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Application for Lump-Sum Payment |
PBGC Form 720CD
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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 request a lump-sum payment if you are a child or dependant pursuant to a Qualified Domestic Relations Order (QDRO). When "proof required" is indicated, please enclose a copy of a birth or baptism certificate, or a U.S. Passport, whichever is appropriate, unless you already sent PBGC a copy of this document. If you have questions about other acceptable documents, call our Customer Contact Center at 1-800-400-7242. Please print clearly with dark ink.
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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female |
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Mailing Address |
Apartment / Route Number |
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City |
State |
Zip Code |
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Country |
Province |
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Daytime Phone |
Extension |
Evening Phone |
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Name of plan participant:
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Signature – Sign and date this application. 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 12/31/15
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Payee Information Form_PBGC Form XXX |
Author | PBGC\IOD |
File Modified | 0000-00-00 |
File Created | 2021-01-12 |