Form 715 Power of Attorney (POA)

PBGC Form 715

Power of Attorney (POA) – 1/07/21 draft
Pension Benefit Guaranty Corporation
P.O. Box 151750, Alexandria, Virginia 22315-1750

Approved OMB 1212-0055
Expires ______

For assistance, call 1-800-400-7242

Plan Name: FX.PrismCase.CaseTitle.XF
Plan Number: FX.PrismCase.CaseIdNmbr.XF
Date Printed:

Participant Name: FX.PrismCust.FullName.XF

INSTRUCTIONS: You may use this form to name one or more person(s) to act as your agent with PBGC. Please
review the Filing Instructions (pages 7 and 8) before completing this form for information
including about when this form may be used and by whom, how to change or revoke it. If you
have any questions, call our Customer Contact Center at 1-800-400-7242.

1. General information about you
Last Name

First Name

Middle Name

Other Name(s) Used

Social Security Number

Date of Birth

-

-

Gender

/

/

Mailing Address

Apartment / Route Number

City

State

Country

Email (OPTIONAL)

Daytime Phone

(

Extension

)

-

x

MALE



FEMALE



Zip Code

Evening Phone

(

I am:

)

MARK ONLY ONE

A. a participant



B. a beneficiary of a deceased participant



C. an alternate payee with a QDRO, entitled to all or part of a participant’s benefit



D. a person appealing a PBGC determination



If you checked B, C or D, provide
name of the plan participant:
Pension Plan Name*

PBGC Case Number

*Only one Pension Plan Name and Case number is needed. If you are in more than one plan, your agent is authorized to
act for all PBGC Pension Plans.

CONTINUE



Participant Name: FX.PrismCust.FullName.XF
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Power of Attorney PBGC Form 715, Page 2 of 8

2. NAME(S) OF YOUR AGENT(S) - (you must name at least one agent)
I hereby revoke any prior PBGC Power of Attorney (Form 715) executed by me and name the following
person(s) to act for me with respect to my PBGC pension(s). I understand from the instructions that
this PBGC Power of Attorney does not revoke any non-PBGC Powers of Attorney granted by me.

Agent 1:
Last Name

First Name

Middle Name

Relationship

Mailing Address

Apartment / Route Number

City

State

Country

Email (OPTIONAL)

Daytime Phone

(

Extension

)

-

x

Zip Code

Evening Phone

(

)

-

Agent 2:
Last Name

First Name

Middle Name

Relationship

Mailing Address

Apartment / Route Number

City

State

Country

Email (OPTIONAL)

Daytime Phone

(

Extension

)

-

x

Zip Code

Evening Phone

(

)

-

Agent 3:
Last Name

First Name

Middle Name

Relationship

Mailing Address

Apartment / Route Number

City

State

Country

Email (OPTIONAL)

Daytime Phone

(

Extension

)

-

x
CONTINUE

Evening Phone

(



Zip Code

)

-

Participant Name: FX.PrismCust.FullName.XF
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Power of Attorney PBGC Form 715, Page 3 of 8

3. If I have appointed more than one agent in item 2, I want my agents to:
(If you do not choose an option below , your agents must act jointly.)

 Act Independently – each of my co-agents may independently request any authorized action.
 Act jointly – my co-agents must jointly request any authorized action.
4. Types of Actions: My agent(s) is/are authorized to only take the following actions on my behalf with
respect to my PBGC pension(s) that I have marked below.
1. _____ Apply for PBGC benefits.
2. _____ Select an optional form of benefits and/or name a contingent annuitant. Selecting an optional form
that requires a contingent annuitant may result in a reduced payment during my lifetime.
3. _____ Designate a beneficiary, including one or more of my agents as a beneficiary.

