Form 705 Beneficiary Application for Pension Benefits

	Beneficiary Application for Pension Benefits		PBGC Form 705
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: 01/15/2021
	Date of Plan Termination: FX.PrismCase.DOPT.XF

INSTRUCTIONS: Please complete this form to ask PBGC to begin payments to you as (1) the beneficiary of a deceased participant who died after retirement, or (2) an alternate payee under a shared payment Qualified Domestic Relations Order (QDRO). For items marked "Proof Required" enclose a legible copy of the appropriate document if you have not already sent it to us. If you have questions, call our Customer Contact Center at 1-800-400-7242. Please print clearly with blue or black ink.

1. General information about you

Last Name

First Name

Middle Name

Other Last Name(s) Used

Social Security Number

Date of Birth

Gender

male



-

-

/

/

female



Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email

Daytime Phone

Extension

Evening Phone

(

)

-

x

(

)

-

Name of Plan Participant

Your relationship to the plan participant:

MARK ONLY ONE

A. Beneficiary - The benefits are from the pension plan of someone who is deceased.



Marriage Proof Required (Certificate or Common Law document)

Date of participant’s death:

/

/

(Copy of Death Certificate 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:



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Beneficiary Application for Pension Benefits				Form 705, page 2 of 4
	Plan Number: FX.PrismCase.CaseIdNmbr.XF		Participant Name : FX.PrismCust.FullName.XF

Designation of Beneficiary for payments owed at Death – If there are payments owed to you at the time of your death, PBGC will pay them to the person(s) you designate below. If you do not make a designation, or if all the beneficiaries you designate below die before you, PBGC will pay the money in this order to: your spouse, your children, your parents, your estate, or your next of kin.

Beneficiary(ies)			Social Security Number*	Date of Birth*	Relationship	Percentage**
Name Address Daytime Tel. No:
Name Address Daytime Tel. No:
Name Address Daytime Tel. No:

* Complete if person

** Not necessary to provide; if provided, must total 100%

3. Method of receiving benefit payments. PBGC pays benefits through safe, secure and convenient electronic funds transfer. You will get your payment on time even if you are out-of-town or unable to get to the bank.

If you have a bank account, you can ask us to deposit your benefit payments to your account through Electronic Direct Deposit (EDD).

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.

Note: PBGC does not transfer funds to financial institutions outside the United States and its territories. If you live outside the United States or its territories and do not have a U.S bank account, PBGC will send your payment to your mailing address.

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Beneficiary Application for Pension Benefits			Form 705, page 3 of 4
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name : FX.PrismCust.FullName.XF

3. Method of receiving benefit payments (continued)

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 or a burden because: You do not have a bank account. You reside in a remote locate that does not have the infrastructure to support electronic fund transfers It is too expensive for you to maintain a bank account	

Financial institution information – Please provide the information below for PBGC to send your payment directly to a financial institution. The information is available from your financial institution or can be found on your checks and account statements. The sample check below shows the location of your nine-digit routing number and your 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.

All fields required

Name(s) on the Account (Your name must be on the account)
Routing Number									Account Number – Numbers only	Account Type
										Checking 	Savings 

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

4. Federal Tax Election - Complete this section by selecting only one option – A or B or C. If you live outside the United States, you cannot select Option A. For additional guidance regarding these options and federal tax withholding, please read the attached page: Information on Federal Tax Withholding. In general, tax laws require PBGC to withhold federal income tax from your pension payments, unless you specifically elect not to have taxes withheld. If you do not choose an option, if you choose multiple options or if the option you select is incomplete, we will withhold federal income taxes as if you were a married individual with three allowances. This means that for the year 2015 we will withhold taxes only if your monthly PBGC benefit is $1,720 or more.

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 or percentage to be withheld monthly is: $					.00	OR ____%

5. 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

Please complete the checklist below to ensure that your application form has all the required signatures and proof documents before you submit it. A MISSING SIGNATURE OR PROOF DOCUMENT COULD DELAY YOUR FIRST PAYMENT.
1. Did you sign and date the application above?	
2. If the participant is deceased, did you enclose a copy of the death certificate?	
3. Did you enclose a copy of your marriage certificate or common law document, if applicable?	
4. Did you make only one election regarding federal tax withholding and is the election complete?	

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 page 4 of the application. You may choose:

1. To have PBGC withhold no federal income taxes from your payments (not available if you live outside of the United States).

2. 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.

3. To have PBGC withhold the amount or percentage you tell us to withhold each month.

What if not enough taxes are withheld based on your choice?

PBGC withholds taxes based on the election you make when you apply for your pension benefit.  If you have other income that would affect the amount of taxes you owe, you may need to pay additional taxes.  You may also need to pay penalties to the IRS.  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 option 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 your federal tax withholding, you may find it helpful to read the IRS instructions for completing the IRS Form W-4P (Withholding Certificate for Pension or Annuity Payments). You can print a copy from the IRS Internet site under Forms and Publications at www.IRS.gov

Do not return this page to PBGC