Pbgc Form 702 - General Information Form - 2008 Page 2
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1
2
3General Information Form
Form 702, page 2 of 3
Plan Number:
Participant Name / SSN:
Your relationship to person who participated in the plan:
MARK ONLY ONE
A. Self – The benefits are from my pension plan
B. Beneficiary - The benefits are from the pension plan of someone who is deceased.
My relationship to the participant:
Spouse
Other:
(
)
PROOF REQUIRED
Name of Participant:
/
/
Date of participant’s death:
(
)
PROOF REQUIRED
C. Alternate payee - I have a Qualified Domestic Relations Order (QDRO) that establishes
my right to receive some or all of a participant's benefits from a pension plan.
Name of Participant:
/
/
Date of QDRO:
D. Other. Please explain:
2. Participant Information – Complete this section only if you checked “Self” in section 1.
Are you currently employed?
If yes, please provide information below:
No
Yes
Employer Name:
City and State
Were you married when the plan terminated?
No
Yes
Spouse’s Last Name
Spouse’s First Name
Spouse’s Middle Name
Other Name(s) Used
Spouse’s Social Security Number
Spouse’s Date of Birth
Date of Marriage
(proof required)
(proof required)
-
-
/
/
/
/
No
Is there a Qualified Domestic Relations Order (QDRO) requiring payment of some or all of your
benefit to someone else?
Yes
/
/
Date of the QDRO:
Name of alternate payee:
CONTINUE
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