OBA Ver: 08/09/2022

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 12th Street, 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.
Application for 

Electronic Direct Deposit

PBGC Form 710

 

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 ninedigit 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.

SIGNATURE DATE