Form 200 Notice of Failure to Make Required Contributions

NOTICE OF FAILURE TO MAKE
REQUIRED CONTRIBUTIONS

PBGC Form 200
OMB Control No. 1212-0041
Expires XX/XX/XXXX

GENERAL PLAN INFORMATION

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This form is for illustrative purposes only. Form 200 information should be submitted to PBGC using the e-filing
portal: efilingportal.pbgc.gov. For questions regarding this form, contact (202) 229-4070 or [email protected].

Plan year commencement date

EIN of contributing sponsor / Plan number

EIN/PN used in previous filings, if different

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Name of Plan

Plan Administrator:

Contributing Sponsor:

Name ofPlan Administrator

Name of Contributing Sponsor

Street address of Plan Administrator

Street address of Contributing Sponsor

City, State, Zip

Telephone number

Ext.

Telephone number

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Individual to Contact:

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Name of contact

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Title of contact

Email of contact

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City, State, Zip

PLAN FUNDING INFORMATION

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Due date of required
payment that resulted in
requirement to notify PBGC

EXPLANATION

Ext.

Street address of contact

City, State,Zip

Telephone number

Ext.

Total unpaid balance of required
payments (including interest)
Amount of required payment that
resulted in requirement to notify PBGC

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.

Check box to indicate the item is attached. If not attached, explain below.

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

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

If required information has not been submitted with this Form 200, explain below.

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FILING INFORMATION

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MISSING INFORMATION

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

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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

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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

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ADDITIONAL INFORMATION TO BE FILED

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Notice Due Date

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REASON FOR LATE FILING

Notice Filing Date (if late, explain below)

ENROLLED ACTUARY CERTIFICATION

Street address

Enrollment number

City, State,Zip

Company/Firm

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Telephone number

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Name

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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.

Signature

Filing Date

CONTRIBUTING SPONSOR OR PARENT CERTIFICATION

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.

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Name of contributing sponsor or parent

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Street address

Name and Title

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Signature

City, State,Zip

Filing Date