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Financial Statement of Debtor
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PBGC Form 722 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 |
Participant Name: FX.PrismCust.FullName.XF |
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Date
Printed: |
Applicant Name: |
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DOPT: FX.PrismCase.DOPT.XF |
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INSTRUCTIONS: Please complete this form to request that PBGC reduce or waive repayment of amounts you were overpaid. If you need additional space for any answer, use item 7B. You must submit a copy of your most recent Federal tax return, including schedules, with this form. You may also provide any other information that you wish PBGC to consider. Print clearly with dark ink.
1. General information about you
Last Name |
First Name |
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Middle Name |
Other Name(s) Used |
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Social Security Number |
Date of Birth |
Gender |
male |
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- |
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/ |
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female |
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Mailing Address |
Apartment / Route Number |
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City |
State |
Zip Code |
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Country |
Email (optional) |
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Daytime Phone |
Extension |
Evening Phone |
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- |
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x |
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- |
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Are you currently married? Yes No |
Spouse’s Last Name |
Spouse’s First Name |
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Age(s) of Dependent(s), if any |
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CONTINUE |
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Financial Statement of Debtor |
Form 722, page 2 of 4 |
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Plan Number: FX.PrismCase.CaseIdNmbr.XF |
Participant Name: FX.PrismCust.FullName.XF |
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2. Average Monthly Income
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Self |
Spouse |
A. Monthly Wage / Salary |
$ |
$ |
B. Social Security Income |
$ |
$ |
C. Pension Income |
$ |
$ |
D. Interest, Dividend, Rental or Other Income |
$ |
$ |
E. Total Monthly Income |
$ |
$ |
3. Average Monthly Expenses
A. Rent or Mortgage Payment |
$ |
B. Food |
$ |
C. Utilities and Heat |
$ |
D. Medical |
$ |
E. Other, Including Insurance |
$ |
F. Monthly Payments on Installment Contracts and other Debts (e.g., car payments, home improvement loans, appliances) |
$ |
G. Total Monthly Expenses |
$ |
4. Discretionary Income
A. Net Monthly Income Less Expenses (Item 2E less Item 3G) |
$ |
B. Amount you can pay on a monthly basis toward your debt |
$ |
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CONTINUE |
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Form 722, page 3 of 4 |
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Plan Number: FX.PrismCase.CaseIdNmbr.XF |
Participant Name: FX.PrismCust.FullName.XF |
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5. Assets
A. Cash in Bank (Checking and savings accounts, other investment accounts, etc.) |
$ |
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B. Cash on Hand |
$ |
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C. U.S. Savings Bonds (Current Value) |
$ |
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D. Stocks and other Bonds (Current Value) |
$ |
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E. Real Estate Owned (Resale Value) |
$ |
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F. Automobiles |
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Make |
Year |
Model |
Resale Value |
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$ |
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$ |
G. Other Assets (Specify below) |
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$ |
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$ |
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$ |
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H. Total Assets |
$ |
6. Installment Contracts and Other Debts -- Show below all debts which you are required to pay, such as payments on a car, television, major appliances, payments to dealers, banks, finance companies; repayment of money borrowed for any purpose, doctor bills, hospital bills, etc. Do not include living expenses.
Name and Address of Creditor |
Date and Purpose of Debt |
Original Amount of Debt |
Unpaid Balance |
Amount Due Monthly |
Amount Past Due (if any) |
A. |
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B. |
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C. |
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D. |
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E. Total: |
$ |
$ |
$ |
$ |
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*Note: If repayment of a debt is not on a monthly basis, enter “0” and describe repayment arrangements in Section 7B. |
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CONTINUE |
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Form 722, page 4 of 4 |
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Plan Number: FX.PrismCase.CaseIdNmbr.XF |
Participant Name: FX.PrismCust.FullName.XF |
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7. Additional Data
A. Have you ever filed for bankruptcy protection? Yes No (If yes, complete items 1 through 4) |
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B. Use this space and additional sheets, if necessary, to supply any pertinent information and to continue your answer to previous items above to which your comments apply. |
8. Signature – You must 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 |
File Type | application/xml |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |