Form 701 Form 701 Payee Information

Locating and Paying Participants

e_Form 701- Payee Information

Locating and Paying Participants

OMB: 1212-0055

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Payee Information Form



PBGC Form 701


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: 01/24/2021



Date of Plan Termination: FX.PrismCase.DOPT.XF


INSTRUCTIONS: You must complete this form to continue receiving pension payments. 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



Last Name

First Name


Middle Name

Other Last Name(s) Used




Social Security Number

Date of Birth

Gender

MALE





-



-







/



/






FEMALE




Mailing Address

Apartment / Route Number


City

State

Zip Code


Country

Email




Daytime Phone

Extension

Evening Phone


(




)




-





x





(




)




-








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.




Participant’s name:

Relationship Spouse

Other





Participant’s Social Security Number

Participant’s Date of Birth

Participant’s Date of Death







-



-







/



/







/



/









C. Alternate payee The benefits are from someone else’s pension plan but were assigned to me based on a court order.




Name of Participant:






Date of order:




/



/










D. Other. Please explain:





CONTINUE ON BACK





Approved OMB 1212-0055

Expires xx/xx/xx


Payee Information Form

Form 701, page 2 of 3


Plan Number: FX.PrismCase.CaseIdNmbr.XF

Participant Name: FX.PrismCust.FullName.XF






2a. Participant InformationComplete this section only if you checked “Self” in section 1. Otherwise, go to Section 3.


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



No

Yes

Employer Name:

City and State


Were you married when you retired? If yes, please provide the information below about your spouse at retirement.


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

Date of Marriage




-



-







/



/







/



/





Spouse’s Date of Death, if applicable (PROOF REQUIRED)




/



/






2b. Court order related to the participant’s benefit

Is there a court order (for example - domestic relations order, divorce decree, child support order, etc.) that requires some or all of your benefit be paid to a spouse, former spouse, child, or other dependent?

No

Yes

Date of the order:




/



/







Name of alternate payee:




3. Designation of Beneficiary for Payments Owed at Death PBGC may owe you money at the time of your death. Typically, this happens if your final benefit is higher than the estimated benefit we have been paying. If another person
continues to receive your benefit after your death (
as with a joint-and-survivor or certain-and-continuous annuity), we will pay the money owed to that person. If there are no continuing benefits or the person designated to receive continuing payments dies before you, PBGC will make any payments owed to you at the time of your death to the person(s) and/or entity(ies) (such as a trust, church, estate or other organization) that you designate in this section. If you do not make a designation, or if all the beneficiaries you designate below die before you, PBGC will pay the money in this order to: your spouse, your children, your parents, your estate, or your next of kin.


I name the following as my beneficiary(ies). This designation replaces any previous designation and will only be effective when PBGC receives it.




CONTINUE



Payee Information Form

Form 701, page 3 of 3


Plan Number: FX.PrismCase.CaseIdNmbr.XF

Participant Name: FX.PrismCust.FullName.XF




Designation of Beneficiary (continued)


Beneficiary(ies)

Social Security Number*

Date of Birth*

Relationship

Percentage**



Shape1 Name

Shape2 Address

Shape3

Shape4 Daytime Tel. No:







Shape5 Name

Shape6 Address

Shape7

Shape8 Daytime Tel. No:







Shape10 Shape9 Name

Shape11 Address

Shape12

Shape13 Daytime Tel. No:






* Complete if person

** Not necessary to provide; if provided, must total 100%



4. 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.



signature



date



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleGeneral Information Form_PBGC Form XXX
AuthorPBGC\IOD
File Modified0000-00-00
File Created2021-01-24

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