Form 200 Notice of Failure to Make Required Contributions

PBGC Form 200
Approved OMB #1212-0041
Expires 02/28/09

NOTICE OF FAILURE TO MAKE
REQUIRED CONTRIBUTIONS

File this form to notify the Pension Benefit Guaranty Corporation of a failure to make required contributions (see ERISA
section 302(f)(4)(A) and Code section 412(n)(4)(A)) to a single-employer plan that is covered under ERISA section
4021.
Do NOT file this form for any other employee benefit plan (e.g., a defined contribution plan).
Do NOT file this form with the Internal Revenue Service.
Do NOT file this form UNLESS the plan's funded current liability percentage is less than 100 percent.
Do NOT file this form UNLESS the total of unpaid balances of required payments exceeds $1 million.
PART I. GENERAL PLAN INFORMATION
1a

Plan name

b. Plan year commencement date
Month

2

Plan administrator
Name
Street address
City, State, Zip
Telephone number

3a

Contributing sponsor
Name
Street address
City, State, Zip
Telephone number

b

Employer identification and
plan numbers

9-digit EIN
3-digit PN

c

Different EIN and/or PN used in
previous filings with PBGC, DOL,

or IRS. Enter "NA" if not applicable.

9-digit EIN

3-digit PN

Day

Year

200-Page 2
4a

b

Is the contributing sponsor in item 3a
a member of a controlled group?
If you checked "YES" to item
4a, enter that contributing
sponsor's parent (if none,
enter "none").

YES

NO

Name
Street address
City, State, Zip
Telephone number
Enter parent's 9-digit EIN

c

d

5a
b

6

If you checked "YES" to item 4a, are there any

controlled group members other than the
one(s) identified in item 3a and/or item 4b?

YES

NO

If you checked "YES" to item 4c, submit the name, address, telephone number, and EIN of each controlled group

member for which information is not provided in item 3a or item 4b and a description of the structure of the

controlled group.

Is there more than one contributing sponsor?

YES

NO

If you checked "YES" to item 5a, submit the name of each contributing sponsor and, for each contributing sponsor
for which information is not provided in previous items, the address, telephone number, and EIN.

Authorized contact (if same as

individual signing certification
in item 12, enter "same").

Name

Street address
City, State, Zip
Telephone number

PART II. PLAN FUNDING INFORMATION
7a

b

Describe the required payment that resulted in the requirement to notify the PBGC.

Due date for the required payment
described in item 7a.

Month

Day

Year

200-Page 3
8a

b

9

Total of unpaid balances of required
payments (including interest).

$

Describe how the amount in item 8a was determined.

Submit the following documentation and information with this form:
a

Copy of most recent plan actuarial valuation report;

b

Copy of Form 5500, Schedule B, for most recent plan year for which filed;

c

Copy of any IRS letter(s) granting or modifying a funding waiver and/or an extension of the amortization period;

d

Statement describing any pending request(s) for a funding waiver and/or for an extension of the amortization
period.

PART III. CONTRIBUTING SPONSOR & CONTROLLED GROUP FINANCIAL
10
a

Submit the following documentation with this form with respect to the contributing sponsor in item 3a and each
other member of the same controlled group as that contributing sponsor:
Copies of financial statements for the most recent three fiscal years for which available and of the most recent
interim financial statements;

b Copies of any SEC filings during the past 6 months, including Form 10-K, Form 10-Q, and Form 8-K;
c

If any member of the controlled group currently is the subject of a bankruptcy, insolvency, receivership, or similar
proceeding, copies of any Statement of Affairs, Disclosure Statement, and Plan of Reorganization (or similar
filing(s)) and interim financial reports filed in such proceeding.

PART IV. CERTIFICATIONS
11

Enrolled Actuary Certification.
I certify that, to the best of my knowledge and belief, the information contained in items 7 and 8 of this form 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 the PBGC is punishable under 18
U.S.C. 1001.

Name

Street address

Enrollment number

City, State, Zip

Company / Firm

Telephone number

Signature

Date

200-Page 4
12

Contributing Sponsor or Parent Certification.
I certify that, to the best of my knowledge and belief, the information made available to the enrolled actuary and all
other information and documentation in this filing 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 the PBGC is punishable under 18 U.S.C. 1001.

Name and title

Street address

Name of contributing sponsor or parent

City, State, Zip
Telephone number

Signature

Date