Pbgc Form 707 - Designation Of Beneficiary Forbenefits Owed At Death
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1
2Designation of Beneficiary for
PBGC Form 707
Approved OMB 1212-0055
Benefits Owed at Death
Expires 12/31/15
(Currently Receiving Pension Benefits)
Pension Benefit Guaranty Corporation.
For assistance, call 1-800-400-7242
P.O. Box 151750, Alexandria, Virginia 22315-1750
Plan Name: FX.PrismCase.CaseTitle.XF
Plan Number: FX.PrismCase.CaseIdNmbr.XF
Participant Name: FX.PrismCust.FullName.XF
Date Printed: 03/25/2013
Date of Plan Termination: FX.PrismCase.DOPT.XF
INSTRUCTIONS
:
Use this form to name your beneficiary. If you have any questions, please call our Customer Contact
Center at 1-800-400-7242. Please print clearly with blue or black 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
Daytime Phone
Extension
Evening Phone
(
)
-
x
(
)
-
2. Signature
– 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, 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
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