Form 711 Change of Beneficiary for Certain Continuous Benefits On

	Change of Beneficiary for Certain & Continuous (C&C) Benefits Only (Currently Receiving Pension Benefits)		PBGC Form 711
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: Use this form to change your beneficiary if you are receiving a Certain & Continuous annuity. If you die before the certain period ends, any remaining payments will go to the person(s) or entity(ies) (such as a trust, church, estate or other organization) that you designate in section 2. If you do not make a designation, or if the beneficiary is a person and dies before you, PBGC will pay the amount we owe in this order to: your spouse, your children, your parents, your estate, or your next of kin. If you have any questions, please 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 Last Name(s) Used

Social Security Number

-

-

Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email

Daytime Phone

Extension

Evening Phone

(

)

-

x

(

)

-

2. Beneficiary - I name the following person(s) and/or entity(ies) as my beneficiary(ies). This designation replaces any previous designation and will be effective only when PBGC receives it. Once the Certain Period ends, no continuing benefit will be paid to the person(s) or entity(ies) designated below.

Beneficiary(ies)	Social Security Number*	Date of Birth*	Relationship	Percentage**
Name Address Daytime Tel. No:
Name Address Daytime Tel. No:

^{CONTINUE ON BACK}

Approved OMB 1212-0055

Expires xx/xx/xx

Change of Beneficiary for Certain & Continuous (C&C) Benefits Only (Currently Receiving Pension Benefits)			Form 711, page 2 of 2
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name : FX.PrismCust.FullName.XF

2. Beneficiary (continued)

Beneficiary(ies)	Social Security Number*	Date of Birth*	Relationship	Percentage**
Name Address Daytime Tel. No:

* Complete if person

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

3. Signature – Sign and date this form for your beneficiary designation to be effective.

signature

date