Form 722 Financial Statement of Debtor

	Financial Statement of Debtor		PBGC Form 722
Pension Benefit Guaranty Corporation. P.O. Box 151750, Alexandria, VA 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: 01/14/2021	Applicant Name:
	DOPT: FX.PrismCase.DOPT.XF

INSTRUCTIONS: Please complete this form to request that PBGC reduce or waive repayment of amounts you were overpaid. If you need additional space for any answer, use item 7B. You must submit a copy of your most recent Federal tax return, including schedules, with this form. You may also provide any other information that you wish PBGC to consider. Print clearly with dark 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

(

)

-

Are you currently married? Yes  No 

Spouse’s Last Name

Spouse’s First Name

Age(s) of Dependent(s), if any

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Approved OMB 1212-0055

Expires xx/xx/xx

Financial Statement of Debtor			Form 722, page 2 of 4
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF

2. Average Monthly Income

	Self	Spouse
A. Monthly Wage / Salary	$	$
B. Social Security Income	$	$
C. Pension Income	$	$
D. Interest, Dividend, Rental or Other Income	$	$
E. Total Monthly Income	$	$

3. Average Monthly Expenses

A. Rent or Mortgage Payment	$
B. Food	$
C. Utilities and Heat	$
D. Medical	$
E. Other, Including Insurance	$
F. Monthly Payments on Installment Contracts and other Debts (e.g., car payments, home improvement loans, appliances)	$
G. Total Monthly Expenses	$

4. Discretionary Income

A. Net Monthly Income Less Expenses (Item 2E less Item 3G)	$
B. Amount you can pay on a monthly basis toward your debt	$

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Financial Statement of Debtor			Form 722, page 3 of 4
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF

5. Assets

A. Cash in Bank (Checking and savings accounts, other investment accounts, etc.)			$
B. Cash on Hand			$
C. U.S. Savings Bonds (Current Value)			$
D. Stocks and other Bonds (Current Value)			$
E. Real Estate Owned (Resale Value)			$
F. Automobiles
Make	Year	Model	Resale Value
			$
			$
G. Other Assets (Specify below)
			$
			$
			$
H. Total Assets			$

6. Installment Contracts and Other Debts -- Show below all debts which you are required to pay, such as payments on a car, television, major appliances, payments to dealers, banks, finance companies; repayment of money borrowed for any purpose, doctor bills, hospital bills, etc. Do not include living expenses.

Name and Address of Creditor	Date and Purpose of Debt	Original Amount of Debt	Unpaid Balance	Amount Due Monthly	Amount Past Due (if any)
A.
B.
C.
D.
E. Total:		$	$	$	$
*Note: If repayment of a debt is not on a monthly basis, enter “0” and describe repayment arrangements in Section 7E.

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Financial Statement of Debtor			Form 722, page 4 of 4
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF

7. Additional Data

_{A. Have you ever filed for bankruptcy protection? Yes No  (If yes, complete items 1 through 4)}

1. _{Date of Bankruptcy Filing}

2. _{Date Discharged from Bankruptcy}

3. _{Location of Court}

4. _{Docket No., if known}

_{B. Use this space and additional sheets, if necessary, to supply any pertinent information and to continue your answer to previous items above to which your comments apply.}

8. Signature – You must 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