Pbgc Form 702 - General Information Form - 2008 printable pdf download

Pbgc Form 702 - General Information Form - 2008

General Information Form

PBGC Form 702

Approved OMB 1212-0055

Expires 08/31/08

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 so PBGC can determine your right to a pension benefit. Use dark ink

and be sure to print clearly. Note those items marked "Proof Required." You must enclose a copy of the

appropriate document if you have not already sent it to us. Acceptable documents for proof of age include your

birth or baptism certificate, or U.S. Passport; for marriage, a marriage certificate; for proof of death is a death

certificate. This is not a benefit application. To begin receiving benefits, or for other information, call our

Customer Contact Center at 1-800-400-7242.

1. General information about you

Last Name

First Name

Middle Name

Other Name(s) Used

Social Security Number

Date of Birth (proof required)

Gender

MALE

FEMALE

Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email (optional)

Daytime Phone

Evening Phone

XTENSION

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CONTINUE

Pbgc Form 702 - General Information Form - 2008