MP-100 Form MP-100 and Schedules A and B - Single-Employer Defi

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

Form MP-100

Approved OMB 1212-####
Expires xx/xx/xxxx

□ Amended Filing

Part I — General Information
1 Plan information
a Plan name___________________________________________________________________________
b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _

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

d Plan contact
(1) Name __________________________
_
(2) Company ___________________________________
(3) Street address ___________________________________________________________________________
(4) City_____________________________
(5) State _____
(6) Zip __________
(7) Telephone _ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _ _
(8) email _______________________________
2 Number of missing distributees
a Annuity purchases
b Benefits being transferred to PBGC
c Total
3 Benefit determination date (BDD)

(1)
Benefit transfer amounts
more than $250

(2)
Benefit transfer amounts
$250 or less

________

________

(3)
Total
__________
__________
__________
_ _ /_ _/_ _ _ _

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

_____________
_____________
_____________
_____________
_____________
_____________

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 ______________________ Last name _____________________________

_________________________________
email
__________________________________________
Signature

_ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _ _
Telephone
_______________
Date

Individual Information - Annuity Purchases

Schedule A
(Form MP-100)
Approved OMB 1212-####
Expires xx/xx/xxxx

This Schedule A is # _______ of __________ (insert total # of Schedules A included in this filing)

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

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

2 Insurance company information
a Insurance company name______________________________________
b Policy number _____________
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 _ _ /_ _/_ _ _ _

(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).

_____

Individual Information - Transfer to PBGC

Schedule B
(Form MP-100)
Approved OMB 1212-####
Expires xx/xx/xxxx

This Schedule B is # _______ of __________ (insert total # of Schedules B included in this filing)

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 information – If the participant is deceased, enter information about the missing beneficiary.
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”)
h Is any portion of the missing distributee’s benefit attributable to non-U.S. source income
(Attachment required if “Yes”)
i Is any portion of the benefit attributable to employee contributions? (Attachment required if “Yes”)

□ Yes □ No
□ Yes □ No
□ Yes □ No

j Beneficiary information Complete only if “Participant” is checked in item 2f

(1) Does the plan have a default beneficiary designation provision? (Attachment required if “Yes”)

□ Yes □ No

(2) Do plan records contain a valid beneficiary election form? If yes, attach a copy of the form

□ Yes □ No

and complete items (3)-(5) with respect to the designated beneficiary

(3) Name ____________________________________ (4) Social Security Number _ _ _- _ _ - _ _ _ _
(5) Relationship _____________________________________________
k 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)

______________
______________

Form MP-100 Schedule B

Page 2 of 2
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 the
de minimis threshold (i.e., $7,000 if Benefit Determination Date is 1/1/2024 or later, otherwise $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

□ Yes □ No
_ _ /_ _/_ _ _ _

Complete this item only if the participant is over age 55 and eligible to commence benefits at
BDD and has not yet reached Normal Retirement Age.

______________

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 ______________

63 ______________

NRD* _____________

*Or if later, the date benefit accruals ceased.