Form 722 Financial Statement of Debtor

Financial Statement of Debtor

PBGC Form 722

Pension Benefit Guaranty Corporation.
P.O. Box 151750, Alexandria, VA 22315-1750
Plan Name: FX.PrismCase.CaseTitle.XF
Plan Number: FX.PrismCase.CaseIdNmbr.XF
Date Printed: 07/07/2021
DOPT: FX.PrismCase.DOPT.XF

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

INSTRUCTIONS: Please complete this form to request that PBGC reduce or waive repayment of amounts you were
overpaid. If you need additional space for any answer, use item 7B. You must submit a copy of your most recent
Federal tax return, including schedules, with this form. You may also provide any other information that you wish
PBGC to consider. 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

-

-

/

Gender
/

Mailing Address

Apartment / Route Number

City

State

Country

Email (optional)

Daytime Phone
(

)

EXTENSION
-

Are you currently married?
Yes 
No 
Age(s) of Dependent(s), if any

x



FEMALE



Zip Code

Evening Phone
(

Spouse’s Last Name

CONTINUE ON BACK

MALE

)

-

Spouse’s First Name


Approved OMB 1212-0055
Expires _________

Financial Statement of Debtor
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Form 722, page 2 of 4
Participant Name: FX.PrismCust.FullName.XF

2. Average Monthly Income
Self

Spouse

A. Monthly Wage / Salary

$

$

B. Social Security Income

$

$

C. Pension Income

$

$

D. Interest, Dividend, Rental or Other Income

$

$

E. Total Monthly Income

$

$

3. Average Monthly Expenses
A. Rent or Mortgage Payment

$

B. Food

$

C. Utilities and Heat

$

D. Medical

$

E. Other, Including Insurance

$

F. Monthly Payments on Installment Contracts and other Debts (e.g., car
payments, home improvement loans, appliances)
G. Total Monthly Expenses

$
$

4. Discretionary Income
A. Net Monthly Income Less Expenses (Item 2E less Item 3G)

$

B. Amount you can pay on a monthly basis toward your debt

$

CONTINUE



Financial Statement of Debtor

Form 722, page 3 of 4

Plan Number: FX.PrismCase.CaseIdNmbr.XF

Participant Name: FX.PrismCust.FullName.XF

5. Assets
A. Cash in Bank (Checking and savings accounts, other investment accounts, etc.)

$

B. Cash on Hand
C. U.S. Savings Bonds (Current Value)
D. Stocks and other Bonds (Current Value)

$
$
$

E. Real Estate Owned (Resale Value)

$

F. Automobiles
Make

Year

Model

Resale Value
$
$

G. Other Assets (Specify below)
$
$
$
$

H. Total Assets

6. Installment Contracts and Other Debts -- Show below all debts which you are required to pay, such as
payments on a car, television, major appliances, payments to dealers, banks, finance companies; repayment of
money borrowed for any purpose, doctor bills, hospital bills, etc. Do not include living expenses.
Name and Address
of Creditor

Date and Purpose of Debt

Original Amount
of Debt

Unpaid
Balance

Amount Due
Monthly

Amount Past Due
(if any)

$

$

$

$

A.

B.

C.

D.

E. Total:

*Note: If repayment of a debt is not on a monthly basis, enter “0” and describe repayment arrangements in Section 7E.

CONTINUE ON BACK



Financial Statement of Debtor
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Form 722, page 4 of 4
Participant Name: FX.PrismCust.FullName.XF

7. Additional Data
A. Have you ever filed for bankruptcy protection?

Yes



No



(If yes, complete items 1 through 4)

1. Date of Bankruptcy Filing
2. Date Discharged from Bankruptcy
3. Location of Court
4. Docket No., if known
B. Use this space and additional sheets, if necessary, to supply any pertinent information and to continue
your answer to previous items above to which your comments apply.

8. Signature – You must 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