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MP-400 Template
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| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
|---|---|
| File Title | MP-400 Template |
| Author | Michael Rae |
| Last Modified By | Calc |
| File Modified | 2023-10-16 |
| File Created | 2026-06-19 |
| Conversion State | failed_conversion |
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1) 2) 3) 4) 5) 6) 7) Instructions for Using Excel Template Review the Form MP-400 Instructions before entering data.https://www.pbgc.gov/sites/default/files/form-mp400 Enter the PBGC case number assigned to your plan in the heading of the applicable tab. Overwrite the sample data shown with the data that needs to be reported. If either Schedule isn't required, delete the non-applicable tab from the spreadsheet. Use the appropriate schedule as a guide while filling out this spreadsheet. Save your spreadsheet as "Form 400 Excel Attachment_12345600" where "12345600" is the applicable case number of your plan. Feel free to add a row at the bottom totalling amounts, counting participants, etc., but please insert a blank row between the individual data and any "total" row you want to add. Schedule A Schedule A individual data - Attachment to Form MP-400 See instructions for detailed information about data to be entered, including information about which item Case Number 12345600 Case Name ABC Part I - Insurance Company Information Company NamPolicy NumberContact NameContact Telep Contact Email Street City 2a 2b Annuties-R-UsABC123435 Annuties-R-UsABC123435 Annuties-R-UsABC123435 2c(1) 2c(2) 2c(3) 2d(1) 2d(2) Geraldine Will800-555-1111 g.williams@A 52 Bluebird DrNewark Geraldine Will800-555-1111 g.williams@A 52 Bluebird DrNewark Geraldine Will800-555-1111 g.williams@A 52 Bluebird DrNewark Page 3 Schedule A ding information about which items may be left blank State Zip 2d(3) NJ NJ NJ 2d(4) 07101 07101 07101 Part II - Individuals for whom Annuities were Purchased Missing distributee's name Date of birth Social securit Last First Middle (enter w-o dashes) 3a(1) 3a(1) 3a(1) 3a(2) 3a(3) White Betty E 000-02-0214 111111111 Yellow Joseph F 000-02-3899 222222222 Black Polly G 000-02-5756 333333333 Page 4 Schedule A h items may be left blank Part II - Individuals for whom Annuities were Purchased Missing distributee's name Certificate nu Last-known address Last First w-o dashes) (enter Street City 3a(1) 3a(1) 3a(4) 3b(1) 3b(2) White Betty 001-11-1111 123 Robin HwyCity1 Yellow Joseph 002-22-2222 123 Blackbird City2 Black Polly 003-33-3333 123 Eagle St City3 Page 5 State 3b(3) DE WV DE Zip 3b(4) 42345 52345 62345 Schedule A h items may be left blank Part II - Individuals for whom Annuities were Purchased Missing distributee's name Accrued benefit information Amended Filing Last First Amount If monthly, entCode 3a(1) 3a(1) 3c 3c 4 White Betty $35,000.00 CV Yellow Joseph $150.00 MB Black Polly $50.00 MB Page 6 Schedule B Schedule B individual data - Attachment to Form MP-400 See instructions for detailed information about data to be entered, including information about which item Case Number 12345600 Case Name ABC Part I - Identifying Information Missing distributee's name Last First Middle 2a White Yellow Black 2a James Joseph Polly 2a E F G Date of birth Social SecurityLast-known Number address Street 2b City 2c 2d(1) 2d(2) 5/5/1955 111-11-1111 123 Robin HwyCity1 6/6/1965 222-22-2222 123 Blackbird City2 7/7/1970 333-33-3333 123 Eagle St City3 Page 7 Schedule B Schedule B individual data - Attachment to Form MP-400 out data to be entered, including See instructions informationfor about detailed which information items mayabout be leftdata blank to be entered, including information about which item Case Number Case Name Part I - Identifying Information Missing distributee's name Other name(s)Type of distribPrior payment Last First State Zip 2a White Yellow Black 2a James Joseph Polly 2d(3) DE WV DE 2d(4) P if Participant B if Beneficiary(Yes or No) 2e 42345 52345 62345 Page 8 2f P P B 2g No No No Schedule B Schedule B individual data - Attachment to Form MP-400 See instructions for detailed information about data to be entered, including information about which item Case Number Case Name Part I - Identifying Information Part II - Amount Owed to PBGC Missing distributee's name Non-U.S. Sour Employee contAmended filin Benefit transfeAdministrative Last First 2a White Yellow Black 2a James Joseph Polly Income (Yes or(Yes or No) 2h 2i No No No No No No code amount @ BD (if applicable) 2j 3 4 35000 10000 150 Page 9 35 35 0 Schedule B Schedule B individual data - Attachment to Form MP-400 See instructions for detailed information about data to be entered, including information about which item Case Number Case Name Part II I --Identifying Amount Owed Information to PBGC Missing distributee's name Late payment Last First Amount 2a White Yellow Black 2a James Joseph Polly 5a Part III - Missing Participant Benefit Information Lump sum eligiNormal retire Monthly SLA Interest 5b $0.00 $0.00 $0.00 (Yes or No) 6 $0.00 Yes $0.00 No $0.00 Page 10 date 7 8a $43,983.00 $47,665.00 318 0 Schedule B Schedule B individual data - Attachment to Form MP-400 See instructions for detailed information about data to be*entered, including information about which item Case Number Case Name art III - Missing Part Participant I - Identifying Benefit Information Information Missing distributee's name Monthly Single Life Annuity payable at various ages Last First Age 55 Age 56 2a White Yellow Black 2a James Joseph Polly 8b 8b 6/23/1900 2/18/1900 Age 57 Age 58 8b 192.5 55 Page 11 Age 59 8b 210 60 8b 227.5 65 245 70 Schedule B Schedule B individual data - Attachment to Form MP-400 See instructions for detailed information about data to be entered, including information about which item Case Number Case Name Part I - Identifying Information Missing distributee's name Last First Age 60 2a White Yellow Black 2a James Joseph Polly 8b Age 61 Age 62 8b 262.5 75 Age 63 8b 280 80 Page 12 Age 64 8b 297.5 85 8b 315 90 332.5 95 Schedule B Schedule B individual data - Attachment to Form MP-400 See instructions for detailed information about data to be entered, including information about which item Case Number Case Name Part I - Identifying Information Missing distributee's name Last First Age 65 2a White Yellow Black 2a James Joseph Polly 8b NRD (or accrual cessation date 8b 350 100 350 100 Page 13 Removed via Amendment Removed via Amendment data - Attachment to Form MP-400 See instructions for detailed information about data to be entered, including information about which items m Case Number 12345600 Case Name ABC Removed via Amendment Last-known address Distributee SSDistributee N Street City State Page 14 Removed via Amendment ng information about which items may be left blank Page 15