Form 200 Notice of Failure to Make Required Contributions

Name of Plan

NOTICE OF FAILURE TO MAKE REQUIRED CONTRIBUTIONS

Plan year commencement date

PBGC Form 200

OMB #1212-0041

Expires xxxx

EIN of contributing sponsor / Plan number

Plan Administrator:

Name of Plan Administrator

Street address of Plan Administrator

City, State, Zip

Telephone number Ext.

Individual to Contact:

Name of contact

Title of contact

Email of contact

EIN/PN used in previous filings, if different

Contributing Sponsor:

Name of Contributing Sponsor

Street address of Contributing Sponsor

City, State, Zip

Telephone number Ext.

Street address of contact

City, State,Zip

Telephone number Ext.

Due date of required payment that ^{Amount of required}

^resulted in requirement to notify PBGC ^{payment that resulted in $}

^{requirement to notify PBGC}

^{Total unpaid balance of required}

^{payments (including interest) $}

EXPLANATION

Describe the required payment that resulted in the requirement to notify PBGC and state how the total unpaid balance of required payments (including interest) was determined. (See Appendix instructions for details) Attach additional pages if necessary.

The next page lists additional information that must be submitted with this form, if not included above.

For each controlled group member:

Name, address, telephone number and EIN of each controlled group member

Name, address, telephone number and EIN of the ultimate parent of the controlled group

Name, address, telephone number and EIN of each contributing sponsor of the plan

Location of all real property owned by each member of the controlled group

Name and address of the controlled group's principal executive offices

Operational status of each controlled group member (in Chapter 7 proceedings, liquidating outside of bankruptcy, in Chapter 11 proceedings, on-going, etc.)

Reason contribution was not made by due date

Copy of any IRS letter(s) granting or modifying a funding waiver and/or extension of the amortization period

Statement describing any pending request(s) for a funding waiver and/or extension of the amortization period

Actuarial Information (see Form 200 instructions)

Copies of financial statements for the most recent three fiscal years available, and the most recent available interim financial statement, for each member of the plan's controlled group, including the contributing sponsor and the ultimate parent

Notice Due Date Notice Filing Date (if late, explain below)

I certify that, to the best of my knowledge and belief, the Plan Funding Information and related explanation above is true, correct, and complete and conforms to all applicable laws and regulations. In making this certification, I recognize that knowingly and willfully making false, fictitious, or fraudulent statements to PBGC is punishable under 18 U.S.C. §1001.

Name

Enrollment number

Company/Firm

Signature

Street address City, State, Zip

Telephone number Filing Date

I certify that, to the best of my knowledge and belief, the information provided in this Form 200 is true, correct, and complete, and conforms to all applicable laws and regulations. In making this certification, I recognize that knowingly and willfully making false, fictitious, or fraudulent statements to PBGC is punishable under 18 U.S.C. §1001.

Name and Title ^{Street address}

Name of contributing sponsor or parent City, State, Zip

Signature Filing Date