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                                                                 Form 200 Instructions 

                      NOTICE OF FAILURE TO MAKE REQUIRED 

                      CONTRIBUTIONS 

The Form 200  is used to notify the Pension Benefit Guaranty Corporation of a failure to make required 
contributions to a single-employer plan that is covered under ERISA section 4021 and whose FTAP is less than 
100% if the total of unpaid balances, including interest, exceeds $1 million (see ERISA section 303(k)(4)
(A) and Code section 430(k)(4)(A)). For questions, contact (202) 326-4070 or form200@pbgc.gov. 

Table of Contents                                                                              Page 

Introduction                                                                                   2 
General Instructions                                                                           4 
Definitions                                                                                    6 
Specific Instructions                                                                          6 
General Plan Information                                                                       6 
Plan Funding Information                                                                       7 
Additional Information to be Filed                                                             7 
Actuarial Information                                                                          8 
Certifications                                                                                 9 

Appendix – Example of Calculation Concerning Failure to Make Required Funding Payments         A-1

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 Form 200 Instructions 
 
                                                              and-several liability of each controlled group 
 INTRODUCTION 
                                                              member  for  required  payments  (whether  the 
 
                                                              controlled  group  of  which  a  contributing 
 ERISA §303(k) and Code §430(k) provide that a 
                                                              sponsor is a member is a “parent-subsidiary,” 
 lien arises in certain cases where there is a failure 
                                                              “brother-sister,”  or   “combined”     group), 
 to make required contributions to a single- 
                                                              the  imposition  of  the  lien  on  all  assets  of 
 employer plan covered under ERISA §4021 whose 
                                                              each  controlled group member, or the ability 
 funding target attainment percentage (as defined in 
                                                              of PBGC  to take  all appropriate  steps  to 
 ERISA §303(d) and Code §430(d)(2)) is less than 
                                                              perfect and enforce the lien. 
 100 percent. The lien arises,  in  favor  of  the plan, 
                                                            
 upon all property and rights to property (whether            PBGC has restricted Form 200 to information 
 real or personal) belonging to the person or persons         generally  needed  in  its  decision-making 
 who  are  liable  for  required  contributions  (i.e.,  a    regarding  enforcement  of  a  lien  imposed  by 
 contributing  sponsor  and  each member of the               ERISA §303(k)  and Code §430(k). If PBGC 
 controlled group of which that contributing sponsor          concludes that it  needs additional information 
 is a member) if:                                             in a particular case, it will notify (in writing) the 
 
                                                              person  required to  supplement the Form  200 
 1. any  person  fails  to  make  a  required 
                                                              and specify the date  by which the additional 
    contribution payment when due, and 
                                                              information must be submitted. 
 
 2. the unpaid balance of the payment (including 
                                                              What’s New 
    interest), when added to the aggregate unpaid 
    balance  of  all  preceding  such  payments  for        
                                                              The Form 200 instructions and Form 200 have 
    which  payment  was  not  made  when  due 
                                                              been changed as follows: 
    (including interest), exceeds $1 million. 
                                                              • Added the amount of required payment 
 
                                                                that resulted in the requirement to notify 
 Any  lien  imposed  for  failure  to  make  required 
                                                                PBGC (this is in addition to the already 
 contributions may be perfected and enforced only 
                                                                required due date of required payment that 
 by  PBGC  or,  at  its  direction,  by  the  plan’s 
                                                                resulted in the requirement to notify 
 contributing  sponsor  or  any  member  of  the 
                                                                PBGC). 
 contributing sponsor’s controlled group. ERISA 
                                                              • PBGC no  longer accepts  electronic 
 §303(k)(4)(A) and Code §430(k)(4)(A) require that 
                                                                filing by email as of October 1, 2021. 
 PBGC  be  notified  whenever there is  a failure to 
                                                                PBGC’s  e-filing  portal,  available for 
 make a required payment and the total of unpaid 
                                                                reportable events filings  since 2016, 
 balances (including  interest) exceeds $1 million. 
                                                                offers a secure  application  for 
 Notice must be provided within 10 days of the due 
                                                                submitting Form 200 information. The 
 date for the required payment. 
                                                                e-filing portal allows filers to: 
 To  comply  with  this  notification  requirement,             − Review filings and generate a list 
 PBGC regulations (29 CFR 4043.81) require that a                 of omissions and inconsistencies 
 contributing  sponsor  and,  if  that  contributing              prior to submission to ensure that 
 sponsor  is  a  member  of  a  parent-subsidiary                 filings are complete. 
 controlled group, the “ultimate parent,” file Form             − Save a partially completed filing. 
 200 whenever such a failure occurs.                            − Modify information any time prior to 
                                                                  submission. 
 
