Form 703 Application for Elective Lump-Sum Payment

Locating and Paying Participants

e_Form703 revised

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⚠️ Notice: This form may be outdated.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:

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Application for Elective Lump-Sum Payment

PBGC Form 703

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: 01/30/2021
	Date of Plan Termination: FX.PrismCase.DOPT.XF

INSTRUCTIONS: Use this form to request a lump-sum payment. As proof of your date of birth, enclose a copy of your birth or baptism certificate, or U.S. Passport. If you are a deceased participant’s spouse, enclose a copy of your marriage certificate if you have not already sent it to us. Please make sure that proof documents are legible before sending to PBGC. If you have questions about other documents we accept as proof, call our Customer Contact Center at 1-800-400-7242. Print clearly with blue or black ink.

1. General information about you

_{Last
Name}

_{First
Name}

_{Middle
Name}

_{Other
Name(s) Used}

_{Social
Security Number}

_{Date
of Birth}_{(Copy
of Proof Required)}

_Gender

_male

_

_female

_

_{Mailing
Address}

_{Apartment
/ Route Number}

_City

_State

_Zip
Code

_Country

_Province

_{Daytime
Phone}

_Extension

_{Evening
Phone}

₍

₎

₍

₎

If you are the participant and worked after the date the plan terminated, what year did you stop working for the employer who sponsored your pension plan?

Year

2. Marital status

_{Are
you currently married?}_Yes__No_

_{Spouse’s
Last Name}

_{Spouse’s
First Name}

_{Spouse’s
Middle Name}

_{Other
Name(s) Used}

_{Spouse’s
Social Security Number}

_{Spouse’s
Date of Birth}

_{Date
of Marriage}_{(PROOF
REQUIRED)}

_{Is there a court order (for example - domestic relations order, divorce decree, child support order, etc.}₎_{that requires some or all of your benefit be paid to a spouse, former spouse, child, or other dependent?}		_Yes_
		_No_
	^CONTINUE		_

_{Application
for Elective Lump-Sum Payment}

_{Form
703, page 2 of 5}

Plan Number: FX.PrismCase.CaseIdNmbr.XF

Participant Name: FX.PrismCust.FullName.XF

3. Lump-sum payment election – If you are the participant, you and your spouse have to make an important decision about how your benefit is paid.

Important Information about Your Benefit Choices

You need to decide whether you want to receive your benefit as a single lump-sum payment now or as a monthly annuity benefit at some future date. If you are currently married and want a lump-sum payment, your spouse’s consent is needed for PBGC to comply with your election.

If you complete this application and your spouse consents on the next page to your election, PBGC will pay your entire benefit to you in a lump-sum. No future benefits will be payable to you or your spouse. If you would prefer to receive your benefit in a monthly annuity form, call PBGC and do not submit this application.

Annuity Benefit Form

At the time that you are eligible to retire, PBGC will pay your benefit as an annuity, generally monthly, for your life. The form of your annuity benefit will depend on your marital status at retirement. If you are married, you will receive a joint-and-survivor benefit unless your spouse consents to your waiver of this form of benefit in writing. The joint-and-survivor form provides a benefit for your life and, if you die before your spouse, at least 50% of your benefit amount will be paid to your spouse for the rest of your spouse’s life. To help pay for your spouse's benefits, your payment will most likely be reduced. If your spouse consents to your waiver of the joint-and-survivor benefit, or if you are not married, you may select from a number of PBGC optional benefit forms.

Lump-Sum Payment

You will receive a single payment now of your entire benefit. No future annuity benefits will be payable to you or your spouse.

An example of your choices:

Lump-sum payment: Sam elects a lump-sum payment and Carol consents to it (Carol signs in front of a notary public), and Sam receives $7,000 in the form of a single lump-sum benefit, with interest. No future payments will be payable to Sam or Carol.

