Form 716A Certification of Pension Plan Disability Status

Certification of Pension Plan Disability
Status
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

PBGC Form 716A

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

INSTRUCTIONS: Please complete and return this form to PBGC within the timeframe indicated in the cover letter.
PBGC needs your certification to determine whether to continue paying your current benefit amount. If you have
questions, call our Customer Contact Center at 1-800-400-7242. Please 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

-

-

/

/

Mailing Address

Apartment / Route Number

City

State

Country

Email (optional)

Daytime Phone

(

Extension

)

-

x

Zip Code

Evening Phone

(

)

-

2. Certification – Check the box below that describes your current disability status.




I certify that I am still disabled as previously determined under my pension plan.
I certify that effective ___/____/______ I am no longer disabled as previously determined under my
pension plan.

I understand that in the future I may be required to provide supporting documentation.

3. Signature – Sign and date this form. 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
Approved OMB 1212-0055
Expires __________