NOTICE OF ELECTION UNDER 

ERISA 4062(e)(4)

PBGC Form 4062(e)-02 

Approved OMB # 1212-0073

Expires 08/31/2025

31TU U31T

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) 229-4070 or 4062e@pbgc.gov 

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 who are eligible

employees 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

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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