714RBD Withdrawal of Employee Contributions – Non-Spouse Benefi

Withdrawal of Employee Contributions – Non-Spouse Beneficiary

PBGC Form
714RBD

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 read the cover letter and complete and return this form to have PBGC pay the pension plan
contributions of FX.PrismPart.FullName.XF, deceased, to you. 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. Last Name

2. First Name

3. Middle Name

4. Other Last Name(s) Used

5. Social Security Number

6. Date of Birth: MM/DD/YYY

-

/

-

/

7. Mailing Address

Apartment / Route Number

City

State

Zip Code

Country
8. Email Address
9. Primary Phone
(

)

10. Phone Type

11. Secondary Phone
(

)

Home
Mobile

-

12. Phone Type
Home
Mobile

-

Section 2: Method of Receiving Benefit Payments
PBGC pays benefits through safe, secure, and convenient electronic funds transfer. You will get your payment on
time even if you are out-of-town or unable to get to the bank.
If you have a bank account, you can ask us to deposit your benefit payment to your account through Electronic Direct Deposit
(EDD).
Note: PBGC does not transfer funds to financial institutions outside the United States and its territories. If you live outside the
United States or its territories and do not have a U.S bank account, PBGC will send your payment to your mailing address

1

Approved OMB 1212-0055
Expires __ /__ /2027

PBGC Form
714RBD

Withdrawal of Employee Contributions – Non-Spouse Beneficiary

How would you like to receive your payment?
My Choice
MARK ONLY ONE
A. By EDD to the account identified below, which must be titled in my name although it is
fine for there to be a joint account or other co-owners on the account.



B.



By mail to my home address, which is printed in Section 1 of this form.

Section 3: Electronic Direct Deposit (EDD) Payment Information Only.
Complete this section to send your payment directly to your account at a bank or a 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 4: 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 OF SPOUSE

DATE

2

Approved OMB 1212-0055
Expires __ /__ /2027