Form 4062-E Section 4062(e) Event Notice

SECTION 4062(e) EVENT NOTICE
PENSION BENEFIT GUARANTY CORPORATION
This Package Contains Form 4062-E and Instructions

Paperwork Reduction Act Notice
Pension Benefit Guaranty Corporation (PBGC) needs this information to determine liability
with respect to an event described in section 4062(e) of the Employee Retirement Income
Security Act of 1974 (ERISA) and PBGC’s regulation thereunder (29 CFR part 4062 subpart B).
You are required to give us this information. An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it displays a currently
valid OMB control number. OMB has approved this collection of information under control
number 1212-00__. Confidentiality is that provided by the Privacy Act and the Freedom of
Information Act and by 18 U.S.C. 1905, which in general prohibits disclosure of commercial and
financial information. See PBGC’s regulation on Examination and Copying of Pension Benefit
Guaranty Corporation Records (29 CFR part 4901). PBGC’s regulations are accessible on
PBGC’s Web site (www.pbgc.gov).
The estimated burden associated with preparing and giving a notice of a section 4062(e)
event using Form 4062-E is 7 hours (for work done in-house) and $2,450 (for work contracted
out). These burden estimates are an average for the filings PBGC expects to receive. The actual
burden will vary depending on the circumstances of each section 4062(e) event.
If you have comments concerning the accuracy of this time estimate or suggestions for
making the form simpler, please send your comments to [email protected] or to:
Pension Benefit Guaranty Corporation
Legislative & Regulatory Department
1200 K Street, NW
Washington, DC 20005-4026
Introduction
Under sections 4062(e) and 4063 of ERISA and PBGC’s section 4062(e) regulation, the plan
administrator of a plan affected by an event described in section 4062(e) must notify PBGC of
the event and request that PBGC determine liability with respect to the event. This booklet
explains what events must be reported, what information a section 4062(e) notice must include,
and when and how to file the notice.
What is a section 4062(e) event
In general, there is a section 4062(e) event if an employer (the “affected employer”) ceases
an operation (the “affected operation”) at a facility in any location and, as a result of the
cessation, more than 20 percent of the total number of the employer’s employees who are
participants under a plan maintained by the employer (the “affected plan”) are separated from
employment (the “affected participants”).

Whether an event is a section 4062(e) event is determined without regard to whether there is
risk or apparent risk to a plan, its participants, or PBGC.
This booklet provides guidance on determining when a section 4062(e) event occurs,
including the meaning of the terms used in the description of a section 4062(e) event, and how to
file notice of an event. PBGC’s section 4062(e) regulation contains further detail.
Plans covered
The requirements of section 4062(e) apply to single-employer defined benefit pension plans
covered by Title IV of ERISA that are not multiple employer plans. (A multiple employer plan
is a single-employer plan with multiple contributing sponsors, at least two of which are not under
common control. A single-employer defined benefit pension plan with multiple contributing
sponsors, all under common control, is covered by section 4062(e).)
If an employer has two or more plans, section 4062(e) applies to each plan separately.
“Operation”
An operation is a set of activities that
constitutes an organizationally, operationally, or
functionally distinct unit of an employer. Whether
a set of activities is an operation may depend on
whether it is (or similar sets of activities are) so
considered or treated in the relevant industry, in the
employer’s organizational structure or accounts, in
relevant collective bargaining agreements, by the
employer’s employees or customers, or by the
public.
“Facility”
The facility (or facility in any location)
associated with an operation is the place or places
where the operation is performed. A facility is
typically a building or buildings. However, a
facility may be or include any one or more
enclosed or open areas or structures.



A facility (a building, for example) may
be the site of more than one operation. Thus,
section 4062(e) may apply where some but
not all activity at a facility ceases, if the
activity that ceases constitutes an operation
distinct from other activities in the facility.
For example, an employer might conduct a
manufacturing operation under the same roof
with shipping and administrative functions —
or with another, distinct manufacturing
operation. If the employer ceased the
manufacturing operation (or one of the two
manufacturing operations) at the facility, the
cessation might come within the scope of
section 4062(e), even though the employer
continued its other activity at the facility.

