Fillable Form MP-400: Plan Information for b Employer identification (Pension Benefit Guaranty Corporation)

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Form MP-400: Plan Information for b Employer identification (Pension Benefit Guaranty Corporation)

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U.S.A. forms for Pension Benefit Guaranty Corporation

BROWSE PENSION BENEFIT GUARANTY CORPORATION (DC) FORMS

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Missing Participants Program
Plan Information for
Multiemployer DB Plans Insured by PBGC
Form MP-400
Approved OMB 1212-0069
Expires 1/31/2021
□ Amended Filing
Part I — General Information
1 Plan information
a Plan name___________________________________________________________________________
b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _ c 8-digit PBGC Case # _ _ _ _ _ _ _ _
d Plan contact
(1) Name __________________________ _
(2) Company
___________________________________
(3) Street address ___________________________________________________________________________
(4) City_____________________________ (5) State _____ (6) Zip __________
(7) Telephone _ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _ _
(8) email _______________________________
2 Number of missing distributees
(1)
Benefit transfer amounts
more than $250
(2)
Benefit transfer amounts
$250 or less
(3)
Total
a Annuity purchases
U__ _U_____
b Benefits being transferred to PBGC
________
________
U
__ _
U
_____
c Total
U
__ _
U
_____
_ _ _ _ _ _ _ _
4 Commercial locator service(s) used (if any) ___________________________________________________________
5 Amended filings only - Did the original filing contain information on anyone who is not reported in this
amended filing (i.e., has anyone been removed from Schedule A or B)? (attachment required if “Yes”)
□ Yes
□ No
Part II — Amount due to PBGC
6 Amounts owed to PBGC for missing distributees reported in this filing
a Aggregate benefit transfer amount as of BDD [sum of item 3 from all Schedules B]
_____________
b Administrative fee [$35 x item 2b from column (1) or sum of item 4 from all Schedules B]
_____________
c Aggregate late payment charge [sum of item 5b from all Schedules B]
_____________
d Total [item 6a + item 6b + item 6c]
_____________
7 Reconciliation (amended filings only)
a Amounts previously paid in conjunction with prior Forms MP-400 for this plan
_____________
b Underpayment/(overpayment) [item 6d – item 7a] _____________
8 Payment method
□ Pay.gov □ Other electronic funds transfer □ Paper check
Part III— Plan Sponsor Certification
9 Certification of plan sponsor – The plan sponsor must sign and complete this item.
I certify that to the best of my knowledge and belief that all the information in this filing is true, correct and complete and has
been determined in accordance with PBGC's Missing Participants regulations and instructions, including the diligent search
requirements of 29 CFR § 4050.404.
Name of person signing: First name ______________U_ U Last name _____________________________
_________________________________
_ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _ _
email
Telephone
__________________________________________
_______________
Signature
Date
Clear Form
0
0
$ 0.00
$ 0.00
Individual Information - Annuity Purchases
Schedule A
(Form MP-400)
Approved OMB 1212-0069
Expires 1/31/2021
This Schedule A is # _______ of __________ (insert total # of Schedules A included in this filing)
Part I — Plan/Insurance Company Information
1 Plan information
a Plan name_________________________________________________________________________________
b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _ c 8-digit PBGC Case # _ _ _ _ _ _ _ _
2 Insurance company information
a Insurance company name______________________________________
b Policy number _____
U
_
U
______
c Insurance company contact information
(1) Name ______________________
(2) Telephone _ _ _ -_ _ _ - _ _ _ _
(3) email ____________________
d Insurance company address
(1) Street address ____________________________________________________________________
(2) City _______________________________ (3) State ____
(
4) Zip _________
Part II — Individuals for whom Annuities were Purchased
Complete items 3-4 for each missing individual for whom an annuity was purchased. If more than two individuals need to be
reported, use additional schedules as needed.
3 Missing distributee information
a Identifying information
(1) Name (last, first, middle) ____________________________________ (2) Date of birth _ _ _ _ _ _ _ _
(3) Social security number _ _ _-_ _-_ _ _ _
(
4) Certificate # _______________
b Last-known address
