Schedule MP Schedule MP

Missing Participant Information

Schedule MP
(to forms 501 and 602)
Approved OMB 1212-0036
Expires 12/31/2013

DO NOT SEND PAYMENT WITH THIS FORM.
SEND PAYMENT TO PBGC’S LOCKBOX WITH MISSING PARTICIPANT PAYMENT VOUCHER.
File this form (with Form 501 or Form 602) if the plan purchased irrevocable commitments for one or more Missing Participants or is
paying amounts to PBGC for one or more Missing Participants.

PART I.

PLAN IDENTIFICATION INFORMATION

Check here if you previously filed a Schedule MP for this plan:

1a

If checked, provide date(s) of filing(s):

Plan Name

1b

9-digit employer identification number (EIN)

1c

3-digit plan number (PN)

1d

8-digit PBGC Case #

PART II.
MISSING PARTICIPANT INFORMATION
2a Name and address (mailing or Internet) of commercial locator service(s) used
(1) Relating to this filing (2) Total for all filings

3a
3b
3c

Number of Missing Participants for whom irrevocable commitments were purchased
Number of Missing Participants for whom amounts are due to PBGC

Deemed distribution date (see definition on page 2 of instructions)

PART III.

(MM/DD/YYYY)

AMOUNTS DUE TO PBGC (Sum of the amounts on all Attachments B)
(1) Relating to this filing (2) Total for all filings

4a Total amount of designated benefits
4b Total of other amounts due for Missing Participants
4c Total amount due to PBGC (line 4a + line 4b)
PART IV.
PLAN ADMINISTRATOR CERTIFICATION

$
$
$

$
$
$

I, the Plan Administrator, certify that to the best of my knowledge and belief (1) I have met the diligent search requirements of 29 CFR § 4050.4 and (2)
the information contained in this filing is true, correct and complete. 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.

Plan Administrator’s company’s name and address

Telephone Number

(Address should include room or suite no.)

Plan Administrator’s signature

PART V.

E-mail address (optional)

Print or type name of individual who signs

Date

ENROLLED ACTUARY CERTIFICATION

NOTE: Not required if all benefits for all Missing Participants are distributed through the purchase of irrevocable commitments from an
insurer.
I, the Enrolled Actuary, certify that to the best of my knowledge and belief (1) the actuarial information contained in this filing is true, correct, and
complete and (2) the designated benefits and/or other amounts payable for Missing Participants have been calculated in accordance with applicable
provisions of ERISA and the Internal Revenue Code and regulations promulgated thereunder. 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.

Enrolled Actuary’s company name and address
(Address should include room or suite no.)

Enrolled Actuary’s signature

Date

Enrolled Actuary’s Name (Print or type)

Enrollment Number

Telephone Number

E-mail address (optional)

Missing Participant
Annuity Purchase Information

Attachment A
(to Schedule MP)
Approved OMB 1212-0036
Expires 12/31/2013

Attach Attachment A to (or submit the required information on a separate page or pages with) Schedule MP if the plan purchased
irrevocable commitments from an insurer for one or more Missing Participants. If requested information is not available, write “N/A”
in the space provided. If any Missing Participant’s annuity certificate number is not available, report it when it becomes available. If
irrevocable commitments were purchased from more than one insurer, complete a separate Attachment A for each insurer.
This Attachment A is Number ______ of ______ total Attachments A.

PART I.

PLAN IDENTIFICATION INFORMATION

Check here if you previously filed an Attachment A for this plan:

1a

Plan Name

PART II.
INSURANCE COMPANY INFORMATION
2a Name and address of Insurer

(Address should include room or suite no.)

PART III.

1b

9-digit employer identification number (EIN)

1c

3-digit plan number (PN)

1d

8-digit PBGC Case #

2b

Insurance company contact name

2c

Telephone number

2d

Policy number

ANNUITIZED MISSING PARTICIPANT INFORMATION

Missing Participant full name (last, first, middle)

Spouse or Beneficiary full name (last, first, middle)

Social Security Number

Social Security Number

Date of Birth (MM/DD/YYYY)

Date of Birth (MM/DD/YYYY)

Certificate Number
Monthly Benefit (see instructions)

$

Missing Participant full name (last, first, middle)

Spouse or Beneficiary full name (last, first, middle)

Social Security Number

Social Security Number

Date of Birth (MM/DD/YYYY)

Date of Birth (MM/DD/YYYY)

Certificate Number
Monthly Benefit (see instructions)

$

Missing Participant full name (last, first, middle)

Spouse or Beneficiary full name (last, first, middle)

Social Security Number

Social Security Number

Date of Birth (MM/DD/YYYY)

Date of Birth (MM/DD/YYYY)

Certificate Number
Monthly Benefit (see instructions)

$

Missing Participant full name (last, first, middle)

Spouse or Beneficiary full name (last, first, middle)

Social Security Number

Social Security Number

Date of Birth (MM/DD/YYYY)

Date of Birth (MM/DD/YYYY)

Certificate Number
Monthly Benefit (see instructions)

$

Missing Participant
Individual Information

Attachment B
(to Schedule MP)
Approved OMB 1212-0036
Expires 12/31/2013

File a separate Attachment B for each Missing Participant for whom an amount is due to PBGC. If requested information is not available,
write “N/A” in the space provided.
This Attachment B is Number ______ of ______ total Attachments B.

