Form 710 Application for Electronic Direct Deposit

Application for
Electronic Direct Deposit

PBGC Form 710

Pension Benefit Guaranty Corporation.
P.O. Box 151750, Alexandria, Virginia 22315-1750
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

For assistance, call 1-800-400-7242
Participant Name : FX.PrismCust.FullName.XF

INSTRUCTIONS: Please complete this form to have PBGC send your pension benefit payments directly to your
bank or other financial institution through electronic direct deposit (EDD). Your name must be on the
account. 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
Plan Name (as shown on check)
Last Name

First Name

Middle Name

Other Last Name(s) Used

Social Security Number

PBGC Plan Number

-

-

Mailing Address

Apartment / Route Number

City

State

Country

Email

Daytime Phone

(

EXTENSION

)

-

x

CONTINUE ON BACK

Zip Code

Evening Phone

(

)

-



Approved OMB 1212-0055
Expires _______

Application for Electronic Direct Deposit
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Form 710, page 2 of 2
Participant Name: FX.PrismCust.FullName.XF

2. Financial institution information – Please provide the information in this section to have your payment
sent directly to a financial institution. The information is available from your financial institution or can be found
on your checks, account statement or deposit slip. The sample check below shows the location of your ninedigit routing number and account number. If you are unsure of the routing number or your account
number, contact your financial institution. You can cancel or change this arrangement by calling PBGC at
1-800-400-7242. The financial institution can cancel it by sending you a written notice.

All fields required
Name(s) on the Account (Your name must be on the account)
Routing Number

Account Number – Numbers only

Account Type
Checking
Savings





3. Signature – I hereby authorize PBGC to deposit my pension benefit funds into my account. I understand that I
may change this election in the future.

SIGNATURE

DATE