717 Monthly Payment Election Form

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	Monthly Payment Election Form		PBGC Form 717 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: «PrismCase.CaseTitle»
	Plan Number: «PrismCase.CaseIdNmbr»	Participant Name: «PrismCust.FullName»
	DOPT: «PrismCase.DOPT»	Applicant Name:
	Date Printed: 02/04/2021

INSTRUCTIONS: Use this form to tell PBGC you want to receive a monthly, rather than annual, payment. If you want to keep receiving annual payments, do not return this form.

1. About your benefit

Annual payments - While most people receive annuity benefits monthly, PBGC makes annual payments to anyone who would receive $50 or less each month. Each year, we pay the full amount in the first month you should start receiving payments. For example, if your monthly benefit is $20, and the first month you should start receiving benefits is February, you will receive $240 in February. Your next payment will be February of the following year.

Monthly payments - If you are entitled to receive annual payments but want monthly payments instead, complete this form provided your monthly payment is $20 or more. You will start receiving monthly payments a year after you received your last annual payment. For example, if your last annual payment was in June, you would receive your first monthly payment the following June.

2. Annuity election

My monthly payment amount is $20 or more. I want this payment each month, not as one annual payment.
	payee's signature		date

	SIGN & DATE BEFORE SUBMITTING. THANK YOU.	