Form 704 Report of Earnings and Social Security Disability Inform

Locating and Paying Participants

e_Form 704 Report of Earnings and Social Security Disability Information

Locating and Paying Participants

OMB: 1212-0055

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Report of Earnings and Social Security Disability Information

PBGC Form 704


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: Use this form to report your earnings from work for the last calendar year and if you are eligible for disability benefits from the Social Security Administration (SSA). Print clearly with blue or black ink. Please complete and return this form to PBGC before February 15 of this year.

  1. General Information About You

    Last Name

    First Name

    Middle Name


    Social Security Number

    Daytime Phone

    Evening Phone




    -



    -





    (




    )




    -





    (




    )




    -






    Mailing Address

    Apartment / Route Number

    City

    State

    Zip Code

    Country

    Email

  2. Earnings Information

    1. Earnings from work include wages, salaries, tips, bonuses, commissions, and self-employment income. It does not include interest or pensions or most other types of income. Did you have any earnings from work last year?



    Yes No

    1. If “Yes”, enter the greater of the amounts shown in Box 1 (Wages, tips, other compensation), and Box 5 (Medicare wages and tips) from all W-2 forms issued to you for last year. Include earnings for which you may not have received a W-2, for example self-employment income.



    $ _________

  3. Eligibility for Social Security Disability Benefits

  1. Are you eligible for disability benefits from the Social Security Administration (SSA)?

Yes

No

  1. If yes, enter the date that you became eligible from your SSA Award letter and send a copy of your award letter with this form.



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  1. Signature – 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



Approved OMB 1212-0055

Expires xx/xx/xx


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorLust Daniel
File Modified0000-00-00
File Created2021-04-07

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