Form 710 Application for Direct Deposit

	Application for Electronic Direct Deposit		PBGC Form 710
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: 01/20/2021 Date of Plan Termination: FX.PrismCase.DOPT.XF

INSTRUCTIONS: Please complete this form to have PBGC send your pension benefit payments directly to your bank or other financial institution through electronic direct deposit (EDD). This form may also be used for an Electronic Transfer Account (ETA). Your name must be on the account. 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

Plan Name (as shown on check)

Last Name

First Name

Middle Name

Other Last Name(s) Used

Social Security Number

PBGC Plan Number

-

-

Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email

Daytime Phone

Extension

Evening Phone

(

)

-

x

(

)

-

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Approved OMB 1212-0055

Expires xx/xx/xx

Application for Electronic Direct Deposit			Form 710, page 2 of 2
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF

2. Financial institution information – Please provide the information in this section to have your payment sent directly to a financial institution. The information is available from your financial institution or can be found on your checks, account statement or deposit slip. The sample check below shows the location of your nine-digit routing number and account number. If you are unsure of the routing number or your account number, contact your financial institution. You can cancel or change this arrangement by calling PBGC at 1-800-400-7242. The financial institution can cancel it by sending you a written notice.

All fields required

Name(s) on the Account (Your name must be on the account)
Routing Number									Account Number – Numbers only	Account Type
										Checking 	Savings 

3. Signature – I hereby authorize PBGC to deposit my pension benefit funds into my account. I understand that I may change this election in the future.

signature		date