Missing Participant Information Schedule MP (to forms 501 and 602)

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Schedule MP

Missing Participant Information

(to forms 501 and 602)

Approved OMB 1212-0036
Expires 09/30/2028

This Schedule MP is for Plans with Termination Dates before 1/1/2018.
DO NOT SEND PAYMENT WITH THIS FORM (see instructions).
File this form (with Form 501 or Form 602) if the plan purchased irrevocable commitments for one or more Missing Participants or is
paying amounts to PBGC for one or more Missing Participants.

PART I.

PLAN IDENTIFICATION INFORMATION

Check here if you previously filed a Schedule MP for this plan:

If checked, provide date(s) of filing(s):

1b 9-digit employer identification number (EIN)

1a Plan Name

1c 3-digit plan number (PN)
1d 8-digit PBGC Case #
PART II.
MISSING PARTICIPANT INFORMATION
2a Name and address (mailing or Internet) of commercial locator service(s) used
(1) Relating to this filing

3a Number of Missing Participants for whom irrevocable commitments were purchased
3b Number of Missing Participants for whom amounts are due to PBGC
3c Deemed distribution date (see definition on page 2 of instructions)
PART III.

(2) Total for all filings

(MM/DD/YYYY)

AMOUNTS DUE TO PBGC (Sum of the amounts on all Attachments B)
(1) Relating to this filing

(2) Total for all filings

4b Total of other amounts due for Missing Participants
4c Total amount due to PBGC (line 4a + line 4b)

$
$
$ 0.00

$
$
$ 0.00

4d Date designated benefits in 4a sent to PBGC

(MM/DD/YYYY)

4a Total amount of designated benefits

4e Is date in 4d more than 90 days after date in 3c?

Yes

No

If "Yes," interest will be assessed by PBGC. See instructions.

PART IV.

PLAN ADMINISTRATOR CERTIFICATION

I, the Plan Administrator, certify that to the best of my knowledge and belief (1) I have met the diligent search requirements of 29 CFR § 4050.4 and (2)
the information contained in this filing is true, correct and complete. In making this certification, I recognize that knowingly and willfully making
false, fictitious, or fraudulent statements to the PBGC is punishable under 18 U.S.C. § 1001.
Plan Administrator’s company’s name and address
Telephone Number
(Address should include room or suite no.)
E-mail address (optional)
Print or type name of individual who signs
Plan Administrator’s signature

PART V.

Date

ENROLLED ACTUARY CERTIFICATION

NOTE: Not required if all benefits for all Missing Participants are distributed through the purchase of irrevocable commitments from an
insurer.
I, the Enrolled Actuary, certify that to the best of my knowledge and belief (1) the actuarial information contained in this filing is true, correct, and
complete and (2) the designated benefits and/or other amounts payable for Missing Participants have been calculated in accordance with applicable
provisions of ERISA and the Internal Revenue Code and regulations promulgated thereunder. In making this certification, I recognize that knowingly and willfully making false, fictitious, or fraudulent statements to the PBGC is punishable under 18 U.S.C. § 1001.
Enrolled Actuary’s company name and address (Address should include room or suite no.)
Enrolled Actuary’s Name (Print or type)
Enrollment Number
Telephone Number
E-mail address (optional)
Enrolled Actuary’s signature

Date

Missing Participant
Annuity Purchase Information

Attachment A
(to Schedule MP)
Approved OMB 1212-0036
Expires 09/30/2028

Attach Attachment A to (or submit the required information on a separate page or pages with) Schedule MP if the plan purchased
irrevocable commitments from an insurer for one or more Missing Participants. If requested information is not available, write “N/A”
in the space provided. If any Missing Participant’s annuity certificate number is not available, report it when it becomes available. If
irrevocable commitments were purchased from more than one insurer, complete a separate Attachment A for each insurer.
This Attachment A is Number

PART I.

of

total Attachments A.

PLAN IDENTIFICATION INFORMATION

Check here if you previously filed an Attachment A for this plan:

1b 9-digit employer identification number (EIN)

1a Plan Name

1c 3-digit plan number (PN)
1d 8-digit PBGC Case #
PART II.
INSURANCE COMPANY INFORMATION
2a Name and address of Insurer

2b Insurance company contact name

(Address should include room or suite no.)

2c Telephone number
2d Policy number
PART III.

