701 Payee Information Form

	Payee Information Form		PBGC Form 701 Approved OMB 1212-0055 Expires 08/31/08
Pension Benefit Guaranty Corporation. P.O. Box 151750 Alexandria Virginia 22315-1750		For assistance, call 1-800-400-7242

	Plan Name: «PrismCase.CaseTitle»
	Plan Number: «PrismCase.CaseIdNmbr»	Participant Name: «PrismCust.FullName»
	Date Printed: 02/06/2021
	Date of Plan Termination: «PrismCase.DOPT»

INSTRUCTIONS: Please complete this form so PBGC can continue to send your pension benefit payments. Use dark ink and be sure to print clearly. If you have questions, call our Customer Contact Center at 1-800-400-7242 for information.

1. General information about you

Last Name

First Name

Middle Name

Other Name(s) Used

Social Security Number

Date of Birth

Gender

male 

-

-

/

/

female 

Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email (optional)

Daytime Phone

Extension

Evening Phone

(

)

-

x

(

)

-

CONTINUE

Payee Information Form Form 701, page 2 of 3
	Plan Number: «PrismCase.CaseIdNmbr»	Participant Name: «PrismCust.FullName»

Your relationship to person who participated in the plan:

mark only one

A. Self – The benefits are from my pension plan



B. Beneficiary - The benefits are from the pension plan of someone who is deceased.



My relationship to the participant:

Spouse

Other:

Name of Participant:

Date of participant’s death:

/

/

C. Alternate payee - I have a Qualified Domestic Relations Order (QDRO) that establishes my right to receive some or all of a participant's benefits from a pension plan.



Name of Participant:

Date of QDRO:

/

/

D. Other. Please explain:



2. Participant Information – Complete this section only if you checked “Self” in section 1.

If you are currently employed please provide information below:
Employer Name:	City and State

Were you married when you retired? If so, please provide the information below about your spouse at retirement.

No 

Yes 

Spouse’s Last Name

Spouse’s First Name

Spouse’s Middle Name

Other Name(s) Used

Spouse’s Social Security Number

Spouse’s Date of Birth

Date of Marriage

-

-

/

/

/

/

Is there a Qualified Domestic Relations Order (QDRO) from a court that requires we pay some or all of your benefit to someone else?

No  Yes 

Date of the QDRO:

/

/

Name of alternate payee:

CONTINUE

Payee Information Form Form 701, page 3 of 3
	Plan Number: «PrismCase.CaseIdNmbr»	Participant Name: «PrismCust.FullName»

3. Signature – You must sign and date this document. Knowingly and willfully making false, fictitious or fraudulent statements to the Pension Benefit Guaranty Corporation is a crime punishable under Title 18, Section 1001, and United States Code.

I declare under penalty of perjury that all of the information I have provided on this form is true and correct.
signature		date

4. Designation of Beneficiary – PBGC may owe you payments at the time of your death. Generally, this will happen if your estimated benefit is too low. If your benefit will continue to be paid to another person after your death (as with a joint-and-survivor or certain-and-continuous annuity), the person receiving those continuing benefits will also receive any payments due to you at the time of your death. If there are no continuing benefits, PBGC will make any payments due to you at the time of your death to the person you designate below. If you do not designate anyone, or if the beneficiary you name dies before you, PBGC will pay the amount we owe you in this order: your spouse, your children, your parents, your estate, and your next of kin.

Beneficiary – I name the following person as my beneficiary for amounts owed to me at my death. This replaces any previous designation and will only be effective when PBGC receives it.

Last Name

First Name

Middle Name

Other Name(s) Used

Social Security Number

Date of) Birth

Gender

male 

-

-

/

/

female 

Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email (optional)

Daytime Phone

Extension

Evening Phone

(

)

-

x

(

)

-

Relationship to me, if any (e.g., spouse or granddaughter, friend)

TO CHANGE THIS DESIGNATION, CALL PBGC’S CUSTOMER CONTACT CENTER AT 1-800-400-7242.

THANK YOU.