Document
MP-100 Template
ICR 202407-1212-003 · OMB 1212-0069 · Object 144284401.
This document may belong to an older filing. More recent activity for OMB 1212-0069:
Document Viewer [xlsx]
Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
|---|---|
| File Title | MP-100 Template |
| Author | Michael Rae |
| Last Modified By | Calc |
| File Modified | 2023-10-16 |
| File Created | 2026-10-14 |
| Conversion State | complete |
Extracted Text
1) 2) 3) 4) 5) 6) 7) Instructions for Using Excel Template Review the Form MP-100 Instructions before entering data.https://www.pbgc.gov/site Enter the PBGC case number assigned to your plan in the heading of the applicable tab. Overwrite the sample data shown with the data that needs to be reported. If either Schedule isn't required, delete the non-applicable tab from the spreadsheet. Use the appropriate schedule as a guide while filling out this spreadsheet. Save your spreadsheet as "Form 100 Excel Attachment_12345600" where "12345600" is the applica number of your plan. Feel free to add a row at the bottom totalling amounts, counting participants, etc., but please inser row between the individual data and any "total" row you want to add. Schedule B Individual COLOR CODE KEY Additional information or attachment Required to describe this situation TAB Removed via Amendment When Data is entered and the Cell is highlighted with a b white font, additional information is needed to describe You can use fields to the right if it's related to a missing d beneficiary or a portion of the benefit attributable to no will need to include an attachment if it's related to Othe Beneficiary election form. dividual data for Transferring Plans - Attachment to Form MP-100 Use these color indicators when reviewing your filing spreadsheet to insure you have included all the necessary data and descriptions. When Data is entered and the Cell is highlighted with a blue background and a white font, additional information is needed to describe the situation. You can use fields to the right if it's related to a missing distributee being a beneficiary or a portion of the benefit attributable to non-US source income. You will need to include an attachment if it's related to Other post-tax contributions or a Beneficiary election form. 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. Part II - Individuals for whom Annuities were Purchased Missing distributee's name Date of birth Last First Middle 3a(1) 3a(1) 3a(1) White Yellow Black source.xlsx Betty Joseph Polly E F G 3a(2) 5/5/1955 6/6/1965 7/7/1970 Social security number (enter w-o dashes) Certificate number 3a(3) 3a(4) 111111111 222222222 333333333 Page 5 of 14 Last-known address Street 3b(1) 1111111 123 Robin Hwy Ave 2222222 123 Blackbird Rd 3333333 123 Eagle St 10/14/2026 art II - Individuals for whom Annuities were Purchased Part II - Individuals for whom Annuities were Purchased Missing distributee's name Last-known address Last First City State Zip 3a(1) 3a(1) 3b(2) 3b(3) 3b(4) White Yellow Black source.xlsx Betty Joseph Polly City1 City2 City3 DE WV DE 42345 52345 62345 Page 6 of 14 10/14/2026 ties were Purchased Part II - Individuals for whom Annuities were Purchased Missing distributee's name Last First 3a(1) 3a(1) White Yellow Black source.xlsx Betty Joseph Polly Accrued benefit information Amount 3c $35,000.00 $150.00 $50.00 Amended Filing If monthly, enter MB. If current value, enter CV Code 3c 4 CV MB MB Page 7 of 14 10/14/2026 Case Name ABC Part I - Identifying Information Missing distributee's name Last First 2a source.xlsx Middle 2a White Yellow Black Last-known address Date of Birth 2a James Joseph Polly 2b E F G 5/5/1955 6/6/1965 7/7/1970 Social Security Number (enter w-o dashes) Street 2c City 2d(1) 111111111 222222222 333333333 123 Robin Hwy Ave 123 Blackbird Rd 123 Eagle St Page 8 of 14 2d(2) City1 City2 City3 State 2d(3) DE WV DE Zip 2d(4) 42345 52345 62345 10/14/2026 Additional information or attachment Required to describe this Case Name Part I - Identifying Information Part I - Identifying Information Part II - Amount Owed to PBGC Missing distributee's name Last First 2a Type of distributee (If Beneficiary, Include information in fields to the right) 2a White Yellow Black source.xlsx Other name(s) ever used 2e James Joseph Polly Prior payments (Yes or No) Non-U.S. Source Income (Yes or No) Employee contributions (Yes or No) Amended filing code 2j 2f 2g 2h 2i P P B No No No No No No No No No Page 9 of 14 Benefit transfer Administrative fee (if applicable) amount @ BDD 3 $35,000.00 $10,000.00 $150.00 4 $35.00 $35.00 $0.00 10/14/2026 Case Name Part II - Amount Owed to PBGC Missing distributee's name Last First 2a 2a White Yellow Black source.xlsx James Joseph Polly Part I - Identifying Part III - Information Missing Participant Benefit Information Late payment Lump sum eligibility (Yes or No) Normal retirement date Monthly SLA @ BDD Monthly Single Life Annuity payable at various Amount Interest Age 55 5a 5b 6 7 8a 8b 8b 8b 8b 8b 8b $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Yes No 6/1/2020 7/1/2030 $318.00 $0.00 $175.00 $50.00 $192.50 $55.00 $210.00 $60.00 $227.50 $65.00 $245.00 $70.00 $262.50 $75.00 Page 10 of 14 Age 56 Age 57 Age 58 Age 59 Age 60 10/14/2026 Case Name Part III - Missing Participant Benefit Information Part I - Identifying Information Missing distributee's name Monthly Single Life Annuity payable at various ages Last First 2a 2a White Yellow Black source.xlsx Age 61 James Joseph Polly Age 62 Age 63 Age 64 Age 65 NRD (or accrual cessation date, if later) 8b 8b 8b 8b 8b 8b $280.00 $80.00 $297.50 $85.00 $315.00 $90.00 $332.50 $95.00 $350.00 $100.00 $350.00 $100.00 Page 11 of 14 10/14/2026 Removed via Amendment data - Attachment to Form MP-100 See instructions for detailed information about data to be entered, including informatio Case Number 12345600 Case Name ABC Removed via Amendment Last-known address Distributee SSN 123456789 Distributee Name A Smith Street 789 Main St City City 1 ed, including information about which items may be left blank own address State VA Zip 22151 ut which items may be left blank Reason Removed Found and paid out Amount Adjusted $ 500.00