Form 701 Payee Information

Locating and Paying Participants

e_Form 701- Payee Information

Locating and Paying Participants

OMB: 1212-0055

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1212-0055 can be found here:

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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: 01/15/2021
	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}

₍

₎

₍

₎

_{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.}

_

_P_{articipant’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 Information – Complete 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**
Name Address Daytime Tel. No:
Name Address Daytime Tel. No:
Name Address 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 Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	General Information Form_PBGC Form XXX
Author	PBGC\IOD
File Modified	0000-00-00
File Created	2021-01-15