Attachment B To Schedule Mp - Missing Participant Individual Information
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1
2
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4Missing Participant
Attachment B
(to Schedule MP)
Individual Information
Approved OMB 1212-0036
Expires 12/31/2013
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 ______ of ______ total Attachments B.
PART I.
PLAN IDENTIFICATION INFORMATION
1a
1b
9-digit employer identification number (EIN)
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
2b
Missing Participant name (last, first, middle)
Social Security Number
2c
2d
Last-known address
Date of birth (MM/DD/YYYY)
2e
2f
Other name(s) ever used (if known)
Sex
Male
Female
2g
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
3
Category of Designated Benefit (Check 1, 2, 3, or 4)
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.
3(a). An adjustment (loading) for expenses of $300 is included because the
designated benefit without the loading is greater than $5,000.
3(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.
4(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.
4(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.
3a
$
$
Amount of Designated Benefit
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