Locating and Paying Participants

MyPBA 2 0 Wireframes OMB partial

Locating and Paying Participants

OMB: 1212-0055

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1212-0055 can be found here:

Document [pdf]

Download: pdf | pdf

My PBA 2.0
Wireframes
New Transactions:
Form 700 Application for Benefits
Form 701 Payee Information Form
Form 702 General Information Form
Form 705 Beneficiary Application for Benefits
Form 706 Beneficiary Application for Benefits-OF
Form 707 Designation of Beneficiary
Request an Estimate

SRA International, Inc.

6/10/2005

Table of Contents
Page
Login

Apply for an Account

Reset Password

Unlock Account

Change Password

First Time Login (Form 701 PIF and Form 702 GIF) (*NEW*)

Home Page

Change Contact Information

Apply for Electronic Direct Deposit

Periodic Election a.k.a. Edit Federal Tax Withholding Election

Designate a Beneficiary (Form 707) (*NEW*)

Apply for Benefits (Forms 700, 705, 706) (*NEW*)

Request an Estimate (*NEW*)

This package represents key screens from the My PBA 2.0 application. A
complete sample transaction is shown with the Change Contact Information
transaction. Each transaction follows the same basic flow: input screen or
screens, confirmation/review screen, Secret Question/Secret Answer input
screen, final confirmation screen. For all the other transactions included in this
package, only the input screen or screens is shown to reduce redundancy.
Transactions listed above designated as (*NEW*) are not in the current
application and will be available after the July 2005 launch.

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Help

Welcome to My PBA!
With My PBA you can perform the following tasks:

New to My PBA?

Apply for an Account

Apply for Electronic Direct Deposit (EDD)
Edit your existing EDD information

Already Have an Account? Log in.

Designate Federal Tax Withholdings
Change your address, telephone number, or e-mail address

User ID:
Password:

Apply for Benefits

Request an Estimate of your Benefits
Forgot your password?

Designate a Beneficiary

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Apply for an Account

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Help

Apply for an Account
Step 1: Find Your Plan
Enter the PBGC-trusteed pension plan name or number that is the original source of your benefit, then click
“Next.” You canfind your plan’s name and number in the top left corner of the letter you should have received from
PBGC announcing trusteeship. To open a new account, you must be able to find at least one plan that owes you
a benefit. If you are owed a benefit from multiple plans, you need only find one of these plans.
Pension Plan Number:

Pension Plan Name:
OR

Cancel

Next >

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Help

Apply for an Account
Step 1: Find Your Plan
Select one plan from the list below that owes you a pension benefit. If you are receiving benefits for more than
one of the plans listed, you still need only select one to open a new account.
LTV Steel Corporation – Hourly (#19524000)
LTV Steel Corporation – Mining (#19524700)
LTV Steel Corporation – Salary (#19524100)
LTV Steel Corporation – Railroads (#19524200)

Cancel

Next >

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PLANS RETURNED

Help

Apply for an Account
Step 1: Find Your Plan
We were unable to find a match for . Please enter another Plan Name or Plan
Number. If you are unable to find your plan after several tries, your plan may not be eligible for an account. If you
have additional questions or need assistance, please call our Contact Center at 1-800-400-7242.
Pension Plan Number:

Pension Plan Name:
OR

Cancel

Next >

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

NO RESULTS
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Help

Apply for an Account
Step 2: Enter Personal Information

Your Plan Information

Edit

Plan Name:

LTV Steel Corporation - Salary

Plan #:

195241

Please use your full legal name.
First Name:
Middle Name (optional):
Last Name:
Social Security Number:

222-22-2222

Date of Birth:

MM/DD/YYYY

E-mail Address:
Confirm E-mail Address:
Notice to Customers using E-mail Filtering "SPAM" Software:
Necessary account information communicated through e-mail may be affected by any e-mail filtering "SPAM"
software you have installed on your computer. We use your e-mail address to confirm your registration,
respond to inquiries and to keep you updated about your account.
To ensure that you receive necessary e-mails, add the "pbgc.gov" domain to your e-mail "safe list". Also,
check trash, deleted, or quarantined folders for e-mails from pbgc.gov.
If your settings do not allow you to add e-mail addresses to a "safe list", use the Help section or contact your email/internet provider's Customer Support to research your configuration options.
< Back

Cancel

Next >

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Help

Apply for an Account
Step 2: Enter Personal Information
Please enter your contact information.
Mailing Address:

City:
State:

Province/Region (if outside US):
Zip/Postal Code:
Country:

22222-2222

UNITED STATES

Daytime Phone:

111-111-1111

Evening Phone (optional):

111-111-1111

Fax (optional):

111-111-1111

Ext.