PART I.

PLAN IDENTIFICATION INFORMATION
1b 9-digit employer identification number (EIN)

1a Plan Name

1c 3-digit plan number (PN)
1d 8-digit PBGC Case #
PART II.

IDENTIFICATION OF MISSING PARTICIPANT

Check here if you previously filed an Attachment B for this individual:

2a

Missing Participant name (last, first, middle)

2b

Social Security Number

2c

Last-known address

2d

Date of birth (MM/DD/YYYY)

2e

Other name(s) ever used (if known)

2f

Sex

2g

Status (check one)

1. Participant

2. Spouse

Female

Male

3. Alternate payee (Attach copy of QDRO)

4. Other beneficiary

(1) Relating to this filing (2) Total for all filings

PART III.
AMOUNTS DUE TO PBGC
3 Category of Designated Benefit (Check 1, 2, 3, or 4)
1. Mandatory lump sum (automatic cashout using plan cashout assumptions
and limits).
2. De minimis lump sum (using PBGC Missing Participant lump sum assumptions).
3. No lump sum (annuity only). Check (a) or (b) below.
3(a). An adjustment (loading) for expenses of $300 is included because the
designated benefit without the loading is greater than $5,000.
3(b). An adjustment (loading) for expenses of $300 is not included because the
designated benefit without the loading is $5,000 or less.
4. Elective lump sum. Check (a) or (b) below.
4(a). An adjustment (loading) for expenses of $300 is included because the
designated benefit amount was determined using the methodology of 29
CFR § 4050.5(a)(3) and the designated benefit amount without the loading
is greater than $5,000.
4(b). An adjustment (loading) for expenses of $300 is not included because
EITHER (1) the designated benefit amount was determined using the
methodology of 29 CFR § 4050.5(a)(1) OR (2) the designated benefit
amount was determined using the methodology of 29 CFR § 4050.5(a)(3)
and the designated benefit amount without the loading is $5,000 or less.

3a Amount of Designated Benefit

$

$

Attachment B • Page 2
Missing Participant’s Social Security No.

3a

(continued)
Yes

Is any part of the Missing Participant’s designated benefit amount attributable
to mandatory employee contributions? If “Yes” complete (1)-(3) below (if “No,” go to 3b).

(1) Relating to this filing

No
(2) Total for all filings

(1) Mandatory employee contributions that fund a portion of the Missing Participant’s
accrued benefit under the plan,

$

$

(2) Interest credited on those contributions to the deemed distribution date

$

$

(3) The total of (1) and (2). The amount in 3a must not be less than this amount.

$

$

(a) Voluntary employee contributions held in a separate account.

$

$

(b) Earnings credited on contributions in (a) to the date sent to PBGC.

$

$

(c) Total of (a) and (b).

$

$

3b

Other amounts due, if any.
Complete (1) if any additional amount is due to PBGC for voluntary employee contributions.
Complete (2) if any amount is due to PBGC for the Missing Participant’s share of residual
assets.
(1) Voluntary employee contributions and earnings

(d) If the amount entered in (1)(c) is not zero, enter the date voluntary contributions
sent to PBGC.

(MM/DD/YYYY)

(2) Residual asssets and earnings
(a) The amount, if any, of residual assets due to PBGC based on a
Missing Participant’s share of residual assets.

$

$

(b) Earnings on residual assets to the date you pay PBGC.

$

$

(c) Total of (a) and (b).

$

$

(d) If the amount entered in (2)(c) is not zero, enter the date residual assets
sent to PBGC.
(3) Total other amounts due, if any, to PBGC (line (1)(c) + line (2)(c)).

3c

(MM/DD/YYYY)

$

$

$

$

Total amount due to PBGC (line 3a + line 3b(3))
Pay this amount

Attachment B • Page 3
Missing Participant’s Social Security No.
Complete item 4 or item 5 or item 6 below (complete only one):
•
For a Missing Participant who is a participant and whose benefit was not in pay status as of the deemed distribution date →
Complete item 4
•
For a Missing Participant who is a beneficiary (including a spouse or alternate payee) and whose benefit was not in pay status
as of the deemed distribution date → Complete item 5
•
For a Missing Participant whose benefit was in pay status as of the deemed distribution → Complete item 6
After completing item 4, item 5 or item 6, go to item 7.

4

For a participant who is missing and whose benefit was not in pay status as of the
deemed distribution date, provide the following information.

4a

Participant’s earliest retirement date (or the deemed distribution date, if later).

4b

Last-known spouse’s full name (last, first, middle)

(MM/DD/YYYY)

Spouse’s Social Security Number

If you checked Category 1 in item 3 above, go to item 7.

4c

Did the participant and last-known spouse waive the QPSA provided under the plan?
If “Yes,” attach waiver.

