711 Change of Beneficiary for Certain & Continuous (C&C) Ben

	Change of Beneficiary for Certain & Continuous (C&C) Benefits Only (Currently Receiving Pension Benefits)		PBGC Form 711 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: 02/04/2021	Applicant Name:
	Date of Plan Termination: FX.PrismCase.DOPT.XF

INSTRUCTIONS: Use this form to change your beneficiary if you are receiving a Certain & Continuous annuity. If you die before the certain period ends, any remaining payments will go to the person you designate in section 2. If you do not name anyone, or if the beneficiary you name dies before you, PBGC will pay the amount we owe in this order: your spouse, your children, your parents, your estate and your next of kin. If you have any questions, please call our Customer Contact Center at 1-800-400-7242. Print clearly with dark ink.

1. General information about you

Last Name

First Name

Middle Name

Other Name(s) used

Social Security Number

-

-

Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email (optional)

Daytime Phone

Extension

Evening Phone

(

)

-

x

(

)

-

2. Beneficiary – I name the following person as my beneficiary. This designation replaces any previous designation and will be effective only when PBGC receives it. Once the Certain Period ends, no benefit will be paid to the person designated below.

Last Name

First Name

Middle Name

Other Name(s) Used

Relationship to me, if any (e.g., spouse, granddaughter, friend)

Social Security Number

Date of Birth

-

-

/

/

Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email (optional)

Daytime Phone

Extension

Evening Phone

(

)

-

x

(

)

-

3. Signature – Sign and date this form for your beneficiary designation to be effective.

signature

date