709 Plan Participant Information

	Plan Participation Information		PBGC Form 709 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: Complete this form if you believe you are eligible for a pension. 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

(

)

-

Name of plan participant, if different	Social Security Number
				-			-

2. Participant employment information - Related to the claim for benefits.

Employer Name

City and State

Title

Location of Employment

Date of Hire

Date Employment Terminated

Reason for Termination

/

/

/

/

CONTINUE

Plan Participant Information Form 709, page 2 of 2
	Plan Number: «PrismCase.CaseIdNmbr»	Participant Name: «PrismCust.FullName»

Was the plan participant covered by a collective bargaining agreement (union contract) with the employer identified above? If yes, during what period:

No  Yes 

From

/

To

/

month

year

month

year

Name of Local Union:

Address

Was the plan participant an hourly paid or a salaried employee?	Hourly 	Salary 
Was the plan participant transferred between hourly and salary?	Yes 	No 
If yes, specify type and date of each transfer:
Any breaks in service?	Yes 	No 
If yes, specify what period? (from when to when):
Explain in detail why you think you may be covered by the pension plan.

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, 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

SIGN & DATE BEFORE SUBMITTING. THANK YOU