700 Application for Benefits

	Participant Application for Pension Benefits		PBGC Form 700 Approved OMB 1212-0055 Expires 08/31/08
Pension Benefit Guaranty Corporation. P.O. Box 151750 Alexandria Virginia 22315-1750		For assistance, call 1-800-400-7242

	Plan Name: «PrismCase.CaseTitle»
	Plan Number: «PrismCase.CaseIdNmbr»	Participant Name : «PrismCust.FullName»
	Date Printed: 02/06/2021
	Date of Plan Termination: «PrismCase.DOPT»

INSTRUCTIONS: Please complete this form to request that PBGC begin your pension benefit payments. Use dark ink and be sure to print clearly. Note those items marked "Proof Required." You must enclose a copy of the appropriate document if you have not already sent it to us. Acceptable documents for proof of age include your birth or baptism certificate, or U.S. Passport; for marriage, a marriage certificate. 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 (proof required)

Gender

male 

-

-

/

/

female 

Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email (optional)

Daytime Phone

Extension

Evening Phone

(

)

-

x

(

)

-

When would you like your pension benefit payments to begin?

/

(This must be a future date, but no more than 90 days from the date of your application.)

month

year

CONTINUE

Participant Application for Pension Benefits Form 700, page 2 of 7
	Plan Number: «PrismCase.CaseIdNmbr»	Participant Name: «PrismCust.FullName»

Are you currently employed? We need this information to determine if you are eligible to begin receiving early retirement benefits. If yes, please provide information below:	No 
	Yes 
Employer Name:
City	State

2. Marital status

Are you currently married?

No 

Yes 

Spouse’s Last Name

Spouse’s First Name

Spouse’s Middle Name

Other Name(s) Used

Spouse’s Social Security Number

Spouse’s Date of Birth (proof required)

Date of Marriage (proof required)

-

-

/

/

/

/

3. Signature – You must sign and date this application. 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. I understand that I cannot change my benefit form election, below, after PBGC makes my first payment.
signature		date



CONTINUE



Participant Application for Pension Benefits Form 700, page 3 of 7
	Plan Number: «PrismCase.CaseIdNmbr»	Participant Name: «PrismCust.FullName»

4. Election of Benefit Form – Please read the information about your benefit choices that PBGC has provided before you make your election below.

Benefit Form	My Choice mark only one	Beneficiary mark only one
A. Plan’s Automatic Form for an Unmarried Participant		Not Applicable if form is a Straight Life Annuity  Spouse  Other Beneficiary
B. Plan’s Automatic Form for a Married Participant		Spouse only
C. Straight Life Annuity		Not Applicable
D. Joint-and-50% Survivor Annuity		 Spouse  Other Beneficiary
E. Joint-and-75% Survivor Annuity		 Spouse  Other Beneficiary
F. Joint-and-100% Survivor Annuity		 Spouse  Other Beneficiary
G. Joint-and-50% Survivor “Pop-up” Annuity		 Spouse  Other Beneficiary
H. 5-year Certain-and-Continuous Annuity		 Spouse  Other Beneficiary
I. 10-year Certain-and-Continuous Annuity		 Spouse  Other Beneficiary
J. 15-year Certain-and-Continuous Annuity		 Spouse  Other Beneficiary

5. Spousal consent to elected form of benefit and beneficiary. Your spouse must complete this section if you are married and elect option A or any of the options C through J above. (Leave this section blank if you elect option B.)

By signing below, I consent to my spouse's election of the Benefit Form checked in section 4, above, and to the beneficiary designated in section 6, below. I understand that my spouse can change the beneficiary without my consent if he or she elects a certain-and-continuous annuity in choice H, I, or J in section 4. I have read the information provided with this application, my consent is voluntary and I understand that I cannot revoke my consent after PBGC makes the first payment.
		spouse’s signature (must be witnessed by a notary public)					date
To be completed by Notary Public witnessing the spouse’s signature above:
Subscribed and sworn to before me this __________________ day of ____________________, Year______
	Date My Commission Expires				Notary Public Name
	City / County				State
			CONTINUE

Participant Application for Pension Benefits Form 700, page 4 of 7
	Plan Number: «PrismCase.CaseIdNmbr»	Participant Name: «PrismCust.FullName»

6. Designation of Beneficiary for Annuity Benefit. Complete this section if you elect any benefit form other than a Straight Life Annuity.

		mark only one
I designate my spouse as my beneficiary	
I designate the person named below as my beneficiary	

If you elect a joint-and-survivor annuity, your beneficiary designation is final and cannot be changed after

PBGC makes your first payment. If you elect a certain-and-continuous annuity, you may change your

beneficiary at any time.