4. _____ Change a beneficiary previously selected by me.
5. _____ Request/receive information from PBGC from my records, including PBGC income verification.
6. _____ Request PBGC forms.
7. _____ Respond to PBGC’s requests for information or documents.
8. _____ Change the payment address or bank account information for my PBGC payments.
9. _____ Change my contact information, such as home address, phone number(s) and/or email.
10. _____ Represent me before PBGC’s Appeals Board.
11. _____ Change Federal income tax withholding.
12. _____ Direct payment of my PBGC payments into an account that bears my name.
13. _____ Direct payment of my PBGC payments to a third-party through a revocable agreement.
(If you choose m, your agent may only take this action on your behalf if you are incapacitated.)
14. _____ All actions (a through m) listed above. If n is selected, no other actions need to be selected.

5. Effective Date and Duration (choose only one) –This Power of Attorney is effective, and my agent(s)
may act as follows:
(If you do not choose an option below, this Power of Attorney is a Non-Durable Power of Attorney.)
 Durable Power of Attorney. This Power of Attorney is effective after I sign it and will remain in effect
even if I become incapacitated
 Non-Durable Power of Attorney. This Power of Attorney is effective after I sign it and will remain in
effect until I become incapacitated.

6. NOTICE TO PRINCIPAL SIGNING THIS PBGC FORM 715 POWER OF ATTORNEY
PLEASE READ THIS NOTICE CAREFULLY. If there is anything about this form that you do not understand, you should
ask a lawyer to explain it to you.

The purpose of this PBGC Power of Attorney is to permit you to give your designated agent(s) broad powers
to handle your PBGC pension affairs, which may include the power to apply for your PBGC benefits, change
your home address, choose or change the location of where to send or deposit your payments electronically,
request verification of your pension income or other information from your files and more based on what you
choose from Types of Actions in item 4. Once your Power of Attorney is effective, your agent(s) may take
these actions even without your consent or any advance notice to you.

Participant Name: FX.PrismCust.FullName.XF
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Power of Attorney PBGC Form 715, Page 4 of 8

On this form, you may name one or more agent(s) in item 2. If you name co-agents you must choose whether
they must act together or each may act independently in item 3.
This form does not impose a duty upon your agent to handle your PBGC pension affairs, so it is important that
you select an agent who will agree to do this for you. It is also important to select an agent whom you trust,
since you are giving that agent control over your PBGC pension. Any agent who does act for you has a duty
to act in good faith for your benefit and to use due care, competence, and diligence. He or she must also act
in accordance with the directions in this form.
You may revoke this Power of Attorney if you wish by notifying the agent(s) and PBGC in writing. Until you
revoke this Power of Attorney in writing or complete a new PBGC Form 715 to replace it, it will remain in
effect, allowing your agent(s) to exercise the powers given to him or her throughout your lifetime. In addition,
a court can take away the powers of your agent if it finds that the agent is not acting properly.
Depending on your choice in item 5, your agent may continue to act if you become incapacitated (Durable
Power of Attorney), OR your agent will no longer be able to act if you become incapacitated (Non-Durable
Power of Attorney).
This Power of Attorney will not take effect without your signature. You should not sign it if you do not
understand everything in it including what your agent will be able to do after you sign it.

7. PRINCIPAL SIGNATURE
I am fully informed as to all the contents of this form and understand the full import of this grant of powers to
my agent(s). I understand that this PBGC Power of Attorney revokes any and all PBGC Powers of Attorney
(Form 715) previously granted by me, but does not revoke any non-PBGC Powers of Attorney granted by me.
I understand that my agent(s) are not authorized to act until they have signed item 10 of this form.

PRINCIPAL SIGNATURE

DATE

(NOTE: This Power of Attorney will not be effective unless it is signed by a witness and your signature is
notarized in items 8 and 9 below. The notary may not sign as a witness.)

