Form 711 Change of Beneficiary for Certain Continuous Benefits On

Locating and Paying Participants

e_Form 711 Change of Beneficiary for Certain continuous (CC) Benefits Only

Locating and Paying Participants

OMB: 1212-0055

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Change of Beneficiary for Certain & Continuous (C&C) Benefits Only

(Currently Receiving Pension Benefits)


PBGC Form 711


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: 01/12/2021



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



INSTRUCTIONS: Use this form to change your beneficiary if you are receiving a Certain & Continuous annuity. If you die before the certain period ends, any remaining payments will go to the person(s) or entity(ies) (such as a trust, church, estate or other organization) that you designate in section 2. If you do not make a designation, or if the beneficiary is a person and dies before you, PBGC will pay the amount we owe in this order to: your spouse, your children, your parents, your estate, or your next of kin. If you have any questions, please 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




-



-






Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email


Daytime Phone

Extension

Evening Phone

(




)




-





x





(




)




-







2. Beneficiary - I name the following person(s) and/or entity(ies) as my beneficiary(ies). This designation replaces any previous designation and will be effective only when PBGC receives it. Once the Certain Period ends, no continuing benefit will be paid to the person(s) or entity(ies) designated below.

Beneficiary(ies)

Social Security Number*

Date of Birth*

Relationship

Percentage**



Shape2 Shape1 Name

Shape3 Address

Shape4

Shape5 Daytime Tel. No:







Shape7 Shape6 Name

Shape8 Address

Shape9

Shape10 Daytime Tel. No:





CONTINUE ON BACK



Approved OMB 1212-0055

Expires xx/xx/xx


Change of Beneficiary for Certain & Continuous (C&C) Benefits Only (Currently Receiving Pension Benefits)


Form 711, page 2 of 2


Plan Number: FX.PrismCase.CaseIdNmbr.XF

Participant Name : FX.PrismCust.FullName.XF





2. Beneficiary (continued)


Beneficiary(ies)

Social Security Number*

Date of Birth*

Relationship

Percentage**



Shape11 Name

Shape12 Address

Shape13

Shape14 Daytime Tel. No:






* Complete if person

** Not necessary to provide; if provided, must total 100%





3. Signature – Sign and date this form for your beneficiary designation to be effective.




signature



date


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleDesignation of Beneficiary PBGC Form 707
AuthorPBGC\IOD
File Modified0000-00-00
File Created2021-01-12

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