“Cessation” of an operation
 An employer may cease an operation at a
In general, an employer is considered to cease
facility even though insignificant activity at
an operation at a facility when the employer
the facility in furtherance of the purpose of
discontinues all significant activity (or all but
the operation continues. Continuing activity
insignificant activity) at the facility in furtherance
that does not further an operation’s purpose is
of the purpose of the operation. This is the
also disregarded.
“cessation date.” There are special rules if the
discontinuance of activity is involuntary.
The first special rule applies if the discontinuance of activity is caused by employee action
such as a strike or sickout. In that case, the cessation date (when the employer is considered to
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cease the operation at the facility) is the date when the employee action ends, unless within one
week after that date the employer has resumed significant activity at the facility in furtherance of
the purpose of the operation. But if, before the employee action ends, the employer decides not
to resume significant activity at the facility in furtherance of the purpose of the operation, the
cessation date is considered to be when that decision is made.
The second special rule applies if the discontinuance of activity is caused by a sudden and
unanticipated event (other than an employee action) such as a natural disaster. In that case,
the cessation date is considered to be 30 days after the discontinuance, unless on that date the
employer has resumed significant activity at the facility in furtherance of the purpose of the
operation. But if, within that 30-day period, the employer decides not to resume significant
activity at the facility in furtherance of the purpose of the operation, the cessation date is
considered to be the date
when that decision is
 Section 4062(e) may apply to an employer’s cessation of an operation
at
one facility even if the employer continues or resumes the operation at
made.
another facility. For example, where an employer has been performing
In deciding whether
manufacturing, shipping, and administrative functions under a single roof,
an employer has ceased
section 4062(e) could apply where the employer moves the manufacturing
an operation at a facility,
operation outside the United States and has manufactured goods shipped
disregard any
in bulk to the original U.S. facility for distribution using the employer’s
continuation or
own existing shipping operation. Section 4062(e) also applies to an
resumption of the
employer’s cessation of an operation at a facility even if the operation is
operation at another
continued or resumed by another employer at the same or another facility.
facility or by another
One example of this would be the not uncommon situation where one
employer. If a different
employer sells the assets used in an operation to another employer that
operation is started up,
continues or resumes the operation.
that must also be
disregarded.
“Separation” from employment
 In general, employees who are laid
An employee of an employer separates from
off are considered separated, because
employment when the employee discontinues the
they are no longer actively working.
active performance, pursuant to the employee’s
Continued provision of benefits to an
employment relationship with the employer, of
employee, such as the continued granting
of credited service for pension purposes,
activities in furtherance of any of the employer’s
is disregarded in deciding whether a
operations, unless, when the discontinuance of active
separation from employment has
work occurs, it is reasonably certain that the employee
occurred.
will resume such active work for the employer within
30 days. However, if the 30-day period passes and the
employee has not resumed active work for the employer, the employee will be considered to
have separated from employment when the discontinuance of active work occurred.
The separation from employment of an employee who is a participant in a plan of the
employer is disregarded if the separation is before the cessation date and, as of the cessation date,
either —
(1) The employee has been rehired and is an employee of the employer and a participant in
the plan, or
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(2) The employee has been replaced and the replacement is an employee of the employer
and a participant in the plan.
However, a subsequent separation from employment (after the cessation date) by the same
employee (or replacement) is not disregarded.
Separation as a “result” of a cessation
An employee’s separation from employment is a result of the employer’s cessation of an
operation at a facility if the separation would not have occurred when it did if the employer’s
cessation of the operation at the facility had not occurred. In deciding whether a separation from
employment is the result of a cessation, it is irrelevant whether separation occurs before, on, or
after the cessation date. Also, an employee’s separation from employment may result from an
employer’s cessation of an operation at a facility even if the employee is employed in a different
operation or at a different facility.
There are four presumptions about when an employee’s separation from employment is the
result of an employer’s cessation of an operation at a facility. These presumptions apply unless
rebutted by appropriate evidence.
● Voluntary cessation; involuntary separation. An employee’s separation from
employment is presumed to result from the employer’s cessation of an operation at a
facility if —
(1) The employee is employed in the
 “Voluntary” as applied to a cessation
operation,
or separation does not mean a cessation or
(2) The cessation is voluntary, and
separation that is desired or preferred, but
(3) The employee involuntarily separates from
merely one that is not involuntary. A
cessation is involuntary if it is caused by
employment on or after the date of the
an employee action, natural disaster, or
employer decision to cease the operation.
other such event (as discussed above). A
● Voluntary cessation; voluntary separation. An
separation is involuntary if it is due to
employee’s separation from employment is
discharge, layoff, or other such employer
presumed to result from the employer’s
action — not, for example, a quit or
cessation of an operation at a facility if —
retirement.
(1) The employee is employed in the
operation,
(2) The cessation is voluntary, and
