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MP-400 Template
ICR 202504-1212-003 · OMB 1212-0069 · Object 156297201.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
|---|---|
| File Title | MP-400 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-400 Instructions before entering data.https://www.pbgc.gov/sites/default/files/form-mp400 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 400 Excel Attachment_12345600" where "12345600" is the applicable case number of your plan. Feel free to add a row at the bottom totalling amounts, counting participants, etc., but please insert a blank row between the individual data and any "total" row you want to add. Schedule A individual data - Attachment to Form MP-400 See instructions for detailed information about data to be entered, including information about which items may be left blank Case Number 12345600 Case Name ABC Part I - Insurance Company Information Company Name Policy Number 2a Annuties-R-Us Annuties-R-Us Annuties-R-Us source.xlsx 2b ABC123435 ABC123435 ABC123435 Contact Name Contact Telephone Contact Email Street City 2c(1) 2c(2) 2c(3) 2d(1) 2d(2) Geraldine Williams Geraldine Williams Geraldine Williams 800-555-1111 [email protected] 800-555-1111 [email protected] 800-555-1111 [email protected] Page 3 of 13 52 Bluebird Drive 52 Bluebird Drive 52 Bluebird Drive Newark Newark Newark 10/14/2026 s may be left blank Part II - Individuals for whom Annuities were Purcha State 2d(3) NJ NJ NJ source.xlsx Missing distributee's name Zip 2d(4) 07101 07101 07101 Date of birth Last First Middle 3a(1) 3a(1) 3a(1) White Yellow Black Betty Joseph Polly E F G Social security number (enter w-o dashes) Certificate number 3a(3) 3a(4) 3a(2) 5/5/1955 6/6/1965 7/7/1970 Page 4 of 13 111111111 222222222 333333333 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 5 of 13 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 6 of 13 10/14/2026 Schedule B individual data - Attachment to Form MP-400 See instructions for detailed information about data to be entered, including information about which items may be left blank Case Number 12345600 Case Name ABC Part I - Identifying Information Missing distributee's name Last First 2a source.xlsx Last-known address Middle 2a White Yellow Black Date of birth Social Security Number (enter w-o dashes) Street 2a James Joseph Polly 2b E F G 5/5/1955 6/6/1965 7/7/1970 2c City 2d(1) 111111111 222222222 333333333 123 Robin Hwy Ave 123 Blackbird Rd 123 Eagle St Page 7 of 13 2d(2) City1 City2 City3 State 2d(3) DE WV DE Zip 2d(4) 42345 52345 62345 10/14/2026 Schedule B individual data - Attachment to Form MP-400 See instructions for detailed information about data to beinformation entered, including information about which items may be left blank Additional Case Number 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 P if Participant B if Beneficiary 2a White Yellow Black source.xlsx Other name(s) ever used 2e James Joseph Polly Prior payments Non-U.S. Employee Source contributions Income (Yes or No) Income (Yes (Yes or No) or No) 2f 2g 2h 2i P P B No No No No No No No No No Page 8 of 13 Amended filing Benefit transfer Administrative fee code amount @ BDD (if applicable) 3 4 2j $35,000.00 $10,000.00 $150.00 $35.00 $35.00 $0.00 10/14/2026 Schedule B individual data - Attachment to Form MP-400 See instructions for detailed information about data to be entered, including information about which items may* be left blank Case Number 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 - Missing Information Participant Benefit Information Late payment Lump sum eligibility Normal retirement (Yes or No) date Monthly SLA @ BDD Amount Interest 5a 5b 6 7 8a $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Yes No 6/1/2020 7/1/2030 $318.00 $0.00 Page 9 of 13 Monthly Single Life Annuity payable at variou Age 55 Age 56 Age 57 Age 58 Age 59 Age 60 8b $175.00 $50.00 8b $192.50 $55.00 8b $210.00 $60.00 8b $227.50 $65.00 8b $245.00 $70.00 8b $262.50 $75.00 10/14/2026 Schedule B individual data - Attachment to Form MP-400 See instructions for detailed information about data to be entered, including information about which items may be left blank Case Number 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 James Joseph Polly Age 61 Age 62 Age 63 Age 64 Age 65 8b $280.00 $80.00 8b $297.50 $85.00 8b $315.00 $90.00 8b $332.50 $95.00 8b $350.00 $100.00 Page 10 of 13 NRD (or accrual cessation date, if later) 8b $350.00 $100.00 10/14/2026 Removed via Amendment data - Attachment to Form MP-400 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