Form Mp-100 - Missing Participants Program Plan Information For Pbgc-Insured Single-Employer Plans

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Missing Participants Program
Form MP-100
Plan Information for PBGC-Insured Single-Employer
Approved OMB 1212-####
Expires xx/xx/xxxx
Plans
Aug 1 draft
Amended Filing-Type 1
Amended Filing-Type 2
Part I — Identifying Information
1 Plan information
a Plan name___________________________________________________________________________
b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _
c 8-digit PBGC Case # _ _ _ _ _ _ _
d Plan contact
(1) Name _______________________ (2) Telephone ________________
(3) email __________________
(4) Street address __________________________________________________________________________
(5) City_____________________________
(6) State _____
(7) Zip __________
Part II — Amounts Transferred to PBGC
2 Number of individuals for whom benefits are being transferred to PBGC
a Number with benefit transfer amounts of $250 or less
_____________
b Number with benefit transfer amounts in excess of $250
_____________
c Total
_____________
3 Benefit transfer date
_ _ /_ _/_ _ _ _
4 Amounts owed to PBGC for missing distributees reported in this filing
a Aggregate benefit-related transfer amount [sum of item 5 from all Schedules B]
_____________
b Administrative fee [$35 x item 2b]
_____________
c Total [item 4a + item 4b]
_____________
d Amounts previously paid (in conjunction with prior Forms MP-100 for this plan)
_____________
e Net amount due [item 4c – item 4d]
_____________
Part III — Diligent Search Information
5 Summarize the steps taken to satisfy the diligent search requirements and report the name of any commercial
locator service used to assist with the search: _________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Part IV — Plan Administrator Certification
6 Certification of plan administrator – The plan administrator must sign and complete this item.
I certify that to the best of my knowledge and belief that: (1) all the information in this filing is true, correct and complete and has been
determined in accordance with PBGC's Missing Participants regulations and instructions, and (2) I have met the diligent search requirements
of 29 CFR § 4050.104.
Name of person signing:
First name _______________ Last name _____________________________
_________________________________
_ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _ _
E-mail address
Telephone
___________________________________________
_ _ /_ _ /_ _ _ _
Signature
Date

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