< Back

Cancel

Next >

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

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Help

Apply for an Account
Step 3: Secret Question/Answer
Create your security key by selecting a secret question from the dropdown list and then entering a secret answer to
the question.
Remember your secret question and secret answer combination because My PBA will ask you to enter it
whenever you conduct a transaction.
Secret Question:

Secret Answer:
Confirm Secret Answer:
I understand that under the Government Paperwork Elimination Act ("GPEA") (Title XVII of Public Law No. 105277), my answer to my secret question will be deemed the equivalent of my handwritten signature and as binding
under 18 U.S.C 1001 as an inked signature.
< Back

Cancel

Next >

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

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Help

Apply for an Account
Step 4: Review Your Information
Please review the information you have submitted.

Your Plan Information

Edit

Plan Name:

LTV Steel Corporation–Salary

Plan Number:

195241

Your Personal Information

Edit

First Name:

Doris

Middle Name (optional):
Last Name:

Jones

Social Security Number:

222-22-2222

Date of Birth:

12/06/1945

E-mail Address:

jones_d@aol.com

Mailing Address:

123 North Main Street

Big City, CA 22222-2222
UNITED STATES
Daytime Phone:

321-431-4545

Evening Phone (optional):

321-431-4545

Fax Number (optional):

Your Secret Question/Answer

Edit

Secret Question:

What is your favorite pet’s name?

Secret Answer:

****

< Back

Cancel

Next >

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* Should not appear if user auto-matches and is not asked to enter this information

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Apply for an Account
Congratulations!
Your request for a Pension Benefit Account has been received and approved. Please complete the following steps to
activate your account:
1. Check your e-mail account for a message from "My PBA Customer Support."
2. Click the link in the e-mail message to begin activating your account.
3. Use the temporary User ID and Password sent to you in the message to log into My PBA.
If you have additional questions or need assistance, please call our Contact Center at 1-800-400-7242.
Go to My PBA Login

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AUTO-MATCHED

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Reset Password

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Reset Your Password
To reset your password, enter the information requested below. We will confirm that it matches our records, then
send you an e-mail with additional instructions.
222-22-2222

Social Security Number:
Secret Question:

Secret Answer:
Cancel

Next >

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

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Reset - Unlock Confirm
An e-mail message has been sent to you with a new password. Please check your e-mail account and follow the
login instructions in the message.
Return to My PBA Login

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

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Unlock Account

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Unlock Your Account
To unlock your account, enter the information requested below. We will confirm that it matches our records, then
send you an e-mail with additional instructions.
222-22-2222

Social Security Number:
Secret Question:

Secret Answer:
Cancel

Next >

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

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Unlock Your Account
An e-mail message has been sent to you with a new password. Please check your e-mail account and follow the
login instructions in the message.
If you have additional questions or need assistance, please call our Contact Center at 1-800-400-7242.
Go to My PBA Home

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

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Change Password

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Change Your Password
To change your password, first provide the answer to your secret question. Then enter your old password and,
finally, your new password.
:
Old Password:
New Password:

Password Tips

Your new password must contain at least one letter and one number and it must be between 8 and 12 characters long.
Your new password is case sensitive, so make sure to enter it exactly as you do here when you log in to My PBA.

Confirm New Password:
Cancel

Next >

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Change Password Confirm
You have successfully changed your password. We will send you an e-mail message confirming this transaction.
Go to My PBA Home

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

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First Time Login
Form 701 (PIF)
Form 702 (GIF)

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Activate Your Account
Create Your Permanent User ID and Password
Step 1 Enter the answer you gave to your secret question.
:

Step 2 Enter new User ID:

Your User ID can be any combination of letters and/or numbers and it must be between 6 and 25 characters long.
Your User ID is not case sensitive. This is the last time that you will be able to change your User ID.

