Form 4062(e)-03 Notice of Additional Contributions Under ERISA 4062(e)(4

NOTICE OF ADDITIONAL
CONTRIBUTIONS UNDER ERISA
4062(e)(4)

PBGC Form 4062(e)-03
Approved OMB # 1212-____
Expires __/__/20__

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 _ _/ _ _/_ _ _ _
2. Check box to indicate which year, of the seven-year period, this filing relates to:
 1 st year  2 nd year  3 rd year  4 th year  5 th year  6 th year  7 th year
P

P

P

P

P

P

P

P

P

P

P

P

P

P

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)

__________________

6. Limitation as determined under ERISA section 4062(e)(4)(B)(iii) for applicable plan year
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.
________________________________________________________________________________________________
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