Missing Participants Program

Plan Information for Defined Contribution Plans

Form MP-200

Approved OMB 1212-0069 

Expires 11/30/2026

□ 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 ___________________________________

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

2 Number of missing distributees reported 

in applicable attached schedules

(Notifying plans may omit breakdown)

(1)

Account $250 or less

(2)

Account more than $250

(3)

Total

________ ________ ________

3 Amended filings only - Did the original filing contain information on anyone who is no longer considered 

missing (i.e., has anyone been removed from the applicable Schedule B)? (attachment required if “Yes”) 

□ Yes

□ No

Part II — Additional Information for Transferring Plans

4 Default beneficiary provision — Does the plan have a default beneficiary designation provision? 

(attachment required if “Yes”) □ Yes □ No

5 Benefit transfer date

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

a Aggregate account balances [sum of item 5 from all Schedules B] _____________

b Administrative fee [$35 x number reported in column (2) of item 2] _____________

c Total [item 5a + item 5b] _____________

7 Reconciliation (amended filings only)

a Amounts previously paid in conjunction with prior Forms MP-200 for this plan _____________

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

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

Part III — Certification

9 Certification – The plan administrator (PA) or qualified termination administrator (QTA) must sign and complete 

this item. Check applicable box to indicate the applicable role of the person certifying this filing: □ PA □ QTA

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 § 4050.204.

Name of person signing: First name _______________ Last name _____________________________

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

email Telephone

___________________________________________ ______________

Signature Date

/ /
Individual Information – Notifying Plans

Schedule A

(Form MP-200)

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 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 DC account 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 Account information

(1) Account number _____________________ (2) Account balance transferred ________________

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 Account information

(1) Account number _____________________ (2) Amount balance transferred ________________

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). _____
Individual Information – Transferring Plans

Schedule B

 (Form MP-200)

Approved OMB 1212-0069 

Expires 11/30/2026

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

Part I — Plan Information

1 Plan information

a Plan name_________________________________________________________________________________

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

Part II — Individual Information 

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

a 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 (if checked, see instructions re: required attachment)

Part III — Transfer Amount

3 Portion attributable to pre-tax contributions ______________

4 Portion attributable to post-tax contributions Contributions Investment 

Earnings Total

a Qualified Roth transfers _____________

b Non-qualified Roth transfers ____________ ______________ _____________

c Other (Attachment required if greater than $0) ____________ ______________ _____________

5 Total transfer amount _____________

6 Is any portion of the missing distributee’s benefit attributable to non-US-source income?

□ Yes □ No (Attachment required if “Yes”)

Part IV— Miscellaneous Information

7 Non-qualified Roth transfer – If the transfer amount includes a non-qualified Roth transfer, enter 

the date the first Roth contribution was made. Complete only if amounts are reported in 4b. _ _ /_ _/_ _ _ _

8 Beneficiary Information – Complete only if “Participant” is checked in item 2f 

a Do plan records contain a valid beneficiary election form? If yes, attach a copy of the form and 

complete items (b)-(d) with respect to the designated beneficiary. □ Yes □ No

b Name ______________________________________ c Social Security number _ _ _-_ _-_ _ _ _

d Relationship _____________________________________________________

9 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). _____