Form MP-100 Template MP-100 Template MP-100 Template

---

Overview

Instructions
Schedule A
Schedule B
Removed via Amendment

---

Sheet 1: Instructions

			Schedule B Individual data for Transferring Plans - Attachment to Form MP-100
	Instructions for Using Excel Template		COLOR CODE KEY		Use these color indicators when reviewing your filing spreadsheet to insure you have included all the necessary data and descriptions.
1)	Review the Form MP-100 Instructions before entering data. https://www.pbgc.gov/sites/default/files/form-mp100-instructions.pdf
2)	Enter the PBGC case number assigned to your plan in the heading of the applicable tab.
3)	Overwrite the sample data shown with the data that needs to be reported.
4)	If either Schedule isn't required, delete the non-applicable tab from the spreadsheet.
5)	Use the appropriate schedule as a guide while filling out this spreadsheet.
6)	Save your spreadsheet as "Form 100 Excel Attachment_12345600" where "12345600" is the applicable case number of your plan.
7)	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.
			TAB
			Removed via Amendment		Use this Tab for participants that were removed from the Plan Via Amendment, why they were removed and any benefit amount in 8a if a copy of the form is not available.

---

Sheet 2: Schedule A

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

Case Name

ABC

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

Certificate number

Last-known address

Accrued benefit information

Amended Filing

Company Name

Last

First

Middle

(enter w-o dashes)

Street

City

State

Zip

Amount

If monthly, enter MB. If current value, enter CV

Code

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

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

Case Name

ABC

Part I - Identifying Information

Part II - Amount Owed to PBGC

Part III - Missing Participant Benefit Information

Information if Missing Distributee is a Beneficiary (if answer in 2f is B= Beneficiary)

Missing distributee's name

Date of

Social Security Number

Last-known address

Other name(s) ever used

Type of distributee

Prior payments

Non-U.S. Source

Employee contributions

Amended filing

Benefit transfer

Administrative fee (if applicable)

Late payment

Lump sum eligibility

Normal retirement

Monthly SLA @ BDD

Monthly Single Life Annuity payable at various ages

Beneficiary's

If participant is deceased

Participant's Last-known address

Last

First

Middle

Birth

(enter w-o dashes)

Street

City

State

Zip

(If Beneficiary, Include information in fields to the right)

(Yes or No)

Income (Yes or No)

(Yes or No)

code

amount @ BDD

Amount

Interest

(Yes or No)

date

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)

Relationship to Participant Include copy of relevant document (QDRO, beneficiary

Participant SSN

Participant Name

Date of Death

Street

City

State

Zip

Country

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

election form, etc)

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

former spouse/AP

555555555

John Black

123 Main St

City3

DE

62345

US

---

Sheet 4: Removed via Amendment

	Removed via Amendment 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
	Case Name	ABC
Removed via Amendment
		Last-known address
Distributee SSN	Distributee Name	Street	City	State	Zip	Reason Removed	Amount Adjusted
123456789	A Smith	789 Main St	City 1	VA	22151	Found and paid out	$500.00