Form 4062(e)-01 Notice of ERISA 4062(e) Event

NOTICE OF SECTION 4062(e)
EVENT

PBGC Form 4062(e)-01
Approved OMB # 1212-____
Expires __/__/20__

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) 326-4070 or [email protected] .
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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

_______________________________________________
City, State, Zip of contact

Plan number

_______________________________________________
Name of contributing sponsor (if different from filer)
Filer is:

Plan administrator

________________________________
Telephone number of contact

_________
Ext

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.

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PBGC Form 4062(e)-01

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 3a ÷ item 3b) (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

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PBGC Form 4062(e)-01

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
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