Form 200 Notice of Failure to Make Required Contributions

NOTICE OF FAILURE TO MAKE
REQUIRED CONTRIBUTIONS

PBGC Form 200
Approved OMB #Pending
Expires XX/XX/XXXX

File this form to notify the Pension Benefit Guaranty Corporation of a failure to make required contributions to a single-employer plan
that is covered under ERISA §4021 and whose FTAP is less than 100% if the total of unpaid balances, including interest, exceeds $1
million (see ERISA section 303(k)(4)(A) and Code §430(k)(4)(A)). For questions regarding this form, contact (202) 326-4070 or
form200@pbgc gov

GENERAL PLAN INFORMATION

Name of Plan

Plan year commencement date

EIN of contributing sponsor / Plan number

EIN/PN used in previous filings, if different

Plan Administrator:

Contributing Sponsor:

Name of Plan Administrator

Name of Contributing Sponsor

Street address of Plan Administrator

Street address of Contributing Sponsor

City, State, Zip

City, State, Zip

Telephone number

Ext.

Telephone number

Ext.

Individual to Contact:
Name of contact

Street address of contact

Title of contact

City, State, Zip

Email of contact

Telephone number

Ext.

PLAN FUNDING INFORMATION
Due date of required payment that
resulted in requirement to notify PBGC

EXPLANATION

Total unpaid balance of required
payments (including interest)

Describe the required payment that resulted in the requirement to notify PBGC and state how the total unpaid
balance of required payments (including interest) was determined. (See Appendix instructions for details)
Attach additional pages if necessary.

The next page lists additional information that must be submitted with this form, if not included above.

ADDITIONAL INFORMATION TO BE FILED
For each controlled group member:
Name, address, telephone number and EIN of each
controlled group member
Name, address, telephone number and EIN of the ultimate
parent of the controlled group
Name, address, telephone number and EIN of each
contributing sponsor of the plan
Location of all real property owned by each member of
the controlled group
Name and address of the controlled group's principal
executive offices
Operational status of each controlled group member (in
Chapter 7 proceedings, liquidating outside of bankruptcy,
in Chapter 11 proceedings, on-going, etc.)

MISSING INFORMATION

Check box to indicate the item is attached. If not attached, explain below.
Reason contribution was not made by due date
Copy of any IRS letter(s) granting or modifying a funding
waiver and/or extension of the amortization period
Statement describing any pending request(s) for a funding
waiver and/or extension of the amortization period
Actuarial Information (see Form 200 instructions)
Copies of financial statements for the most recent three
fiscal years available, and the most recent available interim
financial statement, for each member of the plan's
controlled group, including the contributing sponsor and
the ultimate parent

If required information has not been submitted with this Form 200, explain below.

FILING INFORMATION

Notice Due Date

Notice Filing Date (if late, explain below)

If filing is late, explain below.

REASON FOR LATE FILING

ENROLLED ACTUARY CERTIFICATION
I certify that, to the best of my knowledge and belief, the Plan Funding Information and related explanation above is true,
correct, and complete and conforms to all applicable laws and regulations. In making this certification, I recognize that
knowingly and willfully making false, fictitious, or fraudulent statements to PBGC is punishable under 18 U.S.C. §1001.
Name

Street address

Enrollment number

City, State, Zip

Company/Firm

Telephone number

Signature

Filing Date

CONTRIBUTING SPONSOR OR PARENT CERTIFICATION
I certify that, to the best of my knowledge and belief, the information provided in this Form 200 is true, correct, and complete, and
conforms to all applicable laws and regulations. In making this certification, I recognize that knowingly and willfully making false,
fictitious, or fraudulent statements to PBGC is punishable under 18 U.S.C. §1001.

Name and Title

Street address

Name of contributing sponsor or parent

City, State, Zip

Signature

Filing Date