Step 3 Enter new Password:
Password Tips
Your password must contain at least one letter and one number and it must be between 8 and 12 characters long.
Your password is case sensitive, so make sure to enter it exactly as you do here when you log in to My PBA.

Confirm new Password:

Cancel

Next >

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

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Activate Your Account
About Activating Your Account
In order to better serve its customers, PBGC requires that all new and current My PBA users provide the following
personal information.
. For each plan you are in, PBGC will use the information you provide to determine either your right to a pension
benefit or your right to continue receiving benefits for a particular plan. You must complete this process to access
your My PBA account.
You may need the following to activate your account:
Date of Plan Termination
Marriage Documentation
Employment Information
QDRO Information More info...
Our records indicate you are a:
in the
in the
in the
Note: You will be required to enter information for each plan. If you cancel before providing all information needed for each plan, you will lose any
information you entered for that plan.

Cancel

Next >

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

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Activate Your Account
Verify Your Current Personal Information for
If your name, Social Security Number, or date of birth is incorrect please contact PBGC at 1-800-400-7242.
Name:

Doris Jones

Other Name(s) Used (optional):
Social Security Number:

222-22-2222

Date of Birth:

06/13/1913

Gender:

Male

Female

Mailing Address:

222 South Street

City:

Cityville

State:

Province/Region (if outside US):
Zip/Postal Code:

22222-2222

Country:

UNITED STATES

Daytime Phone:

703-555-5555

111-111-1111

Evening Phone (optional):

703-555-1111

111-111-1111

Fax Number (optional):

22222-2222

Ext.

111-111-1111

E-mail Address:

dorisjones@aol.com

Confirm E-mail Address:

dorisjones@aol.com
< Back

Cancel

Next >

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

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SRA International, Inc.

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Activate Your Account
Answer the Following Questions for
Are you currently employed?
Yes

Is there a Qualified Domestic Relations Order (QDRO) from a court that requires we pay some or all of
your benefit for this plan to someone else?
Yes

If Yes, how many QDRO’s?

Were you married when you began receiving benefit payments for this plan?
Yes

Cancel

Next >

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

PIF, Role PP and WC

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Activate Your Account
Enter Your Current Employment Information for
Employed By:

Steel Retirement Inc.

Mailing Address:

555 Bending Rd.

City:

Cityville

State:

Province/Region (if outside US):
Zip/Postal Code:

22222-2222

Country:

UNITED STATES

22222-2222

< Back

Cancel

Next >

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

Role PP and WC
(Yes to Currently Employed question)

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Activate Your Account
Enter Your Marriage Information for as of
Marriage Date:

03/10/1962

Spouse’s First Name:

Bob

MM/DD/YYYY

Middle Name (optional):
Jones

Current Last Name:
Maiden Name (optional):
Other Name(s) Used (optional):
Social Security Number:

333-44-5555

111-11-1111

Date of Birth:

11/12/1940

MM/DD/YYYY

Gender:

Male

Female

Mailing Address:

222 South Street

City:

Cityville

State:

Province/Region (if outside US):
Zip/Postal Code:

22222-2222

Country:

UNITED STATES

Daytime Phone:

703-555-5555

22222-2222

111-111-1111

Evening Phone (optional):

111-111-1111

Fax Number (optional):

111-111-1111

E-mail Address (optional):

Ext.

bobjones@aol.com

< Back

Cancel

Next >

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

Note: The option to choose this person as your
beneficiary has been removed
Role PP NOT IN PAY (Yes to Married question)

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SRA International, Inc.

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Activate Your Account
Designate Your Beneficiary for the Plan
Designation of Beneficiary - If there are payments owed to you at the time of your death, PBGC will pay them
to the person(s) you designate below. If you do not designate anyone, or if the beneficiary you name dies before
you, PBGC will pay the underpayment in this order: your spouse, your children, your parents, your estate, and
your next of kin.
I name the following person as my beneficiary for amounts owed to me at my death. This replaces any previous
designation and will only be effective when PBGC receives it.
Beneficiary’s First Name:

Jack

Middle Name (optional):
Last Name:

Smith

Other Name(s) Used (optional):
Relationship to me:

brother

Social Security Number:

222-44-6666

111-11-1111

Date of Birth:

08/08/1940

MM/DD/YYYY

Male

Gender:

Female

Mailing Address:

111 West Ave.

City:

Benefit City

State:

Province/Region (if outside US):
Zip/Postal Code:

33333

Country:

UNITED STATES

Daytime Phone:

333-333-9999

22222-2222

111-111-1111

Evening Phone (optional):

111-111-1111

Fax Number (optional):

111-111-1111

Ext.

E-mail Address (optional):
< Back

Cancel

Next >

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

ALL ROLES

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SRA International, Inc.

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Activate Your Account
Enter Qualified Domestic Relations Order (QDRO) Information for

Plan
There is a QDRO from a court that requires PBGC to pay some or all of my benefit for the plan
to the following person:
First Name:

Jane

Middle Name (optional):
Martin

Last Name:
Other Name(s) Used (optional):
Date of QDRO:

11/11/1998

MM/DD/YYYY

Plan
There is a QDRO from a court that requires PBGC to pay some or all of my benefit for the plan
to the following person:

First Name:

Jeff

Middle Name (optional):
Martin

Last Name:
Other Name(s) Used (optional):
Date of QDRO:

11/11/1999

MM/DD/YYYY

< Back

Cancel

Next >

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Role PP BASED ON
NUMBER OF QDROS

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Home page

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In Pay

Variable

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Not In Pay

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Change Contact Information

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Welcome, Doris Jones!

Log Out | Help

Edit Personal Information
Enter Your Current Personal Information
If your name, Social Security Number, or date of birth is incorrect please contact PBGC at 1-800-400-7242.
Name:

Doris Jones

Social Security Number:

222-22-2222

Date of Birth:

06/13/1913

Mailing Address:

222 South Street

City:

Cityville

State:

Province/Region (if outside US):
Zip/Postal Code:

22222-2222

Country:

UNITED STATES

Daytime Phone:

703-555-5555

111-111-1111

Evening Phone (optional):

703-555-1111

111-111-1111

Fax Number (optional):

22222-2222

Ext.

111-111-1111

E-mail Address:

dorisjones@aol.com

Confirm E-mail Address:

dorisjones@aol.com
Cancel

Next >

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

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SRA International, Inc.

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Edit Personal Information
Review Your Information
Please check that your new contact information is correct. The information that you edited is shown below in bold
faced type. If you need to change any information, click the "Edit" link.
If your name, Social Security Number, or date of birth is incorrect please contact PBGC at 1-800-400-7242.
Your Personal Information

Edit

Name:

Doris Jones

Social Security Number:

222-22-2222

Date of Birth:

06/13/1913

Mailing Address:

100 Main St.
Apt 201
New Town, OH 12345
UNITED STATES

Daytime Phone:

202-555-1212

Evening Phone (optional):
Fax Number (optional):
E-mail Address:

jones_d@aol.com

< Back

Cancel

Next >

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

Your Current Tax Withholding Information Edit
LTV STEEL CORPORATION - SALARY
You have elected:

To have Federal income tax withheld based on IRS instructions.

Martial Status:

Married

Number of withholding allowances:

Additional amount to be withheld (optional):

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Verify Secret Answer
Enter the Answer to Your Secret Question
I understand that under the Government Paperwork Elimination Act ("GPEA") (Title XVII of Public Law No. 105277), my answer to my secret question will be deemed the equivalent of my handwritten signature and as binding
under 18 U.S.C 1001 as an inked signature.
Enter the answer you gave to your secret question to ensure a secure transaction of your information.
: *********
< Back

Cancel

Next >

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

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Edit Personal Information
Thank you for using My PBA to edit your contact information. No further action is necessary on your part. Your new
contact information will become effective within the next 30 days. We will send you an e-mail message confirming
this transaction.
Go to My PBA Home

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

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Apply for EDD

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Apply for Electronic Direct Deposit

Any changes made to your electronic direct deposit information apply only to this plan. To change electronic direct
deposit for another plan, please return to My PBA Home and select a different plan.
Type of Bank Account:

Bank Account Number:

View example

Bank Routing Number:

View example

Name on Account: (your name
must be on the account)
Bank Name:
Bank Branch Name:
Bank Branch Address:

City:

22222-2222

State:
Zip Code/Postal Code:
Bank Contact Person (optional):

111-111-1111

Ext:

Contact’s Phone (optional):

Cancel

Next >

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

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SRA International, Inc.

