702 General Information Form

Locating and Paying Participants

702

Locating and Paying Participants

OMB: 1212-0055

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General Information Form


PBGC Form 702

Approved OMB 1212-0055

Expires 08/31/08

Pension Benefit Guaranty Corporation.
P.O. Box
151750 Alexandria Virginia 22315-1750

For assistance, call 1-800-400-7242



Plan Name: «PrismCase.CaseTitle»


Plan Number: «PrismCase.CaseIdNmbr»



Date Printed: 02/06/2021



Date of Plan Termination: «PrismCase.DOPT»



INSTRUCTIONS: Please complete this form so PBGC can determine your right to a pension benefit. Use dark ink and be sure to print clearly. Note those items marked "Proof Required." You must enclose a copy of the appropriate document if you have not already sent it to us. Acceptable documents for proof of age include your birth or baptism certificate, or U.S. Passport; for marriage, a marriage certificate; for proof of death is a death certificate. This is not a benefit application. To begin receiving benefits, or for other information, call our Customer Contact Center at 1-800-400-7242.


1. General information about you


Last Name

First Name

Middle Name

Other Name(s) Used


Social Security Number

Date of Birth (proof required)

Gender

male




-



-







/



/






female


Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email (optional)


Daytime Phone

Extension

Evening Phone

(




)




-





x





(




)




-













CONTINUE



General Information Form Form 702, page 2 of 3


Plan Number: «PrismCase.CaseIdNmbr»

Participant Name / SSN: «PrismCust.FullName»





Your relationship to person who participated in the plan:

mark only one

A. Self – The benefits are from my pension plan

B. Beneficiary - The benefits are from the pension plan of someone who is deceased.



My relationship to the participant:

Spouse (proof required)

Other:


Name of Participant:



Date of participant’s death:




/



/





(proof required)


C. Alternate payee - I have a Qualified Domestic Relations Order (QDRO) that establishes my right to receive some or all of a participant's benefits from a pension plan.



Name of Participant:



Date of QDRO:




/



/







D. Other. Please explain:





2. Participant Information – Complete this section only if you checked “Self” in section 1.


Are you currently employed? If yes, please provide information below:

No

Yes

Employer Name:

City and State


Were you married when the plan terminated?


No

Yes

Spouse’s Last Name

Spouse’s First Name

Spouse’s Middle Name

Other Name(s) Used

Spouse’s Social Security Number

Spouse’s Date of Birth

(proof required)

Date of Marriage

(proof required)




-



-







/



/







/



/






Is there a Qualified Domestic Relations Order (QDRO) requiring payment of some or all of your benefit to someone else?

No


Yes

Date of the QDRO:




/



/







Name of alternate payee:





CONTINUE



General Information Form Form 702, page 3 of 3


Plan Number: «PrismCase.CaseIdNmbr»

Participant Name / SSN: «PrismCust.FullName»





  1. Signature You must 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, and 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


  1. Designation of Beneficiary – If there are payments owed to you at the time of your death, PBGC will pay them to the person(s) you designate below. If you do not designate anyone, or if the beneficiary you name dies before you, PBGC will pay the underpayment in this order: your spouse, your children, your parents, your estate, and your next of kin.


Beneficiary – I name the following person as my beneficiary for amounts owed to me at my death. This replaces any previous designation and will only be effective when PBGC receives it.

Last Name

First Name

Middle Name

Other Name(s) Used


Social Security Number

Date of Birth

Gender

male




-



-







/



/






female


Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email (optional)


Daytime Phone

Extension

Evening Phone

(




)




-





x





(




)




-






Relationship to me, if any (e.g., spouse or granddaughter, friend)





If you want to change this designation, please call PBGC’s Customer Contact Center at 1-800-400-7242.



THANK YOU.




File Typeapplication/msword
File TitleGeneral Information Form_PBGC Form XXX
AuthorPBGC\IOD
Last Modified ByPBGC User
File Modified2006-12-04
File Created2006-12-04

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