Download:
pdf |
pdfParticipant Application
for Pension Benefits
PBGC Form 700
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
Date Printed: 02/01/2019
Date of Plan Termination: FX.PrismCase.DOPT.XF
Participant Name: FX.PrismCust.FullName.XF
INSTRUCTIONS: Please complete this form to apply for your pension benefits. For those items marked “Proof
Required”, enclose a copy of the appropriate document if you have not already sent it to us. Acceptable
documents for proof of age include your birth or baptism certificate, or U.S. passport; for marriage, a marriage
certificate. Please make sure that proof documents are legible before sending to PBGC. If you have questions
about other acceptable documents, 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 last name(s) used
Social Security Number
Date of Birth (Copy of Proof Required)
-
-
/
Gender
/
Mailing Address
Apartment / Route Number
City
State
Country
Email
Daytime Phone
(
Extension
)
-
x
MALE
FEMALE
Zip Code
Evening Phone
(
)
/
Please enter your actual retirement date using the date shown on the enclosed
Month
Optional Benefit Form.
Will you be employed on the date above?
Employer Name:
Year
Yes
No
State
City
If you are employed by the company that sponsored your pension plan on your actual retirement date, contact PBGC to
confirm your eligibility before submitting this application. If you return to work for the company that sponsored your
pension plan, notify PBGC immediately.
CONTINUE ON BACK
Approved OMB 1212-0055
Expires 10/31/21
Participant Application for Pension Benefits
Plan Number: FX.PrismCase.CaseIdNmbr.XF
Form 700, page 2 of 6
Participant Name: FX.PrismCust.FullName.XF
2a. Marital status - Please complete both 2a. and 2b.
Are you currently married?
Spouse’s Last Name
Spouse’s First Name
Spouse’s Middle Name
Other Last Name(s) Used
Spouse’s Social Security Number
-
Spouse’s Date of Birth
Date of Marriage
(PROOF REQUIRED)
(PROOF REQUIRED)
-
/
/
/
Yes
No
/
2b. Court order related to the participant’s benefit
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
_________________________________________________________________________________
3. Election of Benefit Form – Before you choose an option below, please read the examples in Your Benefit,
Your Choice (attached to this application). Refer to the calculations included in your package that show
the amount of your benefit under the Plan’s Automatic Forms (options A and B) and the amount under
PBGC’s Optional Benefit forms (options C through J).
NOTE: You cannot change your benefit election (marked below) after PBGC makes the first payment to you.
Benefit Form
My Choice
Beneficiary
MARK ONLY ONE
MARK ONLY ONE
Not Applicable
B. Plan’s Automatic Form for a Married Participant
Spouse only
C. Straight Life Annuity
Not Applicable
D. Joint-and-50% Survivor Annuity
Spouse
or
Other Beneficiary
E. Joint-and-75% Survivor Annuity
Spouse
or
Other Beneficiary
F. Joint-and-100% Survivor Annuity
Spouse
or
Other Beneficiary
G. Joint-and-50% Survivor “Pop-up” Annuity
Spouse
or
Other Beneficiary
H. 5-year Certain-and-Continuous Annuity
Spouse
or
Other Beneficiary
I. 10-year Certain-and-Continuous Annuity
Spouse
or
Other Beneficiary
J. 15-year Certain-and-Continuous Annuity
Spouse
or
Other Beneficiary
A. Plan’s Automatic Form for an Unmarried
Participant
If you are married and do not choose Benefit Form “B”, your spouse must complete Section 4 on
page 3.
If you chose “Other Beneficiary” in options D through J listed above, you must complete Section
5 on page 4.
CONTINUE
Participant Application for Pension Benefits
Plan Number: FX.PrismCase.CaseIdNmbr.XF
Form 700, page 3 of 6
Participant Name: FX.PrismCust.FullName.XF
4. Spousal consent to elected form of benefit and beneficiary.
If you are married, and chose Benefit Form B (page 2), leave this section blank.
If you are married and did not choose Benefit Form B (page 2), your spouse must consent to your choice by
signing below. Your spouse’s consent must be signed in the presence of or acknowledged by a notary public.
If your spouse does not consent, PBGC will not begin to pay your benefit.