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Apply for Electronic Direct Deposit

Please check that your new bank account information is correct. The information that you edited is shown on the
right in bold faced type. If you need to change any information click the "Edit" link.
Your Electronic Direct Deposit Information Edit
Type of Bank Account:
Bank Account Number:
Bank Routing Number:
Name on Account:
Bank Name:
Bank Branch Name:
Bank Branch Address:
Bank Contact Person (optional):
Contact’s Phone (optional):

Checking
123456789
123456789
Walter Collins
Big Bank
Lower City Branch
234 Anywhere Street
Epicenter, MD 33333
James Smith
321-431-4545

< Back

Cancel

Next >

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

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Cancel

Next >

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

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New EDD Confirm
Thank you for using My PBA to apply for electronic direct deposit. No further action is necessary on your part.
Your new account information will become effective within the next 30 days. We will send you an e-mail message
confirming this transaction.
Go To My PBA Home

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

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Payment Details

Plan #:
Your Role:
Payment Status:
Payment Method:

195241
Participant
Receiving payments
Electronic Direct Deposit

Direct Deposit Information

Edit

Type of Bank Account:
Bank Account Number:
Bank Routing Number:
Name on Account:
Bank Name:
Bank Branch Name:
Bank Branch Mailing Address:

Checking
123456789
987654321
Doris Jones
Big Bank
Lower City Branch
123 North City Branch
Big City, VA 22222-2222
United States
Name of Contact at Bank (optional): James Smith
Contact’s Phone (optional):
123-123-4444

Federal Tax Withholding Election Edit
You have elected:

To have $_______ withheld monthly.

Go To My PBA Home

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

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Payment Details

Plan #:
Your Role:
Payment Status:
Payment Method:

195241
Participant
Receiving payments
Electronic Direct Deposit

Direct Deposit Information

Apply for Direct Deposit

Federal Tax Withholding Election

Edit

You have elected:
Martial Status:
Number of withholding allowances:

To not have Federal income tax withheld.
Married
SEE BELOW FOR OTHER
VARIATIONS.

Additional amount to be withheld (optional):

Go To My PBA Home

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

You have elected:

To have Federal income tax withheld based on IRS instructions.

You have elected:

To have $_______ withheld monthly.

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“Periodic Election”
a.k.a - Edit Federal Tax
Withholding Election

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Edit Federal Tax Withholding Election
Select a Tax Withholding Option
Tax laws require that PBGC withhold Federal income tax from your pension payment(s) unless you instruct us to do
otherwise. You must select one of the three withholding options shown below. More info ...

I elect not to have Federal income tax withheld from my payment(s). (U.S. residents only)

I elect to have Federal income tax withheld from my payment(s) based on IRS Instructions
Marital Status:

Single

Married

Number of withholding allowances:
Additional amount to be withheld (optional):

.00

I elect to have the following amount of Federal income tax withheld from my payment(s):
$

.00

Cancel

Next >

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

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Designate a Beneficiary
Form 707

