705 Beneficiary Application for Pension Benefits

	Beneficiary Application for Pension Benefits		PBGC Form 705 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	Applicant Name / SSN:
	Date of Plan Termination: «PrismCase.DOPT»

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

Beneficiary Application for Pension Benefits Form 705, page 2 of 4

Plan Number: «PrismCase.CaseIdNmbr»

Participant Name: «PrismCust.FullName»

Applicant Name / SSN:

Your relationship to person who participated in the plan:

mark only one

A. Beneficiary - The benefits are from the pension plan of someone who is deceased.



My relationship to the participant:

Spouse

Other:

Date of participant’s death:

/

/

(proof required)

B. Alternate payee - I have a Qualified Domestic Relations Order (QDRO) that establishes my right to receive some or all of a participant's benefits from a pension plan.



Date of QDRO:

/

/

C. Other. Please explain:



2. 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.
signature		date

3. 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’re 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.

CONTINUE

Beneficiary Application for Pension Benefits Form 705, page 3 of 4
	Plan Number: «PrismCase.CaseIdNmbr»	Participant Name: «PrismCust.FullName»
		Applicant Name / SSN:

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 whether to have Federal tax withholdings 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.

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.



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.

CONTINUE

Beneficiary Application for Pension Benefits Form 705, page 4 of 4
	Plan Number: «PrismCase.CaseIdNmbr»	Participant Name: «PrismCust.FullName»
		Applicant Name / SSN:

4. 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 below, 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.	

5. 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 FOR REQUIRED SIGNATURES BEFORE YOU SUBMIT IT.

A MISSING SIGNATURE COULD DELAY YOUR FIRST PAYMENT.

THANK YOU