Form 704 Report of Earnings and Social Security Disability Inform

	Report of Earnings and Social Security Disability Information		PBGC Form 704
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: Use this form to report your earnings from work for the last calendar year and if you are eligible for disability benefits from the Social Security Administration (SSA). Print clearly with blue or black ink. Please complete and return this form to PBGC before February 15 of this year.

1. General Information About You

   Last Name

   First Name

   Middle Name

   Social Security Number

   Daytime Phone

   Evening Phone

   -

   -

   (

   )

   -

   (

   )

   -

   Mailing Address

   Apartment / Route Number

   City

   State

   Zip Code

   Country

   Email

2. Earnings Information

   Earnings from work include wages, salaries, tips, bonuses, commissions, and self-employment income. It does not include interest or pensions or most other types of income. Did you have any earnings from work last year?	Yes No
   If “Yes”, enter the greater of the amounts shown in Box 1 (Wages, tips, other compensation), and Box 5 (Medicare wages and tips) from all W-2 forms issued to you for last year. Include earnings for which you may not have received a W-2, for example self-employment income.	$ _________

3. Eligibility for Social Security Disability Benefits

Are you eligible for disability benefits from the Social Security Administration (SSA)?



Yes



No

If yes, enter the date that you became eligible from your SSA Award letter and send a copy of your award letter with this form.

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4. Signature – Sign and date this form. 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

Approved OMB 1212-0055

Expires xx/xx/xx