715 Power of Attorney

	Power of Attorney		PBGC Form 715 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: 08/05/2004

INSTRUCTIONS: Please complete this form to name a person as your representative to PBGC. If you have any questions, call our Customer Contact Center at 1-800-400-7242.

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

(

)

-

I am:

mark only one

A. a participant in a PBGC-trusteed plan



B. a beneficiary of a deceased participant in a PBGC-trusteed plan



C. an alternate payee with a QDRO, entitled to all or part of a participant’s benefit



D. the legally authorized representative of a participant, beneficiary, or alternate payee



If you checked B, C or D, please provide the name of the plan participant:

Pension Plan Name

PBGC Case Number

CONTINUE

Power of Attorney Form 715, page 2 of 3
	Plan Number: «PrismCase.CaseIdNmbr»	Participant Name: «PrismCust.FullName»

2. Your Representative – I name the following person as my representative to the Pension Benefit Guaranty Corporation.

_{Name of Representative}

3. Types of Actions – I want my representative to: (Please check A or B):

	A. Represent me in my dealings with PBGC. This includes: Applying for my benefit Changing my beneficiary Representing me in any request for information or forms Responding to PBGC’s request for information or documents Changing the address or bank to which I want my PBGC payments sent Representing me before the PBGC’s Appeals Board Changing my tax withholding I understand that my representative cannot take the following actions: Sign a form for me that PBGC requires me to sign in the presence of a notary, such as a spouse’s consent to waive a joint-and-survivor annuity Have PBGC make my check payable to him or her or have PBGC deposit my check payable to an account that does not have my name on it Be recognized or compensated by PBGC for attempting to represent me or claim a fee on my behalf
	B. Take only the following actions for me (I have checked the items that I want to apply): Applying for my benefit Changing my beneficiary Representing me in any request for information or forms Responding to PBGC’s request for information or documents Changing the address or bank to which I want my PBGC payments sent Representing me before the PBGC’s Appeals Board Changing my tax withholding
	C. Copies of Documents I want my representative to receive copies of all correspondence PBGC sends to me.

4. Signature – You must sign and date this form.

signature

date

(You can change or cancel this power of attorney anytime by notifying PBGC in writing of the changes you want.)

CONTINUE

Power of Attorney Form 715, page 3 of 3
	Plan Number: «PrismCase.CaseIdNmbr»	Participant Name: «PrismCust.FullName»

5. Acceptance of Power of Attorney

I accept the power of attorney given on this form.

representative’s signature

date signed

Representative’s printed name

Representative’s Address

City

State

Zip Code

Country

Email (optional)

Representative’s Daytime Phone

Extension

Representative’s Evening Phone

(

)

-

x

(

)

-

SIGN & DATE BEFORE SUBMITTING. THANK YOU.

POWER OF ATTORNEY FORM

FILING INSTRUCTIONS

Who can use this form?

If you are a participant or the beneficiary of a deceased participant, you may use the Power of Attorney form to name someone to represent you on matters relating to your benefits. Other people may also file a PBGC Power of Attorney. An alternate payee under a qualified domestic relations order (“QDRO”) may designate a representative using this form.

What if I am a legally recognized representative, such as a parent or a judicially appointed guardian, conservator, or executor of a person who can sign this form?

If you are a legally recognized representative (a custodial relative or guardian, conservator, or executor) of a participant, beneficiary, or alternate payee, you may use the Power of Attorney Form to name a person to represent you before the PBGC on some or all matters relating to the receipt of pension benefits. Please call PBGC’s Customer Contact Center at 1-800-400-7242 for special instructions for completing this form.

Do I have to use this form?

No. If you do not use this form, you should be careful to include all of the information required by this form.

What can I use this form for?

The representative you name on the Power of Attorney form may do all the actions listed in Section 3A, unless you check Section 3B and allow only certain actions.

How do I file the Power of Attorney?

File the power of attorney by mailing the original form to PBGC, P.O. Box 151750, Alexandria, VA 22315-1750. If you are dealing with any particular person within the PBGC, you may also want to provide a copy of the Power of Attorney to that person.

What if I am a participant in more than one PBGC pension plan?

Usually, you only need to file one form. Be sure to list all of the plans and their case numbers on page 1. You can get the plan names and case numbers from our letters to you.

What if I already have a Power of Attorney on file with PBGC?

The filing of this Power of Attorney does not alter any earlier Power(s) of Attorney filed with PBGC for the matters covered by this Form. Once you have granted a Power of Attorney it will remain in effect unless you revoke it in writing. If you grant a Power of Attorney for a particular matter to more than one person, any of those persons may exercise his or her Power of Attorney on that matter.

Can I limit my representative’s powers?

Yes. Mark in item B on the page 2 only the powers you want to grant.

Does my representative need to sign this form?

Yes. Your representative must sign and date the form on page 3 to accept your designation. PBGC will return a Power of Attorney form unless both you and your representative have signed and dated it.