NOTICE OF ADDITIONAL 

CONTRIBUTIONS UNDER ERISA 

4062(e)(4) 

PBGC Form 4062(e)-03 

Approved OMB # 1212-0073

Expires 08/31/2025

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) 229-4070 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 _ _/ _ _/_ _ _ _

1P

stP year  2PndP year  3PrdP year  4PthP year  5PthP year  6PthP year 

2.

 7P

thP year

Check box to indicate which year, of the seven-year period, this filing relates to:



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