Joint-and-50%survivor annuity: Sam (age 65) and Carol (age 61) are married when Sam retires. Sam receives a payment of $260 for the rest of his life. After Sam dies, Carol receives $130 a month for the rest of her life. If Carol dies first, Sam will continue to receive $260 a month for the rest of his life.
Other annuity choices: If Sam waives a joint-and-survivor annuity when he retires, and Carol consents to his waiver, other annuity benefit forms are available. To learn more about your specific annuity benefit choices, call PBGC at 1-800-400-7242.

_

^CONTINUE

_

_{Application for Elective Lump-Sum Payment}			_{Form 703, page 3 of 5}
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF

4. Spousal consent for a participant to receive an elective lump-sum benefit. If you are married and want to receive your benefit in a lump sum payment, your spouse must complete this section. Your spouse must sign and date this section in the presence of a Notary Public witnessing his/her signature.


By signing below, I consent to my spouse's election to receive his/her benefit in a lump-sum payment. My consent is voluntary. I have read and I understand the information provided with this application. In particular, I understand all of the following: I have a right not to consent to my spouse’s election. If I do not consent, my spouse’s benefit will be paid in the plan’s automatic form for married participants. Under that automatic form, if my spouse dies before me, I would receive a benefit equal to at least 50% of my spouse’s benefit for the rest of my life. If I do consent to my spouse’s election, I cannot revoke my consent after PBGC makes the payment to my spouse.

		^{spouse’s signature (must be witnessed by a notary public)}		^date
_{Must be signed and witnessed in the presence of a Notary Public}
_{To be completed by Notary Public witnessing the spouse’s signature above:}
Subscribed and sworn to before me this __________________ day of ____________________, Year______

	Date My Commission Expires		Notary Public Name

	City / County		State

_

^CONTINUE

_

_{Application for Elective Lump-Sum Payment}			_{Form 703, page 4 of 5}
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF

5. Payment Election – Please read the enclosed Special Tax Notice Regarding Non-Periodic PBGC Payments. Be sure you understand the tax implications of having PBGC pay the lump sum directly to you or an individual retirement arrangement (IRA) or a qualified retirement plan.

Please elect only one option - A or B or C. If you do not elect an option or if you elect more than one option, PBGC will pay you according to option B.

_A. Roll over my payment to an IRA or a plan – Send my entire payment, plus interest, directly to an IRA or a qualified retirement plan. I understand that PBGC will not withhold taxes from my payment.

_

B. Pay me directly – Send the entire payment, plus interest, directly to me. I understand that PBGC will withhold 20% of the taxable amount of my payment for federal income tax.

__

_C_._{Split
my payment -}_{Send
some of the money, plus interest, directly to me, and send some
directly to an IRA or a qualified retirement plan, as follows:}

_

_{1. Send
this much directly to me:}

_{I
understand that PBGC}_{will
withhold}_{20% of the taxable amount for federal income tax.}

_{2.
Send this much to an IRA or a qualified retirement plan.}

_{I
understand that PBGC}_{will
not withhold}_{taxes from this part of my payment.}

_{Note:
the amount must be at least $500.}

If you selected option A or C, complete Section D on page 5.

_

^CONTINUE

_

_{Application for Elective Lump-Sum Payment}			_{Form 703, page 5 of 5}
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name : FX.PrismCust.FullName.XF

Payment Election (continued)

_{D.
Rollover Information}

_{Name
of IRA or Plan}_:

_{Type
of IRA or Plan (check one):}

___{Traditional
IRA}_

_{}

___Roth
IRA

___{Qualified
retirement plan}

_{Account
Number}

_{Name
of the Institution / Trustee}

_{Daytime
Phone}

₍

₎

_{Mailing
Address}

_City

_State

_Zip
Code

6. 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

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	Payee Information Form_PBGC Form XXX
Author	PBGC\IOD
File Modified	0000-00-00
File Created	2021-01-30

Form 703 Application for Elective Lump-Sum Payment

Locating and Paying Participants

e_Form703 revised

Locating and Paying Participants

OMB: 1212-0055

Subscribed and sworn to before me this __________________ day of ____________________, Year______

Subscribed and sworn to before me this ____ day of , Year