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Application for Payment Eligible for Rollover – Non-Spouse Beneficiary
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PBGC Form 721 Approved OMB 1212-0055 Expires
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Pension
Benefit Guaranty Corporation. |
For assistance, call 1-800-400-7242 |
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Plan Name: FX.PrismCase.CaseTitle.XF |
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Plan Number: FX.PrismCase.CaseIdNmbr.XF |
Participant Name: FX.PrismCust.FullName.XF |
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Printed: |
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Date of Plan Termination: FX.PrismCase.DOPT.XF |
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INSTRUCTIONS: Use this form to request a lump-sum payment if you are the beneficiary of a participant who has died and you are not the spouse. Please enclose a legible copy of the death certificate unless you have already sent a copy to PBGC. Please print clearly with blue or black ink.
1. Information about you
Last Name |
First Name
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Middle Name |
Your Relationship to Deceased Payee |
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CONTINUE |
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Application for Payment Eligible for Rollover – Non-Spouse Beneficiary Form 721, page 2 of 3 |
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Plan Number: FX.PrismCase.CaseIdNmbr.XF |
Participant Name: FX.PrismCust.FullName.XF |
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2. Payment Option – Please read the enclosed Special Tax Notice Regarding Non-Periodic PBGC Payments. Be sure you understand the tax implications of having PBGC send your lump-sum payment directly to you or to an inherited individual retirement account (IRA).
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. Rollover my payment into an Inherited IRA – Send my entire payment, plus interest, directly to the inherited (IRA) I designate. I understand that PBGC will not withhold federal income tax from the payment.
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C. Split my payment - Send some of the money directly to me, and send some directly to an IRA as follows:
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1. Send this much directly to me:
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I understand that I cannot rollover this amount later to an inherited IRA and that PBGC will withhold 20% of the taxable amount of this payment for federal income tax.
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2. Send this much to an inherited IRA. |
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I understand that PBGC will not withhold taxes from this part of my payment to the IRA I designate. Note: the amount must be at least $500.00.
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no less than $500 |
If you elected option A or C, complete Section 3 on page 3.
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CONTINUE
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Application for Payment Eligible for Rollover – Non-Spouse Beneficiary Form 721, page 3 of 3 |
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Plan Number: FX.PrismCase.CaseIdNmbr.XF |
Participant Name: FX.PrismCust.FullName.XF |
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3. Information About Your Inherited Individual Retirement Account
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Name of Receiving Account (example – Tom Smith as beneficiary of John Smith) |
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Name of the Institution / Trustee
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4. 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.
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SIGNATURE
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DATE |
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File Type | application/xml |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |