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General Information Form |
PBGC Form 702
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Pension Benefit Guaranty Corporation. P.O. Box 151750 Alexandria Virginia 22315-1750 |
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 |
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Date
Printed: |
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Date of Plan Termination: FX.PrismCase.DOPT.XF |
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INSTRUCTIONS: Please complete this form so that PBGC can determine whether you are entitled to a pension benefit. Note those items marked "Proof Required" and enclose a copy of the appropriate document if you have not already sent it to us. Acceptable documents for proof of age include your birth or baptism certificate, or U.S. Passport; for marriage, a marriage certificate; for proof of death, a death certificate. This is not a benefit application. To begin receiving benefits, or if you have questions about other acceptable documents, call our Customer Contact Center at 1-800-400-7242. Print clearly with dark ink.
1. General information about you
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 (PROOF REQUIRED) |
Gender |
male |
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Mailing Address |
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Daytime Phone |
Extension |
Evening Phone |
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CONTINUE ON BACK |
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Approved OMB 1212-0055
Expires xx/xx/xx
General Information Form Form 702, page 2 of 4 |
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Plan Number: FX.PrismCase.CaseIdNmbr.XF |
Participant Name: FX.PrismCust.FullName.XF |
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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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My relationship to the participant: |
Spouse (PROOF REQUIRED) |
Other: |
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Name of Participant: |
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Date of participant’s death:
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(PROOF REQUIRED) |
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C. Alternate payee - I have a Qualified Domestic Relations Order (QDRO) that establishes my right to receive some or all of a participant's benefits from a pension plan. |
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Name of Participant: |
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Date of QDRO:
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D. Other. Please explain:
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2. Participant Information – Complete this section only if you checked “Self” in section 1.
Are you currently employed? If yes, please provide information below: |
No |
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Yes |
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Employer Name: |
City and State |
Were you married when the plan terminated?
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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 (PROOF REQUIRED) |
Date of Marriage (PROOF REQUIRED) |
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Is there a Qualified Domestic Relations Order (QDRO) requiring payment of some or all of your benefit to someone else? |
No |
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Yes |
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Date of the QDRO:
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Name of alternate payee:
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CONTINUE |
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General Information Form Form 702, page 3 of 4 |
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Plan Number: FX.PrismCase.CaseIdNmbr.XF |
Participant Name: FX.PrismCust.FullName.XF |
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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 had been paying. If another person continues to receive your benefit after your death (as with a joint-and-survivor or certain-and-continuous annuity), PBGC will pay any money owed to that person. If there are no continuing benefits or the person designated to receive continuing benefits dies before you, PBGC will pay any money owed 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.
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%
If you want to change this designation, please call PBGC’s Customer Contact Center at 1-800-400-7242. |
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THANK YOU. |
CONTINUE ON BACK
General Information Form Form 702, page 4 of 4 |
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Plan Number: FX.PrismCase.CaseIdNmbr.XF |
Participant Name: FX.PrismCust.FullName.XF |
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Signature – You must sign and date this document. Knowingly and willfully making false, fictitious or fraudulent statements to the Pension Benefit Guaranty Corporation is a crime punishable under Title 18, Section 1001, and 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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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 |