Form 712 Uniformed Services Information Form

Locating and Paying Participants

e_Form 712 Uniformed Services Information Form

Locating and Paying Participants

OMB: 1212-0055

Document [docx]
Download: docx | pdf

Uniformed Services Information Form



PBGC Form 712

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: Please complete this form for PBGC to determine your eligibility for additional pension service under the Uniformed Services Employment and Reemployment Rights Act (USERRA). This form applies only for the period of uniformed service that includes your plan’s termination date. 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 each item requiring proof are described in the letter accompanying this form. 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 (optional)


Daytime Phone

Extension

Evening Phone

(




)




-





x





(




)




-






2. Information about your service in the Uniformed Services (“uniformed service”) (Proof Required)


A. Your plan terminated on FX.PrismCase.DOPT.XF. If, on the date your plan terminated, you were —

In uniformed service

Recently returned from uniformed service, or

Recovering from injuries or illness incurred during your uniformed service

Check here and go to 2.B

Note: If none of the above applied to you on the date your plan terminated, you do not qualify for this benefit and you do not need to complete the rest of this form.

B. Your last period of uniformed service that began before the date your plan terminated.

Beginning date Ending date




/








/





Month


Year

Monthh


y

Year





CONTINUE ON BACK


Approved OMB 1212-0055

Expires xx/xx/xx




Uniformed Services Information Form

Form 712, page 2 of 2


Plan Number: FX.PrismCase.CaseIdNmbr.XF

Participant Name: FX.PrismCust.FullName.XF






2. Information about your service in the Uniformed Services (“uniformed service”) – Cont’d from page 1



C. If you were hospitalized or recovering from an illness or injury incurred during your uniformed service, on or before the ending date reported in 2.B. – Check here and provide date of recovery, if applicable.





/







Month


Year






3. Information about your discharge or separation from uniformed service (Proof Required)

If you were discharged or separated from uniformed service under honorable conditions, or if you remained in the reserves or federal national guard after your period of uniformed service in 2.B., check here


Note: If this box is not checked, you do not qualify for this benefit and you do not need to complete the rest of this form.


4. Information about your employment with the employer who sponsored your pension plan (Proof Required)



A.


Date you last worked for the employer who sponsored your pension plan before the beginning date reported in 2.B.





Date:



/



/







B.


Date you applied for re-employment (if applicable) after the ending date in 2.B.






Date:



/



/







C.


The first day you worked for the employer after the ending date in 2.B.






Date:



/



/










5. Signature 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, 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


SIGN & DATE BEFORE SUBMITTING. THANK YOU




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleGeneral Information Form_PBGC Form XXX
AuthorPBGC\IOD
File Modified0000-00-00
File Created2021-01-12

© 2024 OMB.report | Privacy Policy