Attachment A To Schedule Mp - Missing Participant Annuity Purchase Information
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1Missing Participant
Attachment A
(to Schedule MP)
Annuity Purchase Information
Approved OMB 1212-0036
Expires 12/31/2013
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.
This Attachment A is Number ______ of ______ total Attachments A.
PART I.
PLAN IDENTIFICATION INFORMATION
Check here if you previously filed an Attachment A for this plan:
1b
1a
9-digit employer identification number (EIN)
Plan Name
1c
3-digit plan number (PN)
1d
8-digit PBGC Case #
PART II.
INSURANCE COMPANY INFORMATION
2a
Name and address of Insurer
2b
Insurance company contact name
(Address should include room or suite no.)
2c
Telephone number
2d
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
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
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
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
Social Security Number
Date of Birth (MM/DD/YYYY)
Date of Birth (MM/DD/YYYY)
Certificate Number
$
Monthly Benefit (see instructions)
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