Fill - Free fillable Missing Participant Information Schedule MP (Pension Benefit Guaranty Corporation) PDF form

Missing Participant Information Schedule MP

(to forms 501 and 602)

pproved OMB 1212-0036

Expires 3/31/2023

This Schedule MP is for Plans with Termination Dates before 1/1/2018.

DO NOT SEND PAYMENT WITH THIS FORM (see instructions).

Plan Name

9-digit employer identification number (EIN)

3-digit plan number (PN)

8-digit PBGC Case #

PART II.

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)

(MM/DD/YYYY)

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

(MM/DD/YYYY)

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

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

Yes

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

Date

Telephone Number

E-mail address (optional)

Print or type name of individual who signs

PART V.

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 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)

Enrollment Number

Telephone Number

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):

0.00

Missing Participant Attachment A

Annuity Purchase Information

(to Schedule MP)

Approved OMB 1212-0036

Expires 3/31/2023

This Attachment A is Number of total Attachments A.

PART I. PLAN IDENTIFICATION INFORMATION

Plan Name

9-digit employer identification number (EIN)

3-digit plan number (PN)

8-digit PBGC Case #

PART II.

INSURANCE COMPANY INFORMATION

Name and address of Insurer

(Address should include room or suite no.)

Insurance company contact name

Telephone number

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

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

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

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

Date of Birth

(MM/DD/YYYY)

Date of Birth

(MM/DD/YYYY)

Certificate Number

Monthly Benefit (see instructions)

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

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.

Missing Participant

Individual Information

Attachment B

(to Schedule MP)

Approved OMB 1212-0036

Expires 3/31/2023

This Attachment B is Number of total Attachments B.

PART

PLAN IDENTIFICATION INFORMATION

Plan Name

9-digit employer identification number (EIN)

3-digit plan number (PN)

8-digit PBGC Case #

PART II.

IDENTIFICATION OF MISSING PARTICIPANT

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

Missing Participant name (last, first, middle)

Social Security Number

Last-known address

Date of birth

(MM/DD/YYYY)

Other name(s) ever used (if known)

Sex

Male Female

Status (check one)

1. Participant

2. Spouse

3. Alternate

payee (Attach copy of QDRO) 4. Other beneficiary

PART III. AMOUNTS DUE TO PBGC

(1) Relating to this filing

(2) Total for all filings

Category of Designated Benefit (Check 1, 2, 3, or 4)

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 great

er 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.

Amount of Designated Benefit

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.

Attachment B • Page 2

(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.

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

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

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

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

sent to PBGC.

(MM/DD/YYYY)

(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.

$ $

(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)).

$ $

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

Pay this amount

$ $

Missing Participant’s Social Security No.

0.00

Attachment B • Page 3

For a participant who is missing and whose benefit was not in pay status as of the

deemed distribution date, provide the following information.

Participant’s earliest retirement date (or the deemed distribution date, if later).

(MM/DD/YYYY)

Last-known spouse’s full name (last, first, middle) Spouse’s Social Security Number

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

Did the participant and last-known spouse waive the QPSA provided under the plan?

If “Yes,” attach waiver.

Yes No N/A

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

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

death, enter the deemed distribution date.

(MM/DD/YYYY)

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

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:

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:

Form of benefit to which the beneficiary or alternate payee is entitled.

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:

Earliest date the beneficiary or alternate payee could commence receiving benefits

(or the deemed distribution date, if later).

(MM/DD/YYYY)

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.

Missing Participant’s Social Security No.

Attachment B • Page 4

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:

Form of benefit that was in pay status. (Attach a copy of form election, if any.)

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

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:

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)

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

of beneficiary designation form, if any.)

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

Social Security Number

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

Waiver of Qualified Pre-retirement Survivor Annuity (QPSA)

Election of optional benefit form

Designation(s) of beneficiary

Qualified Domestic Relations Order(s) (QDROs)

Missing Participant’s Social Security No.

Missing Participant

Payment Voucher

(to Schedule MP)

Approved OMB 1212-0036

Expires 3/31/2023

Do not send Schedule MP or attachments with this payment voucher.

Send Schedule MP and attachments to PBGC at the address listed in the instructions for where to file.

PART I.

PLAN IDENTIFICATION INFORMATION

Plan Name

9-digit employer identification number (EIN)

3-digit plan number (PN)

8-digit PBGC Case #

PART II.

PLAN ADMINISTRATOR CONTACT

Plan Administrator’s name

Telephone number

E-mail address (optional)

PART III. AMOUNTS PAID TO PBGC

Amount enclosed or wired. (Make check payable to Pension Benefit Guaranty Corp.)

Note: The amount enclosed or wired must equal the amount in column (1) of item 4c

Schedule MP

Check

Wire transfer

Amount Enclosed or wired for interest assessed by PBGC, if applicable.

Check number

Date Schedule MP was sent to PBGC

(MM/DD/YYYY)

If you are using the U.S. Postal Service, send payment (with this voucher) to:

Pension Benefit Guaranty Corporation

P.O. Box 955710

St. Louis, MO 63195-5710

If you are using a delivery service other than the U.S. Postal Service, send payment (with this voucher) to:

PBGC Missing Participants Box 955710

U.S. Bank Wholesale Lockbox

1005 Convention Plaza

SL-MO-C1WS

St. Louis, MO 63101

If you are using a wire transfer, send wire transfer to:

US BANK

Routing: 081000210

Account: 152310875843

Beneficiary: PBGC

Payment ID line: (MP, the plan’s EIN/PN, and the standard termination case number)

Please use the following format:

“MP, EIN/PN: XX-XXXXXXX/XXX, CN: XXXXXXXX.”

Use this form if any amount is paid to PBGC for Missing Participants. Send this form (with payment by check or wire transfer

information) to the lockbox address below.

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