PBGC Form 723 Request for Additional Time to File an Appeal of a PBGC

	Request for Additional Time to File an Appeal of a PBGC Benefit Determination		PBGC Form 723 Approved OMB XXXX-XXXX Expires XX/XX/XX
Pension Benefit Guaranty Corporation. P.O. Box 151750 Alexandria Virginia 22315-1750		For assistance, call 1-800-400-7242 ext. 4090

As a recipient of a PBGC benefit determination, you have the right to appeal PBGC’s determination of your benefit if you can provide a specific reason why the determination is wrong. If you simply have a question about your benefit or how it was calculated, you should call PBGC’s Customer Contact Center at 1-800-400-7242. You have 45 calendar days from the date on PBGC’s determination letter to submit an appeal. If you need more time to prepare your appeal, you must request an extension from the Appeals Division before the 45-calendar-day limit expires. The appeal period will be suspended as of the date you file your request for an extension. Your request must be in writing and must state why you need more time to file your appeal and how much more time you will need. You may request an extension of time to file your appeal by using this form or by sending a letter, e-mail or fax that includes the information requested on this form. This request must be postmarked by the U.S. Postal Service or received in the Appeals Division no later than 45 calendar days from the date on PBGC’s determination letter. If you use this form, please use dark ink and be sure to print clearly. Mail this form, and copies of appropriate documents, to the address shown on page 2. If you have questions about the appeals process, please refer to PBGC’s brochure Your Right to Appeal, or call the Appeals Division at 1-800-400-7242 ext. 4090.

1. Appellant Information (Specify one)

Participant

Beneficiary of a Deceased Participant

Alternate Payee

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

(

)

-

2. Plan Information

Plan Name
PBGC Case Number
Date of PBGC Benefit Determination Letter you are appealing (You must submit this form no later than 45 calendar days from the date on the Benefit Determination Letter)				/			/
		(mm/dd/yy)

3. Explain the reason(s) for needing additional time to appeal (Use additional pages, if necessary.)

Request for Additional Time to File an Appeal of a PBGC Benefit Determination Form 723, page 2 of 2

4. How much additional time do you need to file your appeal?

 30 days	 45 days	 _____ days (Specify) _________________________

5. Authorized Representative Information (if any) If you are representing the Appellant identified in Item 1, select the correct box below and complete the remaining information.

_{ An attorney representing the Appellant}

 A spouse, family member, or other person assisting the Appellant with this appeal

If you have not already sent PBGC an original notarized power of attorney signed by the Appellant giving you the authority to act on the Appellant’s behalf, you must submit one with this form.

Last Name

First Name

Middle Name

Other Name(s) Used

Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email (optional)

Daytime Phone

Extension

Evening Phone

(

)

-

x

(

)

-

6. Signature of Appellant or Authorized Representative – You must sign and date this request. 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 to the best of my knowledge.

signature		date

HOW TO FILE: You may either mail this completed form, any additional pages and a power of attorney (if required—see item 5), to:

Pension Benefit Guaranty Corporation

Attention: Appeals Division

Post Office Box 151750

Alexandria, VA 22315-1750

or, you may fax your request to the Appeals Division at (202) 326-4095 or (202) 326-4091, or send it by e-mail to [email protected].

The Appeals Division will acknowledge your correspondence within one week of receipt. If you have any questions, call the Appeals Division at 1-800-400-7242 ext. 4090.

PBGC Privacy Act Notice

The Privacy Act of 1974, as amended, 5 U.S.C. § 552a (1994), requires PBGC to give you this notice when collecting information from you. PBGC uses the information to resolve administrative appeals of matters specified in 29 C.F.R. § 4003(b)(5) – (10). Your Social Security Number is used by PBGC to identify your records within PBGC, to report income for tax purposes, and to respond to lawful requests for information about you from other individuals and entities. Your response is voluntary. However, failure to provide information to PBGC, including your Social Security Number, may delay or prevent PBGC from calculating and paying your pension benefits.

The PBGC may release information about you to other individuals and entities when necessary and appropriate under the Privacy Act, including: to a third party who may be aggrieved by a decision of the Appeals Board such as an alternate payee under a qualified domestic relations order; to a third party to make benefit payments to you; or to a labor organization that represents you.

PBGC may also release information about you to appropriate law enforcement agencies when PBGC becomes aware of a possible violation of civil or criminal law. If PBGC, an employee of PBGC, the United States, or another agency of the United States is involved in litigation, PBGC may provide relevant information about you to a court or other adjudicative body or to the Department of Justice when it represents PBGC. PBGC may also provide information about you to the Office of Management and Budget in connection with review of private relief legislation or to a Congressional office in response to an inquiry that office makes about you at your request.

PBGC publishes notices in the Federal Register that describe in more detail when information about you may be made available to others. A copy of the most recent Federal Register notice may be obtained from PBGC's Customer Contact Center by calling toll-free 1-800-400-7242. For TTY/TDD users, call the federal relay service toll-free at 1-800-877-8339 and ask to be connected to 1-800-400-7242. PBGC's authority to collect information from you, including your Social Security Number, is derived from 29 U.S.C. §§ 1055, 1056(d)(3), 1302, 1321, 1322, 1322a, 1341 and 1350 (1994). If you have any other privacy-related questions or concerns, you may contact PBGC’s Disclosure Officer at 1-800-400-7242 extension 4040.