Form 712 Uniformed Services Information Form

Uniformed Services Information Form
Pension Benefit Guaranty Corporation.
P.O. Box 151750, Alexandria, Virginia 22315-1750

PBGC Form 712

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: 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

/

Mailing Address

Apartment / Route Number

City

State

Country

Email (optional)

Daytime Phone

(

-



FEMALE



Zip Code

Evening Phone

Extension

)

MALE

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

Month

Year



CONTINUE ON BACK

Approved OMB 1212-0055
Expires __________

Uniformed Services Information Form
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Form 712, page 2 of 2
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