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

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

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NOTICE OF ADDITIONAL
CONTRIBUTIONS UNDER ERISA
4062(e)(4)
PBGC Form 4062(e)-03
Approved OMB # 1212-0073
Expires 08/31/2022
This form is used to notify the Pension Benefit Guaranty Corporation of an employer’s additional contributions made
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 PAYMENT AND OBLIGATION TO MAKE ADDITIONAL CONTRIBUTIONSN
1. Applicable plan year. This filing relates to the plan year beginning _ _/ _ _/ _ _ _ _ and ending _ _/ _ _/_ _ _ _
1P
st
P year 2P
nd
P year 3P
rd
P year 4P
th
P year 5P
th
P year 6P
th
P year
2.
7P
th
P year
Check box to indicate which year, of the seven-year period, this filing relates to:
3. For the applicable plan year, was the variable-rate premium funded status 90 percent or greater?
Yes No If “Yes,” no additional contributions are required to satisfy 4062(e) liability; skip to Required
Attachments section.
4. Has the IRS issued a funding waiver under section 302(c) with respect to the plan for applicable plan year?
Yes No If “Yes,” skip to Required Attachments section.
PBGC Form 4062(e)-03
5. Maximum additional annual contribution (Item 4(c) from Form 4062(e)-02)
__________________
a. Unfunded vested benefits (UVBs) for plan year prior to applicable plan year
b. 25% of prior year’s UVBs (.25 x item 6a)
__________________
__________________
c. Minimum required contribution for applicable plan year
__________________
d. Limitation on annual additional contribution (item 6b - item 6c, but not less than $0)
__________________
7. ERISA 4062(e)(4) additional contribution for applicable plan year
a. Amount lesser of item 5 or item 6d
__________________
b. Due date
_ _
/
_ _
/
_ _ _ _
c. Date contribution was made
_ _
/
_ _
/_
_ _ _
REQUIRED ATTACHMENTS
The following must be submitted with this form, if not previously provided to PBGC. Check box to indicate the item is
attached. If not attached, explain in Missing Information.
Actuarial information (see instructions)
Any IRS funding waiver issued under Internal Revenue Code section 302(c) with respect to the plan for the year in
which the cessation occurred or any later year
MISSING INFORMATION
If required information has not been submitted with this form, explain below. If additional space is needed, the
explanation may be submitted as an attachment.
FILING INFORMATION
_ _ / _ _ / _ _ _ _
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.
PBGC Form 4062(e)-03
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
_______________________________________________
Date signed
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CONTRIBUTIONS UNDER ERISA 4062(e)(4) (Pension Benefit Guaranty Corporation)

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Completed 19 July 2020

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