4062-E Section 4062(e) Event Notice

PBGC

Form

Section 4062(e) Event Notice

4062-E

and
Request for PBGC Determination of Liability

Approved OMB
1212-____
Expires __/__/____

IMPORTANT: See instructions for explanation of information to be provided.
 Supplemental notice.
Date in item 6b of prior notice was:
1 Name and postal address of plan administrator
2 Name and postal address of contributing sponsor

3a Plan name
b EIN/PN
 Employer decision to discontinue
 Employee action
 Other event
b Applicable date (date of decision, action, or other event)
4a Event was initiated or caused by (not
more than one):

c Active participant base (as of immediately before applicable date)
d Date employer decision became known to employees
5a Cessation date
b Date when active participant decline exceeded 20 percent
c Section 4062(e) event date (later of 5a or 5b)
6a Number of affected participants as of date in 6b
b Date as of which affected participants in 6a were counted
c Anticipated number of additional affected participants
7 Separated active participants not counted as affected participants
 Other controlled group member(s)
 Other plan(s) covering affected participants
 Union(s) representing affected participants
Filing of this notice constitutes a request that PBGC determine liability arising from the section
4062(e) event described in the notice. False or incomplete information is subject to penalty.
The individual filing this notice must be (or be authorized to act for) the plan administrator.
9 Individual filer’s name (do not sign)
8 Other entities involved (required
additional information listed on page 2):

10a Name of individual to contact
b Phone number
c E-mail address
See page 2 for list of additional information included in this notice.

PBGC Form 4062-E

Page 2
List of additional information included in notice

 11 Information about other entities involved (see item 8 on page 1)
 (i) Controlled group information
 (ii) Information about any other plan(s) covering affected participants
 (iii) Union(s) representing affected participants and collective bargaining agreement(s)
 12 Description of section 4062(e) event
 13 Severance and early retirement incentives
 14 Plan provisions on lump sums, shutdowns, and early retirement
 15 Expectations for merger, termination, or change in plan sponsor or controlled group
 16 Date and copy of each WARN notice, press release, and other announcement
 17 Most recent AFTAP certification
 18 Most recent actuarial valuation report, including information described in instructions
(from 29 CFR § 4010.8(a)(11)):
 (i) Funding target with breakdown by participant category
 (ii) Summary of actuarial assumptions and methods
 (iii) Effective interest rate
 (iv) Target normal cost
 (v) Statement about at-risk status for five years
 (vi) If at-risk, target normal cost computed as if at-risk for five years
 (vii) Value with averaging, and fair market value, of plan assets
 (viii) Funding standard carryover balance and prefunding balance and changes
 (ix) Data on amortization bases
 (x) Age/service scatter for active participants
 (xi) Expected disbursements
 (xii) Summary of principal eligibility and benefit provisions and related data
 19 Additional information (not in the actuarial valuation report) described in instructions:
 (i) A summary of any plan amendments.
 (ii) Any significant changes in plan population or assumptions.
 (iii) The amounts and dates of any lump sums paid.
 (iv) The fair market value of the assets of the affected plan on the cessation date (see
item 5a) or (if the fair market value cannot reasonably be determined as of the cessation
date) on the closest date as of which the fair market value can reasonably be determined
(and specify the date).