Pbgc Form 710 - Application For Electronic Direct Deposit
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1
2Application for
PBGC Form 710
Approved OMB 1212-0055
Electronic Direct Deposit
Expires 04/30/06
Pension Benefit Guaranty Corporation.
For assistance, call 1-800-400-7242
P.O. Box 151750 Alexandria Virginia 22315-1750
Plan Name:
Plan Number:
Participant Name / SSN:
Date Printed:
Date of Plan Termination:
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. Use dark ink and be sure to print clearly. If you have questions, call our Customer Contact Center at
1-800-400-7242 for information.
1. General information about you
Plan Name (as shown on check)
Last Name
First Name
Middle Name
Other Name(s) Used
Social Security Number
PBGC Plan Number
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-
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Mailing Address
Apartment / Route Number
City
State
Zip Code
Country
Email (optional)
Daytime Phone
Evening Phone
E
XTENSION
(
)
-
x
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)
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2. Signature
I hereby authorize PBGC to deposit my pension benefit funds into my account. I understand that
–
I may change this election in the future.
SIGNATURE
DATE
CONTINUE
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