Form 720CD Application for Lump-Sum Payment (child or dependent)

Application for
Lump-Sum Payment

PBGC Form 720CD

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: Use this form to request a lump-sum payment if you are a child or dependant pursuant to a
Qualified Domestic Relations Order (QDRO). When "proof required" is indicated, please enclose a copy of a
birth or baptism certificate, or a U.S. Passport, whichever is appropriate, unless you already sent PBGC a copy
of this document. If you have questions about other acceptable documents, call our Customer Contact Center at
1-800-400-7242. Please 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

Province

Daytime Phone

(

Extension

)

-

x

MALE



FEMALE



Zip Code

Evening Phone

(

)

-

Name of plan participant:

2. 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

Approved OMB 1212-0055
Expires ______