ANNUITIZED MISSING PARTICIPANT INFORMATION

Missing Participant full name (last, first, middle)

Spouse or Beneficiary full name (last, first, middle)

Social Security Number

Social Security Number

Date of Birth (MM/DD/YYYY)

Date of Birth (MM/DD/YYYY)

Certificate Number
Monthly Benefit (see instructions)

$

Missing Participant full name (last, first, middle)

Spouse or Beneficiary full name (last, first, middle)

Social Security Number

Social Security Number

Date of Birth (MM/DD/YYYY)

Date of Birth (MM/DD/YYYY)

Certificate Number
Monthly Benefit (see instructions)

$

Missing Participant full name (last, first, middle)

Spouse or Beneficiary full name (last, first, middle)

Social Security Number

Social Security Number

Date of Birth (MM/DD/YYYY)

Date of Birth (MM/DD/YYYY)

Certificate Number
Monthly Benefit (see instructions)

$

Missing Participant full name (last, first, middle)

Spouse or Beneficiary full name (last, first, middle)

Social Security Number

Social Security Number

Date of Birth (MM/DD/YYYY)

Date of Birth (MM/DD/YYYY)

Certificate Number
Monthly Benefit (see instructions)

$

Attachment B

Missing Participant
Individual Information

(to Schedule MP)
Approved OMB 1212-0036
Expires 09/30/2028

File a separate Attachment B for each Missing Participant for whom an amount is due to PBGC. If requested information is not
available, write “N/A” in the space provided.

This Attachment B is Number

PART I.

of

total Attachments B.

PLAN IDENTIFICATION INFORMATION
1b 9-digit employer identification number (EIN)

1a Plan Name

1c 3-digit plan number (PN)
1d 8-digit PBGC Case #
PART II.

IDENTIFICATION OF MISSING PARTICIPANT

Check here if you previously filed an Attachment B for this individual:

2a Missing Participant name (last, first, middle)

2b Social Security Number

2c Last-known address

2d Date of birth (MM/DD/YYYY)

2e Other name(s) ever used (if known)

2f Sex

2g Status (check one)

1. Participant

2. Spouse

3. Alternate payee (Attach copy of QDRO)

PART III.
AMOUNTS DUE TO PBGC
3a Category of Designated Benefit (Check 1, 2, 3, or 4)

Male

Female

4. Other beneficiary

(1) Relating to this filing (2) Total for all filings

1. Mandatory lump sum (automatic cashout using plan cashout assumptions
and limits).
2. De minimis lump sum (using PBGC Missing Participant lump sum assumptions).
3. No lump sum (annuity only). Check (a) or (b) below.
(a). An adjustment (loading) for expenses of $300 is included because the
designated benefit without the loading is greater than $5,000.
(b). An adjustment (loading) for expenses of $300 is not included because the
designated benefit without the loading is $5,000 or less.
4. Elective lump sum. Check (a) or (b) below.
(a). An adjustment (loading) for expenses of $300 is included because the
designated benefit amount was determined using the methodology of 29
CFR § 4050.5(a)(3) and the designated benefit amount without the loading
is greater than $5,000.
(b). An adjustment (loading) for expenses of $300 is not included because
EITHER (1) the designated benefit amount was determined using the
methodology of 29 CFR § 4050.5(a)(1) OR (2) the designated benefit
amount was determined using the methodology of 29 CFR § 4050.5(a)(3)
and the designated benefit amount without the loading is $5,000 or less.

3b Amount of Designated Benefit

$

$

Attachment B • Page 2
Missing Participant’s Social Security No.

3b

(continued)
Is any part of the Missing Participant’s designated benefit amount attributable
to mandatory employee contributions? If “Yes” complete (1)-(3) below (if “No,” go to 3c).

Yes

No

(1) Relating to this filing

(2) Total for all filings

(1) Mandatory employee contributions that fund a portion of the Missing Participant’s
accrued benefit under the plan,

$

$

(2) Interest credited on those contributions to the deemed distribution date

$

$

(3) The total of (1) and (2). The amount in 3b on p. 1 must not be less than this amount.

$ 0.00

$ 0.00

(a) Voluntary employee contributions held in a separate account.

$

$

(b) Earnings credited on contributions in (a) to the date sent to PBGC.

$

$

(c) Total of (a) and (b).

$ 0.00

$ 0.00

(d) If the amount entered in (1)(c) is not zero, enter the date voluntary contributions
sent to PBGC.

(MM/DD/YYYY)

3c Other amounts due to PBGC, if any.
Complete (1) if any additional amount is due to PBGC for voluntary employee contributions.
Complete (2) if any amount is due to PBGC for the Missing Participant’s share of residual
assets.
(1) Voluntary employee contributions and earnings

(2) Residual assets and earnings
(a) The amount, if any, of residual assets due to PBGC based on a
Missing Participant’s share of residual assets.

$

$

(b) Earnings on residual assets to the date you pay PBGC.

$

$

(c) Total of (a) and (b).