 Note: PBGC’s decision not to require (at this time)            − Pre-populate a filing with data from a 
                                                                  previously submitted filing. 
 controlled    group    members      other    than 
                                                                −
 contributing sponsors and ultimate parents to file               Route the filing as needed to facilitate e- 
                                                                  certifications. 
 Form 200 does not in any way limit the joint- 
                                                                − Review prior filings submitted via the e- 
                                                                  filing portal. 
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                                                   Form 200 Instructions 
                                                                          
 The portal can be accessed using the following 
 address: efilingportal.pbgc.gov. 
 
 Notification of future changes to any forms and 
 instructions may be found under “What’s 
 New” on the Employers & Practitioners page 
 at www.pbgc.gov/whatsnew. 

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Form 200 Instructions

GENERAL INSTRUCTIONS Attaching files

Who Must File Filers may attach electronic files to their submission.
Examples of files that may be attached include, but
Form 200 must be filed by (1) a contributing are not limited to, actuarial valuation reports,
sponsor and (2) if a contributing sponsor is a financial statements, and organizational charts.
member of a “parent-subsidiary” controlled
group, the ultimate parent of such group. If you are filing materials electronically that are
However, if a timely and complete Form 200 is larger than 10 megabytes, please use Leap-FILE.
properly filed by either a contributing sponsor or First send an email to form200@pbgc.gov to request
the ultimate parent, PBGC will deem the other to a recipient email address. The email address provided
have so filed. (As noted in the “Introduction,” will be that of a PBGC staff member, e.g., a “[last
each other member of any controlled group of name].[first name]@pbgc.gov” email address. Enter
which a contributing sponsor is a member also is “pbgc.leapfile.com” in your Internet browser, click
jointly and severally liable for required on “secure upload,” enter the email address provided
payments, and PBGC may enforce the statutory by PBGC in the “Recipient Email” field, and attach
lien imposed on its assets.) the files.

Note: An authorized representative may file a When to File
Form 200 on behalf of a contributing sponsor, a
parent, or both. Form 200, including all required documentation and
information, must be filed with PBGC no later than
Special Rule for Terminating Plans: The fact that 10 days after the due date for the required payment.
a plan is in the process of terminating does not
mean that a Form 200 notice need not be filed. Note: Form 200 must be filed each time there is a
However, a notice is waived if the deadline for failure described in ERISA § 303(k)(1) and Code
filing the notice is on or after the date on which § 430(k)(1) and the total of unpaid balances of
(1) all of the plan’s assets (other than any required payments (including interest) exceeds $1
excess assets) are distributed pursuant to a million.
termination or (2) a trustee is appointed for
the plan under ERISA § 4042(c). Notice Filing Date

How to File The date a Form 200 is considered to have been filed
is the date received through PBGC’s e-filing portal.
Forms must be prepared and filed See 29 CFR § 4000.29.
electronically using the 4043 module of
PBGC’s e-filing portal. To request an Computation of time: In computing the 10-day
exemption from e-filing, send a request via period, the due date of the payment that resulted in
email to form200@pbgc.gov. the requirement to notify PBGC is not included.
Form 200 is due 10 days thereafter unless that
day is a Saturday, Sunday, or Federal holiday, in
which case the 10-day period runs until the next day
that is not a Saturday, Sunday, or Federal holiday.
Information received on a weekend or Federal holiday
or after 5:00 p.m. on a weekday is considered filed
on the next regular business day.

