Form 200 Form 200 Notice of Failure to Make Required Contributions

Notice of Failure to Make Required Contributions

Form 200_Revised_Clean

Notice of Failure to Make Required Contributions

OMB: 1212-0041

Document [docx]
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Shape2 Name of Plan

NOTICE OF FAILURE TO MAKE REQUIRED CONTRIBUTIONS






Plan year commencement date

PBGC Form 200

OMB #1212-0041

Expires xxxx



EIN of contributing sponsor / Plan number


Plan Administrator:



Name of Plan Administrator



Street address of Plan Administrator



City, State, Zip



Telephone number Ext.


Individual to Contact:



Name of contact



Title of contact



Email of contact

EIN/PN used in previous filings, if different


Contributing Sponsor:



Name of Contributing Sponsor



Street address of Contributing Sponsor



City, State, Zip



Telephone number Ext.





Street address of contact



City, State,Zip



Telephone number Ext.


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Due date of required payment that Amount of required

resulted in requirement to notify PBGC payment that resulted in $

requirement to notify PBGC


Total unpaid balance of required

payments (including interest) $


EXPLANATION

Shape24 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.

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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.)

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


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Notice Due Date Notice Filing Date (if late, explain below)


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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



Enrollment number



Company/Firm



Signature

Street address City, State, Zip


Telephone number Filing Date


Shape40 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

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleForm 200
SubjectForm 200
AuthorPBGC
File Modified0000-00-00
File Created2023-10-23

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