By signing below, I consent to my spouse’s election of the benefit form checked in section 3 and the
beneficiary designated in section 5. 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, survivor benefits, if any, will be paid according to the benefit
form and beneficiary designation elected by my spouse. As a result, if my spouse dies before me, I
may not be entitled to any survivor benefits.
•
If my spouse elects a certain and continuous annuity (choice H, I, or J in section 3), and if I consent to
this election, my spouse can make future changes to the beneficiary without my consent.
•
If I do consent to my spouse’s election, I cannot revoke my consent after PBGC makes the first
payment to my spouse.
SPOUSE’S SIGNATURE (MUST BE NOTARIZED)
DATE
To be completed by Notary Public:
Subscribed and sworn to before me this __________________ day of ____________________, Year______
DATE MY COMMISSION EXPIRES
NOTARY PUBLIC NAME
CITY / COUNTY
STATE
CONTINUE ON BACK
Participant Application for Pension Benefits
Plan Number: FX.PrismCase.CaseIdNmbr.XF
Form 700, page 4 of 6
Participant Name: FX.PrismCust.FullName.XF
5. Designation of “Other Beneficiary” for Continuing Payments. Complete this section if you elected any benefit
form from D through J in Section 3 and checked “Other Beneficiary”. If you elected a joint-and-survivor annuity, your
beneficiary designation is final and cannot be changed after PBGC makes your first payment. If you elected a certain-andcontinuous annuity, you may change your beneficiary at any time.
Note: The beneficiary will receive benefits that continue after your death, and will also receive any additional
money owed to you at your death.
Last Name
First Name
Middle Name
Other Name(s) Used
Social Security Number
Date of Birth (PROOF REQUIRED FOR
-
Gender
JOINT AND SURVIVOR BENEFITS ONLY)
-
/
/
Mailing Address
Apartment / Route Number
City
State
Country
Email (optional)
Daytime Phone
(
EXTENSION
)
-
x
MALE
FEMALE
Zip Code
Evening Phone
(
)
-
Relationship to you, if any (for example - granddaughter, friend)
6. Designation of Beneficiary for Payments Owed at Death. PBGC may owe you monies that are not continuing
payments at the time of your death. The person(s) or entity(ies) you designate in this section will receive the money if the
person you named for continuing payments dies before you or if you chose Option A or C in section 3. If you do not make
a designation, PBGC will pay the money in this order: your spouse, your children, your parents, your estate or your next of
kin.
Beneficiary(ies)
Social Security Number*
Date of Birth*
Name ____________________________________
Address ___________________________________
__________________________________________
Daytime Tel. No:___________________________
Name ____________________________________
Address ___________________________________
__________________________________________
Daytime Tel. No:___________________________
* Complete if person. ** Not necessary to provide; if provided, must total 100%
CONTINUE
Relationship
Percentage**
Form 700, page 5 of 6
Participant Application for Pension Benefits
Plan Number: FX.PrismCase.CaseIdNmbr.XF
Participant Name: FX.PrismCust.FullName.XF
7. 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.
How would you like to receive your payments?
MARK ONLY
ONE
A. By EDD or ETA to the account identified below, which must have my 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 location that does not have the infrastructure to support EDD or ETA.
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
CONTINUE ON BACK
Participant Application for Pension Benefits
Plan Number: FX.PrismCase.CaseIdNmbr.XF
Form 700, page 6 of 6
Participant Name: FX.PrismCust.FullName.XF
8. 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 page 4 of the enclosure: Your Benefit, Your Choice. Benefit Options from PBGC. 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 20196 we will withhold taxes only if your
monthly PBGC benefit is $21,033720.00 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)
.00
Additional monthly amount to be withheld (optional): $
OR
C. I elect to have the following amount withheld for federal income tax.
.00
The dollar amount or percentage to be withheld monthly is: $
OR
_____%
9. 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.
PARTICIPANT’S 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. Did you enclose a copy of your proof of age document? Your driver’s license is not a proof
document.
3. If you are married, did you enclose a copy of your marriage certificate?
4. If you are married, did you enclose a copy of your spouse’s proof of age?
5. If you are married and elected a benefit form other than option B on page 2, did your spouse sign
Section 4 on page 3 and was the signature notarized?