8. WITNESS STATEMENT AND SIGNATURE (Witness may not also notarize in item 9.)
The undersigned witness certifies that the person whose name appears in item 1 as the principal of this
Power of Attorney, appeared before me and acknowledged signing item 7, and delivering the instrument as
the free and voluntary act of the principal, for the uses and purposes therein set forth. I believe him or her to
be of sound mind and memory. I also certify that I AM NOT any of the following:
(a) an attending physician or mental health service provider or a relative of same;
(b) an owner, operator, or relative of an owner or operator of a health care facility in which the principal is a
patient or resident;
(c) a parent, sibling, descendant, or any spouse of such parent, sibling, or descendant of either the principal
or any agent under this Power of Attorney, whether such relationship is by blood, marriage, or adoption; or
(d) an agent under the foregoing Power of Attorney.
WITNESS PLEASE CONTINUE READING AND COMPLETE AND SIGN ON NEXT PAGE



Participant Name: FX.PrismCust.FullName.XF
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Power of Attorney PBGC Form 715, Page 5 of 8

WITNESS INFORMATION
Witness Last Name

Witness First Name

Middle Name

Other Name(s) Used

Witness Mailing Address

Apartment / Route Number

City

State

Country

Email (OPTIONAL)

Daytime Phone

(

Extension

)

-

x

Zip Code

Evening Phone

(

WITNESS SIGNATURE

)

-

DATE

9. NOTARIZATION OF PRINCIPAL’S SIGNATURE. (Notary may not also be Witness in item 8.)
On this ________ day of ______________ Month, _______Year, 20______, _____________________
____________________, the Principal, (whose name appears in item 1 of this Power of
Attorney) appeared personally before me, whose identity or signature is personally known to me, or
proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed in
this Power of Attorney, and acknowledged to me that he/she executed the same in his/her capacity,
and that by his/her signature on the instrument, the individual, or the person upon behalf of which the
individual acted, executed the instrument.

DATE MY COMMISSION EXPIRES

NOTARY PUBLIC NAME

CITY / COUNTY, STATE

NOTARY PUBLIC SIGNATURE

10. NOTICE TO AGENT(S) (Your signature is required at the end of this Notice.)
When you accept the authority granted under this Power of Attorney a special legal relationship, known as
agency, is created between you and the principal. Agency imposes upon you duties that continue until you
resign or the Power of Attorney is terminated or revoked.
As agent you must:
Do what you know the principal reasonably expects you to do with the principal's pension benefit and act in
good faith for the best interest of the principal, using due care, competence, and diligence.
As agent you must not do any of the following:
Act so as to create a conflict of interest that is inconsistent with the other principles in this Notice to Agent; do
any act beyond the authority granted in this Power of Attorney. Continue acting on behalf of the principal if
AGENTS PLEASE CONTINUE READING AND SIGN ON NEXT PAGE



Participant Name: FX.PrismCust.FullName.XF
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Power of Attorney PBGC Form 715, Page 6 of 8

you learn of any event that terminates this Power of Attorney or your authority under this Power of Attorney,
such as the death of the principal.
You must disclose your identity as an agent whenever you act for the principal by writing or printing the name
of the principal and signing your own name "as Agent" in the following manner:
"(Principal's Name) by (Your Name) as Agent"
If you violate your duties as agent or act outside the authority granted to you, you may be liable under state
law for any damages, including attorney's fees and costs, caused by your violation. Also, PBGC retains the
right to revoke your authority under this document if you violate your duties or act outside the scope of the
authority granted to you.
If there is anything about this document or your duties that you do not understand, you should seek legal
advice from an attorney.

AGENT 1:

AGENT 1 SIGNATURE

DATE

Print Name

AGENT 2:

AGENT 2 SIGNATURE

DATE

Print Name

AGENT 3:

AGENT 3 SIGNATURE

Print Name

DATE

Participant Name: FX.PrismCust.FullName.XF
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Power of Attorney PBGC Form 715, Page 7 of 8