(3) The employee voluntarily separates from employment on or after the earliest date
when the employer decision to cease the operation becomes known to the employee, to
employees generally, or to the public.
● Involuntary cessation. An employee’s separation from employment is presumed to result
from the employer’s cessation of an operation at a facility if —
(1) The employee is employed in the operation,
(2) The cessation is involuntary, and
(3) The employee voluntarily or involuntarily separates from employment with the
employer on or after the date of the event that causes the cessation.
● Employment by new employer. An employee’s separation from employment is
presumed to result from the employer’s cessation of an operation at a facility if —
(1) The employee is employed in the operation,
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(2) Another employer (the “new employer”) continues or resumes performance of the
operation at the same or another facility, and
(3) The employee becomes employed by the new employer.
Active participant base
When a section 4062(e) event occurs depends not only on when an employer ceases an
operation at a facility, but also on when the number of affected participants (participants in the
affected plan who separate from employment as a result of the cessation) exceeds 20 percent of
total active participants. The section 4062(e) event is not complete until both things have
happened.
The active participant base is the number of total active
 It is irrelevant, for purposes
participants against which the reduction in active participants is of determining the percentage
measured for this purpose. Thus, for a section 4062(e) event to decline in active participants,
occur, the number of affected participants must exceed 20
whether participants are accruing
percent of the active participant base.
benefits — for example, it is
irrelevant whether the affected
The active participant base is determined immediately
plan is frozen or whether
before the applicable date. For a voluntary cessation, the
participants have moved to
applicable date is the date of the employer decision pursuant to
which the cessation occurred. For an involuntary cessation, the employment categories outside
the plan’s coverage group.
applicable date is the date of the event that caused the
cessation.
The participants in the affected plan who are included in the active participant base are those
who were employees of the affected employer and were either (1) engaged in the active
performance, pursuant to their employment relationship with the employer, of activities in
furtherance of the employer’s operations, or (2) reasonably certain to resume such active work
for the employer within 30 days. However, a person is not counted in the active participant base
if the 30-day period passes and the employee has not resumed active work for the employer.
Reporting requirement
Reporting of section 4062(e) events to PBGC is mandatory. PBGC conducts investigations
to discover whether section 4062(e) events have occurred and whether required notices have
been timely filed. Penalties may be assessed under section 4071 of ERISA for failure to file
required information on time. Under PBGC’s Statement of Policy on Assessment of Penalties
for Failure to Provide Required Information (60 FR 36837, July 18, 1995), PBGC bases section
4071 penalties on the facts and circumstances of each case. Penalties are generally $25 or $50
per day, but may be as much as $1,100 per day if a filing delinquency causes substantial harm.
Since failure to timely file notice of a section 4062(e) event may well cause substantial harm, it
may well warrant a penalty of as much as $1,100 per day. The 1995 Statement of Policy is
accessible on PBGC’s Web site (www.pbgc.gov).
Under 18 U.S.C. 1001, it is a crime, in any matter within the jurisdiction of the executive
branch of the Government of the United States, to knowingly and willfully (1) falsify or conceal
a material fact, (2) make a materially false, fictitious, or fraudulent statement or representation,
or (3) make or use a false writing or document knowing that it contains a materially false,
fictitious, or fraudulent statement or entry.
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PBGC may grant waivers to accommodate the facts and circumstances of particular cases
and promote the equitable and rational interpretation and application of title IV of ERISA.
Who must file
If a section 4062(e) event occurs, the plan administrator of the affected plan must file a
notice of the event with PBGC. The individual who submits the filing must be (or be authorized
to act for) the plan administrator. The filing of the notice constitutes a request that PBGC
determine the liability with respect to the event.
When to file
Notice of a section 4062(e) event must be filed with PBGC within 60 days after the later of
(1) the date when the cessation occurs (the cessation date) and (2) the date when the number of
affected participants is more than 20 percent of the active participant base. For information
about how PBGC determines when a filing was made and how to compute time periods, see
subparts C and D of PBGC’s regulation on Filing, Issuance, Computation of Time, and Record
Retention (29 CFR part 4000).
How and where to file
Notice of a section 4062(e) event must be filed using PBGC Form 4062-E, completed in
accordance with these instructions. The form must be accompanied by the additional
information described in these instructions. Notices may be filed on paper (by U.S. Mail,
courier, or hand delivery) or electronically. For more information, see 29 CFR §§ 4000.3 and
4000.4.
The filing address for paper documents is:
Pension Benefit Guaranty Corporation
Department of Insurance Supervision and Compliance
1200 K Street, NW
Washington, DC 20005-4026
The fax number for filing is 202-842-2643.
The e-mail filing address is [email protected].
For secure electronic submission to PBGC, and for materials that are larger than 10
megabytes, use LeapFILE, PBGC’s secure large-file transfer application. Enter
“pbgc.leapfile.com” in your Internet browser, click on “secure upload,” enter
“[email protected]” in the “Recipient Email” field, and attach the files you are submitting.
Information from employer
An employer that may be an affected employer must timely provide to the plan administrator
of any plan that may be an affected plan any information that the plan administrator needs to
decide whether and when a section 4062(e) event has occurred and to file a section 4062(e) event
notice if required.

