710 Application for Electronic Direct Deposit

	Application for Electronic Direct Deposit		PBGC Form 710 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
	Date Printed: 07/03/2008 Date of Plan Termination: FX.PrismCase.DOPT.XF

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). This form may also be used for an Electronic Transfer Account (ETA). Your name must be on the account. If you have questions, call our Customer Contact Center at 1-800-400-7242. Print clearly with dark ink.

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

-

-

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: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF

3. Financial institution information – Please provide the information in this section to have your payment sent directly to a financial institution. The information is available from your financial institution or can be found on your checks, account statement or deposit slip. The sample check below shows the location of your 9-digit routing number and account number. If you are unsure of the routing number or your account number, contact your financial institution. You can 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.

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SAMPLE CHECK Date____________

Pay to the Order of ____________________________ $ _______

___________________________________________

Memo_________________ ___________________

׃012345678

Routing Number

Account Number

Name of Financial Institution

Mailing Address

City

State

Zip Code

Name of contact person

Phone Number

Routing Number

Account Number

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

Account Type Checking  Savings

PLEASE SIGN & DATE THIS FORM ON PAGE 1