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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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            Application for                                                                          PBGC Form 710 
                                                                                                               
            Electronic Direct Deposit 
  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:                                      
    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.  Print clearly with blue 
   or black ink. 
   
1.  General information about you 
    Plan Name (as shown on check) 

    Last Name                                                                    First Name 

    Middle Name                                     Other Last Name(s) Used 

    Social Security Number                          PBGC Plan Number 
                                                                                                      
                   -      -                                                        

     Mailing Address                                                 Apartment / Route Number 

    City                                                             State         Zip Code 

    Country                                                          Email 

     Daytime Phone                                         EXTENSION        Evening Phone 

    (                )        -                        x                    (              )         -      
 
                                                     CONTINUE ON BACK
                                                                              
                                                                                                     Approved OMB 1212-0055 
                                                                                                      Expires 08/31/2024 




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 Application for Electronic Direct Deposit                                               Form 710, page 2 of 2 
   Plan Number: FX.PrismCase.CaseIdNmbr.XF    Participant Name: FX.PrismCust.FullName.XF 
                                               
 2.  Financial institution information      Please provide the information in this section to have your payment 
   sent directly to a financial institution.  The information is available from your financial institution or can be found 
   on your checks, account statement or deposit slip.  The sample check below shows the location of your nine-
   digit  routing  number  and  account  number.   If  you  are  unsure  of  the  routing  number  or  your  account 
   number, contact your financial institution.     You can cancel or change this arrangement by calling PBGC at 
   1-800-400-7242.  The financial institution can cancel it by sending you a written notice.   
  
   All fields required 
  Name(s) on the Account (Your name must be on the account) 

  Routing Number                            Account Number – Numbers only                      Account Type 
                                                                                         Checking Savings 
                                                                                                          
                                                                                                             
3.  Signature – I hereby authorize PBGC to deposit my pension benefit funds into my account.  I understand that I 
   may change this election in the future. 
     
                                                                           DATE 
   SIGNATURE
                                                    






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