General Information Form_PBGC Form XXXPBGC\IODBurns Jo Amato212012-09-10T15:32:00Z2012-09-24T19:27:00Z2012-09-24T19:27:00Z23552025Interim Inc.164237614

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P.O. Box 151750, Alexandria, Virginia 22315-1750For assistance, call 1-800-400-7242Plan Name: FX.PrismCase.CaseTitle.XFPlan Number: FX.PrismCase.CaseIdNmbr.XFParticipant Name : FX.PrismCust.FullName.XFDate Printed: TIME \@ "MM/dd/yyyy" 09/24/2012Date of Plan Termination: FX.PrismCase.DOPT.XFINSTRUCTIONS: Please complete this form to have PBGC send your pension benefit payments directly to your bank or other financial institution through electronic direct deposit (EDD). This form may also be used for an Electronic Transfer Account (ETA). Your name must be on the account. 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

Plan Name (as shown on check)Last NameFirst NameMiddle NameOther Name(s) UsedSocial Security NumberPBGC Plan Number--Mailing AddressApartment / Route NumberCityStateZip CodeCountryEmail (optional)Daytime PhoneExtensionEvening Phone()-x()-CONTINUEApplication for Electronic Direct DepositForm 710, page 2 of 2Plan Number: FX.PrismCase.CaseIdNmbr.XFParticipant Name: FX.PrismCust.FullName.XF

3. Financial institution information – Please provide the information in this section to have your payment sent directly to a financial institution. The information is available from your financial institution or can be found on your checks, account statement or deposit slip. The sample check below shows the location of your nine-digit routing number and account number. If you are unsure of the routing number or your account number, contact your financial institution. You can cancel or change this arrangement by calling PBGC at 1-800-400-7242. The financial institution can cancel it by sending you a written notice.

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Checking



Savings

Name(s) on the Account (Your name must be on the Account)

3.Signature – I hereby authorize PBGC to deposit my pension benefit funds into my account. I understand that I may change this election in the future.

signaturedate