Beneficiary – I name the following person as my beneficiary. If my beneficiary receives benefits that continue after my death, he or she will also receive any benefits owed to me at my death.

Last Name

First Name

Middle Name

Other Name(s) Used

Social Security Number

Date of Birth (proof required for joint and survivor benefits only)

Gender

male 

-

-

/

/

female 

Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email (optional)

Daytime Phone

Extension

Evening Phone

(

)

-

x

(

)

-

Relationship to me, if any (e.g., spouse, granddaughter, friend)

CONTINUE

Participant Application for Pension Benefits Form 700, page 5 of 7
	Plan Number: «PrismCase.CaseIdNmbr»	Participant Name: «PrismCust.FullName»

7. Information on Federal tax withholding – Tax laws require that we withhold Federal income tax from your pension payments unless you instruct us to do otherwise. You have three choices. Please read them carefully and make your selection on the next page. You may choose:

A) To have PBGC withhold no Federal income taxes from your payments (not available if you live outside of the United States).

B) To have PBGC follow IRS guidance and calculate your withholding.

If you choose this option, you need to tell us if you are married and the number of allowances you claim. It is possible that we will not withhold any Federal income tax even if you choose this option – if, for example, your benefit is low or if you claim a large number of allowances. You may increase the amount we withhold by claiming fewer allowances, by having additional money withheld, or by electing option C, below.

C) To have PBGC withhold the amount you tell us to withhold each month.

If you decide not to have PBGC withhold taxes or the amount that we withhold is too low, you may have to pay an estimated tax directly to the Internal Revenue Service. If the amount of your estimated tax or your withholding is too low, you may also have to pay the IRS penalties. You may wish to consult a tax specialist or the IRS about your decision.

What happens if you do not choose any option?

If you do not choose one of these options, we will withhold Federal taxes as if you were a married individual with three allowances. The amount we will withhold depends on your monthly pension.

What if you want to pick a different option later?

You may change your decision at any time. To choose a different option, simply call PBGC's Customer Contact Center at 1-800-400-7242. We will then send you a tax withholding form to complete. Depending on when we receive it, we will make the change by the next month or the month after that.

What if you don't live in the United States?

If you live outside the United States, you cannot elect option A. You may be eligible for special tax treatment under a tax treaty with the country you reside in. We will send you additional information after you file this form.

When determining your Federal tax withholding you may find it helpful to read the IRS instructions for completing the IRS Form W-4P (Withholding Certificate for Pension or Annuity Payments). If you would like a copy, you can either call the PBGC Customer Contact Center at 1-800-400-7242 and request a copy be sent to you, or you can print a copy from the IRS Internet site under Forms and Instructions at www.IRS.gov.

CONTINUE

Participant Application for Pension Benefits Form 700, page 6 of 7
	Plan Number: «PrismCase.CaseIdNmbr»	Participant Name: «PrismCust.FullName»

Election - In general, tax laws require PBGC to withhold Federal income tax from your pension payments, unless you specifically elect not to have taxes withheld. Complete A or B or C (ONLY ONE).

A. I elect not to have Federal income tax withheld. (Available to U.S. residents only)



OR

B. I elect to have Federal income tax withheld based on IRS instructions.



Marital Status

Single 

Married 

Number of withholding allowances

Additional monthly amount to be withheld (optional): $

.00

OR

C. I elect to have the following amount withheld for Federal income tax.								
	The dollar amount to be withheld monthly is: $					.00

If you do not choose an option, we will withhold Federal income taxes as if you were a married individual with three allowances. This means that for year 2006, we will withhold taxes only if your monthly PBGC benefit is $1,480 or more.

8. Method of receiving benefit payments

How would you like to receive your payments?		mark only one
A. By Electronic Direct Deposit (EDD), to the account identified on the next page, which must have your name on it.		
B. By mail to my home address, which is printed in section 1 of this form. You may choose this option if you cannot use EDD because of physical, mental, geographic, language, or literacy barriers; or if using EDD would cause you financial difficulties.		
CONTINUE

Participant Application for Pension Benefits Form 700, page 7 of 7
	Plan Number: «PrismCase.CaseIdNmbr»	Participant Name: «PrismCust.FullName»

Financial institution information – Please provide the information in this section to have your payment sent directly to a financial institution. The financial institution will receive and post credits and/or debits for you. You may cancel or change this arrangement by calling PBGC at 1-800-400-PBGC. The financial institution can cancel it by sending you a written notice.

