Form 702 General Information Form

	General Information Form		PBGC Form 702 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
	Date Printed: 01/30/2021
	Date of Plan Termination: FX.PrismCase.DOPT.XF

INSTRUCTIONS: Please complete this form so that PBGC can determine whether you are entitled to a pension benefit. Note those items marked "Proof Required" and enclose a copy of the appropriate document if you have not already sent it to us. Acceptable documents for proof of age include your birth or baptism certificate, or U.S. Passport; for marriage, a marriage certificate; for proof of death, a death certificate. This is not a benefit application. To begin receiving benefits, or if you have questions about other acceptable documents, 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

Date of Birth (PROOF REQUIRED)

Gender

male



-

-

/

/

female



Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email (optional)

Daytime Phone

Extension

Evening Phone

(

)

-

x

(

)

-

CONTINUE

General Information Form Form 702, page 2 of 3
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF

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.



My relationship to the participant:

Spouse (PROOF REQUIRED)

Other:

Name of Participant:

Date of participant’s death:

/

/

(PROOF REQUIRED)

C. Alternate payee - I have a Qualified Domestic Relations Order (QDRO) that establishes my right to receive some or all of a participant's benefits from a pension plan.



Name of Participant:

Date of QDRO:

/

/

D. Other. Please explain:



2. Participant Information – Complete this section only if you checked “Self” in section 1.

Are you currently employed? If yes, please provide information below:		No	
		Yes	
Employer Name:	City and State

Were you married when the plan terminated?

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 (PROOF REQUIRED)

Date of Marriage (PROOF REQUIRED)

-

-

/

/

/

/

Is there a Qualified Domestic Relations Order (QDRO) requiring payment of some or all of your benefit to someone else?

No



Yes



Date of the QDRO:

/

/

Name of alternate payee:

CONTINUE

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

3. Signature – You must sign and date this document. Knowingly and willfully making false, fictitious or fraudulent statements to the Pension Benefit Guaranty Corporation is a crime punishable under Title 18, Section 1001, and 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

4. Designation of Beneficiary – If there are payments owed to you at the time of your death, PBGC will pay them to the person(s) you designate below. If you do not designate anyone, or if the beneficiary you name dies before you, PBGC will pay the underpayment in this order: your spouse, your children, your parents, your estate, and your next of kin.

Beneficiary – I name the following person as my beneficiary for amounts owed to me at my death. This replaces any previous designation and will only be effective when PBGC receives it.

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

(

)

-

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

If you want to change this designation, please call PBGC’s Customer Contact Center at 1-800-400-7242.

THANK YOU.