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Follow-up information
PBGC may request additional information from a plan administrator that files notice of a
section 4062(e) event. The plan administrator must file the requested information within 45 days
after PBGC’s request or within a different time specified in the request.
Duty to update or correct
If the plan administrator of an affected plan discovers or is notified by the affected employer
that any information filed with PBGC under this section (including the number of affected
participants) is materially erroneous or has become materially outdated, the plan administrator
must promptly file with PBGC the correct or updated information. Corrections and updates may
be made by filing a supplemental notice or by any other means approved by PBGC.
Disregarding certain affected participants
A plan administrator may disregard affected participants who were not employed at the
facility associated with the affected operation for purposes of deciding (1) whether notice of a
section 4062(e) event is required, (2) the due date of the notice, and (3) the number of affected
participants to be reported in the notice.
Recordkeeping
Each employer that may be affected by a section 4062(e) event, and the plan administrator of
each plan that may be affected by a section 4062(e) event, must keep all records that bear on
whether a section 4062(e) event has occurred and on the calculation of liability with respect to
the event. Records must be kept with respect to any discontinuance of all significant activity in
furtherance of the purpose of an operation of the employer at a facility if a section 4062(e) event
may result. Records must be retained for five years.
Contacting PBGC
For requests for information or assistance regarding section 4062(e) events and notices,
including requests for waivers and for reconsideration of penalty assessments, use the same
addresses provided above for filing section 4062(e) event notices or call 202-326-4070.
(TTY/TDD users may call the Federal relay service toll-free at 1-800-877-8339 and ask to be
connected to 202-326-4070.)
Instructions for Form 4062-E and additional information
Instructions are numbered to match the item numbers on Form 4062-E.
Supplemental notice checkbox. If this is a supplemental notice, check the box at the top of
Form 4062-E and enter the date as of which affected participants were counted for the prior
notice (the date in item 6b of the prior notice). A supplemental notice is used to make
corrections and updates.
1 Provide the name and postal address of the plan administrator, even if the plan administrator
is the same as the plan sponsor.
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2 Provide the name and postal address of the contributing sponsor. If the plan is maintained by
a controlled group, and two or more members of the controlled group are contributing sponsors,
provide the information for any contributing sponsor.
3 Provide the name and the EIN/PN (employer identification number and plan number) most
recently reported for the affected plan in a PBGC premium filing or (if no premium filing has
been made for the plan) in a Form 5500 filing. If no premium or Form 5500 filing has been
made, provide the EIN of the contributing sponsor identified in item 2 and the plan’s PN.
4 Item 4 gives PBGC information about the inception or beginning of the section 4062(e)
event. Indicate in item 4a whether the event was initiated or caused by an employer decision to
cease the operation at the facility, by an employee action such as a strike, or by a sudden and
unanticipated event other than an employee action. See the discussions of Cessation and Active
participant base above. Do not check more than one box. In particular, note the difference
between an employer decision to discontinue activity and an employer decision not to resume
activity; do not check the “employer decision to discontinue” box if the cessation is involuntary,
even if the employer decided not to resume the operation.
Report in item 4b the “applicable date” as described in the discussion of Active participant base
above. The applicable date is the date of the employer decision, employee action, or other
causative event (reported in item 4a).
Report in item 4c the active participant base, which is described in the discussion of Active
participant base above. It is determined as of immediately before the applicable date (see
item 4b).
If the event was initiated or caused by an employer decision, report in item 4d the earliest date
when that decision became known to employees, by whatever means — for example, by written
notice, by oral announcement at an employees’ meeting, by informal discussions among
employees, etc. If the exact date cannot be determined (for example, because the information
“leaked”), report a good faith estimate of the date.
5 Item 5 tells PBGC about the timing of the section 4062(e) event. Report the cessation date in
item 5a (see discussion of Cessation above for definition) and the date when the number of
affected participants (those separated from employment because of the cessation) exceeded 20
percent of the active participant base in item 5b. See the discussion of Separation above for an
explanation of when a separation occurs. Report in item 5c the section 4062(e) event date, which
is the later of the two dates reported in items 5a and 5b. A section 4062(e) event notice must be
filed within 60 days after the section 4062(e) event date.
6 Item 6 tells PBGC how many affected participants there are so far for the section 4062(e)
event and how many additional affected participants there may be. Report the number of
affected participants in item 6a and the date as of which they were counted for this notice in item
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6b. That date must be not more than a month before the notice is filed. Also provide an estimate
of the number of additional affected participants that are anticipated after that date. If the
number of actual (not anticipated) affected participants increases materially after a section
4062(e) event notice is filed, the updated information must be filed with PBGC. See the
discussion of Duty to update or correct above. The number of affected participants reported
need not include affected participants who were not employed at the facility where the affected
operation was conducted, unless PBGC has requested that information. See the discussion of
Disregarding certain affected participants above.
7 Item 7 lets PBGC know about separated participants that are not being counted as affected
participants. If any participants in the plan have separated from employment since the applicable
date (see item 4b), but are not included in the number of affected participants (see item 6a)
because they did not separate as a result of the employer’s cessation of the operation at the
facility (or for any other reason), report the number of such separated participants, determined as
of the date in item 6b, who were not counted as affected participants.
8 Item 8 lets PBGC know about companies, plans, and unions possibly involved with the
section 4062(e) event. Indicate if there are other entities that are members of a controlled group
that includes the contributing sponsor identified in item 2. Indicate if there are other plans
covering affected participants. And indicate if there are one or more unions representing
affected participants. See instructions for item 11 for additional information required for any
controlled group members, plans, and unions identified.
9 Report the name of the individual who submits the section 4062(e) event notice to PBGC.
This must be an individual who is, or is authorized to act for, the plan administrator. The name
must be printed, not signed. Penalties for false or incomplete information apply regardless of the
absence of a signature.
10 Provide the name, phone number, and e-mail address of an individual for PBGC to contact.
This may but need not be the individual who submits the filing.
Include with the section 4062(e) event notice the additional information listed on page 2 of
Form 4062-E and described below. If there is no additional information for an item on the list,
provide a statement to that effect, identifying the item by number and subject. If the additional
information for an item on the list has already been submitted to PBGC, provide a statement
identifying the item by number and subject and stating when the information was submitted.
11 Provide additional information about other members of the contributing sponsor’s
controlled group, other plans covering affected participants, and any unions representing affected
participants. (See item 8 above.)
(i) If the contributing sponsor is a member of a controlled group, describe the controlled
group. If there are not more than a dozen members, provide the name and postal address of
each one and describe briefly its relationship to the contributing sponsor. If there are more
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than a dozen, provide the names and postal addresses of the dozen largest (determined in any
reasonable manner) and describe briefly the structure of the controlled group as a whole and
the contributing sponsor’s place in it.
(ii) If there are other plans covering affected participants, provide, for each one, its name
and the EIN/PN most recently reported for it in a PBGC premium filing or (if no premium
filing has been made for it) in a Form 5500 filing. If no premium or Form 5500 filing has
been made, provide the EIN of any contributing sponsor of the plan and the plan’s PN.
(iii) If there are one or more unions representing affected participants, provide the name
and postal address of each one and state what category of participants it represents. Also
provide a copy of each collective bargaining agreement covering affected participants.
12 Provide a general description of the section 4062(e) event. Describe the affected operation,
the facility, and any other activities of the affected employer (distinct from the affected
operation) conducted by the employer at the facility. Describe any cutbacks or contractions of
the affected operation during the year preceding the applicable date (see item 4b). If the
cessation of the affected operation was involuntary, describe the employee action or other event
that caused the cessation and, if the employer then made a decision not to resume the operation,
report the date of that decision. Describe any actual or proposed continuation or resumption of
the operation by the same employer at another facility or by another employer at the same or
another facility.
13 Describe any severance or retirement incentives offered since the date one year before the
applicable date (see item 4b).
14 Describe any current and proposed plan provisions dealing with lump sum options,
shutdowns, and early retirement benefits.
15 Describe any expectations for termination or merger of the affected plan or for any change
in the contributing sponsor(s) or controlled group.
16 Provide the date and a copy of each press release or other written announcement of the
affected employer’s decision to cease the operation at the facility (including any notice issued
pursuant to the Worker Adjustment and Retraining Notification (WARN) Act). For this purpose,
a script for an oral announcement is considered a written announcement if the announcement was
in fact made from the script, and the date to be provided for such an announcement is the date it
was orally given.
17 Provide a copy of the most recent certification of the affected plan’s adjusted funding target
attainment percentage (AFTAP) under ERISA section 206(g) and Internal Revenue Code
section 436.