(1) Street address__________________________________________________________________________
(2) City_____________________________ (3) State _____ (4) Zip _________
c Accrued benefit (enter amount and check applicable box) ___________ □ Monthly benefit □ Current value
4 Amended filing code — If this is an amended filing, enter the applicable code to indicate whether
information for this missing distributee has changed or is being reported for the first time
(see instructions).
_____
3 Missing distributee information
a Identifying information
(1) Name (last, first, middle) ___________________________________
(3) Social security number _ _ _-_ _-_ _ _ _
(2) Date of birth _ _ _ _ _ _ _ _
(4) Certificate
Number____________
b Last-known address
(1) Street address__________________________________________________________________________
(2) City_____________________________ (3) State _____ (4) Zip _________
c Accrued benefit (enter amount and check applicable box) ___________ □ Monthly benefit □ Current value
4 Amended filing code — If this is an amended filing, enter the applicable code to indicate whether
information for this missing distributee has changed or is being reported for the first time (see instructions).
_____
Click here to add another Sch A
Individual Information - Transfer to PBGC
Schedule B
(Form MP-400)
Approved OMB 1212-0069
Expires 1/31/2021
This Schedule B is # _______ of __________ (insert total # of Schedules B included in this filing)
Part I — Identifying Information
1 Plan information
a Plan name_________________________________________________________________________________
c 8-digit PBGC Case # _ _ _ _ _ _ _ _ b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _
d Benefit determination date (BDD) per Form MP-400 _ _ _ _ _ _ _ _
2 Missing distributee identifying information
a Missing distributee’s name (last, first, middle) ___________________________________________________
c Social Security Number _ _ _-_ _-_ _ _ _ b Date of birth _ _ _ _ _ _ _ _
d Last-known address
(1) Street address______________________________________________________________
(2) City_______________________________ (3) State _____ (4) Zip __________
e Other name(s) ever used (if known)___________________________________________________________
f
Type of missing distributee □ Participant □ Beneficiary (See instructions re: required attachment)
g Has missing distributee received any benefit payments from this plan? (Attachment required if “Yes”) □ Yes □ No
h Is any portion of the benefit attributable to employee contributions? ( Attachment required if “Yes”) □ Yes □ No
i If this is an amended filing, enter the applicable code to indicate whether information for this missing
distributee has changed or is being reported for the first time
(see instructions).
_______
Part II – Amount Owed to PBGC
3 Benefit transfer amount as of benefit determination date (BDD) ______________
4 Administrative fee (if item 3 > $250, enter $35, otherwise enter $0) ______________
5 Late payment charge
a Late payment (Portion of item 3 transferred, or to be transferred, more than 90 days after BDD)
______________
b Interest owed on late payment (If item 5a is $0, enter $0; otherwise, see instructions)
______________
Part III — Missing Participant Benefit Information
Complete this part only if “Participant” was checked in item 2f, “no” was checked in item 2g, and amount in item 3 exceeds $5,000
6 Lump sum eligibility – Was participant eligible to elect a lump sum?
□ Yes □ No
7 Normal retirement date*
_ _ _ _ _ _ _ _
8 Annuity information
a Monthly straight life annuity payable starting at Benefit Determination Date
Complete this item only if the participant is over age 55 and eligible to commence benefits at
the BDD and has not yet reached Normal Retirement Age.
______________
b Monthly straight life annuity payable that the participant is entitled to assuming payments commence at each
applicable age below. Enter N/A for ages/dates: (a) after the participant’s NRD*; (b) before the participant would have
been eligible to commence benefits had the plan not terminated; or (c) before BDD.
55 _____________ 58 ______________ 61 ______________ 64 _______________
56 _____________ 59 ______________ 62 ______________ 65 _______________
57 _____________ 60 ______________ 63 ______________ NRD* _____________
*Or if later, the date benefit accruals ceased.
Click here to add another Sch B
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Form MP-400: Plan Information for b Employer identification (Pension Benefit Guaranty Corporation)

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Completed 19 July 2020

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