Form 701 Form 701 Payee Information

	Payee Information Form		PBGC Form 701
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: 04/07/2021
	Date of Plan Termination: FX.PrismCase.DOPT.XF

INSTRUCTIONS: You must complete this form to continue receiving pension payments. 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

Daytime Phone

Extension

Evening Phone

(

)

-

x

(

)

-

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.



Participant’s name:

Relationship Spouse

Other

Participant’s Social Security Number

Participant’s Date of Birth

Participant’s Date of Death

-

-

/

/

/

/

C. Alternate payee – The benefits are from someone else’s pension plan but were assigned to me based on a court order.



Name of Participant:

Date of order:

/

/

D. Other. Please explain:



CONTINUE ON BACK

Approved OMB 1212-0055

Expires xx/xx/xx

Payee Information Form			Form 701, page 2 of 3
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF

2a. Participant Information – Complete this section only if you checked “Self” in section 1. Otherwise, go to Section 3.

Are you currently employed? If yes, please provide information below:		No	
		Yes	
Employer Name:	City and State

Were you married when you retired? If yes, please provide the information below about your spouse at retirement.

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

Date of Marriage

-

-

/

/

/

/

Spouse’s Date of Death, if applicable (PROOF REQUIRED)

/

/

2b. Court order related to the participant’s benefit

Is there a court order (for example - domestic relations order, divorce decree, child support order, etc.) that requires some or all of your benefit be paid to a spouse, former spouse, child, or other dependent?

No



Yes



Date of the order:

/

/

Name of alternate payee:

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

CONTINUE

Payee Information Form			Form 701, page 3 of 3
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF

Designation of Beneficiary (continued)

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%

4. Signature – Sign and date this application. 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