6. Did you elect only one option regarding federal tax withholding and is the election complete?
Your Benefit, Your Choice • Benefit Options from PBGC
Page 1 of 4
Before you begin to receive your monthly pension benefit from PBGC, you have an important decision to make:
How do you wish to receive your monthly benefit?
This question is complex and could be one of the most important financial decisions you will ever make. Your
decision affects the amount of your monthly benefit and how much your beneficiary will receive after your death.
The best option for you depends on your age, health, and other financial resources, as well as the age, health, and
financial needs of anyone for whom you wish to provide a benefit. If you are married, you should discuss this
choice with your spouse. You may also want to discuss this choice with other family members or friends and,
possibly, a financial advisor. The following information is designed to help you make an informed choice.
You may choose your plan’s “automatic” benefit form or one of the PBGC optional benefit forms, described below.
Your plan’s “automatic” benefit form is the benefit form your plan would pay you if you do not make an election.
Your automatic benefit form may be the same as one of the PBGC optional benefit forms.
If you are unmarried, you may choose your plan’s automatic benefit form for unmarried participants or any
of the PBGC optional benefit forms described below. This automatic benefit form in most plans is a straightlife annuity or a certain-and-continuous annuity (see the descriptions below).
If you are married, your automatic benefit form is a joint-and-survivor annuity with your spouse as
beneficiary. You may choose that benefit form or, with your spouse’s written consent, you may choose your
plan’s automatic benefit form for unmarried participants or any of the PBGC optional benefit forms, with your
spouse or another person as beneficiary.
Please note that your spouse has a legal right to the survivor benefit under your pension plan’s automatic
benefit form for married participants. You can elect a different benefit form or a beneficiary other than your
spouse only if your spouse consents by signing Section 4 of the Application and having the signature
notarized.
PBGC OPTIONAL BENEFIT FORMS
This section describes each of the benefit forms that PBGC offers, with examples using a participant named Sam
who is applying for a benefit. Sam will be age 65 when his benefit payments begin. He is married to Carol, who will
be 61 years old when Sam’s benefit payments begin. We show what Sam and Carol would receive under each
benefit form, assuming Sam names Carol as his beneficiary.
Straight-Life Annuity
A straight-life annuity provides a fixed monthly benefit for the rest of your life only. No survivor benefit will be paid
upon your death.
Example: Sam elects a straight-life annuity, and he receives $500 a month for the rest of his life. After Sam
dies, Carol does not receive any benefits.
Joint-and-Survivor Annuities
A joint-and-survivor annuity provides a benefit for the rest of your life at an amount reduced from the straight-life
annuity amount, with your choice of 50%, 75%, or 100% of that reduced amount to be paid to your beneficiary if you
die before that person. If your beneficiary dies before you, your benefit will remain at the reduced level, and no
survivor benefits will be payable when you die.
You may name your spouse or someone else as your beneficiary. You cannot change your beneficiary after PBGC
makes your first payment. The amount of your benefit will depend on the age of your beneficiary.
Your Benefit, Your Choice • Benefit Options from PBGC (continued)
Page 2 of 4
Examples
Joint-and-50% Survivor Annuity: Sam receives $450 a month for the rest of his life. If Sam dies first, Carol
receives $225 a month for the rest of her life. If Carol dies first, Sam continues to receive $450 a month for
the rest of his life.
Joint-and-75% Survivor Annuity: Sam receives $429 a month for the rest of his life. If Sam dies first, Carol
receives $322 a month for the rest of her life. If Carol dies first, Sam continues to receive $429 a month for
the rest of his life.
Joint-and-100% Survivor Annuity: Sam receives $409 a month for the rest of his life. If Sam dies first, Carol
receives $409 a month for the rest of her life. If Carol dies first, Sam continues to receive $409 a month for
the rest of his life.
Joint-and-50% Survivor “Pop-up” Annuity
The “pop-up” annuity is the same as the joint-and-50% survivor annuity (described above) except that if your
beneficiary dies before you, your benefit “pops up” to the straight-life annuity amount. Like the other joint-andsurvivor benefit forms, you may choose your spouse or someone else to be your beneficiary. The amount of your
benefit will depend on the age of your beneficiary. You cannot change your beneficiary after PBGC makes your
first payment.
