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Report for Earnings and Social Security Disability Information
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PBGC Form 704 Approved OMB 1212-0055 Expires
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Pension
Benefit Guaranty Corporation. |
For assistance, call 1-800-400-7242 |
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Plan Name: FX.PrismCase.CaseTitle.XF |
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Plan Number: FX.PrismCase.CaseIdNmbr.XF |
Date
of Plan Termination: FX.PrismCase.DOPT.XF Date
Printed: |
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Participant Name: FX.PrismCust.FullName.XF |
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INSTRUCTIONS: Use this form to report your earnings from work for the last calendar year and if you are eligible for disability benefits from the Social Security Administration (SSA). Print clearly with blue or black ink. Please complete and return this form to PBGC before February 15 of this year.
General Information About You
Last Name |
First Name |
Middle Name |
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Social Security Number |
Daytime Phone |
Evening Phone |
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Mailing Address |
Apartment / Route Number |
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City |
State |
Zip Code |
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Country |
Email (optional) |
2. Earnings Information
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Yes No |
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$ _________ |
Eligibility for Social Security Disability Benefits
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Yes |
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No |
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Signature – Sign and date this form. 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.
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SIGNATURE |
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DATE |
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | General Information Form_PBGC Form XXX |
Author | IOD |
File Modified | 0000-00-00 |
File Created | 2021-01-30 |