Form 704 Report of Earnings and Social Security Disability Inform

Report of Earnings and Social Security
Disability Information
Pension Benefit Guaranty Corporation.
P.O. Box 151750, Alexandria, Virginia 22315-1750

PBGC Form 704

For assistance, call 1-800-400-7242

Plan Name: FX.PrismCase.CaseTitle.XF
Plan Number: FX.PrismCase.CaseIdNmbr.XF
Date Printed: 01/11/2021
Date of Plan Termination: FX.PrismCase.DOPT.XF

Participant Name: FX.PrismCust.FullName.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

Social Security Number
-

-

Middle Name

Daytime Phone
(

)

Evening Phone
-

(

)

Mailing Address

Apartment / Route Number

City

State

Country

Email

-

Zip Code

2. Earnings Information
a. 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?
b. 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
c. Are you eligible for disability benefits from the Social Security
Administration (SSA)?
d. 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.






Yes
No

$ _________



Yes

/

No

/

4. 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 __________