Fillable NOTICE OF FAILURE TO MAKE REQUIRED CONTRIBUTIONS (Pension Benefit Guaranty Corporation)

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NOTICE OF FAILURE TO MAKE REQUIRED CONTRIBUTIONS (Pension Benefit Guaranty Corporation)

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NOTICE OF FAILURE TO MAKE
REQUIRED CONTRIBUTIONS
PBGC Form 200
OMB #1212-0041
Expires 02/28/2022
GENERAL PLAN INFORMATION
File this form to notify the Pension Benefit Guaranty Corporation of a failure to make required contributions to a single-employer plan that
is covered under ERISA §4021 and whose FTAP is less than 100% if the total of unpaid balances, including interest, exceeds $1 million (see
ERISA section 303(k)(4)(A) and Code §430(k)(4)(A)). For questions regarding this form, contact (202) 326-4070 or form200@pbgc.gov.
Name of Plan
EIN of contributing sponsor / Plan number
Plan Administrator:
Name ofPlan Administrator
Street address of Plan Administrator
City, State, Zip
Telephone number
Ext.
Individual to Contact:
Name of contact
Title of contact
Email of contact
Plan year commencement date
EIN/PN used in previous filings, if different
Contributing Sponsor:
Name of Contributing Sponsor
Street address of Contributing Sponsor
City, State, Zip
Telephone number Ext.
Street address of contact
City, State,Zip
Telephone number
Ext.
PLAN FUNDING INFORMATION
Due date of required payment that
Total unpaid balance of required
resulted in requirement to notify PBGC
payments (including interest)
EXPLANATION
Describe the required payment that resulted in the requirement to notify PBGC and state how the total unpaid
balance of required payments (including interest) was determined. (See Appendix instructions for details)
Attach additional pages if necessary.
The next page lists additional information that must be submitted with this form, if not included above.
ADDITIONAL INFORMATION TO BE FILED Check box to indicate the item is attached. If not attached, explain below.
Reason contribution was not made by due date
For each controlled group member:
Name, address, telephone number and EIN of each controlled
groupmember
Name, address, telephone number and EIN of the ultimate
parent of the controlled group
Name, address, telephone number and EIN of each contributing
sponsor of the plan
Location of all real property owned by each member of the
controlledgroup
Name and address of the controlled group's principal
executive
offices
Operational status of each controlled group member (in
Chapter 7 proceedings, liquidating outside of bankruptcy, in
Chapter 11 proceedings, on-going, etc.)
Copy of any IRS letter(s) granting or modifying a funding
waiver and/or extension of the amortization period
Statement describing any pending request(s) for a funding
waiver and/or extension of the amortization period
Actuarial Information (see Form 200 instructions)
Copies of financial statements for the most recent three
fiscal years available, and the most recent available interim
financial statement, for each member of the plan's
controlled group, including the contributing sponsor and
theultimate parent
MISSING INFORMATION
If required information has not been submitted with this Form 200, explain below.
FILING INFORMATION
Notice Due Date Notice Filing Date (if late, explain below)
REASON FOR LATE FILING
ENROLLED ACTUARY CERTIFICATION
I certify that, to the best of my knowledge and belief, the Plan Funding Information and related explanation above is true,
correct, and complete and conforms to all applicable laws and regulations. In making this certification, I recognize that
knowingly and willfully making false, fictitious, or fraudulent statements to PBGC is punishable under 18 U.S.C.
§1001.
Name
Enrollment number
Company/Firm
Signature
Street address
City, State,Zip
Telephone number
Filing Date
CONTRIBUTING SPONSOR OR PARENT CERTIFICATION
I certify that, to the best of my knowledge and belief, the information provided in this Form 200 is true, correct, and complete, and
conforms to all applicable laws and regulations. In making this certification, I recognize that knowingly and willfully making false,
fictitious, or fraudulent statements to PBGC is punishable under 18 U.S.C. §1001.
Name and Title
Street address
Name of contributing sponsor or parent City, State,Zip
Signature Filing Date
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NOTICE OF FAILURE TO MAKE REQUIRED CONTRIBUTIONS (Pension Benefit Guaranty Corporation)

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Completed 19 July 2020

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