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18 Provide a copy of the most recent actuarial valuation report, including or supplemented with
the following information described in 29 CFR § 4010.8(a)(11):
(i) The funding target calculated pursuant to ERISA section 303 without regard to section
303(i)(1) (and Code section 430 without regard to section 430(i)(1)), setting forth separately
the value of the liabilities attributable to retirees and beneficiaries receiving payment, to
terminated vested participants, and to active participants (showing vested and nonvested
benefits separately).
(ii) A summary of the actuarial assumptions and methods used for purposes of ERISA
section 303 and Code section 430, including the form of payment and benefit commencement
date assumptions for all active and deferred vested participants not yet receiving benefits,
information on how lump sums are valued (for plans that provide lump sums other than de
minimis lump sums), and any changes in those assumptions and methods since the previous
valuation and the reasons for such changes.
(iii) The effective interest rate (as defined in ERISA section 303(h)(2)(A) and Code section
430(h)(2)(A)).
(iv) The target normal cost calculated pursuant to ERISA section 303 without regard to
section 303(i)(2) (and Code section 430 without regard to section 430(i)(2)).
(v) For the current plan year and each of the four preceding plan years, a statement as to
whether the plan was in at-risk status for that plan year.
(vi) In the case of a plan that is in at-risk status, the target normal cost calculated pursuant
to ERISA section 303 and Code section 430 as if the plan had been in at-risk status for five
consecutive years.
(vii) The value of the plan’s assets (reflecting any averaging method) as of the valuation
date and the fair market value of the plan’s assets as of the valuation date;
(viii) The funding standard carryover balance and the prefunding balance (maintained
pursuant to ERISA section 303(f)(1) and Code section 430(f)(1)) as of the beginning of the
plan year and a summary of any changes in such balances in the past year (e.g., amounts used
to offset the minimum funding requirement, amounts reduced in accordance with any
elections under ERISA section 303(f)(5) and Code section 430(f)(5), interest credited to such
balances, and excess contributions used to increase such balances).
(ix) A list of amortization bases (shortfall and waiver) under ERISA section 303 and Code
section 430, including the year each base was established, the original amount, the
installment amount, and the remaining balance at the beginning of the plan year.

