Form 710 Application for Electronic Direct Deposit

PBGC Form 710

Application for Electronic Direct Deposit

Pension Benefit Guaranty Corporation
For Assistance Call 1-800-400-7242
If you are deaf, hard of hearing, or have a speech disability, please dial 7-1-1 to access telecommunications relay services.

Participant Name: FX.PrismCust.FullName.XF
Plan Name: FX.PrismCase.CaseTitle.XF
Plan Number: FX.PrismCase.CaseIdNmbr.XF
Date Printed:
Date of Plan Termination: FX.PrismCase.DOPT.XF

INSTRUCTIONS: Please complete this form to have PBGC send your pension benefit payments directly to your bank or other
financial institution through electronic direct deposit (EDD). Your name must be on the account. If you have questions, call
our Customer Contact Center at 1-800-400-7242. Please print clearly with black or blue ink.

Section 1: General Information About You
1. Plan Name
2. Last Name

3. First Name

4. Middle Name

5. Other Last Name(s) Used

6. Social Security Number

7. PBGC Plan Number

-

-

8. Mailing Address

Apartment / Route Number

City

State

Zip Code

Country
9. Email Address
10. Primary Phone
(

)

11. Phone Type

12. Secondary Phone
(

)

Home
Mobile

-

13. Phone Type
Home
Mobile

-

1

Approved OMB 1212-0055
Expires __ /__ /2027

PBGC Form 710

Application for Electronic Direct Deposit

Section 2: Bank or Financial Institution and Account Information
Complete this section to send your payment directly to your account at a bank or other financial institution. The information is
available from your financial institution or can be found on your checks and account statements. The sample check below
shows the location of your nine-digit routing number and your account number. If you are unsure of the routing number or your
account number, contact your financial institution.
You can change this arrangement by filing a new Form
710 Application for Electronic Direct Deposit. You can
cancel this arrangement by notifying PBGC in
writing. The financial institution can cancel it by sending
you a written notice.
Or Attach a VOIDED check to this application.

Do not complete below if VOIDED check is attached to this application.
Name(s) on the Account. (Your Name
must be on the Account)
Routing Number:

Account Number – Numbers only:

Account Type
Checking

Savings





Section 3: 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.
_________________________________________

_______________________

SIGNATURE

DATE

2

Approved OMB 1212-0055
Expires __ /__ /2027