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                                                                                  Form 200 Instructions 

What to File                                              For Questions or Problems Regarding Form 
                                                          200 
A contributing sponsor must use the PBGC Form 200 
to  file  a  notice  of  a  failure  to  make  required   If you have questions or problems regarding Form 
contributions. Certain individual items on the form       200 or these instructions, contact: 
call for additional information. 
                                                          Pension Benefit Guaranty Corporation 
Attachments                                               Corporate Finance and Restructuring Department 
                                                          445 12th Street SW, Washington DC 20024-2101 
If responding to an item requires the attachment of       Telephone: 202-326-4070
documentation or information, mark the attachment         Email: form200@pbgc.gov 
to identify the item to which it responds. 
                                                          If you are having problems using the e-filing portal, 
Previously Submitted Information                          contact PBGC at efiling.portal@pbgc.gov. 

Because ERISA §303(k)(4)(A) and Code                      If  you  are  deaf,  hard  of  hearing,  or  have  a  speech 
§430(k)(4)(A) require  that PBGC be notified  each        disability, please  dial   7-1-1     to  access 
time there is a failure to make a required payment and    telecommunications relay services. 
the total of unpaid balances of required payments
(including interest) exceeds $1 million, more than        Copies of Form 200  and  instructions  may be 
one filing may be required regarding the same plan,       obtained  from  PBGC’s     website   at  http://
and at least some of the information included in a        www.pbgc.gov/prac/ forms. 
previous Form 200 filing may continue to be accurate
and responsive at the time that a subsequent Form         Reportable Event 
200 must be filed. It also is possible that information
submitted to PBGC in another context (e.g., in a          A failure to make a required contribution may also
distress termination filing pursuant to ERISA             be a reportable event under 29 CFR 4043.25(a). If
§4041(c) or in a notice of a reportable event required    with respect to such failure, a  Form 200 is 
by 29 CFR Part 4043) is  responsive. A filer  may         completed and  submitted  in  accordance  with  29 
respond to an item that calls for previously submitted    CFR  4043.81, the  Form 200  filing is deemed 
documentation or other information by identifying         to satisfy the  reportable event     requirement 
the previous submission in which the response was         (see 29  CFR 4043.25(b)). 
provided.
                                                          Note: If a contributing sponsor or controlled group 
Effect of Failure to Timely File                          member files a complete  Form 200 with PBGC 
                                                          within 10 days of the due date of the payment in
If a Form 200 (or other required information) is not      accordance with 29 CFR §4043.81, the Form 200
provided within the specified time limit, PBGC may        filing satisfies the notice requirement for purposes of 
assess a penalty under ERISA §4071 against each           29 CFR 4043.25(a). However, Form 10 may also be 
person required to provide the Form 200 (see 29 CFR       filed if desired. Choosing to rely on Form 200 to
Part  4071  and  PBGC’s  Statement  of  Policy  on        satisfy the Form 10 filing requirement does not make 
Assessment  of  Penalties  for  Failure  to  Provide      the Form 200 a reportable event filing under ERISA 
Required Information (60 FR 36837, July 18, 1995)).       §4043 and does not give the Form 200 filing the 
PBGC  may  pursue  any  other  equitable  or  legal       benefit  of the confidentiality  protection  for 
remedies available to it under the law.                   reportable event notices under ERISA §4043(f).