$ 0.00

$ 0.00

(d) If the amount entered in (2)(c) is not zero, enter the date residual assets
sent to PBGC.

(MM/DD/YYYY)

(3) Total other amounts due, if any, to PBGC (line (1)(c) + line (2)(c)).

$ 0.00

$ 0.00

$ 0.00

$ 0.00

3d Total amount due to PBGC (line 3b (on p. 1) + line 3c(3))
Pay this amount

Attachment B • Page 3
Missing Participant’s Social Security No.
Complete item 4 or item 5 or item 6 below (complete only one):
•
For a Missing Participant who is a participant and whose benefit was not in pay status as of the deemed distribution date →
Complete item 4
•
For a Missing Participant who is a beneficiary (including a spouse or alternate payee) and whose benefit was not in
pay status as of the deemed distribution date → Complete item 5
•
For a Missing Participant whose benefit was in pay status as of the deemed distribution → Complete item 6
After completing item 4, item 5 or item 6, go to item 7.

4

For a participant who is missing and whose benefit was not in pay status as of the
deemed distribution date, provide the following information.

4a Participant’s earliest retirement date (or the deemed distribution date, if later).
4b Last-known spouse’s full name (last, first, middle)

(MM/DD/YYYY)

Spouse’s Social Security Number

If you checked Category 1 in item 3 above, go to item 7.

4c Did the participant and last-known spouse waive the QPSA provided under the plan?
If “Yes,” attach waiver.

4d Spouse’s earliest possible QPSA annuity starting date under the plan (or deemed

Yes

No

N/A

(MM/DD/YYYY)

distribution date, if later). If the QPSA is payable immediately upon the participant’s
death, enter the deemed distribution date.

4e Automatic annuity form of retirement benefit that would be payable with respect to the
participant under the plan. Note: Provide the benefit forms for both married and
unmarried participants regardless of the participant’s last-known marital status.
(1) MARRIED PARTICIPANT

Code from table on page 12 in instructions:

If you entered:

Provide this information:

Code 5 or 6

Survivor percentage:

Code 2, 3 or 6

Number of monthly payments in period certain:

Code 4

Temporary annuity period:

Code 10

Other benefit form. Describe the form:

(2) UNMARRIED PARTICIPANT
If you entered:

5

%

Code from table on page 12 in instructions:

Provide this information:

Code 5 or 6

Survivor percentage:

Code 2, 3 or 6

Number of monthly payments in period certain:

Code 4

Temporary annuity period:

Code 10

Other benefit form. Describe the form:

%

For a beneficiary (including a participant’s spouse or alternate payee) who is missing
and whose benefit was not in pay status as of the deemed distribution date, complete
the following:

5a Form of benefit to which the beneficiary or alternate payee is entitled.
If you entered:

Provide this information:

Code 5 or 6

Survivor percentage:

Code 2, 3 or 6

Number of monthly payments in period certain:

Code 4

Temporary annuity period:

Code 10

Other benefit form. Describe the form:

5b Earliest date the beneficiary or alternate payee could commence receiving benefits
(or the deemed distribution date, if later).

Code from table on page 12 in instructions:

%

(MM/DD/YYYY)

Attachment B • Page 4
Missing Participant’s Social Security No.

6

For a participant or a beneficiary (including a participant’s spouse or alternate payee)
who is missing and whose benefit was in pay status as of the deemed distribution
date, complete the following:

6a Form of benefit that was in pay status. (Attach a copy of form election, if any.)
If you entered:

Provide this information:

Code 5 or 6

Survivor percentage:

Code 2, 3 or 6

Number of monthly payments in period certain
remaining as of deemed distribution date:

Code 4

Temporary annuity period remaining as of the
deemed distribution date (in months):

Code 7 or 8

Fixed sum remaining as of the deemed distribution date:

Code 10

Other benefit form. Describe the form:

Code from table on page 12 in instructions:

%

$

And provide (as applicable):
Date of first missed monthly payment:

(MM/DD/YYYY)

Amount of first missed monthly payment:

$
%

Plan interest rate for missed payments:
Payments that were due before the deemed distribution date but that were not
made, with interest through the deemed distribution date (the amount entered here
must be included in item 3b above; it is part of designated benefit amount)

6b Name of Missing Participant’s beneficiaries, if any (last, first, middle). (Attach a copy

$
Relationship (e.g., spouse, child, estate)

of beneficiary designation form, if any.)
Social Security Number

7

Attached Documents. Check all document(s) which are attached:

a Waiver of Qualified Pre-retirement Survivor Annuity (QPSA)
b Election of optional benefit form
c Designation(s) of beneficiary
d Qualified Domestic Relations Order(s) (QDROs)