200 Notice of Failure to Make Required Contributions

I:\regulatory\RM\Paperwork\1212-0041 Form 200\Form 200_Proposed Rule_to OMB 11_09.doc

NOTICE OF FAILURE TO MAKE REQUIRED CONTRIBUTIONS
PBGC Form 200
Approved OMB #1212-0041
Expires xx/xx/xx
File this form to notify the Pension Benefit Guaranty Corporation of a failure to make required
contributions (see ERISA §303(k)(4)(A) and Code §430(k)(4)(A)) to a single-employer plan that
is covered under ERISA §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 funding target attainment percentage is less
than 100 percent.
• Do NOT file this form UNLESS the total of unpaid balances of required payments,
including interest, exceeds $1 million.
Part I. General Plan Information
1a
b
2

Plan Name
First day of plan year for which this missed contribution was required
Plan administrator
Name
Street Address
City, State, Zip
Telephone number

3

Contributing sponsor
Name
Street Address
City, State, Zip
Telephone number
b

Employer identification
and plan numbers

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 ___________

9-digit EIN ___________
3-digit PN ___________

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Month Day Year

4a

Is the contributing sponsor in item 3a member of a controlled group?

Yes

No

b If you checked “YES” to item 4a, identify the contributing sponsor’s ultimate parent (if
none, enter “none”).
Name
Street Address
City, State, Zip
Telephone number
Enter parent’s 9-digit EIN
c

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

d

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.

5a

Is there more than one contributing sponsor?

Yes

No

b If you checked “YES” to item 5a, attach a statement listing, to the extent known, the name
of each contributing sponsor and the address, telephone number, and EIN (or state there is no
EIN) for each contributing sponsor for which this information is not provided in previous items.
6

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

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

b

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

8a

Total of unpaid balances of required payments (including interest)

Month Day Year
$_______________

Compute the total amount in accordance with the Appendix to the Form 200 instructions.

b Attach a spreadsheet showing in detail how the amount in item 8a was calculated. See the
Appendix to the Form 200 instructions for the required information.
9

Submit the following documentation and information with this form:

a Copy of most recent plan actuarial valuation report;
b

Copy of Form 5500, Schedule SB, for most recent plan year for which filed;
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c Copy of any IRS letter(s) granting or modifying a funding waiver;
d Statement describing any pending request(s) for a funding waiver, including the relief
requested.
Part III. Contributing Sponsor & Controlled Group Financial
10

Submit the following documentation with this form with respect to the contributing sponsor
in item 3a and each other member of the contributing sponsor’s controlled group:

a 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 PBGC is punishable under 18 U.S.C. 1001.

Name
Street Address
City, State, Zip
Telephone number
Enrollment number
Company/ Firm
Signature
Date

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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 on 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 PBGC is
punishable under 18 U.S.C. 1001.

Name and title
Street Address
City, State, Zip
Telephone number
Name of contributing sponsor or parent
Signature
Date

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