710 Application for Electronic Direct Deposit

	Application for Electronic Direct Deposit		PBGC Form 710 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: 12/28/2004	Date of Plan Termination: «PrismCase.DOPT»

INSTRUCTIONS: Please complete this form to have PBGC send your pension benefit payments directly to your bank or other financial institution through electronic direct deposit (EDD). Your name must be on the account. 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

Plan Name (as shown on check)

Last Name

First Name

Middle Name

Other Name(s) Used

Social Security Number

PBGC Plan Number

-

-

0

0

Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email (optional)

Daytime Phone

Extension

Evening Phone

(

)

-

x

(

)

-

2. Signature – I hereby authorize PBGC to deposit my pension benefit funds into my account. I understand that I may change this election in the future.

signature		date

CONTINUE

Application for Electronic Direct Deposit Form 710, page 2 of 2
	Plan Number: «PrismCase.CaseIdNmbr»	Participant Name: «PrismCust.FullName»

3. Financial institution information – Please provide the information in this section to have your payment sent directly to a financial institution. Your name must be on the account to which your payment will be sent. The financial institution will receive and post credits and/or debits for you. You may cancel or change this arrangement by calling PBGC at 1-800-400-7242. The financial institution can cancel it by sending you a written notice.

The information below is available from your financial institution, or you may find it on your checks, account statement, or deposit slip. There are three numbers printed on the bottom of your check: the financial institution’s routing number, your account number, and your check number. The routing number must be nine digits. The first two digits must be 01 through 12 or 21 through 32. Your account number can be up to 17 characters (both numbers and letters). Include hyphens but omit spaces and special symbols. Be sure not to use the check number. If you are unsure of the routing number or your account number, contact your financial institution.

Name of Financial Institution

Branch

Mailing Address

City

State

Zip Code

Name of contact person

Routing Number

Financial Institution Phone Number

Extension

(

)

-

x

Name(s) on the Account (Your name must be on the Account)

Account Type Checking  Savings

Account Number

4. Mail this form to:

Pension Benefit Guaranty Corporation

PO Box 151750

Alexandria, VA 22315-1750