Form MP-400 and Sc Form MP-400 and Sc Missing Participants Program Plan Information for PBGC-I

Missing Participants Program
Plan Information for PBGC-Insured Multiemployer
Defined Benefit Plans

Form MP-400

Approved OMB 1212-####
Expires xx/xx/xxxx

Aug 1 draft

□ Amended Filing-Type 1 □ Amended Filing-Type 2
Part I — Identifying Information
1 Plan information
a Plan name___________________________________________________________________________
b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _
c Plan contact
(1) Name _______________________ (2) Telephone ________________

(3) email __________________

(4) Street address __________________________________________________________________________
(5) City_____________________________

(6) State _____

(7) Zip __________

Part II — Amounts Transferred to PBGC
2 Number of individuals for whom benefits are being transferred to PBGC
a
b
c
3

Number with benefit transfer amounts of $250 or less
Number with benefit transfer amounts in excess of $250
Total
Benefit transfer date

_____________
_____________
_____________
_ _ /_ _/_ _ _ _

4 Amounts owed to PBGC for missing distributees reported in this filing
a Aggregate benefit-related transfer amount [sum of item 5 from all Schedules B]
b Administrative fee [$35 x item 2b]
c Total [item 4a + item 4b]
d Amounts previously paid (in conjunction with prior Forms MP-400 for this plan)
e Net amount due [item 4c – item 4d]

_____________
_____________
_____________
_____________
_____________

Part III — Diligent Search Information
5 Summarize the steps taken to satisfy the diligent search requirements and report the name of any commercial
locator service used to assist with the search: _________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

Part IV — Plan Sponsor Certification
6 Certification of plan sponsor – The plan sponsor must sign and complete this item.
I certify that to the best of my knowledge and belief that: (1) all the information in this filing is true, correct and complete and has been
determined in accordance with PBGC's Missing Participants regulations and instructions, and (2) I have met the diligent search requirements
of 29 CFR § 4050.104.

Name of person signing:

First name _______________ Last name _____________________________

_________________________________
E-mail address
___________________________________________
Signature

_ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _ _
Telephone
_ _ /_ _ /_ _ _ _
Date

Schedule A
(Form MP-400)

Individual Information - Annuity Purchases

Approved OMB 1212-####
Expires xx/xx/xxxx

This Schedule A is # _______ of __________ (insert total # of Schedules A included in this filing)

Part I — Identifying Information
1 Plan sponsor information
a Plan name_________________________________________________________________________________
b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _
2 Insurance company information
a Insurance company name _______________________________________

b Policy number ____________

c Insurance company contact information
(1) Name ____________________

(2) Telephone ________

(3) email __________________

d Insurance company address
(1) Street address ____________________________________________________________________
(2) City_______________________________

(3)
Name

(3) State ____

(4) Zip _________

Part II — Individuals for whom Annuities were Purchased
(4)
(5)
(6)
Social Security
Number

Date of Birth

_ _ _ -_ _ - _ _ _ _

_ _/_ _/_ _ _ _

_ _ _ -_ _ - _ _ _ _

_ _/_ _/_ _ _ _

_ _ _ -_ _ - _ _ _ _

_ _/_ _/_ _ _ _

_ _ _ -_ _ - _ _ _ _

_ _/_ _/_ _ _ _

_ _ _ -_ _ - _ _ _ _

_ _/_ _/_ _ _ _

_ _ _ -_ _ - _ _ _ _

_ _/_ _/_ _ _ _

_ _ _ -_ _ - _ _ _ _

_ _/_ _/_ _ _ _

_ _ _ -_ _ - _ _ _ _

_ _/_ _/_ _ _ _

_ _ _ -_ _ - _ _ _ _

_ _/_ _/_ _ _ _

_ _ _ -_ _ - _ _ _ _

_ _/_ _/_ _ _ _

Certificate
Number

(7)
Enter
applicable code
(Required only if this
is an amended filing)

Schedule B
(Form MP-400)

Individual Information - Transfer to PBGC

Approved OMB 1212-####
Expires xx/xx/xxxx

This Schedule B is # _______ of __________ (insert total # of Schedules B included in this filing)

Part I — Identifying Information
1 Plan sponsor information
a Plan name_________________________________________________________________________________
b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _
2 Missing distributee identifying information
a Missing distributee’s name (last, first, middle) ___________________________________________________
b Social Security Number _ _ _-_ _-_ _ _ _

c Date of birth _ _ /_ _/_ _ _ _

d Last-known address
(1) Street Address______________________________________________________________
(2) City_______________________________

(3) State _____

(4) Zip __________

e Other name(s) ever used (if known)___________________________________________________________
f Type of missing distributee
□ Participant
□ Beneficiary (See instructions re: required attachment)
g Has the missing distributee received any benefit payments from this plan?
□ Yes □ No
(If “yes”, see instructions re: required attachment)

h If any portion of the benefit due is attributable to mandatory employee contributions,
enter the accumulated value of such contributions as of the Benefit Transfer Date

_______________

i If this is an amended filing, enter the applicable code to indicate whether information for

this missing distributee has changed or is being reported for the first time (see instructions).

______

Part II — Benefit-Related Transfer Amount
3 Benefit transfer amount

________________

4 Plan make-up amount, if applicable

________________

5 Total

________________
Part III — Missing Participant Benefit Information

Complete this item only if “Participant” was checked in item 2g and total amount in item 5 exceeds $5,000

6 Lump sum eligibility – Is this participant eligible to elect a lump sum?

□ Yes

□ No

7 Annuity information – Monthly straight life annuity to which participant is entitled assuming benefit
commencement begins at each of the ages below. See instructions for information about which entries may be left blank.
55 _________

58 _________

61 _________

64 _________

67_________

70_________

56 _________

59 _________

62 _________

65 _________

68_________

71_________

57 _________

60 _________

63 _________

66 _________

69_________

RBD_________