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 Form 200 Instructions 

 DEFINITIONS                                              Required  installment means  any  of  the  four 
                                                          quarterly contribution payments required  for each 
 As used in PBGC Form 200 and these instructions:         plan year by ERISA §303(j) and Code §430(j). 
                                                         
 Code  means the Internal Revenue Code of 1986, as        Required payment means a required installment or 
 amended.                                                 other payment required under ERISA §§ 302 and 303 
                                                          and Code §§ 412 and 430 or as a result of a funding 
 Contributing  sponsor means  a  person  that  is  a      waiver. 
 contributing sponsor as defined in ERISA §4001(a)       
 (13).                                                    Single-employer plan  means any  defined benefit 
                                                          plan (as  defined  in  ERISA  §3(35)) that is  not a 
 Controlled group, for purposes of ERISA §303(k)          multiemployer plan (as defined in ERISA 
 and Code §430(k), means any group treated as a           §4001(a)  (3))  and  that  is  covered  by  title  IV  of 
 single employer under subsection (b), (c), (m), or       ERISA. 
 (o) of Code §414.                                       
                                                          Ultimate Parent means the parent at the highest 
 Due date means the date set forth in ERISA §303(j)       level  in  the  chain  of  corporation  and/or  other 
 and  Code  §430(j)  for  payment  of  a  required        organizations  constituting  a  parent-subsidiary 
 installment and, in the case of a payment other than a   controlled group. (For  example, if Corporation A 
 required  installment,  the  date  such  payment  is     owns  all  of  the  stock  of  Corporation  B  and 
 required to be made under ERISA §303 and Code            Corporation C, and  Corporation B  owns all of the 
 §430.                                                    stock of Corporation X, the contributing sponsor, 
                                                          then  the  “ultimate  parent”  of  Corporation  X  is 
 EIN/PN   means       the nine-digit     employer         Corporation A.) 
 identification  number  assigned  by  the  Internal     
 Revenue Service to a person and the three-digit plan     SPECIFIC INSTRUCTIONS 
 number assigned to a plan. The EIN/PN should be         
 the  EIN/PN  most  recently  reported  for  a  PBGC      General Plan Information 
 premium filing (if applicable).                          • Complete name of the plan as it appears on the 
                                                            plan document and the plan year commencement 
 ERISA means the Employee Retirement Income                 date 
 Security Act of 1974, as amended. 
                                                          • The EIN/PN reported should be the EIN/PN most 
 
                                                            recently reported for a PBGC premium filing (if 
 IRS means the Internal Revenue Service. 
                                                            applicable). If the plan has never made a PBGC 
 
                                                            premium filing, enter the EIN assigned to the 
 Notice due date means the deadline for filing a Form 
                                                            contributing sponsor by the IRS for income tax 
 200 with PBGC. 
                                                            purposes and the PN assigned by the contributing 
 
                                                            sponsor. 
 Notice Filing Date means the date the Form 200 
 is received by PBGC.                                     • Name,  address,  telephone  number,  and  email 
                                                            address of the individual or the board or other 
 Person means  an  individual,  partnership,  joint         entity,  if  any,  specifically  designated  as  plan 
 venture, corporation, mutual company, joint-stock          administrator by the terms of the plan or trust 
 company, trust, estate, unincorporated organization,       agreement. If none is so designated, enter the 
 association, or employee  organization.                    name,  address,  telephone  number,  and  email 
                                                            address of the contributing sponsor. 
                                                        6

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                                                                                  Form 200 Instructions 
 
 • The  name,  title,  e-mail  address,  and  phone         • Operational  status  of  each  controlled  group 
   number of  an individual whom PBGC should                  member (in Chapter 7  proceedings, liquidating 
   contact if it has questions about the filing.              outside  of  bankruptcy,  in  Chapter  11 
                                                              proceedings, on-going, etc.) 

