Form 702 General Information

Locating and Paying Participants

e_Form 702 General Information Form

Locating and Paying Participants

OMB: 1212-0055

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_{General
Information Form}

PBGC Form 702

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
	Date Printed: 01/12/2021
	Date of Plan Termination: FX.PrismCase.DOPT.XF

INSTRUCTIONS: Please complete this form so that PBGC can determine whether you are entitled to a pension benefit. Note those items marked "Proof Required" and enclose a copy of the appropriate document if you have not already sent it to us. Acceptable documents for proof of age include your birth or baptism certificate, or U.S. Passport; for marriage, a marriage certificate; for proof of death, a death certificate. This is not a benefit application. To begin receiving benefits, or if you have questions about other acceptable documents, call our Customer Contact Center at 1-800-400-7242. 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}_{(PROOF
REQUIRED)}

_Gender

_male

_

_female

_

_{Mailing
Address}

_{Apartment
/ Route Number}

_City

_State

_{Zip
Code}

_Country

_{Email
(optional)}

_{Daytime
Phone}

_Extension

_{Evening
Phone}

₍

₎

₍

₎

^CONTINUE^{ON BACK}

Approved OMB 1212-0055

Expires xx/xx/xx

_{General Information Form}_{Form 702, page 2 of 4}
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF

_{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.}

_

_{My
relationship to the participant:}

___Spouse_{(PROOF
REQUIRED)}

___Other:

_{Name
of Participant:}

_{Date
of participant’s death:}

_{(PROOF
REQUIRED)}

_{C.
Alternate payee}_{-
I have a Qualified Domestic Relations Order (QDRO) that
establishes my right to receive some or all of a participant's
benefits from a pension plan.}

_

_{Name
of Participant:}

_{Date
of QDRO:}

_D. Other._{Please
explain:}

_

2. Participant Information – Complete this section only if you checked “Self” in section 1.

_{Are you currently employed?}_{If yes, please provide information below:}		_No	_
		_Yes	_
_{Employer Name:}	_{City and State}

_{Were
you married when the plan terminated?}

_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}

_{(PROOF
REQUIRED)}

_{Date
of Marriage}

_{(PROOF
REQUIRED)}

_{Is
there a Qualified Domestic Relations Order (QDRO) requiring
payment of some or all of your benefit to someone else?}

_No

_

_Yes

_

_{Date
of the QDRO:}

_{Name
of alternate payee:}

^CONTINUE

_{General Information Form}_{Form 702, page 3 of 4}
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF

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 had been paying. If another person continues to receive your benefit after your death (as with a joint-and-survivor or certain-and-continuous annuity), PBGC will pay any money owed to that person. If there are no continuing benefits or the person designated to receive continuing benefits dies before you, PBGC will pay any money owed 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.

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%

If you want to change this designation, please call PBGC’s Customer Contact Center at 1-800-400-7242.

_{THANK
YOU.}

^CONTINUE^{ON BACK}

_{General Information Form}_{Form 702, page 4 of 4}
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF

Signature – You must 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, and 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	2021-01-12