POWER OF ATTORNEY FORM
FILING INSTRUCTIONS
1. Who may use this PBGC Power of Attorney form?
Per item 1, you may use this form if you are:
• A participant;
• A beneficiary of a deceased participant;
• An alternate payee under a qualified domestic relations order (“QDRO”) who is entitled to all or part of a
participant’s benefit; or
• A person appealing a PBGC determination.
2. Do I have to use this form?
No, you do not have to use the PBGC Power of Attorney (POA). However, if you do not use this form, your nonPBGC POA must meet the requirements of your state, or the state where you sign the POA, if different. Some
states have model POAs called a “statutory form” that meet that state’s POA requirements. Such forms can be
found on states’ websites.
If you submit a non-PBGC POA, it should clearly identify the types of actions you want to allow your agent(s) to
take and identify whether the POA is a Durable Power of Attorney (DPOA) or Non-Durable Power of Attorney
(NDPOA).
3. What is the difference between a Durable and Non-Durable Power of Attorney?
A Durable Power of Attorney is a document that authorizes a person to act as your agent to perform specified
acts on your behalf, and the person still has authority to act on your behalf in the event of your mental incapacity.
By contrast, the authority you give with a Non-Durable Power of Attorney to another person ceases in the event of
your mental incapacity, after which your agent may no longer act on your behalf. You make that choice in item 5
of this PBGC Power of Attorney form.
Note: In the event you become mentally incapacitated without having designated an agent under a Durable
Power of Attorney form, a person seeking to act for you with respect to your PBGC pension will have to seek
appointment from a court as Guardian or Conservator with authority over your “Property” or “Estate”.
4. How do I file this Power of Attorney form?
After the form is completed with all signatures, file the Power of Attorney by mailing the original form to PBGC,
P.O. Box 151750, Alexandria, VA 22315-1750. You should keep a copy for your records.
5. What if I am a participant in more than one PBGC pension plan?
This form gives authority for all PBGC plans in which you have or may have a benefit, including plans which
come to PBGC after you sign this form. If you know you participate in more than one PBGC plan, you may list
their names and case numbers on page 1 of the form or in a cover letter, but it is not required.
6. What if I already have a PBGC Power of Attorney on file with PBGC?
Filing a new PBGC Power of Attorney Form with PBGC replaces a PBGC Power of Attorney Form on file with
PBGC.

Participant Name: FX.PrismCust.FullName.XF
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Power of Attorney PBGC Form 715, Page 8 of 8

7. What if I already have a non-PBGC Power of Attorney on file with PBGC?
Filing a new PBGC Power of Attorney does not automatically replace a non-PBGC Power(s) of Attorney on file
with PBGC. Once you have granted a non-PBGC Power of Attorney, it will remain in effect unless you revoke it
in writing. If you granted a non-PBGC Power of Attorney for a particular matter to more than one person, any of
those persons may exercise his or her authority under the Power of Attorney on that matter.
8. How do I limit my agent’s powers?
In item 4, you should only mark those actions that you authorize your agent to perform on your behalf.
9. Does my agent(s) need to sign the Power of Attorney Form?
Yes. Your agent(s) must sign and date item 10 of the form for it to be effective. Your agent does not need to sign
the form in your presence. PBGC will reject a Power of Attorney form if it has not been signed by both you and
your agent(s) or if your signature is not witnessed (item 8) and notarized (item 9) by two different people.
10. How do I make changes to this PBGC Power of Attorney after I sign it?
If you want to make changes such as adding or deleted an authority, or adding or removing a named agent, or
changing the duration (durable or non-durable) you must complete and file a replacement form. The new form will
replace your prior PBGC Power of Attorney. You should also notify any agent directly if you are revoking their
authority.
Note: Remember - A PBGC Power of Attorney does not automatically change or revoke a non-PBGC POA.
11. How do I cancel my PBGC Power of Attorney if I change my mind about my agent?
You cancel or revoke a PBGC Power of Attorney by informing PBGC in writing with your signature that you are
revoking any and all PBGC POAs you granted previously. You may not revoke a POA by telephone. You should
also inform the agents in your previous PBGC POA that their authority has been revoked.