 Plan Funding Information                                   • Name, address, telephone number and EIN of 
 
 Note:  An  enrolled  actuary  must  certify  that  the     • each contributing sponsor of the plan 

 information  in  this  section  is  true,  correct,  and   • Reason contribution was not made by due date 
 complete,  and  conforms  to  applicable  regulatory 
 requirements (see Certification section).                  • Copy of any IRS letter(s) granting or modifying 
                                                              a  funding  waiver  and/or  extension  of  the 
                                                              amortization period 
 • Due date of required payment. 
 • Amount of the required payment.                          • Statement describing any pending request(s) for 
                                                              a  funding  waiver  and/or  extension  of  the 
 • The total amount, as of the due date, of  the              amortization period 

   unpaid balance of the required payment and the           • Copies  of  audited  financial  statements  (if 
   aggregate  unpaid  balance  of  all  preceding             available)  or  (if  not)  unaudited  financial 
   required payments for  which payment was not               statements  that  were  prepared  for  the 
   made when due (i.e., include in this amount the            contributing sponsor and each other controlled 
   unpaid  balances,  including  interest,  of  all           group  member  individually,  including  balance 
   required payments for  which payment was not               sheets,  income  statements,  statements  of  cash 
   made when due). See Appendix for an example                flows, 
   of how to compute the total amount. 
                                                            • and  notes  to  financial  statements  and  annual 
 • Description  of  how  the  unpaid  balance  of             reports. However, if  financial statements were 
   required  payments  was  determined.  This                 only prepared on a consolidated basis for more 
   description must include an attached spreadsheet           than one controlled group member, consolidated 
   that  shows  the  details  of  the  calculation  (see      financial statements and consolidating financial 
   Appendix for an example of how  the required               statements (if available)       and   (if       not) 
   information may be shown).                                 consolidating  trial  balances  that  identify  each 
                                                              controlled group member individually may be 
 Additional Information to be Filed                           attached instead. Copies of financial statements 
                                                              for the most recent three fiscal years available, 
 Additional information to be filed (check all boxes          and the most recent available interim financial 
 for  information  attached  to  form;  see  below  for       statement,  for  each  member  of  the  plan’s 
 description of Actuarial Information required).              controlled  group,  including  the  contributing 
 • Description  of  the  plan’s  controlled  group            sponsor and the ultimate parent 
   structure (including the contributing sponsor and       
   the  ultimate  parent  of  the  controlled  group),      Also include an explanation of any information 
   including the name, address, telephone number,           required to be filed but missing from the filing. 
   and EIN of each controlled group member                 
                                                            Note  –  Simplified  Reporting:  Most  “Additional 
 • Location  of  real  property  owned  by  each 
                                                            Information  to  be  Filed”  does  not  need  to  be 
   controlled group member 
                                                            submitted if the  filer has not missed any required 
 • Name  and  address  of  the  controlled  group’s         contribution (other than the missed contribution that 
   principal executive office                               triggered the Form 200 filing requirement) during 
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 Form 200 Instructions 

 the two-year period ending on the notice due date for         430(h)(2)(A)); 
 the  Form  200  and  has  made  up  the  missed 
 contribution  by  the  notice  due  date.  The  only        – The target normal cost calculated pursuant to 
 additional information  required is  the reason the           ERISA  section  303  without  regard  to 
 contribution was not made by the due date. PBGC               subsection  303(i)(2)  (and Code section 430 
 may also request evidence that the contribution has           without regard to subsection 430(i)(2)); 

 been  made.  The  filer  should  note  Simplified           – For the plan year and the four preceding 
 Reporting is being used in the missing information            plan years, a statement as to whether the 
 section of the filing.                                        plan was in at-risk status for that plan year; 
 
                                                             – In the case of a plan that is in at-risk status, 
 Actuarial Information 
                                                               the target normal cost calculated pursuant 
 
