704 Request for Earnings Information

	Request for Earnings Information		PBGC Form 704 Approved OMB 1212-0055 Expires
Pension Benefit Guaranty Corporation. P.O. Box 151750, Alexandria, Virginia 22315-1750		For assistance, call 1-800-400-7242

	Plan Name: FX.PrismCase.CaseTitle.XF
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF
	DOPT: FX.PrismCase.DOPT.XF
	Date Printed: 02/04/2021

INSTRUCTIONS: Use this form to tell PBGC about your income for the prior calendar year. Please mail this form to PBGC before February 28 of this year. Print clearly with dark ink.

1. General Information about you

Last Name

First Name

Middle Name

Social Security Number

Date of Birth

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Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email (optional)

Daytime Phone

Extension

Evening Phone

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x

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2. Earnings information for Prior Year

Total wages shown in section 1 of all W-2 forms issued to you for last year. Attach copy of your W-2 forms to this form. If you had no employment income last year, write “None”.					$ _________
Other earned income not reported in #1 above. Include tips, commissions, earnings from self-employment that you will report on your federal tax return. Do not include interest income or pension income.					$ _________
a. During last year, did you become eligible to receive a Social Security benefit?	Yes No
b. If so, on what date did you become entitled to this benefit?			/				/
c. Is this a disability benefit?	Yes No

3. Signature – Sign and date this form. 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