MP-100 Template MP-100 Template
Missing participants
form-mp100-template.xlsx
Missing Participants
OMB: 1212-0069
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1212-0069 can be found here:
Document [xlsx]
Download: xlsx | pdf
Schedule A
Schedule B
Overview
InstructionsSchedule A
Schedule B
Sheet 1: Instructions
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Instructions for Using Excel Template |
| 1. | Review the Form MP-100 instructions before entering data. |
| 2. | Overwrite the sample data shown with the data that needs to be reported. |
| 3. | If either Schedule isn't required, delete the non-applicable tab from the spreadsheet. |
| 4. | Enter the PBGC case number assgined to your plan in the heading of the applicable tab. |
| 5. | Save your spreadsheet as "Form 100 Excel Attachment_12345600" where "12345600" is the applicable case number of your plan. |
| 6. | Feel free to add a row at the bottom totalling amounts, counting participants, etc., but please insert a blank row between the individual data and any "total" row you want to add. |
Sheet 2: Schedule A
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Schedule A individual data - Attachment to Form MP-100 | ||||||||||||||||||||
| See instructions for detailed information about data to be entered, including information about which items may be left blank | |||||||||||||||||||||
| Case Number | 12345600 | ||||||||||||||||||||
| Part I - Insurance Company Information | Part II - Individuals for whom Annuities were Purchased | ||||||||||||||||||||
| Company Name | Policy Number | Contact Name | Contact Telephone | Contact Email | Street | City | State | Zip | Missing distributee's name | Date of birth | Social security number (enter w-o dashes) | Certificate number | Last-known address | Accrued benefit information | Amended Filing Code | ||||||
| Company Name | Last | First | Middle | Street | City | State | Zip | Amount | If monthly, enter MB. If current value, enter CV | ||||||||||||
| 2a | 2b | 2c(1) | 2c(2) | 2c(3) | 2d(1) | 2d(2) | 2d(3) | 2d(4) | 3a(1) | 3a(1) | 3a(1) | 3a(2) | 3a(3) | 3a(4) | 3b(1) | 3b(2) | 3b(3) | 3b(4) | 3c | 3c | 4 |
| Annuties-R-Us | ABC123435 | Geraldine Williams | 800-555-1111 | [email protected] | 52 Bluebird Drive | Newark | NJ | 07101 | White | Betty | E | 5/5/1955 | 111111111 | 1111111 | 123 Robin Hwy Ave | City1 | DE | 42345 | $35,000.00 | CV | |
| Annuties-R-Us | ABC123435 | Geraldine Williams | 800-555-1111 | [email protected] | 52 Bluebird Drive | Newark | NJ | 07101 | Yellow | Joseph | F | 6/6/1965 | 222222222 | 2222222 | 123 Blackbird Rd | City2 | WV | 52345 | $150.00 | MB | |
| Annuties-R-Us | ABC123435 | Geraldine Williams | 800-555-1111 | [email protected] | 52 Bluebird Drive | Newark | NJ | 07101 | Black | Polly | G | 7/7/1970 | 333333333 | 3333333 | 123 Eagle St | City3 | DE | 62345 | $50.00 | MB | |
Sheet 3: Schedule B
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Schedule B individual data - Attachment to Form MP-100 | ||||||||||||||||||||||||||||||||
| See instructions for detailed information about data to be entered, including information about which items may be left blank | * | ||||||||||||||||||||||||||||||||
| Case Number | 12345600 | ||||||||||||||||||||||||||||||||
| Part I - Identifying Information | Part II - Amount Owed to PBGC | Part III - Missing Participant Benefit Information | |||||||||||||||||||||||||||||||
| Missing distributee's name | Date of birth | Social Security Number (enter w-o dashes) | Last-known address | Other name(s) ever used | Type of distributee | Prior payments (Yes or No) | Non-U.S. Source Income (Yes or No) | Employee contributions (Yes or No) | Amended filing code | Benefit transfer amount @ BDD |
Administrative fee (if applicable) | Late payment | Lump sum eligibility (Yes or No) | Normal retirement date | Monthly SLA @ BDD | Monthly Single Life Annuity payable at various ages | |||||||||||||||||
| Last | First | Middle | Street | City | State | Zip | P if Participant B if Beneficiary | Amount | Interest | Age 55 | Age 56 | Age 57 | Age 58 | Age 59 | Age 60 | Age 61 | Age 62 | Age 63 | Age 64 | Age 65 | NRD (or accrual cessation date, if later) | ||||||||||||
| 2a | 2a | 2a | 2b | 2c | 2d(1) | 2d(2) | 2d(3) | 2d(4) | 2e | 2f |
2g |
2h |
2i |
2j | 3 | 4 | 5a | 5b | 6 |
7 | 8a | 8b | 8b | 8b | 8b | 8b | 8b | 8b | 8b | 8b | 8b | 8b | 8b |
| White | James | E | 5/5/1955 | 111111111 | 123 Robin Hwy Ave | City1 | DE | 42345 | P | No | No | No | $35,000.00 | $35.00 | $0.00 | $0.00 | Yes | 6/1/2020 | $318.00 | $175.00 | $192.50 | $210.00 | $227.50 | $245.00 | $262.50 | $280.00 | $297.50 | $315.00 | $332.50 | $350.00 | $350.00 | ||
| Yellow | Joseph | F | 6/6/1965 | 222222222 | 123 Blackbird Rd | City2 | WV | 52345 | P | No | No | No | $10,000.00 | $35.00 | $0.00 | $0.00 | No | 7/1/2030 | $0.00 | $50.00 | $55.00 | $60.00 | $65.00 | $70.00 | $75.00 | $80.00 | $85.00 | $90.00 | $95.00 | $100.00 | $100.00 | ||
| Black | Polly | G | 7/7/1970 | 333333333 | 123 Eagle St | City3 | DE | 62345 | B | No | No | No | $150.00 | $0.00 | $0.00 | $0.00 | |||||||||||||||||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |
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