Form MP-100 Missing Participants Program - Plan Information for Sing

Form MP-100

Missing Participants Program
Plan Information for Single-Employer DB Plans Insured
by PBGC
□ Amended Filing

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Expires XXXX

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Part I — General Information

1 Plan information
a Plan name

b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _
d Plan contact
(1) Name

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

(2) Company

(3) Street address
(4) City
(7) Telephone _ _ _ -_ _ _ - _ _ _ _ ext
2 Number of missing distributees
a Annuity purchases
b Benefits being transferred to PBGC
c Total
3 Benefit determination date (BDD)

(5) State
(8) email

(6) Zip

(1)
Benefit transfer amounts
more than $250

(2)
Benefit transfer amounts
$250 or less

(3)
Total
_
_0
_0
________
U

U

U

U

U

U

4 Commercial locator service(s) used (if any)
5 Amended filings only - Did the original filing contain information on anyone who is not reported in this
amended filing (i.e., has anyone been removed from Schedule A or B)? (attachment required if “Yes”)
Part II — Amount due to PBGC
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 item 2b from column (1) or sum of item 4 from all Schedules B]
c Aggregate late payment charge [sum of item 5b from all Schedules B]
d Total [item 6a + item 6b + item 6c]
7 Reconciliation (amended filings only)
a Amounts previously paid in conjunction with prior Forms MP-100 for this plan
b Underpayment/(overpayment) [item 6d – item 7a]
8 Payment method
□ Pay.gov □ Other electronic funds transfer
□ Paper check

□ Yes
□ No

$ 0.00

$ 0.00

Part III— Plan Administrator Certification
9 Certification of plan administrator – 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 § 4050.104.

Name of person signing:

First name
email
Signature

U

U

Last name
_ _ _ - ___________ ext
Telephone
Date

Schedule A
(Form MP-100)

Individual Information - Annuity Purchases
This Schedule A is #

of

(insert total # of Schedules A included in this filing)

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

c 8-digit PBGC Case # _ _ _ _ _ _ _ _
b Policy number

U

_

U

c Insurance company contact information
(1) Name
(2) Telephone _ _ _ -_ _ _ - _ _ _ _ (3) email
d Insurance company address
(1) Street address
(2) City
(3) State
(4) Zip
Part II — Individuals for whom Annuities were Purchased

Complete items 3-4 for each missing individual for whom an annuity was purchased. If more than two individuals need to be
reported, 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 _ _ _-_ _-_ _ _ _

(4) Certificate #

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

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 _ _ _ _ _ _ _ _
(4) Certificate

(3) Social security number _ _ _-_ _-_ _ _ _

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

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).

_____

Schedule B
(Form MP-100)

Individual Information - Transfer to PBGC
This Schedule B is #

of

(insert total # of Schedules B included in this filing)

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Expires XXXX

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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-100 _ _ _ _ _ _ _ _
2 Missing distributee identifying 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 missing distributee’s benefit attributable to non-U.S.-source income?

□ Yes □ No

(Attachment required if “Yes”)

______

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

□ Yes □ No

j 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 – Amount Owed to PBGC

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

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.

□ Yes □ No

___

______

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

*Or if later, the date benefit accruals ceased.

63

NRD*