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Schedule B Individual data for Transferring Plans - Attachment to Form MP-100 | |||||
Instructions for Using Excel Template | COLOR CODE KEY | Use these color indicators when reviewing your filing spreadsheet to insure you have included all the necessary data and descriptions. | |||
1) | Review the Form MP-100 Instructions before entering data. https://www.pbgc.gov/sites/default/files/form-mp100-instructions.pdf | ![]() |
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2) | Enter the PBGC case number assigned to your plan in the heading of the applicable tab. | ||||
3) | Overwrite the sample data shown with the data that needs to be reported. | ||||
4) | If either Schedule isn't required, delete the non-applicable tab from the spreadsheet. | ||||
5) | Use the appropriate schedule as a guide while filling out this spreadsheet. | ||||
6) | Save your spreadsheet as "Form 100 Excel Attachment_12345600" where "12345600" is the applicable case number of your plan. | ||||
7) | Feel free to add a row at the bottom totalling amounts, counting participants, etc., but please insert a blank row between the individual data and any "total" row you want to add. | ||||
TAB | |||||
Removed via Amendment | Use this Tab for participants that were removed from the Plan Via Amendment, why they were removed and any benefit amount in 8a if a copy of the form is not available. |
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Schedule A individual data - Attachment to Form MP-100 | ||||||||||||||||||||
See instructions for detailed information about data to be entered, including information about which items may be left blank | |||||||||||||||||||||
Case Number | 12345600 | ||||||||||||||||||||
Case Name | ABC | ||||||||||||||||||||
Part I - Insurance Company Information | Part II - Individuals for whom Annuities were Purchased | ||||||||||||||||||||
Company Name | Policy Number | Contact Name | Contact Telephone | Contact Email | Street | City | State | Zip | Missing distributee's name | Date of birth | Social security number | Certificate number | Last-known address | Accrued benefit information | Amended Filing | ||||||
Company Name | Last | First | Middle | (enter w-o dashes) | Street | City | State | Zip | Amount | If monthly, enter MB. If current value, enter CV | Code | ||||||||||
2a | 2b | 2c(1) | 2c(2) | 2c(3) | 2d(1) | 2d(2) | 2d(3) | 2d(4) | 3a(1) | 3a(1) | 3a(1) | 3a(2) | 3a(3) | 3a(4) | 3b(1) | 3b(2) | 3b(3) | 3b(4) | 3c | 3c | 4 |
Annuties-R-Us | ABC123435 | Geraldine Williams | 800-555-1111 | g.williams@ARU.com | 52 Bluebird Drive | Newark | NJ | 07101 | White | Betty | E | 5/5/1955 | 111111111 | 1111111 | 123 Robin Hwy Ave | City1 | DE | 42345 | $35,000.00 | CV | |
Annuties-R-Us | ABC123435 | Geraldine Williams | 800-555-1111 | g.williams@ARU.com | 52 Bluebird Drive | Newark | NJ | 07101 | Yellow | Joseph | F | 6/6/1965 | 222222222 | 2222222 | 123 Blackbird Rd | City2 | WV | 52345 | $150.00 | MB | |
Annuties-R-Us | ABC123435 | Geraldine Williams | 800-555-1111 | g.williams@ARU.com | 52 Bluebird Drive | Newark | NJ | 07101 | Black | Polly | G | 7/7/1970 | 333333333 | 3333333 | 123 Eagle St | City3 | DE | 62345 | $50.00 | MB |
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Schedule B individual data - Attachment to Form MP-100 | ![]() |
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See instructions for detailed information about data to be entered, including information about which items may be left blank | * | ||||||||||||||||||||||||||||||||||||||||||
Case Number | 12345600 | ||||||||||||||||||||||||||||||||||||||||||
Case Name | ABC | ||||||||||||||||||||||||||||||||||||||||||
Part I - Identifying Information | Part II - Amount Owed to PBGC | Part III - Missing Participant Benefit Information | Information if Missing Distributee is a Beneficiary (if answer in 2f is B= Beneficiary) | ||||||||||||||||||||||||||||||||||||||||
Missing distributee's name | Date of | Social Security Number | Last-known address | Other name(s) ever used | Type of distributee | Prior payments | Non-U.S. Source | Employee contributions | Amended filing | Benefit transfer | Administrative fee (if applicable) | Late payment | Lump sum eligibility | Normal retirement | Monthly SLA @ BDD | Monthly Single Life Annuity payable at various ages | Beneficiary's | If participant is deceased | Participant's Last-known address | ||||||||||||||||||||||||
Last | First | Middle | Birth | (enter w-o dashes) | Street | City | State | Zip | (If Beneficiary, Include information in fields to the right) | (Yes or No) | Income (Yes or No) | (Yes or No) | code | amount @ BDD | Amount | Interest | (Yes or No) | date | Age 55 | Age 56 | Age 57 | Age 58 | Age 59 | Age 60 | Age 61 | Age 62 | Age 63 | Age 64 | Age 65 | NRD (or accrual cessation date, if later) | Relationship to Participant Include copy of relevant document (QDRO, beneficiary |
Participant SSN | Participant Name | Date of Death | Street | City | State | Zip | Country | ||||
2a | 2a | 2a | 2b | 2c | 2d(1) | 2d(2) | 2d(3) | 2d(4) | 2e | 2f |
2g |
2h |
2i |
2j | 3 | 4 | 5a | 5b | 6 |
7 | 8a | 8b | 8b | 8b | 8b | 8b | 8b | 8b | 8b | 8b | 8b | 8b | 8b | election form, etc) | |||||||||
White | James | E | 5/5/1955 | 111111111 | 123 Robin Hwy Ave | City1 | DE | 42345 | P | No | No | No | $35,000.00 | $35.00 | $0.00 | $0.00 | Yes | 6/1/2020 | $318.00 | $175.00 | $192.50 | $210.00 | $227.50 | $245.00 | $262.50 | $280.00 | $297.50 | $315.00 | $332.50 | $350.00 | $350.00 | ||||||||||||
Yellow | Joseph | F | 6/6/1965 | 222222222 | 123 Blackbird Rd | City2 | WV | 52345 | P | No | No | No | $10,000.00 | $35.00 | $0.00 | $0.00 | No | 7/1/2030 | $0.00 | $50.00 | $55.00 | $60.00 | $65.00 | $70.00 | $75.00 | $80.00 | $85.00 | $90.00 | $95.00 | $100.00 | $100.00 | ||||||||||||
Black | Polly | G | 7/7/1970 | 333333333 | 123 Eagle St | City3 | DE | 62345 | B | No | No | No | $150.00 | $0.00 | $0.00 | $0.00 | former spouse/AP | 555555555 | John Black | 123 Main St | City3 | DE | 62345 | US | |||||||||||||||||||
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Removed via Amendment data - Attachment to Form MP-100 | ||||||
See instructions for detailed information about data to be entered, including information about which items may be left blank | |||||||
Case Number | 12345600 | ||||||
Case Name | ABC | ||||||
Removed via Amendment | |||||||
Last-known address | |||||||
Distributee SSN | Distributee Name | Street | City | State | Zip | Reason Removed | Amount Adjusted |
123456789 | A Smith | 789 Main St | City 1 | VA | 22151 | Found and paid out | $500.00 |
File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |