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 |
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 |
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 |
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 |