Example: Sam elects a joint-and-50% survivor “pop-up” annuity and receives a payment of $444 a month. If
Sam dies first, Carol receives $222 a month for the rest of her life. However, if Carol dies first, Sam’s benefit
“pops up” to his straight-life annuity benefit amount of $500 a month for the rest of his life.
Certain-and-Continuous Annuities
A certain-and-continuous annuity provides a benefit for the rest of your life at an amount reduced from the straightlife annuity amount. If you die within 5, 10 or 15 years after your benefit payments start (depending on your
election), your designated beneficiary will receive the benefit for the remainder of that “certain” period. If you die
after the certain period, no survivor benefit is payable. You may choose any beneficiary for your certain-andcontinuous annuity, such as your spouse, another person, an estate, a trust, a church or other organization, etc.
You can change this beneficiary designation at any time. If your beneficiary dies before you and before the end of
the certain period, you should designate a new beneficiary. The amount of your benefit is the same regardless of
whom you designate as beneficiary.
Examples:
5-year Certain-and-Continuous Annuity: Sam receives $494 a month for the rest of his life. If Sam dies
within five years, Carol receives $494 a month for the remainder of the five-year period. If Sam dies after 5
years, Carol does not receive any benefits.
10-year Certain-and-Continuous Annuity: Sam receives $477 for the rest of his life. If Sam dies within ten
years, Carol receives $477 a month for the remainder of the ten-year period. If Sam dies after 10 years,
Carol does not receive any benefits.
15-year Certain-and-Continuous Annuity: Sam receives $452 a month for the rest of his life. If Sam dies
within 15 years, Carol receives $452 a month for the remainder of the 15-year period. If Sam dies after 15
years, Carol does not receive any benefits.
Your Benefit, Your Choice • Benefit Options from PBGC (continued)
Page 3 of 4
SUMMARY OF EXAMPLES
These examples assume that Sam (participant) will be age 65 and Carol will be age 61 when benefit payments
start. These examples assume that in Sam’s plan the automatic form of benefit is a straight-life annuity for an
unmarried participant and a joint-and-50% survivor annuity for a married participant. Automatic forms vary from
plan to plan but a straight-life annuity and a joint-and-50% survivor annuity are common.
Benefit Form
Sam’s
Benefit
Carol’s
Survivor
Benefit
Additional Explanation
A. Plan’s Automatic Benefit Form
for Unmarried Participants
(Straight Life Annuity)
$500
None
Carol will not receive any benefits after Sam’s death.
If Sam dies first, Carol’s survivor benefit will be paid
for the rest of her life.
B. Plan’s Automatic Benefit Form
for Married Participants (Jointand-50% Survivor Annuity)
$450
C. Straight Life Annuity
$500
None
D. Joint-and-50%
Survivor Annuity
$450
$225
E. Joint-and-75%
Survivor Annuity
$429
F. Joint-and-100%
Survivor Annuity
$409
$225
If Carol dies first, Sam’s benefit continues at the
same amount for the rest of his life.
Carol will not receive any benefits after Sam’s death.
If Sam dies first, Carol’s survivor benefit will be paid
for the rest of her life.
$322
If Carol dies first, Sam’s benefit continues at the
same amount for the rest of his life.
$409
If Sam dies first, Carol’s survivor benefit will be paid
for the rest of her life.
G. Joint-and-50%
Survivor “Pop-up”
Annuity
$444
H. 5-year Certain-andContinuous Annuity
$494
$494
10-year Certain-andContinuous Annuity
$477
$477
If Sam dies before the end of the 5-year, 10-year, or
15-year certain period (whichever he chooses),
Carol will receive benefits for the remainder of that
period.
J. 15-year Certain-andContinuous Annuity
$452
$452
If Sam dies after the end of the certain period, Carol
will not receive any benefits.
I.
$222
If Carol dies first, Sam’s benefit will increase to $500
for the rest of his life.
Your Benefit, Your Choice • Benefit Options from PBGC (continued)
Page 4 of 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 page 6 of the application. 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 are 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.
C) 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 these 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 the PBGC 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 your application.
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.
| File Type | application/pdf |
| Author | iotsa09 |
| File Modified | 2019-02-01 |
| File Created | 2019-02-01 |