Form 200 Form 200 Notice of Failure to Make Required Contributions

[LOGO] NOTICE OF FAILURE TO MAKE PBGC Form 200

REQUIRED CONTRIBUTIONS Approved OMB #1212-0041 Expires XX/XX/20XX

File this form to notify the Pension Benefit Guaranty Corporation of a failure to make required contributions to a single-employer plan that is covered under ERISA §4021 if the total of unpaid balances, including interest, exceeds $1 million (see ERISA section 303(k)(4)(A) and Code §430(k)(4)(A)). For questions regarding this form, contact (202) 326-4070 or [email protected].

GENERAL PLAN INFORMATION

____________________________________ Month/Day/Year______________________

Name of Plan Plan year commencement date

____________________________________ ____________________________________

EIN of contributing sponsor / Plan number EIN/PN used in previous filings, if different

Plan Administrator: Contributing Sponsor:

____________________________________ ____________________________________

Name of Plan Administrator Name of Contributing Sponsor

____________________________________ ____________________________________

Street address of Plan Administrator Street Address of Contributing Sponsor

____________________________________ ____________________________________

City, State, Zip City, State, Zip

____________________________________ ____________________________________

Telephone number Ext. Telephone number Ext.

Individual to Contact:

____________________________________

Name of contact

____________________________________

Title of contact

____________________________________

Email address of contact

____________________________________

Street Address of contact

___________________________________

City, State, Zip

____________________________________

Telephone number Ext.

PLAN FUNDING INFORMATION

Month/Day/Year______________________ $____________________________________

Due date of required payment that resulted in Total unpaid balance of required payments (including requirement to notify PBGC interest)

EXPLANATION Describe the required payment that resulted in the requirement to notify PBGC and state how the total unpaid balance of required payments (including interest) was determined (see Appendix to instructions for details). Attach additional pages if necessary.

The next page lists additional information that must be submitted with this form, if not included above.

PBGC Form 200

ADDITIONAL INFORMATION TO BE FILED Check box to indicate the item is attached. If not attached, explain below.

For each controlled group member:

☐ Name, address, telephone number and EIN of each controlled group member

☐ Name, address, and telephone number and EIN of the ultimate parent of the controlled group

☐Name, address, telephone number and EIN of each contributing sponsor of the plan

☐ Location of all real property owned by each member of the controlled group

☐Name and address of the controlled group’s principal executive offices

☐Operational status of each controlled group member (in Chapter 7 proceedings, liquidating outside of bankruptcy, in Chapter 11 proceedings, on-going, etc.)

☐Reason contribution was not made by due date

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

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

☐Actuarial Information (see Form 200 instructions)

☐Copies of financial statements for the most recent three fiscal years available, and the most recent available interim financial statement, for each member of the plan’s controlled group, including the contributing sponsor and the ultimate parent

Missing Information If required information has not been submitted with this Form 200, explain below.

Enrolled Actuary Certification

I certify that, to the best of my knowledge and belief, the Plan Funding Information and related explanation above 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

______________________________________

Enrollment number

______________________________________

Street Address

______________________________________

City, State, Zip

______________________________________ ______________________________________

Company/Firm Telephone number

______________________________________ ______________________________________

Signature

Filing Date

Contributing Sponsor or Parent Certification

I certify that, to the best of my knowledge and belief, the information provided in this Form 200 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

______________________________________

Name of contributing sponsor or parent

______________________________________

Signature

____________________________________

Street Address

____________________________________

City, State, Zip

____________________________________

Filing Date