715 Power of Attorney (POA)

	Power of Attorney (POA)		PBGC Form 715 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: 02/02/2021

INSTRUCTIONS: Please complete this form to name a person as your representative to PBGC. Please read the Filing Instructions for information as to when this form may be used and by whom. 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



B. a beneficiary of a deceased participant



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



D. a person appealing a PBGC determination



E. the legally authorized representative of one of the above



If you checked B, C or D, provide name of the plan participant; if you checked E, provide name of the participant and of the person you are representing.

Pension Plan Name

PBGC Case Number

CONTINUE

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

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: (Check A or B and, if desired, C.)

	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 compensated by PBGC for representing me or claiming a fee from PBGC 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 – Sign and date this form.

payee’s signature

date

CONTINUE

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

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

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

(

)

-

BOTH SECTIONS 4 AND 5 MUST BE SIGNED & DATED BEFORE YOU SUBMIT THIS FORM. THANK YOU.

POWER OF ATTORNEY FORM

FILING INSTRUCTIONS

Who may use this form?

This form may be used by:

• A participant;

• A beneficiary of a deceased participant;

• An alternate payee under a qualified domestic relations order (“QDRO”) who is entitled to all or part of a participant’s benefit;

• A person appealing a PBGC determination; or

• The legally authorized representative of a participant, beneficiary, alternate payee, or appellant.

When may this form be used?

You may use this form only to designate a person to represent you while you are mentally competent. This designation ceases to be effective in the event you become mentally incompetent. For a designation that will be effective in the event of your mental incompetence, you must submit a Durable Power of Attorney form to PBGC at P.O. Box 151750, Alexandria, VA 22315-1750

Note: In the event you become mentally incompetent without having designated a representative in a Durable Power of Attorney form, a person seeking to represent you will have to establish rights as a Guardian, Conservator, or Successor, of the “Person and Estate” or of the “Estate.”

Do I have to use this form?

No, however, if you do not use this form, you should be sure to include all of the information required by this form. Also, any form you submit must not authorize your representative to take any actions that are not permitted or allowed by PBGC (see the last three items in Section 3A of the PBGC Power of Attorney form).

What is a Durable Power of Attorney?

A Durable Power of Attorney is a document that authorizes a person to act as your representative, attorney-in-fact, or agent to perform specified acts on your behalf, and this authorization continues in the event of your mental incompetence.

How do I obtain a Durable Power of Attorney?

You may obtain a Durable Power of Attorney from an attorney or from a state court office.

CONTINUE

How do I file this Power of Attorney form?

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

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

Usually, you need to file only one form. Be sure to list all of the plans and their case numbers on page 1 of the Power of Attorney form. You can get the plan names and case numbers from our letters to you or by calling our Customer Contact Center 1-800-400-7242.

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

The filing of this Power of Attorney does not alter or automatically replace 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. See Section 3B of the Power of Attorney form and mark only those actions that you authorize your representative to perform on your behalf.

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 reject a Power of Attorney form if it has not been signed by both you and your representative.