Missing Participant Information Schedule MP
(to forms 501 and 602)
pproved OMB 1212-0036
This Schedule MP is for Plans with Termination Dates before 1/1/2018.
DO NOT SEND PAYMENT WITH THIS FORM (see instructions).
9-digit employer identification number (EIN)
3-digit plan number (PN)
MISSING PARTICIPANT INFORMATION
Name and address (mailing or Internet) of commercial locator service(s) used
(1) Relating to this filing
(2) Total for all filings
Number of Missing Participants for whom irrevocable commitments were purchased
Number of Missing Participants for whom amounts are due to PBGC
Deemed distribution date (see definition on page 2 of instructions)
PART III. AMOUNTS DUE TO PBGC (Sum of the amounts on all Attachments B)
(1) Relating to this filing (2) Total for all filings
Total amount of designated benefits
Total of other amounts due for Missing Participants
Total amount due to PBGC (line 4a + line 4b)
Date designated benefits in 4a sent to PBGC
Is date in 4d more than 90 days after date in 3c?
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
(Address should include room or suite no.)
Plan Administrator’s signature
E-mail address (optional)
Print or type name of individual who signs
ENROLLED ACTUARY CERTIFICATION
NOTE: Not required if all benefits for all Missing Participants are distributed through the purchase of irrevocable commitments from an
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 know-
ingly 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 signature Date
Enrolled Actuary’s Name (Print or type)
E-mail address (optional)
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):