706 Beneficiary Application for Pension Benefits -- OF

Locating and Paying Participants

706 Locating and Paying Participants

OMB: 1212-0055

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_{Beneficiary
Application}

for Pension Benefits - OF

PBGC Form 706

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. When “proof required” is indicated, please enclose a copy of a birth or baptism certificate, or a U.S. Passport, whichever is appropriate, unless you already sent PBGC a copy of this document. 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}

₍

₎

₍

₎

_{When
would you like your pension benefit payments to begin?}

_{(This
must be a future date.)}

^month

^year

_{Name
of the plan participant:}

^CONTINUE

_{Beneficiary
Application for Pension Benefits - OF}_{Form
706, page 2 of 5}

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_{(proof
required)}

___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:}

_

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

Election of Benefit Form for Alternate Payees and Qualified Preretirement Survivor Annuity recipients. If you are an Alternate Payee with a separate interest under a Qualified Domestic Relations Order, or if you are entitled to a Qualified Preretirement Survivor Annuity because your spouse died prior to retiring, you may receive your benefit in one of several forms. Please read the information about your benefit choices that PBGC has provided before you make your election below.

_{I elect to receive my benefit in the form of a:}		_{MARK ONLY ONE}
_{A. Straight Life Annuity}		_
_{B. 5-year Certain-and-Continuous Annuity}		_
_{C. 10-year Certain-and-Continuous Annuity}		_
_{D. 15-year Certain-and-Continuous Annuity}		_
_{E. The form your plan would pay you automatically, if different from above}		_

	^CONTINUE

_{Beneficiary Application for Pension Benefits - OF}_{Form 706, page 3 of 5}
	Plan Number: «PrismCase.CaseIdNmbr»	Participant Name: «PrismCust.FullName»
		Applicant Name / SSN:

4. Designation of Beneficiary – Complete this section if you elected any form other than a Straight Life Annuity.

Beneficiary – I name the following person as my beneficiary.

_{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}

₍

₎

₍

₎

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

5. 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 - OF}_{Form 706, page 4 of 5}
	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.}

_

_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

_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 - OF}_{Form 706, page 5 of 5}
	Plan Number: «PrismCase.CaseIdNmbr»	Participant Name: «PrismCust.FullName»
		Applicant Name / SSN:

6. 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.	

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

₍

₎

_{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

_{Your
Benefit, Your Choice • Benefit Options from PBGC}

_{Page
1 of 2}

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.

PBGC OPTIONAL BENEFIT FORMS

This section describes each of the benefit forms that PBGC offers you, with examples using a payee named Sam who is applying for a benefit at age 65. We show what Sam and his beneficiary Carol would receive under each benefit form.

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. No one receives any benefits after Sam dies.

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
2 of 2}

SUMMARY OF EXAMPLES

Benefit Form	Sam’s Benefit	Carol’s Survivor Benefit	Additional Explanation
A. Straight Life Annuity	$500	None	Carol will not receive any benefits after Sam’s death.
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
The form your plan would pay you automatically, if different from above	Benefit amounts depend on benefit form payable under the plan.

File Type	application/msword
File Title	General Information Form_PBGC Form XXX
Author	PBGC\IOD
Last Modified By	IOTSA30
File Modified	2006-06-22
File Created	2006-06-22