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Designate a Beneficiary
Designate Your Beneficiary for the Plan
Who can Designate a Beneficiary?
If you are currently receiving a pension check from PBGC, you can use this form to designate a beneficiary. If
you are receiving a Joint & Survivor Annuity, you cannot change the beneficiary designation you made at the
time you applied for benefits. If you do not designate a beneficiary, PBGC will pay the amount we owe you in this
order: your spouse, your children, your parents, your estate, and your next of kin.
You may be eligible for the following beneficiary designations:
Designation of Beneficiary for Annuity Benefits Payable after Death- Annuity benefits, other than joint-andsurvivor benefits, that are payable to your beneficiary for periods after your death.
Designation of Beneficiary for Benefits Due at Death – This designation covers payments that PBGC may owe
you at the time of your death, including back payments for benefit estimates that were too low and certain lumpsum amounts (usually for small benefits). If your benefit is one that provides for benefits to be paid after your death
(as with a joint-and-survivor or certain-and-continuous annuity), the person named to receive those continuing
benefits will receive any payments due to you at the time of your death. If not, PBGC will make any payments due
to you at the time of your death to the person you name below. If you do not name anyone, or if the person you
name dies before you, PBGC will pay the amount we owe you in this order: your spouse, your children, your
parents, your estate and your next of kin, in that order.
Remember that each time you designate a beneficiary, you replace any previous designation.
If you are unsure what type of annuity you have, don’t remember who you previously designated as your
beneficiary, or you have any other questions about your beneficiary designation, please contact PBGC at 1-800400-7242.

Cancel

Next >

Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

In Pay Participant

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Designate a Beneficiary
Designate Your Beneficiary for the Plan
Note: This designation replaces any designation you may have made previously.
Designation of Beneficiary for Benefits Due at Death – This designation covers payments that PBGC may
owe you at the time of your death, including back payments for benefit estimates that were too low and certain
lump-sum amounts (usually for small benefits).
When you apply for benefits you will have an opportunity to designate a Beneficiary for benefits to be paid after
your death (as with a Joint & Survivor (J&S) or Certain & Continuous (C&C) annuity.) More Info...
Beneficiary’s First Name:

Jack

Middle Name (optional):
Smith

Last Name:
Other Name(s) Used (optional):
Relationship to me, if any:

brother

Social Security Number:

222-44-6666

111-11-1111

Date of Birth:

08/08/1940

MM/DD/YYYY

Male

Gender:

e.g., spouse, granddaughter, friend

Female

Mailing Address:

111 West Ave.

City:

Benefit City

State:

Province/Region (if outside US):
Zip/Postal Code:

33333

Country:

UNITED STATES

Daytime Phone:

333-333-9999

22222-2222

111-111-1111

Evening Phone (optional):

111-111-1111

Fax Number (optional):

111-111-1111

Ext.

E-mail Address (optional):
You can also choose a Contingent Beneficiary (except in the case of a joint-and-survivor annuity). A Contingent
Beneficiary becomes eligible for your benefit if the person you have designated as your beneficiary dies before
you.
Would you like to designate a contingent beneficiary for this benefit?
Yes

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Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

Not in Pay Participant
49
SRA International, Inc.

6/10/2005

Designate a Beneficiary
Designate Your Contingent Beneficiary for the Plan
Please provide the contingent beneficiary information requested below for:
Designation of Beneficiary for Benefits Due at Death More info...
Contingent Beneficiary’s First Name: Mary
Middle Name (optional):
Edwards

Last Name:
Other Name(s) Used (optional):
Relationship to me, if any:

friend

Social Security Number:

999-88-7777

111-11-1111

Date of Birth:

10/10/1939

MM/DD/YYYY

Male

Gender:

e.g., spouse, granddaughter, friend

Female

Mailing Address:

111 South St.

City:

Southboro

State:

Province/Region (if outside US):
Zip/Postal Code:

33333

Country:

UNITED STATES

Daytime Phone:

333-666-9999

22222-2222

111-111-1111

Evening Phone (optional):

111-111-1111

Fax Number (optional):

111-111-1111

E-mail Address (optional):

Ext.

maryedwards@aol.com
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Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

Not in Pay Participant

50
SRA International, Inc.

6/10/2005

Apply for Benefits
Form 700, 705, 706

51
SRA International, Inc.

6/10/2005

Apply for Benefits
The Two-Step Process of Applying for Benefits
Step One: Request an estimate
PBGC strongly recommends that you obtain an estimate of your benefit payment(s) prior to applying for benefits.
The estimate will show you the amount your payment(s) would be for each possible form of benefit on the date
you want your benefits to start. Therefore, having an estimate in hand when you apply for benefits ensures that
you will be able to select the form of benefit that will work best for you.
You can expect to receive your benefit estimate from PBGC within 15 to 45 days. If it will take us longer than 45
days to send you a benefit estimate, we will contact you.

