Missing Participants Program Form MP-100 

Plan Information for Approved OMB 1212-0069

Expires 11/30/2026 Single-Employer DB Plans Insured by PBGC 

□ Amended Filing 

Part I — General Information 

1 Plan information 

a Plan name___________________________________________________________________________ 

b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _ c 8-digit PBGC Case # _ _ _ _ _ _ _ _ 

d Plan contact 

(1) Name __________________________ (2) Company ___________________________________ 

(3) Street address ___________________________________________________________________________ 

(4) City_____________________________ (5) State _____ (6) Zip __________ 

(7) Telephone _ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _ _ (8) email ________________________________________ 

(1) (2) (3) 

2 Number of missing distributees Benefit transfer amounts Benefit transfer amounts Total 

more than $250 $250 or less 

a Annuity purchases __________ 

b Benefits being transferred to PBGC ________ ________ __________ 

c Total __________ 

3 Benefit determination date (BDD) _ _ /_ _/_ _ _ _ 

4 Commercial locator service(s) used (if any) ___________________________________________________________ 

5 Amended filings only - Did the original filing contain information on anyone who is not reported in this □ Yes 

amended filing (i.e., has anyone been removed from Schedule A or B)? (attachment required if “Yes”) □ No 

Part II — Amount due to PBGC 

6 Amounts owed to PBGC for missing distributees reported in this filing 

a Aggregate benefit transfer amount as of BDD [sum of item 3 from all Schedules B] 

b Administrative fee [$35 x item 2b from column (1) or sum of item 4 from all Schedules B] 

c Aggregate late payment charge [sum of item 5b from all Schedules B] 

d Total [item 6a + item 6b + item 6c] 

_____________ 

_____________ 

_____________ 

_____________ 

7 Reconciliation (amended filings only) 

a Amounts previously paid in conjunction with prior Forms MP-100 for this plan 

b Underpayment/(overpayment) [item 6d – item 7a] 

_____________ 

_____________ 

8 Payment method □ Pay.gov □ Other electronic funds transfer □ Paper check 

Part III— Plan Administrator Certification 

9 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 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, including the diligent search 

requirements of 29 CFR § 4050.104. 

Name of person signing: First name ______________________ Last name _____________________________ 

_________________________________ _ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _ _ 

email Telephone 

__________________________________________ _______________ 

Signature Date 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Schedule A 

Individual Information - Annuity Purchases (Form MP-100) 

Approved OMB 1212-0069

Expires 11/30/2026

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

Part I — Plan/Insurance Company Information 

1 Plan 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 

Complete items 3-4 for each missing individual for whom an annuity was purchased. If more than two individuals need to be 

reported, use additional schedules as needed. 

3 Missing distributee information 

a Identifying information 

(1) Name (last, first, middle) ____________________________________ (2) Date of birth _ _ /_ _/_ _ _ _ 

(3) Social security number _ _ _-_ _-_ _ _ _ (4) Certificate # _______________ 

b Last-known address 

(1) Street address__________________________________________________________________________ 

(2) City_____________________________ (3) State _____ (4) Zip _________ 

c Accrued benefit (enter amount and check applicable box) ___________ □ Monthly benefit □ Current value 

4 Amended filing code — 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). 

3 Missing distributee information 

a Identifying information 

(1) Name (last, first, middle) ___________________________________ (2) Date of birth _ _ /_ _/_ _ _ _ 

(3) Social security number _ _ _-_ _-_ _ _ _ (4) Certificate # _____________ 

b Last-known address 

(1) Street address__________________________________________________________________________ 

(2) City_____________________________ (3) State _____ (4) Zip _________ 

c Accrued benefit (enter amount and check applicable box) ___________ □ Monthly benefit □ Current value 

4 Amended filing code — 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). 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Schedule B 

(Form MP-100) Individual Information - Transfer to PBGC Approved OMB 1212-0069

Expires 11/30/2026

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

Part I — Identifying Information 

1 Plan information 

a Plan name_________________________________________________________________________________ 

b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _ c 8-digit PBGC Case # _ _ _ _ _ _ _ _ 

d Benefit determination date (BDD) per Form MP-100 _ _ /_ _/_ _ _ _ 

2 Missing distributee information – If the participant is deceased, enter information about the missing beneficiary. 

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

b Date of birth _ _ /_ _/_ _ _ _ c Social Security Number _ _ _-_ _-_ _ _ _ 

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 missing distributee received any benefit payments from this plan? (Attachment required if “Yes”) □ Yes □ No 

h Is any portion of the missing distributee’s benefit attributable to non-U.S. source income □ Yes □ No (Attachment required if “Yes”) 

i Is any portion of the benefit attributable to employee contributions? (Attachment required if “Yes”) □ Yes □ No 

j Beneficiary information Complete only if “Participant” is checked in item 2f 

(1) Does the plan have a default beneficiary designation provision? (Attachment required if “Yes”) □ Yes □ No 

(2) Do plan records contain a valid beneficiary election form? If yes, attach a copy of the form □ Yes □ No and complete items (3)-(5) with respect to the designated beneficiary 

(3) Name ____________________________________ (4) Social Security Number _ _ _- _ _ - _ _ _ _ 

(5) Relationship _____________________________________________ 

k 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 – Amount Owed to PBGC 

3 Benefit transfer amount as of benefit determination date (BDD) ______________ 

4 Administrative fee (if item 3 > $250, enter $35, otherwise enter $0) ______________ 

5 Late payment charge 

a Late payment (Portion of item 3 transferred, or to be transferred, more than 90 days after BDD) 

b Interest owed on late payment (If item 5a is $0, enter $0; otherwise, see instructions) 

______________ 

______________ 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form MP-100 Schedule B Page 2 of 2 

Part III — Missing Participant Benefit Information 

Complete this part only if “Participant” was checked in item 2f, “no” was checked in item 2g, and amount in item 3 exceeds the 

de minimis threshold (i.e., $7,000 if Benefit Determination Date is 1/1/2024 or later, otherwise $5,000). 

6 Lump sum eligibility – Was participant eligible to elect a lump sum? □ Yes □ No 

7 Normal retirement date* _ _ /_ _/_ _ _ _ 

8 Annuity information 

a Monthly straight life annuity payable starting at Benefit Determination Date 

Complete this item only if the participant is over age 55 and eligible to commence benefits at ______________ BDD and has not yet reached Normal Retirement Age. 

b Monthly straight life annuity payable that the participant is entitled to assuming payments commence at each 

applicable age below. Enter N/A for ages/dates: (a) after the participant’s NRD*; (b) before the participant would have 

been eligible to commence benefits had the plan not terminated; or (c) before BDD. 

55 _____________ 58 ______________ 61 ______________ 64 ________________ 

56 _____________ 59 ______________ 62 ______________ 65 ________________ 

57 _____________ 60 ______________ 63 ______________ NRD* _____________ 

*Or if later, the date benefit accruals ceased.