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pdfChange of Beneficiary for Certain &
Continuous (C&C) Benefits Only
PBGC Form 711
(Currently Receiving Pension Benefits)
Pension Benefit Guaranty Corporation
For Assistance Call 1-800-400-7242
TTY/ASCII (American Standard Code for Information Interchange) users, call the federal relay service toll-free at 1-800-877-8339 and ask to be connected to
1-800-400-7242.
Participant Name:
Plan Number:
Date Printed:
Date of Plan Termination:
INSTRUCTIONS:
Print clearly with blue or black ink. You must complete all sections of this form. Use this form to change your beneficiary
if you are receiving a Certain & Continuous annuity. If you die before the certain period ends, any remaining payments will go to
the person(s) or entity(ies) (such as a trust, church, estate or other organization) that you designate in section 2. The beneficiary
designation(s) you provide on this form will replace all previous designations you submitted. If you were married when you began
receiving your benefits, the spouse you were married to at that time must consent to your change of beneficiary.
Section 1: General Information about you
1. Last Name
2. First Name
3. Middle Name
4. Other Last Name(s) used
5. Social Security Number
6. Date of Birth
1
2
3
-
5
5
-
6
7
8
9
M M
/
D
7. Gender
MM/DD/YYYY
D
/
Y
8. Mailing Address
Apartment / Route Number
City
State
Y
Y
Y
MALE
FEMALE
Zip Code
Country
9. Primary Phone
(
5
5
5
)
10. Phone Type
3
4
5
-
6
7
8
9
11. Secondary Phone
(
5
5
5
)
3
Home
Mobile
12. Phone Type
4
5
-
6
7
8
9
Home
Mobile
Approved OMB 1212-0055
Expires ___________
2
13. Marital Status
Were you married when you started receiving benefits
(Annuity Starting Date)?
YES NO
Is your spouse living?
YES NO
Enter spouse information as of your annuity starting date.
Spouse Last Name
Spouse First Name
Spouse Middle Name
Other Last Name(s) used
Spouse Social Security Number
Spouse Date of Birth
1
2
3
-
5
5
-
6
7
8
9
M M
/
D
D
MM/DD/YYYY
/
Y
Y
Y
Y
Section 2: Designation of Beneficiary for Certain and Continuous Annuity
Designate your beneficiary below. This designation replaces any previous designation and is effective only when PBGC
receives it. The beneficiary identified below will receive benefits that continue after your death and any additional money owed
to you at your death. You may name more than one beneficiary. State the percentage you want each one to receive, and make
sure the percentages total 100%. If you do not state percentages that total 100%, the amount owed will be distributed equally
among all beneficiaries.
To name more than four beneficiaries, list the additional beneficiary’s names, dates of birth, relationship to you, Social Security
numbers, contact information, and percentages on a separate sheet of paper, with your name and customer ID. Sign and date
the sheet and attach it to this form.
Check here if additional sheet is attached.
If a beneficiary dies before you, the amount owed will be distributed equally among the living beneficiaries.
If all beneficiaries die before you, PBGC will pay the amount we owe in this order to: your spouse, your children, your parents,
your estate, or your next of kin.
