructions).

_____

3 Missing distributee information
a Identifying information
(1) Name (last, first, middle) _______________________________

(2) Date of birth _ _ /_ _/_ _ _ _

(3) Social security number _ _ _-_ _-_ _ _ _
b Last-known address
(1) Street address__________________________________________________________________________
(2) City_____________________________

(3) State _____

(4) Zip _________

c Account information
(1) Account number _____________________

(2) Amount balance transferred ________________

4 Amended filing code — If this is an amended filing, enter the applicable code to indicate whether
information for this missing distributee has changed or is being reported for the first time (see instructions).

_____

Individual Information - Transferring Plans

Schedule B
(Form MP-200)

Approved OMB1212-####
Expires xx/xx/xxxx

This Schedule B is # _______ of __________ (insert total # of Schedules B included in this filing)

Part I — Plan Information
1 Plan information
a Plan name_________________________________________________________________________________
b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _

c 8-digit PBGC Case # _ _ _ _ _ _ _ _

Part II — Individual Information
2 Missing distributee information
a Name (last, first, middle) ___________________________________________________
b Date of birth _ _ /_ _/_ _ _ _

c Social Security Number _ _ _-_ _-_ _ _ _

d Last-known address
(1) Street address______________________________________________________________
(2) City_______________________________

(3) State _____

(4) Zip __________

e Other name(s) ever used (if known)___________________________________________________________
f Type of missing distributee

□ Participant

□ Beneficiary (if checked, see instructions re: required attachment)

Part III — Transfer Amount
3 Non-taxable portion (e.g., Roth contributions and investment earnings on such
contributions)
4 Taxable portion (e.g., pre-tax employee contributions, employer contributions and
investment earnings on non-Roth contributions)
5 Total account balance [item 3 + item 4]

________________
________________
________________

Part IV— Miscellaneous Information
6 Beneficiary Information – Complete only if “Participant” is checked in item 2f

a Do plan records contain a valid beneficiary election form? If yes, attach a copy of the form and
complete items (b)-(d) with respect to the designated beneficiary.

□ Yes □ No

b Name ______________________________________ c Social Security number _ _ _-_ _-_ _ _ _
d Relationship _____________________________________________________
7 Post-tax contributions — Does this missing distributee’s account contain any post-tax employee
□ Yes □ No
contributions other than Roth contributions? (If “yes”, see instructions re: required attachment)
8 Amended filing code — If this is an amended filing, enter the applicable code to indicate whether
_____
information for this missing distributee has changed or is being reported for the first time (see instructions).