Form 724 Appeal of a PBGC Benefit Determination

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PBGC

Appeal of a PBGC Benefit Determination

PBGC Form 724

Approved 0MB 1212-0061
Expires 7/31/2025

Protecting Amarlc■'• Pensions

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

For assistance, call 1-800-400-7242 ext. 4090

As a recipient of a PBGC benefit determination, you have the right to appeal PBGC's determination of your benefit if you can
provide a specific reason why the determination is wrong. If you simply have a question about your benefit or how it was
calculated, you should call PBGC's Customer Contact Center at 1-800-400-7242. You have 45 calendar days from the date
on PBGC's determination letter to submit an appeal. If you need more time to prepare your appeal, you must request an
extension from the Appeals Division before the 45-calendar-day limit expires. You may file an appeal by using this form or by
sending a letter, e-mail or fax that includes the information requested on this form. If you use this form, please use dark ink
and be sure to print clearly. Mail this form, and copies of appropriate documents, to the address shown on page 2. If you have
questions about the appeals process, please refer to PBGC's brochure Your Right to Appeal, or call the Appeals Division at
1-800-400-7242 ext. 4090.

1. Appellant Information (Specify one)
Participant

□

Beneficiary of a Deceased Participant
First Name

Last Name
Middle Name

Other Name(s) Used

Customer ID # (leave blank if you don't have one)

Date of Birth (mm/dd/yyyy)

Gender
MALE

Mailing Address

Apartment I Route Number

City

State

E-mail (optional)

Country

Daytime Phone

Alternate Payee

EXTENSION

FEMALE

Zip Code

Evening Phone

2. Plan Information
Plan Name
PBGC Case Number
Date of PBGC Benefit Determination Letter you are appealing

(You must submit this form no later than 45 calendar days from the date on the
Benefit Determination Letter)

(mm/dd/yyyy)

3. Explain the specific reason(s) why you believe PBGC's benefit determination is incorrect.
(Use additional pages, if necessary.)

Appeal of a PBGC Benefit Determination

I

Form 724, page 2 of 2

4. Do you have documents to support your appeal (for example, plan pension calculation sheets
or letters from the plan or company officials)?
YES D (Please submit only a copy of the document(s)---do not send originals.)

I

NOD

5. Authorized Representative Information (if any) If you are representing the Appellant identified in Item 1, select
the correct box below and complete the remaining information.

□
□

An attorney representing the Appellant
A spouse, family member, or other person assisting the Appellant with this appeal

If you have not already sent PBGC an original notarized power of attorney signed by the Appellant giving you the
authoritv to act on the Appellant's behalf, vou must submit one with this form.
Last Name

Middle Name

Mailing Address

Other Name(s) Used

City

Apartment I Route Number

State
Country

E-mail (optional)
Daytime Phone

First Name

EXTENSION

Zip Code

Evening Phone

6. Signature of Appellant or Authorized Representative - You must sign and date this request. 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 to the best of my knowledge.

SIGNATURE

DATE

HOW TO FILE: You may submit this completed form one of the following ways:
1) You may mail this completed form, any additional pages, copies of supporting documents (if any), and a
power of attorney (if required - see item 5) to:
Pension Benefit Guaranty Corporation
Attention: Appeals Division
Post Office Box 151750
Alexandria, VA 22315-1750
2) You may fax your request to the Appeals Division at (202) 326-4095 or (202) 326-4091.
3) You may attach this form to an e-mail sent to [email protected].
4) You may send an e-mail to [email protected] provided you answer all of the questions on this form in
your e-mail.
The Appeals Division will acknowledge your correspondence. If you have any questions, call the Appeals
Division at 1-800-400-7242 ext. 4090.

PBGC Privacy Act Notice
The Privacy Act of 1974, as amended, 5 U.S.C. § 552a (1994), requires PBGC to
give you this notice when collecting information from you. PBGC uses the information to
resolve administrative appeals of matters specified in 29 C.F.R. § 4003(b)(5) - (10).
Your Social Security Number is used by PBGC to identify your records within PBGC, to
report income for tax purposes, and to respond to lawful requests for information about
you from other individuals and entities. Your response is voluntary. However, failure to
provide information to PBGC, including your Social Security Number, may delay or
prevent PBGC from calculating and paying your pension benefits.
The PBGC may release information about you to other individuals and entities
when necessary and appropriate under the Privacy Act, including: to a third party who
may be aggrieved by a decision of the Appeals Board such as an alternate payee under
a qualified domestic relations order; to a third party to make benefit payments to you; or
to a labor organization that represents you.
PBGC may also release information about you to appropriate law enforcement
agencies when PBGC becomes aware of a possible violation of civil or criminal law. If
PBGC, an employee of PBGC, the United States, or another agency of the United
States is involved in litigation, PBGC may provide relevant information about you to a
court or other adjudicative body or to the Department of Justice when it represents
PBGC. PBGC may also provide information about you to the Office of Management and
Budget in connection with review of private relief legislation or to a Congressional office
in response to an inquiry that office makes about you at your request.
PBGC publishes notices in the Federal Register that describe in more detail when
information about you may be made available to others. A copy of the most recent
Federal Register notice may be obtained from PBGC's Customer Contact Center by
calling toll-free 1-800-400-7242. For TTY/TDD users, call the federal relay service toll­
free at 1-800-877-8339 and ask to be connected to 1-800-400-7242. PBGC's authority
to collect information from you, including your Social Security Number, is derived from
29 U.S.C. §§ 1055, 1056(d)(3), 1302, 1321, 1322, 1322a, 1341 and 1350 (1994). If you
have any other privacy-related questions or concerns, you may contact PBGC's
Disclosure Officer at 1-800-400-7242 extension 4040.

Paperwork Reduction Act Notice
The PBGC needs this information, which is required to be filed under 29 CFR Part 4003, so
that it can handle appeals of PBGC initial determinations in certain circumstances. PBGC
estimates that it will take an average of 0.78 hours and $100 to comply with these requirements.
If you have any comments concerning the accuracy of this estimate or suggestions for improving
this form, please send your comments to the Pension Benefit Guaranty Corporation, Legislative
and Regulatory Department, 1200 K Street, N.W., Washington, D.C. 20005-4026. This
collection of information has been approved by the Office of Management and Budget (0MB)
under control number 1212-0061 (expires 7/31/2025). Under the Paperwork Reduction Act, an
agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid 0MB control number.