Step Two: Complete the benefit application process
Once you have received an estimate of your benefit payments in the mail from PBGC, you are then able to
complete the benefit application process.
Things to remember about applying for benefits:
* You should apply for benefits no more than 90 days before you wish to receive your first payment
* PBGC will contact you after receipt of your application to confirm the amount of your payment(s) and the date
on which you will receive your first payment
* PBGC will contact you if you are missing any “proof documents” (e.g., birth certificate) that are required to
complete your application. Please be sure to note the required proof documents that are listed at the end of the
application process.
* If you are currently married and select certain forms of benefit, you will be asked to obtain a notarized
signature from your spouse. To facilitate this requirement, My PBA will generate a printable Adobe .PDF
version of your completed application at the end of the application process. You will be asked to print the
generated application, obtain the necessary signatures, and mail it to PBGC. In order for this process to work,
you must have Adobe Acrobat software installed on your computer. You can download this software for free
from the Adobe Web site.

If you have additional questions or need assistance, please call our Customer Contact Center at 1-800-400-7242.
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Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

PP,BE,SP Not in Pay

52
SRA International, Inc.

6/10/2005

Apply for Benefits
Enter Estimate Status for
Have you received an estimate from PBGC of your benefit payments for the plan?
Yes

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Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

53
SRA International, Inc.

6/10/2005

Apply for Benefits
Answer the following questions for
Are you currently married?
Yes

Are you currently employed?
Yes

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Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

Role PP only

54
SRA International, Inc.

6/10/2005

Application for Benefits
Enter Your Current Employment Information
Employed By:

Steel Retirement Inc.

Mailing Address:

555 Bending Rd.

City:

Cityville

State:

Province/Region (if outside US):
Zip/Postal Code:

22222-2222

Country:

UNITED STATES

22222-2222

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Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

Role PP only
(Yes to Currently Employed question)

55
SRA International, Inc.

6/10/2005

Apply for Benefits
Enter Your Marriage Information
Marriage Date:

06/24/1964

Spouse’s First Name:

Walter

Middle Name (optional):

Ernest

Last Name:

Collins

MM/DD/YYYY

Maiden Name (optional):
Other Name(s) Used (optional):

Wally

Social Security Number:

929-65-9870

111-11-1111

Date of Birth:

01/02/1929

MM/DD/YYYY

Male

Gender:

Female

Mailing Address:

1212 Tidewater Road

City:

Hamlet

State:

Province/Region (if outside US):
Zip/Postal Code:

22222

Country:

UNITED STATES

Daytime Phone:

310-555-5555

111-111-1111

Evening Phone (optional):

310-555-1111

111-111-1111

Fax Number (optional):
E-mail Address (optional):

22222-2222

Ext.

111-111-1111

janetandwalt@comcast.com

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Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

Role PP only
(Yes to Married question)

56
SRA International, Inc.

6/10/2005

Apply for Benefits
Select a Form of Benefit
Enter the month and year in which you would like your pension benefit payments to begin:
10/2003

MM/YYYY

Note: The month you enter must be in the future, but no more than 90 days from the date that you submit this application

Select a Form of Benefit and Beneficiary More info about your benefit options...
If you are currently married and select any option below except B, your spouse must provide their consent. In
addition, your spouse must provide their consent if you select “Other” under Beneficiary. To facilitate spousal
consent, My PBA will generate a printable Adobe .PDF version of your completed application at the end of this
“Apply for Benefits” process. You will be asked to print the generated application, obtain the necessary signatures,
and mail it to PBGC. In order for this process to work, you must have Adobe Acrobat software installed on your
computer. You can download this software for free from the Adobe Web site.
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.
Form of Benefit
A. Plan’s Automatic Form for an Unmarried Participant Details
B. Plan’s Automatic Form for a Married Participant Details
C. Straight Life Annuity Details
D. Joint-and-50% Survivor Annuity Details
E. Joint-and-75% Survivor Annuity Details
F. Joint-and-100% Survivor Annuity Details
G. Joint-and-50% Survivor “Pop-up” Annuity Details
H. 5-year Certain-and-Continuous Annuity Details
I. 10-year Certain-and-Continuous Annuity Details
J.15-year Certain-and-Continuous Annuity Details

Beneficiary
Spouse

Other

Note: If you choose option C (Straight Life Annuity ), do not select a Beneficiary

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Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

Role PP
MARRIED
57
SRA International, Inc.

