Pbgc Form 705 - Beneficiary Application For Pension Benefits - 2006
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1
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4Beneficiary Application
PBGC Form 705
for Pension Benefits
Approved OMB 1212-0055
Expires 4/30/06
Pension Benefit Guaranty Corporation.
For assistance, call 1-800-400-7242
P.O. Box 151750 Alexandria Virginia 22315-1750
Plan Name:
Plan Number:
Participant Name / SSN:
Date Printed:
Applicant Name / SSN:
Date of Plan Termination:
INSTRUCTIONS: Please complete this form to request that PBGC begin payments to you as the beneficiary of a
deceased participant, or an alternate payee. Use dark ink and be sure to print clearly. If you have questions,
call our Customer Contact Center at 1-800-400-7242 for information.
1. General information about you
Last Name
First Name
Middle Name
Other 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 the plan participant:
CONTINUE
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