Fillable ADDITIONAL CONTRIBUTIONS UNDER ERISA 4062(e)(4) (Pension Benefit Guaranty Corporation)

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ADDITIONAL CONTRIBUTIONS UNDER ERISA 4062(e)(4) (Pension Benefit Guaranty Corporation)

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NOTICE OF FAILURE TO MAKE
ADDITIONAL CONTRIBUTIONS
UNDER ERISA 4062(e)(4)
PBGC Form 4062(e)-04
Approved OMB # 1212-0073
Expires 08/31/2022
This form is used to notify the Pension Benefit Guaranty Corporation of an employer’s failure to make an additional
contribution pursuant to ERISA section 4062(e)(4). For questions regarding this form, contact (202) 326-4070 or
4062e@pbgc.gov.
Filing date
of related PBGC Form 4062(e)-01: / _ _/_ _ _ _ _ _
Filing date of related PBGC Form 4062(e)-02: _ _/
_ _ _ _ _ _/
IDENTIFYING INFORMATION
_______________________________________________
Plan name
_______________________________________________
Name of authorized contact at filer
_______________________________________________
Name of filer
_______________________________________________
Title of contact
_______________________________________________
Street address of filer
_______________________________________________
Email address of contact
_______________________________________________
City, State, Zip
_______________________________________________
Street address of contact
EIN of contributing sponsor Plan number
_______________________________________________
City, State, Zip
________________________________ _________
Telephone number of contact Ext
CONTRIBUTION INFORMATION
_ _ / _ / _ _ _ _ _
Contribution due date
_________________
Contribution amount due
Explai
n why contribution has not been paid. If additional space is needed, the explanation may be submitted as an
attachment.
PBGC Form 4062(e)-04
_ _ / _ _ / _ _ _ _
Notice due date
_ _ / _ _ / _ _ _ _
Notice filing date
If filing is late (i.e. notice filing date is after the notice due date), explain below. If additional space is needed, the
explanation may be submitted as an attachment.
CERTIFICATION
I certify that, to the best of my knowledge and belief, the information submitted in this filing is true, correct, and
complete. 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.
________________________________________________________________________________________________
N
ame and title of individual certifying form
____
___________________________________________
Employer of individual certifying form
____
___________________________________________
Email address of individual certifying form
_______________________________________________
Telephone number of individual certifying form
____
___________________________________________
Signature of individual certifying form
_______________________________________________
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ADDITIONAL CONTRIBUTIONS UNDER ERISA 4062(e)(4) (Pension Benefit Guaranty Corporation)

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Completed 19 July 2020

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