Spouse (Identified in Block 13)
___________
%
Beneficiary (1)
___________
%
Beneficiary (2)
___________
%
Beneficiary (3)
___________
%
Beneficiary (4)
___________
%
Total of percentages may
not exceed 100% for all
beneficiary entries
Approved OMB 1212-0055
Expires ____________
3
Beneficiary (1)
Beneficiary Last Name
Beneficiary First Name
Beneficiary Middle Name
Other Last Name(s) used
Beneficiary relationship to you
Beneficiary Social Security Number
1
2
3
-
5
5
-
6
7
Beneficiary Date of Birth
8
M
9
M
/
D
D
/
Y
Beneficiary Mailing Address
Apartment / Route Number
City
State
MM/DD/YYYY
Y
Y
Y
Zip Code
Country
Beneficiary Primary Phone
(
5
5
5
)
3
4
Beneficiary Secondary Phone
5
-
6
7
8
9
(
5
5
5
)
3
4
5
-
6
7
8
9
8
9
Beneficiary (2)
Beneficiary Last Name
Beneficiary First Name
Beneficiary Middle Name
Other Last Name(s) used
Beneficiary Date of Birth
Beneficiary Social Security Number
1
2
3
-
5
5
-
6
7
8
M
9
M
/
D
D
/
Y
Beneficiary Mailing Address
Apartment / Route Number
City
State
MM/DD/YYYY
Y
Y
Y
Zip Code
Country
Beneficiary Primary Phone
(
5
5
5
)
3
4
Beneficiary Secondary Phone
5
-
6
7
8
9
(
5
5
5
)
3
4
5
-
6
7
Beneficiary (3)
Beneficiary Last Name
Beneficiary Middle Name
Beneficiary First Name
Other Last Name(s) used
Beneficiary relationship to you
Approved OMB 1212-0055
Expires ____________
4
Beneficiary Social Security Number
1
2
3
-
5
5
-
6
7
Beneficiary Date of Birth
8
M
9
M
/
D
D
/
Y
Beneficiary Mailing Address
Apartment / Route Number
City
State
MM/DD/YYYY
Y
Y
Y
Zip Code
Country
Beneficiary Primary Phone
(
5
5
5
)
3
4
Beneficiary Secondary Phone
5
-
6
7
8
9
(
5
5
5
)
3
4
5
-
6
7
8
9
8
9
Beneficiary (4)
Beneficiary Last Name
Beneficiary First Name
Beneficiary Middle Name
Other Last Name(s) used
Beneficiary relationship to you
Beneficiary Social Security Number
1
2
3
-
5
5
-
6
7
Beneficiary Date of Birth
8
M
9
M
/
D
D
/
Y
Beneficiary Mailing Address
Apartment / Route Number
City
State
MM/DD/YYYY
Y
Y
Y
Zip Code
Country
Beneficiary Primary Phone
(
5
5
5
)
3
4
Beneficiary Secondary Phone
5
-
6
7
8
9
(
5
5
5
)
3
4
5
-
6
7
Approved OMB 1212-0055
Expires ____________
5
Section 3: Spousal Consent to Beneficiary of Certain and Continuous Annuity
This section does not need to be completed by your spouse if:
• you were not married when you started receiving benefits,
• the spouse you were married to when you started receiving benefits is deceased; or
• you are designating the spouse you were married to when you started receiving benefits, as the beneficiary of 100% of
the Certain and Continuous Annuity.
Your spouse’s signature for the consent must be notarized by a notary public.
If your spouse does not consent, your current beneficiary designation will remain unchanged.
To be completed by spouse:
By signing below, I consent to my spouse’s election of the beneficiary designated in Section 2. My consent is voluntary. I have
read and I understand the information provided with this application.
I understand all the following:
•
I have a right not to consent to my spouse’s beneficiary designation.
•
If I do not consent, my spouse’s beneficiary designation for the Certain and Continuous Annuity will not change.
•
If I do consent to my spouse’s election, survivor benefits, if any, will be paid according to the beneficiary designation
elected by my spouse in Section 2. As a result, if my spouse dies before me, I may not be entitled to any survivor
benefits.
•
If I consent to this beneficiary designation, my spouse can NOT make future changes to the beneficiary without my
consent.
________________________________________
SPOUSE’S SIGNATURE (MUST BE NOTARIZED)
_______________________________________
DATE
To be completed by Notary Public:
On this _____________ day of __________ Month, _______Year, I acknowledge that this Spousal Consent to this
designation of beneficiary was signed by _________________________,who appeared personally before me, or whose
identity or signature is personally known to me, or who has proved to me on the basis of satisfactory evidence that he/she is
the authorized signer of this form.
________________________
DATE MY COMMISSION EXPIRES
__________________________________
NOTARY PUBLIC NAME
________________________
CITY / COUNTY
__________________________________
STATE
Approved OMB 1212-0055
Expires ____________
6
Section 6: 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 the information I have provided on this form is true and correct.
_______________________________________
Participant Signature
_________________________________________
Date
Approved OMB 1212-0055
Expires ____________
| File Type | application/pdf |
| Author | Duncan Stacey |
| File Modified | 2021-07-07 |
| File Created | 2021-07-07 |