Form MP 300 and Sc Form MP 300 and Sc Missing Participants Program Plan Information for PBGC N

Missing Participants Program
Plan Information for
Small Professional Service DB Plans

Form MP-300

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

□ Amended Filing

Pending OMB approval

Part I — General Information
1 Plan information
a Plan name___________________________________________________________________________
b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _ c 8-digit PBGC Case # _ _ _ _ _ _ _ _
d Plan contact
(1) Name __________________________
(2) Company ___________________________________
(3) Street address ___________________________________________________________________________
(4) City_____________________________
(5) State _____
(6) Zip __________
(7) Telephone ____________________

(8) email ___________________________________

e Is plan electing to be a transferring plan or a notifying plan? (check applicable box) □ Transferring □ Notifying
(1)
(2)
(3)
2 Number of individuals reported in
Benefit transfer amounts
Benefit transfer amounts
Total
applicable attached schedules
$250 or less
more than $250
(Notifying plans may omit breakdown)
________
________
________
3 Benefit determination date (BDD)

_ _ /_ _/_ _ _

4 Commercial locator service(s) used (if any) ___________________________________________________________
5 Amended filings only - Did the original filing contain information on anyone who is no longer considered
missing (i.e., has anyone been removed from the applicable Schedule B)? (attachment required if “Yes”)

□ Yes
□ No

Part II — Additional Information for Transferring Plans
6 Amounts owed to PBGC for missing distributees reported in this filing
a Aggregate benefit transfer amount as of BDD [sum of item 3 from all Schedules B]

_____________

b Administrative fee [$35 x number reported in column (2) of item (2)]

_____________

c Aggregate late payment charge [sum of item 5b from all Schedules B]

_____________

d Subtotal [item 5a + item 5b]

_____________

7 Reconciliation (amended filings only)
a Amounts previously paid in conjunction with prior Forms MP-300 for this plan

_____________

b Underpayment/(overpayment) [item 5c – item 6a]

_____________

8 Payment method

□ Pay.gov

□ Other electronic funds transfer

□ Paper check

Part III — Certification
9 Certification – The plan administrator must sign and complete this item.
I certify that to the best of my knowledge and belief that 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, including the diligent
search requirements of 29 CFR § 4050.304.

Name of person signing:

First name _______________ Last name _____________________________

_________________________________
e-mail
___________________________________________
Signature

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

Schedule A
(Form MP-300)

Individual Information - Notifying Plans

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

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

Part I — Plan/Financial Institution Information
1 Plan sponsor information
a Plan name_________________________________________________________________________________
b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _
c 8-digit PBGC Case # _ _ _ _ _ _ _ _
2 Financial institution information
a Financial institution name ___________________________________________
b Financial institution contact information
(1) Name ____________________
(2) Telephone ________
(3) email __________________
c Financial institution address
(1) Street address _________________________________________________________________
(2) City_______________________________
(3) State ____
(4) Zip _________
Part II — Individual Information

Complete items 3-4 for each missing individual whose benefit was transferred to a financial institution that you are reporting to
PBGC. Use additional schedules as needed.

3 Missing distributee information
a Identifying information
(1) Name (last, first, middle) _______________________________

(2) Date of birth _ _ /_ _/_ _ _ _

(3) Social security number _ _ _-_ _-_ _ _ _
b Last-known address
(1) Street address__________________________________________________________________________
(2) City_____________________________

(3) State _____

c Accrued benefit (enter amount and check applicable box) ___________
d Account/certificate number (f applicable) ___________

(4) Zip _________
□ Monthly benefit □ Current value

4 Amended filing code — 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).

_____

3 Missing distributee information
a Identifying information
(1) Name (last, first, middle) _______________________________

(2) Date of birth _ _ /_ _/_ _ _ _

(3) Social security number _ _ _-_ _-_ _ _ _
b Last-known address
(1) Street address__________________________________________________________________________
(2) City_____________________________

(3) State _____

c Accrued benefit (enter amount and check applicable box) ___________

(4) Zip _________
□ Monthly benefit □ Current value

d Account/certificate number (f applicable) ___________
4 Amended filing code — 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).

_____

Individual Information – Transferring Plans

Schedule B
(Form MP-300)
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 information
a Plan name_________________________________________________________________________________
b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _

c 8-digit PBGC Case # _ _ _ _ _ _ _ _

d Benefit determination date (BDD) per Form MP-300 _ _ /_ _/_ _ _ _
2 Missing distributee information
a Missing distributee’s name (last, first, middle) ___________________________________________________
b Date of birth _ _ /_ _/_ _ _ _

c Social Security Number _ _ _-_ _-_ _ _ _

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 missing distributee received any benefit payments from this plan? (Attachment required if “Yes”)

□ Yes □ No

h Is any portion of the benefit attributable to employee contributions? ( Attachment required if “Yes”)

□ Yes □ No

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 Benefit transfer amount as of benefit determination date (BDD)

______________

4 Administrative fee (if item 3 > $250, enter $35, otherwise enter $0)

______________

5 Late payment charge
a Late payment (Portion of item 3 transferred, or to be transferred, more than 90 days after BDD)
b Interest owed on late payment (If item 5a is $0, enter $0; otherwise, see instructions)

______________
______________

Part III — Missing Participant Benefit Information

Complete this part only if “Participant” was checked in item 2f, “no” was checked in item 2g, and amount in item 3 exceeds $5,000

6 Lump sum eligibility – Was participant eligible to elect a lump sum?
7 Normal retirement date*
8 Annuity information
a Monthly straight life annuity payable starting at Benefit Determination Date

□ Yes □ No
_ _ /_ _/_ _ _ _

Complete this item only if the participant is over age 55 and eligible to commence benefits at
the BDD and has not yet reached Normal Retirement Age.

______________

b Monthly straight life annuity payable that the participant is entitled to assuming payments commence at each
applicable age below. Enter N/A for ages/dates: (a) after the participant’s NRD*; (b) before the participant would have
been eligible to commence benefits had the plan not terminated; or (c) before BDD.

55 _____________

58 ______________

61 ______________

64 _______________

56 _____________

59 ______________

62 ______________

65 _______________

57 _____________

60 ______________

63 ______________

NRD* _____________

*Or if later, the date benefit accruals ceased.