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(x) An age/service scatter for active participants including average compensation
information for pay-related plans and average account balance information for hybrid plans
presented in a format similar to that described in the instructions to Schedule SB of Form
5500.
(xi) Expected disbursements (benefit payments and expenses) during the plan year.
(xii) A summary of the principal eligibility and benefit provisions on which the valuation
of the plan was based (and any changes to those provisions since the previous valuation),
along with descriptions of any benefits not included in the valuation, any significant events
that occurred during the plan year, and the plan’s early retirement factors, including (in the
case of a plan that provides lump sums other than de minimis lump sums) information on
how annuity benefits are converted to lump sum amounts (e.g., whether early retirement
subsidies are reflected).
19 Provide the following information to the extent not reflected in the most recent actuarial
valuation report:
(i) A summary of any plan amendments.
(ii) Any significant changes in plan population or assumptions.
(iii) The amounts and dates of any lump sums paid.
(iv) The fair market value of the assets of the affected plan on the cessation date (see
item 5a) or (if the fair market value cannot reasonably be determined as of the cessation date)
on the closest date as of which the fair market value can reasonably be determined (and
specify the date).

Form 4062-E is available in a computer format designed for filling out on-screen using Adobe
Acrobat. If you use Adobe Acrobat Pro, you can also save the filled-out form directly to a
computer file for electronic filing with PBGC. No signature is required.

