200 Notice of Failure to Make Required Contributions

NOTICE OF FAILURE TO MAKE REQUIRED CONTRIBUTIONS
PBGC Form 200
Approved OMB #1212-0041
Expires 03/31/12
File this form to notify the Pension Benefit Guaranty Corporation of a failure to make required
contributions (see ERISA section 303(k)(4)(A) and Code section 430(k)(4)(A)) to a singleemployer 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 funding target attainment percentage (see
ERISA §303(d)(2)/Code §430(d)(2)) 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 Plan Name
b Plan year commencement date Month Day Year
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

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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4a
b

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

YES

NO

If you checked “YES” to item 4a, enter that contributing sponsor’s 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

6

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
8a
b
9

Describe the required payment that resulted in the requirement to notify PBGC.
Due date for the required payment described in item 7a.

Month Day Year

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 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 and/or an extension of the
amortization period; and
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
INFORMATION
10 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:
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; and
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 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
Enrollment Number
Company/ Firm
Telephone number
Signature
Date
12

Contributing Sponsor or Parent Certification
I certify to the best of my knowledge and belief, the information contained in items 7 and 8
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

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false, fictitious, or fraudulent statements to PBGC is punishable under 18 U.S.C. 1001.
Name and Title
Street address
City, State, Zip
Name of contributing sponsor or parent
Telephone Number
Signature
Date

I:\regulatory\RM\Paperwork\1212-0041 Form 200\rollover.1011\Form 200_2012 ROLLOVER_to OMB.doc

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