Application for Electronic Direct Deposit                                          PBGC Form 710 

Pension Benefit Guaranty Corporation 
                                                                                For Assistance Call 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. 

Participant Name: FX.PrismCust.FullName.XF 
Plan Name: FX.PrismCase.CaseTitle.XF 
Plan Number: FX.PrismCase.CaseIdNmbr.XF 
Date Printed:  
Date of Plan Termination: FX.PrismCase.DOPT.XF 

INSTRUCTIONS: Please complete this form to have PBGC send your pension benefit payments directly to your bank or other 
financial institution through electronic direct deposit (EDD).  Your name must be on the account.  If you have questions, call 
our Customer Contact Center at 1-800-400-7242. Please print clearly with black or blue ink. 

                                       Section 1: General Information About You 

1. Plan Name
2. Last Name                                                     3. First Name
4. Middle Name                                                   5. Other Last Name(s) Used

6. Social Security Number                                        7. PBGC Plan Number

               -    - 

8. Mailing Address                                               Apartment / Route Number 
City                                                             State                     Zip Code 

Country 

9. Email Address

10. Primary Phone                                                11. Phone Type
                                                                 Home
(                )                   -                           Mobile
12. Secondary Phone                                              13. Phone Type
                                                                 Home
(                )                   -                           Mobile

                                                                                            Approved OMB 1212-0055
                                                                                                    Expires 06/30/2027
                                                                 1     

              Application for Electronic Direct Deposit                                          PBGC Form 710 

                        Section 2: Bank or Financial Institution and Account Information 

Complete this section to send your payment directly to your account at a bank or other financial institution.  The information is 
available from your financial institution or can be found on your checks and account statements.  The sample check below 
shows the location of your nine-digit routing number and your account number.  If you are unsure of the routing number or your 
account number, contact your financial institution.   

You can change this arrangement by filing a new Form 
710 Application for Electronic Direct Deposit.  You can 
cancel this arrangement by notifying PBGC in 
writing.  The financial institution can cancel it by sending 
you a written notice. 

Or Attach a VOIDED check to this application. 

                        Do not complete below if VOIDED check is attached to this application. 

 Name(s) on the Account.   (Your Name 
 must be on the Account) 
 Routing Number:                        Account Number – Numbers only:                         Account Type 
                                                                                         Checking             Savings 
                                                                                                             

                                                     Section 3: Signature 

Sign and date this application.  
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 the information I have provided on this form is true and correct. 

_________________________________________                        _______________________ 
SIGNATURE                                                           DATE

                                                                                         Approved OMB 1212-0055
                                                                                               Expires 06/30/2027
                                                              2