Form 4062(e)-04 Form 4062(e)-04 Notice of Failure to Make Additional Contributions Under

NOTICE OF FAILURE TO MAKE
ADDITIONAL CONTRIBUTIONS
UNDER ERISA 4062(e)(4)

PBGC Form 4062(e)-04
Approved OMB # 1212-____
Expires __/__/20__

This form is used to notify the Pension Benefit Guaranty Corporation of an employer’s failure to make an additional
contribution 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 INFORMATION
__/__/____
Contribution due date

_________________
Contribution amount due

Explain why contribution has not been paid. If additional space is needed, the explanation may be submitted as an
attachment.

PBGC Form 4062(e)-04

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