NOTICE OF FAILURE TO MAKE 

REQUIRED CONTRIBUTIONS 

PBGC Form 200 

OMB Control No. 1212-0041 

Expires XX/XX/XXXX

GENERAL PLAN INFORMATION 

This form is for illustrative purposes only. Form 200 information should be submitted to PBGC using the e-filing 

portal: efilingportal.pbgc.gov. For questions regarding this form, contact (202) 229-4070 or form200@pbgc.gov.

Name of Plan 

EIN of contributing sponsor / Plan number 

Plan Administrator: 

Name ofPlan Administrator 

Street address of Plan Administrator 

City, State, Zip 

Telephone number Ext. 

Individual to Contact: 

Name of contact 

Title of contact 

Email of contact 

Plan year commencement date 

EIN/PN used in previous filings, if different 

Contributing Sponsor: 

Name of Contributing Sponsor 

Street address of Contributing Sponsor 

City, State, Zip 

Telephone number Ext. 

Street address of contact 

City, State,Zip 

Telephone number Ext. 

PLAN FUNDING INFORMATION 

Due date of required 

payment that resulted in 

requirement to notify PBGC 

Total unpaid balance of required 

payments (including interest) 

EXPLANATION Describe the required payment that resulted in the requirement to notify PBGC and state how the total unpaid 

balance of required payments (including interest) was determined. (See Appendix instructions for details) 

Attach additional pages if necessary. 

The next page lists additional information that must be submitted with this form, if not included above. 

Amount of required payment that 

resulted in requirement to notify PBGC

For Illustrative Purposes Only
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDITIONAL INFORMATION TO BE FILED Check box to indicate the item is attached. If not attached, explain below. 

For each controlled group member: Reason contribution was not made by due date 

Name, address, telephone number and EINof each controlled 

group member

Name, address,telephone number andEINofthe ultimate 

parent ofthe controlled group

Name, address, telephone number and EINof each contributing 

sponsor of the plan

Location of allreal property owned by eachmember of the 

controlled group

Name and address ofthe controlled group's principal executive 

offices 

Operational status of each controlled group member (in 

Chapter 7 proceedings, liquidating outside of bankruptcy, in 

Chapter 11 proceedings, on-going, etc.)

Copy of any IRS letter(s) granting or modifying a funding 

waiver and/or extension of the amortization period 

Statement describing any pending request(s) for a funding 

waiver and/or extension of the amortization period 

Actuarial Information (see Form 200 instructions) 

Copies of financial statements for the most recent three 

fiscal years available, and the most recent available interim 

financial statement, for each member of the plan's 

controlled group, including the contributing sponsor and 

theultimate parent 

MISSING INFORMATION If required information has not been submitted with this Form 200, explain below. 

FILING INFORMATION 

Notice Due Date Notice Filing Date (if late, explain below)

REASON FOR LATE FILING

For Illustrative Purposes Only
 

 

 

 

 

ENROLLED ACTUARY CERTIFICATION 

I certify that, to the best of my knowledge and belief, the Plan Funding Information and related explanation above is true, 

correct, and complete and conforms to all applicable laws and regulations. In making this certification, I recognize that 

knowingly and willfully making false, fictitious, or fraudulent statements to PBGC is punishable under 18 U.S.C. §1001. 

Name 

Enrollment number 

Company/Firm 

Signature 

Street address 

City, State,Zip 

Telephone number 

Filing Date 

CONTRIBUTING SPONSOR OR PARENT CERTIFICATION 

I certify that, to the best of my knowledge and belief, the information provided in this Form 200 is true, correct, and complete, and 

conforms to all applicable laws and regulations. In making this certification, I recognize that knowingly and willfully making false, 

fictitious, or fraudulent statements to PBGC is punishable under 18 U.S.C. §1001. 

Name and Title Street address 

Name of contributing sponsor or parent City, State,Zip 

Signature Filing Date 

For Illustrative Purposes Only