                                                               to ERISA section 303 as if the plan has 
 Please  include  the  following  for  each  plan 
                                                               been  in  at-risk  status  for  5 consecutive 
 maintained by any member of the plan’s controlled 
                                                               years; 
 group: 
                                                             –
 • Copy  of  the  most  recent  Actuarial  Valuation           The value of the plan’s assets (reflecting any 
                                                               averaging method) as of the valuation date 
   Report that includes or is supplemented with all 
                                                               and the fair market value of  the  plan’s 
   of the items described below. If the amount of the 
                                                               assets as of the valuation date; 
   most  recent missed contribution  is  based on a 
   calculation that is not reflected in the most recent      – The funding standard carryover balance and 
   Actuarial Valuation Report,  also provide all of            the prefunding  balance  (maintained 
   the information described below that supports the           pursuant to ERISA section 303(f)(1) and 
   calculation:                                                Code  section  430(f)(1))  as  of  the 
                                                               beginning of the plan year and a summary of 
   –    The  funding  target  calculated  pursuant  to 
                                                               any changes in such balances in the  past 
        ERISA  section  303  without  regard  to 
                                                               year (e.g., amounts used to  off-  set 
        subsection 303(i)(1), setting forth separately 
                                                               minimum funding requirement, amounts 
        the  value  of  the  liabilities  attributable  to 
                                                               reduced in accordance with any elections un- 
        retirees and beneficiaries receiving payment, 
                                                               der ERISA section 303(f)(5) or Code section 
        terminated  vested  participants,  and  active 
                                                               430(f)(5), interest credited to such balances, 
        participants (showing vested and non-vested 
                                                               and excess contributions used to increase 
        benefits separately; 
                                                               such balances); 
   –    A summary of the actuarial assumptions and 
                                                             – A list of amortization bases (shortfall and 
        methods used for purposes of ERISA section 
                                                               waiver) under ERISA section 303 and 
        303 and any changes  in those  assumptions 
                                                               Code section 430, including the  year 
        and methods since the previous valuation and 
                                                               the  base  was  established,  the original 
        justifications for any change; in the case of a 
                                                               amount, the      installment amount, and 
        plan that provides lump sums, other than de 
                                                               the remaining balance at the beginning of 
        minimis  lump  sums,  the  summary  must 
                                                               the plan year; 
        include the     assumptions   on which 
        participants are assumed to elect a lump sum         – An  age/service  scatter  for  active 
        and how lump sums are valued;                          participants    including        average 
                                                               compensation  information  for  pay- 
   –    The effective interest rate (as defined in ER- 
                                                               related plans and average account 
        ISA section 303(h)(2)(A) and Code section 

                                                           8

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                                                             Form 200 Instructions 

   balance information for hybrid plans                 Certification  must  be made  by  an  officer  (or  an 
   presented in a format similar to  that               individual  of  comparable  authority  in  an 
   described in the instructions to Schedule SB of      unincorporated  organization)  of  the  contributing 
   the Form 5500;                                       sponsor or  ultimate parent that is  filing the  Form 
                                                        200. 
 – Expected     disbursements     (benefit 
   payments and expenses) during the plan year; 
   and 

 – A summary of the principal eligibility and 
   benefit provisions on which the valuation 
   of the plan was based (and any changes to 
   those provisions since the previous 
   valuation),  along with        descriptions 
   of  any  benefits  not  included       in      the 
   valuation,    any significant events that 
   occurred during  the  plan  year,  and  the 
   plan’s early retirement factors; in the case of a 
   plan that provides lump sums, other than de 
   minimis lump sums, the summary must 
   include information on how annuity 
   benefits are converted to lump sum 
   amounts (for example, whether early 
   retirement subsidies are reflected). 

 • Statement of any material change in liabilities 
   of the plan occurring after the date of the 
   most recent Actuarial Valuation Report. 

 • Most recent month-end market value of 
   plan assets. 

 • Contact name, telephone number, and 
   employer of the plan actuary if different from 
   that listed on the most recently filed 
   Schedule SB to Form  5500. 

 • Copies  of  election   letters   relating   to 
   the application of carryover or prefunding 
   balances to the contributions. 

