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Form Mp-100 - Missing Participants Program Plan Information For Pbgc-Insured Single-Employer Plans Page 2

Schedule A

Individual Information - Annuity Purchases

(Form MP-100)

Approved OMB 1212-####

Expires xx/xx/xxxx

This Schedule A is # _______ of __________ (insert total # of Schedules A included in this filing)

Part I — Identifying Information

1 Plan sponsor information

a Plan name_________________________________________________________________________________

b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _

c 8-digit PBGC Case # _ _ _ _ _ _ _ _

2 Insurance company information

a Insurance company name _______________________________________

b Policy number ____________

c Insurance company contact information

(1) Name ____________________

(2) Telephone ________

(3) email __________________

d Insurance company address

(1) Street address ____________________________________________________________________

(2) City_______________________________

(3) State ____

(4) Zip _________

Part II — Individuals for whom Annuities were Purchased

(3)

(4)

(5)

(6)

(7)

Enter

Social Security

Certificate

applicable code

Name

Date of Birth

Number

(Required only if this

is an amended filing)

_ _ _ -_ _ - _ _ _ _ _ _/_ _/_ _ _ _

Form Mp-100 - Missing Participants Program Plan Information For Pbgc-Insured Single-Employer Plans Page 2