MP-200 Form MP-200 and Schedules A and B for Defined Contributi

Missing Participants Program
Plan Information for Defined Contribution Plans

Form MP-200

Approved OMB 1212-0069
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 ___________________________________

e Is plan electing to be a transferring plan or a notifying plan? (check applicable box) □ Transferring □ Notifying
(1)
(2)
(3)
2 Number of missing distributees reported
Account
$250
or
less
Account
more
than
$250
Total
in applicable attached schedules
(Notifying plans may omit breakdown)
________
________
________
3 Amended filings only - Did the original filing contain information on anyone who is no longer considered
missing (i.e., has anyone been removed from the applicable Schedule B)? (attachment required if “Yes”)
Part II — Additional Information for Transferring Plans
4 Default beneficiary provision — Does the plan have a default beneficiary designation provision?
(attachment required if “Yes”)
5 Benefit transfer date

□ Yes
□ No

□ Yes □ No
_ _ /_ _/_ _ _ _

6 Amounts owed to PBGC for missing distributees reported in this filing
a Aggregate account balances [sum of item 5 from all Schedules B]

_____________

b Administrative fee [$35 x number reported in column (2) of item 2]

_____________

c Total [item 5a + item 5b]

_____________

7 Reconciliation (amended filings only)
a Amounts previously paid in conjunction with prior Forms MP-200 for this plan

_____________

b Underpayment/(overpayment) [item 6c – item 7a]

_____________

8 Payment method

□ Pay.gov

□ Other electronic funds transfer

□ Paper check

Part III — Certification
9 Certification – The plan administrator (PA) or qualified termination administrator (QTA) must sign and complete
this item. Check applicable box to indicate the applicable role of the person certifying this filing: □ PA □ QTA
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 § 4050.204.

Name of person signing:

First name _______________ Last name _____________________________

_________________________________
email

_ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _ _
Telephone

___________________________________________
Signature

______________
Date

Schedule A
(Form MP-200)

Individual Information – Notifying Plans

Approved OMB 1212-0069
Expires xx/xx/xxxx

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

Part I — Plan/Financial Institution Information
1 Plan information
a Plan name_________________________________________________________________________________
b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _
c 8-digit PBGC Case # _ _ _ _ _ _ _ _
2 Financial institution information
a Financial institution name ___________________________________________
b Financial institution contact information
(1) Name ____________________
(2) Telephone _ _ _ -_ _ _ - _ _ _ _
(3) email __________________
c Financial institution address
(1) Street address _________________________________________________________________
(2) City_______________________________
(3) State ____
(4) Zip _________
Part II — Individual Information

Complete items 3-4 for each missing individual whose DC account was transferred to a financial institution that you are reporting
to PBGC. 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 _ _ _-_ _-_ _ _ _
b Last-known address
(1) Street address__________________________________________________________________________
(2) City_____________________________

(3) State _____

(4) Zip _________

c Account information
(1) Account number _____________________

(2) Account balance transferred ________________

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 _ _ _-_ _-_ _ _ _
b Last-known address
(1) Street address__________________________________________________________________________
(2) City_____________________________

(3) State _____

(4) Zip _________

c Account information
(1) Account number _____________________

(2) Amount balance transferred ________________

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-200)

Individual Information – Transferring Plans

Approved OMB 1212-0069
Expires xx/xx/xxxx

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

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

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

Part II — Individual Information
2 Missing distributee information – If the participant is deceased, enter information about the missing beneficiary.
a Name (last, first, middle) ___________________________________________________
b Date of birth _ _ /_ _/_ _ _ _

c Social Security Number _ _ _-_ _-_ _ _ _

d Last-known address
(1) Street address______________________________________________________________

(4) Zip
__________
e Other name(s) ever used (if known) ___________________________________________________________
(2) City_______________________________

f Type of missing distributee

□ Participant

(3) State _____

□ Beneficiary (if checked, see instructions re: required attachment)

Part III — Transfer Amount
3 Portion attributable to pre-tax contributions
4 Portion attributable to post-tax contributions

______________
Investment
Earnings

Contributions

a Qualified Roth transfers

Total
_____________

b Non-qualified Roth transfers

____________

______________

_____________

c Other (Attachment required if greater than $0)

____________

______________

_____________

5 Total transfer amount
6 Is any portion of the missing distributee’s benefit attributable to non-US-source income?
□ Yes □ No (Attachment required if “Yes”)

_____________

Part IV— Miscellaneous Information
7 Non-qualified Roth transfer – If the transfer amount includes a non-qualified Roth transfer, enter
the date the first Roth contribution was made. Complete only if amounts are reported in 4b
_ _ /_ _/_ _ _ _
8 Beneficiary Information – Complete only if “Participant” is checked in item 2f
a Do plan records contain a valid beneficiary election form? If yes, attach a copy of the form and
□ Yes □ No
complete items (b)-(d) with respect to the designated beneficiary.
b Name ______________________________________ c Social Security number _ _ _-_ _-_ _ _ _
d Relationship _____________________________________________________
9 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).

_____