Form MP-200 and Sc Missing Participants Program Plan Information for Define

Missing Participants Program
Plan Information for Defined Contribution Plans

Form MP-200

□ Amended Filing-Type 1 □ Amended Filing-Type 2

July 29th draft

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

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 __________

d Does the plan have a default beneficiary designation provision (notifying plans may skip this item) □ Yes □ No
Part II — Amounts Transferred to PBGC
2 Number of distributees whose account balances are being transferred to PBGC
a Number with accounts of $250 or less
b Number with accounts in excess of $250
c Total

_____________
_____________
_____________

3 Benefit Transfer Date

_ _ /_ _/_ _ _ _

4 Amounts owed to PBGC for missing distributees reported in this filing
a Aggregate account balances [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-200 for this plan)

_____________

e Net amount due [item 4c – item 4d]

_____________

Part III —Certification
5 Certification – The plan administrator or qualified termination administrator 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 § 4050.204.

Name of person signing:

First name _______________ Last name _____________________________

_________________________________
E-mail address
___________________________________________
Signature

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

Schedule A
(Form MP-200)

Individual Information
Transfers to Financial Institution

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 Institution information
a Institution name _______________________________________

b Account number ____________

c Institution contact information
(1) Name ____________________

(2) Telephone ________

(3) email __________________

d Institution address
(1) Street address _________________________________________________________________
(2) City_______________________________

(3) State ____

(4) Zip _________

Part II — Individuals for whom accounts were transferred to the institution reported in item (2)
(3)
(4)
(5)
(6)
(7)
Enter
Account
Social Security
applicable
code
Date of Birth
Name
Number
Number
(Required only if this
is an amended filing)

_ _ _ -_ _ - _ _ _ _

_ _/_ _/_ _ _ _

_ _ _ -_ _ - _ _ _ _

_ _/_ _/_ _ _ _

_ _ _ -_ _ - _ _ _ _

_ _/_ _/_ _ _ _

_ _ _ -_ _ - _ _ _ _

_ _/_ _/_ _ _ _

_ _ _ -_ _ - _ _ _ _

_ _/_ _/_ _ _ _

_ _ _ -_ _ - _ _ _ _

_ _/_ _/_ _ _ _

_ _ _ -_ _ - _ _ _ _

_ _/_ _/_ _ _ _

_ _ _ -_ _ - _ _ _ _

_ _/_ _/_ _ _ _

_ _ _ -_ _ - _ _ _ _

_ _/_ _/_ _ _ _

_ _ _ -_ _ - _ _ _ _

_ _/_ _/_ _ _ _

Individual Information
Transfers to PBGC

Schedule B
(Form MP-200)
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 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 Beneficiary Information – Complete only if “Participant” is checked in item 2g

(1) Do plan records contain a valid beneficiary election form? If yes, attach a copy of the

□ Yes □ No

form and complete items (2)-(4) with respect to the designated beneficiary.

(2) Name __________________________________ (3) Social Security number _ _ _-_ _-_ _ _ _
(4) Relationship _____________________________________________________
h Does this missing distributee’s account contain any post-tax employee contributions other
than Roth contributions. (If “yes”, see instructions re: required attachment)
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 — Transfer Amount
3 Non-taxable portion (e.g., Roth contributions and investment earnings on such
contributions)
4 Taxable portion (e.g., pre-tax employee contributions, employer contributions and
investment earnings on non-Roth contributions)
5 Total account balance

□ Yes □ No
______

________________
________________
________________