Notice Of Failure To Make Required Contributions {PBGC 200} | Pdf Fpdf Doc Docx | Skadden

Notice Of Failure To Make Required Contributions {PBGC 200}

Notice Of Failure To Make Required Contributions {PBGC 200} | Pdf Fpdf Doc Docx | Skadden

Notice Of Failure To Make Required Contributions Form

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This is a Skadden form that can be used for PBGC.

NOTICE OF FAILURE TO MAKE REQUIRED CONTRIBUTIONS PBGC Form 200 Approved OMB #1212-0041 Expires 01/31/06 File this form to notify the Pension Benefit Guaranty Corporation of a failure to make required contributions (see ERISA section 302(f)(4)(A) and Code section 412(n)(4)(A)) to a single-employer plan that is covered under ERISA section 4021. Do NOT file this form for any other employee benefit plan (e.g., a defined contribution plan). Do NOT file this form with the Internal Revenue Service. Do NOT file this form UNLESS the plan's funded current liability percentage is less than 100 percent. Do NOT file this form UNLESS the total of unpaid balances of required payments exceeds $1 million. PART I. GENERAL PLAN INFORMATION 1a Plan name b. Plan year commencement date Month Day Year 2 Plan administrator Name Street address City, State, Zip Telephone number 3a Contributing sponsor Name Street address City, State, Zip Telephone number b Employer identification and plan numbers 9-digit EIN 3-digit PN c Different EIN and/or PN used in previous filings with PBGC, DOL, or IRS. Enter "NA" if not applicable. 9-digit EIN 3-digit PN American LegalNet, Inc. www.USCourtForms.com 200-Page 2 4a Is the contributing sponsor in item 3a a member of a controlled group? If you checked "YES" to item 4a, enter that contributing sponsor's parent (if none, enter "none"). YES NO b Name Street address City, State, Zip Telephone number Enter parent's 9-digit EIN c If you checked "YES" to item 4a, are there any controlled group members other than the one(s) identified in item 3a and/or item 4b? YES NO d If 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 b Is there more than one contributing sponsor? YES NO If you checked "YES" to item 5a, submit the name of each contributing sponsor and, for each contributing sponsor for which information is not provided in previous items, the address, telephone number, and EIN. 6 Authorized contact (if same as individual signing certification in item 12, enter "same"). Name Street address City, State, Zip Telephone number PART II. PLAN FUNDING INFORMATION 7a Describe the required payment that resulted in the requirement to notify the PBGC. b Due date for the required payment described in item 7a. Month Day Year American LegalNet, Inc. www.USCourtForms.com 200-Page 3 8a Total of unpaid balances of required payments (including interest). $ b Describe how the amount in item 8a was determined. 9 a b c d Submit the following documentation and information with this form: Copy of most recent plan actuarial valuation report; Copy of Form 5500, Schedule B, for most recent plan year for which filed; Copy of any IRS letter(s) granting or modifying a funding waiver and/or an extension of the amortization period; Statement 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 10 a Submit the following documentation with this form with respect to the contributing sponsor in item 3a and each other member of the same controlled group as that contributing sponsor: Copies of financial statements for the most recent three fiscal years for which available and of the most recent interim financial statements; b Copies of any SEC filings during the past 6 months, including Form 10-K, Form 10-Q, and Form 8-K; c If 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 filing(s)) and interim financial reports filed in such proceeding. PART IV. CERTIFICATIONS 11 Enrolled Actuary Certification. 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 certification, I recognize that knowingly and willfully making false, fictitious, or fraudulent statements to the PBGC is punishable under 18 U.S.C. 1001. Name Enrollment number Company / Firm Street address City, State, Zip Telephone number Signature Date American LegalNet, Inc. www.USCourtForms.com 200-Page 4 12 Contributing Sponsor or Parent Certification. I certify that, to the best of my knowledge and belief, the information made available to the enrolled actuary and all other information and documentation in this filing 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 the PBGC is punishable under 18 U.S.C. 1001. Name and title Name of contributing sponsor or parent Street address City, State, Zip Telephone number Signature Date American LegalNet, Inc. www.USCourtForms.com