Pbgc Form 701 - Payee Information Form - 2008
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3Payee Information Form
PBGC Form 701
Approved OMB 1212-0055
Expires 08/31/08
Pension Benefit Guaranty Corporation.
For assistance, call 1-800-400-7242
P.O. Box 151750 • Alexandria, VA 22315-1750
Plan Name:
Plan Number:
Participant Name / SSN:
Date Printed:
Date of Plan Termination:
INSTRUCTIONS: Please complete this form so PBGC can continue to send your pension benefit payments. Use
dark ink and be sure to print clearly. If you have questions, contact our Customer Contact Center at
1-800-400-7242 for information.
1. General information about you
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
(
)
-
�
CONTINUE
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