Form 709 Plan Participant Information

Locating and Paying Participants

e_Form 709 Plan Participant Information

Locating and Paying Participants

OMB: 1212-0055

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Plan Participation Information



PBGC Form 709

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: 01/20/2021



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



INSTRUCTIONS: Please complete this form for PBGC to determine your eligibility for a pension. 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 (optional)


Daytime Phone

Extension

Evening Phone

(




)




-





x





(




)




-






Name of plan participant, if different

Social Security Number




-



-







2. Participant employment information - Relating to the sponsor of the plan.


Employer Name

City and State


Job Title

Plant or Facility


Date of Hire

Date Employment Terminated

Reason for Termination




/



/







/



/








CONTINUE ON BACK









Approved OMB 1212-0055

Expires xx/xx/xx


Plan Participation Information

Form 709, page 2 of 2


Plan Number: FX.PrismCase.CaseIdNmbr.XF

Participant Name: FX.PrismCust.FullName.XF





Was the plan participant covered by a collective bargaining agreement (union contract) with the employer identified above? If yes, during what period:

No

Yes


From



/






To



/









month


year



month


year



Name of Local Union:

Address



Was the plan participant an hourly paid or a salaried employee?

Hourly

Salary

Was the plan participant transferred between hourly and salary?

Yes

No

If yes, specify type and date of each transfer:


Any breaks in service?

Yes

No

If yes, specify the period(s) (from when to when):


Please attach any documentation to verify the participant’s employment and/or plan participation.








3. Signature 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, 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




SIGN & DATE BEFORE SUBMITTING. THANK YOU




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleGeneral Information Form_PBGC Form XXX
AuthorPBGC\IOD
File Modified0000-00-00
File Created2021-01-20

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