Privacy Act Notice

The Privacy Act of 1974, as amended, 5 U.S.C. § 552a, requires PBGC to give you this notice in connection 

with your submission of the attached form related to a change of home address. Accordingly, pursuant 

to the requirements of the Act, please be advised that: (1) furnishing of the information solicited is 

voluntary; and (2) the principal purposes for which the information is used by the Pension Benefit 

Guaranty Corporation are to process your address change and communicate with you regarding your 

pension benefit. 

The information provided by you in this form will be subject to the following routine uses:

1. The information on this form will be treated confidentially to the extent allowed under the 

Freedom of Information Act (5 U.S.C. § 552) and the Privacy Act (5 U.S.C. § 552a). PBGC may 

release information about you to other individuals and entities when necessary and appropriate 

under the Privacy Act, including to third parties to make benefit payments to you; to a company 

that was responsible for your pension 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; or to the Department of the 

Treasury and the Department of Labor under some circumstances.

2. PBGC may also release information about you to appropriate 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.

3. 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 from https://www.pbgc.gov/sites/default/files/pbgc-6.pdf or from PBGC’s 

Customer Contact Center by calling toll-free 1-800-400-7242. For TTY/ASCII users, call the 

Telecommunications Relay Service (TRS) at 7-1-1 and ask to be connected to 1-800-400-7242. 

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, 1341, 1342, and 1350; 26 U.S.C. 6103; 44

U.S.C. 3101; 5 U.S.C. 301.

OBA COA Form

Ver: 07/2022
Ver 10/22 

Change of Home Address PBGC Form COA

Participant Name:

Plan Number:

Date Printed:

Date of Plan Termination:

Instructions: Use this form to inform PBGC of a change to home mailing address. 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.

General Information About You

1. Last Name 2. First Name

3. Middle Name 4. Other Last Name(s) Used

5. Social Security Number OR Customer ID Number

- - OR

6. Primary Phone

( ) - 

7. Phone Type

Home 

Mobile

8. Secondary Phone

( ) - 

9. Phone Type

Home 

Mobile

10. Email Address (optional)

11. New Home Address

Mailing Address Apartment/Route Number

City State Zip Code Country

12. Signature - Sign and date this form. 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.

Signature Date