Form 702 General Information Form

General Information Form

PBGC Form 702

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

INSTRUCTIONS: Please complete this form so that PBGC can determine whether you are entitled to a pension
benefit. 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 proof of age include your birth or baptism certificate,
or U.S. Passport; for marriage, a marriage certificate; for proof of death, a death certificate. This is not a benefit
application. To begin receiving benefits, or if you have questions about other acceptable documents, call our
Customer Contact Center at 1-800-400-7242. Print clearly with dark ink.

1. General information about you
Last Name

First Name

Middle Name

Other Last Name(s) Used

Social Security Number

Date of Birth (PROOF REQUIRED)

-

-

/

Gender

/

Mailing Address

Apartment / Route Number

City

State

Country

Email (optional)

Daytime Phone

(

EXTENSION

)

-

x

CONTINUE ON BACK

MALE



FEMALE



Zip Code

Evening Phone

(

)

-


Approved OMB 1212-0055
Expires ________

General Information Form
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Form 702, page 2 of 4
Participant Name: FX.PrismCust.FullName.XF

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.



My relationship to the participant:

 Spouse (PROOF REQUIRED)

 Other:

Name of Participant:
Date of participant’s death:

/

/

(PROOF REQUIRED)



C. Alternate payee - I have a Qualified Domestic Relations Order (QDRO) that establishes
my right to receive some or all of a participant's benefits from a pension plan.
Name of Participant:

/

Date of QDRO:

/


D. Other. Please explain:

2. Participant Information – Complete this section only if you checked “Self” in section 1.
Are you currently employed? If yes, please provide information below:

Employer Name:



Yes



No



Yes



No



Yes



City and State

Were you married when the plan terminated?

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

Date of Marriage

(PROOF REQUIRED)

(PROOF REQUIRED)

/

/

/

/

Is there a Qualified Domestic Relations Order (QDRO) requiring payment of some or all of your
benefit to someone else?
Date of the QDRO:

/

/

Name of alternate payee:

CONTINUE



General Information Form

Form 702, page 3 of 4

Plan Number: FX.PrismCase.CaseIdNmbr.XF

Participant Name: FX.PrismCust.FullName.XF

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 had been paying. If another person continues to
receive your benefit after your death (as with a joint-and-survivor or certain-and-continuous annuity), PBGC will pay any money
owed to that person. If there are no continuing benefits or the person designated to receive continuing benefits dies before you,
PBGC will pay any money owed 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.
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.
If you want to change this designation, please call PBGC’s Customer Contact Center at 1-800-400-7242.

CONTINUE ON BACK



General Information Form
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Form 702, page 4 of 4
Participant Name: FX.PrismCust.FullName.XF

4. Signature – You must 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, and 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