Pbgc Form 702 - General Information Form - 2008 Page 3
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3General Information Form
Form 702, page 3 of 3
Plan Number:
Participant Name / SSN:
Signature
3.
– You must sign and date this document. Knowingly and willfully making false, fictitious or
fraudulent statements to the Pension Benefit Guaranty Corporation is a crime punishable under Title 18,
Section 1001, and United States Code.
I declare under penalty of perjury that all of the information I have provided on this form is true and correct.
SIGNATURE
DATE
Designation of Beneficiary
4.
– If there are payments owed to you at the time of your death, PBGC will pay
them to the person(s) you designate below. If you do not designate anyone, or if the beneficiary you name
dies before you, PBGC will pay the underpayment in this order: your spouse, your children, your parents, your
estate, and your next of kin.
Beneficiary –
I name the following person as my beneficiary for amounts owed to me at my death. This
replaces any previous designation and will only be effective when PBGC receives it.
Last Name
First Name
Middle Name
Other Name(s) Used
Social Security Number
Date of Birth
Gender
MALE
-
-
/
/
FEMALE
Mailing Address
Apartment / Route Number
City
State
Zip Code
Country
Email (optional)
Daytime Phone
Evening Phone
E
XTENSION
(
)
-
x
(
)
-
Relationship to me, if any (e.g., spouse or granddaughter, friend)
If you want to change this designation, please contact PBGC’s Customer Contact Center at 1-800-400-7242.
THANK YOU.
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