Form 701 Payee Information Form

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
Date Printed: 07/07/2021
Date of Plan Termination: FX.PrismCase.DOPT.XF

Participant Name: FX.PrismCust.FullName.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

/

/

Mailing Address

Apartment / Route Number

City

State

Country

Email

Daytime Phone

(

-



FEMALE



Zip Code

Evening Phone

EXTENSION

)

MALE

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

Participant’s Social Security Number

-

-

Participant’s Date of Birth

/

 Spouse

 Other

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 _______

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:

Employer Name:



Yes



No



Yes



No



Yes



City and State

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

Spouse’s First Name

Spouse’s Middle Name

Other Name(s) Used

Spouse’s Social Security Number

-

No

Spouse’s Date of Birth

-

/

/

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

Spouse’s Gender: Male 

Female

Date of Marriage

/

/

/

/



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?

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
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Form 701, page 3 of 3
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:___________________________
*To name more beneficiaries, please list them with requested contact info, DOB and SSN on an attached sheet with your signature.
**Complete if person.
*** Percentage(s) does not have to be provided.
The amount owed will be distributed equally among beneficiaries unless percentages are provided for each beneficiary and they total 100%.
If a beneficiary dies before you, the amount owed will be distributed equally among the remaining beneficiaries.

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