Form 4062(e)-02 Notice of Election Under ERISA 4062(e)(4)

NOTICE OF ELECTION UNDER
ERISA 4062(e)(4)

PBGC Form 4062(e)-02
Approved OMB # 1212-____
Expires __/__/20__

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 4062e@pbgc.gov .
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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.

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PBGC Form 4062(e)-02

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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