The information below is available from your financial institution, or you may find it on your checks, account statement, or deposit slip. There are three numbers printed on the bottom of your check: the financial institution’s routing number, your account number, and your check number. The routing number must be nine digits. The first two digits must be 01 through 12 or 21 through 32. Your account number can be up to 17 characters (both numbers and letters). Include hyphens but omit spaces and special symbols. Be sure not to use the check number. If you are unsure of the routing number or your account number, contact your financial institution.

Name of Financial Institution

Branch

Mailing Address

City

State

Zip Code

Name of contact person

Routing Number

Financial Institution Phone Number

Extension

(

)

-

x

Name(s) on the Account

Account Type Checking  Savings

Account Number

PLEASE REVIEW THIS FORM TO MAKE SURE IT HAS ALL REQUIRED SIGNATURES BEFORE YOU SUBMIT IT.
	A MISSING SIGNATURE COULD DELAY YOUR FIRST PAYMENT.
	THANK YOU

Your Benefit, Your Choice • Benefit Options from PBGC

Page 1 of 3

Before you begin to receive your monthly pension benefit from PBGC, you have an important decision to make: How do you wish to receive your monthly benefit?

This question is complex and could be one of the most important financial decisions you will ever make. Your decision affects the amount of your monthly benefit and how much your beneficiary will receive after your death. The best option for you depends on your age, health, and other financial resources, as well as the age, health, and financial needs of anyone for whom you wish to provide a benefit. If you are married, you should discuss this choice with your spouse. You may also want to discuss this choice with other family members or friends and, possibly, a financial advisor. The following information is designed to help you make an informed choice.

You may choose your plan’s “automatic” benefit form or one of the PBGC optional benefit forms, described below. Your plan’s “automatic” benefit form is the benefit form your plan would pay you if you do not make an election. Your automatic benefit form may be the same as one of the PBGC optional benefit forms.

• If you are unmarried, you may choose your plan’s automatic benefit form for unmarried participants or any of the PBGC optional benefit forms described below. This automatic benefit form in most plans is a straight-life annuity or a certain-and-continuous annuity (see the descriptions below).

• If you are married, your automatic benefit form is a joint-and-survivor annuity with your spouse as beneficiary. You may choose that benefit form or, with your spouse’s written consent, you may choose your plan’s automatic benefit form for unmarried participants or any of the PBGC optional benefit forms, with your spouse or another person as beneficiary.

Please note that your spouse has a legal right to the survivor benefit under your pension plan’s automatic benefit form for married participants. You can elect a different benefit form or a beneficiary other than your spouse only if your spouse consents by signing Section 5 of the Application before a Notary Public.

PBGC OPTIONAL BENEFIT FORMS

This section describes each of the benefit forms that PBGC offers, with examples using a participant named Sam who is applying for a benefit. Sam will be age 65 when his benefit payments begin. He is married to Carol, who will be 61 years old when Sam’s benefit payments begin. We show what Sam and Carol would receive under each benefit form, assuming Sam names Carol as his beneficiary.

Straight-Life Annuity

A straight-life annuity provides a fixed monthly benefit for the rest of your life only. No survivor benefit will be paid upon your death.

Example: Sam elects a straight-life annuity, and he receives $500 a month for the rest of his life. After Sam dies, Carol does not receive any benefits.

Joint-and-Survivor Annuities

A joint-and-survivor annuity provides a benefit for the rest of your life at an amount reduced from the straight-life annuity amount, with your choice of 50%, 75%, or 100% of that reduced amount to be paid to your beneficiary if you die before that person. If your beneficiary dies before you, your benefit will remain at the reduced level, and no survivor benefits will be payable when you die.

You may name your spouse or someone else as your beneficiary. You cannot change your beneficiary after PBGC makes your first payment. The amount of your benefit will depend on the age of your beneficiary.

Your Benefit, Your Choice • Benefit Options from PBGC (continued)

Page 2 of 3

Examples

• Joint-and-50% Survivor Annuity: Sam receives $450 a month for the rest of his life. If Sam dies first, Carol receives $225 a month for the rest of her life. If Carol dies first, Sam continues to receive $450 a month for the rest of his life.

• Joint-and-75% Survivor Annuity: Sam receives $429 a month for the rest of his life. If Sam dies first, Carol receives $322 a month for the rest of her life. If Carol dies first, Sam continues to receive $429 a month for the rest of his life.