 Certifications 
 
 Plan funding information and related explanation 
 certification must be made by an enrolled actuary 
 Contributing Sponsor or Parent 

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  Form 200 Instructions 
                                                                                                                      
                                                       APPENDIX 
 
 Example on How to Describe the Aggregate Unpaid Balance of Required Funding Payments 
 
 Assume the plan sponsor of a calendar-year plan: 

 • missed a required 2017 quarterly installment of $600,000 on January 15, 2018 

 • made a contribution of $200,000 on March 1, 2018 

 • missed a 2018 required quarterly installment of $500,000 on April 15, 2018 

 • missed a 2018 required quarterly installment of $500,000 on July 15, 2018 

 • missed the final 2017 required contribution of $150,000 on September 15, 2018 

 In addition, assume the effective interest rate for plan year 2017 was 8% and for plan year 2018 was 6%. Adding 
 5% (see ERISA §303(j)(3)(A)) to the effective interest rates for the periods of underpayment, the applicable interest 
 rates for the missed quarterlies for the 2017 and 2018 plan years are 13% and 11%, respectively. 
 
 Aggregate Unpaid Balance of Required Contributions as of 7/15/2018 
 
                         Contribution  Applicable Plan  Applicable Interest             Days until Interest 
   Date                                                                     Amount                             Total 
                         Type          Year             Rate                            07/15/2018  Adjustment 
   01/15/2018/Quarterly  Missed        2017             13%                 $600,000    181        $37,488     $637,488 
   03/01/2018/Quarterly  Paid          2017             13%                 -$200,000   136        -$9,318     -$209,318 
   04/15/2018/Quarterly  Missed        2018             11%                 $500,000    91         $13,180     $513,180 
   07/15/2018/Quarterly  Missed        2018             11%                 $500,000    0          $0          $500,000 
   Total                                                                    $1,400,000             $41,350     $1,441,350 
 
 Because the aggregate unpaid balance of required payments as of July 15, 2018 ($1,441,350) exceeds $1,000,000, a 
 Form 200 filing is due on July 25, 2018 (10 days after the missed contribution, with weekend extension). The table 
 shown above is an example of the data to be submitted with the Form 200 filing. 
 
 Aggregate Unpaid Balance of Required Contributions as of 9/15/2018 
 
                         Contribution  Applicable Plan  Applicable Interest             Days until Interest 
   Date                                                                     Amount                             Total 
                         Type          Year             Rate                            07/15/2018  Adjustment 
   01/15/2018/Quarterly  Missed        2017             13%                 $600,000    243        $50,861     $650,861 
   03/01/2018/Quarterly  Paid          2017             13%                 -$200,000   198        -$13,709    -$213,709 
   04/15/2018/Quarterly  Missed        2018             11%                 $500,000    153        $22,358     $522,358 
   07/15/2018/Quarterly  Missed        2018             11%                 $500,000    62         $8,942      $508,942 
   09/15/2018/Final      Missed        2017             8%                  $150,000    0          $0          $150,000 
   Total                                                                    $1,550,000             $68,452     $1,618,452 
 
 Because the aggregate unpaid balance of required payments as of September 15, 2018 ($1,618,452) exceeds 
 $1,000,000, an updated Form 200 filing is due on September 25, 2018 (10 days after the missed contribution, with 
 weekend extension). The table shown above is an example of the data to be submitted with the Form 200 filing. 

                                                        A-1

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                                                                          Form 200 Instructions 

PAPERWORK REDUCTION ACT NOTICE 

PBGC needs this information, which is required to be filed under section 303(k)(4) of ERISA and section 
430(k)(4) of the Internal Revenue Code (the Code) and 29 CFR Part 4043, Subparts A and D, to make decisions 
regarding enforcement of a lien imposed by section 303(k)(1) of ERISA and section 430(k)(1) of the Code. 
Information provided to PBGC is confidential to the extent provided in the Freedom of Information Act and 
the Privacy Act. 

PBGC estimates that it will take an average of 1 hour and $725 to comply with the requirements described in 
these instructions. These figures are estimated  averages that will vary  depending  on  the nature and 
organizational structure of persons liable for plan contributions (in particular, whether the plan’s contributing 
sponsor is a member of a controlled group and, if so, the size of that group) and on the funding history of the 
plan. 

If you have any comments concerning the accuracy of these time estimates or suggestions for improving the 
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tory Affairs Group, Office of the General Counsel, 445 12th Street SW, Washington, DC 20024-2101. 

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