4d

Spouse’s earliest possible QPSA annuity starting date under the plan (or deemed
distribution date, if later). If the QPSA is payable immediately upon the participant’s
death, enter the deemed distribution date.

4e

Automatic annuity form of retirement benefit that would be payable with respect to the
participant under the plan. Note: Provide the benefit forms for both married and
unmarried participants regardless of the participant’s last-known marital status.

(1) MARRIED PARTICIPANT
If you entered:

Provide this information:

Code 5 or 6

Survivor percentage:

Code 2, 3 or 6

Number of monthly payments in period certain:

Code 4

Temporary annuity period:

Code 10

Other benefit form. Describe the form:

(2) UNMARRIED PARTICIPANT

If you entered:

Provide this information:

Code 5 or 6

Survivor percentage:

Code 2, 3 or 6

Number of monthly payments in period certain:

Code 4

Temporary annuity period:

Code 10

Other benefit form. Describe the form:

5

For a beneficiary (including a participant’s spouse or alternate payee) who is missing
and whose benefit was not in pay status as of the deemed distribution date, complete
the following:

5a

Form of benefit to which the beneficiary or alternate payee is entitled.

If you entered:

Provide this information:

Code 5 or 6

Survivor percentage:

Code 2, 3 or 6

Number of monthly payments in period certain:

Code 4

Temporary annuity period:

Code 10

Other benefit form. Describe the form:

5b

Yes

Earliest date the beneficiary or alternate payee could commence receiving benefits
(or the deemed distribution date, if later).

No

N/A

(MM/DD/YYYY)

Code from table on page 12 in instructions:

%

Code from table on page 12 in instructions:

%

Code from table on page 12 in instructions:

%

(MM/DD/YYYY)

Attachment B • Page 4
Missing Participant’s Social Security No.

6

For a participant or a beneficiary (including a participant’s spouse or alternate payee)
who is missing and whose benefit was in pay status as of the deemed distribution
date, complete the following:

6a

Form of benefit that was in pay status. (Attach a copy of form election, if any.)

Code from table on page 11 in instructions:

If you entered:

Provide this information:

Code 5 or 6

Survivor percentage:

Code 2, 3 or 6

Number of monthly payments in period certain
remaining as of deemed distribution date:

Code 4

Temporary annuity period remaining as of the
deemed distribution date (in months):

Code 7 or 8

Fixed sum remaining as of the deemed distribution date:

Code 10

Other benefit form. Describe the form:

And provide (as applicable):

Date of first missed monthly payment:

Amount of first missed monthly payment:

Plan interest rate for missed payments:

Payments that were due before the deemed distribution date but that were
not made, with interest through the deemed distribution date:

6b

Name of Missing Participant’s beneficiaries, if any (last, first, middle). (Attach a copy
of beneficiary designation form, if any.)

7 Attached Documents. Check all document(s) which are attached:
a Waiver of Qualified Pre-retirement Survivor Annuity (QPSA)
b

Election of optional benefit form

c

Designation(s) of beneficiary

d

Qualified Domestic Relations Order(s) (QDROs)

%

$

(MM/DD/YYYY)

$
%

$

Relationship (e.g., spouse, child, estate)

Social Security Number

Missing Participant
Payment Voucher

Payment Voucher
(to Schedule MP)
Approved OMB 1212-0036
Expires 12/31/2013

Do not send Schedule MP or attachments with this payment voucher.
Send Schedule MP and attachments to PBGC at the address listed in the instructions for where to file.

Use this form if any amount is paid to PBGC for Missing Participants. Send this form (with payment by check or wire transfer information)
to the lockbox address below.

PART I.
PLAN IDENTIFICATION INFORMATION
1a Plan Name

1b

9-digit employer identification number (EIN)

1c 3-digit plan number (PN)

PART II.
2a

8-digit PBGC Case #

2b

Telephone number

2c

E-mail address (optional)

PLAN ADMINISTRATOR CONTACT

Plan Administrator’s name

PART III.

1d

AMOUNTS PAID TO PBGC

Note: The amount enclosed or wired must equal the amount in column (1) of item 4c
of Schedule MP

3a
3b
3c

Check number

If you are using the U.S. Postal Service, send payment (with this voucher) to:

Pension Benefit Guaranty Corporation

P.O. Box 64523

Baltimore, MD 21264-4523

Check
Wire transfer

Amount enclosed or wired. (Make check payable to Pension Benefit Guaranty Corp.)
Date Schedule MP was sent to PBGC

$

(MM/DD/YYYY)

If you are using a delivery service other than the U.S. Postal Service, send payment (with this voucher) to:
M&T Bank
Attn: Lockbox #64523, 8th Floor
1800 Washington Blvd.

Baltimore, MD 21230

If you are using a wire transfer, send wire transfer to:
M&T Bank

Baltimore, Maryland

ABA: 022000046

Account:
191-1428-6

Beneficiary: PBGC

Payment ID line: (MP, the plan’s EIN/PN, and the standard termination case number)

Please use the following format: “MP, EIN/PN: XX-XXXXXXX/XXX, CN: XXXXXXXX.”