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NOTICE OF SECTION 4062(e) 

EVENT

PBGC Form 4062(e)-01 

Approved OMB # 1212-0073 

Expires 08/31/2025

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) 229-4070 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 the 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

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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

 Controlled group financial information (see instructions)

 Actuarial information (see instructions)

 Name of each employee pension benefit plan maintained by any member of the plan’s controlled group, its

contributing sponsor(s), and its EIN/PN

 Date and copy of each WARN Act notice, press release, and other written announcement of the cessation

 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

If a new employer assumed pension assets and/or liabilities, the following information must also be provided.

 Statement 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

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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 

__________________ __________________