Pbgc Form 200 – Fill Out and Use This PDF

File this form to notify the Pension Beneit Guaranty Corporation of a failure to make required contributions (see ERISA section 303(k)(4)(A) and Code section 430(k)(4)(A)) to a single-employer plan that is covered under ERISA section 4021.

•Do NOT ile this form for any other employee beneit plan (e.g., a deined contribution plan).

•Do NOT ile this form with the Internal Revenue Service.

•Do NOT ile this form UNLESS the plan’s funding target attainment percentage is less than 100 percent.

•Do NOT ile this form UNLESS the total of unpaid balances of required payments exceeds $1 million.

Part I. General Plan Information

2Plan Administrator

Name

Street Address

City, State, Zip

Telephone number

3a Contributing sponsor

Name

Street Address

City, State, Zip

Telephone number

b	Employer identiication and	9-digit EIN
	plan numbers	3-digit PN

	c Different EIN and/or PN used in	9-digit EIN
	previous ilings with PBGC, DOL,
	or IRS. Enter “N/A” if not applicable.	3-digit PN

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4a	Is the contributing sponsor in item 3a			Yes	No
	a member of a controlled group?
b	If you checked “YES” to item
			Name
	4a, enter that contributing
	sponsor’s parent (if none,
			Street Address
	enter “none”).

City, State, Zip

Telephone number

Enter parent’s 9-digit EIN

cIf you checked “YES” to item 4a, are there any controlled group members other than the

one(s) identiied in item 3a and/or item 4b?

Yes

No

dIf you checked “YES” to item 4c, submit the name, address, telephone number, and EIN of each controlled group member for which information is not provided in item 3a or item 4b and a description of the structure of the controlled group.

5a Is there more than one contributing sponsor?

Yes

No

bIf you checked “YES” to item 5a, submit the name of each contributing spoonsor and, for each contributing sponsor for which information is not provided in previous items, the address, telephone number, and EIN.

Part II. Plan Funding Information

7a Describe the required payment that resulted in the requirement to notify the PBGC.

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8a Total of unpaid balances of required	$
payments (including interest).

bDecribe how the amount in item 8a was determined.

9Submit the following documentation and information with this form:

aCopy of most recent plan actuarial valuation report;

bCopy of Form 5500, Schedule B, for most recent plan year for which iled;

cCopy of any IRS letter(s) granting or modifying a funding waiver and/or an extension of the amortization period;

dStatement describing any pending request(s) for a funding waiver and/or for an extension of the amortization period.

Part III. Contributing Sponsor & Controlled Group Financial

10Submit the following documentation with this form with respect to the contributing sponsor in item 3a and each other member of the controlled group as that contributing sponsor:

aCopies of inancial statements for the most recent three iscal years for which available and of the most recent interim inancial statements.

bCopies of any SEC ilings during the past 6 months, including Form 10-K, Form 10-Q, and Form 8-K;

cIf any member of the controlled group currently is the subject of a bankruptcy, insolvency, receivership, or similar proceeding, copies of any Statement of Affairs, Disclosure Statement, and Plan of Reorganization (or similar iling(s)) and interim inancial reports iled in such proceeding.

Part IV. Certiications

11Enrolled Actuary Certiication:

I certify that, to the best of my knowledge and belief, the information contained in items 7 and 8 of this form is true, correct, and complete and conforms to all applicable laws and regulations. In making this certiication, I recognize that knowingly and willfully making false, ictitious, or fraudulent statements to the PBGC is punishable under 18 U.S.C. 1001.

Signature

Date

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12Contributing Sponsor or Parent Certiication

I certify that, to the best of my knowledge and belief, the information made available to the enrolled actuary and all other information on this form is true, correct, and complete and conforms to all applicable laws and regulations. In making this certiication, I recognize that knowingly and willfully making false, ictitious, or fraudulent statements to the PBGC is punishable under 18 U.S.C. 1001.

Signature	Date