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Payee Information Form
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PBGC Form 701
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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: |
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Date of Plan Termination: FX.PrismCase.DOPT.XF |
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INSTRUCTIONS: You must complete this form to continue receiving pension payments. 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
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Last Name |
First Name |
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Middle Name |
Other Last Name(s) Used |
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Social Security Number |
Date of Birth |
Gender |
MALE |
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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 |
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Daytime Phone |
Extension |
Evening Phone |
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Your relationship to person who participated in the plan: |
MARK ONLY ONE |
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A. Self – The benefits are from my pension plan |
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B. Beneficiary - The benefits are from the pension plan of someone who is deceased. |
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Participant’s name: |
Relationship Spouse |
Other |
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Participant’s Social Security Number |
Participant’s Date of Birth |
Participant’s Date of Death |
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C. Alternate payee – The benefits are from someone else’s pension plan but were assigned to me based on a court order. |
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Name of Participant: |
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Date of order:
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D. Other. Please explain: |
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CONTINUE ON BACK |
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Approved OMB 1212-0055
Expires xx/xx/xx
Payee Information Form |
Form 701, page 2 of 3 |
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Plan Number: FX.PrismCase.CaseIdNmbr.XF |
Participant Name: FX.PrismCust.FullName.XF |
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2a. Participant Information – Complete this section only if you checked “Self” in section 1. Otherwise, go to Section 3.
Are you currently employed? If yes, please provide information below:
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No |
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Yes |
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Employer Name: |
City and State |
Were you married when you retired? If yes, please provide the information below about your spouse at retirement.
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No |
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Yes |
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Spouse’s Last Name |
Spouse’s First Name |
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Spouse’s Middle Name |
Other Name(s) Used |
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Spouse’s Social Security Number |
Spouse’s Date of Birth |
Date of Marriage |
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Spouse’s Date of Death, if applicable (PROOF REQUIRED)
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2b. Court order related to the participant’s benefit
Is there a court order (for example - domestic relations order, divorce decree, child support order, etc.) that requires some or all of your benefit be paid to a spouse, former spouse, child, or other dependent? |
No |
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Yes |
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Date of the order:
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Name of alternate payee:
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3.
Designation of Beneficiary for
Payments Owed at Death – PBGC
may owe you money at the time of your death. Typically, this happens
if your final benefit is higher than the estimated benefit we have
been paying. If another person
continues to receive your
benefit after your death (as
with a joint-and-survivor or certain-and-continuous annuity),
we will pay the money owed to that person. If there are no
continuing benefits or the person designated to receive continuing
payments dies before you, PBGC will make any payments owed to you at
the time of your death to the person(s) and/or entity(ies) (such as a
trust, church, estate or other organization) that you designate in
this section. If you do not make a designation,
or
if all the beneficiaries you designate below die before you, PBGC
will pay the money in this order to: your spouse, your children, your
parents, your estate, or your next of kin.
I name the following as my beneficiary(ies). This designation replaces any previous designation and will only be effective when PBGC receives it.
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CONTINUE |
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Payee Information Form |
Form 701, page 3 of 3 |
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Plan Number: FX.PrismCase.CaseIdNmbr.XF |
Participant Name: FX.PrismCust.FullName.XF |
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Designation of Beneficiary (continued)
Beneficiary(ies) |
Social Security Number* |
Date of Birth* |
Relationship |
Percentage** |
Name Address
Daytime Tel. No: |
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Name Address
Daytime Tel. No: |
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Name Address
Daytime Tel. No: |
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* Complete if person
** Not necessary to provide; if provided, must total 100%
4. Signature – Sign and date this application. 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/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | General Information Form_PBGC Form XXX |
Author | PBGC\IOD |
File Modified | 0000-00-00 |
File Created | 2021-01-15 |