Missing Participants Program Form MP‐300

Plan Information for Approved OMB 1212‐0069

Expires 11/30/2026 Small Professional Service DB Plans

□ 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 ____________________ (8) email ___________________________________

e Is plan electing to be a transferring plan or a notifying plan? (check applicable box)  □ Transferring □ Notifying

(1) (2) (3)

2 Number of individuals reported in Benefit transfer amounts Benefit transfer amounts Total

applicable attached schedules $250 or less more than $250

(Notifying plans may omit breakdown) ________ ________ ________

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 no longer considered □ Yes

missing (i.e., has anyone been removed from the applicable Schedule B)? (attachment required if “Yes”) □ No

Part II — Additional Information for Transferring Plans

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 number reported in column (2) of item 2]

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

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

_____________

_____________

_____________

_____________

7 Reconciliation (amended filings only)

a Amounts previously paid in conjunction with prior Forms MP‐300 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 § 4050.304.

Name of person signing: First name _______________ Last name _____________________________

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

Telephone e‐mail

___________________________________________ _______________ 

Signature Date 
           

   

     

                                  

         

      

   

                                                 

        

       

        

        

   

          

                                         

         

      

      

                         

                 

  

                      

          

                                    

                             

      

      

                         

                 

  

                         

          

                                    

                             

Schedule A

Individual Information – Notifying Plans (Form MP‐300)

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/Financial Institution Information

1 Plan sponsor information

a Plan name_________________________________________________________________________________

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

2 Financial institution information

a Financial institution name ___________________________________________

b Financial institution contact information

(1) Name ____________________ (2) Telephone ______________ (3) email _________________________

c Financial institution address

(1) Street address _________________________________________________________________

(2) City_______________________________ (3) State ____ (4) Zip ___________

Part II — Individual Information

Complete items 3‐4 for each missing individual whose benefit was transferred to a financial institution that you are reporting to

PBGC. 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 _ _ _‐_ _‐_ _ _ _

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

d Account/certificate number (f applicable) ___________

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 _ _ _‐_ _‐_ _ _ _

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

d Account/certificate number (if applicable) ___________

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‐300) Individual Information – Transferring Plans 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‐300 _ _ /_ _/_ _ _ _

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 □ ParƟcipant □ 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 – Transfer Amount

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‐300 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.