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                          PRIVACY ACT NOTICE 
                                             
The Privacy Act of 1974, as amended, 5 U.S.C. § 552a requires PBGC to give you this notice when 
collecting information from you.  PBGC uses the information we collect to determine whether you are 
entitled to a benefit payment from a retirement plan that has terminated, and if so, to calculate the 
amount  due  to  you,  and  to  make  appropriate  benefit  payments.    The  information  collected  here, 
including  your  name,  Social  Security  Number,  date  of  birth,  and/or  other  necessary  personally 
identifiable information (PII), is used by PBGC to identify your records within PBGC, to report income 
for tax purposes, and to respond to lawful requests for information about you from other individuals and 
entities. Your response is voluntary.  However, failure to provide information to PBGC, including your 
name, Social Security Number, date of birth, and/or other necessary PII, may delay or prevent PBGC 
from calculating and paying your benefits.  
 
PBGC  may  release  information  about  you  to  other  individuals  and  entities  when  necessary  and 
appropriate under 5 U.S.C. § 552a(b) of the Privacy Act, including: to third parties to make benefit 
payments to you; to a company that was responsible for your plan or to entities related to that company; 
to  a  labor  organization  that  represents  you;  to  obtain  information  from  the  Federal  Aviation 
Administration relevant to a pilot or former pilot's eligibility for a disability benefit; to obtain your address 
from other sources when PBGC does not have a current or valid address for you; to comply with Federal 
laws requiring disclosure of the information contained in our records; to facilitate statistical research, 
audit or investigative matters; to appropriate agencies for the collection of debt; and, to a limited extent 
to your spouse, former spouse, child, or other dependent when such individual may be entitled to 
benefits from PBGC.    
 
PBGC  may  also  release  information  about  you  to  appropriate  federal,  state,  local  or  tribal  law 
enforcement agencies when PBGC becomes aware of a possible violation of civil or criminal law.  If 
PBGC, an employee of PBGC, the United States, or another agency of the United States, is involved 
in litigation, PBGC may provide relevant information about you to a court or other adjudicative body or 
to the Department of Justice when it represents PBGC.  PBGC may also provide information about you 
to the Office of Management and Budget in connection with review of private relief legislation or to a 
Congressional  office  in  response  to  an  inquiry  that  office  makes  about  you  at  your  request.  This 
information may also be disclosed for any of the PBGC general routine uses as published in the Federal 
Register.    
 
PBGC publishes notices in the Federal Register that describe in more detail when information about 
you may be made available to others.  A copy of the most recent Federal Register notice may be 
obtained online at PBGC.gov/privacy or by calling PBGC's Customer Contact Center, 1-800-400-7242.  
If  you  are  deaf,  hard  of  hearing,  or  have  a  speech  disability,  please  dial  7-1-1  to  access 
telecommunications relay services.  PBGC's authority to collect information from you, including your 
Social Security Number, is derived from 29 U.S.C. §§ 1055, 1056(d)(3), 1302, 1321, 1322, 1322a, 1341 
and 1350. 
 
                                             OBA Ver: 08/09/2022 



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                    PAPERWORK REDUCTION ACT NOTICE 
                                                
The Paperwork Reduction Act of 1995, 44 U.S.C. § 3501, et seq., requires PBGC to give you this notice 
when collecting information from you.  PBGC uses the information we collect, including name, Social 
Security Number, date of birth, and/or other specific personally identifiable information (PII) necessary, 
to determine whether you are entitled to a benefit payment from a retirement plan that has terminated, 
and if so, to calculate the amount due to you, and to make appropriate benefit payments. Your response 
is voluntary.  However, failure to provide information to PBGC, including your name, Social Security 
Number, date of birth, and/or other necessary PII, may delay or prevent PBGC from determining if you 
are entitled to a benefit payment, calculating the amount due, and paying the benefit due to you, if so 
entitled. Certain information provided to PBGC may be disclosable under the Freedom of Information 
Act, as amended, 5 U.S.C. § 552, and the Privacy Act of 1974, as amended, 5 U.S.C. § 552a. 
 