• Joint-and-100% Survivor Annuity: Sam receives $409 a month for the rest of his life. If Sam dies first, Carol receives $409 a month for the rest of her life. If Carol dies first, Sam continues to receive $409 a month for the rest of his life.

Joint-and-50% Survivor “Pop-up” Annuity

The “pop-up” annuity is the same as the joint-and-50% survivor annuity (described above) except that if your beneficiary dies before you, your benefit “pops up” to the straight-life annuity amount. Like the other joint-and-survivor benefit forms, you may choose your spouse or someone else to be your beneficiary. The amount of your benefit will depend on the age of your beneficiary. You cannot change your beneficiary after PBGC makes your first payment.

Example: Sam elects a joint-and-50% survivor “pop-up” annuity and receives a payment of $444 a month. If Sam dies first, Carol receives $222 a month for the rest of her life. However, if Carol dies first, Sam’s benefit “pops up” to his straight-life annuity benefit amount of $500 a month for the rest of his life.

Certain-and-Continuous Annuities

A certain-and-continuous annuity provides a benefit for the rest of your life at an amount reduced from the straight-life benefit amount. If you die within 5, 10 or 15 years after your benefit payments start (depending on your election), your designated beneficiary will receive the benefit for the remainder of that “certain” period. If you die after the certain period, no survivor benefit is payable. You may choose any beneficiary for your certain-and-continuous annuity, such as your spouse, another person, an estate, a trust, a church or other organization, etc. You can change this beneficiary designation at any time. If your beneficiary dies before you and before the end of the certain period, you should designate a new beneficiary. The amount of your benefit is the same regardless of whom you designate as beneficiary.

Examples:

• 5-year Certain-and-Continuous Annuity: Sam receives $494 a month for the rest of his life. If Sam dies within five years, Carol receives $494 a month for the remainder of the five-year period. If Sam dies after 5 years, Carol does not receive any benefits.

• 10-year Certain-and-Continuous Annuity: Sam receives $477 for the rest of his life. If Sam dies within ten years, Carol receives $477 a month for the remainder of the ten-year period. If Sam dies after 10 years, Carol does not receive any benefits.

• 15-year Certain-and-Continuous Annuity: Sam receives $452 a month for the rest of his life. If Sam dies within 15 years, Carol receives $452 a month for the remainder of the 15-year period. If Sam dies after 15 years, Carol does not receive any benefits.

Your Benefit, Your Choice • Benefit Options from PBGC (continued)

Page 3 of 3

SUMMARY OF EXAMPLES

These examples assume that Sam (participant) will be age 65 and Carol will be age 61 when benefit payments start. These examples assume that in Sam’s plan the automatic form of benefit is a straight-life annuity for an unmarried participant, and a joint-and-50% survivor annuity for a married participant. Automatic forms vary from plan to plan but a straight-life annuity and a joint-and-50% survivor annuity are common.

Benefit Form	Sam’s Benefit	Carol’s Survivor Benefit	Additional Explanation
Plan’s Automatic Benefit Form for Unmarried Participants (Straight Life Annuity)	$500	None	Carol will not receive any benefits after Sam’s death.
Plan’s Automatic Benefit Form for Married Participants (Joint-and-50% Survivor Annuity)	$450	$225	If Sam dies first, Carol’s survivor benefit will be paid for the rest of her life. If Carol dies first, Sam’s benefit continues at the same amount for the rest of his life.
C. Straight Life Annuity	$500	None	Carol will not receive any benefits after Sam’s death.
D. Joint-and-50% Survivor Annuity	$450	$225	If Sam dies first, Carol’s survivor benefit will be paid for the rest of her life. If Carol dies first, Sam’s benefit continues at the same amount for the rest of his life.
Joint-and-75% Survivor Annuity	$428	$322
Joint-and-100% Survivor Annuity	$409	$409
Joint-and-50% Survivor “Pop-up” Annuity	$444	$222	If Sam dies first, Carol’s survivor benefit will be paid for the rest of her life. If Carol dies first, Sam’s benefit will increase to $500 for the rest of his life.
5-year Certain-and- Continuous Annuity	$494	$494	If Sam dies before the end of the 5-year, 10-year, or 15-year certain period (whichever he chooses), Carol will receive benefits for the remainder of that period. If Sam dies after the end of the certain period, Carol will not receive any benefits.
10-year Certain-and- Continuous Annuity	$477	$477
15-year Certain-and- Continuous Annuity	$452	$452