718 Installment Repayment Agreement

	Installment Payment Agreement		PBGC Form 718 Approved OMB 1212-0055 Expires 08/31/08

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

1. General information about you (Be sure to print clearly, use black ink, and stay within the boxes).

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

(

)

-

INSTRUCTIONS: If you want to pay your debt in installments, please sign the agreement on the next page and send it to:

Collections and Compliance Division / PIU, FOD

Pension Benefit Guaranty Corporation

1200 K Street, NW, Suite 670

Washington, DC 20005

The agreement may not be altered in any manner. After you sign and return the agreement, PBGC will sign and return a copy of this agreement to you, with instructions concerning your monthly payments. Each month’s payment will be due on the first day of the month, beginning on the first of the month following the date PBGC executes the agreement and returns it to you.

CONTINUE

Installment Payment Agreement Form 718, page 2 of 2
	Plan Number: «PrismCase.CaseIdNmbr»	Participant Name: «PrismCust.FullName»

2. Installment Payment Agreement

I acknowledge that I owe the Pension Benefit Guaranty Corporation (PBGC) a debt for pension benefits that I received, but was not entitled to receive. The amount of this debt is entered below. In exchange for PBGC’s agreement to not demand payment at once of the entire amount of this debt or to take legal or other collection actions, I agree to make monthly payments in the amount indicated below until my debt is fully repaid.

No interest will accrue on the balance while I continue to make timely installment payments. However, I understand that PBGC may declare me to be in default 60 days after a missed payment, and that simple interest will then accrue on the total remaining unpaid balance at the same rate as the U. S. Treasury Department’s Current Value of Funds Rate for the month in which the (first) payment was missed. If interest accrues, my payments will first be applied to outstanding interest, then to reduce the principal amount.

In addition, I understand that PBGC may take legal or other collection actions. When an installment payment is 90 days late, PBGC may forward the debt to the U.S. Treasury Department for debt collection action, including tax refund offset, Social Security benefit offset, and/or wage garnishment.

Total debt: $____________

Monthly payment $____________ for ___ months

PBGC Tracking number: _________________

By signing this form, I agree to the terms set forth in this agreement.

___________________________________________	___________________
Signature	Date

Terms accepted by PBGC:

___________________________________________	___________________
FOD Collections Official	Date

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Printed Name