Form 200 Notice of Failure to Make Required Contributions

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

Plan Name

b First day of plan year for which this missed contribution was required
2

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

3a Contributing sponsor
Name
Street Address
City, State, Zip
Telephone number
Email address
b

Employer identification
and plan numbers

9-digit EIN ___________
3-digit PN ___________

c

Different EIN and/or PN
9-digit EIN ___________
used in previous filings
3-digit PN ___________
with PBGC, Department of Labor, or IRS.
Enter “NA” if not applicable.

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Month Day Year

4a
b

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

Yes

No

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?

b

Yes

No

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.
Authorized contact (if same as individual signing certification in item 12, enter “same”).

6

Name
Street Address
City, State, Zip
Telephone number
Email address
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.

Month Day Year

8a Total of unpaid balances of required payments (including interest) $_______________
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 Provide actuarial information (see page 7 of the Form 200 Instructions);
b Most recent month-end market value of plan assets and statement of material changes in liabilities
since the most recent actuarial valuation report;
c Copy of any IRS letter(s) granting or modifying a funding waiver;

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d Submit copies of election letters relating to the application of any carryover balance and/or prefunding
balance in partial payment for a required contribution;

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 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 Description of each controlled group member’s operational status (in Chapter 7 proceedings,
liquidating outside of bankruptcy, on-going, etc.);
c

Information about all controlled group real property, and identity of controlled group head offices

Part IV. Certifications
11

Enrolled Actuary Certification
I certify that, to the best of my knowledge and belief, the information contained in items 7-9 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
Email address
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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