Pension Verification Request Form printable pdf download

Pension Verification Request Form

(Please Print Clearly)

Section 1. To Be Completed by the FMC Retiree

(Retiree to Complete Section 1 & 2 Only)

Retiree Name: __________________________

_____________________

____________________________

First

Middle

Last

Address:

_______________________________________

______________________________________

Street Address

Address Line 2 - Apt. No/Lot No. (If Applicable)

______________________________

__________________

_________________________

City

State

Zip Code

Telephone: (_______) ________ - __________ Last 4 Digits of Social Security No. : XXX - XX - ____________

PERMISSION FOR RELEASE OF INFORMATION

I hereby authorize FMC to release my pension verification information to the agency or third party listed below.

This authorization shall be valid until revoked by me in writing and provided directly to FMC Corporation HRSC.

________________________________________________________

__________________________________

FMC Retiree Signature

Date (mm/dd/yy)

Section 2. Information Authorized To Be Released To:

Agency or Third Party Name : ________________________________________

Address:

________________________________________

______________________________________

Street Address

Address Line 2 - Apt. No/Suite No. (If Applicable)

______________________________

____________________

________________________

City

State

Zip Code

Attention:

______________________________________

Telephone: (_______) ________ - __________

RETURN FORM VIA:

(Please Check Only One)

Mail to address above

Fax To: (______) _______ - _________

Section 3. To Be Completed by FMC Corporation HR Service Center (HRSC)

Type of Pension:

Individual Life Annuity

Survivor/Beneficiary Annuity

Other ________________

_______________

Gross Monthly Payment $ ______________

Benefit Start Date:

(mm/dd/yy)

I verify that this information is accurate and true based on our current FMC pension payroll processing.

________________________________________

__________________________

Signature

Date Completed (mm/dd/yy)

FMC

Corporation

Human Resource Service Center

801 PrincetonSouth Corporate Center

Ewing, NJ 08628

Phone: 1-888-FMC-444U, Option 1 (or 1-888-362-4448, Option 1)

Fax: 1-866-917-3252

Pension Verification Request Form

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