Form 716A Certificate of Pension Plan Disability Status

	Certification of Pension Plan Disability Status		PBGC Form 716A
Pension Benefit Guaranty Corporation. P.O. Box 151750, Alexandria, Virginia 22315-1750		For assistance, call 1-800-400-7242

	Plan Name: FX.PrismCase.CaseTitle.XF
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name : FX.PrismCust.FullName.XF
	Date Printed: 01/12/2021
	Date of Plan Termination: FX.PrismCase.DOPT.XF

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

Last Name

First Name

Middle Name

Other Last Name(s) Used

Social Security Number

Date of Birth

-

-

/

/

Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email (optional)

Daytime Phone

Extension

Evening Phone

(

)

-

x

(

)

-

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.
Signature		DATE

Approved OMB 1212-0055

Expires xx/xx/xx