MP-400 Template MP-400 Template

Missing participants

form-mp400_OMB.xlsx

OMB: 1212-0069

Document [xlsx]
Download: xlsx | pdf

Overview

Instructions
Schedule A
Schedule B
Removed via Amendment


Sheet 1: Instructions









Schedule B Individual data for Transferring Plans - Attachment to Form MP-400

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-400 Instructions before entering data. https://www.pbgc.gov/sites/default/files/form-mp400-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 400 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-400



















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









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-400









































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 birth Social Security Number (enter w-o dashes) Last-known address Other name(s) ever used Type of distributee Prior payments Non-U.S. Source Income Employee contributions Amended filing Benefit transfer Administrative fee 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

Street City State Zip
P if Participant
B if Beneficiary
(Yes or No) Income (Yes or No) (Yes or No) code amount @ BDD (if applicable) 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-400





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
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File Modified0000-00-00
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