6/10/2005

Apply for Benefits
Designate a Beneficiary
Your Beneficiary’s Personal Information
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.
Beneficiary’s First Name:

Eileen

Middle Name (optional):
Collins

Last Name:
Other Name(s) Used (optional):

Sister-In-Law

Relationship to me:
Social Security Number:
Date of Birth:

929-65-9870

111-11-1111

06/02/1960

MM/DD/YYYY

Male

Gender:

Female

1212 Windy Lane

Mailing Address:

Lincoln

City:

State:
Province/Region (if outside US):
Zip/Postal Code:

22222

22222-2222

UNITED STATES
Country:
431-555-5555

111-111-1111

431-555-1111

111-111-1111

Daytime Phone:

Ext.

Evening Phone (optional):
111-111-1111

Fax Number (optional):
E-mail Address (optional):
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Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

58
SRA International, Inc.

6/10/2005

Apply for Benefits
Select a Tax Withholding Option
Tax laws require that PBGC withhold Federal income tax from your pension payment(s) unless you instruct us to do
otherwise. You must select one of the three withholding options shown below. More info ...

I elect not to have Federal income tax withheld from my payment(s). (U.S. residents only)

I elect to have Federal income tax withheld from my payment(s) based on IRS Instructions
Marital Status:

Single

Married

Number of withholding allowances:
Additional amount to be withheld (optional):

.00

I elect to have the following amount of Federal income tax withheld from my payment(s):
$

.00

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Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

59
SRA International, Inc.

6/10/2005

Apply for Benefits
Select a Payment Method Option

Electronic Direct Deposit (EDD)
I want to receive my benefit payments via EDD to the following bank account:
Type of Bank Account:

Checking

Bank Account Number:

123456789

View example

Bank Routing Number:

123456789

View example

Name on Account: (your name

Walter Collins

must be on the account)

Big Bank

Bank Name:

Lower City Branch

Bank Branch Name:

123 North Main Street

Bank Branch Address:

Big City

City:

State:

34567

Zip Code:

James Smith

Bank Contact Person (optional):

1231234444

22222-2222

111-111-1111

Ext.

Contact’s Phone (optional):

Mailed Paper Check
Note that you may only select Option B if you cannot use EDD because of physical, mental,
geographic, language, or literacy barriers; or if using EDD would cause you financial difficulties.
I want to receive my benefit payments by check sent to:
1234 North Main Street, Apt. 6
Small Town, VA 22222.

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Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

60
SRA International, Inc.

6/10/2005

Request an Estimate

61
SRA International, Inc.

6/10/2005

Request an Estimate
Select Your Retirement Ages & Enter Your Beneficiary’s Information
Select Your Retirement Ages
I want PBGC to estimate the benefit payment that I would receive as a result of retiring at:
The “early” retirement age the participant’s plan has designated
The “normal” retirement age the participant’s plan has designated
The following “alternate” retirement age: 65

Enter Your Beneficiary’s Information
Note: The beneficiary information you enter here will only be used to provide you with an estimate — it will not be saved to your account.

Beneficiary’s First Name:

Karen

Middle Name (optional):
Parkin

Last Name:
Other Name(s) Used (optional):
Relationship to me:

Sister

Social Security Number:

920-34-4587

111-11-1111

Date of Birth:

01/02/1967

MM/DD/YYYY

Gender:

Male

Female

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Privacy Statement | PBGC.gov | Paperwork Reduction Act Notice

62
SRA International, Inc.

6/10/2005

File Type	application/pdf
File Title	Visio-2.0 Wireframesrev5.vsd
Author	doecma30
File Modified	2005-06-10
File Created	2005-06-10