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Plan Participation Information
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PBGC Form 709
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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 this form for PBGC to determine your eligibility for a pension. 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
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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- |
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/ |
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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 |
Email (optional) |
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Daytime Phone |
Extension |
Evening Phone |
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- |
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x |
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( |
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) |
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- |
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Name of plan participant, if different |
Social Security Number |
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- |
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- |
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2. Participant employment information - Relating to the sponsor of the plan.
Employer Name |
City and State |
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Job Title |
Plant or Facility |
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Date of Hire |
Date Employment Terminated |
Reason for Termination |
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CONTINUE ON BACK |
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Approved OMB 1212-0055
Expires xx/xx/xx
Plan Participation Information |
Form 709, page 2 of 2 |
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Plan Number: FX.PrismCase.CaseIdNmbr.XF |
Participant Name: FX.PrismCust.FullName.XF |
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Was the plan participant covered by a collective bargaining agreement (union contract) with the employer identified above? If yes, during what period: |
No |
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Yes |
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From |
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To |
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month |
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year |
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month |
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year |
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Name of Local Union: |
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Address |
Was the plan participant an hourly paid or a salaried employee? |
Hourly |
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Salary |
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Was the plan participant transferred between hourly and salary? |
Yes |
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No |
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If yes, specify type and date of each transfer:
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Any breaks in service? |
Yes |
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No |
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If yes, specify the period(s) (from when to when):
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Please attach any documentation to verify the participant’s employment and/or plan participation.
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3. Signature – 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, 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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SIGN & DATE BEFORE SUBMITTING. THANK YOU |
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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 | 2021-01-12 |