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Form Mp-100 - Missing Participants Program Plan Information For Pbgc-Insured Single-Employer Plans Page 3

Schedule B

(Form MP-100)

Individual Information - Transfer to PBGC

Approved OMB 1212-####

Expires xx/xx/xxxx

This Schedule B is # _______ of __________ (insert total # of Schedules B 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 Missing distributee identifying information

a Missing distributee’s name (last, first, middle) ___________________________________________________

b Social Security Number _ _ _-_ _-_ _ _ _

c Date of birth _ _ /_ _/_ _ _ _

d Last-known address

(1) Street Address______________________________________________________________

(2) City_______________________________

(3) State _____

(4) Zip __________

e Other name(s) ever used (if known)___________________________________________________________

f Type of missing distributee

□ Participant

□ Beneficiary

(See instructions re: required attachment)

g Has the missing distributee received any benefit payments from this plan?

□ Yes □ No

(If “yes”, see instructions re: required attachment)

h If any portion of the benefit due is attributable to mandatory employee contributions,

enter the accumulated value of such contributions as of the Benefit Transfer Date

_______________

If this is an amended filing, enter the applicable code to indicate whether information for

this missing distributee has changed or is being reported for the first time

(see instructions)

______

Part II — Benefit-Related Transfer Amount

3 Benefit transfer amount

________________

4 Plan make-up amount, if applicable

________________

5 Total

________________

Part III — Missing Participant Benefit Information

Complete this item only if “Participant” was checked in item 2g and total amount in item 5 exceeds $5,000

6 Lump sum eligibility – Is this participant eligible to elect a lump sum?

□ Yes

□ No

7 Annuity information – Monthly straight life annuity to which participant is entitled assuming benefit

commencement begins at each of the ages below.

See instructions for information about which entries may be left blank.

55 _________

58 _________

61 _________

64 _________

67_________

70_________

56 _________

59 _________

62 _________

65 _________

68_________

71_________

57 _________

60 _________

63 _________

66 _________

69_________ RBD_________

Form Mp-100 - Missing Participants Program Plan Information For Pbgc-Insured Single-Employer Plans Page 3

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