Form 709 Plan Participant Information

	Plan Participation Information		PBGC Form 709
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: 01/20/2021
	Date of Plan Termination: FX.PrismCase.DOPT.XF

INSTRUCTIONS: Please complete this form for PBGC to determine your eligibility for a pension. 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

Last Name

First Name

Middle Name

Other Last Name(s) Used

Social Security Number

Date of Birth

Gender

male



-

-

/

/

female



Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email (optional)

Daytime Phone

Extension

Evening Phone

(

)

-

x

(

)

-

Name of plan participant, if different	Social Security Number
				-			-

2. Participant employment information - Relating to the sponsor of the plan.

Employer Name

City and State

Job Title

Plant or Facility

Date of Hire

Date Employment Terminated

Reason for Termination

/

/

/

/

CONTINUE ON BACK

Approved OMB 1212-0055

Expires xx/xx/xx

Plan Participation Information		Form 709, page 2 of 2
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF

Was the plan participant covered by a collective bargaining agreement (union contract) with the employer identified above? If yes, during what period:

No



Yes



From

/

To

/

month

year

month

year

Name of Local Union:

Address

Was the plan participant an hourly paid or a salaried employee?	Hourly			Salary		
Was the plan participant transferred between hourly and salary?	Yes			No		
If yes, specify type and date of each transfer:
Any breaks in service?	Yes			No	
If yes, specify the period(s) (from when to when):
Please attach any documentation to verify the participant’s employment and/or plan participation.

3. 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.
signature		date

SIGN & DATE BEFORE SUBMITTING. THANK YOU