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Report of Earnings and Social Security Disability Information |
PBGC Form 704
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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: Use this form to report your earnings from work for the last calendar year and if you are eligible for disability benefits from the Social Security Administration (SSA). Print clearly with blue or black ink. Please complete and return this form to PBGC before February 15 of this year.
General Information About You
Last Name |
First Name |
Middle Name |
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Social Security Number |
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Evening Phone |
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Mailing Address |
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Earnings Information
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Yes No |
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$ _________ |
Eligibility for Social Security Disability Benefits
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Signature – 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 |
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Approved OMB 1212-0055
Expires xx/xx/xx
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Lust Daniel |
File Modified | 0000-00-00 |
File Created | 2021-01-15 |