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Certification of Pension Plan Disability Status |
PBGC Form 716A
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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: Please complete and return this form to PBGC within the timeframe indicated in the cover letter. PBGC needs your certification to determine whether to continue paying your current benefit amount. If you have questions, call our Customer Contact Center at 1-800-400-7242. Please print clearly with blue or black ink.
1. General information about you
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Social Security Number |
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2. Certification – Check the box below that describes your current disability status.
I certify that I am still disabled as previously determined under my pension plan. I certify that effective ___/____/______ I am no longer disabled as previously determined under my pension plan. I understand that in the future I may be required to provide supporting documentation. |
3. 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 |
Approved OMB 1212-0055
Expires xx/xx/xx
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 | 2021-01-14 |