Fillable EVENT PBGC Form 4062(e)-01 Approved OMB # 1212-0073 (Pension Benefit Guaranty Corporation)

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EVENT PBGC Form 4062(e)-01 Approved OMB # 1212-0073 (Pension Benefit Guaranty Corporation)

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1
NOTICE OF SECTION 4062(e)
EVENT
PBGC Form 4062(e)-01
Approved OMB # 1212-0073
Expires 08/31/2022
This form is used to notify the Pension Benefit Guaranty Corporation of the occurrence of an event listed in
ERISA section 4062(e)(2) and satisfies the requirement to request that PBGC determine liability arising from
the event. For questions regarding this form, contact (202) 326-4070 or 4062e@pbgc.gov .
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 of filer
_______________________________________________
Street address of contact
EIN of contributing sponsor Plan number
_______________________________________________
City, State, Zip of contact
_______________________________________________
Name of contributing sponsor (if different from filer)
________________________________ _________
Telephone number of contact Ext
Filer is:
Plan administrator Employer
BRIEF DESCRIPTION OF EVENT
Check the box or boxes that best describe the cause of the substantial cessation of operations.
Facility shutdown Facility sale Discontinued operations
Winding down of the company Reduction in force Other
Briefly describe th
e pertinent facts relating to the substantial cessation of operations. If additional space is needed,
information may be submitted as an attachment.
PBGC Form 4062(e)-01
2
EVENT INFORMATION
__________________
__________________
1. Date of 4062(e) event
2. Eligible employee base date:
a. Date of employer’s decision to implement the cessation
b. Earliest date an eligible employee was separated from employment at the facility in
relation to the cessation (not more than 3 years before the permanent cessation)
c. Earlier of the date in item 2a or item 2b
3. Workforce reduction percentage
a. Number of eligible employees as of immediately before the date in item 2c
b. Number of eligible employees who were separated from employment as a result of
the cessation
c. Workforce reduction percentage (item 3b ÷ item 3a) (If 15 percent or less, no report
is required, and the employer will not incur liability.)
__________________
REQUIRED ATTACHMENTS
The following must be submitted with this filing, if not previously provided to PBGC. Check box to indicate the item is
attached. If not attached, explain in Missing Information section.
Description of the plan’s controlled group structure, including the name of each controlled group member
C
ontrolled group financial information (see instructions)
A
ctuarial information (see instructions)
N
ame of each employee pension benefit plan maintained by any member of the plan’s controlled group, its
contributing sponsor(s), and its EIN/PN
D
ate and copy of each WARN Act notice, press release, and other written announcement of the cessation
A
ny 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
If a new em
ployer assumed pension assets and/or liabilities, the following information must also be provided.
S
tatement explaining the transfer to the new employer, including the plan’s name and EIN/PIN and the number of
participants affected by the transfer
__________________
__________________
__________________
__________________
PBGC Form 4062(e)-01
3
MISSING INFORMATION
If required information has not been submitted with this filing, 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.
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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EVENT PBGC Form 4062(e)-01 Approved OMB 1212-0073 (Pension Benefit Guaranty Corporation)

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Completed 26 January 2021

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