PBGC estimates that the average burden of complying with the information collection request is  21 
minutes  (which  includes  60  minutes  for  benefit  application  forms;  30  minutes  forms  701,  700RN, 
700RSC, 704, and 715; and 6 minutes for the remaining forms), and an average of $3.50 where notary 
services are required to complete a form or application.  These are estimates; the actual time and cost 
will vary depending on the circumstances and type of form or application being made.  If you have any 
comments  concerning  the  accuracy  of  this  estimate  or  suggestions  for  improving  this  information 
collection, please send your comments to Pension Benefit Guaranty Corporation, Office of the General 
Counsel, Regulatory Affairs Division, 445 12 thStreet, SW Washington, DC 20024-2101.  This collection 
of  information  has  been approved  by  the  Office  of  Management  and  Budget (OMB)  under  control 
number 1212-0055 (expires 08/31/2024).  Under the Paperwork Reduction Act, an agency may not 
conduct or sponsor, and a person is not required to respond to, a collection of information unless it 
displays a currently valid OMB control number. 

                                                                         OBA Ver: 08/09/2022 



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               Designation of Beneficiary for                                                           PBGC Form 707 
                                                                                                                                    
               Benefits Owed at Death                                                                                                 
              
               (Currently Receiving Pension Benefits)    
  Pension Benefit Guaranty Corporation.   
  P.O. Box 151750, Alexandria, Virginia 22315-1750                                For assistance, call 1-800-400-7242 
  
     Plan Name: FX.PrismCase.CaseTitle.XF 
     Plan Number: FX.PrismCase.CaseIdNmbr.XF           Participant Name: FX.PrismCust.FullName.XF 
     Date Printed: 08/13/2021                           
     Date of Plan Termination: FX.PrismCase.DOPT.XF 
  
 INSTRUCTIONS:  Use  this  form  to  name  or  change  your  beneficiary(ies)  for  payments  owed  at  death.  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) If you are receiving a certain-and-continuous annuity, you may not use this form to change your beneficiary for the certain 
 period.  You may use PBGC Form 711. 
 2) If you are receiving  payments in a joint-and-survivor annuity, you may  not change your survivor annuity  beneficiary for 
 continuing payments  
  
 1.  General information about you 
     Last Name                                                                    First Name 
     Middle Name                                     Other Last 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. 

                                                                                    DATE 
     SIGNATURE
      
                                                      CONTINUE ON BACK                                               
                                                                               
                                                                                                       Approved OMB 1212-0055 
                                                                                                             Expires 08/31/2024 
                                                                                                                                       



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 Designation of Beneficiary for Benefits Owed at Death                                        Form 707, page 2 of 2 
    (Currently Receiving Pension Benefits)         
    Plan Number: FX.PrismCase.CaseIdNmbr.XF       Participant Name: FX.PrismCust.FullName.XF 
 
3. Designation of Beneficiary for Payments Owed at Death PBGC may owe you money at the time of your death.  
Typically, this happens if your final benefit is higher than the estimated benefit we had been paying.  If another person continues to 
receive your benefit after your death (as with a joint-and-survivor or certain-and-continuous annuity), PBGC will pay any money 
owed to that person.  If there are no continuing benefits or the person designated to receive continuing benefits dies before you, PBGC 
will pay any money owed you at the time of your death to the person(s) and/or entity(ies) (such as a trust, church, estate or other 
organization) that you designate in this section.  If you do not make a designation, or if all the beneficiaries you designate below die 
before you, PBGC will pay the money in this order to: your spouse, your children, your parents, your estate, or your next of kin. 
 
I name the following as my beneficiary(ies).  This designation replaces any previous designation and will only be effective when PBGC 
receives it. 
   
                      Beneficiary(ies)*            Social Security Number**  Date of Birth**           Relationship Percentage*** 
                                                                                                                     
  Name  _______________________________________ 

  Address ______________________________________ 
  _____________________________________________ 

  Daytime Tel. No:_______________________________ 

  Name  _______________________________________ 

  Address ______________________________________ 
  _____________________________________________ 

  Daytime Tel. No:_______________________________ 

  Name  _______________________________________ 

  Address ______________________________________ 
  _____________________________________________ 

  Daytime Tel. No:_______________________________ 

*To name more beneficiaries, please list them with requested contact info, DOB and SSN on an attached sheet with your 
signature.   
**Complete if person. 
*** Percentage(s) does not have to be provided.   
The amount owed will be distributed equally among beneficiaries unless percentages are provided for each beneficiary and they total 100%.  
If a beneficiary dies before you, the amount owed will be distributed equally among the remaining beneficiaries.  
 






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