Fillable ERISA 4062(e)(4) PBGC Form 4062(e)-02 Approved OMB # (Pension Benefit Guaranty Corporation)

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ERISA 4062(e)(4) PBGC Form 4062(e)-02 Approved OMB # (Pension Benefit Guaranty Corporation)

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NOTICE OF ELECTION UNDER
ERISA 4062(e)(4)
PBGC Form 4062(e)-02
Approved OMB # 1212-0073
Expires 08/31/2022
This form is used to notify the Pension Benefit Guaranty Corporation that an employer is electing to make
additional contributions pursuant to ERISA section 4062(e)(4) in connection with liability for an event listed in
ERISA section 4062(e)(2). For questions regarding this form, contact (202) 326-4070 or 31TU4062e@pbgc.gov U31T.
Filing date of related PBGC Form 4062(e)-01: _ _/_ _ /_ _ _ _
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
OBLIGATION TO MAKE ADDITIONAL CONTRIBUTIONS
For the plan year in which the cessation occurred, was the variable-rate premium funded status 90 percent or greater?
Yes No Have not yet determined VRP for that plan year. If “Yes,” no additional contributions are required
to satisfy 4062(e) liability; skip to Required Attachments section.
ADDITIONAL CONTRIBUTION TO SATISFY LIABILITY
1. Beginning of plan year in which cessation occurred
2. Eligible employee base date (item 2c from Form 4062(e)-01)
3. Participant reduction fraction
a. Number of plan participants with accrued benefit liabilities separated from
employment as a result of the cessation __________________
b. Number of plan participants with accrued benefit liabilities immediately before
eligible employee base date __________________
c. Participant reduction fraction (item 3a ÷ item 3b)
__________________
PBGC Form 4062(e)-02
4. Maximum additional annual contribution (before reflecting 4062(e)(4)(B)(iii) limitation)
a. Unfunded vested benefits for plan year immediately preceding plan year in which
cessation occurred
_________________
b. Base amount (item 4a x item 3c)
_________________
c. Maximum additional annual contribution (item 4b ÷ 7)
_________________
5. Date first 4062(e)(4) contribution is due
_ _/_ _ /_ _ _ _
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 section.
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, provide an explanation 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.
2
PBGC Form 4062(e)-02
3
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.
________________________________________________________________________________________________
Name
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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ERISA 4062(e)(4) PBGC Form 4062(e)-02 Approved OMB (Pension Benefit Guaranty Corporation)

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Completed 19 July 2020

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