Form 701 Payee Information Form

Locating and Paying Participants

e_Form701 revised.xml

Locating and Paying Participants

OMB: 1212-0055

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Payee Information Form



PBGC Form 701

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: 01/30/2021



Date of Plan Termination: FX.PrismCase.DOPT.XF



INSTRUCTIONS: You must complete this form to continue receiving pension payments. If you have questions, call our Customer Contact Center at 1-800-400-7242. Print clearly with blue or black ink.

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





(




)




-






Your relationship to person who participated in the plan:

MARK ONLY ONE


A. Self – The benefits are from my pension plan


B. Beneficiary - The benefits are from the pension plan of someone who is deceased.


Participant’s name:

Relationship Spouse

Other



Participant’s Social Security Number

Participant’s Date of Birth

Participant’s Date of Death






-



-





                    • /

                    • /

                    • /

                    • /


C. Alternate payee The benefits are from someone else’s pension plan but were assigned to me based on a court order.


Name of Participant:




Date of order:




/



/








D. Other. Please explain:



CONTINUE





Plan Number: FX.PrismCase.CaseIdNmbr.XF

Participant Name : FX.PrismCust.FullName.XF






2. Participant InformationComplete this section only if you checked “Self” in section 1. Otherwise, go to Section 3.


Are you currently employed? If yes, please provide information below:



No


Yes

Employer Name:

City and State


Were you married when you retired? If yes, please provide the information below about your spouse at retirement.


No


Yes

Spouse’s Last Name

Spouse’s First Name

Spouse’s Middle Name

Other Name(s) Used

Spouse’s Social Security Number

Spouse’s Date of Birth

Date of Marriage

                    • -

                    • -

                    • /

                    • /

                    • /

                    • /

                    • Spouse’s Date of Death, if applicable (PROOF REQUIRED)

                    • /

                    • /


Is there a court order (for example - domestic relations order, divorce decree, child support order, etc.) that requires some or all of your benefit be paid to a spouse, former spouse, child, or other dependent?

No


Yes

Date of the order:




/



/







Name of alternate payee:




3. Designation of Beneficiary PBGC may owe you money at the time of your death. Typically, this happens if your final benefit is higher than the estimated benefit we have been paying. If another person continues to receive your benefit after your death (as with a joint-and-survivor or certain-and-continuous annuity), we will pay the money owed to that person. If there are no continuing benefits or the person designated to receive continuing payments dies before you, PBGC will make any payments owed to you at the time of your death to the person(s) and/or entity(ies) (such as a trust, church, estate or other organization) that you designate in this section. If you do not make a designation, or if the beneficiary is a person and dies before you, PBGC will pay the money in this order to: your spouse, your children, your parents, your estate, or your next of kin.


I name the following as my beneficiary(ies). This designation replaces any previous designation and will only be effective when PBGC receives it.




CONTINUE





Plan Number: FX.PrismCase.CaseIdNmbr.XF

Participant Name: FX.PrismCust.FullName.XF




Designation of Beneficiary (continued)


Beneficiary(ies)

Social Security Number*

Date of Birth*

Relationship

Percentage**


Name _______________________________________


Address ______________________________________


_____________________________________________


Daytime Tel. No:___________________________






Name _______________________________________


Address _____________________________________


____________________________________________


Daytime Tel. No:__________________________






Name _______________________________________


Address ______________________________________


_____________________________________________


Daytime Tel. No:__________________________






* Complete if person

** Not necessary to provide; if provided, must total 100%

s)ficiary(____________________________ill only be effective when PBGC receives it.predeases the ganization or other)lication


4. Signature – Sign and date this application. 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


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