MP-200 Template MP-200 Template

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Overview

Instructions
Schedule A
Schedule B
Removed via Amendment

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Sheet 1: Instructions

	Instructions for Completing Excel Template		Schedule B Individual data for Transferring Plans - Attachment to Form MP-200
	Review the Form MP-200 Instructions before entering data. https://www.pbgc.gov/sites/default/files/form-mp200-instructions.pdf		COLOR CODE KEY		Use these color indicators when reviewing your filing spreadsheet to insure you have included all the necessary data and descriptions.
2)	Enter the PBGC case number assigned to your plan and case name in the heading of the applicable tab.
3)	Use the appropriate schedule as a guide while filling out this spreadsheet.
4)	Overwrite the sample data in each tab and populate the applicable tab for:
	- Notifying PBGC of transfer to Financial Institution: Schedule A; or
	- Transferring Funds to PBGC: Schedule B
	- Missing Distributees Removed via Amendment
5)	The item number on the schedule corresponds to the applicable section or question on the Form MP-200
6)	Save your spreadsheet as "Form 200 Excel Attachment_12345600" where "12345600" is the applicable case number of your plan.
7)	Feel free to add a row at the bottom totaling amounts, counting participants, etc., but please insert a blank row between the individual data and any "total" row you want to add.
	Tips for Schedule B
a)	See Color Coding tips to help understand when additional data or an attachment is required.
b)	See Definitions of Qualified and Non-Qualified Roth Transfers to determine if Post-Tax Roth transfers are Qualified.		TAB
c)	Uncashed checks should be transferred to PBGC without any reduction for tax withholdings.		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.
d)	If the administrative fee gets paid out of participant funds, record the amount net of the fee.
e)	If the plan has Other non-taxable benefits, include a description/plan provisions
f)	If the Missing Distributee is a Beneficiary, list the beneficiary's information and include an attachment, or use the Beneficiary tab, to include the originating Participant and why the beneficiary is due money

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Sheet 2: Schedule A

Schedule A individual data for Notifying Plans - Attachment to Form MP-200

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 - Financial Institution Information

Part II - Individual Information

Financial institution information

Financial institution address

Missing distributee's name

Last-known address

Account information

Amended Filing Code

Name

Contact Name

Contact Telephone

Contact Email

Street

City

State

Zip

Last

First

Middle

Date of birth

Social security number (enter without dashes)

Street

City

State

Zip

Account number

Account balance transferred

Use "Removed via Amendment" tab below if needed

2(a)

2b(1)

2b(2)

2b(3)

2c(1)

2c(2)

2c(3)

2c(4)

3a(1)

3a(1)

3a(1)

3a(2)

3b(1)

3b(2)

3b(3)

3b(4)

3c(1)

3c(2)

4

First National Bank

Sarah Parker

(888) 555-2222

[email protected]

502 Mockingbird Street

Atlanta

GA

30301

White

Betty

E

5/5/1955

111111111

123 Robin Hwy Ave

City1

DE

42345

1111111111

$25,000.00

First National Bank

Sarah Parker

8885552222

[email protected]

502 Mockingbird Street

Atlanta

GA

30301

Yellow

Joseph

F

6/6/1965

222222222

123 Blackbird Rd

City2

WV

52345

2222222222

$10,000.00

First National Bank

Sarah Parker

8885552222

[email protected]

502 Mockingbird Street

Atlanta

GA

30301

Black

Polly

G

7/7/1970

333333333

123 Eagle St

City3

DE

62345

3333333333

$2,500.00

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Sheet 3: Schedule B

Schedule B Individual data for Transferring Plans - Attachment to Form MP-200

See instructions for detailed information about data to be entered, including information about which items may be left blank

COLOR CODE KEY

Case Number

33333300

Case Name

Bus. Corp.

Part II - Individual Information

Part III - Transfer Amount

Part IV - Miscellaneous Information

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

Non-US Source Income (If answer in 6 is Yes)

Missing distributee's name

Last-known address

Type of distributee P if Participant B if Beneficiary

Transfer amount attributable to:

Is any portion of the benefit attributable to

Date of 1st Roth Contribution

Beneficiary information

Amended Filing Code

If there are Non-Qualified Roth Benefits

If participant is deceased

Participant's Last-known address

Last

First

Middle

Social security number

Pre-tax Contributions

Post-tax contributions

non-US source income?

(Required only if part of transfer is non-qualified Roth in 4b)

Beneficiary Election Form

(Use code from instructions for

Beneficiary's Relationship to Participant

Portion of

Portion of

Country of

Date of birth

(enter without dashes

Street

City

State

Zip

Other name(s) ever used (if known)

(If Beneficiary, Include information

Qualified Roth Transfers

Non-qualified Roth transfers

Other (Include attachment if greater than $0)

Total Transfer Amount

Enter "Yes" or "No"; if "Yes", include information

(yes or no, if yes include copy of form)

Name

Social Security Number

Relationship

each customer record)

Include copy of relevant document

Participant SSN

Participant Name

Date of Birth, if participant

Was the participant disabled?

Date of Death

Street

City

State

Zip

Country

benefit treated as

benefit treated as

non-US Source Income

Other comments

AGE

& ensure any lead zeroes are included)

in fields to the right)

Total

Total

Contributions

Investment Earnings

Total (auto calculated)

Contributions

Investment Earnings

Total (auto calculated)

Total (auto calculated)

in "Non-US Source Income" fields to the right

(enter without dashes)

Use "Removed via Amendment" tab below if needed

(QDRO, beneficiary election form, etc)

is still living

US Source Income

non-US Source Income

2a

2b

2c

2d(1)

2d(2)

2d(3)

2d(4)

2e

2f

3

4a

4b

4c

5

6

7

8a

8b

8c

8d

9

White

James

E

7/8/1970

111111111

123 Robin Hwy Ave

City1

DE

42345-1234

P

$500.00

$500.00

$100.00

$50.00

$150.00

$0.00

$1,150.00

yes

1/1/2018

no

surviving spouse

444444444

Joan White

No

1/1/2022

123 Robin Hwy Ave

City1

DE

42345-1234

US

75%

25%

Italy

53.33

Yellow

Joe

F

3/2/1964

222222222

123 Blackbird Rd

City2

WV

52345

P

$300.00

$800.00

$0.00

$0.00

$0.00

$0.00

$1,100.00

yes

Mary Yellow

777777777

daughter

59.68

Black

Polly

G

1/1/1960

003333333

123 Eagle St

City3

DE

62345

Johnson

B

$96.69

$0.00

$0.00

$0.00

$0.00

$96.69

1/1/2020

no

former spouse/AP

555555555

John Black

123 Main St

City3

DE

62345

US

63.85

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Sheet 4: Removed via Amendment

	Removed via Amendment data - Attachment to Form MP-200
	See instructions for detailed information about data to be entered, including information about which items may be left blank
	Case Number	33333300
	Case Name	Bus. Corp.
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