-12-

PBGC

Form

Section 4062(e) Event Notice

4062-E

and
Request for PBGC Determination of Liability

Approved OMB
1212-____
Expires __/__/____

IMPORTANT: See instructions for explanation of information to be provided.
 Supplemental notice.
Date in item 6b of prior notice was:
1 Name and postal address of plan administrator
2 Name and postal address of contributing sponsor

3a Plan name
b EIN/PN
 Employer decision to discontinue
 Employee action
 Other event
b Applicable date (date of decision, action, or other event)

4a Event was initiated or caused by (not
more than one):

c Active participant base (as of immediately before applicable date)
d Date employer decision became known to employees
5a Cessation date
b Date when active participant decline exceeded 20 percent
c Section 4062(e) event date (later of 5a or 5b)
6a Number of affected participants as of date in 6b
b Date as of which affected participants in 6a were counted
c Anticipated number of additional affected participants
7 Separated active participants not counted as affected participants
 Other controlled group member(s)
 Other plan(s) covering affected participants
 Union(s) representing affected participants
Filing of this notice constitutes a request that PBGC determine liability arising from the section
4062(e) event described in the notice. False or incomplete information is subject to penalty.
The individual filing this notice must be (or be authorized to act for) the plan administrator.
9 Individual filer’s name (do not sign)
8 Other entities involved (required
additional information listed on page 2):

10a Name of individual to contact
b Phone number
c E-mail address
See page 2 for list of additional information included in this notice.

PBGC Form 4062-E

Page 2
List of additional information included in notice

 11 Information about other entities involved (see item 8 on page 1)
 (i) Controlled group information
 (ii) Information about any other plan(s) covering affected participants
 (iii) Union(s) representing affected participants and collective bargaining agreement(s)
 12 Description of section 4062(e) event
 13 Severance and early retirement incentives
 14 Plan provisions on lump sums, shutdowns, and early retirement
 15 Expectations for merger, termination, or change in plan sponsor or controlled group
 16 Date and copy of each WARN notice, press release, and other announcement
 17 Most recent AFTAP certification
 18 Most recent actuarial valuation report, including information described in instructions
(from 29 CFR § 4010.8(a)(11)):
 (i) Funding target with breakdown by participant category
 (ii) Summary of actuarial assumptions and methods
 (iii) Effective interest rate
 (iv) Target normal cost
 (v) Statement about at-risk status for five years
 (vi) If at-risk, target normal cost computed as if at-risk for five years
 (vii) Value with averaging, and fair market value, of plan assets
 (viii) Funding standard carryover balance and prefunding balance and changes
 (ix) Data on amortization bases
 (x) Age/service scatter for active participants
 (xi) Expected disbursements
 (xii) Summary of principal eligibility and benefit provisions and related data
 19 Additional information (not in the actuarial valuation report) described in instructions:
 (i) A summary of any plan amendments.
 (ii) Any significant changes in plan population or assumptions.
 (iii) The amounts and dates of any lump sums paid.
 (iv) The fair market value of the assets of the affected plan on the cessation date (see
item 5a) or (if the fair market value cannot reasonably be determined as of the cessation
date) on the closest date as of which the fair market value can reasonably be determined
(and specify the date).