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Pbgc Form 707 - Designation Of Beneficiary For Benefits Owed At Death - Virginia - 2013

Designation of Beneficiary for

PBGC Form 707

Approved OMB 1212-0055

Expires 12/31/13

Benefits Owed at Death

(Currently Receiving Pension Benefits)

Pension Benefit Guaranty Corporation.

For assistance, call 1-800-400-7242

P.O. Box 151750, Alexandria, Virginia 22315-1750

Use this form to n ame your beneficiary. If you have an y question s, please call o ur Custo mer Contact

INSTRUCTIONS

Center at 1-800-400-7242. Please print clearly with dark ink.

1. General information about you

Last Name

First Name

Middle Name

Other Name(s) Used

Social Security Number

Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email (optional)

Daytime Phone

Evening Phone

XTENSION

(

)

(

)

– Sign and date this document. Knowingly and willfully making false, fictitious or fraudulent statements

2. Signature

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 of the information I have provided on this form is true and

correct.

SIGNATURE

DATE



CONTINUE

Pbgc Form 707 - Designation Of Beneficiary For Benefits Owed At Death - Virginia - 2013