705 Beneficiary Application for Pension Benefits

	Beneficiary Application for Pension Benefits		PBGC Form 705 Approved OMB 1212-0055 Expires
Pension Benefit Guaranty Corporation. P.O. Box 151750, Alexandria, Virginia 22315-1750		For assistance, call 1-800-400-7242

	Plan Name: FX.PrismCase.CaseTitle.XF
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF
	Date Printed: 02/04/2021	Applicant Name:
	Date of Plan Termination: FX.PrismCase.DOPT.XF

INSTRUCTIONS: Please complete this form to request that PBGC begin payments to you as the beneficiary of a deceased participant who died after retirement, or as an alternate payee pursuant to a Qualified Domestic Relations Order (QDRO). If you have questions, call our Customer Contact Center at 1-800-400-7242. Please print clearly with dark ink.

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 plan participant:}

CONTINUE - 

Beneficiary Application for Pension Benefits Form 705, page 2 of 5

Plan Number: FX.PrismCase.CaseIdNmbr.XF

Participant Name : FX.PrismCust.FullName.XF

Applicant Name:

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 – 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. Designation of Beneficiary – PBGC will pay the person you designate below payments owed to you at the time of your death and /or for the remaining period of a Certain Period benefit.

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

Relationship to me (e.g., friend, granddaughter)

-

-

/

/

Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email (optional)

Daytime Phone

Extension

Evening Phone

(

)

-

x

(

)

-

CONTINUE

Beneficiary Application for Pension Benefits Form 705, page 3 of 5
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF
		Applicant Name :

4. 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.

What happens if you do not choose any option?

If you do not choose one of the above 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.

CONTINUE

Beneficiary Application for Pension Benefits Form 705, page 4 of 5
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name : FX.PrismCust.FullName.XF
		Applicant Name :

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 (REQUIRED)

Single 

Married 

Number of withholding allowances (REQUIRED)

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 2008, we will withhold taxes only if your monthly PBGC benefit is $1,560 or more.

5. Method of receiving benefit payments. Electronic Direct Deposit (EDD) is the way PBGC makes payments to people with bank accounts. Direct deposit is safe, secure and convenient. You will get your payment on time even if you are out-of-town or unable to get to the bank.

If you do not have a bank account, you can open a low-cost Electronic Transfer Account (ETA) at a financial institution that offers such accounts. For more information about opening an ETA, call 1-888-382-3311 (toll-free) or visit the ETA website at www.eta-find.gov.

How would you like to receive your payments?	mark only one
A. By EDD or ETA 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 EDD or ETA would be difficult because: You do not speak or read English. The costs or fees related to EDD or ETA are greater. Accessing an EDD or ETA account would be difficult based on where you live. You have a physical or mental disability.	

CONTINUE

Beneficiary Application for Pension Benefits Form 705, page 5 of 5
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF
		Applicant Name :

Financial institution information – Please provide the information in this section to have your payment sent directly to a financial institution. The information is available from your financial institution or can be found on your checks, account statement or deposit slip. The sample check below shows the location of your 9-digit routing number and account number. If you are unsure of the routing number or your account number, contact your financial institution. You can cancel or change this arrangement by calling PBGC at 1-800-400-7242. The financial institution can cancel it by sending you a written notice.

׃ 012345678

1234567890

101

SAMPLE CHECK Date____________

Pay to the Order of ____________________________ $ _______

___________________________________________

Memo_________________ ___________________

Routing Number

Account Number

Name of Financial Institution

Mailing Address

City

State

Zip Code

Name of Contact Person

Phone Number

Routing Number

Account Number

Name(s) on the Account (Your name must be on the Account)

Account Type Checking  Savings

PLEASE SIGN AND DATE PAGE 2 BEFORE SUBMITTING

A MISSING SIGNATURE COULD DELAY YOUR FIRST PAYMENT.

THANK YOU